Theses slides are mainly for use in research, study and training for both human nd veterinary professionals, and it was developed on the one health concept

1. NIGERIAN VETERINARY MEDICAL ASSOCIATION (NVMA),
ZAMFARA STATE CHAPTER
2022 WORLD RABIES DAY ANNUAL LECTURE SERIES ON
RABIES AWARENESS CAMPAIGN
TO BE DELIVERED BY
Dr. IBRAHIM HASSAN, DVM, MScPH, MNIM, FIPMA
RESIDENT AT NCDC/FIELD EPIDEMIOLOGY & LABROTORY TRAINING PROGRAM
1

2. 5Ws About World Rabies Day
WHAT: A day of declaration, commitment and action on the menace of rabies wherever possible.
WHO: International and national human and animal health organizations, human and veterinary
public health professionals, non-governmental organizations,
World Health Organization, Collaborating Centers, universities, corporate and private partners.
WHERE: As many countries as possible (more than150 countries have so far joined).
WHY: Raise awareness and enhance prevention and control of this dreaded but neglected disease.
WHEN: September 28th Annually ( www.WorldRabiesDay.org ) 2

3. OBJECTIVES
 To raise global awareness about rabies.
 To raise awareness about impact of rabies on
human and animal.
 To provide information and advise on how to
prevent the disease in at risk community.
 To promote education in local communities to
control and prevent rabies.
 To mobilize and coordinate resources towards
human rabies prevention and animal rabies
control.
 To support advocacy for increased efforts in
rabies prevention and control.
(www.WorldRabiesDay.org )

4. WHY 28TH SEPTEMBER EVERY YEAR
 Louis Pasteur(a French biologist,
microbiologist and chemist).
 He was the first person to diagnose that
rabies targets the Central Nervous System
(CNS).
 On July 6, 1885 he created the rabies
vaccine and saved 9 year old Joseph
Meister after he had been bitten by
a rabid dog.
4
Dec. 27, 1822 to Sept. 28, 1895

5. Since September 2007……
 Number of participating countries keeps increasing
 150+ participating schools of public health, veterinary and medical colleges have
hosted one or more ‘rabies- awareness’ events.
 New animal vaccination programs in endemic countries.
 New and invigorated educational programs.
 Global community networks.
 Listed on UN website of globally observed health days.
 Partnership with governments and the Global Alliance for Rabies Control.
 Additional funds from WHO and other NGOs.
5

6. One Health is a collaborative,
multisectoral and transdisciplinary
approach, working at the local,
regional, national and global levels
with the goal of achieving optimal
health outcomes recognizing the
interconnections between people,
animals, plants and their shared
environment.
What is One Health?
One Health Focus Areas
 Zoonotic and emerging infectious diseases
 Pandemic preparedness and response
 One Health emergencies at the human-
animal-environment interface
 Global health security and capacity building
 Strategic One Health partnerships
 Prevent zoonoses shared between people
and pets etc.
6

7. THEME FOR THE YEAR 2022 WORLD RABIES DAY

7

8. 8

9. 9
ETYMOLOGY
 The word RABIES originates from the Latin word RABERE & this means
to RAGE or RAVE & may have roots in Sanskrit word RAHABS, which
means to do violence.
 The Greeks called RABIES, Lyssa or Lytta which means FRENZY or
MADNESS.

10. WHY IT IS IMPORTANT TO KNOW ABOUT RABIES
 It is acute viral disease that causes fatal encephalomyelitis in
virtually all the warm-blooded animals including man.
 The disease is inevitably fatal and perhaps the most painful and
dreadful of all communicable diseases in which the sick person
is tormented at same time with thirst and fear of water
(hydrophobia).
 Till date there is no cure if you developed the disease and death
is inevitable.
10

