Alejandro Reboron, Jr.

MD
 Rabies is a zoonosis, and human infection usually
occurs following transdermal bite or scratch by
infected animal.

 Transmission may also occur when infectious material,

usually saliva, comes into direct contact with the
victim’s mucosa or fresh skin lesions.

 Very rarely, rabies may occur through inhalation of

virus-containing aerosol or via infected organ
transplant
 Rabies Free: Australia, New zealand, New Guinea, Japan,
Hawaii, Taiwan,UK, Ireland, Iceland, Noway, Finland,
Sweden, Portugal, Greece, West indies, Atlantic Islands,
Oceania

 In the Philippines it is one of the most fatal infections and is

responsible to 200-300 Filipinos annually (245 deaths in
2010).

 Philippines rank 6th in rabies incidence world wide (2004)

 Dogs remain the principal cause of animal bites and rabies
cases in 2010 (>85%).

 Majority of victims are children under the age of 15 with male

predominance

 Rabies free zone: Siquijor; Batanes; Apo island of Negros

Oriental
 Acute, progressive, incurable viral encephalitis with
fatal outcome
 Transmission
 Bite
 Injection of infectious saliva into a break in the skin
 Non-bite
 Licking of scratches, abrasion, open wounds or intact mucous
membrane
 Inhalation/aerosol – bats in caves
 Human to human
 15 documented cases of fatal rabies following transplantation

 Corneal transplant 8

 Solid organ and vascular conduit

 5 Stages of Rabies Disease
Incubation Period  20-90 days
 PEP effective
Prodrome:
 2 – 10 days.
 First Symptoms: Numbeness at Bite site, Malaise/Fatigue, Fever,
Headache, Anorexia, Pain, Itching.

Acute Neurologic Phase

 2-7 days
 Encephalitic/Furious Type or Paralytic/Dumb Type

Coma: Hypotension, hypoventilation, apnea, Pituitary dysfunction, Cardiac

arrhythmia, cardiac arrest

Death or Recovery (Very Rare)

 SIGNS OF ANIMAL RABIES
 Sudden change in behavior (from mild to
vicious temperament or vice versa)
 Solitude
 Restlessness
 Snapping at imaginary objects
 Nervousness
 Anxiety
 Barking at slightest provocation
 ACUTE NEUROLOGIC STAGE
Encephalytic or Furious Type
 Phobic spasms in response to Tactile, auditory, visual or olfactory
stimuli (e.g. aerophobia and Hydrophobia)
 Hypersalivation
 Spontaneous inspiratory spasm
 Restlessness, aggression, hallucinations, disorientation, bizarre
behaviour, agitation, confusion, signs of ANS dysfunction
 Alternating with periods of lucidity
 Seizures

Paralytic Or Dumb Type

 Lack of aggression
 Weakness
 Phobic spasms – 50%
 Aerophobia and hydrophobia may be absent
 Myoedema at percussion sites
 Can be mistaken for GBS
CLINICAL PRESENTATION
 Rabies is influenced by
 Virus content of the saliva
 Severity of the bite
 Location of the bite
 Reduce the quantity of rabies at the bite site
 Local wound care

 Ensure a high titer of neutralizing early and maintain

it for as long as possible
 Rabies Immune globulin (RIG) infiltration (passive)
 Vaccination with anti rabies vaccine (active)
Initiation of (PEP) should not be delayed for any
reason – increases risk of rabies and treatment
failure
There are no absolute contraindication to PEP
Local wound treatment
Wash wounds immediately with
soap and water for 10 minutes.

Apply povidone, alcohol, or any antiseptic

Give antibiotics for:

All frankly infected wound
All Category III
All other category III bites that are deeper, penetrating, multiple or
extensive or located on the hands/face/genital areas.
DRUGS OF CHOICES: Amoxicillin/Clavulanic or Cloxacillin or Cefuroxime
Amoxcillin-Clavulanic acid – 500 mg TID p.o. for
adults. 20-45mg/kg/day in 3 divided doses for kids.

Cloxacillin – 500 mg p.o. QID for adults. 10-100

mg/kg/day in 4 divided doses for kids.

Cefuroxime axetil – 500 mg p.o. BID for adults. 10-15

mg/kg/day in 2 divided doses for kids.

