ANIMAL-ASSOCIATED HAZARDS

Anak Agung Ayu Yuli Gayatri

Tropical and infectious disease division
Internal Medicine Department Sanglah Hospital/ Udayana University
Abstract
Rabies, Herpes B and envenoming are the diseases that result from bites by rabid mammals or
bites and stings by venomous animals, especially snakes and scorpions. In all cases, appropriate
early treatment, including therapeutic anti-sera, can prevent life-threatening systemic spread of
the virus or venom toxins.
Mammals Bite or Scratch Wounds
Animal bites present a risk for rabies, herpes B, tetanus and other bacterial infections. Animals
saliva can be so heavily contaminated. Rabies is present on all continents with the exception of
Antartica, but more than 95% of human deaths occur in Asia and Africa. Rabies occurs in more
than 150 countries and territories. Worldwide, more than 55 000 people die of rabies every year,
and 40 % of people who are bitten by suspect rabid animals are children under 15 years of age.
Dogs are the source of 99% of human rabies deaths. Rabies virus, a rhabdovirus present in
infected animals saliva is inoculated into the bite wounds, enter peripheral nerves and spreads to
the central nervous system where it causes a lethal encephalomyelitis. Fortunately the
availability of efficacious and save vaccines and immunoglobulin has prevented many fatalities
and almost 10 million people receive post exposure treatment annually after potential rabies
exposure, mostly following dogs bites. In Addition, increase public and clinician awareness
about the risk associated with an injury from a macaque, improved first aid after exposure, the
availability of better diagnostic test, and improved antiviral therapeutics have decreased the casefatality ratio to 20% in treated people.
Once clinically established, rabies encephalomyelitis is almost invariably fatal, but the disease is
entirely preventable provided that complete post exposure prophylaxis in implemented promptly.
To mitigate the risk of exposure to rabies and herpes B, dogs, monkeys, bats, and other mammals
should be avoided. Although only macaque bites pose a herpes B virus, any monkey bite may

pose a threat for rabies. Before departure, travelers should have a current tetanus vaccination or
documentation of having received a booster vaccination within the previous 5-10 years. Travel
health provider should assess a travelers need for pre-exposure rabies immunization. In order to
prevent infection, all wounds should be promptly cleaned with soap and water, and the wound
promptly debrided, if necrotic tissue, dirt or other foreigner materials is present. Travelers who
might have been expose to rabies or Herpes B should contact a reliable health care provider for
advice about rabies or Herpes B post-exposure prophylaxis.
Snake bites
Poisonuos snakes are hazards in many locations, although deaths from snakebites are rare. For
extra precaution, when practical, travelers should wear heavy, ankle-high or higher boots and
long pants when walking outdoors in areas possibly inhabited by venomous snakes. Travelers
should be advised to seek immediate medical attention any time a bite wound breaks the skin or
when snake venom is injected into their eyes or mucous membranes. Immobilization of the
infected limb and application of a pressure bandage that does not restrict blood flow are
recommended first aid measures while the victim is moved as quickly as possible to a medical
facility. Specific anti-venoms are available for some snakes in some areas, so trying to ascertain
the species of snakes that bit the victim may be critical.
Insect Bites and Scorpion Stings
Envenomings by scorpion stings are also an important health issue in many part of the world,
particularly in the extreme Northern and Southern parts of Africa, the Middle East, Southren
states of USA, Mexico and parts of South America and Indian sub-continent.Venom from insects
can produce severe allergic reactions and lead to life-threatening anaphylactic shock. More
commonly, insect bites and stings are painful and produce local reaction (redness and swelling)
at the site. Scorpion venoms which are especially lethal in young children, release autonomic
nervous system mediators causing myocardial damage, cardiac arrhythmias, pulmonary edema,
shock, paralysis, muscle spasm and pancreatitis. Early administration of anti-venom is highly
effective, together with intensive care support in severe cases. In addition, infectious diseases can
be spread by insect bites, especially in tropical countries.

Wearing protective clothing, applying insect repellents containing DEET are important
preventive measures.
The general treatment include;
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Ice or cold pack and sting relief swabs (applied topically) will help alleviate local pain
and swelling.

Any bite or sting can become infected and should therefore be examined at regular
intervals for progressive redness, swelling pain or pus drainage

Oral anti-histamines, such as diphenhydramine 25 to 50 mg every hours are helpful in

relieving the itching, rash and swelling associated with many insect bites and stings

If anaphylactic shock occurs it must be treated immediately with epinephrine and

antihistamines.

