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RABIES
Chairperson : Dr Alakes Kole
Presenter : Dr Soumyasil Das
WHY IT IS IMPORTANT TO KNOW ABOUT RABIES
▪ Acute viral disease that causes fatal encephalomyelitis in
virtually all the warm-blooded animals including man.
▪ The disease is invariably fatal and perhaps the most
painful and dreadful of all communicable diseases in
which the sick person is tormented at the same time with
thirst and fear of water (hydrophobia)
▪ Till date there is no cure if u developed the disease and
death is inevitable
▪ Fortunately, development of rabies can be prevented to a
large extent if animal bites are managed appropriately
and in time
EPIDEMIOLOGY
▪ Worldwide endemic canine rabies: 55,000 deaths annually
▪ Most of the deaths are occurring in Asia and Africa
▪ Mainly in rural areas and in children
▪ INDIA : 20,000 deaths per year. 17.4 million animal bite
cases annually. (APCRI 2004)
▪ India accounts for 36% of the Global and 65% of the Asian
human rabies deaths.
▪ EXCEPT LAKSHWADEEP & ANDAMAN-NICOBAR ALL
STATES REPORT RABIES
▪ through their saliva
(following bites, scratches,
licks on broken skin and
mucous membrane).
▪ In India, dogs are
responsible for about 97%
of human rabies, followed
by cats (2%), jackals,
mongoose and others (1%).
 The virus is found in wild and
some domestic animals,
 The disease is mainly transmitted by the
bite of a rabid dog.
THE VIRUSSSS………
▪ Family Rhabdoviridae
▪ Genus Lyssavirus
▪ Serotype 1
▪ Bullet shaped
▪ Neurotropic
THE VIRUSSSS………
▪ Single stranded RNA
▪ Non-segmented
▪ Antisense genome
▪ Consists of 11,932 nucleotides
and encodes 5 proteins.
▪ Six other non-rabies virus
species in Lyssavirus genus
have been reported to cause a
clinical picture similar to
rabies.
TYPES OF RABIES VIRUSES
STREETVIRUS
▪ Recovered from naturally
occurring cases of rabies
▪ Naturally occurring virus, found
in saliva of infected animal
▪ Produce NEGRI Bodies
▪ IP is long  20-90 days
▪ Cannot be used for vaccine
preparation
FIXEDVIRUS
▪ Has short, fixed and reproducible
incubation period
▪ Prepared from repeated culture in rabbit
brain such that its IP is reduced & fixed
▪ Does NOT produce NEGRI Bodies
▪ IP is short  4-6 days
▪ Can be used for vaccine preparation
PATHOGENESIS
▪ The period before the rabies
virus pass into the PNS is called
the incubation period
▪ Usually 20-90 days
▪ During most of this period,
rabies virus is present at or
close to the site of the bite.
Stage of inoculation
PATHOGENESIS
▪ The virus binds to
postsynaptic nicotinic
acetylcholine receptors
(AChR-N)
and spreads centripetally
along peripheral nerves
toward the CNS at a rate of
up to ~250 mm/d.
CNS dissemination
PATHOGENESIS
SYMPTOMS
 fever, confusion, hallucinations,
combativeness, and seizures
 Autonomic dysfunction : hypersalivation,
gooseflesh, cardiac arrhythmia, and/or
priapism.
ENCEPHALITIC FORM 80%
CHARACTERISTIC FEATURES OF RABIES
 AGGRESION AND ANGER
Probably when the virus takes over the
emotional control areas of brain
CHARACTERISTIC FEATURES OF RABIES
 HYDROPHOBIA/AEROPHOBIA
involuntary, painful contraction of
the diaphragm and accessory respiratory, laryngeal,
and pharyngeal muscles
in response to swallowing liquid or exposure to a
draft of air
Dysfunction of infected brainstem neurons that
normally inhibit inspiratory neurons near Nucleus
Ambigus resulting in exaggerated defence reflexes
that protect respiratory tract.
Pathognomic of rabies and absent in animals.
CHARACTERISTIC FEATURES OF RABIES
 Hypersalivation and pharyngeal
dysfunction produce characteristic
foaming at the mouth.
Due to Autonomic dysfunction
Negri bodies
▪ The most characteristic
pathologic CNS finding is the
Negri body—
▪ an eosinophilic cytoplasmic
inclusion
▪ composed of rabies virus
proteins and viral RNA and
▪ Purkinje cells of the
cerebellum and in
▪ Pyramidal neuron of the
hippocampus
Not observed in all cases of
rabies.
Paralytic Rabies 20%
• Muscle weakness predominates.
• Early & prominent flaccid
muscle weakness often in
bitten extremity & spreading to
produce quadriparesis & facial
weakness.
