Dr. Ramakrishna HK Rabies MS, DNB, FMAS. Lakshmi Nursing Home New Bridge Road Bhadravathi swarama@hotmail.com : 94486 67653 Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Meaning Sanskrit Word RABHAS = VIOLENT Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies The Virus A zoonotic disease Neurotrophic Rhabdovirus (bullet shaped virus) Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Introduction Only disease with 100% mortality Incidence maximum in India (36% of world) Causes of high mortality Ignorance Non availability of vaccine Cost of treatment Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Reservoir for Virus Dog: 90% cases Others: cat, other domestic animals and wild animals Transmitted by bites and licks mainly Person to person Aerosol Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies At risk All worm blooded animals Persons working in laboratory with rabies virus, veterinarians, dog handlers, hunters, naturalists, forest deportment workers etc… Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Pathogenesis Virus multiplies near the bite site Enters peripheral nerves Ascends to CNS Spreads centrifugally in peripheral and autonomic nerves Involves the organs: Salivary gland, myocardium, adrenal etc… Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Clinical Feature Incubation period: Long and variable 1 week to many years: Usually 3-8 weeks Depends on many factors Site, severity, number of wounds, amount of virus injected, species of animal, clothing, treatment etc… Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Initial Symptoms Prodromal symptoms: Head ache, malaise, sore throat, fever etc… Specific: Tingling or pain at the site of bite Excitation & Stimulation: All parts of NS Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Later Phases Aerophobia Hydrophobia Intolerant to noise, light Violent spasms of pharyngeal and neck muscles Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Examination Increased reflexes Dilatation of pupils Increased perspiration Increased salivation Lacrimation FEAR OF DEATH, anger, irritability depression Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Duration of illness Usually 2 – 3 days May be prolonged 5 – 6 days Death: Convulsion or paralysis, coma Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Diagnosis H/O animal bite Pain at bite site Hydrophobia Aerophobia Confirmation: Skin biopsy (Immunoflorescence for antigen) Virus isolation in saliva Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Treatment First Aid Active immunization Passive immunization Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies WHO Recommendations Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies First Aid Wash: Copious amount of running water Mild soap Ethanol or iodine solution Avoid suturing: If must, infiltrate with RIG Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Active Immunization: VACCINE: Intra deltoid: Anterolateral thigh Nervous tissue based vaccines are no more used Vaccine: Cell culture is the best VERO CELL CULTURE Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies WHO Schedule 0, 3, 7, 14, 28 90 optional Should not overlap antimalarial treatment Serum antibody titre > 0.5 IU/ml Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Passive Immunization Dr. Ramakrishna HK Rabies

RABIES IMMUNOGLOBULINS Passive Immunization Neutralize virus on contact Gives a coating to the virus so that it cannot enter the nerve ending Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies TYPES Human Rabies Immunoglobulin (HRIG) Equine Rabies Immunoglobulin (ERIG) Dr. Ramakrishna HK Rabies

HUMAN RABIES IMMUNOGLOBULINS Immunoglobulins mainly IgG obtained from plasma or serum of donors immunized against rabies Plasma pooled from more than 1000 donors – previously immunized. Passive protection immediately Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies HRIG: Advantages Purity Minimal or no foreign protein Minimal risk of hypersensitivity Negligible side effects Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies HRIG : Disadvantages Expensive Risk of viral agents – (HIV, Hepatitis-B, Hepatitis-C) Shortage because of low yield Dr. Ramakrishna HK Rabies

EQUINE RABIES IMMUNOGLOBULINS Immunizing horses with rabies vaccines Serum processed by modern automated ultra filtration technology Contains purified antibodies against Rabies Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies ERIG: Advantages Massive Yield Low cost Widely available Modern purification and ultra filtration technologies has made it safer. Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies ERIG: Disadvantages Presence of foreign protein Risk of immediate hypersensitivity Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies INDICATIONS FOR RIG Category III bites (WHO classification) Licks on mucous membranes by wild or pet animals AIDS : Category II & III bites Varicella (Chicken pox) Dr. Ramakrishna HK Rabies

INDICATIONS FOR RIG Cont’d 5. Long term Corticosteroids 6. Long term Chemotherapy 7. Radiation Therapy 8. Wound suturing (pre-infiltration) Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Dosage Human Rabies Immunoglobulin 20 Units per kg of body weight Equine Rabies Immunoglobulin 40 Units per kg of body weight Maximum dosage: HRIG 2000 IU ERIG 4000 IU Dr. Ramakrishna HK Rabies

