RABIES:A PUBLIC HEALTH

PROBLEM

Dr. M.P. Sharma

Professor & Head
Department of Community Medicine
S.M.S. Medical College
Jaipur
 Introduction:
• Rabies, Latin for “madness,” derives
from rabere, to rave, and
• It is related to the Sanskrit word for
violence, rabhas.
• The Greek term for rabies, lyssa, also
means madness, and it provides the
genus name (Lyssavirus).
 Introduction:
• Rabies is a viral disease,
• Caused by rhabdovirus , which
• Infects the central nervous tissue and
salivary gland.
• 6th July is celebrated as ‘WORLD
ZOONOSES DAY’
• September 28 is World Rabies Day.
 Rabies: Burden of Disease
Global burden –
• 55,000 humans deaths by rabies annually.
(WHO estimates)

INDIA -
• 17.4 million animal bite cases annually.

• 20,000 Deaths per year

• Accounts for 36% of the Global deaths

• One death every 30 minutes

 Rabies: Burden of Disease Contd..
INDIA –

• Frequency of animal bite - 1 every 2 seconds

• Rabies is reported from all states except

Lakshadweep and the Andaman & Nicobar
Islands.

• 96 % of human rabies cases are due to bites

from dogs.
• No age or sex predilections
 Findings of Community Based survey by
APCRI
• Dogs & Cats responsible for 98% mortality
• Use of Rabies Vaccination 20%
• Use of RIG 2%
• Indigenous form of treatment 60%
• Died without hospitalization 65%
• Pet care 35%
• Municipal licensing of dogs 4.3%
 ANIMALS TRANSMITTING RABIES IN INDIA

Peridomestic
Wild Not reported
omestic Cows & Buffaloes
Foxes & Jackals Bats *
ogs & Cats Sheep & Goats
Monkeys Rodents *
Pigs
Mongoose Birds
Donkeys
Bears Squirrel
Horses
Camels

Note:
All exposures in wild are considered as category III exposures.
* Bite by Bats or Rodents do not ordinarily necessitate rabies vaccination.
 RABIES-FREE JURISDICTIONS, (JAN 2006)

• Australia • Republic of Irelan

d
• New Zealand
• Norway
• Singapore
• Sweden
• Fiji
• Finland
• Guam
• Iceland
• Hawaii
• Japan
• United Kingdom
• Taiwan
 Morphology of rabies virus

• Belongs to the family Rhabdoviridae

• Genus Lyssavirus (Greek root “lyssa”)
• Infects warm-blooded mammals,
including humans
How Human get infected……
• Infected animal bite & Licks on Broken Skin .
• Can also enter via any mucous membrane,
such as the eye, nose or mouth.
• Handling and skinning of infected animal
carcasses.
• Few cases of human to human transmission.
• Can be transmitted via aerosol, but that’s
also uncommon.
 INCUBATION PERIOD (IN MAN)
• 2 weeks – 6 months (in > 85% cases).
• Ranges between 4 days to 6 years.
• Shorter in children (vulnerable group).
• If site of infection is face - about 30 days.
• If site of infection are hands - about 40 days.
• If site of infection are legs - about 60 days.
• Also very much depend on the severity of
wound.
• longest period noted till date is 25ys
 Clinical features…..
• Pain , irritation or discomfort at the
site of bite.
• Fear and anxiety.
• Depression.
• Intolerance to loud sounds.
 Clinical features…..
• Hoarseness of voice and sense of
constriction in throat with difficulty
in swallowing.
• If spinal cord and brain are infected
then subsequently symptoms of
Furious rabies or
Paralytic(dumb)rabies will develop.
 Furious rabies…..
• Hydrophobia.
• Aerophobia.
• Periods of excitement.
• Cranial nerve lesions(3rd,7th,8th).
• Spasticity.
• Involuntary movements.
• Fluctuating body temperature and blood
pressure.
• Sweating.
• Tachycardia.
 Paralytic or dumb rabies…..
• Patients with paralytic rabies, unlike those
with the furious form, do not have
hydrophobia, aerophobia.
• Is rare, seen in those bitten by vampire bats.
• Flaccid paralysis is often begins in the bitten
limb and ascends symmetrically or
asymmetrically until it involves muscles of
deglutition and respiration killing the patient
in 2/3 days.
 MANAGEMENT

• Isolation
• Relieve of anxiety by sedative
• Hydration and diuresis
• Respiratory and cardiac
support
 Milwaukee protocol
• The is an experimental course of
treatment of an acute infection of
rabies in a human being.
• The treatment involves putting the
patient into a chemically induced
coma and administering antiviral
drugs
 Diagnosis……

• Biopsies.
• Viral detection in saliva, throat swabs and
tracheal aspirates.
• Antibody detection is the most successful
method for confirming diagnosis.

