Nationational gudline for rabes vaccine

lecture of 42 slide

1. National Guidelines for Rabies
Prophylaxis
BY
DR. MagdyShafik
Senior Pediatric Consultant
Diploma, M.S ,Ph.Dof Pediatric

2. Rabies is an acute viral disease which cause fatal
encephalomyelitis in all the warm blooded animals
including man .
Rabies is a rare disease but 100% fatal , 100%
preventable .
The virus is found in wild and some domestic
animals, and is transmitted to other animals and
human through their saliva ( bites , scratches, licks
on broken skin and mucous membrane
Rabies

3. Infectious Agent:
virus that attack nervous system , causes brain
cell to malfunction
worldwide –tens of thousand of human deaths
yearly
0-5 deaths per year in the US

4.  Pathogenesis
Live virus → Epiderms, mucous
membrane → peripheral nerve → CNS
(gray matter) → other tissue (salivary
gland,…)

6. Transmission :
Spread by bites or contact of infected saliva with
mucous membranes( eyes, mouth, etc)
Saliva becomes non –infectious when it dries
Also transmitted by contact with nervous tissue
People have been infected by aerosol in bat caves

7. Rabies is not transmitted by causal contact between
people
Transmission can occur during organ
transplantation
4-40 People who have died of rabies in the US since
1990contractedrabies through organ transplant
8 people have died of rabies after corneal
transplant
some donors were asymptomatic at the time of
death

8. 8
Incubation period :
2 weeks to years
1-5 weeks is the most common
the closer bite to the brain , the shorter the incubation
period
Rabies virus travels 1cm per day
Diagnosis :
Brian Biopsy ( after death )
PCR
Rabies Antibodies

9. 9
Clinical Picture
Symptomatic: neurologic
Early signs are non specific :
Fever, headache, weakness, achy muscle
incoordination, Confusion, Strange behavior ,
Attaching and biting moving and stationary objects.
Salivation ( can not swallow like chocking
Fear of water ( hydro phobia)
Paralysis
Seizures
Death within 2 weeks of showing sign

10. Post-Exposure
prophylaxis

11. Post-exposure prophylaxis:
1-Decision to treat
2-Approach to the post expoureprophylaxis :
A-Management of Animal Bite Wound
B-Rabies Immunoglobulin (RIG)
C-Ant-Rabies Vaccine:
Intra-Muscular Regimen(IM)
Intra-Dermal Regimen
post expoureprophylaxis for previously vaccinated
person
Pre-Exposure Prophylaxis

12. 1-Decision to treat
Classification of animal bites for post-exposure
prophylaxis has been based on WHO
recommendation ( Table 1)

13. Recommendation of
post-exposure
Prophylaxis
Type of
Exposure
Type of contactCategory
None, if reliable case
history is available
None Touching or feeding of animal
Licksonintact skin
1
Wound management
Anti-rabiesvaccine
NoneNibbling of uncovered skin
Minor Scratchor Abrasions
without bleeding
11
Wound management
Rabies-
immunoglobulin
Anti-rabies vaccine
SevereSingle or multiple transdermal
bites or scratches, licks on broken
skin
Contamination ofmucus
membrane with saliva
111

14. Vaccination status of the biting animal :
History of rabies vaccination of an animal
is not always a guarantee that the biting
animal is not rabid
Animal vaccine failure may occur because
of improper administration or poor quality
of the vaccine, poor health status of the
animal, and the fact that one vaccine dose
not always provide long lasting protection
against infection in dogs

15. Observation of biting animal :
The treatment should be started immediately
after the bite
The treatment may be modified if animal
involved (dog or cat) remains healthy throughout
the observation period of 10 days by converting
post-exposure prophylaxis to pre-exposure
vaccination by skipping the vaccine dose on day
14 and administrating it on day 28.
The observation period is valid for dogs and
cat only

16. Bites by wild animal :
Bites by all wild animals should be treated as
category 111
Special Circumstances:
Pregnancy, lactation , infancy, old age and
concurrent illness are not contraindication of
Rabies post-exposure prophylaxis since it is a
life saving procedure
Rabies vaccine dose not have any adverse effect
on the fetus , mother
complete post-exposure prophylaxis treatment
should be given depending on the category of
the exposure

17. post-exposure prophylaxis of
immune-compromised patients:
immune-compromised patients with category 11
should receive rabies –immunoglobulin in
addition to a full post-exposure prophylaxsis
Ant rabies antibodies estimation should be done
10 days after the completion of course of
vaccination .

