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What is rabies? (DEFINITION & ETIOLOGY

Is an acute infectious disease of warm-blooded animals and humans characterized by an involvement of the nervous system . resulting in death It is caused by the RABIES VIR S! a rhabdovirus of the genus .lyssavirus Rabies is a serious disease" Each year! it #ills more than
$%!%%% &eo&le and millions of animals around the world" Rabies is a big &roblem in Asia! Africa! and 'entral and South America" In the nited States! rabies has been re&orted in every state e(ce&t )awaii" Any mammal can get rabies" Raccoons! s#un#s! fo(es! bats! dogs! and cats can get rabies" 'attle and humans can also get rabies" *nly mammals can get rabies" Animals that are not mammals -- such as birds! sna#es! and fish -- do not get rabies" Rabies is caused by a virus" An animal gets rabies from saliva! usually from a bite of an animal that has the disease"

The Rabies Virus RV + a neurotro&ic filterable virus &resent in the

saliva of rabid animals" It has a &referrence for nerve tissues"

Rod-shaped rabies viruses colored for effect

Virus + minute organism not visible with ordinary light microsco&y" It is &arasitic in that it is entirely de&endent on nutrients inside cells for its metabolic and re&roductive needs" 'an only be seen by use of eclectron microsco&y" 'onsists of ,-A or R-A covered with a &rotein covering called ca&sid" -eurotro&ic + viruses that re&roduce in nerve tissue .ilterable virus + virus causing infectious disease! the essential elements of which are so tiny that they retain infectivity after &assing through a filter of the Ber#efeld ty&e" Ber#efeld filter + a filter of diatomaceous earth designed to allow virus-size &articles to &ass through ,iatomaceous earth + substance com&osed of diatoms! a grou& of unicellular microsco&ic algae that &ossess a siiceous or calcium-containing cell wall"
Parts of the rabies virus

A rhabdovirus of the genus lyssavirus"

R)AB,*VIR S/ any grou& of rod-sha&ed R-A viruses with 0 im&ortant member! rabies virus! &athogenic to man" 1he virus has a &redilection for tissue of mucus-secreting glands and the 'entral -ervous System" All warm-blooded animals are susce&tible to infection with these viruses"

This is a photograph of the virus under electron microscope

R)AB,*/ from 2ree# rhabdos! 3rod3 45SSA/ 2ree# + frenzy! rage! fury! canine madness

vesiculovirus ephemerovirus novirhabdovirus nucleorhabdovirus lyssavirus





s e!ies

Australian Bat lyssavirus

European Bat lyssavirus 1

European Bat lyssavirus 2

Duvenhage virus

Lagos Bat virus

Mokola Bat virus

Rabies virus

)ow do you get rabies6


All warm-blooded mammals are susce&tible" -atural immunity in man is un#nown" 5ou get rabies through the saliva of an infected animal by an e(&osure to an o&en brea# in the s#in such as bites! o&en wound or scratch and inhalation of infectious aerosols such as from bats" In some cases! it is transmitted through organ trans&lants 7corneal trans&lant8! from an infected &erson" 1he virus gets transmitted through saliva! tears! semen! some li9uor 7amniotic fluid! 'S18 but not blood! urine or stool"
5ou get rabies from the saliva of a rabid animal! usually from a bite" 1he rabies virus is s&read through saliva" 5ou cannot get rabies by &etting an animal" 5ou may get rabies from a scratch if the animal! such as a cat! was lic#ing its &aw before it scratched you" 7Remember that the rabies virus is found in the saliva of an animal8"

?How do you know if an animal has rabies Animals with rabies may act differently from . healthy animals Some signs of rabies in animals are
changes in an animal:s behavior (general sic#ness 7fever! restlessness &roblems swallowing increased drooling (aggression 7biting at inanimate ob;ects! aimless running

<ild animals may move slowly or may act as if they are tame" Some wild animals 7fo(es! raccoons! s#un#s8 that normally avoid &orcu&ines! may even try to bite these . &ric#ly rodents .A &et that is usually friendly may sna& at you or may try to bite

1here is yet no way of immediately #nowing who had ac9uired rabies virus" -o tests are available to diagnose rabies in humans before the onset of clinical disease"

