Post exposure prophylaxis in Rabies
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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
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� 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.
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�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.
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� 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.
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� Bites by domestic and per idomestic
mammals does not cause rabies like
� Rat
� Squirrel
� Rabbits
�Genie pig
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� 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.
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� 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.
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� 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.
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� 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.
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� 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
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� 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%.
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� 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.
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� 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
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� 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.
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�Malaise
�Headache
� Fever
�Numbness�Numbness
� And tingling sensation at site of bite.
� Thease symptoms are common in both type
of rabies
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� Symptoms are mainlly related with spasm
due to stimulation of olfactory system
�Hydrobhobia
� Aerobhobia
�Dysphagia
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�Myoedema (in chest, deltoid muscle , thigh)
� Ascending paralysis
� Tingling at site of bite
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�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.
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� To detect antibodies to rabies virus
� Post mortem diagnosis
�Demonstration of negries body in brain tissue
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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
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�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.
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� 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.
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�Management of wound
�Passive immunization – rabies
immunoglobin
�Active immunization- anti-rabies �Active immunization- anti-rabies
vaccine
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� 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.
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� 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.
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� 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.
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� 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.
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� 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)
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� 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.
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� 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.
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�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.
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� Two booster doses either by intradermal or
IM will be given on day 0 and 3.
�No Rabies immunoglobin is required.
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� Immunocompromised with category II
exposure should receive rabies immunoglobin
in addition to full post exposure vaccination.
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� 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.
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