11. What is rabies
 Rabies is an acute infectious disease characterized by abnormal behaviours, nervous
disturbances, ascending paralysis followed by death.
 It is an acute, progressive, incurable viral encephalitis (inflammation of the brain) that
affect man and all warm blooded animals such as Dogs, Skunk, Cats, Jackals, Bats and
wolves etc.
 It is an ancient ( since 3000 B. C.) viral zoonotic disease (disease that is transmitted
from animals to humans) that is invariably fatal in humans and mammals.
 It is caused by neurotropic RNA viruses of the Rhabdoviridae family, genus Lyssavirus.
Mammalian reservoirs include the Carnivora (dogs, foxes, raccoons, skunks, jackals,
mangoose etc) and Chiroptera (Insectivorous, hematophagous, and frugivorous bats)
 Dogs bite mediated rabies still pose the greatest hazard worldwide. A single infected
dog is capable of transmitting the disease to over an area of 40 km.
 Rabies is a 100% vaccine-preventable disease. 11

12. Of
12

13. EPIDEMIOLOGY
 Globally more than 60,000 people died due to rabies infection annually.
 > 95% of human death is coursed by dog-mediated rabies.
 Worldwide almost half of all rabies death occur in children under 15 yrs.
 > 95% of human death occur in Africa & Asia.
 It is present in all continent except Antarctica.
 It is a Neglected Tropical Disease (NTD) affecting poor and vulnerable
population.
 It is a threat to more than 3 billion people across the globe.
 One of the oldest described infectious diseases known for more than 4000 yrs.
13

14. COUNTRIES AT RISK OF RABIES
14

15. GLOBAL BURDEN OF ENDEMIC CANINE RABIES
 Every year there is 3.7 million DALYS due to canine rabies worldwide.
 Global total death is 60,000 every year.
 The annual overall economic cost was estimated at 8.6 billion USD
 Premature death is 2.27 billion USD
 Direct expenditure for PEP is 1.70 billion USD
 Lost of income while seeking for PEP is 1.31 billion USD
 Livestock death ( in Africa) is 512 million USD
 Globally over 70% of the estimated economic burden was societal (premature death &
losses due seeking for PEP).
 20% goes medical sector/bite victims (direct cost )
 More than 8% goes to veterinary sector due to livestock losses (direct to community)
 Only 0.01% of cost were for Laboratory – based surveillance.
15

16. DIVISION OF COST ASSOCIATED WITH RABIES
16

17. MORPHOLOGY OF CLASSICAL RABIES VIRUS
 Order :– Mononegavirales
 Family :– Rhabdoviridae
 Genus :– Lyssa virus
 Species :– Classical rabies virus
 Bullet-shaped (75 x 180 nm)
 Enveloped
 Single stranded RNA genome
 Virus cannot grow unless it is inside a living
cell.
 Has a lipoprotein envelope
 Knob like spikes or glycoprotein G.
 Matrix protein layer
 Genome –unsegmented ,linear, negative
sense RNA.

17

18. LYSSAVIRUS GENERA
 Rabies virus (RABV genotype 1) being the most prevalent & worldwide in distribution.
 Lagos Bat Virus (LBV genotype 2)
 Mokola Virus (MKV- genotype 3)
 Duvenhage Virus (DV, genotype 4)
 European Bat Lyssavirus -1 (EBLV-1 Genotype 5)
 European Bat Lyssavirus -2 (EBLV-2 genotype 6)
 Australian Bat Lyssavirus (ABLV, genotype 7)
 Khujand Virus (KV)
 Avian Virus (AV)
 Irkut Virus (IV)
 West Caucasian Bat Virus (WCBV)
Identified in Nigeria in 1950
Identified in South Africa in 1970
NEW GENERA
18

19. MAP OF 7 CONTENENTSAND 5 OCEANSOF THE WORLD
19

20. Global distribution of animals involved in rabies viruses transmission
20

21. MODE OF TRANSMISSION
 Bite/ scratch that introduces virus-bearing Saliva into the victim’s body and
this has 90% chances of developing the infection more than all other route
(Fitzpatrick et al., 2012).
 Direct contact (viral contamination) such as broken skin or mucous
membranes in the eyes, nose or mouth with saliva or brain/nervous system
tissue from an infected animal.
 Organ transplantation ( very rare).
 Aerosol of rabies virus ( especially for lab. Workers).
 Ingestion of the virus.
21