How do you know if one has "DI#GNO$I$' ?rabies

1he most reliable test for rabies in &atients who have clinical signs of the disease is a ,IRE'1 I== -*.4 *RES'E-1 S1 ,5 of a full thic#ness bio&sy of the s#in ta#en from the bac# of the nec# above the hair line" 1he RA>I, .4 *RES'E-1 .*' S I-)IBI1I*- 1ES1 is used to measure rabies-neutralizing antibodies in serum" 1his test has the advantage of &roviding results within ?@ hours" *ther tests of antibodies may ta#e as long as 0@ days"

EPI E!I"#"$%
RABIES INCIDENCE: WORLDWIDE:35, 00050, 000 cases/ year (WHO)

&arts of Africa and Asian continents and many &arts of South America are endemic for rabies

A and most of <estern Euro&e are rabies free due to success of coordinated wildlife oral vaccination &rograms

annual B of deaths caused by rabies worldwide/ $%!%%%-C%!%%%

EPI E!I"#"$%

P&I#IPPI'ES( )*+-,*+ cases- .ear *-/ per million population

"$ BITE I'0I E'0E( 1,+2 +++- *3+2 +++- .ear 4++-5++ per 1++2 +++ population- .ear 6 A$E !"ST A77E0TE ( *-1, .ear age group (*)8 of cases9 BITI'$ A'I!A#S( (S#& ST: % 1;54- 4++49 6 "$S( ;58 PET( 558 6 STRA%( 1+8 0ATS( 48

Based on the report from NCDPC (200 !" the si# re$ions with the most number of rabies %ases are Western &isayas" Central 'u(on" Bi%ol" Central &isayas" )lo%os and Ca$ayan &alley Data shows that *+,- per%ent of animal bite patients are %hildren Do$s remain the prin%ipal animal sour%e of rabies

The trend for animal bite cases has increased from 1;;4 to 4++1 but decreased in the .ear 4++4-4++,< The increasing number of patients =ho are consulting the health centers for animal bite cases is due to the increasing level of a=areness on rabies< "n the other hand2 the human rabies cases have been decreasing from 1;;* to 4++,< This is due to earl. provision of post e>posure vaccination to dog bite victims<
In 4++,2 there =ere ;*2*35 animal bite victims reported =ith 55 percent of them bitten b. dogs< "f this animal bite victims2 **2*54 or *5 percent had poste>posure vaccination and the other ,+2+++ or so had no vaccine protection at all< uring the same .ear2 445 (+<4 percent of the total animal bite cases9 =ere confirmed cases based on the appearance of the une?uivocal signs and s.mptoms of rabies =hich include death for most<

istribution of Animal Bite 0ases of 0ebu Province (@an-@une 4++39

?How does rabies affe%t us

(PATHOPHYSIOLOGY & SIGNS N SYMPTOMS) <hat does the virus do6
1he targets of the rabies virus are nerve cells" -erve cells are one &art of the body:s nervous system" *nce inside the body! the rabies virus infects the nerve cells and travels along the &eri&heral nerves 7the nerves that run throughout the body8" Its main target is the central nervous system! which is made u& of the brain and s&inal cord"

)ow does the virus travel6

<hen the virus travels from the &eri&heral nerves 7infected &eri&hery8 to the brain! it is called 'E-1RI>E1A4 S>REA," 1he viral travel and s&read from the center 7brain8 to the &eri&hery is called 'E-1RI. 2A4 S>REA,"

!A"#$L$%& '#AR" 1 Rabies in(ection

PAT&"#"$% 0&ART 4( Rabies Infection

./012. 34 50B)2. )N42C/)3N

Rabies virus Entr. into the bod.

