Seminar

On

RABIES THE FACTS

Presented byVijay kr. Singh

DNB PGT (Pediatrics)

Under guidance of Under guidance of

Dr T K MONDAL

MD(PEDIATRICS)

Consultant pediatrician M R Bangur Hospital

Date 20 july 2013

Venue

DNB Seminar hall M R Bangur hospital Kolkata-33

� Intoduction-Rabies is an acute viral diease

which cause fatal encephalitis in virtually all

warm blooded animals including man.

� This virus is found in wild and some

domestic animal like Dog, Cat, Cattle, and domestic animal like Dog, Cat, Cattle, and

Pigs, Mangoose and jackals and, Bats.

�Human death from rabies is estimated from

26000 to 61000.

� 85% death occurs in rural area.

� According to APCRI(Association for

preventive control of Rabies in India) the preventive control of Rabies in India) the

annual incidence of human rabies death in

India was 17137.

� In India 50-60% of rabies death occur in

children, particularly age under 15 yrs.

� Shorter stature of children lead to more bite

in the upper part of the body which lead to

shorter time for virus to reach brain.shorter time for virus to reach brain.

� Bites by domestic and per idomestic

mammals does not cause rabies like

� Rat

� Squirrel

� Rabbits

�Genie pig

� Rabies virus is a single structure RNA virus

belonging to the genus Lyssavirus of the

family Rhhabdo viridae.

� It is neurotropic virus and rapidly inactivated

by-by-

�Oxidizing agent

�Quaternary ammonium compound, soap and

detergent.

� Rabies virus enters the body through wound

or by direct contact with mucosal surface.

� It can not cross intact skin.

� Rabies virus replicates in the bitten muscle

and gain access to motor ends plates and and gain access to motor ends plates and

reach central nervous system not by sensory

and parasympathetic ending.

� Viruses can also enter motor axon in

peripheral nerve directly during a

penetrating injury.

� In Bat variant – viral propagation may also

occur via sensory nerve due skin tropism.occur via sensory nerve due skin tropism.

� It is highly variable.

� It varies from 5day to several yrs.

�Usually 2-3 months

� It is rarely more than 1 yr.� It is rarely more than 1 yr.

� Incubation period depends upon.

� The amount of virus in the incolution

� The density of motor end plates

� The proximity of virus entry to CNS� The proximity of virus entry to CNS

� There are two distinct clinical forms

� 1. Furious Rabies or encephalitis type. It is

about 80%

� 2. Dumb Rabies or Paralytic type. It is about

20%.20%.

� Accoding to WHO

� Suject presenting with an acute neurological

syndrome(encephalitis) dominated by forms

of hyperactivity(furious) or paralytic

syndrome(dumb rabies) progresssing towards syndrome(dumb rabies) progresssing towards

coma and death, usually by cardiac or

respiratory failure, typicaly within 7-10 days

after sign, if no intensive care s instituted.

� It may be used in diagnosis

� Presence of viral antigen

� Isolation of virus in cell culture

� Presence of virus specific antibodies in CSF � Presence of virus specific antibodies in CSF

or in serum in unimmunized

� Suspected- It is compantable with clinical

case definition.

� Probable –reliable history with exposure to

rabid animal.

Confirmed-suspected or probable case that is � Confirmed-suspected or probable case that is

laboratory confirmed.

�Malaise

�Headache

� Fever

�Numbness�Numbness

� And tingling sensation at site of bite.

� Thease symptoms are common in both type

of rabies

� Symptoms are mainlly related with spasm

due to stimulation of olfactory system

�Hydrobhobia

� Aerobhobia

�Dysphagia

�Myoedema (in chest, deltoid muscle , thigh)

� Ascending paralysis

� Tingling at site of bite

�Diagnosis of rabies mainly clinical

� Laboratory test may be required in atypical

cases.

Ante mortem diagnosis

It is by detection of virus or viral antigen in

saliva or CSF.

Viral nucleic acid may be detected in

infected tissue by reverse transcriptase or

PCR.

� To detect antibodies to rabies virus

� Post mortem diagnosis

�Demonstration of negries body in brain tissue

CATEGORY I Licks on intact skin,

fall down on animal,

touching, feeding of

animal.

No prophylaxis if

history is reliable.