18. Approach to the post expoure
prophylaxis :
A-Management of Animal Bite Wound
B-Rabies Immunoglobulin (RIG)
C-Ant-Rabies Vaccine:

19. A-Management of Animal Bite Wound
1-Wound toilet :
the rabies virus can persist and even
multiply at the site of bite for a long time ,
wound toilet must be performed even if the
patient report late .
Washing with soap or detergent
flushing the wound with running water
for 10 mintues
DO NOT:
TOUH THE WOUND with bare hand
Apply irritant like soil , chillisoil, herbal , chalk

20. 2-Application of antiseptics:
Betadine, Alcohol , Detoll, Chlorhexidine, Savlon
3-local infiltration of rabies immunogloblin
4-Suturing of the wound should be avoided as far
possible :
if surgically unavoidable , minimum loose
suture should be applied after adequate local
treatment along with proper infiltration of rabies
immunoglobins
5-Injection of Tetanus :
given to un-immunisedindividual
a suitable course of antibiotic

21. Post-exposure prophylaxis:
1-Decision to treat
2-Approach to the post expoureprophylaxis :
A-Management of Animal Bite Wound
B-Rabies Immunoglobulin (RIG)
C-Ant-Rabies Vaccine:
Intra-Muscular Regimen(IM)
Intra-Dermal Regimen
post expoureprophylaxis for previously vaccinated
person
Pre-Exposure Prophylaxis

22. B-Rabies Immunoglobulin (RIG)
Provide passive immunity
Ant rabies immunogloblinhas the
probalityof binding with virus
Two types of RIG are available :
1-Equine rabies immunoglobulin
2-Human Rabies immunoglobulin( HRIG)

23. Dose of rabies immunoglobulin :
20 IU per kg (maximum 1500iu ) –
dose not require skin testing
Should be infiltrated into and around
the wound
Remainingshould administered by
deep intramuscular injection at an
injection site distant from the vaccine
injection site

24. If Animal bite wounds was severe
and multiple , dilute the
immunoglobulin in a sterile normal
saline 2-3 fold to be able to permit
infiltration of all the wound
Totalrecommended dose of
immunoglobulin must not be exceeded
as it may suppress the antibody
production by the vaccine .

25. If immunoglobulinwas not
administered when vaccination was
begun , it can be administered up to
seventh day after the 1st dose of vaccine.
Beyond the seventh day , Rabies
Immunoglobulin's is not indicated
since an antibody response to ant rabies
vaccine is presumed to be have
occurred

26. Approach to a patient requiring rabies
immunoglobulin when none is
available :
proper wound cleaning
Double dose of vaccine on day 0at
2 different sites intramuscularly (0
day-2doses on the left and right deltoid
, 3,7,14,28 days)

27. Post-exposure prophylaxis:
1-Decision to treat
2-Approach to the post expoureprophylaxis :
A-Management of Animal Bite Wound
B-Rabies Immunoglobulin (RIG)
C-Ant-Rabies Vaccine:
Intra-Muscular Regimen(IM)
Intra-Dermal Regimen
post expoureprophylaxis for previously vaccinated
person
Pre-Exposure Prophylaxis

28. C-Ant-Rabies Vaccine
Indications :
all age groups of animal bite victim of category
11 and 111
Storage and transportation :
temperature range of 2-8 C
Reconstruction :
reconstructed with the diluent provided

29. Protective level of anti-rabies antibody :
a titreof o.5 IU\ml or more in serum as tested
by Rapid Fluorescent Focus Inhibition
Test(RFFIT) is considered as protective
Intra-muscular (IM) Regimen :
The currently available vaccine :
1-Cell Culture Vaccine:
Human Diploid Cell Vaccine
2-Purified Duck Embryo Vaccine

