Rabies supertable
TERMS
Rabies
Epidemiology
 RA 9482 (Anti-Rabies Act of 2007)
National Rabies Prevention and
 Vision: To declare Philippines Rabies-Free by year 2022
Control Program (NRPCP)
 Mission: To eliminate human rabies by the year 2020
Strategy 1: Provision of Post
Exposure Prophylaxis to all
rabies exposures/animal bite
victims (Provided by RA 9482)
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DEFINITION
 A zoonotic disease and human infection caused by Lyssavirus
 Principal Reservoir: dogs
 MOT: bite from an infected animal where the infectious material directly contact the victim’s
mucosa or fresh skin lesion.
 Incubation Period: 1-3 weeks depends on:
 Amount of the virus inoculated
 Severity of exposure
 Location of exposure
 Clinical Stages:
 Prodromal Period (0-10 days)
 Acute Neurologic State
 Furious stage
 Paralytic/ dumb girl
 Coma
 Death
Worldwide
 55,000 deaths every year
 56% of the cases occurring in Asia
 43% in Africa
 mostly in rural areas
 Present in all continents except in Antarctica.
Philippines
 2014-2018: 1176 cases
 Predominantly males (73%)
 Affects 3-87 years old
 Region 3 comprises 26% of cases followed by Region 4A (16%), and Region 7 (10%)
 Giving vaccine with or without Rabies Ig (RIG) depending on the level or category of exposure.
Guiding Principle:
 Shared responsibility of the DOH, Local Government Units, animal bite patients and dog/pet
owner
 Epinephrine and antihistamines should be made available for possible hypersensitivity
reactions
 All clinically significant Adverse Events Following Immunization (AEFI) shall be reported to the
AEFI Surveillance and Response System.
Management of Rabies Exposure
 Should not be delayed for any reason
 No absolute contraindications to rabies PEP (even pregnancy and infancy)
 Babies who are born to a rabid mother should be given a vaccination as well as RIG as early
as possible
CATEGORY TYPE OF EXPOSURE MANAGEMENT
Category 1  Feeding/touching an animal  Wash exposed skin immediately with
 Licking of intact skin soap and water.
 Exposure to patient (with SSX of  No vaccine or RIG needed
rabies) by sharing of eating or  Pre-exposure prophylaxis may be
drinking utensils considered for high risk persons.
 Casual contact and routine
delivery of health care to patient
with SSX of rabies
Category 2  Nibbling of uncovered skin with  Wash wound with soap and water.
or without bruising/hematoma  Start vaccine immediately:
 Minor /superficial  Complete vaccination regimen until
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Category 3
Active Immunization
scratches/abrasions without
bleeding, including those induced
to bleed
 All Category II exposures on the
head and neck area are
considered Category III and
should be managed as such.
 Transdermal bites (puncture
wounds, lacerations, avulsions) or
scratches/abrasions with
spontaneous bleeding
 Licks on broken skin or mucous
membrane
 Exposure to a rabies patient
through bites, contamination of
mucous membranes or open
skin lesions with body fluids
through splattering and mouth-to
mouth resuscitation
 Unprotected handling of
infected carcass
 Ingestion of raw infected meat
 Exposure to bats
 All Category II exposures on head
and neck areas
 Anti- tetanus immunization may be given if indicated. History of tetanus immunization
(TT/DPT/Td) should be reviewed. Animal bites are considered tetanus prone wounds.
 Intradermal Regimen
 Patients with hematologic
 ID injection should produce a minimum of 3 mm wheal
 Updated 2-Site Intradermal Region
Day 28 if:
 Biting animal is laboratory proven
to be rabid OR
 biting animal is killed/died without
laboratory testing OR
 biting animal has signs and
symptoms of rabies OR
 biting animal is not available for
observation for 14 days
 May omit Day 28 dose if:
 biting animal is alive AND remains
healthy after the 14-day
observation period, OR
 biting animal died within the 14
days observation period, confirmed
by veterinarian to have no signs
and symptoms of rabies and was
FAT negative
 RIG is not indicated.
 Wash wound with soap and water.
 Start vaccine immediately:
 Complete vaccination regimen until
Day 28 if:
 Biting animal is laboratory proven
to be rabid OR
 biting animal is killed/died without
laboratory testing OR
 biting animal has signs and
symptoms of rabies OR
 biting animal is not available for
observation for 14 days
 May omit Day 28 dose if:
 biting animal is alive AND remains
healthy after the 14-day
observation period, OR
 biting animal died within the 14
days observation period,
confirmed by veterinarian to have
no signs and symptoms of rabies
and was FAT negative
 RIG is indicated.