NON- INFECTED WOUNDS – Amoxicillin 500 mg TID

p.o. and 30-45 mg/kg/day in 3 divided doses (PEDIA)
Dirty wound  wounds >6 hours old, contaminated with soil, saliva,
feces, or dirt; puncture or crush wounds; avulsions; wounds from
missiles, burns, or frostbite.
Passive immunization
 Rabies Immune Globulin
 Equine Rabies Immune Globulin (ERIG)
 Human Rabies Immune Globulin (HRIG)
RIG Guidelines
 Given only to Category III exposure not affected by
status of biting animal
 Should not be given alone but with combination with
anti-rabies vaccine
 Administered at day 0
 If cannot be given, can still be given until day 7
RIG Guidelines
 RIG is computed based on weight

HRIG 20 IU/kg BW
ERIG/fabs2 40 IU/kg BW

 Should not be exceed the computed dose because it

reduces efficacy of vaccine
RIG Guidelines
 Skin test should be done prior to giving ERIG
 Hypersensitivity to ERIG may not be predicted by skin
test and still should be ready with epinephrine and
anti-histamine
 Observe the patient for at least 1 hr after giving
RIG
RIG Guidelines
 RIG should be infiltrated aroung and into the wound
as anatomically feasible, even if the lesion has began to
heal
 Any remaining RIG ( from the computed dose) should
be given intramuscularly at site distant from the site of
vaccine injection
 DON’TS
 If possible, suturing should be avoided ( may inoculate
virus deeper)
 If suturing is necessary, anti-rabies immunoglobulin
should be infiltrated first around the wound then wait
for 2 hours before suturing
Anti-Rabies Vaccine
 Active immunization – induces body to produce
immune response after 7-10 days
 Administered
 Intradermal
 recommended route
 Except in immunocompromised, patient taking chloroquine,
patient with chronic liver disease
 Cost effective

 Intramuscular
 Recommended for all except those with hematologic
conditions
Anti-Rabies Vaccine
 It should be given in the deltoid area of each arm in
adults or anterolateral aspect of the thigh in infants
 Never injected in the gluteal area as absorption is
unpredictable
 ID injection should produce a minimum of 3mm
wheal
Intradermal Vaccination
 Category I  Management
1. Feeding/touching an 1. Wash exposed skin
animal immediately with soap
2. Licking of intact skin and water
3. Exposure to patient 2. No vaccine or RIG
with sign and needed
symptoms of rabies by 3. Pre- exposure
sharing of food or prophylaxis may be
drinking utensils considered for high
4. Casual contact (talking risk persons
to, visiting and feeding
suspected rabies) and
routine delivery of
healthcare to patients
with sign and
symptoms of rabies
 Category II  Management
1. Nibbling of uncovered 1. Wash exposed skin
skin with or without immediately with soap
bruising or hematoma and water
2. Minor/superficial 2. Start vaccine
scratches/abrasion immediately
without bleeding, 3. RIG not indicated
including those
induced to bleed
3. All category II exposure
on the head and neck
area are considered
Category III
 Category III  Management
1. Transdermal bites 1. Wash exposed skin
(punctured wound, immediately with soap
laceration, avulsions) or and water
scratches/abrasions with 2. Start vaccine and RIG
spontaneous bleeding immediately
2. Licks on broken skin
3. Exposure to rabies
patient through bites,
contamination of
mucous membrane
4. Unprotected handling of
infected carcass or
ingestion of raw infected
meat
5. All category II exposure
on head and neck
TYPES OF RABIES VACCINES & DOSAGES
LIST OF TCV PROVIDED BY THE NATIONL RABIES PREVENTION AND CONTROL PROGRAM TO
ANIMAL BITE TREATMENT CENTERS WITH CORRESPONDING PREPARATION AND DOSE

GENERIC NAME PREPARATION DOSE

PURIFIED VERO CELL 0.5 ml/vial ID 0.1 ml

RABIES VACCINE IM 0.5 ml
(PVRV)
e.g. Verorab
PURIFIED CHICK 1 ml/ vial ID 0.1 ml
EMBRYO CELL VACCINE IM 1.0 ml
(PCECV)
e.g. Rabipur
HOW TO COMPUTE FOR THE DOSE AND THE NUMBER OF
VIALS TO USE
ERIG (BW x Dose divided by Preparation)
20 Kg x 40 IU/kg = 800 IU /1000 IU x 5ml = 4ml
50 kg x 40 IU/Kg = 2000 IU/ 1000 IU x 5ml = 10ml

