VaxiRab CME Slides - English
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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
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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)
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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
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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
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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
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Animals transmitting the disease in India
Frequently
Dogs & cats
RESERVOIR of INFECTION
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Sometimes
Monkeys
Horses
Foxes
Cows & Buffaloes
Donkeys
Pigs
Sheep
Animals transmitting the disease in India
RESERVOIR of INFECTION
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Occasionally
Camels
Mongoose
Jackals
Bears
Other wild animals
RESERVOIR of INFECTION
Animals transmitting the disease in India
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Not reported
Bats
House Rats
Mice
Birds
Animals transmitting the disease in India
RESERVOIR of INFECTION
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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
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Multiplication locally(in the muscle fibres)
Peripheral nerves
Dorsal root ganglia
Spinal cord
Brain
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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
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Minimal Pathological changes
Grossly - Brain is oedematous, congested
Histopathologically - Perivascular cuffing, Gliosis
Minimal Neuronal Damage (Necrosis)
Presence of Negri bodies (Pathognomonic)
PATHOLOGY
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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
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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
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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)
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PRINCIPLES OF TREATMENT
Wound Treatment
Anti - Rabies Immunization
Active Immunization: Administration of antirabies vaccine.
Passive Immunization: Administration of rabies immunoglobulin (in Category III exposures).
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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
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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
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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
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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)
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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.
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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
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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.
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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
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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
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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
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PASSIVE IMMUNIZATION
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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
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Equine antirabies
immunoglubulin (ERIG)
Human antirabies
immunoglubulin (HRIG)
40IU/Kg 20IU/Kg
RABIES IMMUNOGLOBULINs (RIG)
ERIG must be administered only after the Test dose
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Severe Class III exposures, Sutured wounds
Proven rabid animal exposures
Exposure in immune compromised persons
Pregnancy and Lactation
Extremes of age
SPECIAL SITUATIONS
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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
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NOT a Contraindication
Routine schedule
Routine dose
MTP is not indicated
PREGNANCY AND LACTATION
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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
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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
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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
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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