Rabies

• Neglected zoonosis, 100% fatal

• 59000 deaths/year Globally due to Dog mediated Rabies

• 1/3rd of Global burden is from India

• 2/3rd of Burden from SEAR is from India

• 96% of the mortality and morbidity with dog bites

• 40%Cases in<15 years.

• In India, Rabies is endemic in all States/UTs except

Andaman and Nicobar, and Lakshadweep Islands
4
 CLINICAL DIAGNOSIS OF RABIES IS
CHALLENGING IN ANIMALS
It is said:
“The only thing typical about rabies is its
atypical presentation”
● Different species have different signs
● Bite history……
● No hydrophobia, aerophobia, photophobia
Jeanna Giese
• First person in the world to survive rabies
without receiving the vaccination, before
or after exposure.
1885-live attenuated vaccine

Louis Pasteur and Émile Roux developed the first Rabies vaccine in 1885
Most common rabid animals Animals almost never gets
rabies
Fox
Rabbit

Squirrel

Skun
k

Raccoo
n
Risk of rabies following animal bite

• Head 55%
• Upper limb 22%
• Trunk 9%
• Lower limb 12%

WHO position paper

2018
 Rabies in Dogs

Furious Rabies Dump Rabies

• Behavioral changes • Dropped jaw and

• Hides in dark corners, incoordination.
• Unusual agitations, • Progressive paralysis
• Restless. begins with the muscles of
the head and neck region
• Bite without provocation
• Change in tone of bark
• Hyper excitability
• convulsions

National guidelines
2019
 Rabies in Humans
Furious Rabies Dump Rabies

• Acute progressive ascending

• Hyperactivity (anxiety,
myelitis, symmetrical or
agitation, running, biting, asymmetrical with flaccid
bizarre behavior paralysis,
alternating with periods of
calm) • Pain and fasciculation in the
affected muscles with mild
• Hydrophobias, sensory disturbance.
• Aerophobia,
• Photophobia • Complete paraplegia develops

• Spasmodic muscle eventually with fatal paralysis of

contractions the respiratoryNational
and pharyngeal
guidelines
2019
muscles.
 “GLOBAL
TARGET”
“Zero human deaths due to
dog-mediated Rabies by 2030”

World Hethe World Health Organization (WHO),

The World Organization for Animal Health (OIE),
The Food and Agriculture Organization of the United Nations
(FAO), and
The Global Alliance for Rabies Control (GARC)
“National Action Plan for dog mediated Rabies
Elimination from India by 2030” (NAPRE)

“Zero human deaths due to

dog-mediated Rabies by
2030”
 Decision to treat
• Every animal bite is • PEP is considered
suspected as a in
potentially rabid
• Bites by all warm
animal bite
blooded animals
• Treatment should be
• Wild animal
started immediately bites- treated as
after exposure severe bite
 Rabies Prevention
• Wound care
• Wash with soap and water
• Apply povidone iodine(0.01%), 70% alcohol
• Delayed suturing
• Antibiotics
• Anti tetanus measure

• Immunization
• Passive immunization
• Human Rabies Immunoglobulin (20IU/kg)
• Equine Rabies Immunoglobulin(40IU/kg)
• Monoclonal antibodies(3.33IU/kg)
• Active immunization
• Intradermal Rabies Vaccination
17 • Intramuscular rabies vaccination
Wound category & Post Exposure Prophylaxis
(PEP)
Category I
• Touching or feeding animal
• Licks on intact skin
• Contact of intact skin with secretions
or excretions of rabid animal or human
case

PEP measure
• Not regarded as exposure
• Wash with soap &running water
• No prophylaxis required
18
 Wound category & Post Exposure Prophylaxis
(PEP)
Category II
• Nibbling of uncovered skin
• Minor scratches or abrasions
without oozing of blood

PEP measure
• Local treatment
• Wash with soap & water
• Antiseptics- povidone iodine/ 40-70%
alcohol
• Tetanus prophylaxis
• Anti-Rabies vaccine -IDRV/IMRV
19
 Category III
• Bites or scratches with
oozing

• Licks on broken skin, mucosa

20
 Category III

• Local treatment
CH
ILI
PP

• IDRV / IMRV

• Immunoglobulin

21
 Wound care

* Depending on the charateristic of the wound, antibiotics, analgesics

and a tetanus vaccination may be indicated.
 IMRV/ IDRV site
• ID site
• Deltoid region Rabies vaccine
• Antero lateral thigh should not be
• Supra scapular regions . administered IM in
the gluteal area.

