Department of Health and Department of Agriculture

February 2,2411 DEPARTMENT OF I{EALTH ADMINISTRATIVE ORDER NO.

2 O II

OOO2

DEPARTMENT OF AGRICULTURFADMINISTRATIVE ORDER NO. ? I

SERIES 2011

SUBJECT:

AI\D CATS.

BACKGROI JIID/RATIONALE
Rabies, present in all continents and endemic in most African and Asian countries, is a fatal zoonotic viral disease, transmitted to humans through contact with infected per animals, both domestic and wild. Rabies is estimated to cause at least 55,000 deaths year worldwide, about 56% of which occur in Asia and 43.6Yo in Africa" particularly in rural areas on both continents. In the Philippines, although rabies is not among the leading causes of morbidity and mortality, it is considered a significant public^health probleir for several reasons: l) it is one- of the most acutely fatal infections; 2) it is responsible for the death of 200-fOO Filipinos annually and 3) post-exposure prophylaxis (PEP) for victims of animal bites entails considerable expense' The Departrnent of Health and Department of Agriculture continues to be committed to the fighi against rabies and has set the goal of rabies elimination in 2020. An essential part of tttir tttut"gy is the provision of Fnp to bite victims as mandated by the Antiitabies Act of 2007. pursuant thereto, guidelines for the appropriate as well as costeffective management of animal bite patients have been issued.

(5) Historically the management of animal bite cases had to be updated every five years and the guidelinesleed to be revised accordingly to incorporate new and better ireatnent modalities based on research results and recommendations of inte-rnational 3'd in 2007 bodies. The first revision was made rnlggT,the second in2002 and the which was amended in 2009.

of the latest guidelines in 2009, the issue on the management of been rabies exposure secondary to bites from vaccinated dogs and cats has not in many for4 adequately addressed. Thii has been consistently raised by veterinarians particulariy the issue on g1ing PEP to all bite cases even those involving vaccinated iogs and cats. Given the above situatiorU a joint DA- DOH Administrative Order is
Since the release hereby

issued.

U.

DECLARATION OF POLICIES
These operational guidelines shall be guided by- fhe follou{ng legal mandates md policies: A. Republic
9482 or the Anti-Rabies Ae of 2O$7 * An Act Providing for the Cantrol ^ct and Elimination of Humam and Animal Rabies, Prccribing Penalties for Violation Thereof and Appropriating Funds Therefor.

B. Memorandum

of Agrement entered into by the Secretaries of the Department of Agriculture, Health, Education, Culture and Sport and &e Interior and Local
Gor,-ernment on May 8,

l9gl.

C. Batas Pambansa
D.

Blg. 9? - An Act Pro*.iding for the Compulsory Immunization of Livestock, Poultry and OtherAnimals Against Dangerous Communicable Diseases.
DOH Administratile Order iqol eoOZ- 0o29: Guidelines on Management of Animal Bite Patients

E.

DOH Administrdiv-e Order No. 2009- 0027: Amendment to AO 2W7regarding the Revised Guidelines on Management of Animal Bite Patients

OO29

A. WHO Expert Consultation on Rabies. WHO Technical Report Series 931 First Report
2AA5

ilr.

GOALS AI{D OBJECTIVES

To provide updated guidelines and procedures to ensure the effective and efficient rnanagemefi of rabies xposures toward eventual reductioq ifnot eliminatiorq of human
rabies

rv.

SCOPE AND COVERAGE

heatth workers at atl levels shall adopt these Post Exposure Prophylaxis (PEP) guidelines to eRsure standardized and rational management of animal bite patients. Private practitioners in the country are strongly encouraged to adopt these guidelines.

