RABIES Microbiology (dra De Castro)

Rabies
 Viral infection of animals VARIATION
 Excreted in saliva of an infected animal  Severity13ofDecember
bite 07
 Almost always fatal once symptoms appear  Site of bite in relation to nerve supply and distance
from CNS
ORDER: Mononegavirales  Size of inoculum, protection offered by clothing
 Non-segmented, negative stranded RNA genomes  Age and immune status of the host

Classified in Rhabdoviridae family CLINICAL MANIFESTATION

(bullet shaped)
 Lyssavirus – includes rabies virus Animal Rabies
 Ephemo virus  Sudden change in behavior
 Vesiculovirus  Characteristic hoarse howl
 Watchful, apprehensive expression of eyes, staring,
STRUCTURE blank gaze
 Approximately 180nm long & 75nm wide  Drooling of saliva
 Genome encodes 5 proteins:  Paralysis of lower jaw and tongue, inability to drink
a. Nucleoproteins (N)  Pralysis or uncoordinated gait
b. Phosphoprotein (P)  In some cases, lies quiescent, biting when provoked
c. Matrix Protein (P): associated with RNP & envelope  Marked excitability and restlessness pacing in cage
d. Glycoprotein (G)  If restrained, attacks objects within range, bites cage
e. Polymerase (L)  If at large, runs aimlessly, biting anything in its way
 2 major structural components  Depraved appetite, self-mutilation
1. helical ribonucleoprotein core (RNP)  Snaps at imaginary objects
2. envelope  Sudden death without associated s/sx

EPIDEMIOLOGY Prodromal Symptom

Asia  Lasts from 2 to 10 days
 >3.1 B people potentially exposed to dog bites  Non specific
 >35000 human rabies deaths (malaise, fatigue, headache, anorexia, nausea and
 98% from rabid dog bites vomiting, restlessness, ill defined anxiety, sore throat,
 >10 M PET annually fever, pain or paresthesia close to the site of exposure)
 >40% < 15 years old
Philippines 2 Clinical Forms
 400 cases or 6/M population annually  Encephalitic (Furious) rabies : 80%
 Dogbites >98% of cases  Paralytic (Dumb) rabies : 20%
 Almost 3000 lab confirmed
 (+) in almost all islands of the country A. Encephalitic or Neurologic Phase
 Region V (Central Luzon) II  Excessive restlessness
National rabies Control and Eradication Program, 1994  Increasing or uncontrollable excitement
 Annual consultation of 400000 cases  Agitation, confusion, hallucination, combativeness
 >80% require PET  Seizures, meningismus, opisthotonus, focal
 Only 15% receive PET paralysis
 DOG 98% responsible for all human rabies cases  Hydrophobia, foaming at the mouth
 CAT 1.3%  Aerophobia
 Others : <1% B. Dumb or Paralytic
RITM (2001)  Flaccid ascending, symmetric paralysis
 Dog bites # 1 consultation  Sensory abnormalities
 1500 new cases: >3000 ff-up/ mo  Decreased tendon reflexes
 27% : < 5 years  Coma
 65.5% : <19 yrs  Respiratory paralysis  death

Exposures
 Circulatory collapse  death
 Category III – 83%
DIAGNOSIS
 Category II – 16%
 High index of suspicion
 Category I – 1%
 History of animal exposure
TRANSMISSION  Clinical symptoms
 Fluorescent antibody staining : most rapid skin biopsy
 Bites of rabid animals
Early Intervention Holds The Key
 Licking of mucosa or open wounds

PERIOD OF COMMUNICABILITY  Once inoculated ( dog bite)

Virus starts growing at the site of wound
 Dogs and cats:
o 3-5 days before the onset of symptoms until
the entire course of the illness
 Once fixed to peripheral nerves
INCUBATION PERIOD
Virus begins to spread to the nervous system
 1 day to 5 years (8 weeks)
 Average IP : 10-90 days
 N = 707
 Once symptoms appear
 71% cases < 1 month
 87% cases < 3months
 Microbiology – Rabies by Dra De Castro Page 2 of 3

*no training for ID injections

Death in virtually 100% cases o 8 site ID regimen (8-0-4-0-1-1)
PVRV/ PDEV (0.1ml) ID
at 8 sites on day 0
WHO Recommendations on Rabies PET 4 sites on day 7
1 site on days 30,90
Category Tx Type of Contact Recommended *useful when RIG is unavailable or cannot given
I Touching or feeding of None, if reliable *deltoid, lateral thigh, suprascapular area and lower
animals – licks on history is quadrant of the abdomen D0. deltoid and thigh D7
intact skin available o 2-1-1 regimen (zaagreb)
II Nibbling of uncovered Administer PVRV (0.5ml) / PDEV (1.0ml) IM
skin vaccine at 2 sites on day 0
Minor scratches or immediately 1 site on days 7 and 21
abrasions w/o bleeding, * (+) potential suppression of antibody levels if used
licks on broken skin with RIG

