vaxirab cme slides - english

Dangerous zoonotic disease caused by Lyssavirus type 1.

One of the oldest diseases known to mankind.

Known before 2300 BC.

Latin word “rabies” originated from Sanskrit word “Rabhas”- to do violence.

100 % fatality rate.

RABIES – An Introduction

RABIES VIRUS

Bullet Shaped enveloped Virus belongs to Mononegavirales order, Rhabhoviridae & Lyssavirus genus.

Measures 75 nm X 100 - 300 nm.

Spikes are 10 nm long & the virus moves at speed of 3 mm/ hr.

Numerous spikes present on the envelope, these are made up of glycoprotein.

Glycoprotein (G) necessary for viral attachment & also induce protective antibodies.

Other viral proteins are Nucleoprotein (N), Phosphoprotein (P), matrix protein (M) & Polymerase (L)

Human rabies is mostly confined to some countries in Asia and Africa. The Indian Sub continent account for 80% of the Global human deaths due to Rabies.

No age or sex predilections (higher incidence among children and adult Males).

EPIDEMIOLOGY

RABIES – Indian Scenario

Highest number of victims from India

(> 17,000 deaths annually).

At least 1 –1.5 million people reported to receive PET annually.

Dogs constitute nearly 96% of source of infection to human beings (Around 25 million street dogs in India).

Reported from all areas except Andaman, Nicobar and Lakshadweep Islands.

APCRI 2003

COMMON MODES OF TRANSMISSIONANIMAL BITES: Dogs, Cats, Monkey, Horse, Sheep and

Goat.LICKS: Licks, Scratch and Bites.

RARE MODES OF TRANSMISSIONAEROSOLS: Respiratory aerosol transmission can occur.HUMAN: Man to man transmission. Corneal & Organ

transplants.

Ref:Park text book of preventive medicine - 17th Edition

MODES OF TRANSMISSION

Animals transmitting the disease in India

Frequently

Dogs & cats

RESERVOIR of INFECTION

Sometimes

Monkeys

Horses

Foxes

Cows & Buffaloes

Donkeys

Pigs

Sheep



Occasionally

Camels

Mongoose

Jackals

Bears

Other wild animals



Not reported

Bats

House Rats

Mice

Birds



3 weeks - 3 months (in > 85% cases).

Ranges between 4 days to 4 years.

Bites on the head or face - upto 1 month.

Bites on the extremities - upto 3 months.

Commonly

INCUBATION PEROID

Multiplication locally(in the muscle fibres)

Peripheral nerves

Dorsal root ganglia

Spinal cord

Brain

A rabid animal bites the victim, introducing virus A rabid animal bites the victim, introducing virus from the saliva into the muscle tissue.from the saliva into the muscle tissue.Virus grows in the muscle tissue in the Virus grows in the muscle tissue in the area of the bite.area of the bite.Virus infects the sensory and motor Virus infects the sensory and motor nerves serving the infected muscle.nerves serving the infected muscle.Virus travels from peripheral nerves to Virus travels from peripheral nerves to the central nervous system.the central nervous system.Virus migrates throughout the central Virus migrates throughout the central nervous system, arriving at the brain.nervous system, arriving at the brain.Virus is conducted by nerves to the salivary Virus is conducted by nerves to the salivary gland, where it grows, then is shed in saliva.gland, where it grows, then is shed in saliva.

PATHOGENESIS OF RABIES

Minimal Pathological changes

Grossly - Brain is oedematous, congested

Histopathologically - Perivascular cuffing, Gliosis

Minimal Neuronal Damage (Necrosis)

Presence of Negri bodies (Pathognomonic)

PATHOLOGY

Furious Type (80%) Paralytic Type (20%)

Tingling / numbness at bite site Tingling / numbness at bite site

Non specific symptoms Non specific symptoms(Fever, malaise, headache,etc.) (Fever, malaise, headache etc.)

Hydrophobia, Aerophobia Ascending Paralysis

Photophobia Coma

Death (cardio respiratory failure) Death (cardio respiratory failure)

Survival : 3 – 5 Days Survival : 7 – 21 Days

CLINICAL MANIFESTATION IN HUMANS

Category Type of contact with a suspect Recommended Treatment or confirmed rabid domestic or

wild animal, or animal unavailable

for observation

I Touching or feeding of animals None, if reliable case history

Licks on intact skin is available.

II Nibbling of uncovered skin Administer vaccine immediately

Minor scratches or abrasions Stop treatment if animal remains

without bleeding. healthy throughout an observation

Licks on broken skin. period of 10 days or if animal is euthanised and found to be negative

by appropriate laboratory techniques.

WHO Guidelines for Post exposure Prophylaxis

Category Type of contact with a suspect Recommended Treatment or confirmed rabid domestic or

wild animal, or animal unavailable

for observation

III Single or multiple transdermal bites or Administer rabies immunoglobulin

scratches.

and vaccine immediately. Contamination of mucous membrane Stop

treatment if animal remain healthy

with saliva (i.e. licks) throughout an observation period of

10 days or if animal is killed humanely and

found to be negative for rabies by

appropriate laboratory techniques.

WHO Classification of BiteGuide for Post-Exposure Treatment (Cont’d)

PRINCIPLES OF TREATMENT

Wound Treatment

Anti - Rabies Immunization

Active Immunization: Administration of antirabies vaccine.

Passive Immunization: Administration of rabies immunoglobulin (in Category III exposures).

Any change in behaviour - undue aggression/depression.

Running aimlessly and attacking others without any provocation.

Becomes too drowsy and withdraws itself to a corner.

