Rabies and Animal Bite

Management
ARMAND JERIC W. MANABAT, MD
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
DR. PJGMRMC
Rabies Epidemiology
 Key Facts

• One of the oldest and most feared zoonotic diseases

known to mankind
• Dogs are the source of the vast majority of human
rabies deaths, contributing up to 99% of all rabies
transmissions to humans
• Rabies is a vaccine preventable disease which occurs
in >150 countries.
• Rabies is generally a disease of children.
 Rabies in Asia

• Asia has the highest human mortality (due to

endemic canine-mediated rabies)
• One Asian dies every 15 minutes.
• 40% likely to be a child under 15 years
• More than 3B people in Asia are potentially exposed
to dog rabies
Animal Bite Cases, Philippines
Human Rabies Cases, Philippines
 Top 10 Regions with Highest Number of
Human Rabies Cases, 2017

Region Human Rabies Rank

Region 3 37 1
Region 12 33 2
Region 4a 28 3
Region 7 21 4
Region 5 18 5
Region 6 14 6
Region 10 14 6
Region 1 10 7
Region 8 8 8
Region 9 7 9
Region 2 6 10
CARAGA 6 10
 Provinces with highest number of Human
Rabies Cases, 2017
Province Human Rabies Rank
South Cotabato 18 1
Cebu 13 2
Nueva Ecija 11 3
Zambales 10 4
Camarines Sur 10 4
North Cotabato 9 5
Pangasinan 8 6
Negros Occidental 8 6
Bukidnon 7 7
Batangas 6 8
 Rabies Virology

• Bullet shaped- single stranded RNA virus belonging

to the genus Lyssavirus, family Rhabdoviridae
• Sensitive to heating/boiling, drying, UV and xray,
sunlight, ether, detergents.
• Cannot cross intact skin.
• Vectors : Rabies has been shown to infect all
mammals so far tested. Dogs, cats and cattle are
particularly susceptible
• Rabies due to monkey bites are rare
• Horses and donkeys get aggressive and bite ferociously
• Cattle and buffaloes do not bite when they are rabid.
 Transmission

• In almost all cases – due to a bite, scratch or lick on

mucous membrane from animals whose saliva
contains the virus.
• In very exceptional cases – by inhaling virulent
aerosol (laboratory experiment, exploration of
enclosed caves inhabited by infected bats.
• Human to human transmission
• Directly – bite or contact with saliva and other body fluids of
infected person
• Indirectly – transplant. Cornea (8) Solid organs and a vascular
conduit (7)
 Stages of Rabies

RABIES PEP EFEECTIVE ONLY DURING IP

 Exposure

• The rabies virus enters the human body via exposure

to an infected animal
 Incubation Period

• The rabies virus replicates in the muscle at the bite

site
• Virus binds to nicotinic acetylcholine receptors on
post synaptic membranes at neuromuscular
junctions.
• Travels by retrograde transport along the PNS
(250mm/day)
• 5 days to 6 years
• Average IP 20-60 days
 Prodrome

• Rabies Virus replicates in the dorsal root ganglion

and travels along the CNS
• Manifestations
• Malaise
• Anorexia
• Fever
• Pain/itching/numbness at bite site
• Duration 2-10 days
 Acute Neurologic Phase

• Rabies virus infects the brain

• Virus spreads centrifugally to the other organs
• Duration 2-7 days
 Acute Neurologic Phase

Encephalitic/ Furious type Paralytic/Dumb type

80% 20%
Aerophobia/Hydrophobia Lack of Agression
Autonomic dysfunction Weakness
(hypersalivation, gooseflesh) Aerophobia and hydrophobia may
Spotaneous inspiratory spasms be absent
Restlessness, agression, Myoedema at percussion sites
hallucination, disorientation, Sphincter involvement common
bizarre behavior, agitation, Can be mistaken for GBS
confusion Generally survive a few days longer
Alternating periods of lucidity
(decreases as disease progresses)
Seizures
MULTIPLE ORGAN FAILURE
 Coma and Death

• Onset 4-10 days after symptoms start

• Onset of complications
• Respiratory
• Cardiovascular
• Neurologic
• Others
 Laboratory Tests

• Most routine laboratory tests are normal or non

specific
• CBC usually normal
• CSF Studies – mild mononuclear pleocytosis, mildly
elevated protein
• CT scan usually normal
• MRI signal abnormalities in the brainstem or other
gray-matter areas – non specific
• EEG non specific
 Diagnosis

• Usually Clinical
• No tests are available to diagnose rabies infection in
humans before onset of clinical disease
• Lack of history of exposure not unusual (6% with no
bite history)
 Treatment

• None
• Many recent treatment failures with the combination
of antiviral drugs, ketamine and therapeutic
(induced) coma
• Palliative
 Rabies Prevention

• 2 main strategies
• Dog vaccination to interrupt the virus transmission to humans
• Human vaccination
• PrEP for high risk individuals
• PEP for exposed individuals
 Post exposure Prophylaxis