(4+ A ;+ da.s9

I'VASI"' (+ A 1+ da.s9

(4 A / da.s9


(* A 1, da.s9


bite at ob;ects! and have an increase in saliva" In the movies and in boo#s! rabid animals foam at the mouth" . In real life! rabid animals loo# li#e they have foam in their mouth because they have more saliva 1he second and more common form is #nown as &aralytic or 7dumb7 rabies" 1he dog &ictured below has this ty&e" An animal with 3dumb3 rabies is timid and shy" It often re;ects food and has &aralysis of the lower ;aw and .muscles .Another two ty&es of rabies" *ne ty&e is 8urban9 rabies" 1he ty&e of rabies in domestic dogs and cats 1he other ty&e is called 8 syl:ati%9 rabies" 1hese ty&e came from wild animals such as bats! weasels! s#un#s and .moles D voles H;60N 50B)2. )umans also have a EfuriousF ty&e! the classic foaming of the mouth! aggression! a&&rehension D .hydro&hobia! and the EdumbF ty&e! &rogressive &aralysis of the body until they couldn:t breathe anymore

0N)60' 50B)2. 1here are two common ty&es of rabies" *ne ty&e is 7furious7 rabies" Animals with this ty&e are hostile! may


, * 2 S ' A 1 S B A T S












Res&onsible &et ownershi&


a8 &et immunization! es&" cats! usually starting at G months of age and every year thereafter b8 don:t allow &ets to roam around the streets c8 ta#e care of your &ets! #ee& them in good health + bathe! feed with clean ade9uate food and &rovide clean slee&ing 9uarters

If dog is a&&arently healthy! observe the dog for 0@ days" If it dies or show signs suggestive or rabies! .consult a &hysician If the dog shows signs suggestive of rabies! #ill the dog immediately and bring head for lab e(amination" .Submit for immunization while waiting for results If the dog is not available for observation 7#illed! died or stray8! submit for .immunization

1horoughly clean A44 BI1ES A-, S'RA1')ES made by any animal with strong .medicinal soa& or solution Res&onsible awareness" Re&ort immediately rabid or suggestive of rabies domestic or wild animals to &ro&er authorities 7local government clinic! ).veterinarians or community officials >re-e(&osure to high ris# individuals" Veterinarians! hunters! &eo&le in contact with animals 7zoo8! butchers! lab-staff in contact with rabies! forest .rangersHcareta#ers ,*) Standard >rotocol

A catCs brain for e>amination

(see DO)* Revised Guidelines on Managemen+ of #nimal ,i+e -a+ien+s* .//0 for more !om le+e guide

4ocal wound treatment" Immediately wash wound with soa& and water" 1reat with .antise&tic solutions such as iodine! alcohol and other disinfectants .Antibiotics and anti-tetanus as &rescribed by &hysician Rabies + S&ecific 1reatment" >ost-e(&osure treatment is given to &ersons who are e(&osed to the rabies virus" It consists of active immunization 7vaccination8 and ).&assive immunization 7immune globulin administration

62D)C0' )N/25&2N/)3N.

A'1IVE I== -IIA1I*- + aims to induce the body to develo& antibodies and 1-cells against rabies u& to G years" It induces an active immune res&onse in J-0% days after vaccination! which may &ersist for one year or more &rovided &rimary immunization is com&leted )=E,I'A4 A2E-1/ )uman ,i&loid 'ell rabies Vaccine 7),'V >ASSIVE I== -IIA1I*- + aims to &rovide I==E,IA1E >R*1E'1I*- against rabies which should be administered within the first J days of active immunization" 1he effect of the immune globulin is only short term" Rabies antibodies are introduced before it is &hysiologically &ossible for the &atient to begin &roducing his own antibodies after vaccination" Some of the RI2 is infiltrated around the site and the rest is given .intramuscularly )=E,I'A4 A2E-1/ Rabies Immune 2lobulin 7RI2

&rovide &atient isolation handwashing" <ash hands before and after each &atient contact and following &rocedures that offer contamination ris# while caring for an individual &atient" )andwashing techni9ue is im&ortant in reducing transient flora on outer e&idermal .layers of s#in <ear gloves when handling fluids and other &otential contaminated articles" ,is&ose of every after &atient care" 2loves . &rovide effective barrier &rotection" 'ontaminated gloves becomes a &otential vehicle for the transfer of organisms . >ractice isolation techni9ues" 1o &revent self-contamination and s&read of disease .assess &atient:s and family:s level of #nowledge on the disease including conce&ts! beliefs and #nown treatment >rovide &ertinent data about the disease organism and route of transmission treatment goals and &rocess community resources if necessary allow o&&ortunities for 9uestions and discussions

)I2) RISA .*R I-.E'1I*- 1RA-S=ISSI*

N;5.)N1 )N/25&2N/)3N.