• Sphincter involvement
common.
• Sensory involvement mild.
• Lacks cardinal features
(hyperexcitability, hydrophobia,
aerophobia )
Investigations
- Mild mononuclear cell pleocytosis with mildly elevated protein
- Severe pleocytosis >1000WBC/mcl unusual & search alternate
diagnosis.
- Rabies virus specific antibodies in CSF suggest rabies
encephalitis regardless of immunisation status.
CSF Study
Investigations..
▪ RT – PCR amplification :-
– Highly sensitive & specific in rabies virus detection in fresh saliva, skin, CSF &
brain tissues.
▪ Direct FluorescentAntibody testing :-
– Highly sensitive & specific in testing rabies virus antibodies conjugated to
fluorescent dyes.
– Quickly performed & applied to skin biopsies and brain.
Investigations..
 Skin biopsy
– Obtained from nape of neck.
– Demonstration of virus in cutaneous nerves at base of
hair follicles.
 Corneal impressive smears – low diagnostic yield.
 MRI brain – variable & non-specific.
 EEG – non specific abnormalities.
Treatment
▪ No established treatment.
▪ Isolation in quiet room (as bright light, noise, cold draughts
precipitates spasms/convulsions)
▪ Sedatives to relieve anxiety
▪ Intensive respiratory & cardiac support.
99.99% preventable if managed in time
PRINCIPLES OF TREATMENT
Categorization of the wound
Wound treatment
▪ Vaccination PEP
▪ Immunoglobulin/anti sera
▪ Advice to Patient
Categorization of the wound
CATEGORY I
▪ TOUCHING OR FEEDING
ANIMALS
▪ LICKING BY ANIMALS
ON INTACT SKIN
NOTHINGTO WORRY
NOVACCINE/RIG NEEDED
JUST CLEANTHE SURFACE
Categorization of the wound
CATEGORY II
(NO BLOOD/OOZING)
▪ Nibbling of uncovered skin
▪ Minor scratches or abrasions
Administer anti-rabies
vaccine immediately.
Convert post exposure prophylaxis to pre exposure
prophylaxis if dog/cat remains healthy throughout the
observation period of 10 days or if it is euthanised and
found to be negative for Rabies by appropriate
laboratory techniques.
Categorization of the wound
CATEGORY III
▪ Single or multiple transdermal
bites/scratches.
▪ Contamination of mucous
membrane with saliva (i.e.
licks)
▪ Licks on broken skin
Wound Management
Administer RIG and
vaccine immediately.
Stop treatment if dog/cat remains with saliva (i.e.
licks) healthy throughout an observation period of 10
days or if it is killed humanely and found to be
negative for rabies by appropriate laboratory
techniques.
CATEGORY III BITES
WOUND MANAGEMENT
 MECHANICAL:
Wash under Running tap water
▪ CHEMICAL:
Soap (Preferably detergent)
Disinfectants - Povidone Iodine, Spirit, antiseptics
▪ BIOLOGICAL:
Infiltrate immunoglobulins/RIG
Suturing only if required (1 - 2 loose sutures)
& only after administration of RIGs.
Don’t apply irritants & don’t touch wound with
bare hands
VACCINE & PEP CAT II & CAT III
▪ Active immunization is achieved by administration of safe and
potent
CELL CULTUREVACCINES (CCVs)
or
PURIFIED DUCK EMBRYOVACCINE (PDEV)
 It is absolutely essential that every batch of CCVs have
minimum potency of 2.5IU per dose, irrespective of whether
the vaccine is administered by IM or ID route.
 should be kept and transported at a temperature range of 2-
8ºC and protected from sunlight
▪ CAN BE GIVEN EITHER IM/ID
▪ CCVs approved for ID use shall be
administered by ID regimen
▪ Rabies vaccines containing an adjuvant
should not be used intradermally
▪ Use as soon as possible, but at the
maximum within 8 hours,(PROVIDED
VACCINE IS STORED AT 2-8°C)
▪ Shifting from one brand/type of CCV to
other brand/type should not be
encouraged in routine practice
▪ SHIFTING BETWEEN IM & ID NOT
RECOMMENDED
ESSEN INTRA MUSCULAR REGIME
▪ The deltoid region is ideal for the
administration (INCH ABOVE
INSERTION OF DELTOID)
▪ Gluteal region is not
recommended because the fat
present in this region retards the
absorption of antigen and hence
impairs the generation of optimal
immune response.
