This document provides information about rabies, including: - Rabies is a fatal viral disease transmitted through the bites or scratches of infected animals. It affects over 150 countries worldwide. - Dogs are responsible for transmitting rabies to humans in 99% of cases. India has the highest rabies burden with 20,000 deaths annually. - Post-exposure prophylaxis including wound cleansing, rabies immunoglobulin, and vaccination is highly effective in preventing rabies if administered promptly after exposure. Pre-exposure vaccination is recommended for at-risk groups. Rabies remains virtually 100% fatal if left untreated.

1. RABIES
Dr. Sushrit A. N.

2. INTRODUCTION:
• Mentioned in the Vedas & other ancient scripts.
• Derived from the Latin word – “madness”
• Sanskrit word ‘Rabhas’ - “to do violence”.
• Acute fatal viral encephalitis- ss RNA virus
• Zoonotic disease which is virtually 100% fatal
but 100% preventable.

3. THE PROBLEM…
• Rabies occurs in >150 countries and territories.
• World- >55 000 people die of rabies every year.
• 40% of people - bitten by suspect rabid animals-
children under 15 years of age.
• Dogs are the source of 99% of human rabies
deaths.

4. Global Endemicity of Rabies
Source: APCRI Survey, 2007

5. • India- 20,000 deaths, 17.4 million animal bite
cases annually.
• 36% - Global & 65% - Asian human rabies
deaths.
• All states - except Lakshadweep and Andaman &
Nicobar Islands.

6. EPIDEMIOLOGY

7. Agent:
• SS-RNA Virus-
Lyssa virus
• Family-
Rhabdoviridae
• Bullet Shaped.
• Size 75 nm x 180 nm.
• Enveloped

8. • Thermo labile – sensitive pasteurization and
boiling.
• Inactivated by- detergents, alcohol, iodine,
formaldehyde, phenol and BPL
• Preserved by freeze drying, at ultra low
temperatures (≤ -200C) and glycerine.

9. Reservoirs of Infection:
A. Urban Rabies: Dogs & Cats
B. Wild Life Rabies (Sylvatic): Jackal, Hyena,
Fox, Mongoose
C. Bat Rabies: Vampire Bats

10. Animals Transmitting Rabies:
Domestic
• Dogs & Cats
Wild
• Foxes & Jackals
• Monkeys
• Mongoose
• Bears
• Bats
Peri-domestic
• Cows & Buffaloes
• Sheep & Goats
• Pigs
• Donkeys
• Horses
• Camels

11. Source of Infection:
• Saliva of rabid animals
Carrier State:
• Dogs with virus in saliva
• Host:
• All age groups, more in children < 15 yrs
• M > F
• Dead end infection

12. Modes of Transmission:
1) Bites from infected animals
2) Licks on Broken Skin or Mucous Membrane
3) Scratches
4) Organ transplantation

13. Incubation Period (In Man):
• 2 weeks– 6 months (in > 85% cases).
• Ranges between 4 days to 19 years.
• Shorter in children (vulnerable group).

14. Pathogenesis:

15. Clinical Manifestation:
• Tingling / numbness at bite site
• Non specific symptoms
• Hydrophobia, Aerophobia
• Photophobia
• Paralysis, Coma
• Death (cardio - respiratory failure)
• Survival : 3–5 Days

17. Symptoms in
humans:
•Fever
•Depression
•Agitation
•Painful spasms
 excessive
saliva
•Death within a
weak without
vaccine
Treatment:
•Hospitalization
•IG
•Vaccine
Foaming at
mouth after
drinking:
Produced by
spasms in throat

18. Laboratory Diagnosis:
Laboratory diagnosis - not mandatory for
managing animal bite cases
Samples and tests:
• Saliva -Virus isolation / RNA detection
• Skin - Antigen detection
• CSF - Virus / RNA isolation & antigen detection

19. Treatment:
• Admit in a separate
quiet & breeze free area.
• Sedation with Morphine / Barbiturates.
• Muscle relaxants, Intensive cardio respiratory
support
• Emotional support and physical comfort.
• Barrier nursing and universal precautions.

20. • Invasive procedures
- avoid.
• Early disposal of body by cremation/ deep burial
• All disposables contaminated with secretions or
excretions, patient tissue or body fluids -
managed as infected.

21. Advice to the attendants:
• To avoid contact with secretions and excretions
of the rabies patient.
• To wash hands and exposed areas thoroughly
with soap and water
• Post-exposure vaccination
for close contacts

22. PREVENTION
A. Post-exposure prophylaxis.
B. Pre-exposure prophylaxis.
C. Post-exposure treatment of persons who have
been vaccinated previously.

23. POST EXPOSURE PROPHYLAXIS (PEP)
• Local treatment of Wounds
• Immunization: Immunoglobulin
Vaccination
• Advice and counselling

24. Local Treatment:
Do’s
• Gently wash under running water with soap
over a period of 15 min.
• Disinfectants- Povidone Iodine, Spirit, etc.
• Suturing only if required & after RIG.
• Simple, non occlusive dressing can be done if
required

25. • Tetanus toxoid and antibiotics to be given as
appropriate.
• Observe animal for 10 days
Don’ts
• Apply Irritants like chilli powder, plant sap,
lime, atta, etc.
• Cauterize

27. Signs Of Rabies In Dogs / Cats During
10 Days’ Observation Period
• Change in behaviour– undue aggression/
depression.
• Running aimlessly and attacking others without
any provocation.
• Becomes too drowsy and withdraws itself to a
corner.

