RABIES

DEFINITION:

- Rabies is a deadly virus spread to people from the saliva of infected animals. The rabies virus is usually
transmitted through a bite.
- Animals most likely to transmit rabies in the United States include bats, coyotes, foxes, raccoons and
skunks. In developing countries of Africa and Southeast Asia, stray dogs are the most likely to spread
rabies to people.

- The virus can affect the body in one of two ways:

o It enters the peripheral nervous system (PNS) directly and migrates to the brain.
o It replicates within muscle tissue, where it is safe from the host's immune system. From here, it
enters the nervous system through the neuromuscular junctions.
o Once inside the nervous system, the virus produces acute inflammation of the brain. Coma and
death soon follow.

- There are two types of rabies.

o Furious, or encephalitic rabies: This occurs in 80 percent of human cases. The person is more
likely to experience hyperactivity and hydrophobia.
o Paralytic or "dumb" rabies: Paralysis is a dominant symptom.

ANATOMY AND PHYSIOLOGY:

To carry out its normal role, the nervous system has three overlapping functions.

1) Monitoring changes. Much like a sentry, it uses its millions of sensory receptors to monitor changes
occurring both inside and outside the body; these changes are called stimuli, and the gathered
information is called sensory input.
2) Interpretation of sensory input. It processes and interprets the sensory input and decides what should
be done at each moment, a process called integration.
3) Effects responses. It then effects a response by activating muscles or glands (effectors) via motor
output.
4) Mental activity. The brain is the center of mental activity, including consciousness, thinking, and
memory.
5) Homeostasis. This function depends on the ability of the nervous system to detect, interpret, and
respond to changes in the internal and external conditions. It can help stimulate or inhibit the activities
of other systems to help maintain a constant internal environment.

Structural Classification

The structural classification, which includes all of the nervous system organs, has two subdivisions- the central
nervous system and the peripheral nervous system.

- Central nervous system (CNS). The CNS consists of the brain and spinal cord, which occupy the dorsal
body cavity and act as the integrating and command centers of the nervous system
- Peripheral nervous system (PNS). The PNS, the part of the nervous system outside the CNS, consists
mainly of the nerves that extend from the brain and spinal cord.
ETIOLOGY:

- Rabies infection is caused by the rabies virus. The virus is spread through the saliva of infected animals.
Infected animals can spread the virus by biting another animal or a person. In rare cases, rabies can be
spread when infected saliva gets into an open wound or the mucous membranes, such as the mouth or
eyes. This could occur if an infected animal were to lick an open cut on your skin.
- For most of the incubation period (which is usually one to three months), the virus stays close to the
exposure site.

The virus can affect the body in one of two ways:

- It enters the peripheral nervous system (PNS) directly and migrates to the brain.
- It replicates within muscle tissue, where it is safe from the host's immune system. From here, it enters
the nervous system through the neuromuscular junctions.

Rhabdovirus

1. It is a bullet-shaped filterable virus with strong affinity to the CNS.

2. It is sensitive to sunlight, ultraviolet light, ether, formalin, mercury, and nitric acid. The organism is resistant
to phenol, merthiolate, and common antibacterial agents.

Incubation Period:

1. One week to seven and a half months in dogs.

2. Ten days to fifteen years in human.
3. Incubation period depends upon the following factors.
a. Distance of the bite to the brain
b. Extensiveness of the bite
c. Specie of the animal
d. Richness of the nerve supply in the area of the
e. Resistance of the host

Period of communicability:

The patient is communicable from three to five days before onset of symptoms until the entire course of
illness.

SYMPTOMATOLOGY:

Rabies progresses in five distinct stages:

- incubation
- prodrome
- acute neurologic period
- coma
- death
Incubation period
 - This is the time before symptoms appear. It usually lasts from 3 to 12 weeks, but it can take as little as
5 days or more than 2 years.
- The closer the bite is to the brain, the sooner the effects are likely to appear.
- By the time symptoms appear, rabies is usually fatal. Anyone who may have been exposed to the virus
should seek medical help at once, without waiting for symptoms.