 Intramuscular Regimen
 Immunocompromised patients (px with HIV infection, cancer, chronic liver disease
and those taking chloroquine and systemic steroids
 Standard Intramuscular Regimen – Essen

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  Rabies Immunoglobulin (RIG)
 ERIG / HRIG
 Given to patients with Category III exposures
 Indicated for immunocompromised individuals (with HIV Infection, cancer/transplant patients,
patients on immunosuppressive therapy)

Administration:
 Skin test must be performed prior to ERIG administration (0.02 ml of 1:10 dilution solution)\
 A positive skin test is an induration of >6 mm surrounded by a flare/erythema
Passive Immunization
 Give HRIG
 Indications of HRIG:
- History of hypersensitivity to equine sera
- Multiple severe exposures especially where the dog is sick or
suspected of being rabid
- Symptomatic HIV infected patients
 In case of anaphylactic reaction, give adrenaline/epinephrine (0.5 ml of 0.1 per cent solution)
 1 in 1000, 1 mg/ml for adults
 0.01 ml/kg body weight for children,
 RIG should be administered at the same time with the first dose of rabies vaccine (Day 0).
 If RIG is unavailable on Day 0 , it may still be given until 7 days after the first dose of
the vaccine (Day 0).
 Beyond Day 7, RIG is not indicated because an active antibody response has
already started and interference between active and passive immunization may
occur

Management of Previously
Immunized Cases

 Vaccinated Animal - Dog/cat must be at least 1 year and 6 months old and has updated
VACCINATED ANIMALS vaccination certificate for the last 2 years.
 Updated Vaccination - the last vaccination must be within the past twelve months

