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Basic rabies-for-dep ed


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basic rabies for Dep Ed

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Basic rabies-for-dep ed

  1. 1. RABIES JOMELL V. MOJICA, RN Rabies Prevention and Control Program Coordinator DOH Regional Office IV-A
  2. 2. WHAT IS RABIES Rabies is a zoonotic disease caused by a virus. Rabies is the deadliest disease on earth and you will have a 99.9% chance of dying if you do not receive vaccine immediately after getting infected.
  3. 3. RABIES  Human rabies caused by the classical rabies virus continues to be 99.9% fatal  No specific treatment available anywhere in the world  Responsible for the death of 188 Filipinos for the year 2015
  4. 4. RABIES  Dogs remain the principal cause of animal bites and rabies cases in 2015- 72%, Cats 27%.
  5. 5. CAUSATIVE AGENT Rabies Virus  Bullet-shaped, single stranded RNA- virus belonging to the genus Lyssavirus, family of Rhabdoviridae.  Cannot cross intact skin  Sensitive to heating/ boiling, drying, UV and X- ray, sunlight, ether, and detergents
  6. 6. TRANSMISSION Is due to a bite, scratch or even lick on mucous membrane from animals (dogs) whose saliva contains the virus By inhaling virulent aerosol (laboratory experiment, exploration of enclosed caves inhabited by infected bats) By transmission: from man to man  Indirectly: transplantation of infected cornea  Directly: from bite or through saliva of an infected person IN ALMOST ALL CASES IN VERY EXCEPTION AL CASES
  7. 7. TRANSMISSION Human to Human Transmission  Directly- bite or contact with saliva and other body fluids of infected person  Indirectly- transplant  15 documented cases of fatal rabies following transplantation  Corneal transplantation (8)  Transplantation of solid organs and vascular conduit (7)
  8. 8. TRANSMISSION Human to Human Transmission  There are no human cases due to consumption of cooked meat  Although rabies patients are extremely unlikely to bite other people, caregiver should be watchful and alert when looking after them, and avoid contact with patient’s saliva.
  9. 9. TRANSMISSION  Risk of developing clinical rabies  Approximately 15-20 %  Influenced by: 1. Virus content of saliva- intermittent viral shedding in saliva 2. Severity of the bite 3. Location of the wound 4. Virus variant Head 50-80% Legs 3-10% Finger/ Hand 15 – 40%
  10. 10. WHAT MATERIALS CAN SPREAD RABIES  Rabies virus is transmitted through saliva and brain/ nervous system tissue. Only these specific bodily excretions and tissues transmit rabies virus.  Contact such as petting or handling an animal, or contact with blood, urine or feces does not constitute an exposure. No PEP is needed in these situations.
  11. 11. EXPOSURE The rabies virus enter the human body via exposure to an infected animal Scratches from an infected animal can give rabies because if an animal has rabies, it often drools excessively, and the saliva drips on to its claws.
  12. 12. INCUBATION PERIOD The rabies virus replicates in the muscle at the bite site. IP: 2 weeks to 6 years Average IP: 1-3 months 3 months 87% 1 month 71% 6 months 95%
  13. 13. INCUBATION PERIOD  The Rabies virus travels by retrograde transport along the peripheral nervous system  Speed of virus migration: 12-24 mm/day  Length of Incubation Period affected by:  Infecting strain  Size of inoculum  Degree of innervation  Proximinity to CNS
  16. 16. PRODROMAL PHASE The rabies virus replicates in the dorsal root ganglion and travels along the CNS Manifestations: o Fatigue/ Malaise o Headache o Anorexia o Fever o Pain, Itching, numbness at the bite site Duration: 2-10 days
  17. 17. ACUTE NEUROLOGIC PHASE  Hydrophobia  Fear of water (shows panic when presented with liquids to drink)  Difficulty swallowing  Painful spasm of the muscles in the throat and larynx  Hypersalivation  Aerophobia  Restlessness, aggression, hallucinations.  seizure  Lack of aggression  Weakness  Can be mistaken for GBS The Rabies Virus Infect the brain Duration: 2-7 days Encephalytic/ Furious/ Frantic Type Paralytic/ Dumb Type
  18. 18. COMA  Onset of complications  Respiratory  Cardiovascular  Neurologic  Pituitary  Others Ends in Death in almost 100% of cases
  19. 19. WHAT SHOULD WE DO WHEN A PERSON SHOWS ANY OF THESE SYMPTOMS?  Take them immediately to the nearest health facility.  Rabies cannot be cured once the symptoms appear in a person, but the person ca be made comfortable and given medicines to help relieve the suffering.  Provide comfort to the patient’s family
  20. 20. THE OUTCOME IS DEATH… …PREVENTION is the answer
  22. 22. • Animal Rabies Control • Human Rabies Control • Post-exposure prophylaxis (PEP) – for exposed individuals • Pre-exposure prophylaxis (PrEP) – before exposure, to high risk individuals 22 Rabies prevention
