National Rabies Prevention and Control Program
World Rabies Day Sept. 28
To end human deaths due to rabies by 2030
• Program priorities:
1. Improve access to PEP
2. Ensure completion of PEP
3. Reduce the incidence of animal bites and rabies among school children
4. Ensure quality PEP service is provided by ABTCs and ABCs
5. Address the problem of traditional healers mismanaging animal bite victims
6. Develop & disseminate updated guidelines
• Target: 95% of all animal bites are given anti-rabies vaccination
• Most continents affected: Asia < Africa
• Philippines: 200-300 cases per year
• 96-98% of bites are from dogs’
• Rabies free zone = 3 years consecutive w/o cases of rabies encephalopathy
• Lyssavirus, RNA- affects all mammals, affinity to nerve cell and salivary glands
o Entry – wounds, mucosal surfaces
o Viral RNA detection- CSF, tears, skin, hair follicles at nape of neck, brain tissue, saliva & urine
o Cannot cross intact skin
o Can live long in cold temp and is inactivated by high temps in 1.5hours exposure
o Risk of developing rabies – virus content of saliva, severity & location of bite
o Symptoms
▪ Neuropathic pain (pain at bite site; 1st symptom)
History/ Physical Examination
1. Hx of Exposure
• Animal bite/ scratch
• Non-bite exposure
• Date of bite & onset of S/Sx
2. Physical Exam
• Location of bite, # of bite wounds
• Categorization of bite wound/s
3. Other relevant info
• Status of biting animal and after 14 days observation period
• Vaccination status of biting animal
• Other victims of the same dog
• Nes of “mad” dog in an area
• Treatment of bite victim – vaccination, traditional remedies
5 Stages of Rabies Disease
1. Incubation- 2wks to 6yrs, ave IP: 1-3mos
2. Prodrome- Duration 2-10days; 73% die w/in 3days of onset of S/Sx, 84% die w/in 24hrs of admission
3. Acute Neurologic Phase- neuro symptoms start
4. Coma
5. Death- caused by circulatory insufficiency with myocarditis cardiac arrhythmia
***Prodromal Phase
• Symptoms:
o Non-specific: fever, malaise, fatigue, HA, anorexia
o Pain, numbness, pruritic at bite site
o Intense & progressive local rxn
• Signs
o Healed wound or scar at bite site
***Acute Neurologic Phase-
o Duration: 2-7days
o Affects brainstem, thalamus, basal ganglia, SC
o 2 types
o Encephalitic/ Furious (80%)
▪ Hydrophobia, Aerophobia, Inspiratory Spasms, Fluctuating Consciousness, Autonomic
Instability (hypersalivation, hyperthermia, piloerection, fixed/dilated pupils, excessive
sweating)
o Paralytic/ Dumb (20%)
▪ Weakness, various forms of paralysis
▪ Absent hyperactivity & agitation
▪ 50% only have aero/hydrophobia
▪ Usually these cases have a previous anti-rabies vaccination and was exposed again
***Coma – begins within 10days of onset
ANIMAL BITE TREATMENT AND MANAGEMENT
CATERGORY ON EXPOSURE MANAGEMENT
CATEGORY I
o Feeding/touching o Wash skin
o Licking intact skin o No PEP needed
o Sharing food by eating/ drinking utensils o PrEP may be given for high risk persons
o Casual contact
CATEGORY II
o Nibbling of uncovered skin o Wash wound (decreases virus by 50%)
o Minor/Superficial scratches/abrasions with o Start PEP until Day 7 regardless of
bleeding including induced status of biting animal
o RIG not indicated
CATEGORY III
o Transdermal bites w/spontaneous o Wash wound (decreases virus by 50%)
bleeding o Start PEP until Day 7 regardless of
o Licks on broken skin status of biting animal
o Unprotected handling of infected carcass/ o RIG immediately
