1. Dr. Ramakrishna HK Rabies
MS, DNB, FMAS.
Lakshmi Nursing Home
New Bridge Road
Bhadravathi :
Dr. Ramakrishna HK Rabies

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

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

4. 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

5. Dr. Ramakrishna HK Rabies

6. 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

7. Dr. Ramakrishna HK Rabies

8. Dr. Ramakrishna HK Rabies

9. Dr. Ramakrishna HK Rabies

10. 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

11. 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

12. 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

13. 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

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

15. 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

16. 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

17. 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

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

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

20. Dr. Ramakrishna HK Rabies

21. 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

22. 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

23. 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

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

25. 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

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

27. 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

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

29. 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

30. 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

31. 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

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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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 – ml
Adolescents – 0.3 – 0.5 ml
Dr. Ramakrishna HK Rabies

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

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

51. 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

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

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

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

55. Animal bite: Exceptions
Rodents
Rabbit
Dr. Ramakrishna HK Rabies

56. 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

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