▪ In case of infants and young
children antero-lateral part of
the thigh is the preferred site
INTRADERMAL REGIMEN
(APPROVED IN INDIA)
A dose of 0.1ml of vaccine,
irrespective of reconstituted volume
(0.5ml or 1 ml for IM route), is
administered per ID site.
considerable savings in total amount
of vaccine needed thereby reducing
the cost of active immunization.
wider coverage of PEP in available
quantity of vaccines
Drug Controller General of India
(DCGI) approved the use of intra-
dermal vaccination regimen for
rabies post-exposure prophylaxis.
4VIALS
4VISITS
MATERIALS REQUIRED FOR ID INJECTION
▪ A vial of anti-rabies vaccine along with its diluent that
is approved by the DCGI for ID administration.
▪ 2 ml disposable syringe with 24 G needle for
reconstitution of vaccine.
▪ Disposable 1 ml (insulin) syringe (with gradations up
to 100 or 50 units) with a fixed (self-mounted) (28 G or
more) needle for infiltration.
▪ Syringes with detachable needles are not preferred as
they contribute to wastage of vaccine.
▪ Disinfectant swabs (e.g. 70% ethanol, isopropyl
alcohol) for cleaning the top of the vial and the
patients' skin.
TECHNIQUE OF ID INJECTION
▪ Using aseptic technique, reconstitute with diluent.
▪ With 1 ml insulin syringe draw 0.2 ml (up to 20 units in a 100 units syringe
is) of vaccine needed for one patient (i.e. 0.1 ml per ID site for 2 sites).
▪ stretch the surface of the skin  insert the tip of the needle with bevel
upwards
▪ slowly inject half (i.e. 0.1ml; 10 units)  uppermost dermal layer of skin,
over the deltoid area an inch above the insertion of deltoid muscle.
▪ If the needle is correctly placed inside the dermis, resistance is felt while
injecting.
▪ A raised bleb should begin to appear immediately causing a peau d'
orange (orange peel) appearance
▪ Remaining volume of vaccine (i.e. 0.1ml; 10 units) on the opposite
deltoid area.
Check points during ID injection
▪ If the vaccine is INJECTED subcutaneous, bleb (Peau de orange) is
not seen.
▪ Then the needle should be withdrawn and reinserted at an
adjacent site and ID vaccine given once more.
▪ Alternate to deltoid region is suprascapular area or the
anterolateral thigh.
RIG
The anti-rabies serum/Rabies Immunoglobulin
▪ provides passive immunity in the form of ready-made anti-rabies
antibodies, before it is physiologically possible for the victim to begin
producing his/her own antibodies following anti-rabies vaccination.
▪ All Category III exposures: irrespective of the biting animal.
▪ In immune compromised individuals: RIG should be administered in
both Category II and III exposures.
▪ RIG is administered only once, preferably within 24 hrs after
exposure (on day 0 along with the first dose ofARV).
▪ Administer even when treatment is delayed but should not be given
after 7 days of start of vaccination.
▪ In re-exposure cases (completed post exposure prophylaxis
previously) RIGs are not indicated.
RIG INFILTRATION
ERIG : 40 IU per kg body weight of
patient.The ERIG produced in India
contains 300 IU per ml.
HRIG : 20 IU per kg body weight.
Provides protection until active
immunity begins (7- 10 days since
initiation of vaccination).
Should be brought to room
temperature (25°C to 30°C) before
administration to the patient.
RIG INFILTRATION
Infiltrate as much as possible in the
depth and around the wound(s).
Remaining quantity, if any, to be given
by deep intramuscular injection at a site
distant from the vaccine injection site.
infiltration of half the dose of RIG locally
and half intramuscularly is not
recommended.
RIG must never be given intravenously.
Multiple needle pricks into the wound(s)
should be avoided. Use as few entry
points as possible.
RIG IN MULTIPLE BITES
▪ In such cases, the calculated dose of the
rabies immunoglobulin may not be
sufficient to infiltrate all wounds.
▪ Dilute the calculated volume of RIG in
sterile normal saline to a volume
sufficient to infiltrate all the wounds.
▪ The total recommended dose of RIG
must not be exceeded as it may suppress
the antibody production stimulated by
the anti-rabies vaccine.
SKIN TEST BEFORE RIG?
▪ There is no rationale of performing a skin test before RIG
administration.
▪ SkinTest does not reliably predict reaction.
▪ Presently available ERIGs are highly purified and the occurrence of
adverse events has been significantly reduced. So anaphylactic
reactions are extremely rare.
▪ If Anaphylaxis occur  administer ADRENALINE The dose is 0.5
ml of 0.1 percent solution (1 in 1000, 1mg/ml) for adults and
0.01ml/kg body weight for children by SC or IM route.
RIG IN INDIA
ALL CAT III
IMMUNOCOMPROMISED BOTH
CAT III & CAT II
DOSE SHOULD NOT BE
INCREASED IN MULTIPLE BITES,
ONLY INCREASETHEVOL BY
DILUTING,TO INFILTRATE ALL
WOUNDS
SIGLE DOSE (WITHIN 7-10 DAYS)
ADVICE TO PATIENT AFTER PEP/RIG
▪ No dietary restriction.
