Dave Jay S. Manriquez RN.

I E

FAST FACTS
DEFINITION: An acute infectious disease of warm-blooded animals characterized by involvement of the nervous system resulting in death. It is caused by the RABIES VIRUS, a rhabdovirus of the genus lyssavirus.

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. LYSSAVIRUS: Greek frenzy. family Rhabdoviridae. A genus of the

There are 2 kinds of rabies. URBAN or CANINE RABIES are transmitted by dogs. SYLVATIC RABIES are transmitted from wild animals and bats which sometimes spread to dogs, cats and livestock. MODE OF TRANSMISSION: It is commonly communicated to man through the saliva of an infected mammal by an exposure to an open break in the skin such as bites 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.

MEDIA OF TRANSMISSION: Through saliva, tears, urine, serum, liquor and other body fluids.

INCUBATION PERIOD: The period between the exposure to the virus to the occurrence of the first symptom, is usually 2-8 weeks. It may be as short as 4 days or as long as 2 years depending on depth of laceration and site of wound. The virus moves along nerve axons passively about 3 millimeters per hour. It is not known how the virus remains viable or where it is located during prolonged incubation period.

SUSCEPTIBILITY AND RESISTANCE: All warm-blooded mammals are susceptible. immunity in man is unknown.

Natural

DIAGNOSIS: There is yet no way of immediately segregating those who had acquired rabies infection from those who had been bitten by non-rabid sources. 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 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.

 True rabies must be distinguished from RABIES HYSTERIA, a psychological condition in persons who think they have been bitten by a rabid animal. In such cases, a patient ordinarily attempts to emulate convulsive seizures. Patient receiving rabies vaccine treatment may develop paralysis attributable to a sensitization caused by the rabbit brain material in the vaccine. This paralysis may simulate paralytic rabies and may produce symptoms referable to cranial nerves, such as difficulty swallowing, paralysis of the masseter muscles and unilateral or bilateral facial paralysis. Encephalitis without paralysis may be caused by the vaccine treatment and in such cases the disease begins with high fever and headache with may be followed by convulsions and coma.

I.EPIDEMIOLOGY
RABIES IN THE PHILIPPINES
Although rabies is not among the leading causes of disease and death in the country it has become a public health problem of significance for two reasons: it is one of the most acutely fatal infections which causes the death of between 200-500 Filipinos annually, and the Philippines ranked number six among the countries with the highest reported incidence of rabies in the world. 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. Since the Philippines is highly endemic of rabies, voluntary pre-exposure prophylaxis among people who are at risk, like pet owners, animal handlers, health personnel working in anti-rabies units and children below 15 years old, is a must. Data shows that 53.7 percent of animal bites patients are children. 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. Dogs remain the principal animal source of rabies. Although a great majority of animal bites are non-infected with the rabies virus, animal control and other public health measures are undertaken because of the high case fatality rate for rabies. It is hard to make a definite early diagnosis of rabies, and the disease almost always leads to death even when vaccination and medical management are given as soon as the symptoms have set in. Further, the cost of post-exposure vaccination against rabies can be prohibitive.

II. PATHOPHYSIOLOGY

Rabies virus

Entry into break in skin (bites, abrasions, mucosa)

Incubation period (4 days 2 years)

Imminent thoracolumbar involvement (PNS): Pupillary dilation, lacrimation, increased thick saliva production / foaming of mouth, excessive perspiration Anxiety & fear Hydrophobia Pronounced muscular stimulation & general tremor Mania & hallucinations with lucid intervals Convulsions

INV A SION PHA SE

Pain Fever Headache Malaise Sore throat Anorexia Increased sensitivity

EX CITEM ENT PHA SE

PA RA LY TIC PHA SE
( DEPRESSI PH ON ASE)

coma

Gradual weakness of muscle groups: muscle spasms cease , ocular palsy, vertigo, facial & masseter palsy, weakness of muscles of phonation, loss of tendon reflexes, neck stiffness (+)Babinski [lesions at pyramidal tract], (-) Kernigs, (-) Brudzinskis HR shifting from tachycardia (100-120) to bradycardia (40-60) Cheyne-Stokes respiration Local sensation diminshed (pain, heat, cold) Incoordination General arousal Bladder & intestinal retention (damage to the innervation of the musculature of intestine & bladder) Hydrophobia disappear but with slight difficulty swallowing insom cases, pat show periodofrecov e ient s ery, thisapparentrem issionisfollow byrapid ed progressiv paraly e sis Ascending paralysis ,flaccid paralysis of extremities until it reaches the respiratory muscle Apathy, stupor

Death

III. SIGNS & SYMPTOMS (most common)

Sensory change on or near the site of entry Fever Laryngeal spasm Sense of apprehension, anxiety, irritabilty Headache Delirium Insomnia Convulsions Salivation or foaming of the mouth Acute attack: fever, muscle twitching, hyperventilation and excess salivation

The usual duration is 2-6 days without medical intervention. Death is often due to convulsion or respiratory paralysis.

