Rabies PPT FOR UNDERGRADUATES useful for MBBS students

RABIES

1. 28 th September WORLD RABIES DAY 2024 Theme: “Breaking Rabies Boundaries ” Department of Community Medicine SABVGMC, Chhainsa , Faridabad 1

2. 2 RABIES HUA TOH REMEMBER THIS TILL LAST SILDE

3. In May 2024, a tragic incident in Alappuzha, Kerala, highlighted the ongoing threat of rabies in the 21st century. A nine-year-old boy  died from rabies after being bitten by a stray dog . He was not vaccinated after the attack owing to the absence of major wounds. 3

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5. RABIES 5

6. Overview WHY RABIES ??? Introduction Epidemiology Clinical picture Laboratory diagnosis Prevention of human rabies Classification of exposure Post exposure and pre exposure prophylaxis Discussion 6

7. WHY RABIES IS IMPORTANT ??? 7

8. SHOPPING 8

9. INTRODUCTION DEFINITION: Rabies is an acute, highly fatal zoonotic viral disease of the central nervous system, caused by Lyssavirus type 1 . ANIMALS INVOLVED: All warm blooded animals (mammals). E.g., Dogs, Cats, Bats, Jackals, Wolves, Monkey. 9

10. Introduction Rabies is almost always 100% fatal following the onset of clinical signs. In about 95-98% of human cases dogs are agents, cats 1-2% other 2-3%; Spreads by bites or scratches, usually via saliva . With Availability of vaccines and immunoglobulin's rabies has become preventable . 10

11. Introduction: RABIES i s 100% untreatable , NO CURE is 100% fatal but is 100% preventable With modern post exposure prophylaxis Immediate wound wash Immediate administration of Passive immunization (RIG) Active immunization with Rabies vaccine . Louis Pasteur developed the 1st vaccine (neural tissue) against Rabies in 1885. 11

12. BURDEN OF RABIES Globally, estimates indicate that human mortality is highest in Asia, with the highest incidence and deaths reported in India . DEATHS Globally: 59000 deaths due to rabies every year India accounts for 30% of death due to rabies in the world with 18,000 to 20,000 deaths per year . Incidence of rabies in India has been constant for a decade, due to lack of awareness of preventive measures, insufficient vaccination of dog. 12

13. BURDEN OF ANIMAL BITE FARIDABAD??? SEPTEMBER 2024 DOG BITE: 288 MONKEY BITE: 31 Other BITE: 26 INGESTION OF BUFFLO MILK: 28 AUGUST 2024 DOG BITE: 396 MONKEY BITE: 17 OTHER BITE: 16 13

14. Geographical distribution Rabies is an enzootic and epizootic disease of worldwide importance . Water appears to be the most effective barrier to rabies . Australia, Ireland, Japan, New Z ealand , UK, Iceland are all free of the disease . In India , Union Territory of Lakshadweep and Andaman and Nicobar islands are free of the disease. 14

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16. Agent factors The causative agent Lyssavirus type 1. Bullet shaped neurotropic RNA containing virus. It belongs to Rhabdoviridae family. Serotype 1 is the causative agent of rabies. Serotype 2, 3 and 4 are rabies related but antigenically distinct viruses . 16

17. Agent: Single Strand RNA Virus- Lyssa virus Family- Rhabdoviridae Bullet Shaped. Size 75 nm x 180 nm. Enveloped

18. Thermo labile - sensitive to pasteurization and boiling. Inactivated by detergents (soap), alcohol, iodine, formaldehyde, phenol and betapropiolactone (BPL). Preserved by freeze drying, at ultra low temperatures (≤ - 20 C) and glycerin .

19. Domestic :- Dogs & Cats Wild :- Foxes & Jackals Monkeys Mongoose Bears Not reported :- Bats* Rodents* Birds Squirrel Peridomestic :- Cows & Buffaloes Sheep & Goats Pigs Donkeys Horses Camels Animals Transmitting Rabies in India

20. Mode of transmission Bites from infected animals. Dogs are the main host and transmitter of rabies . Licks on Broken Skin or Mucous Membrane. Scratches. Inhalation of virus containing aerosol. Transplantation of an infected organ. 20

21. Host All age groups, more in children < 15 yrs M > F Dead end infection

22. Incubation Period in man 22 1 months – 3 months But may vary from 7 days to many years Depends on the site of bite, severity of bite, number of wounds, amount of virus injected . Incubation period is shorter in severe exposures and bites on face, head, neck and upper extremities.

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24. Clinical features: Clinical picture in man: Rabies in man is called hydrophobia. videoplayback.webm Disease begins with prodromal symptoms such as headache, malaise, sore throat and slight fever lasting for 3-4 days. About 80% of patients complain of pain or tingling at the site of bite. The Prodromal stage is followed by widespread excitation and stimulation of all parts of nervous system , the motor system, the sympathetic and mental system . The patient is intolerant to noise , bright light or a cold draught of air. Hydrophobia - pathognomic feature of rabies.