)A-*<4E,2E ,E.I'I1 7about the disease! cause of infection and &reventive measures

*If &atient is still well oriented! Inform the relation of fever to the disease &rocess" 1he &resence of virus in the body =onitor tem&erature at regular intervals .>rovide a well ventilated environment free from drafts and wind

A41ERE, B*,5 1E=>ERA1 RE/ .EVER RE4A1E, 1* 1)E >RESE-'E *. I-.E'1I*-" Since fever is .continuous! &rovide other modes to reduce discomfort

,E)5,RA1I*- related to refusal to ta#e in fluids secondary to throat s&asms and fear of s&asmodic . attac#s
.Assess level of dehydration of &atient =aintain other routes of fluid introduction as &rescribed by the &hysician e"g" &arenteral routes .=oisten &arched mouth with cotton or gauze di&&ed in water but not dri&&ing

To provide ne= polic. guidelines and procedure to D ensure an effective and efficient management for eventual reduction if not elimination of human rabies To increase voluntar. pre-e>posure coverage D among high risE group (animal handlers2 field =orEers2 health staff =orEing in rabies unit2 rabies diagnostic lab staff2 children F 1* .o living in .endemic areas


!anagement of Potential Rabies E>posure


CATEGORY 7eeding- touching an animal #icEing of intact sEin (=- reliable histor. and )thorough ph.sical e>amination E>posure to patient =ith signs and s.mptoms of ,rabies b. sharing of eating or drinEing utensils 0asual contact to patient =ith signs and ,s.mptoms of rabies I


1.-ash e.posed skin immediately /0 soap and /ater

2. 1o vaccine or R2% needed ,!re3e.posure vaccination may be considered

CATEGORY II 'ibbling- nipping of uncovered sEin D =ith bruising !inor scratches- abrasions =ithout D ,,bleeding #icEs on broEen sEin D includes =ounds that are induced to,, bleed

:Complete vaccination regimen until day !"#$ i% Animal is rabid2 Eilled2 died "R unavailable for 1,- da. observation or e>amination "R Animal under observation died =ithin 1, da.s and =as I!!:'"7#":RES0E'T A'TIB" % TEST (I7AT9- positive "R no I7AT testing =as done "R had signs of rabies


:Complete vaccination regimen until day & i% remains health. after 1,- da. observation period Animal under observation died =ithin 1, da.s but had .no signs of rabies and as I7AT- negative Animal is alive A'


CATEGORY III Transdermal bites or scratches ( to include puncture )=ounds2 lacerations2 avulsions 0ontamination of mucous membrane =ith saliva (i<e< )licEs E>posure to a rabies patient through bites2 contamination of mucous membranes or open sEin lesions =ith bod. fluids (e>cept blood-feces9 through splattering2 mouth-to-mouth resuscitation2 licEs of the e.es2 lips2 vulva2 se>ual activit.2 e>changing Eisses on the mouth or other direct mucous membrane contact .=ith saliva &andling of infected carcass or ingestion of ra= infected meat All 0ategor. II e>posures on head and necE area



oes not include sharing of food- drinE- utensils and, casual contact =ith rabid patient

:Complete vaccination regimen until day !" #$ i% Animal is rabid2 Eilled2 died "R unavailable for 1, da. observation or e>amination "R Animal under observation died =ithin 1, da.s and =as I!!:'"7#":RES0E'T A'TIB" % TEST (I7AT9- positive "R no I7AT testing =as done "R had signs of rabies


:Complete vaccination regimen until day & i% remains health. after 1,-da. .observation period Animal under observation died =ithin 1, da.s but had no signs of rabies and =as I7AT- negative Animal is alive A'


