This document provides information on rabies control in Sri Lanka. It discusses the global and local epidemiology of rabies, describing it as a neglected tropical disease transmitted primarily from dogs to humans. It then outlines strategies for rabies control, including post-exposure prophylaxis for exposed individuals, mass dog vaccination programs to achieve herd immunity, environmental control measures, and inter-sectoral coordination between ministries. Surveillance systems are also summarized to monitor rabies in humans and animals. The overall aim is elimination of rabies in Sri Lanka by 2020 through coordinated prevention and control efforts.

1. Rabies Control Unit

2.  Epidemiology of rabies (Global and local
situation)
 Human rabies
 Post Exposure Treatment (PET)
 Strategies for rabies control in Sri Lanka

3.  A global public health problem,
 Neglected Tropical Disease affecting poor and
vulnerable population
 Present in all continents with the exception of
Antarctica
 Human deaths from rabies 55000 annually
around the world.
 >95% of human deaths occur in Asia and Africa
 20,000 persons die in India annually (>1/3 of
global deaths)

4. • Almost half of all rabies
deaths occur in children
under the age of 15
years in the world.

6. 2009 2010 2011 2012 2013
Human Rabies
Deaths
52 41 38 28 16
Incidence of
human rabies per
100,000
population
0.25 0.2 0.19 0.14
Elimination of rabies by 2020

7. Generally >95% of human deaths caused by dog-
mediated rabies.

8.  Rabies is a zoonotic disease (a disease that is
transmitted from animals to humans)
 Affect Central nervous system of warm
blooded animals
 Domestic dogs are the most common
reservoir
 Rabies is a 100% vaccine-preventable
disease.

9.  Virus exist in saliva, nervous tissue, urine,
lymph and milk of warm blooded animals
Transmission via
 Bite/ scratch that introduces virus-bearing
Saliva.
 By viral contamination of existing fresh
wound/ mucous membrane.
 Skinning and handling of infected carcasses
 Organ transplantation
 Ingestion

10.  Belongs to “Rhabdo virus” family, genus
Lysavirus
 Bullet-shaped (75 x 180 nm)
 Enveloped
 Single stranded RNA genome
 Virus cannot grow unless it is inside a living
cell

11.  Dog rabies is characterized by clinical
manifestations, including, changes to normal
behavior, such as:
 Biting without provocation
 Eating abnormal items such as sticks, nails, faeces,
etc.
 Vocal changes (e.g. hoarse barking and growling) or
inability to produce sounds
 Excessive salivation or foaming from the mouth

14.  Generally between 20 and 90 days in 75%
of cases.
 But may be as short as 4 days or long as
many years.
 The shortest incubation periods are
observed inpatients with facial Bites

15. 1 – Non specific prodrome
2 – Acute neurologic encephalitis
3 – Coma
4 - Death (99.999%)

16.  1 - 2 days - 1 week
 Fever, headache, sore throat
 Anorexia, nausea, vomiting,
 symptoms of upper respiratory tract and
gastrointestinal infections
 Paresthesia or fasciculation at or around the
site of inoculation of virus

17.  Depending on whether the spinal cord or
brain is predominantly affected Symptoms of
either paralytic or furious rabies will then
develop.
 encephalitic = furious
 ~ 80%
 paralytic = dumb
 ~ 20%

18. 1 – 2 days to < 1 week
 Excessive motor activity, Excitation,
Agitation
 Confusion, Hallucinations, Delirium,
 Seizures,
 Muscle spasms, Meningism,
 Opisthotonic posturing
 Hypersalivation, Aphasia, Pharyngeal
spasms
 Incordination, Hyperactivity,
 Lacrimation, Salivation & Perspiration
 Hydrophobia or Aerophobia (50 -70% )

19.  Inspiratory muscle spasms with or without
painful laryngo-pharyngeal spasms .
 The reflex is provoked initially by attempts
to drink water.
 But later by a variety of. stimuli, like
draught of air ( aerophobia) water splashed
on the skin, irritation of the respiratory tract
or eventually, by the sight, sound or mere
mention of water.

24.  Suspect clinically and confirm by using
tests.
 No single test is sufficient.
 Several tests are necessary to diagnose
rabies ante-mortem (before death) in
humans
 Tests are performed on samples of saliva,
serum, spinal fluid, and skin biopsies of
hair follicles at the nape of the neck.

