INCIDENCE OF RABIES IN THE PHILLIPPINES :

Rabies continue to be a public health problem in the Philippines.

The country is one of the top 10 countries with rabies problem. It
is responsible for the deaths of 200 to 300 Filipinos per year. In
2010, 257 died of rabies, and in 2011, 202 deaths were reported.

At least 1/3 of deaths due to human rabies are among children

less than 15 years old. Animal bite cases has been increasing for
the past 5 years. At least 328,459 persons in 2011, and 266, 220
individuals in 2010 were bitten by animals. Almost half of rabies
exposures are among school children. Dogs remain the principal
cause of animal bites and rabies cases.

Region 5 has 26 rabies cases in 2011, the highest among the

regions. Bukidnon registered 13 cases, the highest among the
provinces in the country.

WHO supported Region 5, in partnership with the Department of

Education, in continuing its initiatives to include rabies program
activities in their elementary school curriculum. The region has
developed the teaching materials, as well as the monitoring and
evaluation tools to assess the practices of school children,
teachers and the community.

The Province of Kalinga was also supported by WHO. All mayors

were provided with orientation and advocacy to implement mass
dog vaccination, with the goal of eliminating rabies in both men
and animals.

RABIES PREVENTION AND CONTROL PROGRAM :

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

INTRODUCTION

The Davao animal bite treatment centre is located at A. pichon st,

poblacion district, davao city 8000 davao del sur ( behind office of
the city veterinarian)- . It is a new animal bite centre started on
August 2016. A veterinary clinic and the centre are located
together for the convenience and easy access of the people.

SET UP

The centre is open from Monday to Friday 8.30am to 4 pm with a

noon break between 12pm to 1 pm.The centre provides health
care for all patients exposed by animals which may be stray or
pet. The centres has a total of 9 employees including one doctor
consultant and 2 nurses provided by the government CITY

HEALTH OFFICE. The other employees include 4 assistants for

recording and assisting the details of the patients and 2 utility
staffs.

The centre has specific methods to follow up animal bite patients

and easily guided

TABLE 1 : assigned by one faulty member of centre who record

new patient registration and the interview of the new patient
taken down in patient health record.

PATIENT HEALTH RECORD contains patients personal data,

contacts, registration number , date of entry , weight, past
medical history , rabies exposure ( category of animal bite, type
of exposure , date exposure ), site of exposure, local wound
treatment , category of exposure , assessment management of
anti rabies regimen , anti tetanus injection and schedule.
CONSULTATION( DOCTOR): one acting health department
doctor ,who under take consultation over patients.

TABLE 2 : prioritization of patients and follow up injection ( old

patient).

TABLE 3: receiving of vaccine and record patient to logbook and

old patient follow for injection also recorded.
TABLE 4: filling up of treatment record and schedule of injection

TABLE 5: entry of data to masterlist, updates of follow up injection

of anti rabies vaccine (ARV)/rabies immunoglobin(RIG)to
masterlist

TABLE 6: for injection (ARV/RIG/TT) and handled by 2 working

nurse

BACK TO THE TABLE 5 : for health teaching

THE MANAGEMENT OF ANIMAL BITES AND RABIES EXPOSURE

This is the main algorithm of management practised in the centre

and patients are categorized into 3 based on the site of exposure
as follow

CATEGORY 1 : touching and feeding animal, licking by animal of

intact skin(with reliable history and through physical
examination , exposure to patient with sign and symptoms of
rabies by contact of eating or drinking utensils, casual contact ,
routine delivery of health care to patient with sign and symptoms
of rabies

Management : if the animal is not available for observation

( unknown, escape, sick, proven rabid) then RIG + full ( course of
vaccine) taken up further may opt discontinue vaccine or
continue as pre-exposure prophylaxis
If the animal is health then RIG + VACCINE ( observed for 14
days ) and may opt discontinue vaccine or continue as pre-
exposure prophylaxis
CATEGORY 2 : nibbling of uncovered skin with or without
bruising/hematoma, minor scratches/abrasions without bleed, all
category exposures on the head and neck area are considered
category 3 and should be managed as such.

Management: if the animal is not available for observation then

take up full course vaccine ( do not give RIG)
If healthy animal then give vaccine and observe for 14 days,
check for the condition of animal
Dies or sick ( sacrifice animal) : send head for laboratory
examination
POSITIVE or ( no exam) : continue vaccination ( no RIG)
NEGATIVE : may opt discontinue vaccine or continue as pre-
exposure prophylaxis .
CATEGORY 3: transdermal bites ( puncture wounds , lacerations ,
avulsions) or scratches/abrasions with bleeding and all category
2 exposure on the head and neck area .

Management : if the animal sick or proven rabid then give RIG +

full course of vaccine
If the animal healthy then give RIG + VACCINE observed for 14
days check for the condition of animal
Dies or sick ( sacrifice animal) : send head for laboratory
examination
POSITIVE or ( no exam) : continue vaccination ( no RIG)
NEGATIVE : may opt discontinue vaccine or continue as pre-
exposure prophylaxis.

VACCINATION

The vaccines are received from the DEPARTMENT OF HEALTH

(DOH) and provide to the patients for free except the Tetanus
Toxoid( TT) and the syringes are to be bought by the patients.
The vaccines available are 2 antirabies vaccines VERORAB &
RABIPUR , Antirabies serum(equine) and Tetanus toxoid and
vaccine are stored at +5degree celsius
PVRV( verorab) given intradermal( deltoid) about 0.1ml of dose of
two shots
PCECV(rabipur) given intradermal( deltoid) about 0.1ml of dose of
two shots.
ERIG(purified equine rabies immune globulin) about 40iu/kg
HRIG(human rabies immune globulin ) about 20iu/kg

OBSERVATION

The vaccines are given as in 3 doses of antirabies vaccines on day

0 day 3 day 7 with the exception of 4th dose on day 21 and
antirabies serum(equine) for category 3 patients. As Monday is
the first day of the week all patients come in for their first dose
making Monday to receive the maximum number of 200 patients.
The same goes for Thursday when patients come in for their
subsequent doses with 2 days interval. The centre receives
varying aged patients from 1 month old neonate to 80 yrs old
elderly person with mostly young patients. The patients are
accompanied by 1 companion and given given consultion by
doctor before receiving vaccination.The vaccination is done by 2
nurses intradermally for antirabies vaccines on both the arms and
intramuscularly on the deltoid muscle for the Tetanus Toxoid .
Upon request by doctor the more vulnerable patients are tested in
laboratory and if rabies positive they are immediately transferred
to Southern Philippines Medical Centre(SPMC).

RECOMMENDATIONS

Proper ventilation for the centre is required ( air condition).

For increasing the awareness among the patients large blow ups
regarding rabies is required.
For easy access of the patients all the table numbers should be in
big bold letters with the purpose is required.
To manage the crowding of patients token system can be
introduced .
strictly implementing patient to be accompanied by one person
only.
It could be better to assign one more working nurse for the
practise of centre
The comfort room is in good condition, hygienic and well
maintain.

ANIMAL BITE TREATMENT CENTRE

REACTION PAPPER
( community medicine )