▪ No restriction of physical exercise.
▪ Avoid immune suppressants (Steroids, anti-malarials) if possible.
▪ Best to avoid consumption of alcohol during the course of
treatment.
▪ Complete the course of vaccination.
MGT OF RE-EXPOSURE
▪ Re exposure after a full course (Pre/Post-exposure) I/M or I/D
irrespective of Category of exposure orTime since previous
vaccination 2 boosters (Day 0 & Day 3) No RIG
▪ All incomplete/partial vaccinations -Treat as fresh case
▪ Re-exposure following PEP with NTV  As fresh case &Treatment
as per merits of the case
PRE-EXPOSURE PROPHYLAXIS
PRE-EXPOSURE PROPHYLAXIS MONITORING FOR
SUBSEQUENT BOOSTER DOSE
Check neutralising antibody
titres
Every 6 months
(for initial 2 yrs. of vaccination)
If <0.5 IU/ml
Give a single
BOOSTER Dose
After 2 yrs.
check
antibodies
every 2 yrs.
NO NEED OF
RIG AFTER
EXPOSURE IN
ANY
CATEGORY OF
BITE
DECISION TO TREAT
▪ Rabies is ENDEMIC in INDIA  Suspect every animal bite as a
potentially rabid animal bite
▪ As rabies is practically 100% fatal, consider as a “medical
emergency” and the “life-saving” PEP must be provided
immediately.
▪ The observation period of 10 days is valid for dogs and cats only.
▪ If the animal is healthy throughout the observation period then we
can skip the dose of DAY 14 & DAY 28.
▪ While using ID administration complete course of vaccination
should be given irrespective of status of animal.
DECISION TO TREAT
▪ Vaccination status of the biting animal:
A history of rabies vaccination in an animal is not always a guarantee
that the biting animal is not rabid.
Animal vaccine failures may occur.
Hence, appropriate documentation of vaccination status of dog/cat and
proper history should be elicited before deciding to defer post-
exposure prophylaxis after bite by vaccinated dog/cat.
BETTERTO START PEP
DECISION TO TREAT
▪ Provoked versus unprovoked bite:
A provoked dog bite should also be managed as an
exposure and PEP started immediately.A provoked
bite does not mean that the biting animal is not rabid.
It is difficult to understand what provokes a dog so
it is prudent to start PEP at the earliest.
DECISION TO TREAT
▪ Human to Human transmission: very rare.
▪ But if you gets contaminated by biting of a rabid human or saliva of a rabid
human got contaminated with broken skin or mucous membrane  START
PEP
▪ You drank milk of a rabid cow  NO NEED FOR PEP (rabies gets
transmitted by saliva)
▪ BUT You got BITTEN by rabid cow  START PEP (every warm blooded
animals has the potential to transmit rabies through their saliva)
▪ Irrespective when the patient is coming after the day of bite (i.e. after 2
months for eg ) and patient is asymptomatic or not & NO PEP given 
START PEP because it has been reported of development of rabies after
1 year
DECISION TO TREAT
▪ Bite by wild animals: treat as category III exposure.
▪ Bite by rodents: Exposure to domestic rodents, squirrel, hare and
rabbits do not ordinarily require PEP.
▪ Bat rabies: Bat rabies has not been conclusively proved in India and
hence, at present, exposure to bats does not warrant PEP.
▪ PEP in immune-compromised patients: RIG in both CAT II & III;
CHECK ANTI RABIES ANTIBODY AT DAY14
IF <0.5 IU/ml GIVE ADDITIONAL DOSE
Contraindications and precautions
As rabies is nearly 100% fatal disease, there is no contraindication to PEP.
Pregnancy, lactation, infancy, old age and concurrent illness are no
contraindications for rabies PEP in the event of an exposure.
PEP against rabies takes preference over any other consideration as it is a
lifesaving treatment.
Moreover, rabies vaccine does not have any adverse effect on pregnant
woman, course of pregnancy, foetus or lactating mother.
Hence, complete PEP should be given depending on the category of the
exposure.
People taking CHLOROQUINE for malaria treatment or prophylaxis may
have a reduced response to ID rabies vaccination.These patients should
receive the rabies vaccine INTRAMUSCULARLY.
