RABIES & SNAKE BITE

MANAGEMENT

REMELYN JOY E. BOGADOR,

MD
Resident Physician
St. Elizabeth Hospital
 RABIES:
A Preventable Disease
 RATIONALE
Rabies is present in all continents, endemic in most
African & Asian countries
Estimated to cause at least 55,000 deaths/year worldwide
 56% in Asia
 43.6 % in Africa

In the PHILIPPINES, it is considered a significant health

problem
 It is one of the most acutely fatal infections
 It is responsible for the death of 200 – 300 Filipinos annually

Rabies free country in 2020

 Anti –Rabies Act of 2007 – post & pre exposure prophylaxis
 The ANTI – RABIES ACT
Republic Act 9482

“An act providing for the control and eradication of HUMAN

& ANIMAL RABIES, prescribing penalties for violation
thereof and appropriating funds therefore”

Provide a system for the control, prevention of the spread ,

and eventual eradication of human and animal rabies
Establish the advocacy on responsible pet ownership
 Mandatory registration & vaccination of dogs
 Leashing of dogs
 Shoulder medical expenses relative
to the victim’s injury
 PENALTIES
 Failure or refusal to have their dog registered and immunized
against rabies (P2,000)
 Refusal to have his dog put under observation after said dog
has bitten an individual (P10,000)
 Refusal to have their dog put under observation and do not
shoulder the medical expenses of the person bitten by their
dog (P25,000)
 Refusal to put leash on their dogs when they are brought
outside the house (P500)
 Impounded dog shall be released to its owner upon payment
of a fine not less than P500 but not more than P1,000
 Person found guilty of trading dogs meat shall be fined not
less than P5,000 per dog & subject to imprisonment for 1 to 4
years
 What is RABIES?
- Rabies is am acute viral encephalitis caused by rabies virus after being
bitten or exposed to infected animals.

THE VIRUS IS SENSITIVE TO:

 Heating/Boiling
 Drying
 UV and X-ray
 Sunlight
 Trypsin
 B-propiolactone
 Ether
 Detergents

WHAT IS THE MOST COMMON RESERVOIR OF RABIES VIRUS?

- In the Philippines, the most common reservoir of rabies virus are the dogs
which accounts for more than 98% and cats at 1.3%.**
 How is the rabies virus transmitted?
 It can be transmitted through a bite, an abrasion, lick on
mucous membrane or damaged skin and eating of raw or
partially cooked infected meat of animals.
Is due to a bite, scratch or even lick on mucous
membrane by animals (Dogs/Cats) whose saliva
IN ALMOST contains the virus.
ALL CASES

By inhaling virulent aerosol (laboratory

experiment, exploration of enclosed caves
inhabited by infected bats*)
IN VERY
EXCEPTIONAL
CASES By transmission: from man to man
Indirectly: transplantation of infected
cornea*
Directly: from a bite or through saliva of an
infected person***
 How long is the incubation period of Rabies?

Average incubation period is 20-90 days.

INCUBATION A few days to several weeks especially in
PERIOD MAY children with severe exposures in well
BE MUCH innervated areas (face, head, neck…….)
SHORTER

IN VERY
EXCEPTIONAL Incubation of up to 6 years has been
recently reported in the United States
CASES MUCH
LONGER

INCUBATION PERIOD
is the only time when vaccination is effective
How long is the prodromal period of Rabies?

 Duration: 2-10 days

 Earliest rabies specific symptoms:

 Pain / paresthesia / itching at the bite site

 There will be non-specific symptoms such as:

 Fever
 Malaise
 Fatigue
 Headache
 Anorexia

Post-exposure treatment is no longer useful in this stage.

 What is the course of the virus in the body?

1. Clinic Symptom:
Virus spread within the brain

2. Incubation:
• The animal vector is
Multiplication, penetration in the local
noninfectious during the
nerve endings and spread by the axonal majority of the incubation
route towards central nervous system. period**

3. Contamination:
Inoculation of the virus mainly through a • When infectious rabies virus is
bite from infected animal secreted in the saliva of rabies
vectors, the host becomes
infectious
4. Possible contamination:
Migration through peripheral nerve in the
secretory and excretory glands (at this stage
the virus is found in the saliva)
POST EXPOSURE PROPHYLAXIS (PEP)

Refers to anti-rabies treatment administered after an

exposure (bite, scratch, lick, etc) to potentially rabid
animals
Includes local wound care, administration of rabies
vaccine + RIG
CATEGORIES of RABIES
EXPOSURE
Category of Exposure Management
CATEGORY 1
1.) WASH exposed skin immediately
a.) Feeding/touching an animal with soap & water.

b.) Licking of intact skin (with reliable 2.) NO vaccine or RIG needed
history & thorough physical
examination) 3.) Pre-exposure prophylaxis may be
considered for high risk person
c.) Exposure to patient with signs and
symptoms of rabies by sharing of
eating or drinking utensils

d.) Casual contact (talking to, visiting

and feeding suspected rabies cases)
and routine delivery of health care to
patient with signs and symptoms of
rabies
 CATEGORIES of RABIES
EXPOSURE
Category of Exposure Management