All govemment

v. DEFINITION OF TERMS A. Post Exposure Proplryla:ris

(PEP) - formerly post enposrre ireafinent (PETi; refers to mti-rabies treafrnent administered afier anexposure {such as bitg scratctr, lick, etc-) to poteirtially rabid animals- It includes local wound carg administration of rabies vaccine with or without Rabies Immune Globulin (RIG) deffdir on the calegory of exposure. Updated rabis vaccindion- Dog/cat mustbe at least 1 yr6 nnnths old and has updatd vaccination certificate from aduly licensed veterinarian for the last 2 years with the last vaccination within the past 12 months. Rabid Animal - refers to biting animal with clinical manifestation of rabies and/or confirmed laboratory findinss of rabies.

B.
C.

vr.

GENERAL GUIDELII\{ES

A. The Department

of Health in collaboration with the LGUs shall be resporxible

for the managernnt of animal bite victims including provision of human rabis vaccine to alrgmenl stryplies of the LGUs. B. The Rabies Control Prograrn shall be integrated with the regular health
services provided by local health facilities.

C. PEP shall be carried out both by the

D.

E.

F.

Departrrnent of Health and Local Govemment Units. The funding requirements to operationalize this issuance shall be secured prior to its implementation. Advocacy througfu informafion dissernindion and training of health workers shall be conducted at all levels. Collaboration among govemment agencies, non-govemment and private organizations to ensure successful implementation shall be sre,ngthend.

VII. SPECIFIC GUII}ELINES AND PROCEDURES :

A.

Categorizatioa of Babies Exposurrc:

Table
Category of exposune

l.

Categories of Rabies Expsure Type of ExFlsune

CATEGORY

a)
b)

Feeding/touching an animal

Licking of intaa skin (with reliable history and thorough physical examinaion)
Expozure to patient with signs and rymptoms of rabies by sharing of eating or drinking utensils
Casual contact (talking to, visiting and feeding suspected rabies cass) and routine delivwy of health care to pdient with signs and

c)
d)

symptoms of

rabie

CATEGORY

II

a) Nibbling of uncovered skin with orwithout

bruising/hematoma

b)

Minor scratcheslabrasions without bleding Minor scratches/abrasions which are induced to bleed

c)

d) All Category II exposrnes on the head and nwk area are considered
Category

III

and should be managed as such

CATEGORY

III

a)
b)

Transdermal bites (puncture wounds, lacerations, avulsions) or scratches/ abrasions with spontaneous bleeding

Licks on broken skin

Expozure to a rabis patient through bites, contarrirdion of mucous membranes (eyes, oral/nasal mucos4 gelritayanal mucous membrane) oropen skin lesions with body fluids through splattering and mouth'to-mouth resuscitation.

c)

d)

Handling of infected carcass or ingestion of raw infected meat

expos.nes onhead and neck area

e) All Category il

B.

Managernent

I. PEP is not rccomnended for all Categorlr I exmsurcs. providd that ALL of the II. PEP can be delayed for @

following conditions are satisfied: i. Dog/cat is healthy and available for observation for 14 days ii. Doglcat was vaccinated against rabies for the past 2 years. a- Dog/cat must be at least 1 yr 6 monttu old and has updated vaccination certificate from a duly licersed veterinarian for the
last 2 years

The last vaccination must be within the past 12 months, the immunization status af the do$cat will not be considered updated if the animal is not vaccinatsd on the due date of the next vaccinalion * If biting dog/cat becomes sick or dies within the observation period, PEP should be started immediatelv

b.

III.

PEP should bc given immediatety for ANY of the following conditions: Ths rabies s(posure is caregory III;

i. ii.

The dog/cd is proven rabidlsicld dead with no laboratory exam for

rabies/not available before or during ihe consultation; The dog/cal is involved in at least 3 biting incidr$s within 24 hows or Doglcat manifests the following behavior change zuggestive of rabies before, during or after the biting incideirt:

iii. iv.

