The document provides information about rabies including its definition, causes, transmission, symptoms, diagnosis, treatment and prevention. It defines rabies as a viral disease affecting the nervous system that is fatal if not treated. The rabies virus is transmitted via saliva, usually through animal bites. Symptoms start with fever and pain at the bite site then progress to neurological symptoms. Diagnosis involves biopsy of skin or antibody tests. Post-exposure prophylaxis within 7 days of exposure can prevent onset of disease. Vaccination and avoiding contact with wild animals are key prevention methods.

1. DAVE JAY S. MANRIQUEZ RN. RABIES

2. RABIES

3. CONTENTS:

4. What is rabies? ( DEFINITION & ETIOLOGY) Is an acute infectious disease of warm-blooded animals and humans characterized by an involvement of the nervous system resulting in death. It is caused by the RABIES VIRUS, a rhabdovirus of the genus lyssavirus. Rabies is a serious disease. Each year, it kills more than 50,000 people and millions of animals around the world. Rabies is a big problem in Asia, Africa, and Central and South America. In the United States, rabies has been reported in every state except Hawaii. Any mammal can get rabies. Raccoons, skunks, foxes, bats, dogs, and cats can get rabies. Cattle and humans can also get rabies. Only mammals can get rabies. Animals that are not mammals -- such as birds, snakes, and fish -- do not get rabies. Rabies is caused by a virus. An animal gets rabies from saliva, usually from a bite of an animal that has the disease.

5. The Rabies Virus RV – a neurotropic filterable virus present in the saliva of rabid animals. It has a preferrence for nerve tissues. Virus – minute organism not visible with ordinary light microscopy. It is parasitic in that it is entirely dependent on nutrients inside cells for its metabolic and reproductive needs. Can only be seen by use of eclectron microscopy. Consists of DNA or RNA covered with a protein covering called capsid. Neurotropic – viruses that reproduce in nerve tissue Filterable virus – virus causing infectious disease, the essential elements of which are so tiny that they retain infectivity after passing through a filter of the Berkefeld type. Berkefeld filter – a filter of diatomaceous earth designed to allow virus-size particles to pass through Diatomaceous earth – substance composed of diatoms, a group of unicellular microscopic algae that possess a siiceous or calcium-containing cell wall. RHABDOVIRUS: any group of rod-shaped RNA viruses with 1 important member, rabies virus, pathogenic to man. The virus has a predilection for tissue of mucus-secreting glands and the Central Nervous System. All warm-blooded animals are susceptible to infection with these viruses. RHABDO: from Greek rhabdos , "rod" LYSSA: Greek – frenzy, rage, fury, canine madness A rhabdovirus of the genus lyssavirus. This is a photograph of the virus under electron microscope Parts of the rabies virus Rod-shaped rabies viruses colored for effect

6. Mononegavirales Rhabdoviridae lyssavirus novirhabdovirus cytorhabdovirus nucleorhabdovirus Australian Bat lyssavirus European Bat lyssavirus 1 Lagos Bat virus Rabies virus Duvenhage virus European Bat lyssavirus 2 Mokola Bat virus ephemerovirus vesiculovirus order family genus species

7. How do you get rabies? (MODE & MEDIA OF TRANSMISSION, IMMUNITY) All warm-blooded mammals are susceptible. Natural immunity in man is unknown. You get rabies through the saliva of an infected animal by an exposure to an open break in the skin such as bites, open wound or scratch and inhalation of infectious aerosols such as from bats. In some cases, it is transmitted through organ transplants (corneal transplant), from an infected person. The virus gets transmitted through saliva, tears, semen, some liquor (amniotic fluid, CST) but not blood, urine or stool. You get rabies from the saliva of a rabid animal, usually from a bite. The rabies virus is spread through saliva. You cannot get rabies by petting an animal. You may get rabies from a scratch if the animal, such as a cat, was licking its paw before it scratched you. (Remember that the rabies virus is found in the saliva of an animal).

