RABIES

INTRODUCTION

Rabies or hydrophobia is an

acute, highly fatal viral disease of the central nervous system, caused by Lyssavirus

DEFINITION

In India, about 15 million people are bitten by animals

In india 25,000–30,000 human deaths from rabies annually.

INCIDENCE

Lyssavirus is a bullet shaped RNA virus. It belongs to the family rabdoviridae

AGENT FACTORS

Lassa virus

3 epidemiological forms

1. Urban rabies

2.Wild life rabies

3.Bat rabies

RESERVOIRS OF INFECTION

The transfer of infection from wild life to domestic dogs

results in the creation of urban cycle and is responsible for 99% of human cases in India

Urban rabies

The wild life is perpetuated by the jackal, fox and other

wild life carriers.

Wild life rabies

In Latin American countries and U.S.A vampire

bat is an important host and vector of rabies

Bat rabies

Source of infection to man is the saliva of rabid animal. In dogs and cats, the virus may be present in the saliva for 3-4 days before the onset of clinical symptoms and during the course of

illness till death.

SOURCE OF INFECTION

All warm blooded animals including man are susceptible to rabies. Laboratory staff working with rabies virus, veterinarians, dog handlers, hunters faces higher risk of rabies than general public.

HOST FACTORS

1.Animal bites

2.Licks

3.Aerosols

4.Person-to-person

MODE OF TRANSMISSION

In India most of the human rabies cases have resulted

from dog-bites. Transmission to man is particularly through rabid dog bites. As a prerequisite for transmission, the saliva of the dog must contain the virus at the time of bite. It may also occur from other animals beside dog like cat, sheep, goat, monkey, horse.

 

Animal bites

Dogs have the habit of licking.

Licks on abraded skin and mucosa can transmit the disease.

Licks

Aerosol or respiratory transmission is found only in

certain caves harbouring rabies infected bats.

Aerosols

Man to man transmission, although rare is possible.

A case of a child biting his parent is in record

There is also reports of transmission of rabies by corneal and organ transplants.

Person-to-person

3-8 weeks The incubation period in man is highly

variable, commonly 3-8 weeks, but may vary from 4 days to many years.

INCUBATION PERIOD

Bite

Entry of rabies virus in man

Virus replicate in muscle or connective tissue cells at the site of introduction

Virus attaches to nerve endings

PATHOPHYSIOLOGY

Enters peripheral nerves

Spreads centripetally via peripheral nerves towards CNS

Infects CNS

Virus spreads centrifugally in peripheral nerves to many tissues

Invades skeletal, myocardial muscle, adrenal glands, skin

Contd..

Duration of illness 2-3 days rarely 5-6 days PRODROMAL SYMPTOMS Headache Malaise Sore throat Slight fever lasting for 3-4 days Pain and tingling at the site of bite

CLINICAL FEATURES

widespread excitation and stimulation of all parts of nervous

system

1. Intolerance to noise2. Intolerance to bright light3. Intolerance to cold draught of air4. Aerophobia5. Increased reflexes6. Muscle spasms7. Dilatation of pupils 8. Increased perspiration

SPECIFIC SYMPTOMS

1. Salivation2. Lacrimation3. Mental changes due to fear of death, anger, irritability

and depression4. Symptoms progressively aggravate 5. All attempts at swallowing liquid become unsuccessful6. Mere sight or sound of water provoke spasm of

muscles of deglutination- hydrophobia7. Patient may die abruptly during one of the convulsion

or may pass on to the stage of paralysis or coma

Contd…

History of bite by a rabid animal Signs and symptoms Detection of rabies antigen Using immunofluroscence of skin biopsy Virus neutralizing antibodies appear in CSF

and serum after 7-10 days of illness Virus isolation from saliva, CSF and other

secretions

DIAGNOSIS

Nervous tissue vaccines Duck embryo vaccine Cell culture vaccines Human diploid cell vaccine (HDCV) Non- human origin-second generation vaccines

TREATMENT

Intramuscular schedule

 

VACCINE ADMINISTRATION

Schedule consist of 6 doses (1 ml each) on days 0, 3,7,14 and 28 and a booster dose on day 90.

Injections are given IM on deltoid and must not be given to buttocks

Dose: one dose, IM dose into deltoid (1ml)

Day 0 3 7 14 28

2 site ID method

0.5 ml of Purified Vero Cell Vaccine (PVRV) 1 ml of Purified Chick Embryo Cell Vaccine (PCECV) 1 ml of Purified Duck Embryo Vaccine (PDEV) Volume of ID dose is one-fifth of IM dose per site. ie if IM dose is 0.5 ml, ID dose is 0.1 ml.

