Rabies

At the end of this presentation,

you will be able to:
Know what Rabies is
Know the nature of rabid animals
Know the mode of transmission
Identify signs and complications of rabies
infection
Prescribe, treat and refer infected person for
post-exposure prophylaxis
Assess, implement and manage appropriately
Know the prevention measures

Definitions
What is Rabies?
Brief history of Rabies
Statistics & Surveillance
Pathophysiology & Incubation
Signs & Symptoms
Physiology of the organism causing rabies
Mode of transmission
Prognosis & Complications
Management
Prevention
Summary
Reference

 The word rabies is taken directly from the Latin ,

and it means rage, a reference to the acute
neurological symptoms . The virus is classified as a
Lyssavirus, in a group of viruses which tend to be rod
or bullet shaped.
Prodrome an early or premonitory sign of a disease.
Pre-exposure & Post-exposure vaccine vaccine
administered before and after the rabies virus attack.
Rabid animals animals that causes rabies in human

CDC_MMWR (2007)

Rabies is a viral infection that attacks the central nervous system in

warm- blooded animals. It can be transmitted by rabid animals , and
caused by a neurotropic species of lyssavirus (Rhabdoviridae).
The virus normally affects the nervous system and the salivary gland.
The virus is often transmitted to humans when an infected animal's
saliva comes into contact with broken skin, such as with a bite or
scratch. Dogs, cats, skunks, wolves, foxes and bats.
In most cases, dogs are responsible for the majority of infections
globally, but in countries that vaccinate pets against the virus, or that
are generally rabies-free, wild animals like raccoons, bats and foxes
tend to be the source of infection.
Noah et al, (2009)

Rabies is an ancient disease. It is well described in writings by

Egyptians dating back to 2300 B.C. Rabies is caused by a virus
that is present predominately in the saliva of rabid animals. The
virus is transmitted by the bite of an infected animal.

Pasteur, Louis (1822-1895), French chemist and biologist, who

founded the science of microbiology, proved the germ theory of
disease, invented the process of pasteurization, and developed
vaccines for several diseases, including rabies.

Pasteur Louis Rabies (2007) Microsoft Encarta . Microsoft Corporation

Statistics
Geographical Distribution of Rabies in the world.

23%
34%

Americas
Asia
Pacific Ocenia
Europe

14%

Middle East

Africa
9%
15%

About 5% of rabies cases were reported

in the Pacific region where Australia
alone has lyssavirus cases from bats.

5%

CDC_MMWR (2007)

Statistics
Global Surveillance on Rabies
1. Global surveillance efforts and reporting standards differ dramatically, conditions may
change rapidly because of animal translocation, and bat rabies may exist in some areas
that are reportedly free of rabies in other mammals.
2. Bat lyssaviruses have been reported throughout Europe, including areas that are
reportedly free of rabies in other wild mammals.
3. Most of Pacific Oceania is reportedly rabies-free, with the exception of Australia,
where lyssaviruses in bats have been reported, as well as fatal human rabies cases.
PACIFIC Oceania

Australia, Cook Islands, Fiji, French Polynesia, Guam, Hawaii, Kiribati,

Micronesia, New Caledonia, New Zealand, Northern Mariana Islands, Palau, Papua
New Guinea, Samoa, Solomon Islands, and Vanuatu.

Mills et al, (2011)

Rabid Animals
It is important to remember that you cant tell
if an animal or your pet has rabies just by its
behavior.

Matrix protein
Envelope

Glycoprotein

Nucleocapsid protein

Source: http://www.cdc.gov

Physiology of the organism causing rabies

Noah et al, (2009)

CDC_MMWR (2007)

 The rabies virus is often transmitted through the saliva of

the dogs, cats, bats, squirrel and raccoons.
Rabies doesnt have to come from the bite of an animal.
Sometimes saliva exposure is enough to cause this deadly
disease. One of the most likely rabies exposure scenarios is
when people get exposed to sick bats, which they may
handle.
People who think they have been exposed to a sick animal,
even theyve not received a bite, should contact their
doctors immediately, because post exposure vaccination
works best if the first shot is given right away.
Emmons et al, 2011

Source: http://www.cdc.gov

Clinical course of rabies in humans

The following is a list of the clinical stages of human rabies infection. Not all of these symptoms may
occur in every case of human rabies.
(A) Incubation period - Usually 20-90 days; very rarely as long as several years.
There are no symptoms and the animals behavior remains normal during this period. This is the period of
time from the exposure to rabies virus until the animal finally becomes sick and/or acts differently and is
capable of infecting other animals or people. The incubation period can be as short as two weeks or in very
rare cases as long as one year.

(B) Prodromal Phase - lasting 2 to 10 days

-fever, anorexia (poor appetite), nausea, vomiting
-headache malaise, lethargy pain or paresthesia (numbness or tingling) at site of the bite.
(C) Acute Neurological Phase
-lasting 2 to 7 days hyperactivity, disorientation
- hallucinations, seizures, neck stiffness, hydrophobia or aerophobia (intense -fear of water or air caused by
pain from tightening of muscles in the -throat) paralysis or weakness.
(D)

Coma
- lasting 0-14 days.

