Rabies

epidemiology of Rabies and its control and prevention

1. RABIES
Dr.SumitaSharma
PGstudent,Dept.ofCommunityMedicine
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2. CONTENTS
•INTRODUCTION
•EPIDEMIOLOGY
•CLINICAL MANIFESTATIONS
•CLASSIFICATION OF ANIMAL BITE
•PREVENTION
•POST EXPOSURE PROPHYLAXIS
•PRE EXPOSURE PROPHYLAXIS
•PROGRAMS FOR CONTROL OF RABIES
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3. INTRODUCTION:
ThenameRabiesisderivedfromtheLatinword
“madness”also,Sanskritword‘Rabhas’-“todo
violence”.
Rabiesisanacutefatalviralencephalitiscausedbya
singlestrandedRNAvirus
Zoonotic disease which is virtually 100% fatal but 100%
preventable.
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4. Rabiesoccursin>150countriesandterritories.
Worldwide>59,000peopledieofrabieseveryyear.
India>10,000
Odisha:6deaths/100,000populationreportedin2015,
3deaths/100,000populationreportedin2016
BURDEN OF RABIES
4

5. 40%ofpeople-childrenunder15yearsofage.
Dogsarethesourceof99%ofhumanrabiesdeaths.
Mostrecentestimateoftheburdenofrabies-DALYs
➢directcost:rabiesvaccinesimmunoglobulins
➢indirectcost:transportandlossofincome
Lossesinproductivityduetoprematuredeath(55%oftotal
cost)
CostofPEP(20%)
Spendingondogvaccinationis<1.5%
(LatinAmerica17%ofcostsareallocatedtodogvaccination).
Forindividuals,PEPequivalentto3.8%ofGNIforaperson
inAsia(31dayswagesfortheavgAsian)&
5.80%forapersoninAfrica(51dayswagesforanavgAfrica)
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6. DALYs
3.7 million/year
Most DALYs were due to premature death(99%) & a few to
adverse event after administration of nerve tissue vaccines(0.8%)
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7. AGENT:
•SingleStrandRNAVirus-Lyssavirus
•Order–mononegavirales
•Family-Rhabdoviridae
•BulletShaped.
•Size75nmx180nm.
EPIDEMIOLOGY
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8. 8

9. RESERVOIRS OF INFECTION:
A.Urban Rabies: Dogs & Cats
B.Wild Life Rabies ( Sylvatic):
C.Bat Rabies: Vampire Bats
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10. HOST:
•Allagegroups,moreinchildren<15years
•M>F
ModesofTransmission:
1)Bitesfrominfectedanimals
2)LicksonBrokenSkinorMucousMembrane
3)Scratches
4)Inhalationofviruscontainingaerosol.
5)Organtransplantation
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11. INCUBATION PERIOD (IN MAN):
•2 weeks –6 months (in > 85% cases).
•Ranges between 4 days to 19 years.
•Shorter in children (vulnerable group).
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12. PATHOGENESIS:
Negri bodies
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13. CLINICAL MANIFESTATION:
Furious Type ( 80%)
•Tingling / numbness at
bite site
•Non specific symptoms
•Hydrophobia,
Aerophobia
•Photophobia
•Death (cardio -
respiratory failure)
•Survival : 3 –5 Days
Paralytic Type ( 20%)
•Tingling / numbness at bite
site
•Non specific symptoms
•Ascending Paralysis
•Coma
•Death (cardio -respiratory
failure)
•Survival : 7 –21 Days
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14. LABORATORY DIAGNOSIS:
Laboratory diagnosis is not mandatory for managing
animal bite cases
Samples and tests:
Saliva -Virus isolation / RNA detection
Skin -Antigen detection
CSF -Virus isolation & antigen detection
The samples that afford the highest diagnostic sensitivity are at least
3 saliva samples taken at intervals of 3-6 hr and skin biopsies
(including hair follicles)
Ideally samples should be stored at -20˚c or less.
Brain tissue is the preferred specimen in sampling for post-mortem
diagnosis in humans and animals
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15. TREATMENT:
•Admit in a separate
quiet & breeze free area.
•Sedation with Morphine / Barbiturates.
•Muscle relaxants, Intensive cardio respiratory support
•Emotional support and physical comfort.
•Barrier nursing and universal precautions.
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16. •Invasiveprocedures
shouldbeavoided.
•Earlydisposalofbodybycremationordeepburial.
•Alldisposablescontaminatedwithsecretionsor
excretions,patienttissueorbodyfluidsshouldbe
managedasinfected.
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17. PREVENTION
A.Post-exposure prophylaxis.
A.Pre-exposure prophylaxis.
B.Post-exposure treatment of persons who have been
vaccinated previously.
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18. POST EXPOSURE
PROPHYLAXIS (PEP)
•Local treatment of Wounds
•Active immunisation : Anti-Rabies Vaccines (ARV)
•Passive immunisation: Rabies Immunoglobulins (RIG)
•Inj. tetanus toxoid
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19. 19