ingestion of raw infected meat
o All Cat II bites on head, neck, hand, feet,
genitalia
o Exposure to rabies patient thru bites,
contamination of mucous membranes
(eyes, oral, nasal, genital) or open skin
lesions w/body fluids thru splattering &
mouth-to-mouth resuscitation
o Exposure to bats
1. Local Wound Care
o 10mins germicidal soap and running water
o Antiseptic (alcohol, iodine)
o Antibiotics (for all frankly infected wounds)
1. DOC – Co-amoxiclav 625mg TID x 7days
2. OR Cloxacillin, Cefuroxime, Doxycycline, Erythromycin
3. Bite wounds >72 hrs with no signs of infection, do not give antibiotic anymore
o Ointment, cream, wound dressing shall not be applied
o Anti-tetanus immunization
o Do not suture, if suturing cannot be avoided, delay for at least 2hrs after ERIG admin
2. Passive Immunization
o Can provide protection upto 15days vs active that can protect upto 1year
o RIG should always be given together with rabies vaccine
o May be given upto day 7 of rabies vaccine
o Beyond day 7, RIG is no longer indicated
o Do not give add on RIG even if the biting animal died or status is unknown
3. Active Immunizations
o ID is recommended route for all eligible except the ff:
o IC Px, Px taking chloroquine, Px with chronic liver disease
o 2 types:
o PVRV (0.5ml/vial)
o PCEC (1.0ml/vial)
o PVRV – WHO PQ- Verorab (Sanofi), Rabivax-S
Non WHO PQ- Speeda, Changchun, Abhayrab-PF
o PCEC – WHO PQ- Rabipur, Vaxirab N | Non WHO PQ- VINRAB, CTN
Updated 2-site ID regimen
2-2-2-0-2 (Day 28 optional)
Ex.
Day 0 – March 1
Day 3 – March 4
Day 7 – March 8
**Day 28 – biting animal is unobservable, dies after 14 days, or positive in rabies test; but if vaccine is NON-PQ,
better to give the Day28 dose
• For ID admin – deltoid, lateral thigh, suprascapular areas
• For IM admin – deltoid >2y/o, anterolateral thigh <2y/o
• Management of Adverse Reactions
o Anaphylaxis – 0.1% Epinephrine (1:1000 or 1mg/ml) under the skin or IM
o Hypersensitivity – antihistamine, if SQ for 48hrs despite antihistamine
• DELAYS – no need to restart series if the doses are not given
o If late for 1-2 wks after,continue the schedule
o If late for >2wks, back to zero
IM regimen
• We can switch from ID to IM, 1 brand to another
• Standard IM regimen (Essen) : 1-1-1-1-1
• 2-1-1
Management of Previously Vaccinated Patients
• To consider as prev. vacc – PrEP – Day 0, 7, 21/28 or
PEP – Day 0,3,7
1. Local Wound care
2. Do not require RIG including Cat III exposure
3. All Cat II & III must be given PEP booster doses only
Schedule of PEP booster dose
• Give 0.1ml ID dose at 1 site on D0 & D3 OR
• Give 1 vial IM at 1 site on D0 & D3 ***interchanging site & vaccine is allowed
Management of Rabies Exposures secondary to bites by Vaccinated Animals
• PEP
o Not indicated for Cat I
o Can be delayed for Cat II, provided
▪ Animal is healthy & can be observed for 14days
▪ Pet is vaccinated for the past 2yrs
• Last vaccination is w/in the past 12mos.
o Cannot be delayed if Cat III
Pre-Exposure Prophylaxis
• Receiving this does not eliminate the need for PEP
• May just give booster if PrEP is complete
EXPERT INSIGHTS FROM SAN LAZARO HOSPITAL
• ERIG – always implement skin test for legal implications
• ERIG amount – we need to compute the weight and indicate on the chart for legal implications; However, the
amount to be administered depends on the number & size of the wound
• Dosing – there is NO minimum dose. However, it should not exceed the computed dose.