  24. 24. MASS DOG VACCINATION Mass dog vaccination campaigns have been most effective measures for controlling rabies
  25. 25. DOG POPULATION MANAGEMENT  Stray dog management through enforced confinement of owned strays  Humane capture, euthanasia and disposal
  26. 26. DOG POPULATION MANAGEMENT  Surgical Sterilization  Non- Surgical sterilization  Habitat control
  28. 28. Given to exposed patients Objectives: To minimize the amount of virus at the site of inoculation To develop a high titer of neutralizing antibody early and maintain it for as long as possible 28 Post-exposure Prophylaxis
  29. 29. Components: Local wound care Categorization of exposure Immunization Active immunization Passive immunization 29 Post-exposure Prophylaxis
  30. 30. Local wound care
  31. 31. 31  Wounds should be immediately and vigorously washed and flushed with soap and water preferably for 10-15 minutes Local Wound Care
  32. 32. Apply antiseptic (alcohol, tincture of iodine etc) 32 Local Wound Care
  33. 33. Local Wound Care oGive antibiotics for: • All frankly infected wounds • All category III cat bites • All other category III bites that are either deep, penetrating, multiple or extensive or located on the hand/face/genital area • Drugs of choice: Amoxicillin/clavulanic OR Cloxacillin OR Cefuroxime axetil
  35. 35. 35 Rubbing garlic on wound Local Wound Care: Don’ts
  36. 36. 36  Suturing of wounds should be avoided (as it may inoculate virus deeper into the wound)  Wounds may be coaptated using sterile adhesives strips Local Wound Care: Don’ts
  37. 37. 37  However, if suturing is unavoidable:  RIG should be infiltrated around and into the wound before suturing  Suturing should be delayed for at least 2 hours after administration of RIG to allow diffusion of the RIG to occur through the tissues Local Wound Care: Don’ts
  38. 38. 38
  39. 39. Categorization of exposure
  40. 40. 40  Feeding/touching an animal  Licking of intact skin (with reliable history and thorough physical examination)  Exposure to patient with S/Sx of rabies by sharing of eating or drinking utensils  Casual contact to patient with S/Sx of rabies (talking, visiting, feeding, routine health care delivery) Category I
  41. 41. Wash exposed skin immediately with soap and water No vaccine or RIG needed Consider pre-exposure prophylaxis for high risk persons 41 Category I
  42. 42.  Nibbling of uncovered skin w/ or w/o bruising/hematoma  Minor/superficial scratches/abrasions without bleeding, including those induced to bleed 42 All Category II exposures on the head and neck area are considered Category III and should be managed as such Category II
  43. 43.  Wash wound with soap and water  Start vaccine immediately  RIG is not indicated  Complete vaccination regimen until day 28 if:  Animal is rabid  Animal is killed/died w/o testing  Animal has signs and symptoms of rabies  Animal is unavailable for 14 -day observation (e.g. stray) 43 Category II
  44. 44.  May omit day 28 dose if:  Animal is alive AND remains healthy after 14-day observation period  Biting animal died within the 14 days observation period, confirmed by veterinarian to have no signs of rabies AND was FAT-negative  Patients who have completed 3 doses (day 0, 3 and 7 doses) are considered to have completed pre- exposure prophylaxis 44 Category II
  45. 45.  Transdermal bites (puncture wounds, lacerations, avulsions, deep abrasions) or scratches with spontaneous bleeding  Licks on broken skin or mucous membranes (eyes, oral/nasal, genital/anal mucous membranes)  Exposure to a rabies patient through bites, contamination of mucous membranes or open skin lesions with body fluids through splattering, through mouth-to-mouth resuscitation 45 Category III
  46. 46. CATEGORY III  Unprotected Handling of infected carcass  Ingestion of raw infected meat  All Category II exposures on head and neck area  Exposure to bats
  47. 47. 47 Category III
  48. 48.  Wash wound with soap and water  Start vaccine and RIG immediately  Complete vaccination regimen until day 28 if:  Animal is rabid  Animal is killed/died w/o testing  Animal has S/Sx of rabies  Animal is unavailable for 14 -day observation (e.g. stray) 48 Category III
  49. 49.  May omit day 28 dose if:  Animal is alive AND remains healthy after 14-day observation period  Biting animal died within the 14 days observation period, confirmed by veterinarian to have no signs of rabies AND was FAT-negative  Patients who have completed 3 doses (day 0, 3 and 7 doses) are considered to have completed pre-exposure prophylaxis Category III
  51. 51. ACTIVE IMMUNIZATION o Vaccine is administered to induce antibody and T- Cell production in order to neutralize the rabies virus in the body. o It induce an active immune response in 7-10 days after vaccination.