Note: Laboratory diagnosis is not mandatory

for managing animal bite cases.
 Diagnostic Techniques
1. Histological examination for Negri
bodies
-negri bodies are cytoplasmic masses of
viral nucleocapsids found in the brain
tissue

2 DIRECT FLOURESCENT ANTIBODY TEST.

Jogai 2002
 Negri body

http://www.med.sc.edu:85/virol/negri-bris.jpg
 Diagnostic Techniques
3. RT-PCR
-Reverse Transcriptase-Polymerase
Chain Reaction
-can make a DNA copy of the viral
genome and use PCR, with a
primer specific to the rabies
genome, to determine its presence
Pre- and Post-exposure
Prophylaxis
 Pre-exposure Prevention
1. Avoid contact with wild animals
2. Do not handle dead animals
3. People that work with wild or
domestic animals should be
vaccinated
4. Vaccination of domestic and
reservoir wild animals
 PRE-EXPOSURE PROPHYLAXIS
• Person who run a high risk of
repeated exposure such as lab
staff working with rabies
virus, veterinarians, animal
handler, wild life officer
 PRE-EXPOSURE PROPHYLAXIS

DOSE 1ML /0.5ML IM

DAY 0 7 28

Booster one dose 1 year after

primary immunization followed by
one dose every 5 years
PRINCIPLES OF POST EXPOSURE PROPHYLAXIS (PEP)

• Local treatment of Wounds

• Immunoglobulins
• Vaccination
• Advice and counseling
 LOCAL TREATMENT OF WOUNDS

• Do’s
• Gently wash under running water with
soap for 5 times over a period of 15
minutes
• Disinfectants - Povidone Iodine, Spirit,
etc.
• Suturing (1 - 2 loose sutures) only if
required and only after administration
of RIG.
 LOCAL TREATMENT OF WOUNDS
• Simple, non occlusive dressing can be
done if required
• Tetanus toxoid and antibiotics to be given
as appropriate.
• Don’ts
• Apply Irritants like chilli powder, plant
sap, lime, atta, etc.
• Cauterize
 Post Exposure Prophylaxis/WHO

• Category I: Exposure : none

• touching
• feeding potentially rabid animal
• licking intact skin

Treatment: no treatment
Post Exposure Prophylaxis/WHO

• Category II: Exposure : minor

• nibbling on uncovered skin
• licks on broken skin
• minor scratches without bleeding

Treatment: wound disinfection, vaccine

only
 Post Exposure Prophylaxis/WHO
• Category III:
• Exposure : severe
• Single, multiple transdermal bites
• Contamination of scratches or MM
with saliva

Treatment: wound cleansing, rabies IG,

vaccine
 I.M SCHEDULE

• ESSEN REGIMEN

DOSE 1ML /0.5ML

DAY 0 3 7 14 28
• MULTI SITE REGIMEN

DOSE 1ML /0.5ML

DAY 0 7 21

SITES 2 1 1

DELTOID OR A/L THIGH

 INDICATIONS FOR
PASSIVE IMMUNIZATION
• All category III exposures, irrespective of status of

biting animal.

• Administer even when treatment is delayed but

RIGs should not be given after 7 days of start of

vaccination (3 doses administered)

 WHO
CATEGORY III EXPOSURES
 PASSIVE IMMUNIZATION
Human Rabies Immuneglobulin : 20 IU/kg body wt.
(HRIG) Maximum of 1500 IU

Equine Rabies Immuneglobulin:40 IU/kg body wt.

(ERIG) Maximum of 3000 IU

ERIG must be administered only after the Test dose.

Test dose (ERIG)

Follow the Manufacturer Guidelines or Inject 0.1 ml of 1:10
dilution of the ERIG in normal saline, Intra Dermally over
flexor aspect of forearm.
 RIG INFILTRATION
Positive test reaction: Induration >10mm with or without
constitutional symptoms.
•If skin test is positive – HRIG is preferred (affordability,
availability)
•If ERIG has to be administered then pre treat with
Adrenaline / Epinephrine
and with Antihistamine before administering full dose.
 PASSIVE IMMUNIZATION

• RIG is most effective when administered

locally and early.

• Infiltrate as much as possible into and around

the wounds; remaining if any to be given
Intra Muscularly at a site away from the site
where vaccine has been administered.
THING TO REMEMBER

• NO ANTI MALARIAL OR
IMMUNOSUPPRESSIVE MEDICATION
DURING TREATMENT AFTER EXPOSURE

• NO ALCOHOL DURING AND 1 MONTH AFTER

TREATMENT
 EDUCATION OF PET OWNERS
• Regular examination of pets

• Get your pet vaccinated at three months of age and

again 1 month later; boosters must be given every year
subsequently.

• Obtain a Municipal License, put a collar and keep your

pet under leash in public places.

• Do not allow your pet to come in contact with community /

street dogs / cats or other animals.

• Inform the Municipal authorities about sick / mad dogs.

• Take treatment even after pet dog bite including pups.