MANAGEMENT

OF
RABIES

N O R H AYAT I B I N T I D I N
5/9/2017
 INTRODUCTION
Rabies zoonotic disease, caused by virus
Sarawak rabies infectious areas (800 cases, 5 died)
Modes of transmission:
Dogs( saliva, bites, scratch) Asia & Africa
Bats (USA & Canada)
Foxes,raccoons, skunks, jackals, mongooses etc.
through ingestion of raw meat/tissue from animal
infected with rabies.
Incubation period: 1-3months (vary from < 1 week to
> 1 year)
 CLINICAL MANIFESTATION
Initial sx: fever, pain, unusual/unexplained
tingling, pricking or burning sensation
(paraesthesia) at the wound site.
CNS sx: progressive, fatal inflammation of
the brain & spinal cord
Dx progression depend on:
a) Furious rabies: hyperactive, excited behavior,
hydrophobia, sometimes aerophobia.
b)Paralytic rabies: muscles become paralyzed
starting at site of scratch or bite, coma,
 LABORATORY INVESTIGATION
No single test is sufficient
Include:
Detection of viral RNA by RT-PCR
Detection of rabies viral antigens by direct fluorescent
antibody (DFA) or immunohistochemistry (IHC)
Isolation of rabies virus (Viral Isolation, VI)
Detection by electron microscopy
Specimens:
saliva (RT-PCR)
Skin biopsy of hair follicles at nape of neck
Brain biopsy for post mortem cases
Corneal scrapping/corneal touch impression
CFS (antibody test)
Serum (antibody test)
 PREVENTION OF RABIES
CASE DEFINITION
A person presenting with an acute neurological
syndrome (encephalitis) dominated by forms of
hyperactivity (furious rabies) or paralytic
syndromes (dumb rabies) progressing towards
coma and death, usually by respiratory failure,
within 7-10 days after the first symptom.
CASE CLASSIFICATION
1. Suspected A case that is compatible with the
clinical case definition and with history of dog
bite or scratch.
2. Probable A suspected case plus history of
contact with a suspected rabid dog.
3. Confirmed A case that is
 EXPOSURE CLASSIFICATION
1. Possible had close contact with dog with
clinical signs of rabies or within 10 days
following exposure in rabies infected area.
2. Exposed had close contact with a laboratory
confirmed rapid animal.
NOTIFICATION
PKD
-Sent Annex 1b to JKN
District Veterinary -Submit
Hospita Office daily
l -District Veterinary report to
Office clarified dog KKM
-Sent status within 48h. before
Annex 1a 12pm the
to PKD -Submit daily line
next day
listing & report to JKN
via email
not later than 10am
the next day
 RISK
TYPE OF EXPOSURE ACTION TO BE TAKEN
CATEGORY
1 Touching/feeding animal. Nil if history is reliable.
Licking of intact skin. If history not reliable, treat as
category 2.
2 Nibbling of uncovered Apply wound treatment.
skin. Administer vaccine.
Superficial scratch, no Do not administer anti-rabies Ig.
bleeding. Stop vaccination if animal is
Licking of broken skin. rabies negative in laboratory
tests, or remains healthy after 10
-14 days observation (dog or cat).
Continue vaccination if animal is
not found/captured.
3 Bites/scratches which Apply wound treatment.
penetrate the Administer vaccine.
skin and draw blood. Administer anti-
Licking mucous rabiesimmunoglobulin.
membrane. Administer anti-tetanus and abx
Multiple bites. treatment.
Any wild animals bites Stop vaccination if animal is
rabies negative in laboratory
tests, or remains healthy after 10
- 14 days observation (dog or
cat). Continue vaccination if
POST EXPOSURE MANAGEMENT
Acute Dog Bite Case Mx At Primary & 2nd
Settings
1. Primary Settings:
a) Local Treatment of The Wound
Remove rabies virus by chemical or physical
means.
Immediate & thorough flushing and washing
of wound for min 15mins with soap and water,
detergent, povidone iodine etc.
Start abx if dirty wound
Risk cat 1: discharge with advice.
Risk cat. 2 & 3; refer to hosp.
2. Secondary Settings:
Asymptomatic pt.: discharge w Home Alert
Card and Rabies Vaccination Certificate.
Continue PEP if dog positive for rabies.
Discontinue PEP if dog neg for rabies or dog
still healthy after 10-14d.
Symptomatic pt.: start PEP & RIG. Admission
to ward immediately.

Old Dog Bite Case Mx:

I. w/o wound: discharge with advise
II. With wound: wound care, start PEP if patient
was bitten < 3months with dog with status
unknown, unvalid dog vaccination or dog die
within 10-14d of quarantine. Discharge with
advice.
 RABIES VACCINE
VERORAB by Sanofi
Purified inactivated rabies vaccine, prepared on vero cell
INJ Area:
Adult IM at deltoid area
Child IM at anterolateral aspect of thigh, Xgluteal
Same dose for Adult & Child
CI:- hypersensitive to API or excipients(Neomycin,
Streptomycin, Polymyxin B)
Side Effects:
Minor local pain, erythema, oedema, pruritus & induration
at inj. Site
Systemic: moderate fever, shivering, headache, dizziness,
arthralgia, myalgia, GI disorder,
Exceptionally, anaphylactic reaction, urticaria, rash.
 DOSE SCHEDULE
Pre- 3 IM Inj on day 0, 7 & 28, followed by
Exposure booster inj after 1 year & booster inj
every 5 years.
Post- Unvaccinated 4 doses on day 0,
Exposure pt 3,7 & 14.
+1 dose of RIG at
same time of 1st
dose of vaccine
Vaccinated pt 2 doses on day 0 &
3.
RIG no need
Immunocompro 5 doses on day
mised pt 0,3,7, 14 & 28.
+ RIG
RABIES IMMUNOGLOBULIN
(RIG)
Perlis, Kedah, P.Pinang, Kelantan & Perak
RIG for risk category 3
Other states, risk cat. 2 &3 should be
assessed by physician for PEP&/RIG.
Individualized tx due to global shortage.
Dose: Human RIG - 20iu/kg
Equine RIG - 40IU/kg
Route: IM, distant for vaccine inj. site.
Time: same day as first vaccine dose or up
to 7 days post 1st vaccine.
APPLICATION DURING
WORKING
During screening:
IM only, vaccination hx, duration, drug-drug
interaction (corticosteroids & immunosuppressant)
Pregnancy (category C) & lactation
During filling:
Packaging: powder in vial + 0.5ml solvent in
prefilled syringe.
Just reconstitution, no dilution
Used immediately after reconstitution
Stored at 2-8C.
During counterchecking: same as screening
TAKE HOME MESSSAGE
REFERENCES
1. Interim Guideline for Human Rabies Prevention & Control In Malaysia
2. Verorab Leaflet
3. https://www.cdc.gov/vaccines/hcp/vis/vis-statements/rabies.html
4. WHO guide for rabies pre- and post-exposure prophylaxis in humans
5. Atkinson WL, Pickering LK, Schwartz B, Weniger BG, Iskander JK,
6. Watson JC. General recommendations on immunization.
Recommendations of the Advisory Committee on Immunization
Practices (ACIP) and the American Academy of Family Physicians
(AAFP). MMWR 2002;51(No. RR-2).