REMEMBER AND HAMMER YOUR MIND
▪ TREATING RABIES IS MUCH AND MUCH
BETTER CHOICETHANTO LEAVE
▪ PEP CAN PREVENT RABIESVIRTUALLY
100% CASES AND NONTREATING
CONVERTSTHE CASE INTO 100%
FATALITY
100%
PREVENTABLE
IF MANAGED
ACCORDINGLY
AND INTIME
HENCE
TREATING IS
BETTER CHOICE

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Rabies

  • 1. RABIES Chairperson : Dr Alakes Kole Presenter : Dr Soumyasil Das
  • 2. WHY IT IS IMPORTANT TO KNOW ABOUT RABIES ▪ Acute viral disease that causes fatal encephalomyelitis in virtually all the warm-blooded animals including man. ▪ The disease is invariably fatal and perhaps the most painful and dreadful of all communicable diseases in which the sick person is tormented at the same time with thirst and fear of water (hydrophobia) ▪ Till date there is no cure if u developed the disease and death is inevitable ▪ Fortunately, development of rabies can be prevented to a large extent if animal bites are managed appropriately and in time
  • 3. EPIDEMIOLOGY ▪ Worldwide endemic canine rabies: 55,000 deaths annually ▪ Most of the deaths are occurring in Asia and Africa ▪ Mainly in rural areas and in children ▪ INDIA : 20,000 deaths per year. 17.4 million animal bite cases annually. (APCRI 2004) ▪ India accounts for 36% of the Global and 65% of the Asian human rabies deaths. ▪ EXCEPT LAKSHWADEEP & ANDAMAN-NICOBAR ALL STATES REPORT RABIES
  • 4. ▪ through their saliva (following bites, scratches, licks on broken skin and mucous membrane). ▪ In India, dogs are responsible for about 97% of human rabies, followed by cats (2%), jackals, mongoose and others (1%).  The virus is found in wild and some domestic animals,  The disease is mainly transmitted by the bite of a rabid dog.
  • 5. THE VIRUSSSS……… ▪ Family Rhabdoviridae ▪ Genus Lyssavirus ▪ Serotype 1 ▪ Bullet shaped ▪ Neurotropic
  • 6. THE VIRUSSSS……… ▪ Single stranded RNA ▪ Non-segmented ▪ Antisense genome ▪ Consists of 11,932 nucleotides and encodes 5 proteins. ▪ Six other non-rabies virus species in Lyssavirus genus have been reported to cause a clinical picture similar to rabies.
  • 7. TYPES OF RABIES VIRUSES STREETVIRUS ▪ Recovered from naturally occurring cases of rabies ▪ Naturally occurring virus, found in saliva of infected animal ▪ Produce NEGRI Bodies ▪ IP is long  20-90 days ▪ Cannot be used for vaccine preparation FIXEDVIRUS ▪ Has short, fixed and reproducible incubation period ▪ Prepared from repeated culture in rabbit brain such that its IP is reduced & fixed ▪ Does NOT produce NEGRI Bodies ▪ IP is short  4-6 days ▪ Can be used for vaccine preparation
  • 8. PATHOGENESIS ▪ The period before the rabies virus pass into the PNS is called the incubation period ▪ Usually 20-90 days ▪ During most of this period, rabies virus is present at or close to the site of the bite. Stage of inoculation
  • 9. PATHOGENESIS ▪ The virus binds to postsynaptic nicotinic acetylcholine receptors (AChR-N) and spreads centripetally along peripheral nerves toward the CNS at a rate of up to ~250 mm/d. CNS dissemination
  • 10. PATHOGENESIS SYMPTOMS  fever, confusion, hallucinations, combativeness, and seizures  Autonomic dysfunction : hypersalivation, gooseflesh, cardiac arrhythmia, and/or priapism. ENCEPHALITIC FORM 80%
  • 11. CHARACTERISTIC FEATURES OF RABIES  AGGRESION AND ANGER Probably when the virus takes over the emotional control areas of brain
  • 12. CHARACTERISTIC FEATURES OF RABIES  HYDROPHOBIA/AEROPHOBIA involuntary, painful contraction of the diaphragm and accessory respiratory, laryngeal, and pharyngeal muscles in response to swallowing liquid or exposure to a draft of air Dysfunction of infected brainstem neurons that normally inhibit inspiratory neurons near Nucleus Ambigus resulting in exaggerated defence reflexes that protect respiratory tract. Pathognomic of rabies and absent in animals.
  • 13. CHARACTERISTIC FEATURES OF RABIES  Hypersalivation and pharyngeal dysfunction produce characteristic foaming at the mouth. Due to Autonomic dysfunction
  • 14. Negri bodies ▪ The most characteristic pathologic CNS finding is the Negri body— ▪ an eosinophilic cytoplasmic inclusion ▪ composed of rabies virus proteins and viral RNA and ▪ Purkinje cells of the cerebellum and in ▪ Pyramidal neuron of the hippocampus Not observed in all cases of rabies.
