RABIES AND ITS PREVENTIVE

MANAGEMENT

Dr M Amir Sohail MBBS DCH

 Rabies - A killer
disease widespread
throughout the world
 It is estimated every 15
minutes one person dies
of rabies, & 15,00,000
bites occur per year
Rabies is endemic in most parts
of the world & severe in
developing countries of Africa,
Asia & South America, where
99% of world’s human rabies
death occur
 Rabies free countries
• Antartica • New Zealand
• Australia • Malaysia
• British Isles • Singapore
• Cyprus • Taiwan
• Japan • Lashwadeep,
Andaman & Nicobar
Islands
 BANGLADESH
Almost 80000 people seek post-
exposure vaccination and 2000
people die of rabies
 Pre valenc e o f Human Rabie s
in Bang lade s h

Hospital records indicate about 2000 cases per year

Statistics from I.D.H, Dhaka alone
200
200
171
171 173
173
162
162
145
145 151
151
150
150
140
140
132
132
116
116 120
120
100
100
101
101

50
50

00
1991
1991 1992
1992 1993
1993 1994
1994 1995
1995 1996
1996 1997
1997 1998
1998 199
19999 200
20000

nn (Z. Ahmed, 4thth Int. Symp.

On Rabies in Asia, Vietnam, March 2001)
 Statistics from IDH
Year Rabies cases
1991 116
1992 120
1993 132
1994 162
1995 171
1996 140
1997 145
1998 151
1999 101
2000 173
Z. Ahmed, 4th Int. Symp. On Rabies Vietnam 2001
Children often suffer the major
burnt of the trauma due to
animal bites and in several
studies account for 60% of
animal bite cases
TK Ghosh, Journal of APCRI, 1999; pp21-25
 Rabies virus
• RNA virus; family - Rhabdoviridae, genus -
Lyssavirus
• Bullet shaped
• Resistant to cold, dryness, decay & is known to
remain infectious for weeks in cadavers
• Readily inactivated by soap, common disinfectants
(Dettol, Savlon, tincture iodine, povidone iodine),
acid & alkali, UV light, pasteurization, 40%
alcohol
 ANIMAL RESERVOIR OF VIRUS

• All mammals are capable of being infected with

rabies
• Dogs major vector of transmission of rabies (99%
of human rabies transmitted by dog, 90% people
seek PET line areas where canine rabies is
endemic)
• Other predominant reservoir - cats, jackals,
wolves, foxes, mongoose, skunks, raccoons,
coyotes, bats
 RABIES RESERVOIR IN DIFFERENT COUNTRIES

• Dogs Major vector of rabies throughout the world, especially Asia,

Latin America & Africa
• Foxes Eastern Europe, Subartic & eastern parts of N. America, Suartic
Asia
• Jackals Asia & Africa

• Raccoons Eastern United States

• Mongooses Yellow mongoose in Asia & Africa, Indian mongoose in the

Caribbean Islands
• Skunks Midwestern United States, Western Canada

• Bats Vampire bats from Northern Mexico to Argentina, insectivorous

bats in N. America & Europe
 TRANMISSION OF VIRUS

• Broken skin
• Intact mucous membrane
• Aerosol
• Organ transplant
 INCUBATION PERIOD

• Average - 30 to 90 days, but varies from

days to years

• Depends on degree & site of bite, amount of

virus inoculated & host factor (age/
immunodeficiency)
 Lower extremity is the
commonest site of exposure in
65% of cases followed by the
upper extremity in 28.8%, head,
neck & face in 5.8%, abdomen in
5.8% and chest in 0.6%
AK Dutta, Journal of APCRI, 1999; pp26 30
 PATHOGENESIS IN HUMANS
• Inoculation of the virus mainly through a bite
from infected animal
• Multiplication, penetration in the local nerve
ending & spread by the axonal route towards
CNS
• Virus spread within brain
• Migration through peripheral nerves in the
secretory & excretory glands
 CLINICAL MANIFESTATION