  52. 52. ACTIVE IMMUNIZATION Type of Rabies Vaccines and Dosage The NRPCP shall provide the following anti-rabies tissue culture vaccines(TCV): a) Purified Vero Cell Rabies Vaccine (PVRV)- 0.5ml/vial b) Purified Chick Embryo Cell Vaccine (PCECV)- 1.0ml/vial Generic Name Preparation Dose Purified Vero Cell Rabies Vaccine (PVRV) 0.5ml/vial ID- 0.1 ml IM- 0.5 ml Purified Chick Embryo Cell Vaccine (PCECV) 1ml/vial ID- 0.1 ml IM- 1.0 ml
  53. 53. Requirements for Vaccines • Registered with and approved by FDA • WHO prequalified • Proven safe and efficacious for PEP when administered by the IM/ID route using WHO recommended schedules • Vaccine potency •IM use - at least 2.5 IU/dose •ID use - at least 0.5 IU/dose • Product insert must contain the vaccine’s approved ID dose consistent with its CPR
  54. 54. 55 Day 0 Day 3 Day 7 ID dose = 0.1 ml Day 28 Updated 2-site ID regimen
  55. 55. 56 Day 0 Day 3 Day 7 Day 14 Day 28 IM dose = 0.5 ml for PVRV; 1.0 ml for PCECV Into the deltoid muscle or anterolateral thigh in infants 5-dose Intramuscular regimen
  56. 56. o To neutralize rapidly the virus locally in the wound before it reaches the local nerve endings (usually 7 to 14 days later) Passive Immunization
  57. 57. PASSIVE IMMUNIZATION To provide the immediate availability of neutralizing Ab at the site of the exposure before it is physiologically possible for the patient to begin producing his or her own Ab after vaccination
  58. 58. RABIES IMMUNE GLOBULIN Computation and Dosage of RIG a. HRIG at 20 IU/kg. body weight (!%) IU/ml) 50kg. Patient X 20 IU/kg- 1,000 IU 1,000 IU ÷150 IU/ml= 6.7 ml b. ERIG/ F(ab’)2 at 40 IU/kg. body weight (200IU/ml) 50kg. Patient X 40 IU/kg- 2,000 IU 2,000 IU ÷200 IU/ml= 10 ml
  59. 59. Guidelines for Passive Immunization  A skin test is performed prior to ERIG administration and read after 15 min  Induration of > 6 mm = positive skin test  Hypersensitivity to ERIG may not be predicted by skin test. Always be ready with epinephrine and antihistamines for treatment of hypersensitivity  Patients should be observed for at least 1 hr after injection of ERIG
  60. 60. Passive Immunization: Skin testing for ERIG  There are no scientific grounds for performing a skin test prior to administering equine immunoglobulin because testing does not predict reactions, and it should be given whatever the result of the test.  The treating physician should be prepared to manage anaphylaxis which, although rare, could occur during any stage of administration. WHO position paper, 2010
  61. 61. Use of HRIG HRIG is preferred in the following circumstances: history of hypersensitivity to equine sera multiple severe exposures (especially where dog is sick or suspected of being rabid) symptomatic HIV infected patients
  62. 62. Guidelines for Passive Immunization RIG should be given as a single dose for all Category III exposures, in combination with anti-rabies vaccine Dose: HRIG - 20 iu/kg ERIG - 40 iu/k RIG should be infiltrated around and into the wound as much as anatomatically feasible, even if the lesion has begun to heal Any remaining RIG should be administered IM at a site distant from the site of vaccine injection
  63. 63. Guidelines for Passive Immunization o Avoid multiple needle injections o If a finger/toe needs to be infiltrated, care must be taken not to impair blood circulation o Injection of excessive amount may lead to cyanosis, swelling, pain
  64. 64. GUIDELINES FOR PASSIVE IMMUNIZATION o RIG should not exceed the calculated dose as it may reduce the efficacy of the vaccine o If the calculated dose of RIG is insufficient to infiltrate bite wounds, it may be diluted with sterile saline 2 or 3 fold for thorough infiltration o Can infiltrate RIG even if wound is infected
  65. 65. Guidelines for Passive Immunization RIG should be administered at the same time as the first dose of vaccine If RIG is unavailable when the first dose of vaccine is injected, it may be given until 7 days after the first dose of the vaccine. Beyond day 7, RIG is no longer indicated, regardless of whether day 3 and 7 doses were given In the event that RIG and vaccine cannot be given on the same day, the vaccine should be given before the RIG since the latter inhibits the development of Ab from immunization RIG is given only once during the course of PEP
  66. 66. PEP under Special Conditions • There are no contraindications to rabies PEP pregnant newborns Immune- compromised elderly Sick
  67. 67. Local wound treatment Previously Immunized Animal Bite Patients
  68. 68. Guidelines 1. Patients with chronic liver disease and those taking chloroquine and systemic steroids should be given standard IM regimen as the response to ID regimen is not optimum for these conditions 2. Immunocompromised individuals should be given vaccine using standard IM regimen and RIG for both Category II and III exposures  Patients with hematologic conditions where IM injections are contraindicated, should receive rabies vaccine by ID route. 3. Delay in consult  Treat as if the exposure occurred recently  If the biting animal has remained healthy and alive w/o signs of rabies until 14 days after the bite, no treatment is needed
  69. 69. Guidelines 4. Shifting from one vaccine brand to another is not recommended but may be warranted for the ff situations provided that it is one of the WHO recommended cell culture vaccines:  Severe hypersensitivity reaction  unavailability of initial vaccine used 5. Shifting from one regimen to another is not recommended. As much as possible the initial regimen should be completed.