22. DAYNAMICS OF RABIES VIRUSTRANSMISSIONAND EXPOSURE
22
DEAD-END HOST

23. DAYNAMICSOF RABIES VIRUS TRANSMISSIONCONT…….
23

24. NOTE
Man remains the dead-end host, as he can’t transmit the disease to his
fellow human being or animal.
24

25. INCUBATIONPERIOD
 This is the period from the time of exposure up to the appearance of first clinical signs
and symptoms of rabies.
 It has high variability, usually 3 to 8 weeks in some cases.
 It may be from 2 weeks to 6yrs, with an average of 2 to 3 months.
 It maybe be within 4 days or maybe prolonged for years.
The variability in the incubation period also depends on;
a. Concentration of the viral load contained in the saliva
b. Site of the bite or scratches
c. innervation density of the site
d. Severity of the bite
e. Number of wound
f. Presence/absence of appropriate treatment and PEP protocols 25

26. 26

27.  After inoculation, the rabies virus multiplies in the muscle cells (myocytes or may
invade the nerve directly without prior multiplication in the myocytes.
 The virus then penetrates the peripheral nerve cells via viral uptake at neuronal
endings and then transported through both the sensory and motor nerve fibers to the
central nervous system (CNS).
 Once the virus reaches the CNS, rabies replication occurs primarily in the neurons or
brain cells through viral budding and the virus spreads and infects the nearby brain
cells.
 While viral dissemination occurs in the central nervous system, the rabies virus
spreads into the peripheral tissues such as muscle fibres, salivary glands, corneas,
adrenal medullae, lacrimal glands, myocardium, kidneys, lungs, pancreas and
epidermis.
 Infection of salivary glands allows further transmission of the disease to other
mammals. 27

28. 28

29. 29

30. PATHOGENESIS CONT……
30

31. CLINICAL STAGES OF
RABIES
31

32. CLINICAL STAGES IN MAN
Prodromal stage (Non specific sign/symptoms) occurs when there is initial viral
replication at the striated muscle cells at the site of inoculation just before it enters the
brain.
 Headache
 Malaise
 Sore throat
 Slight fever
 Nausea
 Vomiting
 Anorexia
 Abdominal pain
 Paraesthesia 32

33. AcuteNeurological Stage: This is when the virus reaches the CNS and replicates
especially in the gray matter. It has two types of presentation Encephalitic or furious
type, which has 80% of cases and paralytic or dumb type, which is seen in 20 % of
cases. This stage lastfor 2 – 7 days
Encephalitic or Furious Rabies
 Excessive motor activity, Excitation
,Agitation
 Confusion, Hallucinations, Delirium
 Hypersalivation, Aphasia, Pharyngeal
Spasms
 Hydrophobia or Aerophobia (50 -70% )
 Incoordination, Hyperactivity,
 Lacrimation, Salivation & Perspiration
 Seizures, Muscle spasms, Meningism,
Opisthotonic posturing
paralytic or dumb Rabies
 Acute progressive ascending myelitis
 symmetrical or asymmetrical flaccid paralysis
 pain and fasciculation in the affected muscles with
mild sensory disturbance.
 A complete paraplegia develops eventually with
fatal paralysis of the respiratory and pharyngeal
muscles.
33

34. 34
Furious
Rabies Paralytic Rabies

35. COMA STAGE: This is the progression of stages mentioned earlier and is associated with
multi-organ failure, especially Haematemesis and Cardiac arrhythmias seen among 30-
60% of patients.
DEATH STAGE: This occur following cardiac and circulatory insufficiency with myocarditis,
cardiac arrhythmia or congestive heart failure. Once the clinical sign/symptoms sets in,
chances of dying is 99.999%.
35

36. CLINICAL STAGES IN DOG
INCUBATION PERIOD: Ranges from 3-8 weeks but it may be as short as 10 days or as
long as 1 year.
 Loses its fear of people , aggression.
 Bites unusual objects- stick , straw and mud
(pica appetite)
 Tendency to run away from home and
wander.
 Barks and growls in a hoarse voice or
unable to bark.
 Excessive & Foamy salivation at the angle
of Mouth.
 Later stage paralysis of the whole body
leading to coma and death.
 Exciting and irritating stage is lacking .
 Its predominantly paralytic.
 Dog withdraws from being seen and
disturbed.
 Elapses into stage of sleepiness and dies.
 Dies in about 3 days.
ENCEPHALITIC OR FURIOUS RABIES PARALYTIC OR DUMB RABIES
36