• Analgesic – May use topical or do sedation in cases of complicated wounds
• For Challenging Wound Areas – If the wound poses more risk when administering vaccine, may give IM
anterolateral thigh to ensure systemic absorption
• Administration – For wounds on the eyes, mucosa, or other challenging areas, may give computed ERIG as
drops and still give IM anterolateral thigh. SQ admin does not generate titer. Bleeding during vaccine admin
means SQ route.
• For Wound closure – Suggest interrupted suturing for better wound healing & cosmetic purposes
• Viability of vaccine once opened – ideally within 6 hours
• Monkey bite – presence of Herpes Virus – include 200mg Acyclovir TID x 5 days
• For skipped days of vaccination – for D3 & D7 maximum 7 days. If the biting animal is alive & well, shift to
pre-exposure prophylaxis
• Bites after 5 yrs – for patients with comorbidities (COPD, DM, HIV) Cat III- restart with ERIG
• Route – Clinically controlled conditions (HIV, DM) with evidence & those under hormone therapy may use ID
• Frequency of booster –
For non-WHO PQ vaccine: may not give booster within 1 month
For WHO PQ vaccine: may not give booster within 3 months
• Frequency of booster if more than 3 mos –
For less than 3 yrs. from last full course given, may just give booster dose (D0, D3)
For more than 3 yrs from last full course given, should give full course again but RIG not indicated even if
bite is Cat III
REMINDERS FOR ABTC
1. Right Patient – proper Px Identification
2. Right drug – ensure that the medication to be administered is identical to the drug name that was prescribed
(generic name, brand name), expiry date
3. Right preparation – hand hygiene, reading labels/packaging, checking the environment & the materials
needed
4.
5.
6. Right route – ID or IM or SQ
7. Right documentation – immediately recording the appropriate information about the drug administered;
informed consent
8. Right education – name of medication, purpose of medication, how & when to take medication, how to
monitor medication, drug/food that may cause interactions; possible side effects; S/Sx to bring to the doctors
attention; storing & handling
9. Right Hx & assessment – proper Hx taking leads to proper mgmt.
10. Right to refuse – patient can refuse the medication
11. Right to receive the medication respectfully – medications must be administered in a respectful, discrete
manner & individually to each person
12. Right reason – you must know that the medication does & why it has been prescribed
EXTRA NOTES:
• May be given together with any inactivated vaccines or spacing of 1 day before, 1 day after for better titer
formation
• Stray or domesticated has no bearing on categorization, only based on the physical examination
• Mad dog – 3 bites in 24 hrs
• Delay -
COLD CHAIN MANAGEMENT
[Link] Chain Equipment
• Slow Cold Chain – for long vaccine storage duration
o Cold Room, chest-type, vertical refrigirator
• Fast Cold Chain – means of transport
o Vaccine transport box/ cold box, vaccine carriers, ice packs
[Link] Chain Temperature
• +2 to +8°C = body/cold room
• -15 to -25°C = freezer
• -69 to -90°C = ultra-low freezer (ULF)
[Link] = loss by use, erosion, damage, or loss by extravagant use
• How to reduce?
o Proper stock mgmt.