Never give intravenously Dr. Ramakrishna HK Rabies Administration Infiltrated into and around the wound. The remaining portion if any, to be injected in to the opposite deltoid Never give intravenously Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies NEVER EXCEED CALCULATED DOSE Partially suppresses active production of rabies antibody. Only once: Not beyond the 7th day of bite Interferes with antibody production Dr. Ramakrishna HK Rabies

Administration: Precautions Warm before intramuscular injection. Site & syringe – different from ARV. Avoid RIG seeping out of wounds. If so, the volume should be estimated and replaced. Caution is needed if injecting into a tissue e.g. finger pulp, excess fluid can result in increased compartmental pressure and lead to necrosis. Dr. Ramakrishna HK Rabies

RIG TREATMENT - CHILDREN The same calculated dosage If insufficient to infiltrate all wounds, dilute with sterile NS 2 to 3 fold Total dose of RIG should not be increased Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies RIG Provides immediate passive antibodies Protects the patient until the patient can produce own antibodies from the rabies vaccine. Adequate titre of passive antibody is present 24 hours after RIG administration. Dr. Ramakrishna HK Rabies

Duration of Protective Effect: Short Half-life: Approximately 21 days. Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Cross sensitivity Patients sensitive to other human immune globulin products may be sensitive to Rabies Immunoglobulin also. Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies SIDE / ADVERSE EFFECTS Rare. Local: Pain, tenderness at injection site Systemic: Headache, Fever, Chills, Flushing, Backache, Nausea Sensitization and subsequent reaction to IgA containing material, such as blood and plasma Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Drug Inter actions Can impair the efficacy of live attenuated virus vaccines such as Measles, Mumps, Rubella and Varicella (for a period of at least 6 weeks and up to 3 months). Vaccines should be administered 14 days prior to or 3 months after administration of RIG. Over dosage: Significant depression of active immunity. Avoid repeated doses: prevents full development of the active immunity expected from the vaccine. Dr. Ramakrishna HK Rabies

STORAGE AND OTHER PRECAUTIONS Store between 20C - 80C (350F - 460F) Do not freeze Do not use if discolored or contains particulate matter Do not heat Do not be administer in the same syringe or into the same body site as the rabies vaccine. Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Intradermal Test Intradermal test: mandatory Test: 0.1 ml of RIG: intradermally on the left forearm. Observation: observed for 30 minutes for local: 24 hours for systemic reactions Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Reactions Local: Erythema, Wheal, Severe pain at the local site. Systemic: Giddiness, mild circulatory collapse with fall of BP. Precaution: Keep Resuscitation set ready History of sensitization to other vaccines or immunoglobulins, give anti- histamines prior to administration. Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Management Mild Local Reaction: Anti histamines Systemic reaction: Adrenaline 1:1000 (Aqueous) – 0.01ml/Kg/ dose repeated every 10 – 20 minutes. Usual Doses: Infants – 0.05ml – 1ml Children – 0.1 0.3 ml Adolescents – 0.3 – 0.5 ml Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Management: Cont’d SEVERE CASES: HYDROCORTISONE : I.V 100 – 200 Mg Dr. Ramakrishna HK Rabies

CHILDREN, PREGNANCY AND LACTATION Not a Contra indication Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Previously Immunized Do not use RIG Active immunization: 0, 3, 7. If antibody titre > 0.5 IU/ml 0, 3. Dr. Ramakrishna HK Rabies

Anti tetanus Treatment Dr. Ramakrishna HK Rabies Additional treatment Anti tetanus Treatment Dr. Ramakrishna HK Rabies

Observation of dog & cat If dog is alive at 14 days Further Vaccination can be stopped Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Storage Vaccine and RIG At 2-8*C Not in Freezer Dr. Ramakrishna HK Rabies

Animal bite: Exceptions Rodents Rabbit Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Prevention Vaccine: 0, 7, 28 (Or 21). Maintain continued immune status by boosters at 1 yr and every 2-3 yrs For at risk group Dr. Ramakrishna HK Rabies

Dr. Ramakrishna HK Rabies Thank You Dr. Ramakrishna HK Rabies