HRIG
20 kg x 20 IU/kg = 400 IU/300 IU x 2ml = 2.66ml
50 kg x 20 IU/kg = 1000 IU/300 IU x 2ml = 6.66ml
UPDATED 2 SITE INTRADERMAL REGIMENS FOR POST
EXPOSURE TREATMENT
(Thai Red Cross Regimen)
Day 0 Day 3 Day 7

ID dose = 0.1 ml PVRV/

Day PCECV
28/30
2 deltoid muscle or 2
anterolateral thigh in infants
5-dose Intramuscular Regimen
(ESSEN REGIMEN)

Day 0 Day 3 Day 7 Day 14 Day 28

IM dose = 0.5 ml for PVRV; 1.0 ml for PCECV

One deltoid muscle or one

anterolateral thigh in infants
2-1-1-dose Intramuscular Regimen
(Zagreb Regimen)

Day 0 Day 7 Day 21

IM dose = 0.5 ml for PVRV; 1.0 ml for PCECV

Into the deltoid muscle or one

anterolateral thigh in infants
 Post exposure prophylaxis for missed doses

MISSED DOSES
If delay is 1-2 days from day 3 GIVE DAY 3 UPON VISIT AND
schedule FOLLOW THE ORIGINAL
SCHEDULE OF DAY 7 AND DAY
28

If delay is 3-4 days from day 3 give day 3 dose upon visit,
schedule adjust succeeding doses (day 7
and 28/30) according to the
prescribed interval

If delay is 5 days or more from restart a new course

day 3
 Post exposure prophylaxis for missed doses
MISSED DOSES
DELAY IN DAY 7: IF LESS GIVE DAY 7 DOSE UPON VISIT AND
THAN 7 DAYS FROM DAY FOLLOW THE SAME SCHEDULE FOR
7 SCHEDULE FOR DAY 28

IF DELAY IS GREATER REPEAT DAY 3 DOSE AND REVISE

THAN 7-14 DAYS FROM ACCORDING TO PRESCRIBED
DAY 7 SCHEDULE INTERVAL

IF DELAY IS GREATER RESTART NEW COURSE

THAN 14 DAYS FROM DAY
7

IF DELAY IN DAY 28/30 GIVE DAY 28/30 UPON VISIT; THIS MAY
DOSE BE CONSIDERED AS BOOSTER DOSE.
 DeLAY IN GIVING RIG
RIG SHOULD BE ADMINISTERED AT THE SAME TIME AS DAY O

IF RIG IS UNAVAILABLE ON DAY IT MAY STILL BE GIVEN

0 ANYTIME BEFORE DAY 7 DOSE
OF THE VACCINE.

HOWEVER, IF DAY 0 AND DAY 3

HAVE NOT BEEN GIVEN, RIG
MAY STILL BE GIVEN ANYTIME.

THE VACCINE SHOULD BE

IF RIG AND VACCINE CANNOT GIVEN BEFORE THE RIG
BE GIVEN ON THE SAME DAY BECAUSE THE VACCINE
INHIBITS THE LEVEL OF
NEUTRALIZING ANTIBODIES

RIG IS GIVEN ONLY ONCE DURING THE COURSE OF POST

EPOSURE TREATMENT
The following are considered to have complete the
primary immunization

 Those who had day 0, 7 and 21/28 of PreP or those who

had at least 0, 3, 7 of PEP
 Persons with incomplete PreP/PEP should be managed as if
no previous injections have been given
 Local wound care still should be done
 RIG is not required including category III
 Category II and III should be given booster doses
Category of Local wound care Rabies Immune Anti-Rabies
Exposure Globulin