• Components:
• Wound washing and care
• Vaccination: Active Immunization
• Administration of RIG: Passive Immunization
 Wound Care

• All bite wounds/scratches should be immediately

and vigorously washed and flushed for 10 minutes
with soap/detergent (as much as 40% reduction in
rabies infection rate)
• If soap is unavailable, the wound should be
thoroughly washed with water
• Apply Iodine containing similarly viricidal topical
preparation to the wound
• DONT”S – garlic, tandok, bato, sucking bite wound
 Wound Care

• Give Antibiotics for:

• All frankly infected wounds
• All Category 3 cat bites
• All other category 3 bites that are either deep, penetrating,
multiple or extensive or located on the hand/face/genital area
• Recommended Antimicrobials:
• Prophylaxis: Amoxicillin
• Frankly infected wound Coamoxiclav or Cefuroxime or Ampi-
Sulbactam or Cloxacillin
• Alternative Doxycycline
 Suturing

• Should be avoided as it may inoculate the virus

deeper into the wound
• However if suturing is unavoidable:
• RIG should be infiltrated around and into the wound before
suturing
• Delayed for at least 2 hours after RIG administration to allow
diffusion of the RIG to occur
• Sutures – loose and not interfere with bleeding/drainage
• Ointments/creams/occlusive dressing shall not be
applied because it favors bacteria growth and may
occlude wound drainage
 Tetanus Prophylaxis

VACCINATION HISTORY
ALL Unknown or <3 doses 3 or more doses
ANIMAL TD TIG/ATS TD if more NO ATS
BITES than 5
years since
last dose
 Categories of Rabies Exposure
Category 1 Category 2 Category 3
- Feeding/ touching an - Nibbling of uncovered - Transdermal bites or
animal skin with or without scratches with spontaneous
- Licking of intact skin bruising/hematoma bleeding
- Exposure to patient - Minor superficial - Contamination of mucous
with signs and scratches/ abrasions membrane with saliva .
symptoms of rabies by without spontaneous - Licks on broken skin
sharing of utensils. bleeding - Unprotected Handling of
- Casual contact to - All category 2 exposures infected carcass
patient with signs and on the head and neck are - Ingestion of raw infected
symptoms of rabies considered category 3 meat
and shall be managed as
such
Wash Exposed skin Wash wound with soap Wash wound with soap and
NO vaccine or RIG and water water
needed Start vaccine immediately Start Vaccine and RIG
PrEP may be immediately
considered for high risk
persons
 Management of Biting Animal

• Observe biting animal for 14 days

• During 14 days observation period:
• Provide adequate care/ food/ drink during observation period
• Consult veterinarian if animal becomes sick
• If the animal dies or sickens, sacrifice the animal and submit
the head for testing
 Types of Rabies Immunoglobulin

Generic Dose Preparation

Name
HRIG 20iu/kg 150 iu/ml at
2ml/vial
ERIG 40iu/kg 200ml iu/ml
at 5ml/vial
RIG is not indicated for those who can reliably document previous PEP or PrEP
 Skin testing for ERIG

• Skin testing is not recommended before RIG

administration as such tests poorly predict severe
adverse events and should not be the basis of not
giving ERIG if needed
• Treating physician should be prepared to manage
anaphylaxis which, although rare, could occur during
any stage of administration
 RIG Guidelines

• RIG is given as single dose.

• Total computed dose should be infiltrated around the
wound and into the wound as much as anatomically
feasible, even if the lesion has begun to heal.
• The remainder of the computed dose of RIG does
not need to be injected IM at a distance from the
wound but can be fractionated in smaller,
individual syringes to be used for other patients
following aseptic techniques.
 RIG Guidelines

• RIG should not exceed the computed dose as it may

reduce the efficacy of the vaccine
• If computed RIG is insufficient to infiltrate bite
wounds, it may be diluted with sterile saline 2 or 3
fold for thorough infiltration
• Avoid multiple needle injections
• Can infiltrate RIG even if wound is infected
 RIG Guidelines

• RIG shall always be given in combination with rabies

vaccine
• If rig is unavailable when the first dose of vaccine is
injected. It may be given until 7 days after the first
dose of the vaccine. Beyond day 7,RIG is no longer
indicated because an active AB response to rabies
vaccine has already started.
• In the event that RIG and vaccine cannot be given on
the same day, the vaccine shall be given before RIG
 Types of Rabies Vaccine

Generic Name Preparation Dosage

Purified Vero 0.5ml/vial ID – 0.1ml
cell Rabies IM – 0.5ml
Vaccine (PVRV)
Purified chick 1.0ml/vial ID – 0.1ml
embryo cell IM – 1.0ml
vaccine
(PCECV)
 PEP regimens- IM