A0TIVE I!!:'IGATI"' induce antibod. and T-cell production in order to neutraliHe the rabies virus in the bod.< It induces an active immune response in /-1+ da.s after vaccination2 =hich ma. persist for one .ear or .more provided primar. immuniHation is completed T%PES )PVRV (Purified Vero 0ell Rabies Vaccine a< )P0EV0 (Purified 0hicE Embr.o 0ell Vaccine b<

PASSIVE I!!:'IGATI"' )RI$ (Rabies Immune $lobulins3 provide the immediate availabilit. of antibodies at the site of e>posure before it is ph.siologicall. possible for the pt<to begin producing his o=n .antibodies after vaccination Important for pts< =- 0at III e>posures T.pes )&RI$ (&uman Rabies Immune $lobulins a< &ighl. Purified Antibod. Antigen Binding fragments b< )ERI$ (E?uine Rabies Immune $lobulins c<

)P"ST-EBP"S:RE TREAT!E'T (PET D #"0A# I":' TREAT!E'T A< Iash =ith soap-detergent and =ater preferabl. .for 1+ mins Appl. alcohol2 povidone iodine- an. antiseptic Anti-Tetanus Avoid suturing =ounds, onCt appl. ointment2 cream- =ound dressing,

A'TI!I0R"BIA# D Amo>icillin 0lo>acillin 0efuro>ime 7or those instances =here thereCs no, obvious signs of infection( Amo>icillin as )>is Educate the public simple local =ound,,, treatment J =arn not to use procedures that ma. further contaminate the =ounds

VA00I'ATI"' )(Intradermal Schedule

Day of Immunization
A% +

ml 4.1

# J R deltoidsanterolateral thighs of infants # J R deltoidsanterolateral thighs of infants # J R deltoids anterolateral thighs of infants # J R deltoidsanterolateral thighs of infants

A% )

ml 4.1

A% /

ml 4.1

A% 45-)+

ml 4.1

Intramuscular Schedule
Day of Immunization a. + PVRV ml 4.5 PCECV ml 1.4 Site "ne deltoidanterolateral thigh of infants Same Same Same same

a. ) a. / a. 1, a. 45

ml 4.5 ml 4.5 ml 4.5 ml 4.5

ml 1.4 ml 1.4 ml 1.4 ml 1.4

Special 0onditions
Pregnanc. J infanc. are not 0-I to treatment Babies born of rabid mothers should be given ARV as earl. as birth as possible Alcoholics should be given standard I! regimen Immunocomrpomised individuals- I! Interchangeabilit. of vaccine brands J shifting from one regimen to another is not recommended Bites of rodents2 rabbits2 guinea pig- no PET ogs2 cats2 livestocE2 =ild animals- give PET


PET Schedule for previousl. immuniHed patients

Interval from the la t !o e month 16 month- 3 months 1 months- ) .ears 87 Than ) .ears7 Give 'o booster booster dose 1 )booster doses ( +2 )2

.7ull course of active immun


"nce s.mptoms start2 treatment should center D on comfort care2 using sedation J avoidance of intubation J life support measures once diagnosis is certain !E I0ATI"'S iaHepam !idaHolam ipenh.dramine

&aloperidol K

1< b< c< d<

S:PP"RTIVE 0ARE. 2 Pts =- confirmed rabies should receive ade?uate sedation J comfort care in an .appropriate medical facilit. "nce rabies diagnosis has been confirmed2 a< invasive procedures must be avoided Provide suitable emotional and ph.sical b< support iscuss J provide important info< to c< relatives concerning transmission of dse< J indication for PET of contacts &onest gentle communication concerning d< prognosis should be provided to relatives of pt

I'7E0TI"' 0"'TR"#. + Patient should be admitted in a a< ?uiet2 draft-free2 isolation room &#0R =orEers J relatives in contact b< =- pt should =ear proper personal protective e?uipment (go=n2 gloves2 )masE2 goggles ISP"SA# "7 EA B" IES. 9

? How %an ) pre:ent rabies

Vaccinate your dogs! cats! and ferrets against . rabies . Aee& your &ets under su&ervision ,o not handle wild animals" If you see a wild animal or a stray! es&ecially if the animal is acting . strangely! call an animal control officer If you do get bitten by an animal! wash the wound with soa& and water for at least $ minutes" =a#e sure you tell an adult and call your doctor to see if . you need shots 2et your &ets s&ayed or neutered" >ets that are fi(ed are less li#ely to leave home! become strays! .and ma#e more stray animals

