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Viral Zoonosis Rabies
Viral Zoonosis Rabies
Definition
Zooneses are diseases of vertebrate animals that can be transmitted to man: either directly or indirectly through an insect vector. When an insect vector is involved, the disease is also known as an arboviral disease.
However, not all arboviral diseases are zoonosis: where the transmission cycle takes place exclusively between insect vector and human e.g. dengue and urban yellow fever. Examples of viral zoonoses that can be transmitted to man directly include rabies, hantaviruses, lassa and ebola fevers.
GENOM
PROTEIN REPLIKASI ENVELOPE CIRI KHAS
Rabies Virus
member of the Lyassavirus of the Rhabdoviridae.
ssRNA enveloped virus, characteristic bullet-shaped appearance with 6-7 nm spike projections.
STRUKTUR VIRUS
UKURAN Pj 180 nm, Lebar 75 nm Genom mengkode 5 protein Nukleoprotein (N) Phosphoprotein (P) matrix protein (M) Glikoprotein (G) Polymerase (L) Komponen struktural core Ribonukleoprotein (RNP) dikelilingi envelope. Genom RNA nukleoprotein/kapsid (heliks) N, L, P genom RNA M envelope membran G tonjolan glikoprotein envelope
Rabies Virus
Viral Structure
REPLIKASI
Epidemiology
Rabies is a zoonosis which is prevalent in wildlife. The main animals involved differs from continent to continent.
Europe Middle East Asia Africa N America
S America
fox, bats wolf, dog dog dog, mongoose, antelope foxes, skunks, raccoons, insectivorous bats dog, vampire bats
TINGGI
HAMSTER MUSANG
SEDANG
ANJING LEMBU
RENDAH
TUPAI
SERIGALA
ANJING HUTAN
RAKUN
KUCING KELELAWAR
DOMBA
KAMBING KUDA
KELINCI
WABAH RABIES
INDONESIA 2004-2008 15.000 DIGIGIT BADUNG, BALI VAKSIN 20.000 ANJING TH 2008 14.106 ORANG: 9565 DIBERI VAKSIN DAN OBAT; 85 RABIES BALI 1700 ORANG PENYEBAB: POPULASI ANJING TDK TERKENDALI KRN LEMAHNYA SISTEM DETEKSI DINI DAN EVALUASI PERIODIK SURVEY SEROLOGI ANTIBODI DARI HEWAN SUMBER PENULARAN HARUSNYA DILAKUKAN PERIODIK
Pathogenesis
The commonest mode of transmission in man is by the bite of a rabid animal, usually a dog. Rabies is an acute infection of the CNS which is almost invariably fatal.
Following inoculation, the virus replicates in the striated or connective tissue at the site of inoculation and enters the peripheral nerves through the neuromuscular junction. It then spreads to the CNS in the endoneurium of the Schwann cells.
Terminally, there is widespread CNS involvement but few neurons infected with the virus show structural abnormalities. The nature of the profound disorder is still not understood.
Viral cycle
Viral cycle
Viral Pathogenesis
VIRUS MEMBENTUK BADAN INKLUSI INTRASITOPLASMA, ASIDOFILIK PD SEL SARAF TERINFEKSI BADAN NEGRI
GEJALA KLINIS
ENSEFALITIS AKUT, FULMINANT, FATAL
MASA INKUBASI 1 MINGGU, 1-2 BULAN, BBRP TH (> 6 TH) : HEWAN TIMBUL GJL > 2 MINGGU (20 HARI-8 MINGGU) MANUSIA TIMBUL GJL 2-3 MINGGU SMP 1 TAHUN FASE KLINIS FASE PRODOMAL PENDEK FASE NEUROLOGI AKUT KOMA
GEJALA KLINIS
FASE PRODOMAL PENDEK : 2-10 HARI MALAISE, ANOREXIA, NYERI KEPALA, FOTOPOBIA, MUAL, MUNTAH NYERI TENGGOROKAN, DEMAM
FASE NEUROLOGI AKUT : GELISAH, CEMAS, HALUSINASI, LAKRIMASI, DILATASI PUPIL, SALIVASI (AKTIVITAS MENELAN SBBK SPASME & NYERI OTOT TENGGOROKAN), BERKERINGAT, SEBAG HIDROPOBIA KEJANG/KOMA KEMATIAN (2-7 HARI STLH ONSET) KRN KELUMPUHAN PERNAFASAN
RABIES PARALITIK TERJADI SEKITAR 20% PASIEN AKIBAT TERINFEKSI VIRUS RABIES KELELAWAR BBRP BTHN 30 HARI, TP JARANG YANG DPT SEMBUH & BTAHAN HIDUP
BENTUK ASYMPTOMATIS:
TANPA GEJALA, TIBA-TIBA MATI
Dumb Rabies
Dumb Rabies, manifested as depresion and an attempt at self-imposed isolation
Human rabies
Hospitalized human rabies, who was restrained while bedridden
Laboratory Diagnosis
Histopathology - Negri bodies are pathognomonic of rabies. However, Negri bodies are only present in 71% of cases. Rapid virus antigen detection - in recent years, virus antigen detection by IF had become widely used. Corneal impressions or neck skin biopsy are taken. The Direct Fluorescent Antibody test (DFA) is commonly used. Virus cultivation - The most definitive means of diagnosis is by virus cultivation from saliva and infected tissue. Cell cultures may be used or more commonly, the specimen is inoculated intracerebrally into infant mice. Because of the difficulties involved, this is rarely offered by diagnostic laboratories. Serology - circulating antibodies appear slowly in the course of infection but they are usually present by the time of onset of clinical symptoms.