Excessive Salivation.

Change in voice.

Refusal to feed or eating unusual objects like stones, papers, wood, metal pieces etc.

Death of animal.

SIGNS OF RABIES in DOGS/CATS DURING 10 DAY OBSERVATION PERIOD

Do’s

Wash under Running tap waterSoap (Preferably detergent)

Disinfectants - Povidone Iodine, Spirit, household antiseptics

Note:

Suturing only if required (1 - 2 loose sutures) and only after administration of RIGs.

Don’ts

Apply Irritants

Cauterize

WOUND TREATMENT

Points to remember

Day 0 (D0) - Day of 1st dose of vaccine given, not the day of bite.

All modern ANTI RABIES Vaccines are equally effective and safe.

Never inject the vaccines into the gluteal region.

Interchange of vaccines acceptable in special circumstances but not to be done routinely.

Reconstituted vaccine to be used immediately.

Vaccine dosage is same for all age groups.

POST EXPOSURE PROPHYLAXIS

CLASSIFICATION OF RABIES VACCINES

Can be classified as

Nerve Tissue Vaccines (NTVs)e.g. Semple vaccine

New Generation Vaccines Purified Duck Embryo Vaccine (PDEV) Purified Chick Embryo Vaccine (PCEV) Purified Vero Cell Vaccine (PVRV)

Liquid Human Diploid Cell Vaccine (HDCV)

PDEV – Purified Duck Embryo Vaccine

Highly purified innovative rabies vaccine developed in virus grown in specific pathogen free (SPF) duck eggs.

Introduced in 1985. Millions of doses administered around the world successfully.

Patented method developed with technical collaboration of world renowned Berna Biotech, Switzerland (earlier known as Swiss Serum Institute) - European leaders in sera & vaccines.

Well appreciated in many international publications.

Composition of VaxiRab

Each vial containsInactivated purified rabies virus

Potency >2.5 IU

Lyophilized powder For one immunizing dose (1 ml)

Viral Strain

and

Inactivation

Pitman Moore strain propagated in duck embryo

Beta propiolactone inactivation

Stabilizer (1 dose) Gelatin, L-cystine HCl, 0.1 mg Thiomersal q.s

Solvent Water for Injection

The antigenic value of the reconstituted 1 ml dose is not less than 2.5 IU as per WHO recommendations

VaxiRab – Unique Features

Inactivated Rabies virus - Pitman Moore strain.

Highly purified viral antigen ensures high G - protein content.

Intact, inactivated rabies virions for better immunogenicity.

High content of N protein for enhancing protective activity of vaccine.

Design

Open-label, non-comparative multicentric

trial in post-exposure animal bite cases

Number of subjects

150

Age Group

Between 5 - 60 years (either sex)

Category of exposure

WHO Category II or III

Trial DesignTrial Design

10.00

15.87

9.83

5.77

1.33

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

Day 14 Day 30 Day 90 Day 180 Day 365

GEOMETRIC MEAN TITRE IU/mLGEOMETRIC MEAN TITRE IU/mL

0.50.5

GMT on Day 14, 30, 90, 180 and 365

Note - Rabies vaccine must never be given in gluteal region.

Pre Exposure Prophylaxis

0 7 21/28

Post Exposure Prophylaxis

0 3 7 14 28

Re Exposure Prophylaxis

0 3

PASSIVE IMMUNIZATION

RIG is indicated as per WHO recommendations in all category III exposures

• According to the WHO grade III bite is defined as a single or multiple transdermal bites or scratches. Contamination of mucous membrane with saliva of animal i.e licks

PASSIVE IMMUNIZATION

Equine antirabies

immunoglubulin (ERIG)

Human antirabies

immunoglubulin (HRIG)

40IU/Kg 20IU/Kg

RABIES IMMUNOGLOBULINs (RIG)

ERIG must be administered only after the Test dose

Severe Class III exposures, Sutured wounds

Proven rabid animal exposures

Exposure in immune compromised persons

Pregnancy and Lactation

Extremes of age

SPECIAL SITUATIONS

Persons on:AntimalarialsSteroidsAnticancer drugs

HIV/AIDS Malnourishment

Wound Toilet and RIGs are lifesaving, specially in situations where the immune response is doubtful.

BITES IN IMMUNE COMPROMISED PERSONS

NOT a Contraindication

Routine schedule

Routine dose

MTP is not indicated

PREGNANCY AND LACTATION

Bites on the Head, Face, Hands, Genitalia Multiple bites Extensive lacerations Bites by

– proven rabid animals– animals not available for observation– more than one animal – wild animals

SEVERE EXPOSURES

Get the pet regularly examined.

Get the pet vaccinated at three months of age and again

one month later, boosters must be given every year

subsequently.

Obtain a municipal license, put a collar and leash.

Do not allow the pet to come in contact with stray dogs/ cats

or other animals.

Ensure removal of stray dogs / animals.

ADVICE TO PET OWNERS

Do not touch animal bite wounds with bare hands.

Do not touch fomites (chain, food plates etc.) of an animal

suspect or proven rabid.

Do not touch stray / sick animals.

Do not stare at or provoke any animal.

Take pre-exposure vaccination if you are in constant touch

with animals.

Avoid contact with saliva, urine, tears and other secretions

of a patient of hydrophobia.

PERSONAL SAFETY

No dietary restriction.

No restriction of physical exercise.

Avoid immunosuppressants:

(Steroids, anti-malarials).

Avoid alcohol consumption.

Complete the course of vaccine.

MEDICAL ADVICE TO VACINEES

vaxirab cme slides - english

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