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RABIES

INFECTIOUS AND TROPICAL DISEASE DIVISION

DEPARTMENT OF PEDIATRICS

FACULTY OF MEDICINE

UNIVERSITY OF NORTH SUMATERA

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ConclusionsChocolate consumption enhances

cognitive function, which is a sinequa non for winning the NobelPrize, and it is closely correlatedwith the number of Nobellaureates in each country.

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RABIES VIRUS

Rabies virus is a member of the genus Lyssavirus in the family

Rhabdoviridae. The viruses are bullet shape with 10-nm spike

like glycoprotein peplomers covering the surface.

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Rabies is spread to people through close contact with infected

saliva via bites or scratches.

Though transmission has been rarely documented via other

routes such as contamination of mucous membranes (i.e. eyes,

nose, mouth), aerosol transmission, and corneal and organ

transplantations.

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RABIES

Rabies is a zoonotic disease (a disease that is transmitted from

animals to humans) that is caused by a virus.

All species of mammals are susceptible to rabies virus infection,but only a few species are important as reservoirs of the disease.

Domestic dogs, cats, cattle, foxes, raccoons, bats, ferrets,

skunks.

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INCUBATION PERIOD

The incubation period is typically 1 3 months, but may vary

from < 1 week to > 1 year.

Incubation period is shorter in children, and the nearer the bite isto the head the shorter the incubation period.

It also depends on the severity of wound.

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RESPONSE TO INFECTION

Following a rabid bite, no immune response is detectable in

unvaccinated subjects before encephalitis has developed.

Rabies antibody is found in serum, then in CSF at least a week

after the onset.Pleocytosis is observed in only 60% of patients.

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SYMPTOMS

Prodromal Symptoms

Itching or paraesthesiae at the site of the healed bite wound in 40% ofpatients

Nonspecific symptoms including fever, headache, myalgia, fatigue, sore

throat, gastrointestinal symptoms, irritability, anxiety and insomnia.The disease progresses within 1 week.

Common Symptoms

1. Itching at the healed bite wound

2. Hydrophobic spasms

3. Aerophobia

4. Feeling of terror

5. Aggression

6. Hypersalivation

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FURIOUS VS PARALYTIC

Furious (Encephalitic) Rabies

Occurred in 80% of cases.

Fever, confusion, hallucinations, combativeness, muscle spasms,

hyperactivity and seizures.

Autonomic dysfunction including hypersalivation, excessive

perspiration, gooseflesh, pupillary dilation and/or priapism.

Hydrophobia and aerophobia: involuntary, painful contraction of

the diaphragm and accessory respiratory, laryngeal andpharyngeal muscles in response to swallowing liquids

(hydrophobia) or a draft of air (aerophobia).

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Hypersalivation and pharyngeal dysfunction resulted in

appearance offoaming at the mouth

Episodes ofexcitation, aggression, anxiety or hallucinations

interspersed with periods of calm lucidity.Cranial nerve lesions (III, VII and IX)

Coma followed withing days by death.

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FURIOUS VS PARALYTIC

Paralytic (Dumb) Rabies

Less common.

Prodromal symptoms are followed by paraesthesiae or

hypotonic weakness.

Started near the site of the bite and spreading cranially.

Ascending paralysis results in constipation, urinary retention,

respiratory failure and inability to swallow.

Hydrophobic spasms may occur in terminal phase and death

after 1-3 weeks.

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DIFFERENTIAL DIAGNOSIS

Tetanus

Intoxication

GuillainBarre syndrome

Other viral encephalomyelitides

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DIAGNOSIS

Laboratory is usually normal initially.

Complete blood counts are usually normal.

CSF may reveals mild mononuclear cell pleocytosis, with a mildly

elevated protein level.

Diagnostic useful specimens: serum, CSF, fresh saliva, braintissue, skin biopsy from the neck (must include at least 10 hairfollicles)

Rabies virus-specific antibodies

RT-PCR

DFA

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BITE AND SCRATCH WOUND

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LOCAL TREATMENT

Prompt local treatment of all bite wounds and scratches.

Immediate and thorough flushing and washing of the wound for

a minimum of 15 minutes with soap and water, or detergent.

Followed by application of 70% ethanol or povidone-iodinesolution.

The wound closure, if possible, should not be sutured.

Tetanus toxoid and antibiotics for other infection (if needed).

