Standard Operating Procedure for Rabies

November 2011

Key facts

Rabies occurs in more than 150 countries and territories.

Dogs are the source of 99% of human rabies deaths.

Worldwide, more than 55 000 people die of rabies every year.

40% of people who are bitten by suspect rabid animals are children under 15 years of
age.

Wound cleansing and immunization within a few hours after contact with a suspect rabid
animal can prevent the onset of rabies and death

In Rwanda, an estimation of 127 Human dogs bites was registered in 11 Health Center
and Hospital from January to September 2010 (Ministry of agriculture,animal resources)

Contents
1.

Introduction .......................................................................................................................................... 3

2.

Transmission ......................................................................................................................................... 3

3.

Estimated burden of rabies in the world and in rwanda ...................................................................... 3

4.

Symptoms ............................................................................................................................................. 4

5.

Diagnosis ............................................................................................................................................... 4

6.

5.1.

Clinical Diagnosis ......................................................................................................................... 4

5.2.

Laboratory diagnosis ..................................................................................................................... 5

Treatment ............................................................................................................................................. 7
6.1.

After exposure ............................................................................................................................... 7

Local treatment of the wound .............................................................................................................. 7

7.

Prevention ............................................................................................................................................. 9
7.1.

Eliminating rabies in dogs............................................................................................................. 9

7.2.

Preventive immunization in people .............................................................................................. 9

7.3.

Epidemiological surveillance ......................................................................................................... 9

1. Introduction
Rabies is a zoonotic disease (a disease that is transmitted to humans from animals) that is caused
by a virus (Lyssavirus). The disease infects domestic and wild animals, and is spread to people
through close contact with infected saliva via bites or scratches.
Rabies is present on all continents with the exception of Antartica, but more than 95% of human
deaths occur in Asia and Africa. Once symptoms of the disease develop, rabies is nearly always
fatal.
2. Transmission
People are infected through the skin following a bite or scratch by an infected animal. Dogs are
the main host and transmitter of rabies. They are the source of infection in all of the estimated 55
000 human rabies deaths annually in Asia and Africa. Bats scratch can also be a source of rabies
infection
Transmission can also occur when infectious material usually saliva comes into direct contact
with human mucosa or fresh skin wounds.
Rarely, rabies may be contracted by inhalation of virus-containing aerosol or via transplantation
of an infected organ. Ingestion of raw meat or other tissues from animals infected with rabies is
not a source of human infection.
3. Estimated burden of rabies in the world and in Rwanda
The highest financial expenditure in any country is the cost of rabies post-exposure
prophylaxis. The type of vaccine, vaccine regimen and route of
administration as well as the type of immunoglobulin used all significantly
influence the cost of treatment. In Rwanda, an estimation of 127 Human bites dogs was
registered in 11 Health Center and Hospital from January to September 2010(Ministry of
agriculture, animal resources)

4. Symptoms
The incubation period for rabies is typically 13 months, but may vary from <1 week to >1 year.
The initial symptoms of rabies are fever and often pain or an unusual or unexplained tingling,
pricking or burning sensation (paraesthesia) at the wound site.
As the virus (Lyssavirus) spreads through the central nervous system, progressive, fatal
inflammation of the brain and spinal cord develops.
Two forms of the disease can follow. People with furious rabies exhibit signs of hyperactivity,
excited behaviour, hydrophobia and sometimes aerophobia. After a few days, death occurs by
cardio-respiratory arrest.
Paralytic rabies accounts for about 30% of the total number of human cases. This form of rabies
runs a less dramatic and usually longer course than the furious form. The muscles gradually
become paralyzed, starting at the site of the bite or scratch. A coma slowly develops, and
eventually death occurs. The paralytic form of rabies is often misdiagnosed, contributing to the
underreporting of the disease.
5. Diagnosis
5.1.