8. How do you know if an animal has rabies? Animals with rabies may act differently from healthy animals. Some signs of rabies in animals are: changes in an animal’s behavior general sickness (fever, restlessness) problems swallowing increased drooling aggression (biting at inanimate objects, aimless running) Wild animals may move slowly or may act as if they are tame. Some wild animals (foxes, raccoons, skunks) that normally avoid porcupines, may even try to bite these prickly rodents. A pet that is usually friendly may snap at you or may try to bite.

9. How do you know if one has rabies? There is yet no way of immediately knowing who had acquired rabies virus. No tests are available to diagnose rabies in humans before the onset of clinical disease. The most reliable test for rabies in patients who have clinical signs of the disease is a DIRECT IMMUNOFLUORESCENT STUDY of a full thickness biopsy of the skin taken from the back of the neck above the hair line. The RAPID FLUORESCENT FOCUS INHIBITION TEST is used to measure rabies-neutralizing antibodies in serum. This test has the advantage of providing results within 24 hours. Other tests of antibodies may take as long as 14 days. (DIAGNOSIS)

10. RABIES INCIDENCE: WORLDWIDE:35, 000- 50, 000 cases/ year (WHO) EPIDEMIOLOGY

11. parts of Africa and Asian continents and many parts of South America are endemic for rabies UK and most of Western Europe are rabies free due to success of coordinated wildlife oral vaccination programs annual # of deaths caused by rabies worldwide: 50,000-60,000

12. EPIDEMIOLOGY PHILIPPINES: 350-450 cases/ year 5-7 per million population DOG BITE INCIDENCE: 140, 000- 560, 000/ year 200-800 per 100, 000 population/ year AGE MOST AFFECTED: 5-14 year age group (53% of cases) BITING ANIMALS: (SLH STUDY 1982- 2002) DOGS: 98% PET: 88% STRAY: 10% CATS: 2%

13. Based on the report from NCDPC (2004), the six regions with the most number of rabies cases are Western Visayas, Central Luzon, Bicol, Central Visayas, Ilocos and Cagayan Valley Data shows that 53.7 percent of animal bite patients are children Dogs remain the principal animal source of rabies

14. The trend for animal bite cases has increased from 1992 to 2001 but decreased in the year 2002-2004. The increasing number of patients who are consulting the health centers for animal bite cases is due to the increasing level of awareness on rabies. On the other hand, the human rabies cases have been decreasing from 1995 to 2004. This is due to early provision of post exposure vaccination to dog bite victims. In 2004, there were 95,568 animal bite victims reported with 88 percent of them bitten by dogs. Of this animal bite victims, 55,582 or 58 percent had post-exposure vaccination and the other 40,000 or so had no vaccine protection at all. During the same year, 228 (0.2 percent of the total animal bite cases) were confirmed cases based on the appearance of the unequivocal signs and symptoms of rabies which include death for most.

15. Distribution of Animal Bite Cases of Cebu Province (Jan-June 2006)

16. How does rabies affect us? (PATHOPHYSIOLOGY & SIGNS N SYMPTOMS) What does the virus do? The targets of the rabies virus are nerve cells. Nerve cells are one part of the body’s nervous system. Once inside the body, the rabies virus infects the nerve cells and travels along the peripheral nerves (the nerves that run throughout the body). Its main target is the central nervous system, which is made up of the brain and spinal cord. How does the virus travel? When the virus travels from the peripheral nerves (infected periphery) to the brain, it is called CENTRIPETAL SPREAD. The viral travel and spread from the center (brain) to the periphery is called CENTRIFUGAL SPREAD.