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CATEGORIES OF

CONTACT AND RECOMMENDED PEP

Categories of contact withsuspected rabid animal

Post-exposure prophylaxis measures

Category ITouching or feeding animals, licks of

intact skin

None

Category IINibbling of uncovered skin, minorscratches or abrasions withoutbleeding

Immediate vaccination and localtreatment of the wound

Category IIISingle or multiple transdermal bites orscratches, licks on broken skin;contamination of mucous membranewith saliva from licks, contacts withbats

Immediate vaccination andadministration of rabiesimmunoglobulin; local treatment ofthe wound

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History of animal bite (dog, cat, monkey)

Animal is missing or death Animal can be observed for 10-14 days

High riskwound

Low riskwound

Give Rabiesvaccine &

Rabies IG

Give Rabiesvaccine

Check the specimen ofanimal brain

Positive Negative

Continuevaccine

Stopvaccine

If brain specimen is not

checked, continue vaccine

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History of animal bite (dog, cat, monkey)

Animal is missing or death Animal can be observed for 10-14 days

High riskwound

Low riskwound

Give Rabiesvaccine &

Rabies IG

Wait forthe

observation outcome

Animal ishealthy

Animaldied

Stopvaccine Continue vaccine

Animal ishealthy

Animaldied

Novaccine

Check the specimen ofanimal brain

Positive Negative

Continue vaccine Stop vaccine

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RABIES VACCINE &

IMMUNOGLOBULIN

WHO (Essen) Regimen

Day Rabies Vaccine Rabies Immunoglobulin

0 1 dose IM +

3 1 dose IM -

7 1 dose IM -

14 1 dose IM -

28 1 dose IM -

Day Rabies Vaccine Rabies Immunoglobulin

0 2 dose IM +

7 1 dose IM -

21 1 dose IM -

Zagreb Regimen

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RABIES VACCINE &

IMMUNOGLOBULIN

Rabies vaccine Purified vero cell vaccine (available in Indonesia as Verorab)Dose 0,5 mL IM on deltoideus muscle in adult or lateral thigh in children

Human diploid cell vaccine Purified chick embryo cell vaccineDose 0.5 mL IM on deltoideus muscle in adult or lateral thigh in children

Rabies ImmunoglobulinHuman rabies immunoglobulin; dose 20 IU/kg

Equine rabies immunoglobulin; dose 40 IU/kgHalf of the dose is given around the wound, and the other half is intramuscularlyinjected in different part from the vaccine.Should be given within 7 days after vaccination.

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PROGNOSIS

Wound cleansing and vaccination within a few hours after

contact with a suspect rabid animal can prevent the onset of

rabies and death.

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PROGNOSIS

Once a person exhibit signs of the disease, the person most

likely will die.

Less than 10 documented cases worldwide survive from clinicalrabies have been reported, and only 2 have not had a history of

pre- or postexposure prophylaxis.

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15-year-old girl in whom clinical rabies developed one month after she was bitten at herleft index finger by a bat. Rabies vaccine was not administered.Treatment including induction of coma with ketamine and midazolam was done, whilea native immune response matured. Ribavirin and amantadine were also added.Lumbal puncture after 8 days showed increased level of rabies antibody, and sedationwas tapered.Patient was removed from isolation after 31 days, and discharged after 76 days.After 5 months, she was alert and communicative, but with choreoathetosis,

dysarthria, and unsteady gait.

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RECOMMENDED READINGS

Rabies fact sheets. World Health Organization.http://www.who.int/mediacentre/factsheets/fs099/en/

Rabies. Centers for Disease Control and Prevention.http://www.cdc.gov/rabies/index.html

Warrell MJ. Rabies. In: Cook GC, Zumla A, eds. Mansons TropicalDiseases, 22nd ed.

Wiloughby Jr RE, Tieves KS, Hoffman GM, Ghanayem NS, Amlie-Lefond CM, Schwabe MJ, et al. Survival after treatment of rabies

with induction of coma. NEJM. 2005; 352:2508-14

http://www.who.int/mediacentre/factsheets/fs099/en/http://www.cdc.gov/rabies/index.htmlhttp://www.cdc.gov/rabies/index.htmlhttp://www.cdc.gov/rabies/index.htmlhttp://www.who.int/mediacentre/factsheets/fs099/en/http://www.who.int/mediacentre/factsheets/fs099/en/

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THANK YOU