RABIES

…when “man’s best friend” betrays.

Top 10 1 INDIA 2 BANGLADESH 3 CHINA 4 PHILIPPINES 5 VIET NAM 6 PAKISTAN 7 SRI LANKA 8 MYANMAR 9 THAILAND 10 INDONESIA

1987-2007 244478 22900 13995 5658 5183 2843 2042 1683 1377 1208 WHO 2008

RABIES Defined
• a zoonotic disease that is caused by rhabdovirus. • a disease that causes acute encephalitis in warm-blooded animals.

The Culprit: RHABDOVIRUS
• Thought to be the origin of vampire legends (bats, biting, hypersexuality) • Commonly known as rabies virus • a virus that attacks the central nervous system of warmblooded animals (only mammals, including human) • From Lyssavirus genus • length =180 nm; • cross-section = 75 nm • Enveloped, single stranded, RNA

Rabies Reservoirs

• Racoon
• Silvertailed bat

• Red fox

• Striped skunk

Rabies Reservoirs
• Men

• Dogs

• Cats

Mode of Transmission
• Bite of infected animals through the skin and mucous membrane • Licking of infected animals to damaged mucous membrane • Aerosol transmission (bat)

Incubation Period
• Incubation period varies from 2 weeks to a year (depends on how large the infecting dose and how fast). • The virus travels to the CNS:

• Animal are infectious only weeks before they die

– human - 10 days - 1 year (most cases occurring 20 - 90 days after exposure) – Bite occurring in the head, neck & upper extremity IP < 30 days.

Nursing Care: Post-Exposure Wound Care
• Prompt and thorough cleaning: flush wound with soap and water • Benzalkonium chloride not superior to soap • Update tetanus immunization • Treat secondary bacterial infection • Do not suture wound if possible

Signs and Symptoms
• Early-stage: flu-like
– Fever – Headache

• 2nd stage:
– Malaise – Acute pain – Violent movements – Uncontrolled excitement – Depression – Hydrophobia

Signs and Symptoms
• Critical stage
– Paranoia – Terror – Hallucinations progressing to delirium – signs of hyperactivity (furious rabies) – paralysis (dumb rabies) to complete paralysis – coma and death in all cases (due to breathing failure)

Clinical Manifestations
• Fever • Nuchal rigidity • Paresthesia • Fasiculations • Convulsions • Hypersalivation • Hyperventilation

Laboratory Diagnosis
• Direct microscopic demonstrate of virus antigen by: Direct immunofluorescence staining → detect virus in brain tissue and corneal scrapings. • Brain biopsy→ histologic staining of brain tissue (seller stain).

Laboratory Diagnosis
• Animal inoculation → tissue or saliva inoculated intracerebral into mice
– presence of rabies virus is indicated by
1. flaccid paralysis of leg 2. encephalitis 3. death

• Serological
– detect rabies antibodies by
1. Immunofluorescence test 2. Complement fixation test 3. Neutralization test

• Antibodies are developed during progression of the disease.

• Rabies control
– Eliminate rabies from hosts/victims
• Oral baits w/antivirus.
– Has been effective (Europe, Canada). – Slowed potential outbreak in Ohio raccoons. – Used in Texas for coyotes & foxes.

Prevention

• Trap/vaccinate/releas e (TVR)
– Effective in Canada raccoons. – Often combined with oral baits.

• Control measures against canine; – stray dog control. – vaccination of dogs. – quarantine of imported animals. • Wildlife - Rabies in wild animals is much more difficult to control than canine rabies. However, on-going trials in in the USA and Europe using bait containing rabies vaccine given to foxes and raccoons reduces rabies levels.

Prevention

• Pre-exposure prophylaxis: vaccination of people in high risk groups:
– Veterinarians – Animal handlers – Certain lab workers – Travel to areas where canine rabies is common

Prevention

Milwaukee Protocol
• Basic treatment
– – – – – – – Assure airway External cardiac pacing wires Maintain central venous pressure Nasojejunal (NJT) feeding Heparin prophylaxis Physical therapy Prophylactic supplementation of cofactor deficiencies

Milwaukee Protocol
• Sedation
– Deep sedation-anesthesia
• Ketamine • Diazepam or alprazolam

– Continuous EEG monitoring

Milwaukee Protocol
• Antiviral treatment
– Avoid ARV after onset of clinical symptoms – Avoid ARIG and IFNα – Ribavirin no longer recommended – Amantadine per NJT – Monitor rabies titer
• CSF assay q7d • Saliva & serum assays q2d

Rabies Survivor: the ‘Medical Marvel’
Jeanna Giese -18 years old -one-of-a-kind case: She survived rabies without vaccination

Thank You! :D
Ameril, Hayma M.