Category I YES NO NO

Category II YES NO Give PEP booster

dose every
exposure

Category III YES NO Give PEP booster

dose every
exposure
 Give 0.1 ml ID dose of PCEC or PVRV at 1 site each on
Day 0 and 3 or
 Give 1 vial IM dose of PCEC or PVRV at 1 site each on
Day 0 and 3
Management of Rabies Exposure secondary to
bites by Vaccinated Animal
 PEP not recommended for category I exposure
 PEP can be delayed for category II exposure provided
ALL of the following conditions are satisfied
 Dog/cat is healthy and available for observation for
14 days
 Dog/cat have updated vaccine for 2 years
 Last vaccine must be within 12 months
* If biting dog/cat becomes sick or dies within the
observation period, PEP should be started
immediately
Management of Rabies Exposure secondary to
bites by Vaccinated Animal
 PEP cannot be delayed for any category III
 Dog/cat is proven rabid/sick/ not available for
observation
 Dog/cat is involved in at least 3 biting incidents within
24 hours
 Dog/cat manifest behavior changes suggestive of
rabies
Special Conditions
 Pregnant and infancy
 Both are not contraindication to treatment with
modern tissue culture vaccine
 Drugs and Chronic liver disease
 Patients with chronic liver disease and those taking
chloroquine and systemic steroids should be given
standard IM regimen as the response to ID is not
optimum
Special Conditions
 Babies of rabid mothers
 Babies born to rabid mothers should be given rabies
vaccination as well as RIG as early as possible at birth
 Patients with hematologic conditions
 IM injection in contraindicated; should recieve ID
Special Conditions
 Immunocompromised
 Such as those HIV infected, cancer, transplant patients
should recieve IM regimen and RIG for both category II
and III
 Delay in consult
 Exposed persons who present for evaluation weeks or
months after the bite
 Treat as if bite was recent
 If the biting animal has reamined healthy and alive after
14 days after the bite, PEP is not needed
Special Conditions
 Bites by other animal
 Rodents, guinea pigs, rabbits, snakes and other cold
blooded animals do not require rabies PEP
 Bites by domesticated animal other than dogs and cat (
cattle, pigs, horses, monkey and other wild animals)
require rabies PEP
 Shifting from 1 vaccine brand
 Not recommended unless
 Hypersensitivity reaction
 Unavailability of initial vaccine used
Special Conditions
 Shifting from 1 regimen
 IM to ID, or ID to IM is not recommended
Pre- exposure Prophylaxis (PreP)
 Refers to vaccination before an exposure to a
potentially rabid animal; usually given to high risk
population
Pre- exposure Prophylaxis (PreP)
 Three doses of 0.1 ml PCEC or PVRV ID or
1 ml vial PCEC or 0.5 ml PVRV IM
 Given on day 0, 7, 21/28
Pre- exposure Prophylaxis (PreP)
Type of risk Population at risk recommended booster
schedule ( without
definite exposure)
High risk Health workers handling 1 Booster dose 1 year after
primary immunization
(exposure may not be rabies cases a. One site 0.1 ml ID dose of
known) Veterinarians PCEC or PVRV on Day 0; OR
Animal handlers b. One site 0.5 ml dose of
PVRV or 1 ml of PCEC on
Day 0 given intramuscularly

Thereafter 1 booster dose

if Ab titer falls below 0.5
IU/ml or
In absence of serologic
testing 1 booster dose
every 5 years
Low risk General population No routine booster after
(exposure are known) primary immunization
Pre- exposure Prophylaxis (PreP)
 Pre- exposure prophylaxis does not eliminate the
need for Post-exposure prophylaxis after a rabies
exposure
 Simplifies the PEP requirement for previously
vaccinated person by eliminating the need for RIG and
decreasing the number of doses of vaccine needed
 Observe patient for at least 1 hr after ERIG/ATS
administration to watch for immediate adverse
reactions
 Hypersensitivity is an inappropriate response to
generally harmless agents

 Anaphylaxis represents the most dramatic and severe

form of immediate hypersensitivity.

 Anaphylaxis is a medical emergency requires

immediate diagnosis and treatment
Clinical Manifestations
• FIRST-LINE THERAPY
- Airway and Oxygenation
-Decontamination
-Epinephrine
-Crystalloids
•SECOND-LINE THERAPY
-Corticosteroids
-Antihistamines
-Agents for Allergic bronchospasm
THANK YOU