Prodrome

- Early, flu-like symptoms, include:

- a fever of 100.4 degrees Fahrenheit (38 degrees Celsius) or above
- headache
- anxiety
- feeling generally unwell
- sore throat and a cough
- nausea and vomiting
- discomfort may occur at the site of the bite
- These can last from 2 to 10 days, and they worsen over time.

Acute neurologic period

Neurologic symptoms develop, including:

- confusion and aggression
- partial paralysis, involuntary muscle twitching, and rigid neck muscles
- convulsions
- hyperventilation and difficulty breathing
- hypersalivation or producing a lot of saliva, and possibly frothing at the mouth
- fear of water, or hydrophobia, due to difficulty swallowing
- hallucinations, nightmares, and insomnia
- priapism, or permanent erection, in males
- photophobia, or a fear of light
- Toward the end of this phase, breathing becomes rapid and inconsistent.

Coma and death

- If the person enters a coma, death will occur within a matter of hours, unless they are attached to a
ventilator.
- Rarely, a person may recover at this late stage.

GENERAL PATHOPHYSIOLOGY:

MEDICAL MANAGEMENT

LABORATORY TEST:

(1) “FLUORESCENT RABIES ANTI-BODY (FRA) TEST”

- which looks for the presence of rabies virus antigens in brain tissue.
- For post mortem diagnosis, the gold-standard diagnostic technique is to detect rabies virus antigen in
infected tissues, preferably brain smears or touch impressions collected from a biopsy, by fluorescent
antibody test (FAT).
 - The dFA test is based on the observation that animals infected by rabies virus have rabies virus proteins
(antigen) present in their tissues. Because rabies is present in nervous tissue (and not blood like many
other viruses), the ideal tissue to test for rabies antigen is brain. The most important part of a dFA test
is flouresecently-labeled anti-rabies antibody. When labeled antibody is incubated with rabies-suspect
brain tissue, it will bind to rabies antigen. Unbound antibody can be washed away and areas where
antigen is present can be visualized as fluorescent-apple-green areas using a fluorescence microscope.
If rabies virus is absent there will be no staining.
(2) “ELECTRON MICROSCOPY”
- The ultrastructure of viruses can be examined by electron microscopy. Using this method, the
structural components of viruses and their inclusions can be observed in detail. Rabies virus is in the
family of Rhabdoviruses. When viewed with an electron microscope Rhabdoviruses are seen as bullet-
shaped particles.
(3) “PRESENCE OF NEGRI BODIES IN THE DOG’S BRAIN”

TREATMENT AND/OR SURGERY:

If you've been bitten by an animal that is known to have rabies, you'll receive a series of shots to prevent the
rabies virus from infecting you. If the animal that bit you can't be found, it may be safest to assume that the
animal has rabies. But this will depend on several factors, such as the type of animal and the situation in which
the bite occurred.

- Rabies shots include:

o A fast-acting shot (rabies immune globulin) to prevent the virus from infecting you. Part of this
injection is given near the area where the animal bit you if possible, as soon as possible after
the bite.
o A series of rabies vaccines to help your body learn to identify and fight the rabies virus. Rabies
vaccines are given as injections in your arm. You receive four injections over 14 days.

- Treatment after exposure, known as post-exposure prophylaxis or “P.E.P.”, is highly successful in

