RABIES

Clinical Clerks Gangoso and Mavinta

Iloilo Doctors’ College of Medicine
February 2024
Table of Contents
01 02 03
Rabies Epidemiology Pathophysiology
Overview about Statistical data of Mode of transmission
Rabies incidence Clinical Stages

04 05 06
Approach to Management & Best Practices in
Diagnosis Prevention RHU
Categories and its
Management
Rabies
➔ Order of Mononegavirales,
Rhabdovirus family
➔ Domestic and wild animals
➔ “Hydrophobia”
Rabies
➔ Neglected Tropical Disease (World Health Organization)
➔ Rapidly progressive, acute infectious disease of the central
nervous system
➔ Preventable!
Rabid Animals
ALL MAMMALS
Example of Rabid animals:
➔ Dogs (most common)
➔ Cats
➔ Cows
➔ Horses
➔ Bats
➔ Monkeys
Non-Rabid Animals
➔ Birds
➔ Reptiles
➔ Amphibians
➔ Fish/Invertebrates
➔ Most rodents (rats, mice, hamsters, guinea pigs , rabbits,
squirrels, chipmunks)
150 countries
Mainly in Asia and Africa.

10,000 deaths
Annually and globally.

40% under 15
years old
Rabies in the Philippines:
Rabies in the Western Visayas:
Animal Bite Cases in Region 6, 2022
• Total Cases: 118,845
• Deaths: 27
• Mortality Rate: 3.38 per million population
• Increase from 2021: 2 deaths
• Provinces with Most Deaths:
• Negros Occidental: 11
• Capiz: 6
• Aklan & Iloilo: 4 each
• Bacolod City & Iloilo City: 1 each
Transmission

BITE or NON-BITE EXPOSURES

Transdermal bite or scratch by an infected animal

Transmission through
➔ Usually saliva-direct contact with the victim’s fresh skin lesion
➔ Inhalation of virus-containing spray
➔ Organ transplant
Transmission

Low to No Risk High Risk

➔ Touching a person infected with ➔ Bite exposures (head and neck
Rabies areas)
➔ Contact with non-infectious fluid
or tissue (urine, blood, feces)
➔ Contact with someone receiving
Rabies Vaccination
Pathophysiology
Signs
and Symptoms
 Clinical Stages
Phase Typical Duration Symptoms and Signs

Incubation period 20-90 days None

(4 days-7 years)

Prodrome 2-10 days Fever, malaise, anorexia, nausea,

vomiting, paresthesias, pain or pruritus at
the wound site

Acute neurologic disease

Encephalitic (80%) 2-7 days Anxiety, agitation, hyperactivity, bizarre

behavior, hallucinations, autonomic
dysfunction, hydrophobia

Paralytic (20%) 2-10 days Flaccid paralysis in limb(s) progressing to

quadriparesis with facial paralysis

Coma death 0-14 days

Approach to Px: Diagnosis

History Taking
➔ Bite or Non-bite?
➔ Location? Characteristic? Associated signs and symptoms?
➔ Status of biting animal at time of bite and after 14 days
➔ Is the biting animal vaccinated?
➔ Does the patient have hx of previous rabies vaccination? (pre or post-exposure
prophylaxis)
Approach to Px: Diagnosis
Laboratory Testing
➔ Complete Blood Count
◆ Normal
➔ Cerebrospinal fluid
◆ mild mononuclear cell pleocytosis with a mildly elevated protein level
➔ CT head scans
◆ Normal
➔ MRI brain scans
◆ may show signal abnormalities in the brainstem or other gray-matter areas
Approach to Px: Diagnosis
Histologic Examination

➔ Negri Body
◆ Most characteristic pathologic
finding
◆ Eosinophilic cytoplasmic
inclusions in brain neurons
◆ Rabies virus proteins and viral
RNA
Approach to Px: Diagnosis
Histologic Examination

➔ Direct Fluorescent Antibody

Testing
◆ Highly sensitive and
specific
◆ Can be performed quickly
◆ Skin biopsies and brain
tissue
Approach to Px: Diagnosis
Histologic Examination

➔ RT-PCR Amplification
◆ Highly sensitive
◆ Specific
◆ RT-PCR with genetic sequencing can distinguish among rabies
virus variant
◆ Specimen:
● Saliva
● Skin, CSF and brain tissues
Management
Management
Management
Management
1. Initiation of post-exposure prophylaxis (PEP) shall not be delayed for
any reason.
2. Immediate washing of the bite wound/ exposed area with soap and
water and application of an antiseptic solution.
3. There are no absolute contraindications to rabies PEP.
4. Patients allergic to a specific vaccine/RIG or its components shall be
given the alternative vaccine/RIG.
5. Dog owners have the responsibility to keep their dogs for observation
under the Rabies Act of 2007.
Post-Exposure Prophylaxis
Local Wound Treatment