o Record vital info when receiving, managing supplies
▪ Use stock cards
o Use First expiry, First Out principle
o Monitoring & recording cold chain temp for each cold chain equipment 2x daily, including
weekends & holidays
[Link]
• Use temperature monitoring devices
o 30-day electronic temperature recorder – data can be downloaded to a computer and an alarm
goes off when temp goes beyond +2 to +8°C temp
o Integrated Digital temperature – monitors current temp & displays temp externally
o Cold room control panel
• Temperature monitoring & recording – temperature chart
[Link]
• Optimal use of equipment
• Reduce mal/non-functioning equipment
• 2 types
o Preventive = perform periodic tasks daily, weekly, monthly
o Curative = troubleshooting/repair
[Link] Packs
• Specific per vaccine carrier or Cold Box
• 3 forms
o Frozen ice pack -
o Cool ice pack -
o Conditioned ice packs – not frozen/solid, thaw the frozen ice pack (no specific strategy or temp
to be achieved), this is the one used in NIP, Rabies Program
[Link] Exposure
• Causes
o Passive container packed w/ too few or inappropriately sized coolant packs – use correct number
o Exposure of vaccines to high temperature during immunization sessions – use foam pad. PQ
vaccine carrier
o Storage: ex. Storing vaccines to close to the freezer
[Link] Vaccines & Safe Vaccination Supplies
• Clean & disinfect storeroom regularly
• Store injection safety commodities in a dry, well-lit, well ventilated storeroom
• Limit storage area access to authorized personnel
• Stack cartons at least 10cm off the floor, 30 cm away form walls, no more than 2.5m high
• Store health comm. Away from chemicals, flammable products & hazardous mtrls.
[Link] Plan
• Site & Equipment specific in case of emergencies
• In case of power cut
o Do not open refrigerator
o If there is a gen set, look for somebody that can on the gen set,
o If brownout is longer than 2 hrs, transfer the vaccine to the transport box with conditioned ice
packs
o If brownout is more the 24 hrs,
▪ Transfer the vaccine to the nearest facilities w/power supply
▪ Prepare the cold boxes/frozen ice packs
▪ Assign a responsible person & an alternate to transfer the vaccines
• In case of mechanical failure
o Contact a local technician for immediate check-up & repair
o If repair will take more than 5 days, prepare transfer
RA 9482 – “Anti Rabies Act of 2007”
• Dr. Louis Pasteur- father of rabies vaccine
• Joseph Meister – 1st human inoculated with ‘live’ virus at 9yo
• RABIES VIRUS
o RNA, bullet shaped virus
o Fragile, easily inactivated by desiccation, UV rad, detergents
o Rapidly destroyed above 50°C
o Destroyed w/in a few hours at room temp
o May persist for years when frozen
o Pathophysiology
▪ After inoculation, viral replication in the SQ tissue or muscle, into peripheral nerves
▪ Replicates in the dorsal ganglion, then migrates along nerves to the SC & brain
▪ The victim exhibits behavioral changes and clinical signs when the virus reaches the
brain
o Transmission
▪ Infected saliva, CNS tissue, CSF penetrates skin/mucosa of susceptible person/animal
▪ Usually by bite wounds, but may involve saliva contact w/mucous membranes or a fresh
break in the skin
▪ NOT transmitted by contact w/ blood, urine, fever, petting or touching fur
▪ Factors that may contribute to the transmission, incubation period & development or
prevention of rabies infection:
1. Amount of rabies virus introduced into the body
2. The anatomic location of the bite or saliva exposure
3. Post-exposure wound mgmt. (washing the wound, rabies IG, vaccination)
o Case definition
▪ SUSPECT case
• Animal may show any of the ff clinical signs
o Sudden behavioral chanes (anorexia, apprehension, nervousness,
irritability, hypersensitivity)
o Hydrophobia
o Muscle paralysis
o Nervous signs
• Animal involved in a biting incident
▪ PROBABLE case
• Suspect case w/ known exposure to a confirmed rabies case
• A suspect that dies within the observation period (14 days from time of bite) but
no laboratory confirmation
▪ CONFIRMED case
• Tested brain tissue
Component Activities of RA no. 9482
1. Mass registration & vaccination of dogs
2. Establishment of central database system for registered, & vaccinated dogs
3. Impounding, field control & disposition of unregistered, stray & unvaccinated dogs
4. Conduct of information & education campaign on the prevention & control of rabies
5. Povision on pre-exposure treatment to high-risk personnel & post-exposure treatment to animal bite
victims
6. Provision of free routine immunization or PEP of school-children aged 5-14 in areas where there is a high
incidence of rabies
7. Encouragement of the practice of responsible pet ownership (RPO)