A specifics antidote is available for those suffering severe symptoms

Reference
1. World Health Organisation. Rabies. Geneva: WHO, 2011. URL: http//www.who.int/ith
2. Susan E., Charles E., Daniel Fishbein, Cathleen A. Hanlon, Boonlert Lumlertdacha,
Marta Guerra, et al. Human Rabies Prevention --- United States, 2008. MMWR
Recommendations of the Advisory Committee on Immunization Practices. May 7, 2008 /
57(Early Release);1-26,28
3. World Health Organization. Rabies. Current strategies for human rabies pre and postexposure prophylaxis, September 2010
4. Meslin FX, Hemachuda T, Wilde H, Gongal G. WHO Standards for Rabies Control. At
The Occasion of the OIE Global Conference on Rabies Control: towards sustainable
prevention at the source, Incheon Republic of Korea 7-9 September 2011
5. WHO Guide for Rabies Pre and Post exposure prophylaxis in Humans. Department of
Neglected Tropical Disease-Neglected Zoonotic Disease Team. Revised 15 Juni 2010
6. Weiss EA. A Comprehensive Guide to Wilderness and Travel Medicine. 3 rd ed.
Adventure Medical Kits, 2005: 121-133

Objectives

To describe why rabies continues to be a feared zoonotic disease.

To describe how is rabies spread

To describe disease that Rabies most commonly mimic

To understand how Rabies is diagnosed

To describe the current recommendation for Rabies treatment

To describe pre and post exposure prophylaxis

To describe clinical presentation of Rabies

To describe the clinical management of snake bite envenoming

To describe the clinical management of scorpion sting envenoming

Case
Male, 40 years old, Badung regency
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Patient referred from Badung District Hospital due to probable rabies. Has complained
agitated since 4.5 hour prior to admission. Accompanied by fear and wont drink water.
No fever reported. He has history from dog bite about 1.5 month ago on his right foot, a
un-bleeding scratch on dorsal of right foot found. At that time the wound did not clean or
wash. He did not go to hospital for vaccination. The dog is his own pet, not vaccine yet,
and one month latter the dog that bit him died with unclear cause.

Level of Conciousness: E4V5M6 BP: 120/80 mmHg, PR: 110x / min, weak, regular, RR:
20 x / min, regular, Tax : 36.5

Laboratory findings: WBC: 32.8 k/l, HGB: 15.1 g/dl, PLT: 398 k/l. AST: 39.82 Iu,
ALT: 11.02 Iu, BS: 186.0 mg/dl, BUN: 22.5 mg/dl, SC:0.72 mg/dl

Learning task:
1. Find key words related to this case
2. Describe condition related to key words
3. Define organ system that involved in this condition and find probably cause of the
key words
4. Define differential diagnosis and other examinations to support the diagnosis

5. Describe laboratory examination to diagnose rabies

6. Define management of this case
7. Define complication and prognosis
8. Define prevention based on individual, family, and community
Self assessment:
1. Describe kinds of animals get rabies
2. Describe pathogenesis of rabies
3. Describe diagnosis of rabies
4. Define management of animal bite or scratch wounds
5. Describe how can rabies be prevented
6. Describe who should get rabies vaccine and when?
7. Describe the clinical management of snake bite envenoming
8. Describe the clinical management of scorpion sting envenoming

Questions: Animal associated hazard

( Dr A.A.Ayu Yuli Gayatri, SpPD)
1. Why rabies does continue to be a feared zoonotic disease?
A. Rabies encephalomyelitis causes an acute renal failure
B. Rabies causes a spontaneous systemic bleeding
C. Rabies causes an inflammation and tissue damage
D. Once clinically established, rabies encephalomyelitis is almost invariably fatal
E. Rabies causes shock, paralysis, muscle spasm and pancreatitis
2. Diagnosed of Rabies:
A. The first clue to clinicians of possibility of Rabies is often from history of bitten
by rabid mammals.
B. The first clue to clinicians of possibility of skin biopsy for Rabies virus antigen.
C. A magnetic resonance brain may be used for the detection of Rabies virus.
D. All of statements were correct.
E. All of statements were false.

3. The symptoms of rabies are including:

A. myocardial damage, cardiac arrhythmias, pulmonary edema
B. Hydrophobia, Aerophobia, agitation and coma
C. High fever, watery diarrhea and vomiting
D. Spontaneous bleeding and moderate anemia
E. Local reaction (redness, swelling and gangrene) at the site.
4. Transmission of rabies:
A. Ingestion of raw meat or other tissues from animals infected with rabies is not a
source of human infection.
B. Bats are the source of most human rabies deaths in the United States of America and
Canada.
C. Dogs are the main host and transmitter of rabies
D. All of statement were correct
E. All of the statement were false
5. The laboratory test to probable Rabies patient includes
A. Detect rabies virus antigen in the wound tissue
B. Thin blood smear for detect rabies virus
C. Detection of rabies virus RNA (brain tissue, cerebro-spinal fluids, or saliva)
D. Stick rapid diagnostic test
E. All of the statements were false.
6. Pre-exposure vaccination should be offered to persons in high-risk groups, such as:
A. veterinarians and their staff
B. animal handlers
C. rabies researchers
D. certain laboratory workers
E. All of above
7. Management therapy for Rabid mammals bite or scratch wound:
A. Effective treatment soon (within a few days, but as soon as possible) can prevent the
onset of symptoms and death
B. Early administration of anti-venom is highly effective