37. 37

38. 38

39. DIAGNOSIS IN HUMANS
Laboratory diagnosis of rabies is often based on the following:
 Clinical manifestations
 History of exposure to rabid animal
NOTE:
 In cases where pathognomonic signs (Hydrophobia &/or Aerophobia) are present
diagnosis is straight forward.
 Clinical diagnosis may be difficult in paralytic rabies (Atypical presentation).
 Laboratory confirmation is necessary.
 No single test is sufficient
39

40. DIAGNOSISCONT…….
Array of lab sample required for Rabies diagnosis:
 Saliva
 CSF
 Tears
 Serum INTRA VITAM
 Urine
 Skin biopsy(
(Dachex et al., Plos NTD, 2010)
 Array of lab tests required for Rabies diagnosis:
 Fluorescent Antibody Testing (FA), it is gold standard test for rabies Dx. (AM)
 Polymerase Chain Reaction (PCR), it is extremely efficient & sensitive
 Serology
 Histology, to identify negri bodies, which are round cytoplasmic inclusion
bodies. (gold standard for PM). 40
Samples for post-mortem diagnosis
includes brain tissue that can be
collected through trans-orbital or
trans-foramen magnum route if
autopsy cannot be performed.

41. DIAGNOSIS IN DOGS
 DIRECT FLUROSCENT ANTIBODY TEST (DFAT): Highly reliable and best single
test for rabies antigen detection. It is gold standard test approved by both
World Health Organization (WHO) and World Organization for Animal Health
(OIE).
 MICROSCOPIC EXAINATION: This is histopathological test conducted at post
mortem, it identifys negri bodies bodies in 75-90% of cases.
41
In 1903, Negri, an Italian
scientist demonstrated
the viral particles as
cytoplasmic inclusion
bodies in the Neurones of
the rabid Animal, now
named after him as
NEGRI BODIES

42. Case management of rabies patient
Once the sign and symptoms sets in, attention should be centred on comfort care as there is no
specific treatment so far, and it include sedation, avoidance of intubation and life support
measures.
1. MEDICATION
 Diazepam
 Midazolam
 Haloperidol + Diphenhydramine
2. SUPPORTIVE CARE
 Patient with confirmed rabies case should receive in an appropriate medical facility
 Intensive therapy in the form of respiratory and cardiac Support
 Ensure hydration and diuresis
 Provide suitable emotional and physical support
 Honest and gentile discussion concerning prognosis should be provided to the relatives of
the patient.
42

43. Case management cont.……
3. INFECTION CONTROL
 Patient should be admitted in a quiet, draft-free, isolation room
 Health care workers and relatives in contact with the patient should wear proper PPE (gown,
gloves, mask, goggles).
43

44. RABIES PREVENTION AND
CONTROL
44

45. DEFINITIONS OF TERMS
 PREVENTION: This: is the management of those factors that could lead to disease or a
negative health outcome in order to halt the occurrence of that disease or negative
health outcome in a population.
 CONTROL: Is the reduction of disease incidence, prevalence, morbidity or mortality to
a locally acceptable level as a result of deliberate efforts, continued intervention
measures which are designed in order to maintain the reduction.
 PREVENTION & CONTROL PROGRAM: Is a set of policies, plans and guidelines that
form a comprehensive strategy in order to prevent and control infectious diseases.
45

46. CONPONENT OF RABIES PREVENTION AND CONTROL
 Generally this has two components viz:
1. Animal Rabies Control
2. Human Rabies Prevention
NOTE:
Disease can be controlled and prevented by adequate measures which include
 Diagnosis Investigation
 Notification Disinfection
 Isolation Blocking of transmission
 Treatment Immunization
 Quarantine Health education
46