• IM site
• Deltoidfor adults and ≥2 years,
• Anterolateral area of the thigh for <2 years

WHO position paper

2018
 IDRV
• Reconstituted vaccines

• Store at 2ºC to 8ºC

• used within 6 to 8
hours

• Discard, if not used in

6-8 hours

Photo courtesy of Claudius Malerczyk (Novartis)

 IDRV schedule

• 2-site ID schedule – 0.1ml X 2sites

2 2 2 0 2

• Day 0 3 7 28

• Insulin syringe- 40u/ml OR 100u/ml

 PEP- IM schedule
• 1site IM schedule (5doses)

• Day 0 3 7 14 28
• Indications
• Immuno compromized
• Chronic renal failure
• Long term steroid therapy
• Chloroquine therapy
• IDRV –technique failure
 DCGI recommended post-exposure
IM and ID regimens: Summary
Regime Day 0 Day 3 Day 7 Day 14 Day 21 Day 28 Day 90 Vials Visits
n
Essen 1.0 1.0 1.0 1.0 – 1.0 – 5 5
mL mL mL mL mL

Regime Day Day Day Day 14 Day 21 Day Day 90 mL Visits

n 0 3 7 28
Thai 2x 2x 2x 2x
Red 0.1 0.1 0.1 – – 0.1 – <1 4
Cross mL mL mL mL
(update
d)

National Guidelines for Rabies Prophylaxis and Intra-dermal Administration of Cell Culture Rabies Vaccines,
2007
 WHY IMMUNOGLOBULIN???

vaccine-inducedhumoralimmuneresponse
CIvSvirus

Passiveimmunity-HRIG Soresan

Viruspresentatentryate

appropnatePEP

TORARENT

AMATISORR

nication
 IMMUNOGLOBULIN

• Should be brought to room temperature before administration

• RIG is administered only once
• RIG is not indicated beyond seventh day after 1st dose of
vaccine
• Maximum possible dose should be infiltered into or close to
wound
• Remaining dose is given IM
• Mucosal exposure without injury- Rinse with RIG & IM
• Aerosol exposure- RIG is given as IM
 RIG INFILTRATION
➢ Inject RIG into all wounds if
anatomically feasible

➢ If RIG is insufficient dilute it

with sterile normal saline

➢ ERIG must be administered

with full precautions .
 Immunoglobulin
• ATD & informed consent

• 5ml vials -300iu/ml

• Test dose
• 0.1ml serum+0.9ml NS
• Read after 10-15mts

A negative test is not a guarantee that Anaphylaxis

will not occur.
 equine RIG Positive skin test
• Induration >10mm
with or without
constitutional
symptoms

•If skin test is positive – HRIG / RmAb is preferred

•ERIG after desensitization

A negative test is not a guarantee that Anaphylaxis will not occur.

 Desensitization
Adults
Children

Inj. 100mgIV Inj.Hydrocortizone 2mg/kgIv

Hydrocortizone

Inj.Avil OR 25mgIM Inj.Avil OR 0.2mg/kg

Inj.CPM 10-
20mgIM
Anaphylaxis

Inj.Adrenalin 0.5mgIM Inj.Adrenalin 0.01mg/kgIM

Inj.Hydrocortizo 100mgIV Inj.Hydrocortizone (not

Inj.Avil
 Immunoglobulin

• RmAb -3.33iu/kg
• 2.5ml vial -40iu/ml
• Weight X3.33 ml
40

• hRIG -20iu/kg
• 2mlvial -150iu/ml

• Weight X 20 ml
150
RECENT ADVANCES
 PEP for immune compromised
• May have a significantly lower or no detectable antibody
response
• Not possible to determine the severity of immune
suppression at times of PEP
• So presence of immunological memory cant be assured
• Proper wound management followed by RIG in Cat II &III

• Complete course of IM vaccination in Cat II & III

• If possible, antibody titer estimation 14 days after complete
course of vaccination to assess the need for booster doses
 Post Exposure Prophylaxis

Category I Category II Category III

* Wash exposed * Wound * Wound

skin washing & washing &

* Immediate * Immediate
vaccination vaccination

* No PEP
required.
* RIG

WHO position paper

April2018
Pre exposure prophylaxis
 High risk groups
• Check antibody titer
every 6months • Lab staff handling the virus
during first 2years and infected material,
then every 2years clinicians and individuals
attending human rabies cases

• If titer, <0.5 IU/ml • Veterinarians, animal handlers,

give booster dog catchers

• Wildlife wardens, quarantine

• Booster dose officers
indicated only when
antibody titre • Travelers from rabies free
dropped to<0.5 areas to rabies endemic areas
IU/ml National guidelines
2019
 Pre-exposure rabies prophylaxis
Tissue culture vaccine: 1 dose IM or one site 0.1 ml
ID