(E) Death, or extremely rarely, recovery

Noah et al, 2009

Initial symptoms of rabies are very similar to flu.

Fever
Headache
Weakness
Discomfort
* Usually exhibited for 2-10 days

More Severe Symptoms

Insomnia

Excitation (altered
condition)

Anxiety
Confusion

Agitation (Vigourous
shaking)

Slight or Partial Paralysis

Hyper-salivation (foaming)

Hallucinations
Depression

Difficulty Swallowing

Hydrophobia (fear of water)

* Death usually occurs within days of the onset
of the more severe symptoms

 Early stage (1-3days)

fever (37.5-38)
vomit
wound: pain, red, itching
Exciting stage(1-3days)
fever (39-40)
hydrophobia: pharyngeal muscle cramp, dyspnea
dehydration
Paralytic stage (15-20hs)
nerve fiber paralysis
respiratory and circulatory failure (death).

Noah et al, (2009)

Pathogenic history- stray, wild & rage

Isolating the dog (7-10days)

- blood & saliva of the rabid animal
- euthanized the suspected animal

Diagnostic Tests
1. Cerebral smear or slice

2. Immune fluorescent stain

NB: Blood and saliva of the suspected rabid animal is not reliable method of diagnose for rabies. The
only sure method for determining if an animal has rabies is to look for the presence of the rabies
virus in the brain under the microscope with a special fluorescent antibody test technique.

Mills et al, (2011)

Prognosis & Complications

Prognosis

Rabies is a preventable disease.

Recovery is possible, but may have prolonged shedding for many months.

Increased awareness of sources and routes of virus transmission could save lives.

Complications
Incoordination, confusion, strange behavior. Attacking and biting moving and
stationary objects
Salivation (cant swallow, like choking)
Fear of water (hydrophobia)
Paralysis
Seizures

Prevention
Pre-exposure vaccine
People work in wildlife, zoos etc
Traveling to a country where rabies is
widespread. Consult your doctor.
Plan activity, esp to contact with animals. Eg
biologist, veterinarian and agriculture officers.
Travelling to remote place where medical care
is difficult to obtain.

CDC_MMWR (2007)

Pre-Exposure Vaccination
Although pre-exposure vaccination does not eliminate the
need for additional therapy after a rabies exposure, it
simplifies management by eliminating the need for rabies
immune globulin and decreasing the number of doses of
vaccine needed.

Gautret et al, (2012)

21

Management
Pre-exposure rabies prophylaxis
3 doses of rabies vaccine (days 0, 7, and 21 or 28)

Tissue culture vaccine: 1 dose IM or 0.1 ml ID

Day 0

21

28

If CHLOROQUINE malaria prophylaxis, give IM only

Rupprecht et al, (2004)

Primary Vaccinations
Type

Name

Route

Indications

Human Diploid
Cell Vaccine
(HDCV)

Imovax Rabies

Intramuscular

Pre-exposure or
Postexposure

Purified Chick
Embryo Cell
Vaccine (PCEC)

RabAvert

Intramuscular

Pre-exposure or
Postexposure

22

Gautret et al, (2012)

Weinmann et al, (2012)

Adverse Reactions to Rabies Vaccines

Most common side-effects of rabies vaccines:

Systemic reactions such as headache, myalgia,

malaise.
Mild to moderate local reactions at injection site.

CDC_MMWR (2007)

Management
Rabies post-exposure guide:
Exposure to dogs, cats, bats and foxes.
Evaluation of Animal

Recommendation

Healthy and available for 10

days observation

No treatment unless animal

develops clinical signs of
rabies

Rabid or suspected rabid

Immediate treatment*

Unknown (e.g., escaped)

Consult local public

health department

*Discontinue treatment if tests on animal prove negative.

Weinmann et al, (2012)

How to Prevent Rabies Infection

1. Get your pets vaccinated
The most common way for humans to get rabies infections is by way of
their pets. Having your dogs, cats, and ferrets vaccinated is an important
form of prevention, both for you and for them. Take your pets to the vet to
start the process right away.

Wikihow (Online,2015)

2. Supervise your pets when they're outdoors.

Do not allow them to come in contact with wild animals. Mammals like
squirrels, raccoons, opossums, and bats can carry rabies and pass them to dogs,
cats and ferrets by biting them. Keep your animals on a leash or behind a fence
to prevent this from happening.
The Center for Disease Control and Prevention (CDC) recommends keeping
cats and ferrets indoors at all times for this reason.
If you wish to let your dog loose in a natural area, talk with authorities about
whether rabies is a problem in that area beforehand.

CDC_MMWR (2007

3. Reduce the stray population in your neighborhood.

Have your pets spayed or neutered. This can help reduce the large number
of unwanted pets, most of which will not be vaccinated.
Ensure that your children are aware they should never handle stray
animals, wild or domesticated.