TicE meL This racoon is eating a special bait =hich contains a vaccine against rabies<

:3ther ways to pre:ent rabies in your pets

<al# your dog on a leash" -ever let them roam freely . where wildlife may be &resent . 'onsider #ee&ing your &ets indoors 'all animal control to ta#e wild or stray animals away! . es&ecially if you see an animal acting strangely If an animal bites your &et! handle your &et carefully so you do not get bitten" 2et a rabies booster vaccination for them" Even if they have had the rabies vaccination! a booster shot will hel& them fight off . the disease better 2et your &ets s&ayed or neutered" >ets that are fi(ed are less li#ely to leave home! become strays! and ma#e . more stray animals =a#e sure your &et gets and wears their rabies vaccination tags" 1hey should also wear a tag with their name and your address and &hone number" Aee& .them in a fenced yard or on a leash

1he best way to &revent rabies is to ma#e sure your &ets :: get and stay vaccinated against rabies

How do ) keep my pet from $ettin$ rabies?

1his dog wears a s&ecial tag which says EI:m rabies vaccinatedKF

-ever touch unfamiliar or wild animals" . En;oy wild animals from afar Avoid direct contact with stray animals" Stray cats and dogs may not . have been vaccinated against rabies -ever ado&t wild animals or bring them . into your home ,o not try to nurse sic# animals to health" It is common to want to rescue and nurse a hurt wild animal! but that animal may have rabies" 'all an animal control &erson or animal rescue grou& if . you find a sic# animal =a#e sure that your trash cans and &et foods are secured so that they do not . attract wild animals

?How do ) keep from $ettin$ rabies



M:ESTI"'( Is an increase in the incidence of rabies r-t El 'iNoO A'SIER( 'o< Rabies both in humans J animals doesnCt in an. =a. follo= a seasonal . pattern

M:ESTI"'( D Is it true that a dog =hich is rabid dies onl. after it has bitten a personO A'SIER( 'o< Ihether the dog has bitten a person or not2 a rabid dog .dies =ithin 1, da.s

M:ESTI"'( D Is rabies curableO A'SIER( 'o< "nce signs and s.mptoms of brain involvement are manifested2 the rabies victim dies .=ithin 1-) da.s

M:ESTI"'( D Is rabies preventableO A'SIER( %es< B. administering vaccine J immunoglobulin at the right time to an animal bite victim2 rabies . can be prevented

M:ESTI"'( D If bitten b. a stra. animal2 =hat should be properl. doneO A'SIER A< Immediatel. =ash the bite =ound D B< 0onsult ph.sician- ABT0 D 0< 0onsult a vet for mgt of biting dog D

M:ESTI"'( D o =e need to Eill the dog immediatel.O A'SIER( 'o< If the dog is apparentl. health.2 it should not be Eilled immediatel. J should be Eept on leash - caged for observation for 1, .da.s

M:ESTI"'( D oes a person bitten b. a rabid person need to be given AR immuniHationO A'SIER( %es2 a rabid person can transmit the rabies virus to another person J need .to be given AR immuniHation

Incubation period

the interval between e(&osure to infection and the a&&earance of the first sym&tom

*ne wee# to seven and a half momths in dogs 1en days to fifteen years in human Incubation &eriod de&ends u&on the following factors
,istance of the bite to the brain E(tensiveness of the bite S&ecie of the animal Richness of the nerve su&&ly in the area of the bite Resistance of the host

0" ?" G"


1here are four main stages the virus goes through Attachment/ 1he rabies virus attaches itself to a healthy . nerve cell . >enetration/ 1he virus is ta#en in by the cell . Re&lication/ Inside the cell! the virus multi&lies ra&idly

)ow does the rabies virus interact with ;the nerve cells

Budding/ 1he new rabies virus leaves the host cell" It attaches to other nerve cells" 1he virus then s&reads from .the brain to the rest of the body by the nerves 1hese different stages are ha&&ens during the I-' BA1I*.>ERI*,
TicE meL