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Delays In Schedule
Anti-Tetanus Immunization
Supportive Management
Antimicrobials
STRATEGY 2: ABTC/ABC
certification as quality PEP
providers
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 Animal bites are tetanus-prone wounds.
 most common organism isolated from dog and cat bites is Pasteurella multocida
 Indications:
 All Category III cat bites
 All other Category III bites that are either deep, penetrating, multiple or extensive or
located on the hand, face/genital area
 Animal bite treatment centers (ABTC) are government- owned/operated
 Animal bite centers (ABC) are private-owned/operated
 Department of Health
 Ensures the provision of quality vaccines
 Provides certification using a self assessment form
 Guiding principles:
 Established based on CHD recommendations
 Established for every 150,000 population
 Manned by trained physician
 Shall use only FDA approved (RIG)and WHO prequalified vaccines.
 Certified by DOH and accredited by PhilHealth
 Maintain a standardized recording and reporting system.
 Functional two-way referral system.
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STRATEGY 3: Provision of Pre-
Exposure Prophylaxis (PrEP) to
high risk individuals and
school children in high
incidence area (Provided by RA
1984)
STRATEGY 4: Strengthened IEC
(Information, Education, and
Communication) campaign
Dog Population Management
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 Requirements:
 Physical set-up (Signage, consultation and wash area, refrigerator, etc)
 Manpower (DOH/CHD trained Medical Doctor and Nurse)
 Supplies (Vaccines and RIG, Syringes, dressing kit, emergency materials, etc)
 Recording and Reporting (Exposure registry, PEP card, quarterly/annual reports,
etc)
 Policies and Procedures (cold chain management, waste management, etx )
 Pre-exposure prophylaxis (PrEP)
Recommended Booster Schedule:
 1 Booster dose after 1 year of primary immunization:
 0.1 ml ID dose of PVRV or PCEC on D0 OR
 0.5 ml IM dose of PVRV or 1.0 ml PCEC on D0
 Thereafter 1 booster, if Ab titers fall below 0.5 IU/ml OR
 In the absence of serologic testing, 1 booster dose every 5 years
 RESPONSIBLE PET OWNERSHIP (RA 9482 or the Anti Rabies Act of 2007)
 Have their dog regularly vaccinated against Rabies and
 mandatory registration
 Maintain control over their dog and not allow it to roam
 Provide dog with proper grooming, adequate food, and clean shelter
 Report immediately any dog biting within twenty-four (24) hours
 Assist the dog bite victim
 Stray Dog Management
 Impounding
 Field Control
 Surgical Sterilization through spaying/castration
 Non-surgical Sterilization
 Chemical sterilization
 Isolation of females
 Habitat Control
 Proper garbage disposal
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Dog Movement Control
STRATEGY 5: Advocacy
Campaign
STRATEGY 6: Training of
Medical Doctors and Registered
Nurses of ABTCs/ABCs
STRATEGY 7: Disease-Free Zone
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 Rabies Awareness Month (March)
 World Rabies Day (September 28)
 Main Stakeholders
 Building Healthy Public Policy
 Animal bite victims
 Legislators, local chief executives, NGOs, and POs
 5 Key Strategies for Health Promotion
 Building Healthy Public Policy
 Creating Supportive Environment
 Strengthening Community Action
 Developing Personal Skills
 Re-orienting Health Services
 Required for certification of Animal Bite Treatment Centers by the DOH and
accreditation by PhilHealth
 Training is conducted by the Research Institute for Tropical Medicine
See p.12 of Trans S2T2 (3A) for discussion of Training Program
 Local ordinance on the prevention and control of rabies.
 Localized comprehensive Rabies Prevention/Control and Elimination Program.
 Specific Requirements: Human Rabies-Free Zone
 No case of indigenously acquired infection by a Lyssavirus should be confirmed in
any human at anytime for at least two (2) years through monthly zero-case
reporting from the Municipal Health Office.
 Comprehensive rabies vaccination program in a place for two (2) years
 Adequate laboratory-based surveillance system
 Enforcement of control measures to eliminate, destroy and dispose straydogs as
per existing ordinance.
 Effective dog movement control measures
 Information, education and communication campaign
 Sustaining Rabies-Free Zones
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STRATEGY 8: Integration of
Rabies Curriculum in Elementary
Curriculum
STRATEGY 9: Post-Mortem
Review
STRATEGY 10: Support to
Department of Agriculture on
Dog Vaccination
Surveillance of Human Rabies
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 Local Level
 The Governor and City/Municipal Mayors takes charge for
implementation of guidelines
 “BantayRabis Sa Barangay” headed by the Barangay Captain
 The Rabies Control Committees oversee the implementation of the
rabies control program components
 Epidemiology and Surveillance Units (ESU) under the Philippine
Integrated Disease Surveillance and Response System
 Regional Level
 Regional Rabies Control Committees must regularly supervise and
assess the implementation of the Rabies-Free zones
 Regional Animal Disease Diagnostic Laboratory (RADDL) must continue
to conduct routine animal surveillance and must investigate the
occurrence of animal rabies
 National Level
 Department of Health (DOH) and Department of Agriculture(DA-BAI)
 The DILG Regional/Provincial Directors shall monitor the compliance of
the Local Chief Executives
 The DOH shall refer to RITM all rabies cases for confirmation when
possible
 DepEd is involved in Rabies control as mandated by RA 9482
 Memorandum 34 s. 2017
 Requires schools to propagate Rabies awareness and prevention through
BrigadaEskwela
 Aims to to review the diagnostic history, clinical aspect, and outcome of the patient, status of
the biting animal, and location of biting incidence of human death cases
 Mass Dog Vaccination
 Dogs aged 3 months old and above
 Registration and permanent identification of vaccinated dogs is recommended,
annual vaccination against rabies is mandatory
 One dose of 1 ml is given to them IM or SQ, regardless of weight
 A repeat vaccination is given to them yearly for continuous protection for 3 years
 70% of the dog population must be vaccinated within 3 months, but coverage may
vary
 Philippine Integrated Disease Surveillance and Response (PIDSR)
 Classified human rabies as an immediately-notifiable disease (must be reported
within 24 hours)
 The National Animal Disease Diagnostic Laboratory (NADDL)
 Established to confirm animal rabies as part of the surveillance of the Department
of Agriculture
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Case Definition