III Single or multiple Rabies Ig + Active Immunization Against Rabies

transdermal bites or vaccine
scratches, immediately Regimen Dose No. of doses on specified days
Day
contamination of PVRV PDEV
Day Day Day Day Day
28/3
Day
0 3 7 14 21 90
mucous membrane w/ 0
saliva 2 site ID 0.1ml
0.2m
2 2 2 0 0 1 1
l
Standard 1.0m
0.5ml 1 1 1 1 0 1 0
IM l
BITE MANAGEMENT : RITM 8 site ID 0.1ml
0.2m
8 0 4 0 0 1 1
l
 If dog is > 1 yr old and vaccination certificate shows that it 1.0m
has received at least 2 doses of a potent vaccine, the 2-1-1 IM 0.5ml 2 0 1 0 1 0 0
l
patient may not need treatment.
 Observe dog for 10 to 14 days
Supportive Management
Indications of Admission
 Only patients requiring parenteral antibiotics for secondarily Local Wound Care
infected bites  Immediate vigorous washing and flushing with soap and
water, detergent or water
Laboratory Work-up  Apply alcohol, tincture or aqueous solution of iodine or
 None, unless bite wound is frankly infected povidone iodine
 Gm stain, C/S of wound discharge  Avoid or delay suturing of wounds.
If unavoidable, do so loosely
OBSERVE DOG for 14 days from time of bite Instill RIG deep into wound before suturing
 Anti-tetanus prophylaxis should be initiated
POST EXPOSURE TREATMENT (PET)
Antibiotic Prophylaxis
General Principles:  Administer prophylactic antibiotics to..
 To minimize the amount of virus at the site of inoculation all category III cat bites
 To develop a high titer of neutralizing antibody early and category III dog bites that are either deep, penetrating,
monitor it for as long as possible multiple or extensive
category III dog bites on the hand
Passive Immunization  Amoxicillin
 Human rabies Immune Globulin (HRIG)  For frankly infected wounds
20 U/kg on day 0 Cloxacillin or Co-Amoxyclav
Or  Other exposures (category I and II) may be given antibiotics
 Equine Rabies Immune Globulin (ERIG) only IF the wound is infected
40 U/kg on day 0 ANST
 If total computed dose is inadequate to infiltrate all wounds, GUIDELINES
it may be diluted 2-3 fold using sterile saline solution  Pregnancy is NOT a contraindication for treatment with
PVRV, however, nerve tissue vaccine is not recommended
 If RIG was omitted on day 0, it may still be given anytime
within the 1st 7 days after the initial dose of the vaccine  Persons consulting even after months of the bite should be
Active Immunization treated as 1st time consultation. If animal was healthy after
 Given : deltoid muscle in adults anterolateral thigh in young 14 days, no PET needed.
infants  Vaccine should never be given in the gluteal area
 Recommended Regimen  Avoid chloroquine, anti-epileptic drugs, systemic steroids,
o 2-site ID regimen (2-2-2-0-1-1) heavy alcohol consumption during vaccination 
o Purified Vero Cell Rabies Vaccine (PVRV) or interference
o Purified Duck Embryo Vaccine (PDEV) If cannot be avoided, use standard IM regimen
0.2 ml ID @ 2 sites on days 0, 3, 7 and 1 site on days  Treat cat bites as dog bites
30 and 90  Bites by rats, rabbits, rodents and bats rarely warrant
 Alternative Regimen vaccination
o Full IM regimen (Essen)
PVRV 0.5ml/ PDEV 1.0 ml on the deltoid on days POST EXPOSURE PROPHYLAXIS
0,3,7,14,28
 Microbiology – Rabies by Dra De Castro Page 3 of 3

WHY?
To protect even in case of inapparent
Exposure or in case of delayed PET
To simplify PET
To avoid the need for RIG administration

WHO?
Subjects at permanent risk MUST be vaccinated
working with rabies virus dx’tic,
research, production lab staff
Subjects at frequent risk contact SHOULD be vaccinated
with sensitive animals
In enzootic areas due to
profession (veterinarians)
Pastime or travel
Children, more likely SHOULD be particularly
To be exposed considered

HOW?
Regimens:
PVRV (0.5ml) or PDEV (1.0ml) IM Or 1 site on
PVRV (0.1ml) or PDEV (0.2ml) ID days 0, 7, 28
Booster dose q 1-3 years

HOW To Prepare and Transport the Animal’s Head

1. Place the head in leak proof container  bigger container
with liberal amounts of ice/dry ice
2. Label with owner’s name, date of preparation and words “
CAUTION: RABIES SUSPECT ”
3. Freeze if transit time will be >48
i. If kept in room T not > 12 hours from death of
animal
ii. If kept in ref for a period not > 2 days
iii. If kept in frozen condition
4. DO NOT put head in any chemical disinfectant or
preservative

“If your patient with rabies survives, it only means the

diagnosis was wrong”