17. PATHOLOGY CHART 1: Rabies infection

18. PATHOLOGY CHART 2: Rabies Infection

19. STAGES OF RABIES INFECTION Rabies virus Entry into the body INCUBATI0N PERIOD (20 – 90 days) INVASION (0 – 10 days) PARALYTIC EXCITEMENT (2 – 7 days) COMA (5 – 14 days) DEATH

20. RABIES CLASSIFICATION ANIMAL RABIES There are two common types of rabies. One type is "furious" rabies. Animals with this type are hostile, may bite at objects, and have an increase in saliva. In the movies and in books, rabid animals foam at the mouth. In real life, rabid animals look like they have foam in their mouth because they have more saliva. The second and more common form is known as paralytic or "dumb" rabies. The dog pictured below has this type. An animal with "dumb" rabies is timid and shy. It often rejects food and has paralysis of the lower jaw and muscles. Another two types of rabies. One type is “urban” rabies. The type of rabies in domestic dogs and cats. The other type is called “ sylvatic” rabies. These type came from wild animals such as bats, weasels, skunks and moles & voles. HUMAN RABIES Humans also have a “furious” type, the classic foaming of the mouth, aggression, apprehension & hydrophobia, and the “dumb” type, progressive paralysis of the body until they couldn’t breathe anymore.

21. DIFFERENT STAGES OF RABIES INFECTION INVASION PHASE VIRUS IN SALIVA EXCITEMENT INHALED AEROSOLS INVASION PHASE VIRUS IN SALIVA DEATH DEATH B A T S PARALYSIS PARALYSIS DOGS CATS

22. MANAGEMENT PREVENTION Responsible pet ownership a) pet immunization, esp. cats, usually starting at 3 months of age and every year thereafter b) don’t allow pets to roam around the streets c) take care of your pets, keep them in good health – bathe, feed with clean adequate food and provide clean sleeping quarters Thoroughly clean ALL BITES AND SCRATCHES made by any animal with strong medicinal soap or solution. Responsible awareness. Report immediately rabid or suggestive of rabies domestic or wild animals to proper authorities (local government clinic, veterinarians or community officials). Pre-exposure to high risk individuals. Veterinarians, hunters, people in contact with animals (zoo), butchers, lab-staff in contact with rabies, forest rangers/caretakers. DOH Standard Protocol If dog is apparently healthy, observe the dog for 14 days. If it dies or show signs suggestive or rabies, consult a physician. If the dog shows signs suggestive of rabies, kill the dog immediately and bring head for lab examination. Submit for immunization while waiting for results. If the dog is not available for observation (killed, died or stray), submit for immunization. *see DOH- Revised Guidelines on Management of Animal Bite Patients- 2007 for more complete guide A cat’s brain for examination

23. MANAGEMENT MEDICAL INTERVENTIONS Local wound treatment. Immediately wash wound with soap and water. Treat with antiseptic solutions such as iodine, alcohol and other disinfectants. Antibiotics and anti-tetanus as prescribed by physician. Rabies – Specific Treatment. Post-exposure treatment is given to persons who are exposed to the rabies virus. It consists of active immunization (vaccination) and passive immunization (immune globulin administration). ACTIVE IMMUNIZATION – aims to induce the body to develop antibodies and T-cells against rabies up to 3 years. It induces an active immune response in 7-10 days after vaccination, which may persist for one year or more provided primary immunization is completed MEDICAL AGENT: Human Diploid Cell rabies Vaccine (HDCV) PASSIVE IMMUNIZATION – aims to provide IMMEDIATE PROTECTION against rabies which should be administered within the first 7 days of active immunization. The effect of the immune globulin is only short term. Rabies antibodies are introduced before it is physiologically possible for the patient to begin producing his own antibodies after vaccination. Some of the RIG is infiltrated around the site and the rest is given intramuscularly. MEDICAL AGENT: Rabies Immune Globulin (RIG)