preventing the disease if administered promptly, generally within six days of infection. Thoroughly
washing the wound as soon as possible with soap and water for approximately five minutes is very
effective at reducing the number of viral particles. “If available, a virucidal antiseptic such as povidone-
iodine, iodine tincture, aqueous iodine solution or alcohol (ethanol) should be applied after washing.”
Exposed mucous membranes such as eyes, nose or mouth should be flushed well with water. In the
United States, patients receive one dose of immunoglobulin and five doses of rabies vaccine over a
twenty-eight day period. One-half the dose of immunoglobulin is injected in the region of the bite, if
possible, with the remainder injected intramuscularly away from the bite. This is much less painful
compared with administering immunoglobulin through the abdominal wall with a large needle, as was
done in the past. The first dose of rabies vaccine is given as soon as possible after exposure, with
additional doses on days three, seven, fourteen, and twenty-eight after the first. Patients that have
previously received pre-exposure vaccination do not receive the immunoglobulin, only the post-
exposure vaccinations on day 0 and 3. Since the widespread vaccination of domestic dogs and cats and
the development of effective human vaccines and immunoglobulin treatments, the number of
recorded deaths in the U.S. from rabies has dropped from one hundred or more annually in the early
twentieth century, to 1–2 per year, mostly caused by bat bites, which may go unnoticed by the victim
and hence untreated.
- P.E.P. is effective in treating rabies because the virus must travel from the site of infection through the
peripheral nervous system (nerves in the body) before infecting the central nervous system (brain and
spinal cord) and glands to cause lethal damage. This travel along the nerves is usually slow enough that
 vaccine and immunoglobulin can be administered to protect the brain and glands from infection. The
amount of time this travel requires is dependent on how far the infected area is from the brain: if the
victim is bitten in the face, for example, the time between initial infection and infection of the brain is
very short and P.E.P. may not be successful.
- Pre-exposure prophylaxis
- Currently pre-exposure immunization has been used on domesticated and normal non-human
populations. In many jurisdictions, domestic dogs, cats, and ferrets are required to be vaccinated. A
pre-exposure vaccination is also available for humans, most commonly given to veterinarians and those
traveling to regions where the disease is common, such as India. Most tourists do not need such a
vaccination, just those doing substantial non-urban activities. However, should a vaccinated human be
bitten by a carrier, failure to receive subsequent post-exposure treatment could be fatal, although
post-exposure treatment for a vaccinated human is far less extensive than that which would normally
be required by one with no pre-exposure vaccination.
- In 1984 researchers at the Wistar Institute developed a recombinant vaccine called V-RG by inserting
the glycoprotein gene from rabies into a vaccinia virus. The V-RG vaccine has since been
commercialised by Merial under the trademark Raboral. It is harmless to humans and has been shown
to be safe for various species of animals that might accidentally encounter it in the wild, including birds
(gulls, hawks, and owls).
- V-RG has been successfully used in the field in Belgium, France, and the United States to prevent
outbreaks of rabies in wildlife. The vaccine is stable under relatively high temperatures and can be
delivered orally, making mass vaccination of wildlife possible by putting it in baits. The plan for
immunization of normal populations involves dropping bait containing food wrapped around a small
dose of the live virus. The bait would be dropped by helicopter concentrating on areas that have not
been infected yet. Just such a strategy of oral immunization of foxes in Europe has already achieved
substantial reductions in the incidence of human rabies. A strategy of vaccinating “neighborhood dogs”
in Jaipur, India, (combined with a sterilization program) has also resulted in a large reduction in the
number of human cases.

NURSING MANAGEMENT:

1. Isolate the patient.

2. Give emotional and spiritual support.
3. Provide optimum comfort.
4. Darken the room and provide a quiet environment.
5. Patient should not be bathed and there should not be any running water in the room or within the
hearing distance of the patient.
6. If IV fluid has to be given it should be wrapped and needle should be securely anchored in the vein to
avoid dislodging in times of restlessness.
7. Concurrent and terminal disinfection should be carried out.
8. Vaccination of all dogs
9. Enforcement of regulations for pickup and destruction of stray dogs
10. Confinement of any dog that has bitten a person for ten to fourteen days
11. Availability of laboratory facilities for observation and diagnosis
12. Providing public education, especially among children, in avoiding and reporting all animals that appear
sick.

POSSIBLE PRIORITY NURSING DIAGNOSIS:

(1) Ineffective Breathing Pattern r/t asphyxia.

(2) Imbalanced Nutrition: Less than Body Requirements r/t decreased swallowing reflexes.
 (3) Hyperthermia r/t viremia.
(4) Risk for injury r/t seizures and weakness.
(5) Risk for infection r/t open wounds.

PROGNOSIS:

- In unvaccinated humans, rabies is almost always fatal after neurological symptoms have developed.
Vaccination after exposure, PEP, is highly successful in preventing the disease if administered promptly,
in general within 6 days of infection.