CATEGORY II 1. Wash wound with soap and water

a.) Nibbling of uncovered skin with or without 2. Start vaccine immediately:

bruising/hematoma
b.)Minor scratches/abrasions without bleeding
c.)Minor scratches/abrasions which are induced
to bleed
d.) All Category 2 exposures on the head and
neck area are considered Category 3 and should
be managed as such
a.) Complete vaccination regimen until Day 28/30:
i. Biting animal is laboratory proven to be rabid
ii. Biting animal is killed/died without laboratory
testing OR
iii. Biting animal has signs & symptoms of rabies
OR
iv. Biting animal is not available for observation
for 14 days
b.)May omit day 28/30 dose if
i. Biting animal is alive AND remains healthy
after the 14-day observation period, OR
ii. Biting animal died within the 14 days
observation period, confirmed by veterinarian to
have FAT –negative

3. RIG is not indicated

CATEGORIES of RABIES
EXPOSURE
Category of Exposure
CATEGORY III
a.) transdermal bites (puncture wounds,
lacerations, avulsions) or scratches/abrasions with
spontaneous bleeding
b.) licks on broken skin
c.) exposure to rabies patient through bites,
contamination of mucous membranes (eyes,
oral/nasal mucosa, genital/anal mucous
membranes)or open skin lesions with body fluids
through splattering and mouth-to-mouth
resuscitation.
d.) handling of infected carcass or ingested of raw
infected meat
e.) all category II exposures on head and neck area
Management
1. Wash wound with soap and water
2. Start vaccine and RIG immediately
a. Complete vaccination regimen until day 28/30
i. Biting animal is laboratory proven to be rabid
OR
ii. Biting animal is killed/died without laboratory
testing OR
iii. Biting animal has signs and symptoms OR
iv. Biting animal is not available for observation
for 14 days
b. May omit day 28/30 dose
i. Biting animal is alive AND remains healthy
after the 14 day observation period OR
ii. Biting animal dead within the 14 days
observation period, confirmed by veterinatian
to have no signs and symtoms of rabies and
was FAT negative
 PRE EXPOSURE PROPHYLAXIS
Refers to rabies vaccination administered before an
exposure to potentially rabid animals
Usually given to those who are at high risk of getting
rabies such as veterinarians, animal handlers, staff in
the rabies laboratory, hospitals handling rabies patients
and school children from high risk areas, etc.
DAY 0, 7, 21/28
Are there any contraindications to anti-rabies
vaccination?

There is no contraindication to anti-rabies vaccination

Is it safe to give anti-rabies vaccination during

pregnancy?

 Yes, rabies vaccine and RIG can be given safely during pregnancy
 The risk of teratogenicity is less than the risk of rabies

Can we interchange vaccine brands?

Interchanging of vaccine brands is NOT RECOMMENDED by
WHO
 Only if it cannot be avoided, one may interchange brands as
long as it is one of the WHO recommended modern vaccines
 Can we interchange vaccine regimens?

Interchanging of vaccine regimens is NOT RECOMMENDED by

WHO

 Practice should be the exception since no immunegenicity studies

available
 Antibody monitoring highly recommended for these case
Can the vaccine be given on the buttocks?

Vaccine should always be given on the deltoid muscle in adults

and on anterolateral thigh in young infants, never on teal region
since it results in lower neutralizing antibody titers
Why is it necessary to vaccinate the patient if the dog is vaccinated?

Reasons:
 At least 80% of dog population need to be vaccinated to
cut the transmission of rabies among dogs
 As in humans, not all dogs will respond to vaccination
 Some dog owners may claim their dog is vaccinated
even if they are not

How long can you keep an open reconstituted vial of vaccine?

Open reconstituted vials that have been kept in the

refrigerator may still be used up to 8 hours
World Health Organization

SNAKE BITES
 Venomous snakes of South-East Asia
CLASSIFICATIONS:
1. ELAPIDAE
 have short permanently erect fangs
 this family includes the cobras, king cobra, kraits, coral
snakes and the sea snakes

Short, permanently erect, fangs of a Indo-Chinese spitting

North Indian or Oxus cobra (Naja
typical elapid (Thai monocellate cobra cobra (Naja Saimensis)
oxiana) (Copyright DA Warrell) Viperdae
– Naja kaouthia)
have long fangs
2. VIPERIDAE
 have long fangs which are normally folded up against the
upper jaw but, when the snake strikes, are erected
 There are two subgroups, the typical vipers (Viperinae) and
the pit vipers (Crotalinae)

Russell’s vipers
(Copyright DA Warrell) details
of
fangs

Head of a typical pit viper – white-lipped green pit viper

(Trimeresurus albolabris) showing the pit organ situated
between the nostril and the eye (arrow head)

White-lipped green pit viper

(Trimeresurus albolabris) (Copyright
DA
Warrell)
How to Identify Venomous Snakes?
 Some of the most notorious
venomous snakes can be
recognized by their SIZE,
SHAPE, COLOR, PATTERN
of MARKINGS, their
BEHAVIOUR, SOUND they
make when they feel
threatened
 COBRAS – rear up, spread a
hood, hiss and make repeated
strikes towards the aggressor
 Blowing hiss of Russells viper &
grating rasp of saw scaled viper
 How Common are Snake Bites?