  • 15. Paralytic Rabies 20% • Muscle weakness predominates. • Early & prominent flaccid muscle weakness often in bitten extremity & spreading to produce quadriparesis & facial weakness. • Sphincter involvement common. • Sensory involvement mild. • Lacks cardinal features (hyperexcitability, hydrophobia, aerophobia )
  • 16. Investigations - Mild mononuclear cell pleocytosis with mildly elevated protein - Severe pleocytosis >1000WBC/mcl unusual & search alternate diagnosis. - Rabies virus specific antibodies in CSF suggest rabies encephalitis regardless of immunisation status. CSF Study
  • 17. Investigations.. ▪ RT – PCR amplification :- – Highly sensitive & specific in rabies virus detection in fresh saliva, skin, CSF & brain tissues. ▪ Direct FluorescentAntibody testing :- – Highly sensitive & specific in testing rabies virus antibodies conjugated to fluorescent dyes. – Quickly performed & applied to skin biopsies and brain.
  • 18. Investigations..  Skin biopsy – Obtained from nape of neck. – Demonstration of virus in cutaneous nerves at base of hair follicles.  Corneal impressive smears – low diagnostic yield.  MRI brain – variable & non-specific.  EEG – non specific abnormalities.
  • 19. Treatment ▪ No established treatment. ▪ Isolation in quiet room (as bright light, noise, cold draughts precipitates spasms/convulsions) ▪ Sedatives to relieve anxiety ▪ Intensive respiratory & cardiac support.
  • 20. 99.99% preventable if managed in time
  • 21. PRINCIPLES OF TREATMENT Categorization of the wound Wound treatment ▪ Vaccination PEP ▪ Immunoglobulin/anti sera ▪ Advice to Patient
  • 22. Categorization of the wound CATEGORY I ▪ TOUCHING OR FEEDING ANIMALS ▪ LICKING BY ANIMALS ON INTACT SKIN NOTHINGTO WORRY NOVACCINE/RIG NEEDED JUST CLEANTHE SURFACE
  • 23. Categorization of the wound CATEGORY II (NO BLOOD/OOZING) ▪ Nibbling of uncovered skin ▪ Minor scratches or abrasions Administer anti-rabies vaccine immediately. Convert post exposure prophylaxis to pre exposure prophylaxis if dog/cat remains healthy throughout the observation period of 10 days or if it is euthanised and found to be negative for Rabies by appropriate laboratory techniques.
  • 24. Categorization of the wound CATEGORY III ▪ Single or multiple transdermal bites/scratches. ▪ Contamination of mucous membrane with saliva (i.e. licks) ▪ Licks on broken skin Wound Management Administer RIG and vaccine immediately. Stop treatment if dog/cat remains with saliva (i.e. licks) healthy throughout an observation period of 10 days or if it is killed humanely and found to be negative for rabies by appropriate laboratory techniques.
  • 26. WOUND MANAGEMENT  MECHANICAL: Wash under Running tap water ▪ CHEMICAL: Soap (Preferably detergent) Disinfectants - Povidone Iodine, Spirit, antiseptics ▪ BIOLOGICAL: Infiltrate immunoglobulins/RIG Suturing only if required (1 - 2 loose sutures) & only after administration of RIGs. Don’t apply irritants & don’t touch wound with bare hands
  • 27. VACCINE & PEP CAT II & CAT III ▪ Active immunization is achieved by administration of safe and potent CELL CULTUREVACCINES (CCVs) or PURIFIED DUCK EMBRYOVACCINE (PDEV)  It is absolutely essential that every batch of CCVs have minimum potency of 2.5IU per dose, irrespective of whether the vaccine is administered by IM or ID route.  should be kept and transported at a temperature range of 2- 8ºC and protected from sunlight ▪ CAN BE GIVEN EITHER IM/ID ▪ CCVs approved for ID use shall be administered by ID regimen ▪ Rabies vaccines containing an adjuvant should not be used intradermally ▪ Use as soon as possible, but at the maximum within 8 hours,(PROVIDED VACCINE IS STORED AT 2-8°C) ▪ Shifting from one brand/type of CCV to other brand/type should not be encouraged in routine practice ▪ SHIFTING BETWEEN IM & ID NOT RECOMMENDED
  • 28. ESSEN INTRA MUSCULAR REGIME ▪ The deltoid region is ideal for the administration (INCH ABOVE INSERTION OF DELTOID) ▪ Gluteal region is not recommended because the fat present in this region retards the absorption of antigen and hence impairs the generation of optimal immune response. ▪ In case of infants and young children antero-lateral part of the thigh is the preferred site
  • 29. INTRADERMAL REGIMEN (APPROVED IN INDIA) A dose of 0.1ml of vaccine, irrespective of reconstituted volume (0.5ml or 1 ml for IM route), is administered per ID site. considerable savings in total amount of vaccine needed thereby reducing the cost of active immunization. wider coverage of PEP in available quantity of vaccines Drug Controller General of India (DCGI) approved the use of intra- dermal vaccination regimen for rabies post-exposure prophylaxis. 4VIALS 4VISITS
  • 30. MATERIALS REQUIRED FOR ID INJECTION ▪ A vial of anti-rabies vaccine along with its diluent that is approved by the DCGI for ID administration. ▪ 2 ml disposable syringe with 24 G needle for reconstitution of vaccine. ▪ Disposable 1 ml (insulin) syringe (with gradations up to 100 or 50 units) with a fixed (self-mounted) (28 G or more) needle for infiltration. ▪ Syringes with detachable needles are not preferred as they contribute to wastage of vaccine. ▪ Disinfectant swabs (e.g. 70% ethanol, isopropyl alcohol) for cleaning the top of the vial and the patients' skin.
