RABIES

(Hydrophobia, Lyssa)

Rabies is an acute viral encephalomyelitis caused by the rabies virus, a rhabdovirus , of the genus lyssavirus. It is fatal once signs and symptoms appear.

Rabies under a microscope

There are two kinds: urban or canine rabies is transmitted by dogs. sylvatic rabies is a disease of wild animals and bats which sometimes spread to dogs, cats and livestock.

PHILIPPINES: 200-300 deaths/ year

In 2010, 257 died of rabies, and in 2011, 202 deaths were reported. 1/3- less than 15 years old. At least 328,459 persons in 2011, and 266, 220 individuals in 2010 were bitten by animals. Dogs remain the principal cause of animal bites and rabies cases.

Mode of Transmission
Bites of a rabid animal whose saliva has the virus. Scratch or in fresh breaks in the skin (very rare). Transmission from man to man is possible. Airborne spread in a cave with millions of bats have occurred, although rarely. Organ transplant (corneal) taken from person dying of diagnosed CNS disease have resulted in rabies in the recipients.

Incubation Period The usual incubation period in 2 to 8 weeks. It can be as long as a year or several years depending on; the severity of wounds; site of the wound as distance from the brain; amount of virus introduced ; and protection provided by clothing.

Period of Communicability

In dogs and cats, for 3 to 10 days before onset of clinical signs (rarely over 3 days) and throughout the duration of the disease.

Susceptibility and Resistance: All warm-blooded mammals are susceptibility. Natural immunity in man is unknown.

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.

Signs and Symptoms in Man (Common)

Sense of apprehension Headache Fever Sensory change near site of animal bite Spasms of muscles or deglutition on attempts to swallow (fear of water / hydrophobia) Paralysis Delirium and convulsions. Without medical intervention, the rabies victim would usually last only for 2 to 6 days. Death is often due to respiratory paralysis.

PATHOPHYSIOLOGY
(Video)

PREVENTION

MANAGEMENT

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

Thoroughly clean ALL BITES AND SCRATCHES made by any animal with strong medicinal soap or solution. Responsible awareness. Report immediately rabid or suggestive of rabies domestic or wild animals to proper authorities (local government clinic, veterinarians or community officials). Pre-exposure to high risk individuals. Veterinarians, hunters, people in contact with animals (zoo), butchers, lab-staff in contact with rabies, forest rangers/caretakers. DOH Standard Protocol

If dog is apparently healthy, observe the dog for 14 days. If it dies or show signs suggestive or rabies, consult a physician. 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. If the dog is not available for observation (killed, died or stray), submit for immunization.

A cats brain for examination

*see DOH- Revised Guidelines on Management of Animal Bite Patients- 2007 for more complete guide

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

MANAGEMENT
NURSING INTERVENTIONS

HIGH RISK FOR INFECTION TRANSMISSION

KNOWLEDGE DEFICIT (about the disease, cause of infection and preventive measures)

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 self-contamination and spread of disease. assess patients and familys level of knowledge on the disease including concepts, beliefs and known treatment. Provide pertinent data about the disease: organism and route of transmission treatment goals and process community resources if necessary allow opportunities for questions and discussions

ALTERED BODY TEMPERATURE: FEVER RELATED TO THE PRESENCE OF INFECTION. Since fever is continuous, provide other modes to reduce discomfort.

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.

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.

OBJECTIVES:
To provide new policy guidelines and procedure to ensure an effective and efficient management for eventual reduction if not elimination of human rabies To increase voluntary pre-exposure coverage among high risk group (animal handlers, field workers, health staff working in rabies unit, rabies diagnostic lab staff, children 15 yo living in endemic areas.

SPECIFIC GUIDELINES AND PROCEDURES:

Management of Potential Rabies Exposure

3 CATEGORIES OF EXPOSURE
CATEGORY I Feeding/ touching an animal Licking of intact skin (w/ reliable history and thorough physical examination) Exposure to patient with signs and symptoms of rabies by sharing of eating or drinking utensils * 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
Nibbling/ nipping of uncovered skin with bruising Minor scratches/ abrasions without bleeding** Licks on broken skin

**includes wounds that are induced to bleed

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

CATEGORY III Transdermal bites or scratches ( to include puncture wounds, lacerations, avulsions) Contamination of mucous membrane with saliva (i.e. licks) 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. Handling of infected carcass or ingestion of raw infected meat All Category II exposures on head and neck area

*Does not include sharing of food/ drink/ utensils and casual contact with rabid patient

MANAGEMENT
Complete vaccination regimen until day 28/ 30 if:

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

IMMUNIZATION
ACTIVE IMMUNIZATION - induce antibody and T-cell production in order to neutralize the rabies virus in the body. 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. TYPES: a. PVRV (Purified Vero Cell Rabies Vaccine) b. PCEVC (Purified Chick Embryo Cell Vaccine)