DIAGNOSA LABORATORIUM
ANTIGEN RABIES/ASAM NUKLEAT IMMUNOFLUORESCENS, PCR (JAR OTAK/KORNEA ISOLASI VIRUS INTRACEREBRAL PADA TIKUS YG BLM DISAPIH ENSEFALITIS & KEMATIAN SEROLOGI IMMUNOFLUORESCENS, TES Nt OBSERVASI HEWAN SELAMA 10 HARI PADA HEWAN RESERVOAR
Diagnosis of Rabies
Postexposure Prophylaxis
Wound treatment - surgical debridement should be carried out. Experimentally, the incidence of rabies in animals can be reduced by local treatment alone.
Passive immunization - human rabies immunoglobulin around the area of the wound; to be supplemented with an i.m. dose to confer short term protection.
Active immunization - the human diploid cell vaccine is the best preparation available. The vaccine is usually administered into the deltoid region, and 5 doses are usually given. There is convincing evidence that combined treatment with rabies immunoglobulin and active immunization is much more effective than active immunization alone. Equine rabies immunoglobulin (ERIG) is available in many countries and is considerably cheaper than HRIG.
PENANGGULANGAN
KASUS NON AKUT: CUCI LUKA DG SABUN/DETERGEN SLM 510 MENIT DI BAWAH AIR BERI ALKOHOL 70%/YODIUM BERI Ig ANTI RABIES DAN VAKSIN HEWAN KIRIM KE DINAS PETERNAKAN ORANG YANG DIGIGIT RS KHUSUS INFEKSI
PENANGGULANGAN
KASUS AKUT: VAKSIN EFEK SAMPING: MENINGITIS + GJL SEPERTI RABIES YODIUM TDK MEMBANTU KRN VIRUS SDH MSK Ig ANTI RABIES CEGAH VIRUS TDK MENYEBAR KE SYARAF OTAK ISOLASI PENDERITA BISA MENULARKAN OBAT TDK ADA, TERAPI SYMPTOM: ANTI KEJANG, OBAT CEGAH INFEKSI SEKUNDER, OBAT PENENANG
Rabies Vaccines
The vaccines which are available for humans are present are inactivated whole virus vaccines. Nervous Tissue Preparation e.g. Semple Vaccine - associated with the rare complication of demyelinating allergic encephalitis. Duck Embryo Vaccine - this vaccine strain is grown in embryonated duck eggs This vaccine has a lower risk of allergic encephalitis but is considerably less immunogenic.
Human Diploid Cell Vaccine (HDCV) - this is currently the best vaccine available with an efficacy rate of nearly 100% and rarely any severe reactions. However it is very expensive.
Other Cell culture Vaccines - because of the expense of HDCV, other cell culture vaccines are being developed for developing countries. However recent data suggests that a much reduced dose of HDCV given intradermally may be just be effective.
PENCEGAHAN SEBELUM PEMAPARAN : VAKSINASI PADA INDIVIDU BERESIKO TINGGI PENCEGAHAN SETELAH PEMAPARAN : PENATALAKSANAAN & PENGENDALIAN :
Control of Rabies
Urban - canine rabies accounts for more than 99% of all human rabies. Control measures against canine rabies include;
stray dog control.
Vaccination of dogs quarantine of imported animals
Wildlife - this is much more difficult to control than canine rabies. However, there are on-going trials in Europe where bait containing rabies vaccine is given to foxes. Success had been reported in Switzerland.
KLB Rabies
Jumlah yang digigit meningkat Jumlah vaksin terbatas Vaksin rabies pasca paparan mahal (VeroRab 4x suntikan/bulan Sumber: muntah, ludah pasien Sulit edukasi masyarakat untuk:
Eradikasi anjing liar Henti makan daging anjing
Skor LARAT
LARAT: nama titik terluar NKRI, yang berbatasan langsung dengan Samudra Hindia Probability/Peluang kejadian Rabies pada pasien gigitan anjing saat KLB Rumus
1 1 + e-(F)
Skor LARAT
F = 6,3 + 1,6 (selisih waktu gigit anjing < 2 bulan) + 1,3 (lokasi luka gigitan di kepala, wajah, leher, dada, atau punggung) + 2,5 (karakteristik anjing dominan ciri rabies) + 2 (anjing mati sendiri/dibunuh namun diketahui telah digigit anjing yang mati sendiri berasal dari korban). e = Hasil analisis multivarian model epidemiologi
Sistem skoring prediksi rabies pada pasien gigitan anjing saat KLB Rabies
No 1 2 3 4 Variasi Selisih waktu gigitan anjing Lokasi luka gigitan anjing Karakteristik anjing (ada 7 karakteristik) Akibat kematian anjing < 2 bulan 2 bulan Kepala, wajah, leher, dada, punggung Lengan, tangan, perut, tungkai, kaki Dominan Rabies ( 4 sifat) Tidak dominan Rabies (< 4 sifat) Anjing mati sendiri, atau anjing dibunuh namun diperoleh informasi bahwa anjing tersebut mati telah digigit anjing lain yang mati sendiri Anjing dibunuh, tidak mati, tidak tahu Kategori Skor 2 0 1 0 3 0
3 0 9 0
Analisis sensitivitas dan spesifisitas pada ROC curve, skor 5 memberikan prediksi Rabies sehingga perlu mendapat prioritas vaksinasi di saat KLB