Prodromal symptoms

Headache, restlessness, fever

Itching at the site of bite, even if it is healed
 Classical Manifestation

Occurs in 80- 90% of patients

• Hyperexitability
• Hydrophobia
• Aerophobia
• Photophobia
• Respiratory paralysis, cardiac arrest, death
in 1-5 days
 Paralytic Rabies

Less common
• Gradual ascending paralysis
• Stupor, coma & death in 1-2 weeks
• Hydrophobia usually absent
LABORATORY DIAGNOSIS

Antemortem
• Skin biopsy from nuchal region
• Corneal impression & saliva
smear
Postmortem
• Brain - Negri bodies
• Biological test
 MANAGEMENT OF RABIES PATIENT

• Isolation • Medical attendants - self

• iv rehydration, protection
prednisolone, mannitol • Avoid contact with
saliva, other body fluids
• Sedatives,
antipyretics, • Pre-exposure
analgesics, vaccinationWash
clothes & other objects
antihistamines &
anticonvulsants • Room to be washed
 RABIES IS A
100% FATAL DISEASE
 PREVENTION OF
RABIES IN MAN

• Post-exposure treatment
• Pre-exposure immunization
POST-EXPOSURE TREATMENT

• Wound treatment
• Anti-rabies immunization
a. Anti-rabies vaccine
b. Anti-rabies sera/immunoglobulin
 WOUND TREATMENT
• Clean & flush wound with profuse water & soap
• Application of viricidal agents
• Thorough exploration of wound, debriment &
removal of dirt, dead tissue, foreign bodies
• No dressing/bandaging & avoid suturing
• Proper tetanus prophylaxis
• Systemic antibiotics
 RABIES VACCINATION
On July 6, 1885, Louis Pasteur saved
a young boy - Joseph Meister bitten
by a rabid dog by vaccinating him
with an attenuated virus strain
obtained by repeated passage from a
rabbit spinal cord
 THE PROGRESS OF
RABIES VACCINE IN 100 YEARS
Brain of adult animals
Brain of suckling animals
Embryonated eggs
CELL CUTURE
Human diploid cell
Purified Chick Embryo Cell
Purified Vero Cell Vaccine
 NERVE TISSUE VACCINE

Prepared from sheep brain

Virus inactivated with phenol
Composition - 5% infected sheep
brain suspension
 NERVE TISSUE VACCINE
• High drop out rate
- large volume
- daily administration over 7-14 days
- sc tissue of anterior abdominal wall
• Poorly immunogenic
• High incidence of local & systemic reactions
• High risk of neurological complication (1:5000 -
1:1100)
TISSUE CULTURE VACCINE

• Human diploid cell

• Purified Chick Embryo Cell
• Purified Vero Cell Vaccine
 TISSUE CULTURE VACCINE
• Relatively painless
• Highly immunogenic
• Very well tolerated
• 5 spaced-out injections in the arm instead of daily
injection in abdomen
• Small volume
• Hardly any neurological complaint
• Pre-exposure prophylaxis for high risk person
• Can be given at any stage of pregnancy
 Since 1983, the WHO has indicated its support
for the trend to limit or abandon completely,
where economically and technically possible, the
production of encephalogenetic brain tissue
vaccine, and strongly advocates discontinuation
of the nerve tissue vaccines in favour of these cell
culture vaccines in both developed and
developing countries
WHO Expert Committee on Rabies, 7th Report, WHO Technical Series 709
(“Essen” Scheme)
 Post exposure prophylaxis
(Essen schedule)

One injection each on day

0, 3, 7, 14, 30 & 90(optional)
Day 0 is the day of first injection & Days
3, 7, etc are to be counted from Day 0
 Rabies immunization
with tissue culture vaccine