Dose: 1, ID dose = one fifth of IM dose

Day 0 3 7 28 90

Sites X2 X2 X2 X1 X1

Intradermal schedule

8 site ID method

Human Diploid Cell Vaccine (HDCV) and Purified Chick Embryo Cell Vaccine (PCECV) On day 0--- 0.1 ml of reconstituted vaccine is given at each of 8 sites. Sites are deltoid, lateral thigh, supra scapular region and lower quadrant of abdomen On day 7--- 0.1 ml of vaccine is given at each of 4 sites over deltoid and thighs. On days 28 and 90--- 0.1 ml of vaccine is given at one site, over deltoid

Dose 0.1ml ID per site

Day 0 7 28 90

Sites X8 X4 X1 X1

8 site ID method

The patient should be isolated in quiet room protected as far

as possible from external stimuli such as bright light, noise or cold draughts which may precipitate spasms or convulsions

Relieve anxiety and pain by liberal use of sedatives. Ensure hydration and diuresis Intensive therapy in the form of respiratory and cardiac

support may be given Nursing personnel attending rabid patient should be warned

against possible risk of contamination and should wear face masks, gloves, goggles and aprons to protect themselves

Pre- exposure prophylaxis with 2-3 doses of HDC vaccine is reco

GENERAL MANAGEMENT

POST- EXPOSURE PROPHYLAXIS Local treatment of wound 1. Cleansing 2. Chemical treatment 3. Suturing 4. Anti rabies serum 5. Antibiotics and anti tetanus measure 6. Observe the animal for 10 days

PREVENTION

1. Horse anti rabies serum 2. Human rabies immunoglobulin

ANTI RABIES SERUM

laboratory staff working with rabies virus,

veterinarians, animal handlers and wild- life officers

1ml cell culture vaccine, IM on days 0, 7 and 28

PRE-EXPOSURE PROPHYLAXIS

1 ml, IM doses of human diploid cell vaccine

on days 0, 3 and 7.

POST EXPOSURE PROPHYLAXIS

ASSESSMENT

ask for a history of bite by an animal - assess whether he has undergone immediate

prophylactic measures - assess for characteristics like photophobia,

hydrophobia etc - check for the presence of antigen

NURSING MANAGEMENT

1. Hyperthermia related to infectious

process as evidenced by elevated body temperature more than 100 degree farenheit

2. Acute pain related to tissue injury at the site of bite as evidenced by pain scale score more than 7

3. Fatigue related to bacterial invasion of central nervous system as evidenced by inability to perform ADLs

4. Risk for injury related to confusion

NURSING DIAGNOSIS

Malaria

Malaria is a protozoal disease caused by

infection with parasites of the genus Plasmodium and transmitted to man by infected female Anopheles mosquito

DEFINITION

Female anophelous mosquito

300-500 million clinical cases each year.

INCIDENCE

1. P.vivax,2. P. falciparum3. P. malariae,4. P. ovale.

AGENT FACTORS

Age- malaria affects all ages Gender- males are more frequently affected

because of the outdoor life they lead Pregnancy-pregnancy increases risk of malaria in

women. Malaria during pregnancy may cause intrauterine death of foetus, premature labour or abortion

Socio-economic development- poor socioeconomic status contributes to malaria

Occupation - It is predominantly a rural disease and is related to

HOST FACTORS

Season – it is a seasonal disease and has

maximum prevalence from July to November. Temperature – malarial parasite develops at the

temperature of 20-30 degree celcius Humidity – a relative humidity of 60% is

considered necessary for mosquitoes to live Rainfall – rainfall provides opportunities for

breeding of mosquitoes and increases epidemics Man-made malaria – burrow pits, garden pools,

irrigation channels, engineering projects led to breeding of mosquitoes.

ENVIRONMENTAL FACTORS

VECTOR TRANSMISSION DIRECT TRANSMISSION CONGENITAL MALARIA

MODE OF TRANSMISSION

Usually less than 10 days falciparum malaria it is 9-14days quarten malaria it is 18-40 days vivax it is 8-17 ovale it is 16-18

INCUBATION PERIOD

COLD STAGE HOT STAGE SWEATING STAGE

CLINICAL FEATURES

Demonstration of parasite in blood Dipstick (antigen capture) assay for detection

of plasmodium falciparum

DIAGNOSIS

Presumptive Treatment Radical Treatment Treatment of resistant infection Severe and Complicated Malaria

NURSING DIAGNOSIS 1. Acute pain related to inflammatory

process as evidenced by pain scale score above 7

2. Hyperthermia related to infectious process as evidenced by elevated body temperature

3. Fatigue related to bacterial invasion as evidenced by inability to perform ADLs

NURSING MANAGEMENT

EVIDENCE BASED PRACTICE

SUMMARY

CONCLUSION

BIBLIOGRAPHY

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