24. MANAGEMENT NURSING INTERVENTIONS HIGH RISK FOR INFECTION TRANSMISSION provide patient isolation handwashing. Wash hands before and after each patient contact and following procedures that offer contamination risk while caring for an individual patient. Handwashing technique is important in reducing transient flora on outer epidermal layers of skin. Wear gloves when handling fluids and other potential contaminated articles. Dispose of every after patient care. Gloves provide effective barrier protection. Contaminated gloves becomes a potential vehicle for the transfer of organisms. Practice isolation techniques. To prevent self-contamination and spread of disease. KNOWLEDGE DEFICIT (about the disease, cause of infection and preventive measures) assess patient’s and family’s level of knowledge on the disease including concepts, beliefs and known treatment. Provide pertinent data about the disease: organism and route of transmission treatment goals and process community resources if necessary allow opportunities for questions and discussions ALTERED BODY TEMPERATURE: FEVER RELATED TO THE PRESENCE OF INFECTION. Since fever is continuous, provide other modes to reduce discomfort. If patient is still well oriented, Inform the relation of fever to the disease process. The presence of virus in the body … Monitor temperature at regular intervals Provide a well ventilated environment free from drafts and wind. DEHYDRATION related to refusal to take in fluids secondary to throat spasms and fear of spasmodic attacks. Assess level of dehydration of patient. Maintain other routes of fluid introduction as prescribed by the physician e.g. parenteral routes Moisten parched mouth with cotton or gauze dipped in water but not dripping.

26. OBJECTIVES: To provide new policy guidelines and procedure to ensure an effective and efficient management for eventual reduction if not elimination of human rabies To increase voluntary pre-exposure coverage among high risk group (animal handlers, field workers, health staff working in rabies unit, rabies diagnostic lab staff, children ↓ 15 yo living in endemic areas.

27. SPECIFIC GUIDELINES AND PROCEDURES: Management of Potential Rabies Exposure

28. 3 CATEGORIES OF EXPOSURE CATEGORY I Feeding/ touching an animal Licking of intact skin (w/ reliable history and thorough physical examination) Exposure to patient with signs and symptoms of rabies by sharing of eating or drinking utensils * Casual contact to patient with signs and symptoms of rabies*

29. MANAGEMENT: Wash exposed skin immediately w/ soap and water 2. No vaccine or RIG needed *Pre-exposure vaccination may be considered

30. CATEGORY II Nibbling/ nipping of uncovered skin with bruising Minor scratches/ abrasions without bleeding** Licks on broken skin **includes wounds that are induced to bleed

31. MANAGEMENT: Complete vaccination regimen until day 28/30 if: Animal is rabid, killed, died OR unavailable for 14- day observation or examination OR Animal under observation died within 14 days and was IMMUNOFLOURESCENT ANTIBODY TEST (IFAT)- positive OR no IFAT testing was done OR had signs of rabies Complete vaccination regimen until day 7 if: Animal is alive AND remains healthy after 14- day observation period Animal under observation died within 14 days but had no signs of rabies and as IFAT- negative.

32. CATEGORY III Transdermal bites or scratches ( to include puncture wounds, lacerations, avulsions) Contamination of mucous membrane with saliva (i.e. licks) Exposure to a rabies patient through bites, contamination of mucous membranes or open skin lesions with body fluids (except blood/feces) through splattering, mouth-to-mouth resuscitation, licks of the eyes, lips, vulva, sexual activity, exchanging kisses on the mouth or other direct mucous membrane contact with saliva. Handling of infected carcass or ingestion of raw infected meat All Category II exposures on head and neck area *Does not include sharing of food/ drink/ utensils and casual contact with rabid patient

33. MANAGEMENT Complete vaccination regimen until day 28/ 30 if: Animal is rabid, killed, died OR unavailable for 14 day observation or examination OR Animal under observation died within 14 days and was IMMUNOFLOURESCENT ANTIBODY TEST (IFAT)- positive OR no IFAT testing was done OR had signs of rabies Complete vaccination regimen until day 7 if: Animal is alive AND remains healthy after 14-day observation period. Animal under observation died within 14 days but had no signs of rabies and was IFAT- negative

34. IMMUNIZATION ACTIVE IMMUNIZATION induce antibody and T-cell production in order to neutralize the rabies virus in the body. It induces an active immune response in 7-10 days after vaccination, which may persist for one year or more provided primary immunization is completed. TYPES: PVRV (Purified Vero Cell Rabies Vaccine) PCEVC (Purified Chick Embryo Cell Vaccine)

35. PASSIVE IMMUNIZATION - RIG (Rabies Immune Globulins) provide the immediate availability of antibodies at the site of exposure before it is physiologically possible for the pt.to begin producing his own antibodies after vaccination. Important for pts. w/ Cat III exposures Types: HRIG (Human Rabies Immune Globulins) Highly Purified Antibody Antigen Binding fragments ERIG (Equine Rabies Immune Globulins)