25.  Laboratory finding:
 Exclusion of other etiologies
 Pathology:
 Formation of cytoplasmic inclusions in
neuron cell bodies : (Negri bodies )
 Saliva (saliva,CSF, brain ) can be tested by
virus isolation or reverse transcription
followed by polymerase chain reaction (RT-
PCR).

26. Wounds should be washed immediately with soap
and water for about 10 minutes.
Wounds should be cleaned thoroughly at the
hospital with 70% alcohol or povidone iodine
Anti tetanus immunization should be inoculated
when necessary
Antimicrobials should be prescribed if necessary to
control bacterial infections

28. Patient
Screening
Categorization of the exposure
Major exposure
or
Minor exposure

29. 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

30. 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

31. Animal screening
 Healthy or sick
 Vaccinated or unvaccinated
 Observable or unobservable

32. Healthy
Normal behavior of the animal
Bitten under provocation
Not Healthy
Animal behavior not normal
Presence any suspected symptoms/signs

33. Unobservable
Animal dead, killed, missing, stray
or wild animal
Observable
Animal should be put in a cage or
leashed

34. Major exposures to dogs and cats
vaccinated …………
Should have minimum of 2 Rabies vaccinations
given not more than 2 years apart,
last vaccination given within 1 year of the
incident

35. Minor exposures to dogs and cats :
Vaccinated ……..
Has a minimum of 1 vaccination
Last vaccination given within 1 year of the incident
vaccination should be given at an age above 3 months

36. Major Minor
Healthy &
Vaccinated &
observable
Suspicious,
sick
or
unvaccinated
observable
Delay
observe
14 days
PET sos
Initiate
PET
observe 14 d
discontinue ±
Lab
confirmed
or
unobservable
Initiate
PET
continue full
course
Patient screening
Animal screening
Delay
observe
14 days
PET sos
Initiate
PET
continue full
course
Initiate
PET
observe 14 d
discontinue ±
Healthy &
Vaccinated &
observable
Suspicious,
sick
or
unvaccinated
observable
Lab
confirmed
or
unobservable

37. If PET is indicated:
Major category
Anti Rabies immunoglobulin (RIG)
and
Anti Rabies vaccine (ARV)
Minor category
only Anti Rabies vaccine (ARV)

38. Anti Rabies Immunoglobulins
(RIG)
1.Equine Rabies Immunoglobulin
(ERIG)
40IU/Kg body Weight
2. Human Rabies Immunoglobulin
(HRIG)
20IU/Kg body Weight

39.  Inactivated anti rabies cell culture vaccines
available
 Purified Chick embryo cell culture vaccine
(PCEC)
 Purified verocell rabies vaccine (PVRV)

40. I D Schedule D0 D3 D7 D14 D 30
ID 2 sites
0.1 ml per site 2 2 2 0 2
ID 4 sites
0.1 ml per site 4 2 2 0 2
The reduced volume required by ID vaccines, in comparison to the IM vaccine
results in cost savings of 60-80%.
ID vaccination may be a more cost-effective option for high-flow clinics where
the disease is endemic.

41.  Control of human rabies
 Proper post exposure management
 Encourage of pre exposure prophylaxis for those
engaged in occupations at higher risk of exposure
rabies infections
 Control of animal (dog) rabies
 Immunize of all dogs (domestic, community and
stray) through mass vaccination campaigns to
achieve adequate coverage.
 Need over 70% coverage to get Heard immunity

42.  Dog population control
 Sterilize female dogs through appropriate chemical
and surgical methods
 Environmental measures
 Garbage disposal, stray dog control in public
places (not by killing)
 Inter-sectoral coordination
 Encourage other ministries to work towards
rabies elimination
 Legal enactment
 Rabies Ordinance
 Dos registration Act

43.  Human rabies surveillance
 Animal rabies surveillance

44.  Hospital notification
 MOH
 SPHI
 Weekly report
 Epidemiology Unit
 WER
 Quarterly Epidemiological Bulletin
 Special Investigation by MOH

45.  MRI
 TH- Karapitiya
 Peradeniya- Vet Department
 Veterinary Investigation Centers – Department
of animal production and health

46. Thank You