47. ELEMENT OF HUMANRABIES PREVENTION
1. Avoiding Exposure i.e.
Avoiding contact with unknown animals
Nursing rabid human/animal with extreme precaution
2. Pre-Exposure Prophylaxis (PrEP): This is a series of Human anti- rabies vaccines
recommended for anyone who is at continual, frequent or increased risk for
exposure to the rabies virus such as laboratory workers, veterinarians and animal
handlers.
3. Post- Exposure Prophylaxis (PEP): This is an anti- rabies vaccine administered to
anyone after an exposure to a confirmed or suspected rabies virus.
4. Post-exposure treatment of persons who have been vaccinated previously.
47

48. FIRST AID FOLLOWING ANIMAL BITE
 Wound should be washed immediately with
soap and running water for about 10 minutes.
 Wound should be clean thoroughly with 70%
alcohol, or povidines iodine.
 Next visit the hospital/health facility to receive
specialized treatment such as Anti tetanus
immunization when necessary.
 Antimicrobials should be prescribed if
necessary to control bacterial infections.
48

49. PATIENT SCREENING
Patient Screening
Categorization of the exposure
Major exposure
or
Minor exposure 49
Before the decision for
PET is made

50. MAJOR EXPOSURES
 Single or multiple bites with bleeding on head, face, neck, chest, upper arms, palms,
tips of fingers and toes and genitalia.
 Multiple scratches with bleeding on head, neck and face.
 Single or multiple deep bites on any part of the body.
 Contamination of mucus membranes with saliva.
 Bites of wild animals with bleeding.
50

51. MINOR EXPOSURES
Single, superficial bite or scratch with oozing of blood or scratches with bleeding
on the lower limb, abdomen and back.
Nibbling of uncovered skin.
Contamination of open wounds with saliva.
Multiple bites without bleeding or scratches with oozing of blood on any part of
the body.
Drinking raw milk of rabid cow or goat.
Superficial bites and scratches of wild animal without bleeding. 51

52. ANIMAL SCREENING
Healthy or sick
Vaccinated or unvaccinated
Observable or unobservable
52

53. ANIMAL SCREENING cont.….
 Healthy means:
The behaviors of the animal is normal
Bitten under provocation (provoked bite)
 Not Healthy means:
Animal behaviors not normal
Presence of any suspected symptoms/signs
 Unobservable means:
Animal dead, killed, missing, stray or wild animal
 Observable means:
Animal should be put in a cage or Leashed 53

54. ANIMAL SCREENING cont.….
 Vaccinated means: The status of the animal before the bite incidence.
1. Should have minimum of 2 Rabies vaccinations, given not more than 2 years
apart, last vaccination given is within 1 year of the Incident. Bite from animal
of this status is termed as major exposure.
2. Has a minimum of 1 vaccination and the last vaccination given within 1 year
of the incident. Bite from animal with such kind of vaccination status is
termed as minor exposure.
NOTE:
54
vaccination of animal especially dogs and cats is annual.

55. SCHEMATIC DIAGRAM FOR PEP INDICATION
55
PATIENT SCREENING
MAJOR MINOR
ANIMAL SCREENING
HEALTHY,
VACCINATED &
OBSERVABLE
SUSPECIOUS,SICK
OR
UNVACCINATED
OBSERVABLE
LAB CONFIRM
OR
UNOBSERVABLE
HEALTHY,
VACCINATED &
OBSERVABLE
SUSPECIOUS,SICK
OR UNVACCINATED
OBSERVABLE
LAB CONFIRM
OR
UNOBSERVABLE
Delay
Observe 14
PEP SUSPENDED
Initiate
PEP
Observe 14 d
Discontinue ±
Initiate PEP
Continue full
course
Delay
Observe 14
PEP SUSPENDED
Initiate
PEP
Observe 14 d
Discontinue ±
Initiate PEP
Continue full
Course

56. If PEP is indicated:
 Major category
Immunoglobulin (RIG)
and
Anti Rabies vaccine (ARV)
 Minor category
Anti Rabies vaccine (ARV)
56
IMMUNOGLOBULINS
ANTI RABIES VACCINE