20. Local Treatment 20

21. INDICATIONS FOR ANTI-RABIES TREATMENT:
a)Observation of biting dog/cat:
If the animal shows signs of rabies or dies within 10
days of observation.
b)Vaccinationstatusofthebitinganimal:
c)Provokedversusunprovokedbite:
d)Bitebywildanimals:category–III
e) Bite by rodents: No requirement of PEP
f) Bat rabies:bat rabies has not been conclusively proved in
India .
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22. g)post-exposure prophylaxis of immune-compromised
patients:
h)Human to human transmission:few cases resulting from
organ/tissue(cornea) transplant.
CONTRAINDICATIONS
•There is no contraindication to PEP.
•Pregnancy, lactation , infancy , old age and concurrent illness –
no contraindication for PEP
•People taking chloroquine for malaria treatment or prophylaxis
may have a reduced response to ID rabies vaccination. Hence
these people should be given PEP intramuscularly.
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23. ANTI-RABIES VACCINE ADMINISTRATION:
ARV : Fluid or dried preparation of rabies “fixed” virus grown in neural
tissues of rabbits, sheep, goats, mice, rats or in embryonated duck eggs or
in cell cultures and inactivated by a suitable method.
1.Nervous tissue vaccines (NTV):Govt. of India stopped producing nervous
tissue vaccine since 2004.
2.Purified Duck embryo vaccine (PDEV)
3. Cell-culture vaccines(CCVs)
•ARVs are produced as one single intramuscular dose with potency of
>2.5IU per IM dose for post exposure and pre-exposure prophylaxis.
•It is absolutely essential that every batch of CCVs have minimum potency
of 2.5IU per IM dose, irrespective of whether the vaccine is administered
by IM or ID route.
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24. Indications:allanimalbitevictimsofcategoryIIandIII
Storageandtransportation:temp2-8˚candprotectedfromsunlight
Reconstitutionandstorage:thelyophilizedrabiesvaccineshouldbe
reconstitutedwiththediluentprovidedwiththevaccineimmediatelypriorto
use.
Somevaccineshave0.5mldiluentsandothershave1mldiluentsasperthe
approvalofthebrand,whichcannotbealtered.
IDadministration-vaccinevialshouldbestoredat2-8˚cafter
reconstitution.Thetotalcontentofthevialshouldbeusedassoonaspossible
butatthemaximumwithin8hours.
IMadministration-vaccineshouldbeusedimmediatelyafter
reconstitution.
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25. INTRADERMAL (ID) REGIMEN :
•Pioneered by the Queen Saovabha Memorial Institute of the Thai Red Cross
Society during the 1980s
•Vaccines approved by DCGI
➢PVRV –Verorab, Aventis Pasteur (Sanofi Pasteur) India Pvt. Ltd.
➢PCECV –Rabipur, Chiron Behring Vaccines Pvt. Ltd.
➢PVRV –Pasteur Institute of India, Coonoor
➢PVRV –Abhayrab, Human Biologicals Institute
Regimen Updated Thai Red Cross Schedule (2-2-2-0-2)on
days 0, 3, 7 and 28.
•This involves injection of 0.1ml of reconstituted vaccine per ID site and on
two sites per visit (one on each deltoid area, an inch above the insertion of
deltoid muscle) on days 0, 3, 7 and 28.
•The day 0 is the date of first dose administration of anti-rabies vaccine and
may not be the date of rabies exposure/animal bite.
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26. Advisetothevaccinatedperson:
•Donotrubtheinjectionsite
•DonotapplyanythingtotheinjectionsiteCompletethecourseof
vaccination
Materials required
•A vial of anti-rabies vaccine along with its diluent that is approved by the
DCGI for ID administration.
•2 ml disposable syringe with 24 G needle for reconstitution of vaccine.
•Disposable 1 ml (insulin) syringe (with gradations up to 100 units) with a
fixed (self-mounted) (28 G or more) needle
•Disinfectant swabs (e.g. 70% ethanol, isopropyl alcohol) for cleaning the top
of the vial and the patients' skin.
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27. INTRAMUSCULAR SCHEDULES
A) Essen Regimen :
•Dose :1 ml, 6 doses
•Site :Deltoid or anterolateral
aspect of thigh (children)
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28. B) Zagreb regimen (2 –1 –1) :
❖Humoral antibodies play an important role in protection against rabies.