CATEGORY II Minor scratches or

abrasion without

bleeding or licks on

Wound management

ant anti rabies

vaccine.bleeding or licks on

broken skin and

nibbling of uncovered

skin

vaccine.

CATEGORY III Single or multiple

transdermal bites or

scratches, or

contamination of

mucous membrane

with saliva.

Wound management

with rabies

immmunoglobin plus

anti-rabies vaccine

�Hostory of bite

� Animal vaccine failure does occur and

considering the fatal nature of the disease, it

is mandatory to start prophylaxis

After starting the vaccination, the schedule � After starting the vaccination, the schedule

may be modified in cases where the animal is

suspected not being rabid.

� If it is healthy throughout an observation

period of 10 days by converting post

exposure to pre- exposure prophylaxis.

� This observation is valid for dogs and cats

only because natural history of rabies is not

known in other animals.

� Bat rabies is not conclusively proved in

India. India.

� Exposure to Bat bite does not warrant

treatment.

� Tretment must be started as soon as possible

� Person who exposure is months before, must

be treated like recent exposure.

�Management of wound

�Passive immunization – rabies

immunoglobin

�Active immunization- anti-rabies �Active immunization- anti-rabies

vaccine

� Immediate washing and flushing the wound

with soap and water.

� Followed by disinfection with ethanol or

iodine.

Suturing of wound should be avoided.� Suturing of wound should be avoided.

� But if suturing is necessary, it will be loosely

sutured with infiltration of immuniglobin.

� Administration of tetanus toxoid or tetanus

immunoglobin as per requirement.

� Two types of RIG(Rabies immunoglobin)

� ERIG(Equine RIG)

�HRIG(Human RIG)

� ERIG Require sensitivity testing as per � ERIG Require sensitivity testing as per

manufactured instruction.

�HRIG does not require sensitivity testing.

� ERIG Available in 300 IU /ml.Doses 40 IU/kg

with maximum 3000 IU.

�HRIG Available in 150 IU/ml. Doses 20 IU/kg

with maximum 1500 IU.

� Total calculated dose should be infiltrede

locally around the wound.

� Remaining amount, if any, must be

administered deep intramuscular injection

distant site from vaccine site.distant site from vaccine site.

� In case of multiple wound, ammunoglobin

mixed with normal saline and infitreted

locally and remaining will be given deep IM

Injection.

� RIG can be given up to 7th day of first dose of

ARV.

� RIG should never be given at same site or

same syringe as vaccine.

Transient tendrenes and mild fever may � Transient tendrenes and mild fever may

occurs, required no any treatment.

� RIG never be used intra venouslly.

� Anti rabies vaccine

� There are different types of ARV available in

market like

�Human diploid cell vaccine(HDCV)

� Purified chick embryo cell vaccine(PCEC)

� Purified vero cell vaccine(PVRV)

� All cell culture vaccine are in dried –freezed

form and should be stored at 2-8 degre

centigrate.

� Reconstited vaccine must be used within 6-8

hours.hours.

� Inter switching between different cell

culture vaccine is not recommended.

� All vaccines should must have potency

above2.5IU per dose.

� INTRAMUSCULAR REGIMEN

� ESSEN Schedule – Five dose of ARV

intramuscularly(1-1-1-1-1) given single

intramuscular on day0,3,7,14,28.

Zagreb Schedule-four dose intramucular (2-0-� Zagreb Schedule-four dose intramucular (2-0-

1-0-1) given as two dose on day 0, on day

0,7, and on day 21.

�Updated Thai red cross schedule(2-2-2-0-2) –

two doses of 0.1 ml of vaccine at different

sites on each deltoid area on day 0, 3, 7, 28.

� Thai red cross schedule- it is same as

previous except a single dose dose on day 28 previous except a single dose dose on day 28

and 90.

� Vaccine are approved by DCGI should be

used.

� Two booster doses either by intradermal or

IM will be given on day 0 and 3.

�No Rabies immunoglobin is required.

� Immunocompromised with category II

exposure should receive rabies immunoglobin

in addition to full post exposure vaccination.

� Children constitute special risk group of

exposure.

�High risk children will be vaccinated after 3

yrs.

IM schedule- On day 0, 3, 28.� IM schedule- On day 0, 3, 28.

� ID schedule – On day 0, 7, 28.