  • 31. TECHNIQUE OF ID INJECTION ▪ Using aseptic technique, reconstitute with diluent. ▪ With 1 ml insulin syringe draw 0.2 ml (up to 20 units in a 100 units syringe is) of vaccine needed for one patient (i.e. 0.1 ml per ID site for 2 sites). ▪ stretch the surface of the skin  insert the tip of the needle with bevel upwards ▪ slowly inject half (i.e. 0.1ml; 10 units)  uppermost dermal layer of skin, over the deltoid area an inch above the insertion of deltoid muscle. ▪ If the needle is correctly placed inside the dermis, resistance is felt while injecting. ▪ A raised bleb should begin to appear immediately causing a peau d' orange (orange peel) appearance ▪ Remaining volume of vaccine (i.e. 0.1ml; 10 units) on the opposite deltoid area.
  • 32. Check points during ID injection ▪ If the vaccine is INJECTED subcutaneous, bleb (Peau de orange) is not seen. ▪ Then the needle should be withdrawn and reinserted at an adjacent site and ID vaccine given once more. ▪ Alternate to deltoid region is suprascapular area or the anterolateral thigh.
  • 33. RIG The anti-rabies serum/Rabies Immunoglobulin ▪ provides passive immunity in the form of ready-made anti-rabies antibodies, before it is physiologically possible for the victim to begin producing his/her own antibodies following anti-rabies vaccination. ▪ All Category III exposures: irrespective of the biting animal. ▪ In immune compromised individuals: RIG should be administered in both Category II and III exposures. ▪ RIG is administered only once, preferably within 24 hrs after exposure (on day 0 along with the first dose ofARV). ▪ Administer even when treatment is delayed but should not be given after 7 days of start of vaccination. ▪ In re-exposure cases (completed post exposure prophylaxis previously) RIGs are not indicated.
  • 34. RIG INFILTRATION ERIG : 40 IU per kg body weight of patient.The ERIG produced in India contains 300 IU per ml. HRIG : 20 IU per kg body weight. Provides protection until active immunity begins (7- 10 days since initiation of vaccination). Should be brought to room temperature (25°C to 30°C) before administration to the patient.
  • 35. RIG INFILTRATION Infiltrate as much as possible in the depth and around the wound(s). Remaining quantity, if any, to be given by deep intramuscular injection at a site distant from the vaccine injection site. infiltration of half the dose of RIG locally and half intramuscularly is not recommended. RIG must never be given intravenously. Multiple needle pricks into the wound(s) should be avoided. Use as few entry points as possible.
  • 36. RIG IN MULTIPLE BITES ▪ In such cases, the calculated dose of the rabies immunoglobulin may not be sufficient to infiltrate all wounds. ▪ Dilute the calculated volume of RIG in sterile normal saline to a volume sufficient to infiltrate all the wounds. ▪ The total recommended dose of RIG must not be exceeded as it may suppress the antibody production stimulated by the anti-rabies vaccine.
  • 37. SKIN TEST BEFORE RIG? ▪ There is no rationale of performing a skin test before RIG administration. ▪ SkinTest does not reliably predict reaction. ▪ Presently available ERIGs are highly purified and the occurrence of adverse events has been significantly reduced. So anaphylactic reactions are extremely rare. ▪ If Anaphylaxis occur  administer ADRENALINE The dose is 0.5 ml of 0.1 percent solution (1 in 1000, 1mg/ml) for adults and 0.01ml/kg body weight for children by SC or IM route.