36. TREATMENT POST-EXPOSURE TREATMENT (PET) LOCAL WOUND TREATMENT Wash with soap/detergent and water preferably for 10 mins. Apply alcohol, povidone iodine/ any antiseptic Anti-Tetanus *Avoid suturing wounds *Don’t apply ointment, cream/ wound dressing

37. ANTIMICROBIAL Amoxicillin Cloxacillin Cefuroxime *For those instances where there’s no obvious signs of infection( Amoxicillin as prophylaxis ) ***Educate the public simple local wound treatment & warn not to use procedures that may further contaminate the wounds

38. VACCINATION (Intradermal Schedule) Day of Immunization PVRV/PCECV Site DAY 0 0.1 ml L & R deltoids/ anterolateral thighs of infants DAY 3 0.1 ml L & R deltoids/ anterolateral thighs of infants DAY 7 0.1 ml L & R deltoids / anterolateral thighs of infants DAY 28/30 0.1 ml L & R deltoids/ anterolateral thighs of infants

39. Intramuscular Schedule Day of Immunization PVRV PCECV Site Day 0 0.5 ml 1.0 ml One deltoid/ anterolateral thigh of infants Day 3 0.5 ml 1.0 ml Same Day 7 0.5 ml 1.0 ml Same Day 14 0.5 ml 1.0 ml Same Day 28 0.5 ml 1.0 ml same

40. Special Conditions: Pregnancy & infancy are not C/I to treatment Babies born of rabid mothers should be given ARV as early as birth as possible Alcoholics should be given standard IM regimen Immunocomrpomised individuals- IM Interchangeability of vaccine brands & shifting from one regimen to another is not recommended Bites of rodents, rabbits, guinea pig- no PET Dogs, cats, livestock, wild animals- give PET

41. PET Schedule for previously immunized patients: Interval from the last dose Give < 1 month No booster 1 month- 6 months 1 booster dose > 6 months- 3 years 2 booster doses (D0, D3) > Than 3 years Full course of active immun.

42. MANAGEMENT OF RABIES PATIENT Once symptoms start, treatment should center on comfort care, using sedation & avoidance of intubation & life support measures once diagnosis is certain MEDICATIONS Diazepam Midazolam Haloperidol + Dipenhydramine

43. 2. SUPPORTIVE CARE Pts w/ confirmed rabies should receive adequate sedation & comfort care in an appropriate medical facility. Once rabies diagnosis has been confirmed, invasive procedures must be avoided Provide suitable emotional and physical support Discuss & provide important info. to relatives concerning transmission of dse. & indication for PET of contacts Honest gentle communication concerning prognosis should be provided to relatives of pt

44. 3. INFECTION CONTROL Patient should be admitted in a quiet, draft-free, isolation room HLCR workers & relatives in contact w/ pt should wear proper personal protective equipment (gown, gloves, mask, goggles) 4. DISPOSAL OF DEAD BODIES

47. How can I prevent rabies? Vaccinate your dogs, cats, and ferrets against rabies. Keep your pets under supervision. Do not handle wild animals. If you see a wild animal or a stray, especially if the animal is acting strangely, call an animal control officer. If you do get bitten by an animal, wash the wound with soap and water for at least 5 minutes. Make sure you tell an adult and call your doctor to see if you need shots. Get your pets spayed or neutered. Pets that are fixed are less likely to leave home, become strays, and make more stray animals. This racoon is eating a special bait which contains a vaccine against rabies. Tick me!