Table 2. Clinical Si of Animal Rabies (uzuallv lasts 2-3 davs: sometime onlv a few hous) Prodromal Stace A. Changes in attitude/behavior/temperanrent sudr as unusual shyness or
aggressiveness

b. Solitude c. Rstlessness d. Snapping at imaginary e. Apprehension

Friendly animal becomes aggressive

objects

Anxiefy Brkiag/vocalization at the slightest provocation B. Dilated pupils; become myotic in advance state C. Mydriasis and/or sluggish palpebral or comeal reflexes D. Slisht rise in body temperature (slisht fever) Clinical Rabies Furious Stage (usually lasts 1-7 days) ParalSrtic (dumb) shge (develops 2-10 days after clinical signs; usually last2-4

f g.
h.

Nervousness

Increased response to auditory and visual stimulation such as

davs) Paralysis
a Paralysis may begin at the

o o I r t o r r

bite

II.

Restlssness Photophobia Hyperaesthesi4 Eating unusual objects Aggression Attacking any live or inanimate objects

area

And progress until entire CNS

involvement Following paralysis of the head and neclg the entire body becomes paralyzs Change in tone of vocalization/barking (indicative of laryngeal/phryngeal paralysis) Hypersalivation or frothing ; drooling/slobbering of saliva (indicative of taryngeaVpharyngeal paralysis) Dysphagia/diffi culty/inability to swallow (indicative of laryngeaVpharyngeal paralysis) "Jaw drop"/Dropped jaw due to masseter muscle paralysis (suspects foreign body in mouth or esophagus) Pupil dilation or pupil constriction Protrusion of third eyelid Ataxia, progressive paralysis and cannibalism (terminal stage) Coma andlor respiratory paralysis resulting in death within 24 davs

Erratic behavior

Bitingor snapping Licking or chewing of

wound/bite site
caged, biting of their cage Wandering and roaming

o o o

If

Excitabili8: rtrritability;

Vicioumess

III. Sellmutilation
IV. Muscular in-coordination and
seizures

V.

Disorientation

Roams and bites

inanimate object and also other animals including

ilun

IV. VIIL

PEP is not required for bite/s of the following biting animals: rds, mousg rabbits, makes and other reptiles, birds and other avian, insects and frsh.

IMPLEMENTINGMECHANISM:

Roles and Responsibilities Departrnent ofHealth

i.

1. The National Center for

2.

Disease Prevention and Control {NCDPC) shall be rmponsible for disseminating &is Joint AO to all Centers for Health Development. All Centers for Health Developmort (CHD) through the Directors and the Rabie Control Program Coordinators shall ensure that this Joint AO is disseminated to all ProvinciaUCity/Ivlunicipal Health Offices, Animal Bite Treatrnent Centers and private practitioners, hospitals and animal bite clinics in their respective regions.

ii"

Department o f Agriculture The Bureau of Animal Industry (BAI) shall be responsiblq for disseminating this Joint AO to all DA- Regional Field Units 2. The Department of Agriculture - Regional Field Units (DARFUs) ttnoughthe Regional Executive Directors and the Rabies Control Program Coordinators shall ensure that this Joint AO is disseminated to all ProvinciaVCity/Municipal Veterinary Offices or their equivalents in their respective

l.

regions.

I|L Local Govemment Units:

The Provincial Health Offices shall be responsible for disseminating this Joint AO to all Cityllvlunicipal Health Offices, Animal Bite Treatment Centers and private practitioners, hospilals and animl bite clinics in their rspective provinces. Likewise, The Provincial Veterinary Offices shall be responsible for disseminating this Joint AO to all City/efmicipal Veterinary Offices or their equivalents in their respective provinces.

Ix.

REPEALING CLAUSE

The provisions of the National Rabies Prevention and Control Program Manual of Operations, National Rabies Cornmittee CY 20Sl and any other issuances inconsistent here$.ith are hereby rescinded"

X.

EFFECTTYITY
This order shall take effect immediatel-v.

* !=7.

isE=l F Eg Ei
3
ENRTQUE T. ONA, MD, FPCS, FACS Secretarv of Health

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