C. immediate and thorough flushing and washing of the wound for a minimum of 15
minutes with soap and water, detergent or povidone iodine
D. A & C were correct
E. All of statement were correct
8. The clinical management of snake bite envenoming, are as the follows:
A. It is centred on the intravenous administration of anti-venom
B. Ventilator support for neuro-toxic envenoming
C. Fluid replacement for hypo-volemic shock
D. All of statements were correct
E. All of statements were false
9. Treatment for scorpion stings envenoming are including:
A. There are no specific treatment for its
B. Early administration of anti-venom is highly effective
C. Pre and post exposure prophylaxis is needed
D. A,B & C were correct
E. All of statements were false
10. Snake bites and scorpion stings are related to:
A. Snake bites and scorpion stings are well-known medical emergencies in many parts of
the world
B. Agricultural travelers and children are the most affected
C. The true incidence of snake bite and scorpion stings envenoming are not known
because many cases do not seek medical attention
D. All of statements were correct
E. All of the statements were false

Soal Bahasa Indonesia

1. Mengapa rabies berlanjut menjadi penyakit zoonosis ditakuti?
A. Rabies encephalomyelitis menyebabkan gagal ginjal akut
B. Rabies menyebabkan perdarahan sistemik spontan
C. Rabies menyebabkan peradangan dan kerusakan jaringan
D. Setelah tegak diagnosis klinis, rabies encephalomyelitis hampir selalu fatal

E. Rabies menyebabkan shock, kelumpuhan, kejang otot dan pankreatitis

2. Dalam mendiagnosis Rabies;

A. Petunjuk pertama untuk dokter, kemungkinan Rabies sering dari riwayat digigit
oleh mamalia.
B. Petunjuk pertama untuk dokter, biopsi kulit untuk antigen virus Rabies.
C. Sebuah resonansi magnetik otak dapat digunakan untuk mendeteksi virus
Rabies.
D. Semua pernyataan di atas benar.
E. Semua pernyataan adalah salah.

3. Gejala-gejala rabies meliputi:

A.kerusakan miokard , aritmia jantung, edema paru
B. Hydrophobia, Aerophobia, agitasi dan koma
C. Demam tingg,i diare cair dan muntah
D. perdarahan spontan dan anemia sedang
E. reaksi lokal (kemerahan, pembengkakan dan gangren) di tempat gigitan.

4. Penularan rabies:
A. Makanan yang mengandung daging mentah atau jaringan lain dari hewan
terinfeksi rabies bukanlah sumber infeksi pada manusia.
B. Kelelawar adalah sumber penularan rabies paling mematikan pada manusia di
Amerika Serikat dan Kanada.
C. Anjing adalah host utama dan penularan rabies
D. Semua pernyataan di atas benar
E. Semua pernyataan adalah salah

5. Tes laboratorium untuk pasien yang dicurigai Rabies meliputi

A. Deteksi antigen virus rabies pada jaringan luka
B. hapusan darah untuk mendeteksi virus rabies

C. Deteksi virus rabies RNA (jaringan otak, cairan cerebro-spinal, atau air liur)
D. Stik tes diagnostic cepat
E. Semua pernyataan di atas salah

6. Vaksinasi sebelum paparan harus disarankan kepada orang-orang kelompo risiko

tinggi, seperti:
A. dokter hewan dan staf
B. Pemelihara hewan
C. Peneliti Rabies
D. Pekerja laboratorium tertentu
E. Semua di atas benar

7. Manajemen terapi untuk gigitan mamalia Rabid atau goresan luka:

A. Pengobatan efektif segera (dalam beberapa hari, sesegera mungkin) bisa
mencegah timbulnya gejala dan kematian
B. Pemberian anti-racun sedini mungkin sangat efektif
C. Pembilasan dan mencuci luka selama minimal 15 menit dengan yodium sabun
dan air, deterjen atau povidon, segera setelah gigitan
D. A & C yang benar
E. Semua pernyataan itu benar

8. Manajemen klinis gigitan ular berbisa, adalah sebagai berikut:

A. Hal terpenting adalah pemberian intravena anti-racun
B. Ventilator untuk mendukung untuk gejala neuro-toksik
C. Cairan pengganti pada kondisi hipo-volemic
D. Semua pernyataan itu benar
E. Semua pernyataan adalah salah

9. Pengobatan untuk sengatan kalajengking berbisa meliputi:

A. Tidak ada pengobatan khusus

B. Pemberian awal anti-bisa sangat efektif

C. Profilaksis sebelum dan pasca paparan diperlukan
D. A, B & C yang benar
E. Semua pernyataan adalah salah

10. Gigitan ular dan sengatan kalajengking terkait dengan:

A. Gigitan ular dan sengatan kalajengking dikenal sebagai kondisi darurat medis di
berbagai belahan dunia
B. Wisatawan pertanian dan anak-anak adalah yang paling terkena dampak
C. kejadian sebenarnya dari gigitan ular dan sengatan kalajengking beracun tidak
diketahui dengan pasti karena banyak kasus tidak mencari pertolongan medis
D. Semua pernyataan itu benar
E. Semua pernyataan yang salah

Answer/Jawaban :
1. D
2. A
3. B
4. D
5. C
6. E
7. D
8. D
9. B
10. D