❖Anti –rabies neutralizing antibody titre of 0.5 IU/ml or more in serum is
considered as protective.
❖This level is achieved in most healthy individuals by day 14 of PEP
regimen, with or without simultaneous administration of rabies
immunoglobulin.
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29. PASSIVE IMMUNIZATION:
All category III exposures, irrespective of status of biting
animal.
Administer even when treatment is delayed but (not after 7
days of start of vaccination-3 doses administered)
In re-exposure cases (completed post exposure prophylaxis
previously) RIGs are not indicated.
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30. ADMINISTRATION OF RABIES
IMMUNOGLOBULIN (RIG)
•Infiltrate into the depth of the wound and around the wound
•Quantities/volume of RIG:
20IU/ kg for Human RIG or 40 IU/ kg of Equine RIG
•If the calculated dose is insufficient to infiltrate all wounds,
sterile saline may be used to dilute it 2 to 3 fold to permit
thorough infiltration
•For adults 400 Rs. and children 200 Rs .
•Sensitivity test before administration of
ERIG
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31. Test dose (ERIG)
Inject 0.1 ml of 1:10 dilution of the ERIG in normal saline,
ID over flexor aspect of forearm.
Observe for : Wheal, Erythema, Induration, Itching,
Tachycardia, Fall in Blood Pressure, Feeble Pulse.
RIG Infiltration:
Positive test reaction: Induration >10mm
If skin test is positive –HRIG is preferred
If ERIG has to be administered then pre-treat with Adrenaline
/ Epinephrine and with Antihistamine before administering full
dose.
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32. ✓Ifre-exposedpersonswhohavepreviouslyreceivedand
documentedfullpre-orpost-exposureprophylaxis(eitherbyIMorID
route)withacell-culturevaccineorPDEVshouldnowbegivenonly
twoboosterdosesintramuscularly(0.5ml/1ml)orCCVsintra-dermally
(0.1mlat1site)ondays0and3.
▪Properwoundtoiletshouldbedone.
▪TreatmentwithRIGisnotrequired.
✓Personswhohavepreviouslyreceivedfullpost-exposuretreatment
withNTVorvaccineofunprovenpotencyorcannotdocument
previouspre-orpost-exposuretreatmentshouldbetreatedasfreshcase
andgiventreatmentaspermeritsofthecase.
VACCINATION AFTER RE -EXPOSURE:
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33. PRE -EXPOSURE PROPHYLAXIS
•Groups of persons at high risk of exposure to live rabies virus
•Three doses of vaccine on days 0, 7 and 28
Dose :IM: HDCV, PCEC & PDEV -1 ml
PVRV -0.5ml
ID : 0.1 ml
Monitoring
•Persons working with live rabies virus in diagnostic
laboratories, research laboratories, vaccine production
laboratories
✓one serum sample every six months
✓booster when the titre falls below 0.5 IU/ml
•Others professions (veterinarians, animal handlers, wildlife
officers...) at permanent risk of exposure to rabies
✓testing every year
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34. ADVICE TO PATIENTS:
•No dietary restrictions.
•No restriction of physical exercise.
•Report adverse effects (if any) to the physician without fail.
•Best to avoid consumption of alcohol during the course of
treatment.
•Complete the course of vaccination.
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35. CURRENTLY AVAILABLE EQUINE RABIES
IMMUNOGLOBULIN IN INDIA
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36. CURRENTLY AVAILABLE HUMAN RABIES
IMMUNOGLOBULIN IN INDIA
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37. CURRENTLY AVAILABLE ANTI -RABIES
VACCINES IN INDIA
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38. RABIES IN ANIMALS
Excitative Type or “Furious” rabies:
Agitated, restless, excitable, Indiscriminant biting, Profuse
salivation, Vocal cords affected, Convulsions, paralysis, and death
Paralytic Type or “Dumb” rabies:
Muscles of head and neck affected, Difficulty in swallowing,
Paralysis spreads to extremities, coma, death.
Unexplained sudden deaths in dogs should be viewed as
suspected rabies, hence handlers should be treated by PEP
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39. SIGNS OF RABIES IN DOGS / CATS DURING 10
DAYS’ OBSERVATION PERIOD