Day 0 7 21/28
•Neutralizing Antibody titre ≥ 0.5 IU/ml
HIV positive patients - CD4 counts <200 may be unresponsive

WHO position paper

2018
Re exposure in previously vaccinated
 Repeat exposure <3 months

• Fully vaccinated
• Only wound treatment is required;
• Neither vaccine nor RIG is
needed i

WHO position paper

2018
 Repeat exposure >3 months

1 dose IM or one site 0.1 ml ID

)NOVARTIS
n
1doseavec seringuedinjectio
malspritze
1DosismitEin ectiespuit
1dosismetinj
7014
276544400008

R ®
RABIPU
llung
telzurHerste
Lösungsmit ctie
le/Pulverund ngvoorinje eerd
tioninjectab lvooroplossi abi@svaccin,geinactiv
ntpoursolu noplosmidde rt/R
etsolvalösu
Poudrejekt ions ng/Poederelwut-Impfstoff,inaktivie
ein erIn tive/Tol
abique,inac
Vaccinantir

0 3

• Day 0 3 No
Immunoglobulin
 Repeat exposure
Repeat Category I Category II Category III
exposure
<3months **Wash exposed skin surfaces
**No
No PEP required.

>3months * Wash * Wound * Wound

exposed skin washing washing
surfaces & &
* Immediate * Immediate
vaccination vaccination

* No PEP
* No RIG * No RIG
WHO position paper
April2018
FAQ
• I GOT BITTEN BY WOLF 7 DAYS BACK
DURING TREKKING.

• I DIDN’T TAKE ANY VACCINE.

 When to start PEP
• The first dose of rabies vaccine should be
administered as soon as possible after
exposure.

• PEP to be given even months or years after

the exposure.

• RIG is recommended after cat. III exposures

who have not previously been vaccinated
against rabies.

WHO position paper

2018
• I GOT BITTENT BY RAT.

• CAN I GET RABIES.???

• DO IN NEED IDRV??
 Rodent bite Exposure to
bats
• Exposure to domestic • Bat rabies has not
rodents, hares , been conclusively
rabbits do not proved in India
ordinarily require
PEP • At present,
exposure to bats
• Rodent bites in forest does not warrant
areas necessitates PEP
PEP
National guidelines
2019
 Bat rabies
• Not reported from India

• Bat bites or scratches are not readily visible or

detectable, therefore for exposures involving physical
contact with a bat, needs PEP

• RIG should be injected around the site of exposure to

the degree that is anatomically feasible. .
• WHY IS IT SAID THAT TO OBSERVE THE
BITING DOG FOR 10 DAYS??
 Observation of biting dog/cat for 10d
• Valid only for dogs and cats

• IMRV schedule-Treatment may be modified if

dog/cat is healthy after 10d & PEP can be
converted to PrEP
• IDRV schedule-complete course of vaccination
irrespective of the status of the animal
 PET BITE
• I GOT BITTEN BY MY PET DOG
• SHE IS MY PET FOR THE PAST 8 MONTHS
• I HAD TAKEN HER VACCINE
• SHOULD I NEED PEP??
Bite by vaccinated animal

• Full PEP should be given irrespective

of the vaccination status of the biting
animal
 Provoked/unprovoked bite

• PEP should be given immediately for both

provoked and unprovoked bite
• IS THERE ANY CONTRA INDICATIONS FOR
VACCINE??
Contra indications
• No absolute contra indications

• Previousreaction to any component of

vaccine – change to other tissue culture
vaccines
 BOOSTER

• I HAD COMPLETED MY PrEP

• DO I NEED TO TAKE BOOSTER DOSES??

 Periodic booster injections

Periodic injections are not required for

those who received complete
prophylaxis
(primary, pre or post exposure)

Periodic boosters are recommended

only
For those at occupational risk
All incomplete vaccinations, or
doubtful vaccination need to be
treated as fresh cases
cases.
 VACCINE FAILURE
• WHY THERE IS DEATH FOLLOWING
VACCINE??

• DO PEP GOT FAILURES??

 PEP failure
• Delay in seeking PEP,
• Improper wound care,
• Unnoticed wounds,
• Direct nerve inoculation, and

• Lack of patient compliance with vaccination schedules

WHO position paper

2018
• CAN I GET RABIES FROM ANOTHER
HUMAN??
 Human-Human exposure
• Found in Saliva, Tears, Urine and nervous
tissue - ? Theoretical possibility

• RABV NOT found in blood

• Transmission- organ transplants

WHO position paper

2018
 MILK,MEAT ,RABIES
• I HAPPENED TO DRINK MILK OF A RABID
COW/SHEEP.
• I ATE THE MEAT OF RABID ANIMAL.

• DO I GET RABIES??