30. Regimen :
Five doses intramuscular on
days(0,3,7,14,28)
The Sixth injection (D90) should be
considered as optional and should be given to
those individuals who are immunologically
deficient
Site of inoculation :
The deltoid region is ideal for the
inoculation of the vaccine

31. Gluteal region is not recommended
because the fat present in this region retard
the absorption of antigen and hence impair
the generation of optimal immune response
In case of infant and young children
anterolateral part of the thigh is the
preferred site

32. Intra-dermal (ID) regimen
The use of intra-dermal route leads to
considerable savingin term of total
amountof vaccine needed for full pre or
post –exposure vaccination therapy
reducing the cost of active immunization
This involves injection of 0.1 ml ID on 2
sites( one on each deltoid area ) on day
0,3,7,14,28.

33. Single dose (0.5ml) of rabies vaccine IM is
deposited in the muscle . Then the antigen
is isabsorbed by the blood vessel and is
presented to antigen presenting cell which
triggers the immune response.
While using ID route small amount (0.1
ml) antigen is deposited in the layers of the
skin and then presented to antigen
presenting cell which triggers the immune
response without circulation and dilution
in the blood.

34. Post-exposure prophylaxis:
1-Decision to treat
2-Approach to the post expoureprophylaxis :
A-Management of Animal Bite Wound
B-Rabies Immunoglobulin (RIG)
C-Ant-Rabies Vaccine:
Intra-Muscular Regimen(IM)
Intra-Dermal Regimen
post expoureprophylaxis for previously vaccinated
person
Pre-Exposure Prophylaxis

35. post expoureprophylaxis for
previously vaccinated person
If vaccinated within one year give only one dose
on day 0
If vaccinated from 1-3 year give vaccine on day
0,3,7

36. Post-exposure prophylaxis:
1-Decision to treat
2-Approach to the post expoureprophylaxis :
A-Management of Animal Bite Wound
B-Rabies Immunoglobulin (RIG)
C-Ant-Rabies Vaccine:
Intra-Muscular Regimen(IM)
Intra-Dermal Regimen
post expoureprophylaxis for previously vaccinated
person
Pre-Exposure Prophylaxis

37. Pre-Exposure Prophylaxis
High risk groups:
1-laboratory staff handling the virus and
infected material .
2-Clinicians and persons attending to human
rabies cases
3-Veterinarians
4-Animal handlers and catchers
Pre-exposure vaccination is administered as full
doses IM on day 0, 7 and either 21 or 28

38. High risk group should have their neuter sing
antibody titter checked every 6 months
If the titer is less than 0.5 IU \ml a booster dose
of vaccine should be given .
On getting exposed to rabies virus after
successful pre-exposure immunization require
only two booster on day 0,3 without anti-rabies
immunoglobulin

39. Take Home Massage
1-Rabies is a rare disease but 100% fatal , 100%
preventable .
2-incubation period is 2 week to years
3-Pregnancy, lactation , infancy, old age and
concurrent illness are not contraindication of Rabies
post-exposure prophylaxis since it is a life saving
procedure
4-immune-compromised patients with category 11
should receive rabies –immunoglobulin in addition
to a full post-exposure prophylaxsiswith 6
th
dose at
90 day

40. 5-20 IU per kg (maximum 1500iu ) –Should be
infiltrated into and around the wound , Remaining
should administered by deep IM.
6-Total recommended dose of immunoglobulin
must not be exceeded as it may suppress the
antibody production by the vaccine .
7-Anti-rabies vaccine: five doses IM on day 0,
3,7,14,28 in the deltoid muscle
8 -Intra-dermal vaccine should be approved by
drug company

41. 9-For previously vaccinated person :
If vaccinated within one year give only one
dose on day 0
If vaccinated from 1-3 year give vaccine on day
0,3,7
10-pre-exposure vaccination:
for high risk group
on day 0,7 and either 21 or 28