Changeinbehaviour–undueaggression/depression.
Runningaimlesslyandattackingotherswithoutanyprovocation.
Becomestoodrowsyandwithdrawsitselftoacorner.
ExcessiveSalivation.
Changeinvoice.
Refusaltofeedoreatingunusualobjectslikestones,papers,wood,metal
pieces.
Deathofanimalduetounknowncause.
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40. RESERVOIR CONTROL
Domestic animals
•Vaccination programs for all dogs and cats.
•Removal of strays and unwanted animals.
•Animal Birth Control (ABC) for stray dogs
•To create rabies free areas and maintain them by adequate
Monitoring and surveillance
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41. IMMUNIZATION OF DOGS
•Primary immunization at age of 3-4 months
A) BPL inactivated nervous tissue vaccine:
•20% suspension of infected sheep brain
•Dose: Dogs-5ml; Cats –3ml
•Booster: after 6 months
& every year
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42. B) Modified Live Virus Vaccine:
•33% chick embryo suspension infected with modified virus.
•Dose: 3ml
•Booster:every 3 years
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43. CONTROL OF URBAN RABIES:
•Registration and licensing of domestic dogs
•Restraint of dogs in public places
•Immediate destruction of dogs and cats bitten
by rabid animals
•Quarantine for about 6 months of imported dogs
•Health education of people regarding the care of dogs and
prevention of rabies
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44. PERSONAL SAFETY AGAINST RABIES
Do not touch animal bite wounds with bare hands.
Do not touch fomites(Chain, food plate etc.) of an animal
suspect or proven rabid.
Keep away from stray / sick animals.
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45. Do not stare at or provoke any animal.
Take pre-exposure vaccination if you are in constant touch
with animals.
Avoid contact with saliva, urine, tears, semen, vaginal
secretions and other body secretions of a rabies patient.
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46. RECOMMENDATIONS FORHEALTH CARE
PERSONNEL ANDFAMILYMEMBERS OF
PATIENTSWITHRABIES:
•Postexposureprophylaxis(PEP)
•Personalprotectiveequipment's(wearinggloves,glasses&
mask)
•Hospitalsthatarelikelytoreceiverabiespatientscanconsider
PrEPforhealthcarestaffwhomaybeinvolvedintheirmgt.
•PEPforpartnersofpatients;howevernoreportshaveclearly
establishedhumantohumantransmission
•Riskofaninfantcontractingrabiesfrombreastmilkisnot
reportedyet.Howeveritisadvisableforavoidanceof
breastfeeding.
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47. EDUCATION OF PET OWNERS:
Get your pet regularly and periodically examined by a
qualified veterinarian.
Get your pet vaccinated
at three months of age
and again 1 month later
Boosters every year
subsequently.
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48. NATIONAL RABIES CONTROL PROGRAMME
•Pilot tested under 11
th
five year plan in 2008, found
successful
•Ministry of HFW has approved the programme in 12
th
five
year plan
•NCDC New Delhi is the nodal centre
•One Health approach includes animal and human component
•Animal welfare board, min of environment and forest will be
nodal centre for co-ordinatinghuman component
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49. ORGANIZATIONS /AGENCIES
INVOLVED IN RABIES CONTROL IN
INDIA
•Governmental Agencies
•Ministry of Health -Central and State
•Ministry of Agriculture--Central and State
•State Animal Husbandry Department
•Animal Welfare Board
•Local Civic bodies
•National Institute of Mental Health & Neurosciences, Bangalore
•Government Veterinary Colleges
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50. NON GOVERNMENTAL ORGANIZATIONS
INVOLVED IN RABIES CONTROL IN INDIA
•Kempegowda Institute of Medical Sciences, Bangalore
•Rabies in Asia Foundation (RIA)
•Association for the Prevention and Control of Rabies in India
(APCRI)
•Commonwealth Veterinary Association (CVA)
•Global Alliance for Rabies Control (GRAC)
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51. 51

52. WORLD RABIES DAY
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