PHILIPPINES
 there are no reliable estimates of mortality
Figures of 200-300 deaths each year have been suggested
Only cobras cause fatal envenoming, their usual victims
being rice farmers.
INDIA
It is estimated that between 35,000 and 50,000 people
die of
snake bite each year among India’s population of 980
million.
 How can snake bites be avoided?
 Snake bite is an occupational hazard that is very difficult to avoid
completely
 Education! Know your local snakes, know the sort of places
where they like to live and hide, know at what times of year, at
what times of day/night or in what kinds of weather they are most
likely to be active
 Be specially vigilant about snake bites after rains, during
flooding, at harvest time and at night.
 Try to wear proper shoes or boots and long trousers, especially
when walking in the dark or in undergrowth
 Avoid or take great care handling dead snakes, or snakes that
appear to be dead
SIGNS & SYMPTOMS (venom
injected)
Local symptoms and signs in
the bitten part
 fang marks
 local pain
 local bleeding
 bruising
 lymphangitis
 lymph node enlargement
 Inflammation (swelling,
redness, heat)
 blistering
 local infection, abscess
formation
 necrosis
 Systemic Signs & Symptoms
 General - nausea, vomiting, malaise, abdominal pain, weakness, drowsiness,
prostration
 Cardiovascular (Viperidae) -visual disturbances, dizziness, faintness, collapse,
shock, hypotension, cardiac arrhythmias, pulmonary oedema, conjunctival oedema
 Bleeding and clotting disorders (Viperidae)- epistaxis, bleeding into the tears,
haemoptysis, haematemesis, rectal bleeding or melaena,haematuria, vaginal
bleeding, bleeding into the skin (petechiae, purpura,ecchymoses) and mucosae,
intracranial haemorrhage
 Neurological (Elapidae, Russell’s viper) -drowsiness, paraesthesiae, abnormalities
of taste and smell, “heavy” eyelids, ptosis, external ophthalmoplegia , paralysis of
facial muscles and other muscles innervated by the cranial nerves, aphonia,
difficulty in swallowing secretions, respiratory and generalised flaccid paralysis
 Skeletal muscle breakdown (sea snakes, Russell’s viper)- generalised pain,
stiffness and tenderness of muscles, trismus, myoglobinuria, hyperkalaemia,
cardiac arrest, acute renal failure
 Renal (Viperidae, sea snakes)- lower back pain, haematuria,
haemoglobinuria, myoglobinuria, oliguria/anuria,symptoms and signs of
uraemia (acidotic breathing, hiccups, nausea, pleuritic chestpain....)
 Endocrine (acute pituitary/adrenal insufficiency) (Russell’s viper)
 Acute phase: shock, hypoglycaemia
 Chronic phase (months to years after the bite): weakness, loss of secondary sexual
hair, amenorrhoea, testicular atrophy, hypothyroidism etc
 MANAGEMENT OF SNAKE BITE
Most traditional first aid methods should be discouraged:
They do more harm than good !

Recommended first aid methods

Reassure the victim who may be very anxious
Immobilise the bitten limb with a splint or sling (any
movement or muscular contraction increases absorption of
venom into the bloodstream and lymphatics)
Consider pressure-immobilisation for some elapid bites
Avoid any interference with the bite wound as this may
introduce infection, increase absorption of the venom and
increase local bleeding
 The special danger of rapidly developing paralytic envenoming after
bites by some elapid snakes: use of pressure-immobilisation

Pressure bandaging is not recommended for bites by vipers and cobras whose
venoms cause local necrosis.
 Early clues that a patient has severe envenoming:
• Snake identified as a very dangerous one
• Rapid early extension of local swelling from the site of the bite
• Early tender enlargement of local lymph nodes, indicating spread of venom in
the lymphatic system
• Early systemic symptoms: collapse (hypotension, shock), nausea, vomiting,
diarrhoea, severe headache, “heaviness” of the eyelids, inappropriate
(pathological) drowsiness or early ptosis/ophthalmoplegia
• Early spontaneous systemic bleeding
• Passage of dark brown urine
 Antivenom is the only specific antidote to snake
venom. A most important decision in the
management of a snake bite victim is whether or
not to give antivenom.

Antivenom treatment carries a risk of severe

adverse reactions and in most countries it is
costly and may be in limited supply. It
should therefore be used only in patients in
whom the benefits of antivenom treatment
are considered to exceed the risks.