1he rabies virus in this &icture has been made large so . that you can understand it better

Also called >R*,*=E >ERI*,L >rodrome + sym&tom indicative of an a&&roaching disease ,A5S 2314 .Sensory changes on the site of entry >ain/ dull! constant &ain referable to the nervous &athways &ro(imal to the location of the wound or itching! intermittent! stabbing &ains radiating distally to the region of inoculation" In general! sensitivity is the early sym&tom which may be ascribed to the stimulative action of the virus affecting grou&s of neurons! es&" sensory system" 1hough there is a&t to be decreased sensitivity to local &ain e"g" needle introduction! &atient may com&lain bitterly of drafts D bed clothes which &roduce a general stimulation .ever!headache malaise sore throat anore(ia increased sensitivity 7bright lights! loud noises8 increased muscle refle( irritability! tics and muscle tone *veractive facial e(&ression
TicE meL

Also called A' 1E -E R*4*2I'A4 >)ASEL hy&eractivity ,A5S 14 < 2 Imminent thoraco-lumbar involvement 7S-S8/ &u&illary dilation! lacrimation increased thic# saliva &roduction H foaming of mouth! e(cessive &ers&iration! increased )R An(iety/ increased nervousness! insomnia! a&&rehensionL a strong desire to be u&! wandering aimlessly about! and .ear/ a sense of im&ending doom )ydro&hobia 7&erha&s! S-S stimulation/ de&resses 2I activity M inhibits eso&hageal! gastric D intestinal function8 M violent e(&ulsion of fluids! drooling 7in attem&t not to swallow8 M dehydration and &arched mouth D tongue >ronounced muscular stimulation D general tremor =ania 7tearing of clothes D bedding! cases of biting D fighting rare but may occur8 and )allucinations with lucid intervals 7normal mental function in which &atient is well-oriented D ) answers 9uestions intelligently 'onvulsions7 besides rHt &ronounced muscular stimulation! further &reci&itated by sensory stimuli + sight! sound! name of water M throat s&asms M cho#ing M a&nea! cyanois! gas&ing death2 but if patient survive e>citement7 *phase

S.mpathetic nervous s.stem Paras.mpathetic nervous s.stem

TicE me 1stL

TicE me ne>tL

TicE meL


also called ,E>RESSI*- >)ASE3 2radual wea#ness of muscle grou&s A muscle s&asms cease A *' 4AR >A4S5 + strabismus! ocular incoordination! nystagmus! di&lo&ia! central ty&e &artial blindness M res&onds &oorly to light! N times &u&il is constricted or une9ual )7&arasym&athetic involvement A *ro-facial/ .A'IA4 D =ASSE1ER >A4S5 M difficulty closing eyes D mouth! face e(&ressionless A *ral/ <ea#ness of muscles of &honation M hoarsness D loss of voice 4oss of tendon refle(es! always &recedes wea#ness of e(tremity 'orneal refle( decreased or absent! dry Ears/ VER1I2* " =iddle ear disease " Early sym&tom! but may develo& N any &eriod -ec# stiffness Babins#i Olesions of &yramidal tractP! 7 - 8 Aernig:s 7 - 8 Brudzins#i:s=>) )'ardiac/ shifts from tachycardia 70%% + 0?%b&m8 N bed rest to bradycardia 7@% -C% b&m Res&i/ 'heyne-Sto#es M breathing &attern characterized by a &eriodic 0% + C- sec of a&nea followed by gradual increasing de&th and fre9uency of res&iration 4ocal sensation 7&in &ric#! heat! cold8 diminished Incoordination )ydro&hobia and aero&hobia gone! but still has some difficulty swallowing )2eneral arousal 7>-S stimulation Bladder D intestinal retention and obsti&ation 7damage to to innervation of the musculature of )intestine D bladder87S-S damage in some !ases% a+ien+ sho1s eriod of re!overy% +his a aren+ remission is follo1ed by rogressive

Ascending! flaccid &aralysis of e(tremities until it reaches the res&iratory muscle A&athy! stu&or 'om&lications/ >neumothora(! thrombosis! secondary infections TicE meL

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