I NEED PEP
 RABV in milk
• Infectious RABV has never been isolated from
milk of rabid cows in quantities sufficient to
produce infection

• NO documented human rabies case has been

attributed to consumption of raw milk.

• Consumption of meat or raw milk from a

rabid animal should be avoided
WHO position paper
2018
• I TOOK RABIES VACCINE,
• CAN I TAKE COVID VACCINE??
Co administration

• Rabies vaccines can be co-

administered with other inactivated

and live vaccines, using separate
syringes and different injection
sites
sites..

WHO position paper

2018
Switching the route of
administration
• I HAD TAKEN IMRV.

• CAN I SHIFT TO IDRV ??

Switching the route of administration

National guidelines
2019
• A monkey bite patient received the first two doses of
ARV on time (on days 0 and 3)
• also RIG on day 0.
• Then he defaulted for the third dose of ARV (day
7).
• However, the patient comes back on day 9.
• What should be done?
• The first two doses of ARV are the most important.
• For the 3rd or 4th doses two or three days deviation
may be accepted
• A boy bitten by a cat received the first three doses of
ARV in time (Day-0, Day-3 and day 7).
• In between 3rd and 4th shot of vaccine the boy got
scratched again by a monkey drawing blood.
• What should be done?
• No need to repeat the vaccine schedule.
• Just complete the usual vaccination up to 4th dose as
per schedule.
• As first 3 doses of vaccination would be enough to
produce antibodies
• immunoglobulin is not needed for the latter incident
• WHAT SHOULD I DO IF I MISS ONE DOSE ??
 Missing doses
• Strictly follow the recommended PEP schedule

• If any doses are delayed, vaccination should be

resumed, not restarted.

• First 3 doses should be completed within

maximum 10 days to achieve effective immunity

• One or two days deviation do not necessitate

restarting of vaccination schedule

National guidelines
2019
 Missing doses
• A change in the route of administration or in
vaccine product during a PEP or PrEP course is
acceptable if such a change is unavoidable.

• Restarting the series of injections is not

necessary; vaccination should continue
according to the schedule for the new route of
administration.

• If the patient fails to receive first 3 doses and

missed one or more dose, consider additional
doses
• Is there any single dose human rabies
vaccine??
• Are there any dietary restrictions during
ARV??
• Can a vaccinated dog transmit rabies??

• Is observation of animal for 10 days without

starting PEP justified??
 Why a person does not acquire Ab after
natural infection ?

• No viraemia

• Virus is not
accessible to the
normal immune
mechanism of the
body

80
 Whether newborns/infants require lesser
dosage ?

• All modern anti rabies vaccines have

uniform dosage schedule for all age
groups

81
 Can we use ARV accidentally kept in freezer?

• Asfreezing and thawing is known to affect the

potency of ARV, it should not be used

• ARV should be stored at 2-8ºC

• Vaccine should not be exposed to sunlight, heat,

dust and dirt

82
 Can modern vaccines be interchanged ?

• All modern vaccines (HDCV,PCECV, PVRV) are

interchangeable

• Should not be encouraged as a routine practice

• Rarely this may be allowed following allergy/

non availability

83
What drugs are contra indicated during ARV ?

• All immuno suppressive drugs( steroids, anti

malarials, anti cancer drugs etc)

• If these drugs cannot be avoided, give double dose

of IM vaccine on Do along with RIG and
remaining dose as per schedule

• Test antibody titer wherever possible

84
 Can HRIG/ERIG be given to a healed wound
?

• If scab is formed, RIG is infiltrated around the

wound without disturbing the scab

• If completely healed without any sign, then the

total amount is given by IM route in thigh and at
site away from the site of injecting the rabies
vaccine

85
State Technical Advisory Group on Immunisation (STAGI)

HELD on 17th September, 2022

• All animal handlers, livestock inspectors and
veterinary personnel involved in canine vaccination
drive should avail PEP
• who have received PrEP or Booster dose within the last
2 years do not require additional doses
• who have received PrEP or Booster dose before 2 years
should receive a single dose of IDRV as booster
• who have NOT received PrEP, the recommended
schedule of PrEP is the Single site IDRV schedule on
Days 0, 7, 21
• who have completed the 0,7,21 intradermal schedule
can be engaged in canine control activities after the
21st day
ACCIDENTAL EXPOSURE
• on or before the 7th day of the PrEP should be
treated as a fresh case and should receive RIG and
Rabies Vaccine as per category of exposure
• after the 7th day before 21st day treat as new case
with complete IDRV , but NO RIG
• after completing the PreP schedule Single Site
Intradermal vaccine on Days 0 and 3
Thank Thank
you
You