48. How do I keep my pet from getting rabies? The best way to prevent rabies is to make sure your pets get and stay vaccinated against rabies!! Other ways to prevent rabies in your pets: Walk your dog on a leash. Never let them roam freely where wildlife may be present. Consider keeping your pets indoors. Call animal control to take wild or stray animals away, especially if you see an animal acting strangely. If an animal bites your pet, handle your pet carefully so you do not get bitten. Get a rabies booster vaccination for them. Even if they have had the rabies vaccination, a booster shot will help them fight off the disease better. Get your pets spayed or neutered. Pets that are fixed are less likely to leave home, become strays, and make more stray animals. Make sure your pet gets and wears their rabies vaccination tags. They should also wear a tag with their name and your address and phone number. Keep them in a fenced yard or on a leash. This dog wears a special tag which says “I’m rabies vaccinated!”

49. How do I keep from getting rabies? Never touch unfamiliar or wild animals. Enjoy wild animals from afar. Avoid direct contact with stray animals. Stray cats and dogs may not have been vaccinated against rabies. Never adopt wild animals or bring them into your home. Do not try to nurse sick animals to health. It is common to want to rescue and nurse a hurt wild animal, but that animal may have rabies. Call an animal control person or animal rescue group if you find a sick animal. Make sure that your trash cans and pet foods are secured so that they do not attract wild animals.

50. QUESTION: Is an increase in the incidence of rabies r/t El Niño? ANSWER: No. Rabies both in humans & animals doesn’t in any way follow a seasonal pattern. QUESTIONS MOST FREQUENTLY ASKED ABOUT RABIES

51. QUESTION: Is it true that a dog which is rabid dies only after it has bitten a person? ANSWER: No. Whether the dog has bitten a person or not, a rabid dog dies within 14 days.

52. QUESTION: Is rabies curable? ANSWER: No. Once signs and symptoms of brain involvement are manifested, the rabies victim dies within 1-3 days.

53. QUESTION: Is rabies preventable? ANSWER: Yes. By administering vaccine & immunoglobulin at the right time to an animal bite victim, rabies can be prevented.

54. QUESTION: If bitten by a stray animal, what should be properly done? ANSWER: A. Immediately wash the bite wound B. Consult physician/ ABTC C. Consult a vet for mgt of biting dog

55. QUESTION: Do we need to kill the dog immediately? ANSWER: No. If the dog is apparently healthy, it should not be killed immediately & should be kept on leash / caged for observation for 14 days.

56. QUESTION: Does a person bitten by a rabid person need to be given AR immunization? ANSWER: Yes, a rabid person can transmit the rabies virus to another person & need to be given AR immunization.

58. THANK YOU! BY Jane n Jenni

59. We hope you enjoyed the show!

60. Incubation period the interval between exposure to infection and the appearance of the first symptom 20-90 days (in 60% of cases), extreme cases between some days and several years ( 4 days – 2 years ) Entry of virus @ day 0 How does the rabies virus interact with the nerve cells? Persistence at site of local entry hours/days/months Replication Passive transport to brain 100-400 mm/ day pain and paresthesia: numbness, prickling, tingling; experienced in central and peripheral nerve lesions Tick me 1st! Tick me next!

61. How does the rabies virus interact with the nerve cells? There are four main stages the virus goes through: Attachment: The rabies virus attaches itself to a healthy nerve cell. Penetration: The virus is taken in by the cell. Replication: Inside the cell, the virus multiplies rapidly. Budding: The new rabies virus leaves the host cell. It attaches to other nerve cells. The virus then spreads from the brain to the rest of the body by the nerves. These different stages are happens during the INCUBATION PERIOD. The rabies virus in this picture has been made large so that you can understand it better. Tick me!

62. INVASION STAGE Also called PRODOME PERIOD; Prodrome – symptom indicative of an approaching disease 2-10 DAYS Sensory changes on the site of entry. Pain: dull, constant pain referable to the nervous pathways proximal to the location of the wound or itching, intermittent, stabbing pains radiating distally to the region of inoculation. In general, sensitivity is the early symptom which may be ascribed to the stimulative action of the virus affecting groups of neurons, esp. sensory system. Though there is apt to be decreased sensitivity to local pain e.g. needle introduction, patient may complain bitterly of drafts & bed clothes which produce a general stimulation Fever,headache malaise sore throat anorexia increased sensitivity (bright lights, loud noises) increased muscle reflex irritability, tics and muscle tone Overactive facial expression Tick me!