Clinical Diagnosis

No tests are available to diagnose rabies infection in humans before the onset of clinical disease,
and unless the rabies-specific signs of hydrophobia or aerophobia are present, the clinical
diagnosis may be difficult.
After the first exposure (in most people, an animal bite), the symptoms of itching or discomfort
like pins or needles pricking the skin occur at the bite area. In addition, the person may develop
fever and a headache. Investigators suggest these symptoms may last from about two days to
weeks. This is the acute phase or the acute incubation phase of the disease. Unfortunately, there
is another incubation period before the next set of signs and symptoms develop.

The symptoms and signs of rabies in humans may consist of some or many of the following:
Anxiety, stress, and tension,delirium,drooling,convulsions,exaggerated sensation at the bite site,
excitability or combative, hallucinations, loss of feeling in an area of the body, loss of muscle
function, low-grade fever, muscle spasms, numbness and tingling, pain at the site of the biter,
restlessness, insomnia, swallowing difficulty (drinking causes throat spasms and the person may
become hydrophobic)
Post mortem, the standard diagnostic technique is to detect rabies virus antigen in brain tissue by
fluorescent antibody test.
5.2.
Laboratory diagnosis
Laboratory Diagnosis
Definite diagnosis of rabies can only be obtained by laboratory investigations.
Biosafety considerations
Rabies has the highest case-fatality rate of any currently recognized infectious
disease. Safety is of paramount importance when working with lyssaviruses.
In general, biosafety level 2 safety practices are adequate for routine laboratory
activities such as diagnosis and animal handling. Besides basic facility design,
precautions should also include personal protection equipment (e.g. clothing) and
pre-exposure vaccination. Certain situations may entail consideration of a
biosafety level 3 classification, including production of large quantities of
concentrated virus, conducting procedures that may generate aerosols and when
working with lyssaviruses for which the effectiveness of current prophylaxis is
not known. All national safety guidelines for working with infectious agents
should be followed.
Transport of specimens
Specimens for rabies diagnosis should be shipped according to the national and
international regulations to avoid exposure hazards. Information on classification
(UN 2814) and packing instructions (P620 packaging) can be found in Transport
of infectious substances (15). Diagnostic specimens should either be refrigerated

or shipped at room temperature in 50% glycerine-saline solution.

Source of specimens for diagnosis and storage conditions
Rabies diagnosis can be performed on fresh specimens from several different
tissue sources or on appropriate specimens stored at proper temperatures,
preferably refrigerated. The choice of specimens depends on the test to be
performed and the stage of the disease in humans.
Formalin fixation of brain tissues is not recommended. If specimens are
nevertheless received in formalin, the duration of fixation should be less than 7
days. The specimens should be transferred rapidly to absolute ethanol for
subsequent molecular diagnosis.
Sampling for intra vitam diagnosis
Secretions and biological fluids (saliva, spinal fluid, tears, etc.) and tissues can be
used to diagnose rabies during life (intra vitam). They should be stored at 20 C
or below. Serum should be collected from blood samples prior to freezing and
stored at 20 C or below.
Sampling for postmortem diagnosis
Brain tissue is the preferred specimen for postmortem diagnosis in both humans
and animals. In cases where brain tissue is not available, other tissues may be of
diagnostic value. In field studies or when an autopsy cannot be performed,
techniques of collecting brain-tissue samples via trans-orbital or trans-foramen
magnum route can be used (16, 17). The use of glycerine preservation
(temperature: +4 C or 20 C) or dried smears of brain tissue on filter paper(temperature: +30
C) also enables safe transportation of infected material.

6. Treatment
6.1.

After exposure

Effective treatment soon (within a few days, but as soon as possible) after exposure to rabies can
prevent the onset of symptoms and death.
Post-exposure prevention consists of local treatment of the wound, administration of rabies
immunoglobulin (if indicated), and immediate vaccination.