PASSIVE IMMUNIZATION - RIG (Rabies Immune Globulins) - provide the immediate availability of antibodies at the site of exposure before it is physiologically possible for the pt.to begin producing his own antibodies after vaccination. - Important for pts. w/ Cat III exposures

Types: HRIG (Human Rabies Immune Globulins) Highly Purified Antibody Antigen Binding fragments ERIG (Equine Rabies Immune Globulins)

TREATMENT
POST-EXPOSURE TREATMENT (PET) A. LOCAL WOUND TREATMENT - Wash with soap/detergent and water preferably for 10 mins. - Apply alcohol, povidone iodine/ any antiseptic - Anti-Tetanus *Avoid suturing wounds *Dont apply ointment, cream/ wound dressing

 ANTIMICROBIAL - Amoxicillin - Cloxacillin - Cefuroxime *For those instances where theres no obvious signs of infection( Amoxicillin as prophylaxis )
***Educate the public simple local wound treatment & warn not to use procedures that may further contaminate the wounds

Post-exposure Prophylaxis
consists of 1 dose of rabies immunoglobulin (20IU/kg) and 5 doses of rabies vaccine over 28 days (days 0, 3, 7, 14 and 28)

VACCINATION (Intradermal Schedule)

Day of Immunization
DAY 0

PVRV/PCECV
0.1 ml

Site
L & R deltoids/ anterolateral thighs of infants L & R deltoids/ anterolateral thighs of infants

DAY 3

0.1 ml

DAY 7

0.1 ml

L & R deltoids / anterolateral thighs of infants L & R deltoids/ anterolateral thighs of infants

DAY 28/30

0.1 ml

Intramuscular Schedule
Day of Immunization Day 0 PVRV PCECV Site

0.5 ml

1.0 ml

One deltoid/ anterolateral thigh of infants

Same Same Same same

Day 3 Day 7 Day 14 Day 28

0.5 ml 0.5 ml 0.5 ml 0.5 ml

1.0 ml 1.0 ml 1.0 ml 1.0 ml

Special Conditions:
Pregnancy & infancy are not C/I to treatment Babies born of rabid mothers should be given ARV as early as birth as possible Alcoholics should be given standard IM regimen Immunocomrpomised individuals- IM

 Interchangeability of vaccine brands & shifting from one regimen to another is not recommended Bites of rodents, rabbits, guinea pig- no PET Dogs, cats, livestock, wild animals- give PET

PET Schedule for previously immunized patients:

Interval from the last dose < 1 month Give No booster

1 month- 6 months
> 6 months- 3 years > Than 3 years

1 booster dose
2 booster doses (D0, D3) Full course of active immun.

MANAGEMENT OF RABIES PATIENT

Once symptoms start, treatment should center on comfort care, using sedation & avoidance of intubation & life support measures once diagnosis is certain 1. a. b. c. MEDICATIONS Diazepam Midazolam Haloperidol + Dipenhydramine

2. SUPPORTIVE CARE - Pts w/ confirmed rabies should receive adequate sedation & 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 & provide important info. to relatives concerning transmission of dse. & indication for PET of contacts d. Honest gentle communication concerning prognosis should be provided to relatives of pt

3. INFECTION CONTROL a. Patient should be admitted in a quiet, draftfree, isolation room b. HLCR workers & relatives in contact w/ pt should wear proper personal protective equipment (gown, gloves, mask, goggles) 4. DISPOSAL OF DEAD BODIES

World Rabies day September 28 raise awareness about the impact of human and animal rabies, how easy it is to prevent it, and how to eliminate the main global sources

 Since the inaugural campaign in 2007, World Rabies Day events have been held in 135 countries; educating 150 million people and vaccinating 4.6 million dogs.

In the Philippines
National Rabies Prevention and Control Program Goal: To eliminate human rabies in the Philippines and Declare a Rabies free Philippines by year 2020

Rabies Free Visayas Project

In 2009, the Bill and Melinda Gates Foundation through WHO, provided support to three countries, Philippines included, in its program for rabies-free communities. Called "Rabies-free Visayas Islands Project", its goal is to declare the Visayas Region rabies-free zones at the end of project implementation. The project is jointly implemented by the Department of Health (DOH), as lead proponent, the Department of Agriculture (DA) and the local government units (LGUs). The main strategy is prevention of human rabies through the control and elimination of canine rabies

Activities include mass dog vaccinations, consultative meetings and planning workshops, advocacy meetings with LGUs, strengthening of rabies diagnostic laboratories, providing additional vaccines for post-exposure prophylaxis of animal bite patients, as well as promoting responsible pet ownership and surveillance.