57. Intramuscular administration of vaccine for PEP
 Essen regimen :
The 5-dose regimen prescribes 1 dose on each of day
0, 3, 7, 14, and 28.
DOSE: one IM dose (1.0 or 0.5 ml) into deltoid (or thigh)
DAY: 0 3 7 14 28
HUMAN RABIES IMMUNOGLOBULINS
HUMAN ANTI
RABIES VACCINE
57

58. Im administration of vaccine for PEP CONT….
 Zagreb regimen:
The 4-dose abbreviated multisite regimen prescribes 2 doses on day 0 (1 in
each of the 2 deltoid or thigh sites) followed by 1 dose on each of days 7 and
21, as shown below.
DOSE: one IM dose (1.0 or 0.5 ml) into deltoid (or thigh)
Day: 0 7 21
Sites: X2 Xl Xl
HUMAN RABIES IMMUNOGLOBULIN
HUMAN
ARV
5

59. INTRADERMAL ADMINISTRATIONFOR PEP
 The 2-site regimen prescribes injection of 0.1 ml at 2 sites (deltoid or
thigh) on days 0, 3, 7 and 28. The day 14 dose is missed.
 2-site intradermal regimen (2+2+2+0+2)
 Dose : one ID dose is one fifth of IM dose (0.1 ml) ID per site
Day: 0 3 7 28
Sites: X2 X2 X2 X2
IMMUNOGLOBULIN
ARV
59

60. Post-exposure prophylaxis for previously vaccinated individuals
 For rabies-exposed patients who can document previous complete pre-
exposure vaccination or complete post exposure prophylaxis with
human anti rabies vaccine, 1 dose delivered intramuscularly or delivered
intradermally on days 0 and 3 is sufficient.
60

61. Immunization of immunocompromisedindividuals
 In immunocompromised individuals including patients with HIV/AIDS, a complete series of 5 doses
of intramuscular CCEEV in combination with comprehensive wound management and local
infiltration with human rabies immunoglobulin is required for patients with category II and III
exposures.
61
Pre-exposure prophylaxis
IM or 0.1 ml ID on days 0, 7 and either day 21 or 28 is recommended for clinicians and
persons attending to human rabies cases, veterinarians, animal handlers

62. ELEMENT OF ANIMAL RABIES CONTROL
1. Massvaccinationof dogs.
2. Movementrestriction/confinement.
3. Inter-sectoral collaboration and coordination.
4. Comprehensive surveillance system.
5. CommunityHealtheducationand participation
6. Legal enactment ( dog ordinance and dog registration act.)
62

63. MASS VACCINATION OF DOGS
 Immunize of all dogs (domestic and community dogs) through
mass vaccination campaigns to
 achieve adequate coverage.
 Need over 70% - 80% coverage to get Heard immunity
 Elimination of stray dogs and ownerless dogs.
 Immediate destruction of dogs/cats bitten by rabied animals.
 Pre-exposure prophylaxis of all pet dogs, with booster dose at an
appropriate interval.
63

64. Movement restriction /confinement
 Restrain of dogs in public places
 Effective DPM programs.
 Registration and licensing of all domestic dogs.
 Strong environmental policies/measure against indiscriminate
garbage disposal which stimulate the uncontrolled movement of
dogs.
 Quarantine for 6 month of all imported dogs/cats.
64

65. ONE HEALTH APPROACH ON RABIESPREVENTIONAND CONTROL
GOVERNMENT
ENVIRONMENTAL HEALTH
SECTORS
HUMAN HEALTH SECTOR ANIMAL HEALTH SECTOR
WILD LIFE SECTOR
NON GOVERNMENTAL
ORGANIZATION
OTHER SECTORS
65
RABIES PREVENTION AND
CONTROL
Develop a pilot or Research
project

66. CONCEPTUAL FRAMEWORK ON HOW TO PREVENT HUMAN RABIES.
66

67. RABIESELIMINATIONtarget IN
AFRICA/NIGERIAbytheyear2030:
AREALITYORAMIRRAGE????
POINT OF DISCUSSION & CONCERN
67

68. 68
Initial stage

69. ACTION PLAN FOR RABIES ELIMINATION BY THE YEAR 2030 IN NEPAL
69

70. EMAIL: ibrahim.day.and.night@gmail.com
GSM: 08065946867, 08024608893
70