28. • Excessive Salivation.
• Change in voice.
• Refusal to feed or eating unusual objects like
stones, papers, wood, metal pieces.
• Death of animal due to unknown cause.

29. CLASSIFICATION OF EXPOSURE (WHO)

32. Cat III exposures

33. Indications For Anti-rabies Treatment:
a. If the animal shows signs of rabies or dies
within 10 days of observation.
b. If the biting animal cannot be traced or
identified.
c. Unprovoked bites.
d. Laboratory tests of the brain of the biting
animal are positive for rabies.
e. All bites by wild animals.

34. Passive Immunization:
• All category III exposures, irrespective of status
of biting animal.
• Administer even when treatment is delayed
• In re-exposure cases (completed post exposure
prophylaxis previously) RIGs are not indicated.

35. • RIG is most effective when administered locally
and early.
• Infiltrate as much as possible into and around
the wounds
• If RIG is insufficient to infiltrate all the wounds,
dilute it with sterile normal saline

37. Vaccines
1. Nervous tissue vaccines (NTV)
a. Derived from adult animal nervous tissue
(sheep).
b. Derived from suckling mouse brain
2. Duck embryo vaccine (DEV)
3. Cell-culture vaccines
a. Human diploid cell (HDC) vaccine
b. "Second generation" tissue culture (animal
cell) vaccines

38. Cell Culture Vaccines:
A. Human diploid cell vaccine (HDCV):
• "Fixed" virus in human diploid fibroblast cells.
B. Second generation tissue culture vaccines:
• derived from non-human sources
- primary cell substracts
- non-tumorogenic continuous cell lines

39. In India HDCV, PCEC and PDEV are available.

40. Vaccination Schedule:
• Vaccines : HDCV, PCEC, PVRV, PDEV.
• Route : Intra Muscular / Intradermal
• Never inject into the gluteal region.

41. Intramuscular schedules
A) Essen Regimen :
• Dose : 1 ml, 6 doses
• Site : Deltoid or anterolateral
aspect of thigh (children)

42. B) Zagreb regimen (2 – 1 – 1) :
*Not approved in India

43. Intradermal Schedules
• Approved by the WHO & DCGI (Feb 2006).
• Cost effective
• DCGI presently has approved only PCEC
(Rabipur) and PVRV (Verorab / Abhayrab) for
ID administration

44. A) Thai Red Cross (TRC) regimen
• PVRV, PCECV and PDEV
• Dose: 0.5 ml for PVRV
1 ml for PCECV, PDEV.
• Site : Upper arm over each deltoid
• Schedule : 2- 2- 2- 0- 1-1
• ID dose is one fifth of the IM dose per site.

46. B) 2 SITE REGIMEN (Updated TRC)
• Dose : 0.1 ml / ID site
• Site : Upper arm over each deltoid
• Schedule : 2- 2- 2- 0- 2
Day 0 3 7 14 28
Sites x2 x2 x2 x0 x2
<2 vials
5 visits

47. C) 8 Site Regimen:
• Dose : 0.1 ml / ID site
• Schedule : 8- 0- 4- 0- 1-1 Sites

49. Adverse reactions:
Local:
• HDCV - redness, swelling or pain
at the site of injection within 24-48
hours of administration.
• Reactions to the vaccine may become more
severe with repeated doses.

50. General:
• Systemic reactions such as headaches, fever,
muscle aches
• Vomiting
• Urticarial rashes.
• Anaphylactic shock, Guillain-Barré Syndrome

51. PRE - EXPOSURE PROPHYLAXIS
• Veterinarians, Laboratory personnel working
with rabies virus, medical and paramedical
personnel treating Rabies patients.
• Dog catchers, Forest staff, Zoo keepers.
• Postmen, Policemen, Courier Boys.
• Children in Canine rabies endemic countries.

52. • Dose : IM : HDCV, PCEC & PDEV - 1 ml
PVRV - 0.5ml
ID : 0.1 ml
• Site : Deltoid or anterolateral thigh Route
• Schedule : Day 0 - 1st dose
Day 7 - 2nd dose
Day 21 or 28 - 3rd dose
Estimate antibody titres annually, if titres are
<0.5 IU/ml, give booster.

53. VACCINATION AFTER RE-EXPOSURE
• 3 boosters ( D0, D3 & D7 ) No RIG.
• All incomplete vaccinations, partial vaccinations
or doubtful vaccination need to be treated as
fresh cases.
• In case of severe exposure anti rabies antibody
titres may be done if possible.

54. Personal Safety Against Rabies
• Do not touch animal bite wounds with bare
hands.
• Do not touch fomites (Chain, food plate etc.) of
an animal suspect or proven rabid.
• Keep away from stray / sick animals.

55. Education of Pet Owners:
• Get your pet regularly and periodically examined
by a qualified veterinarian.
• Get your pet vaccinated
at three months of age
and again 1 month later
• Boosters every year
subsequently.

56. • Obtain a Municipal License, put a collar and
keep your pet under leash in public places.
• Do not allow your pet to come in contact with
community /street dogs / cats or other animals.
• Inform the Municipal authorities about
sick / mad dogs.
• Take treatment even after pet dog bite including
pups

57. World Rabies Day
• 28th September

58. THANK YOU