Wikihow (Online,2015)

4. Don't handle wild animals.

Do not handle, feed, or attempt to attract wild animals to your home. Do not
adopt wild animals. Being around wild animals puts you and your pets at risk
for contracting rabies.
When traveling, avoid contact with wild animals, especially dogs in
developing countries.
Do not attempt to nurse sick or wounded wild animals. Call your local
Animal Control Center or a veterinarian.
Take steps to prevent bats from entering living quarters or homes, schools,
workplace, and other similar areas, where they may come in contact with
people and/or pets.

Wikihow (Online,2015)

6. Be careful when you're abroad

Certain countries still have high rates of rabies infections. Consult with
a doctor, travel clinic, or your local health department before traveling
abroad. Ask them about the risk of exposure to rabies, pre-exposure
prophylaxis, and what you should do in case of an exposure to the
virus.
If traveling to a country where there is an increased incidence in rabies,
especially in canine populations, rabies pre-exposure vaccination may
be recommended

Rabies vaccination should also be

considered if you will be
spending lots of time outdoors
in rural areas or plan to handle
animals

Gautret et al, 2012

Treat the wound in the meantime

If it's going to be a few hours before you get medical attention,
you'll need to take steps to clean the wound:
Wash the bitten area with soap and water. According to the
World Health Organization, elimination of rabies virus at the site
of infection by chemical or physical means is the most effective
mechanism of protection.
Put ethanol or iodine solution on the wound. These are antiseptic
that works by killing sensitive bacteria

Wikihow (Online,2015)

3.Treatment
Go to the hospital and get the proper shots
If you've never had a vaccination, doctors will administer anti-rabies
immune globulin, which helps by inhibiting the spread of the virus from the
bite. No matter what, you'll need shots administered at the proper intervals.
A person who is exposed and has never been vaccinated against rabies
should get 4 doses of rabies vaccine with one dose right away, and an
additional dose scheduled on the 3rd, 7th, and 14th day. They should
also get another shot called Human Rabies Immune Globulin (HRIG)
at the same time as the first dose.
If you have already been vaccinated, you'll get 2 doses of rabies
vaccine, one taken right away and another on the 3rd day.

Wikihow (Online,2015)

Treatment
Recommended prophylaxis in exposed individuals not
previously vaccinated against rabies.
Wound site(s)

Immediate thorough cleansing of all

wounds with soap and water.
Tetanus prophylaxis; antibiotics

Human Rabies
Immune Globulin
(HRIG)

20 IU/kg body weight

Rabies Vaccine

IM (1 mL) in the deltoid area on days 0,

3, 7, 14, and 28

- As much of the RIG as possible

should be infiltrated in wound(s)
- The remainder should be given IM
at a site distant from vaccine

CDC_ MMWR (2007)

Remember
Rabies is a 100% vaccine preventable disease.
Vaccinate your pets.

Stay away from stray animals.

Appreciate wildlife from a distance.
Avoid stray animals, others pets or wild animals.
Always ask the owner or an adult before petting a dog, cat or any other
animal.
Never adopt wild animals or stray animals and bring them into your home
without consulting a veterinarian.

Prevent your pets from straying far away from your house.
Always wash the wound immediately with soap and water for at least 15
minutes.
37

Summary
Failure to recognize a risk of infection results in
human deaths.
Increased awareness of sources and routes of
virus transmission could save lives.
Pre-exposure vaccination should be used widely.
Post-exposure treatment is urgent.
For previously vaccinated people post -exposure
treatment is simpler, cheaper and more effective.

Reference
Centers for Disease Control and Prevention (2007) Human rabies prevention recommendations of the
Advisory Committee on Immunization Practices (ACIP). MMWR ;48 (5) (RR-1):1-21.

Emmons W, Leonard L, DeGenaro F Jr, (2011). Human rabies with prolonged survival. Lancet ;2 (13) 45-6

Pasteur, Louis", (2007). Rabies Virus. Microsoft Encarta [DVD]. Microsoft Corporation.
Gautret P, Parola P (2012). Rabies vaccination for international travelers. Vaccine. 30(2):12633.
Mills DJ, Lau CL, Weinstein P. (2011). Animal bites and rabies exposure in Australian travellers. Med J Aust. (9)
19 :1112
Noah DL, Drenzek CL, Smith JS, et al (2009)
Epidemiology of human rabies in the United States, . Ann Intern Med ; 8 (4) :922-30.

Rupprecht CE, Gibbons RV. (2004). Clinical practice. Prophylaxis against rabies. N Engl J Med. 87 (25) 2626
35.
Weinmann E, Majer M, Hilfenhaus J (2012) Intramuscular postexposure treatment of rabies virus infected
human. Communicable diseases. New York: Churchill Livingstone.
Wikihow (Online,2015) Rabies in Children
https://www.google.com.pg/search?q=Rabies+in+children-wikihow

Thank you

40