  70. 70. Guidelines 6. Missed doses delay in day 3 (2nd) dose  If delay is 1-2 days from day 3 schedule – give day 3 dose upon visit and follow the original schedule of day 7 and 28/30.  If delay is 3-4 days from day 3 schedule- give day 3 dose upon visit, adjust succeeding doses (day 7 and 28) according to the prescribed interval.  If delay is > 4 days from day 3 schedule – restart a new course
  71. 71. Guidelines 6. Missed doses delay in day 7 (3rd) dose  If delay is <7 days from day 7 schedule - give day 7 dose upon visit, give day 28 dose as originally scheduled  If delay is >7 - 14 days from day 7 schedule – repeat day 3 dose and revise according to the prescribed interval  If delay is > 14 days from day 7 schedule - restart a new course delay in day 28 (4th) dose  give day 28 upon visit; this may be considered as a booster.  If RIG has already been administered, it should not be given again
  72. 72. Guidelines 8. Bites by vaccinated dogs/cats PEP is not recommended for Category I exposures PEP can be delayed* for CATEGORY II bites provided that ALL of the following conditions are satisfied: Dog/cat is healthy and available for observation for 14 days Dog/cat was vaccinated against rabies for the past 2 years: Dog/cat must be at least 1 yr 6 months old and has updated vaccination certificate from a duly licensed veterinarian for the last 2 years The last vaccination must be within the past 12 months; the immunization status of the dog/cat will not be considered updated if the animal is not vaccinated on the due date of the next vaccination * If biting dog/cat becomes sick or dies within the observation period, PEP should be started immediatelv Joint DA-DOH AO 2011-002
  73. 73. Guidelines 8. Bites by vaccinated dogs/cats PEP should be given immediately for ANY of the following conditions: Category III exposure The dog/cat is proven rabid/sick /dead with no laboratory exam for rabies/not available before or during the consultation; The dog/cat is involved in at least 3 biting incidents within 24 hours or Dog/cat manifests behavioral changes suggestive of rabies before, during or after the biting incident
  74. 74. Pre-exposure prophylaxis o Given prior to exposure o Benefits o The need for RIG is eliminated o PEP vaccine regimen is reduced from five to two doses o Protection against rabies is possible if PEP is delayed o Protection against inadvertent exposure to rabies is possible o The cost of PEP is reduced
  75. 75. Pre-exposure prophylaxis Target population Personnel in rabies diagnostic or research laboratories Veterinarians and veterinary students Animal handlers Health care workers directly involved in care of rabies patients Individuals directly involved in rabies control Field workers Rabies Act of 2007 provides for pre-exposure immunization of children 5-14 yrs old living in areas with high incidence of rabies
  76. 76. Pre-exposure prophylaxis Day 0 84 Day 7 Day 21/28 IM dose = 0.5 ml PVRV or 1.0 ml PCECV ID dose = 0.1 ml PVRV/ PCECV There is no need to restart series if doses are not given on the exact schedule Into the deltoid muscle or anterolateral thigh in infants
  77. 77. Booster doses Routine boosters in the absence of exposure Recommended only for those with continuous and frequent risk Not necessary for general population In the event of an exposure, previously immunized persons require 2 booster doses regardless of time interval from last dose to repeat exposure Day 0, Day 3; 1 dose each
  78. 78. THINGS TO REMEMBER  The best way to control rabies is to vaccinate dogs regularly  Rabies vaccination is only effective during the incubation period  After clinical symptoms appear the patient usually dies within few days  There is no test to diagnose rabies before the symptoms appear  Traditional or folk practices cannot cure or prevent rabies
  79. 79. THANK YOU