IV. MANAGEMENT
A. PREVENTION
1. Responsible pet ownership a) pet immunization, esp. cats, usually starting at 3 months of age and every year thereafter b) dont 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

2. Thoroughly clean ALL BITES AND SCRATCHES made by any animal with strong medicinal soap or solution. 3. Responsible awareness. Report immediately rabid or suggestive of rabies domestic or wild animals to proper authorities (local government clinic, veterinarians or community officials). 4. Pre-exposure to high risk individuals. Veterinarians, hunters, people in contact with animals (zoo), butchers, lab-staff in contact with rabies, forest rangers/caretakers. 5. DOH Standard Protocol a) If dog is apparently healthy, observe the dog for 14 days. If it dies or show signs suggestive or rabies, consult a physician. b) 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.

c) 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

B. MEDICAL INTERVENTIONS

a. Local wound treatment. Immediately wash wound with soap and water. Treat with antiseptic solutions such as iodine, alcohol and other disinfectants. b. Antibiotics physician. and anti-tetanus as prescribed by

c. 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)

C. NURSING INTERVENTIONS 1. 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 selfcontamination and spread of disease.

2. KNOWLEDGE DEFICIT (about the disease, cause of infection and preventive measures) assess patients and familys level of knowledge on the disease including concepts, beliefs and known treatment. Provide pertinent data about the disease: a. organism and route of transmission b. treatment goals and process c. community resources if necessary allow opportunities for questions and discussions 3. 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. 4. 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.

SOURCE:
Tabers Cyclopedic Medical Dictionary 17th Edition. 1994. Singapore: Davis Company. Department of Health.2000. Community Health Nursing Services in the Philippine Department of Health, 9th Edition.Philippines.DOH Smeltzer, Suzanne and Bare, Brenda. 2000. Brunner & Suddarths Textbook of Medical-Surgical Nursing, 9th Edition. Philadelphia: Lippincott Williams and Wilkins

(DOH- Revised Guidelines on Management of Animal Bite Patients- 2007)

MANAGEMENT OF POTENTIAL RABIES EXPOSURE

I. CATEGORIES OF EXPOSURE TO A RABID ANIMAL OR TO ANIMAL CATEGORY I a. Feeding/ touching an animal

b. Licking of intact skin (w/ reliable history and thorough physical examination) c. Exposure to patient with signs and symptoms of rabies by sharing of eating or drinking utensils * d. Casual contact to patient with signs and symptoms of rabies* Management: 1. Wash exposed skin immediately w/ soap and water 2. No vaccine or RIG needed
*Pre-exposure vaccination may be considered

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

Management:

a. Complete vaccination regimen until day 28/30 if: 1. Animal is rabid, killed, died OR unavailable for 14- day observation or examination OR 2. Animal under observation died within 14 days and IMMUNOFLOURESCENT ANTIBODY TEST positive (IFAT +) OR no IFAT testing was done OR had signs of rabies b. Complete vaccination regimen until day 7 if: 1. Animal is alive AND remains healthy after 14- day observation period 2. Animal under observation died within 14 days but had no signs of rabies and as IFAT- negative.
CATEGORY III a. Transdermal bites or scratches ( to include puncture wounds, lacerations, avulsions) b. Contamination of mucous membrane with saliva (i.e. licks)

c. 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. d. Handling of infected carcass or ingestion of raw infected meat e. All Category II exposures on head and neck area
*Does not include sharing of food/ drink/ utensils and casual contact with rabid patient

Management:

a. Complete vaccination regimen until day 28/ 30 if: 1. Animal is rabid, killed, died OR unavailable for 14 day observation or examination OR 2. 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 b. Complete vaccination regimen until day 7 if: 1. Animal is alive AND remains healthy after 14-day observation period. 2. Animal under observation died within 14 days but had no signs of rabies and was IFAT- negative

II. POST- EXPOSURE TREATMENT

CONCEPT OF THERAPY/ REMEDY: removal or neutralization of infectious virus before it enters the Nervous System

1. Local Wound Treatment - Soap and water - Alcohol, povidone iodine or any antiseptic - Suturing of wounds should be avoided - Dont apply any ointment, cream/ dressing - Anti-tetanus immunization

2. Antimicrobial - Amoxicillin/ clavulanic - Cloxacillin - Cefuroxime axetil 3. Vaccination - Updated 2- Site Intradermal Schedule - Standard IM Schedule

MANAGEMENT OF RABIES PATIENTS

(DOH- Revised Guidelines on Management of Animal Bite Patients- 2007)