63. EXCITATION STAGE Also called ACUTE NEUROLOGICAL PHASE; hyperactivity 2 – 10 DAYS Imminent thoraco-lumbar involvement (SNS): pupillary dilation, lacrimation increased thick saliva production / foaming of mouth, excessive perspiration, increased HR Anxiety: increased nervousness, insomnia, apprehension; a strong desire to be up, wandering aimlessly about, and Fear: a sense of impending doom Hydrophobia (perhaps, SNS stimulation: depresses GI activity > inhibits esophageal, gastric & intestinal function) > violent expulsion of fluids, drooling (in attempt not to swallow) > dehydration and parched mouth & tongue Pronounced muscular stimulation & general tremor Mania (tearing of clothes & bedding, cases of biting & fighting rare but may occur) and Hallucinations with lucid intervals (normal mental function in which patient is well-oriented & answers questions intelligently) Convulsions( besides r/t pronounced muscular stimulation, further precipitated by sensory stimuli – sight, sound, name of water > throat spasms > choking > apnea, cyanois, gasping > death, but if patient survive excitement phase… Tick me next! Sympathetic nervous system Parasympathetic nervous system Tick me 1st!

64. Tick me!

65. PARALYTIC STAGE -also called DEPRESSION PHASE Gradual weakness of muscle groups muscle spasms cease OCULAR PALSY – strabismus, ocular incoordination, nystagmus, diplopia, central type partial blindness > responds poorly to light, @ times pupil is constricted or unequal (parasympathetic involvement) Oro-facial: FACIAL & MASSETER PALSY > difficulty closing eyes & mouth, face expressionless Oral: Weakness of muscles of phonation > hoarsness & loss of voice Loss of tendon reflexes , always precedes weakness of extremity Corneal reflex decreased or absent, dry Ears: VERTIGO . Middle ear disease . Early symptom, but may develop @ any period Neck stiffness (+) Babinski [lesions of pyramidal tract], ( - ) Kernig’s ( - ) Brudzinski’s Cardiac: shifts from tachycardia (100 – 120bpm) @ bed rest to bradycardia (40 -60 bpm) Respi: Cheyne-Stokes > breathing pattern characterized by a periodic 10 – 6- sec of apnea followed by gradual increasing depth and frequency of respiration Local sensation (pin prick, heat, cold) diminished Incoordination Hydrophobia and aerophobia gone , but still has some difficulty swallowing General arousal (PNS stimulation) Bladder & intestinal retention and obstipation (damage to to innervation of the musculature of intestine & bladder)(SNS damage) in some cases, patient shows period of recovery, this apparent remission is followed by progressive Ascending, flaccid paralysis of extremities until it reaches the respiratory muscle Apathy, stupor Complications: Pneumothorax, thrombosis, secondary infections Tick me!

66. A painting of the US’ campaign against rabies in wildlife. Wildlife advocates believe that a vaccinated racoon is the best tool for combating rabies in the wildlife. Racoons are one of the most common vectors of Rabies. It may eat an infected bat yet may also spread the virus itself to the bats as it rummages through the bat colony. Tick me!

67. SOURCES: SOURCE: Taber’s Cyclopedic Medical Dictionary 17th Edition. 1994. Singapore: Davis Company. Department of Health. Community Health Nursing Services in the Philippine Department of Health , 9th Edition. 2000. Philippines: DOH Smeltzer, Suzanne and Bare, Brenda. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing , 9th Edition. 2000. Philadelphia: Lippincott Williams and Wilkins Geddes and Grossett Limited. Killer Bugs. 1997. New Lanark, Scottland: David Dale House. Rivers, Thomas and Horsfall Jr., Frank. Viral & Rickettsial Infections of Man 3 rd Edition. 1959. Philadelphia: Lippincott Company. www.pasteur.fr www.wikipedia.com www.cdc.com/us/ www.doh.gov.ph www.ritm.gov.ph (RITM Rabies Research Program) www.bai.ph (Bureau of Animal Industry Programs)