RABIES…when “man’s best friend” betrays.

Top 10 1987-2007

1 INDIA 244478

2 BANGLADESH 22900

3 CHINA 13995

4 PHILIPPINES 5658

5 VIET NAM 5183

6 PAKISTAN 2843

7 SRI LANKA 2042

8 MYANMAR 1683

9 THAILAND 1377

10 INDONESIA 1208

WHO 2008

RABIES Defined

• a zoonotic disease that is caused by rhabdovirus.

• a disease that causes acute encephalitis in warm-blooded animals.

The Culprit: RHABDOVIRUS• Thought to be the origin of

vampire legends (bats, biting, hypersexuality)

• Commonly known as rabies virus

• a virus that attacks the central nervous system of warm-blooded animals (only mammals, including human)

• From Lyssavirus genus• length =180 nm;• cross-section = 75 nm• Enveloped, single stranded,

RNA

Rabies Reservoirs

• Racoon

• Red fox • Striped skunk

• Silvertailed bat

• Dogs • Cats

• Men

Rabies Reservoirs

Mode of Transmission

• Bite of infected animals through the skin and mucous membrane

• Licking of infected animals to damaged mucous membrane

• Aerosol transmission (bat)

Incubation Period

• Incubation period varies from 2 weeks to a year (depends on how large the infecting dose and how fast).

• The virus travels to the CNS:– human - 10 days - 1 year (most cases

occurring 20 - 90 days after exposure)– Bite occurring in the head, neck &

upper extremity IP < 30 days.• Animal are infectious only weeks

before they die

Nursing Care: Post-Exposure Wound Care

• Prompt and thorough cleaning: flush wound with soap and water

• Benzalkonium chloride not superior to soap

• Update tetanus immunization

• Treat secondary bacterial infection

• Do not suture wound if possible

Signs and Symptoms

• Early-stage: flu-like– Fever– Headache

• 2nd stage:– Malaise– Acute pain– Violent movements– Uncontrolled excitement– Depression– Hydrophobia

Signs and Symptoms

• Critical stage– Paranoia– Terror– Hallucinations progressing to delirium – signs of hyperactivity (furious rabies)– paralysis (dumb rabies) to complete paralysis– coma and death in all cases (due to breathing

failure)

Clinical Manifestations

• Fever • Nuchal rigidity • Paresthesia• Fasiculations• Convulsions • Hypersalivation • Hyperventilation

Laboratory Diagnosis

• Direct microscopic demonstrate of virus antigen by: Direct immunofluorescence staining detect virus in brain tissue and corneal scrapings.

• Brain biopsy histologic staining of brain tissue (seller stain).

Laboratory Diagnosis

• Animal inoculation tissue or saliva inoculated intracerebral into mice– presence of rabies virus is indicated by

1. flaccid paralysis of leg2. encephalitis3. death

• Serological– detect rabies antibodies by

1. Immunofluorescence test2. Complement fixation test 3. Neutralization test

• Antibodies are developed during progression of the disease.

Prevention• Rabies control

– Eliminate rabies from hosts/victims

• Oral baits w/antivirus.

– Has been effective (Europe, Canada).

– Slowed potential outbreak in Ohio raccoons.

– Used in Texas for coyotes & foxes.

• Trap/vaccinate/release (TVR)

– Effective in Canada raccoons.

– Often combined with oral baits.

• Control measures against canine;– stray dog control.– vaccination of dogs. – quarantine of

imported animals.• Wildlife - Rabies in wild

animals is much more difficult to control than canine rabies. However, on-going trials in in the USA and Europe using bait containing rabies vaccine given to foxes and raccoons reduces rabies levels.

Prevention

• Pre-exposure prophylaxis: vaccination of people in high risk groups: – Veterinarians– Animal handlers– Certain lab

workers– Travel to areas

where canine rabies is common

Prevention

Milwaukee Protocol

• Basic treatment– Assure airway– External cardiac pacing wires– Maintain central venous pressure– Nasojejunal (NJT) feeding– Heparin prophylaxis– Physical therapy– Prophylactic supplementation of cofactor

deficiencies

• Sedation– Deep sedation-anesthesia

• Ketamine• Diazepam or alprazolam

– Continuous EEG monitoring

Milwaukee Protocol

• Antiviral treatment– Avoid ARV after onset of clinical symptoms– Avoid ARIG and IFNα– Ribavirin no longer recommended– Amantadine per NJT– Monitor rabies titer

• CSF assay q7d• Saliva & serum assays q2d

Milwaukee Protocol

Rabies Survivor:the ‘Medical Marvel’

Jeanna Giese

-18 years old

-one-of-a-kind case: She survived rabies without vaccination

Thank You! :D

Ameril, Hayma M.