Considering the fatal outcome and lack of cure for human rabies once symptoms start, treatment should center on comfort care, using sedation and avoidance of intubation and life- support measures once the diagnosis is certain. 1. Medications any of the ff. Regimens may be used:

a. Diazepam b. Midazolam c. Haloperidol plus Dipenhydramine this regimen has been used at San Lazaro Hospitald 2. Supportive Care Patients with confirmed rabies should receive adequate sedation and comfort care in an appropriate medical facility. a. Once rabies diagnosis has been confirmed, invasive procedures must be avoided. b. Provide suitable emotional and physical support. c. Discuss and provide important information to relatives concerning transmission of disease and indication for post- exposure treatment of contacts d. Honest gentle communication concerning prognosis should be provided to the relatives 3. Infection Control a. Patients should be admitted in a quiet, draft- free, isolation room. b. Healthcare workers and relatives coming in contact with patients should wear proper personal protective equipment (PPE) including gown, gloves, mask, goggles 4. Disposal of dead bodies a. Humans who have died of rabies generally presents a small risk of transmission to others. There is evidence that blood does not contain virus but that the virus is present in many tissues such as the CNS, salivary glands and muscle. It is also present in saliva and urine. b. Embalming should be discouraged c. Performing necropsies carelessly can lead to mucous membrane and inhalation exposures

d. Wearing protective clothing, goggles, face mask and thick gloves should provide sufficient protection. e. Instruments must be autoclaved or boiled after use. f. Early disposal of the body by cremation or burial is recommended.

Rabies is a human infection that occurs after a transdermal bite or scratch by an infected animal, like dogs and cats. It can be transmitted when infectious material, usually saliva, comes into direct contact with a victims fresh skin lesions. Rabies may also occur, though in very rare cases, through inhalation of virus-containing spray or through organ transplants. Rabies is considered to be a neglected disease, which is 100% fatal though 100% preventable. It is not among the leading causes of mortality and morbidity in the country but it is regarded as a significant public health problem because (1) it is one of the most acutely fatal infection and (2) it is responsible for the death of 200-300 Filipinos annually.

Vision: To Declare Philippines Rabies-Free by year 2020

Goal: To eliminate human rabies by the year 2020

Program Strategies: To attain its goal, the program employs the following strategies: 1. Provision of Post Exposure Prophylaxis (PEP) to all Animal Bite Treatment Centers (ABTCs) 2. Provision of Pre-Exposure Prophylaxis (PrEP) to high risk individuals and school children in high incidence zones 3. Health Education Public awareness will be strengthened through the Information, Education, and Communication (IEC) campaign. The rabies program shall be integrated into the elementary curriculum and the Responsible Pet Ownership (RPO) shall be promoted. In coordination with the Department of Agriculture, the DOH shall intensify the promotion of dog vaccination, dog population control, as well as the control of stray animals. In accordance with RA 9482 or The Rabies Act of 2007, rabies control ordinances shall be strictly implemented. In the same manner, the public shall be informed on the proper management of animal bites and/or rabies exposures. 4. Advocacy The rabies awareness and advocacy campaign is a year-round activity highlighted on two occasions March as the Rabies Awareness Month and September 28 as the World Rabies Day. 5. Training/Capability Building Medical doctors and Registered Nurses are to be trained on the guidelines on managing a victim.

6. Establishment of ABTCs by Inter-Local Health Zone 7. DOH-DA joint evaluation and declaration of Rabies-free islands

Program Achievements: The DOH, together with the partner organizations/agencies, has already developed the guidelines for managing rabies exposures. With the implementation of the program strategies, five islands were already declared to be rabies-free. In 2010, 257 rabies cases and 266,200 animal bites or rabies exposures were reported. A total of 365 ABTCs were established and strategically located all over the country. Post Exposure Prophylaxis against rabies was provided in all the 365 ABTCs.

Partner Organizations/Agencies: The following organizations/agencies take part in attaining the goal of the National Rabies Prevention and Control Program:

Department of Agriculture (DA) Department of Education (DepEd) Department of Interior and Local Government (DILG) World Health Organization (WHO) Animal Welfare Coalition (AWC) BMGF Foundation WHO/BMGF Rabies Elimination Project
1. 2. 3. Bill and Melinda Gates Foundation World Society for the Protection of Animals (WSPA) Medical Research Council (MRC)

March is Rabies Awareness Month and September 28 is World Rabies Day!

March is Rabies Awareness Month and September 28 is World Rabies Day! Rabies is 100% fatal viral disease affecting the nervous system of humans and animals. It remains a serious public health problem in the country which causes the death of between 200 - 500 Filipinos annually, and the Philippines ranked No. 6 among the countries with the highest incidence of rabies in the world. A three-pronged approach dog immunization, responsible pet ownership and dogbite victim immunization is still recommended for all government units to control rabies in their areas of responsibility. The rabies prevention and control program received its needed boost when President Gloria Macapagal-Arroyo signed into law the Republic Act No. 9482 (An Act Providing for the Control and Elimination of Human and Animal Rabies, Prescribing Penalties for Violation Thereof and Appropriating Funds Therefore) on May 27, 2007. This next three years, the

Department of Health, Department of Agriculture Bureau of Animal Industry, local government units and partner agencies will advocate for the full implementation of the law nationwide. The battlecry is SUMUNOD SA BATAS RABIES. Meanwhile, the said agencies are also gearing up their efforts towards the goal of declaring the Philippines as Rabies-Free by the 2020.