IM Day 0 Day 3 Day 7 Day Day Day

14 21 28
5 dose
IM
4
dose
IM
2-1-1
dose
IM
 PEP Regimens - ID

ID Day 0 Day 3 Day 7 Day 28

OLD

New
(PQ)
 Guidelines

• Initiation of PEP shall not be delayed for any reason

regardless of interval between exposure and
consultation
• Immuno compromised individuals should be given
vaccine using either IM or ID regimen and RIG for
both Category II and III exposures.
• Patients with hematologic conditions where IM
injections are contraindicated, should receive rabies
vaccine via ID route.
 Guidelines

• Delay in consult
• Treat as if the exposure occurred recently
• If the biting animal has remained healthy and alive with no
signs of rabies until 14 days after the bite, no treatment is
needed.
• Babies born of rabid mothers shall be given rabies
vaccination and RIG as early as possible at birth
• Changes in the human rabies vaccine product during
the same PEP course if unavoidable are acceptable to
ensure PEP course completion. Restarting in not
necessary.
 Guidelines

• As much as possible, the initial regimen/route

should be completed. However, in unavoidable
circumstances, changes in route of administration
during PEP course is acceptable.
• There is no need to restart
• The schedule of the new regimen should be adapted
• Should a vaccine dose be delayed for any reason, the
PEP regimen should be resumed (not restarted)
• Patients with chronic liver disease and those taking
chloroquine and systemic steroids shall be given
standard IM regimens
 Guidelines

• Bite by other animals other than dogs/cats

• NO PEP – rodents, rabbits and guinea pigs. Anti
tetanus prophylaxis should be given.
• GIVE PEP
• Other domestic – cattle, pigs, horses etc
• Monkeys, bats, and other wild animals
 PEP for Previously Immunized Patients

2018 Guidelines PrEP/PEP History Give RIG MANAGEMENT

PrEP/PEP History
Patient received the complete Prep prophylaxis on (Days 0,
Give RIG MANAGEMENT
(Regardless of type of TCV7)
and route of
administration in previous PrEP/PEP Determine if high or low
No
OR risk bite
Patient received the complete pre-exposure Give 0.1ml ID dose at 1 site eaxh on D0
prophylaxis on Days 0,7and 21/28 using TCV and D3
Patient received at least Day 0 and Day 3 of PEP ID/IM
OR No OR
Patient received the complete Prep prophylaxis on (Days 0,
7) 0,3,7
Patient received at least Days OR of ID/IM dose 1 vial IM dose at 1 site each on D0 and
using TCVs D3
Patient received at least Day 0 and Day 3 of PEP ID/IM Give if
Patient did not complete the 3 doses of PrEP Give full course of PEP
indicated
OR AND
Give if indicated Give full course of PEP
Patient
Patient received is1immunocompromised
only or 2 ID/IM dose of the PEP

Patient did not complete Prep

OR YES, if indicated Give full course of PEP

Patient received only 1 dose of PEP

2018 New Guidelines on the Management of Rabies Exposures AO 2018-0013
PEP of Previously Immunized Animal Bite
Patients
RISK OF CRITERIA RECOMMENDATI
EXPOSURE ON
HIGH risk Any one of the following: Immediate
Biting animal cannot be observed, dies or is Provide booster
sick injection
Bite site is highly innervated parts of the body:
neck, head, genital area, hands and toes
Multiple deep bites
Patient from GIDA ( area of infrequent
transportation)
* Geographically isolated and disadvantaged
areas
LOW risk Last dose within 3 months AND Observe biting
Biting animal is healthy , owned, kept animal for 14 days
AND ANY ONE OF THE FOLLOWING: If animal remains
1. Biting animal is same animal at bit healthy, withhold
patient previously or booster
2. Biting animal previously immunized
or
3. Bite is on the proximal extremity
2018 New Guidelines on the Management of Rabies Exposures AO 2018-0013
 Pre exposure Prophylaxis

• Given prior to exposure

• Benefits
• The need for RIG is eliminated
• PEP vaccine regimen is reduced from 5 to 2 doses
• Protection against rabies is possible if PEP is delayed
• The cost of PEP is reduced
 Pre exposure Prophylaxis

• Target Population
• Personnel in rabies diagnostic or research laboratories
• Veterinarians and veterinary students
• Animal Handlers
• HCW directly involved in care of rabies patients
• Individuals directly involved in rabies control
• Field workers
 PrEP Regimens

Immuno- Day 0 Day 7 Day

competent 21/28
OLD
IM – 1 site
ID – 1 site
NEW
IM – 1 site
ID – 2 sites
 PrEp Regimens

Immuno- Day 0 Day 7 Day

compromised 21/28
OLD
IM – 1 site
NEW
IM – 1 site
ID – 2 sites
 Routine Booster Dose

• Indicated for Individuals with continuous and

frequent risk
• Booster 1 year after PreP
• Serologic testing every 6 months to 2 years
• Booster if Ab <0.5 iu/ml
• Not indicated for general population in the absence
of exposure
Thank You!!