• Preferred site - deltoid region

• In infants & children - lateral aspect of
thigh
• Avoid gluteal region
• Same dose for age group
• Use reconstituted vaccine in 6-8 hours
 Preferred site : Deltoid
 In infants and small children:
antero-lateral aspect of the
thigh
 Avoid gluteal region.
- inadvertant deposition of vaccine in
thick S.C. adipose tissue instead of
muscle, retards immune response

 Same dose for all age groups

 Use reconstituted vaccine in
6-8 hours
 INDICATIONS FOR ANTI_RABIES
IMMUNIZATION

• Stray animal & not available for

observation
• Animal shows clinical signs of rabies
• Animal is proved positive for rabies by
laboratory examination
 SITUATIONS WHERE ANTI-RABIES
IMMUNIZATION IS NOT REQUIRED

• Drinking of boiled milk of rabid animal

• Biting animal has remained healthy & alive for
10 days (??)
• Mere touching of a rabid animal
• Bite or scratch over clothing without tearing or
piercing it & no sign of injury on skin at all
• Unprovoked & accidental bites by rodents, rats,
mice, hares, rabbits, birds, bats & insects
 With the advent of modern tissue culture
vaccines, and in view of the fact that literature
records several instances where the animal
has outlived the man it has bitten, there is no
longer a rationale in observing the animal
while withholding treatment

AK Dutta, SK Kanwal, Journal of APCRI, 1999; pp5-13

 The post exposure vaccination
allows for the rapid induction of
antibodies against rabies virus
and to be successful, a full course
should be administered as early
as possible at an appropriate
site, and without any delay
 Unfavourable host factors like
alcoholism, malnutrition,
immunosuppressive treatment, certain
chronic disease
- two initial intramuscular injection of
the vaccination into both deltoid muscle
followed by the classical regimen
 The post exposure vaccination
allows for rapid induction of
antibodies against rabies virus
and to be successful, a full course
should be administered as early
as possible at an appropriate
site, and without any delay
Management of patients, who are
previously vaccinated within last
5 years and have re-exposure,
involves as always, local
treatment of the wound and
repeat vaccination with 2 booster
doses on days 0 and 3
 RABIES IMMUNOGLOBULIN

• Single or multiple transdermal bites or

scratches (especially near the CNS)
• Contamination of mucous membrane with
saliva
Post-exposure Prophylaxis of Rabies
together with RIG (“Essen” Scheme)
 RABIES IMMUNOGLOBULIN

• Equine RIG - 40IU/kg

• Human RIG - 20IU/kg

• Single dose at the same time as the first dose of vaccine

• RIG should be infiltrated around & into the wound. Any
remaining RIG should be injected intramuscularly at a
distance from the site of vaccine innoculation
Pre-exposure prophylaxis for high risk
persons

• Veterinary doctors
• Doctors treating rabies patients
• Laboratory personnel
• Hunters
• Animal attendants
• Postman
One injection each on days :

0 7 21 or 28

or

0 28 56
 Pre-exposure prophylaxis

Day 0, 7, 21 or 28
Day 0, 28 & 56

Booster after 1 year & subsequently 1

injection every 3-5 years
 Factors adversely influencing response

• Inappropriate local wound treatment

• Delayed initiation of PET
• Vaccination not in deltoid region
• No rabies immunoglobulin
• Failure to infiltrate RIG locally
• Treatment with RIG 24 hours before vaccination
• Host factors
• Vaccination not completed
 POINTS TO REMEMBER
• Rabies is 100% fatal disease
• Immediate & early wound treatment to remove traces of saliva is
very important
• Suturing of wounds to be avoided
• Correct PET, including the use of serum in high risk exposure, is
life saving
• There is no contraindication for post-exposure immunization
including pregnancy, lactation, AIDS and other infectious condition
• TCV are superior & safe, & is always preferred & injected
intramuscularly into deltoid (thigh in children) & never in gluteal
region
 In an endemic & enzootic
country where every animal bite
is considered a risk, immediate
starting of vaccine in low risk
exposures and serum and vaccine
in higher risk exposure is
strongly recommended
THANK YOU