➔ Wash wounds immediately and

vigorously with soap/detergent
and water, preferably for 10
minutes.
➔ If soap is not available, wound
should be thoroughly and
extensively washed with water
➔ Don’t substitute into folk beliefs
and actions!
Post-Exposure Prophylaxis
Local Wound Treatment

➔ Apply pressure if wound is

bleeding.
➔ Alcohol, povidone or any
antiseptic can also be applied
➔ Avoid suturing at all times.
Post-Exposure Prophylaxis
Anti-Tetanus Immunization
Post-Exposure Prophylaxis
Antimicrobials

➔ All frankly infected wounds

➔ All category III cat bites
➔ All other category III bites that
are either deep, penetrating,
multiple or extensive or located
on the hand/face/genital area.
Post-Exposure Prophylaxis
Antimicrobials
Post-Exposure Prophylaxis
Antimicrobials
Administration Area
 Types of Rabies Vaccines
ACTIVE IMMUNIZATION (VACCINE)

1. Intradermal (ID) regimen:

➔ Dose: 0.1 mL for both Purified Verocell Rabies Vaccine (PVRV) and
Purified Chick Embryo Cell Vaccine (PCECV)
➔ One dose should be given on each deltoid (right & left) or anterolateral
thighs in infants on days 0,3,7,28.

1. Intramuscular (IM) regimen:

➔ Dose: 0.5 mL for PVRV and 1.0 mL for PCECV
✔ Zagreb regimen schedule: Day 0, 7, 21.
✔ CDC shortened schedule: Day 0,3,7,14.
Types of Rabies Vaccines
ACTIVE IMMUNIZATION (VACCINE)
 Types of Rabies Vaccines
Passive IMMUNIZATION (VACCINE)
➔ Total dose infiltrated around & into the wound, administered
at the same time with the 1st dose of rabies vaccine (Day 0)
➔ If RIG is unavailable on 1st visit (Day-0), it may still be
given until 7 days after the 1st dose of the rabies vaccine.
➔ Beyond 7 days, if vaccine regimen is completed, RIG is not
indicated.
Dose:
✔ Human rabies immunoglobulin (HRIG): 20 IU/kg
✔ Equine rabies immunoglobulin (ERIG): 40 IU/kg (skin test
needed)
Types of Rabies Vaccines
PASSIVE IMMUNIZATION (VACCINE)
Who should be given RIG?

➔ Even if RIG is not available or affordable, prompt local treatment

of all bite wounds or scratches, and for category II and III
exposures a complete course of rabies vaccine is indicated.

➔ For patients who can reliably document previous post exposure

prophylaxis (PEP of 6 doses (3 visits) or PrEP of 4 doses (2 visits)
using WHO pre-qualified CCEEV or PEP of 8 doses (4 visits) or
PrEP of 6 doses (3 visits) using non-WHO pre-qualified CCEEV,
RIG is not indicated.
Who should be given RIG?
➔ In cases of shortage or unaffordability, the following groups should be
prioritized for RIG allocation:

◆ Multiple bites
◆ Deep wounds
◆ Highly innervated parts of the body, as head, neck, hands, genitals
◆ Immunocompromised patients
◆ History of biting animal indicative of confirmed or probable rabies
◆ A bite or scratch or exposure of a mucous membrane by a bat can
be ascertained
Management of Adverse Reactions

Anaphylaxis
➔ 0.1% adrenaline or epinephrine underneath the skin or into the muscle
◆ Adults: 0.5mL
◆ Children: 0.01ml/kg
◆ Give steroids after epinephrine

Hypersensitivity Reactions
➔ Antihistamines
Management of Previously Vaccinated
Individuals
Prevention
NATIONAL RABIES CONTROL PROGRAM

➔ Department of Agriculture and Department of Health

➔ Standardized the treatment and management guidelines of human
rabies
➔ Address management of animal rabies particularly
◆ Massive dog vaccination
Prevention
Health Promotion

➔ Massive health information campaigns

➔ Integration of rabies programs in school curriculums
Prevention
Patient- centered
➔ Immediate local wound care
➔ Early clinical consult and prompt medical attention
➔ Post-exposure prophylaxis

Family - focused
➔ Handwashing
➔ Immediate isolation of suspected and confirmed cases
➔ Prophylaxis for those exposed to rabid patients
Prevention
Community - oriented
➔ Pet Vaccination drives
➔ Improve access to affordable healthcare
➔ Health promotion and increase awareness of risks associated with animal
bites
➔ Responsible pet ownership
➔ Leave stray and wild animals alone
Practices in Zarraga and Sta. Barbara

Proper The lowest price

Health Education
Management possible!
 Thank
You!
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References:

Department of Health Revised CPG on Rabies

https://www.cdc.gov/rabies/index.html
https://www.cdc.gov/rabies/about.html