Local treatment of the wound

Removing the rabies virus at the site of the infection by chemical or physical means is an
effective means of protection. Therefore, prompt local treatment of all bite wounds and scratches
that may be contaminated with rabies virus is important. Recommended first-aid procedures
include immediate and thorough flushing and washing of the wound for a minimum of 15
minutes with soap and water, detergent, povidone iodine or other substances that kill the rabies
virus.
N.B: Stitching of the wound is contraindicated
Patient with Confirmed cases of rabies should be isolated, sedated and transferred appropriate
medical facility (referral hospital), preferably in a private room with suitable emotional and
physical support because of the perceived risk of transmission of the virus through contact.
Once rabies diagnosis has been confirmed, invasive procedures should be avoided.
N.B: Treatment should centre on comfort care; using heavy sedation (barbiturates, morphine)
and avoidance of intubation and life-support measures once the diagnosis is certain.

Recommended treatment
The recommended post-exposure prophylaxis depends on the type of contact with the suspected
rabid animal (see table).

Table: Recommended post-exposure prophylaxis for rabies infection

Category of exposure to suspect rabid animal
Category I touching or feeding animals, licks on
intact skin (i.e. no exposure)

Post-exposure measures
None

Category II nibbling of uncovered skin, minor

Immediate vaccination and local

scratches or abrasions without bleeding

treatment of the wound

Category III single or multiple transdermal bites or Immediate vaccination and

scratches, licks on broken skin; contamination of

administration of rabies

mucous membrane with saliva from licks, exposures

immunoglobulin; local treatment of the

to bats.

wound

N.B: The health officer (Doctor, Nurse,) should contact immediately the nearest
veterinary for dog isolation and follow up.
Other factors that should be taken into consideration when deciding whether to initiate postexposure prevention include:

the likelihood of the implicated animal being rabid

the clinical features of the animal and its availability for observation and laboratory
testing.

In developing countries, the vaccination status of the suspected animal alone should not be
considered when deciding whether to initiate prophylaxis or not.

7. Prevention
7.1.

Eliminating rabies in dogs

Rabies is a vaccine-preventable disease. The most cost-effective strategy for preventing rabies in
people is by eliminating rabies in dogs through vaccination. Vaccination of animals (mostly
dogs) has reduced the number of human (and animal) rabies cases in several countries,
particularly in Latin America. However, recent increases in human rabies deaths in parts of
Africa, Asia and Latin America suggest that rabies is re-emerging as a serious public health
issue.
Preventing human rabies through control of domestic dog rabies is a realistic goal for large parts
of Africa and Asia, and is justified financially by the future savings of discontinuing postexposure prophylaxis for people.

7.2.

Preventive immunization in people

Safe, effective vaccines also exist for human use. Pre-exposure immunization in people is
recommended for travellers to high-risk areas in rabies-affected countries, and for people in
certain high-risk occupations such as laboratory workers dealing with live rabies virus and other
lyssaviruses, and veterinarians and animal handlers in rabies-affected areas. As children are at
particular risk, their immunization could be considered if living in or visiting high risk areas.

7.3.

Epidemiological surveillance

Dogs bites must be notifiable within national surveillance system on weekly basis.
Epidemiological data should be collected, processed, analysed and disseminated
rapidly between sectors and different administrative levels.
Steps supposed to be taken after reporting dog b ite:

Dog movement: Is it a stray or restricted dog?

Circumstances around the bite: Is the dog provoked or not?

Dog vaccination status

The offending dog should be contained and observed for 14 days

Key message: Rabies Prevention

1. Visit your veterinarian with your dog or cat on a regular basis and keep rabies
vaccinations up-to-date for all dogs and cats.
2. Maintain control of your dog or cat by keeping them indoors and keeping dogs under
direct supervision.
3. Call animal control/Police or local leader to remove all stray animals (dogs and cats)
from your neighborhood since these animals may be unvaccinated or ill.
4. Wash the wound with soap immediately after a dog bites
5. Immediate consultation at the nearest hospital for medical care
6. Inform the nearest veterinarian for dog isolation