25. 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 / RNA isolation & antigen detection

26. RABIES PREVENTION PREVENTION

27. 3 SCENARIOS 27

28. REMEMBER – C I I I C ARE OF WOUND I NJECTION OF VACCINE I NJECTION OF IMMUNOGLOBULIN I NJECTION OF TT 29

29. Post-Exposure Prophylaxis (PEP) Management of animal bite wound Passive immunisation: Rabies Immunoglobulins (RIG ) Active immunisation: Anti- Rabies Vaccines (ARV ) Inj tetanus toxoid 31

30. Wound treatment Should be immediate and is essential even if the person presents long after exposure Do’s Wash the wound in running tap water -removes virus ( MINIMUM 15 MINUTES) Wash with soap and apply disinfectant - inactivation of virus Infiltrate with immunoglobulin - neutralization of virus DO NOT’S Touch the wound with bare hand Apply irritants like soil, chilies, oil, herbs, chalk, betel leaves etc Suturing and cauterization of wound 32

31. Wound Toileting Wound should be washed immediately with running tap water and SOAP for 10 minutes. 33

32. Anti Rabies Vaccine 34

33. Intra-muscular (IM) Regimen Essen Schedule: Five dose intramuscular regimen five injections on days 0, 3, 7, 14 and 28. (1 ML EACH) The sixth injection (D90) should be considered as optional for immune compromised The deltoid region is ideal for the inoculation In case of infants and young children antero -latera l part of the thigh is the preferred site . The antigenic potency of all the WHO approved vaccines has proven similar and is well above the minimum value of 2.5 IU/ampoule 35

34. Intra-dermal (ID) Regimens 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 . 0.1ML IN EACH ARM 36

35. Rabies Immunoglobulin 37 Should be given immediately around the wound. It Neutralizes the virus before it invades nervous system. • Recommended by all national/international authorities (WHO, CDC, HPA etc) for all category 3 exposures.

36. 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 (max 10 ml) The total recommended dose should not be exceeded 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 Sensitivity test before administration of ERIG 38

37. PEP for previously vaccinated persons Local treatment of wound Vaccination schedule (with vaccines fulfilling WHO requirements) one dose on days 0 and 3 Not needed if completely vaccinated within 3 months No RIG should be applied Full treatment should be given to persons : All incomplete vaccinations, partial vaccinations or doubtful vaccination need to be treated as fresh cases 39

38. Pre-exposure rabies vaccination Groups of persons at high risk of exposure to live rabies virus three doses of vaccine on days 0, 7 and 21 or 28 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 booster when the titre falls below 0.5 IU/ml 40

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40. MEDICAL 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. 42

41. SPECIAL CIRCUMSTANCES Post exposure treatment should be given to Immune compromised patients (AIDS, long term Steroid therapy, Chloroquine treatment, anti cancer therapy, immune suppressive therapy, etc.) Pregnant and Lactating mothers. Note: There is no absolute contraindication for Post Exposure Prophylaxis 43

42. Currently available equine rabies immunoglobulin in India 44

43. Currently available human rabies immunoglobulin in India 45

44. Currently available anti-rabies vaccines in India 46

45. Proforma for management of animal bite case at an antirabies centre/clinic(ARC ) 47

46. Rabies Case Record 48

47. Special Circumstances If RIGs are not available: - Proper local wound treatment - Double the first dose of vaccine (D ). Note: There is no substitute for RIG and all other options are inferior. “When in doubt an infectious disease specialist with expert knowledge on rabies should be consulted ” 49

48. 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. 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 . 50

49. FAQs Is there a single dose human rabies vaccine for life long immunity? Advantage of chillies lime salt oil application to animal bite? What are dietary restrictions for animal bite cases receiving vaccination ? Can vaccinated dog transmit rabies? Antibody tests in all animal bite victims? Is simply observing the bitting animal for 10 days without starting PEP justified? 51

50. FAQs Is pregnancy safe to pregnant women ? Can consumption of raw meat from rabies infected animal transmit rabies? Is PEP required in cat bite? Is PEP required in patients with organ transplantation? How should dead bodies of rabies patients disposed of ? Blood borne rabies? Natural immunity ? Milk? 52

51. References National guidelines on rabies prophylaxis, ministry of health and family welfare. http://ncdc.gov.in/writereaddata/mainlinkfile/File557.pdf http://www.who.int/rabies/PEP_prophylaxis_guidelines_June10.pdf http://rabies.org.in/rabies/wp-content/uploads/2009/11/APCRI-Guidelines-for-Rabies-Prophylaxis.pdf 53

52. 54 THANK YOU