  • 38. RIG IN INDIA ALL CAT III IMMUNOCOMPROMISED BOTH CAT III & CAT II DOSE SHOULD NOT BE INCREASED IN MULTIPLE BITES, ONLY INCREASETHEVOL BY DILUTING,TO INFILTRATE ALL WOUNDS SIGLE DOSE (WITHIN 7-10 DAYS)
  • 39. ADVICE TO PATIENT AFTER PEP/RIG ▪ No dietary restriction. ▪ No restriction of physical exercise. ▪ Avoid immune suppressants (Steroids, anti-malarials) if possible. ▪ Best to avoid consumption of alcohol during the course of treatment. ▪ Complete the course of vaccination.
  • 40. MGT OF RE-EXPOSURE ▪ Re exposure after a full course (Pre/Post-exposure) I/M or I/D irrespective of Category of exposure orTime since previous vaccination 2 boosters (Day 0 & Day 3) No RIG ▪ All incomplete/partial vaccinations -Treat as fresh case ▪ Re-exposure following PEP with NTV  As fresh case &Treatment as per merits of the case
  • 42. PRE-EXPOSURE PROPHYLAXIS MONITORING FOR SUBSEQUENT BOOSTER DOSE Check neutralising antibody titres Every 6 months (for initial 2 yrs. of vaccination) If <0.5 IU/ml Give a single BOOSTER Dose After 2 yrs. check antibodies every 2 yrs. NO NEED OF RIG AFTER EXPOSURE IN ANY CATEGORY OF BITE
  • 43. DECISION TO TREAT ▪ Rabies is ENDEMIC in INDIA  Suspect every animal bite as a potentially rabid animal bite ▪ As rabies is practically 100% fatal, consider as a “medical emergency” and the “life-saving” PEP must be provided immediately. ▪ The observation period of 10 days is valid for dogs and cats only. ▪ If the animal is healthy throughout the observation period then we can skip the dose of DAY 14 & DAY 28. ▪ While using ID administration complete course of vaccination should be given irrespective of status of animal.
  • 44. DECISION TO TREAT ▪ Vaccination status of the biting animal: A history of rabies vaccination in an animal is not always a guarantee that the biting animal is not rabid. Animal vaccine failures may occur. Hence, appropriate documentation of vaccination status of dog/cat and proper history should be elicited before deciding to defer post- exposure prophylaxis after bite by vaccinated dog/cat. BETTERTO START PEP
  • 45. DECISION TO TREAT ▪ Provoked versus unprovoked bite: A provoked dog bite should also be managed as an exposure and PEP started immediately.A provoked bite does not mean that the biting animal is not rabid. It is difficult to understand what provokes a dog so it is prudent to start PEP at the earliest.
  • 46. DECISION TO TREAT ▪ Human to Human transmission: very rare. ▪ But if you gets contaminated by biting of a rabid human or saliva of a rabid human got contaminated with broken skin or mucous membrane  START PEP ▪ You drank milk of a rabid cow  NO NEED FOR PEP (rabies gets transmitted by saliva) ▪ BUT You got BITTEN by rabid cow  START PEP (every warm blooded animals has the potential to transmit rabies through their saliva) ▪ Irrespective when the patient is coming after the day of bite (i.e. after 2 months for eg ) and patient is asymptomatic or not & NO PEP given  START PEP because it has been reported of development of rabies after 1 year
  • 47. DECISION TO TREAT ▪ Bite by wild animals: treat as category III exposure. ▪ Bite by rodents: Exposure to domestic rodents, squirrel, hare and rabbits do not ordinarily require PEP. ▪ Bat rabies: Bat rabies has not been conclusively proved in India and hence, at present, exposure to bats does not warrant PEP. ▪ PEP in immune-compromised patients: RIG in both CAT II & III; CHECK ANTI RABIES ANTIBODY AT DAY14 IF <0.5 IU/ml GIVE ADDITIONAL DOSE
  • 48. Contraindications and precautions As rabies is nearly 100% fatal disease, there is no contraindication to PEP. Pregnancy, lactation, infancy, old age and concurrent illness are no contraindications for rabies PEP in the event of an exposure. PEP against rabies takes preference over any other consideration as it is a lifesaving treatment. Moreover, rabies vaccine does not have any adverse effect on pregnant woman, course of pregnancy, foetus or lactating mother. Hence, complete PEP should be given depending on the category of the exposure. People taking CHLOROQUINE for malaria treatment or prophylaxis may have a reduced response to ID rabies vaccination.These patients should receive the rabies vaccine INTRAMUSCULARLY.
  • 49. REMEMBER AND HAMMER YOUR MIND ▪ TREATING RABIES IS MUCH AND MUCH BETTER CHOICETHANTO LEAVE ▪ PEP CAN PREVENT RABIESVIRTUALLY 100% CASES AND NONTREATING CONVERTSTHE CASE INTO 100% FATALITY