 Conducted by CHD program coordinator along with the RSU staff

 Suspected patients who went home against medical advice, they should be reported
 NOTIFICATION shall be consolidated by the RESU and the NEC describing the distribution
Case Investigation and of human rabies cases by:
Reporting  Age
 Sex
 Geographic location
 Time of occurrence
 PCR or viral culture
 Samples:
 Brain samples (taken after death)
Laboratory Confirmation  Skin samples (taken before death)
 Saliva
 Urine
 CSF
 Rabies is a notifiable disease both in the national health and veterinary systems in the
Philippines
 Surveillance of canine rabies and submission of laboratory reports of suspected cases
is essential for the management
 Recognition:
 animals directly noted to have manifestations of rabies
 Dogs or cats that have bitten a person and are being observed for
Surveillance of Animal Rabies
manifestations
 Notification:
 If animal died after biting a person or while being observed, report immediately
 Trained personnel shall carry out handling and preparation of the dog
specimen for laboratory confirmation
 Submit the dog for laboratory confirmation of rabies Preparation/Handling and
Packing of Animal Specimens for Rabies Diagnosis

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  Preparation/Handling and Packing
 Collected by a veterinarian in a clinic
 Use of basic personal protective equipment (PPE)
 For household setting, a clean table or bench is needed for the decapitation of the
animal
 The head should be cut two (2) inches away from the base
 Placed in a leak-proof double household plastic bag
 Do not put any ice cubes inside this primary container
 No chemical preservative
 Storage of Animal Specimens before transport
 liberal amounts of ice on the secondary container
 placed in a styrofoam box or any leak-proof transport container and brought to the
nearest rabies diagnostic laboratory
 Label the transport container as “Rabies Suspect”.
Animal Specimens for Rabies  Affix Complete name, Address, Phone number of shipper and laboratory recipient
Diagnosis  If specimen cannot be transported at once, it should be frozen or stored inside a
leak-proof Styrofoam or ice box container.
 Specimen Transport
 through air freight or hand carried
 Disposal of Carcass/Disinfection
 Burying in a pit or burning
 Working area = 10% household bleach (Chlorox) or 3% Lysol
 Laboratory Diagnosis of Rabies in Dogs and other animals
 Fluorescent Antibody Test (FAT)
 Results of laboratory examination
 laboratory diagnosticians should inform the AHD-BAI immediately of all specimens
examined positive for rabies
 Collate all DA-BAI-DOH Form I using the standardized DA-BA I-DOH Form two (2)
and should submit the filled-up forms to AHD-BAI on or before the 7th day of the
succeeding month.
 Main goal in any disease outbreak: to control the spread of the disease

Outbreak Response
RECORDING AND REPORTING
Evaluation Indicators
 NRPCP shall utilize the Rabies Exposure Registry and PEP Card as its official
recording forms
 Quarterly reports on animal bite cases, cohort analysis and Summary of Human
Rabies shall be submitted
 Recording and reporting shall be implemented at all ABTCs/ DOH recognized
ABCs
 Shall include all animal bite cases categorized according to NRPCP guidelines
 NRPCP shall adopt the official DOH recording and reporting system
 Records and reports shall verify the accomplishment of the program.
 Rabies Exposure Registry
 Post-Exposure Prophylaxis (PEP) Card
 Report of Animal Bite
 Summary of Human Rabies

MONITORING, SUPERVISION, AND EVALUATION

 done by Provincial/City/CHD NRPCP Coordinators every quarter
 analyze and provide feedback of findings with corresponding recommendations to the staff
or authorities concerned
 Continuous advocacy efforts to secure commitment of LGUs to purchase anti-rabies
vaccine, RIG and other supplies.

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Treatment Outcomes

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