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RABIES

RABIES. Dr. Ramakrishna HK MS, DNB, FMAS. Lakshmi Nursing Home New Bridge Road Bhadravathi swarama@hotmail.com : 94486 67653. Meaning. Sanskrit Word RABHAS = VIOLENT. The Virus. A zoonotic disease Neurotrophic Rhabdovirus (bullet shaped virus). Introduction.

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RABIES

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  1. RABIES Dr. Ramakrishna HK MS, DNB, FMAS. Lakshmi Nursing Home New Bridge Road Bhadravathi swarama@hotmail.com : 94486 67653 Dr. Ramakrishna HK Rabies

  2. Meaning Sanskrit Word RABHAS = VIOLENT Dr. Ramakrishna HK Rabies

  3. The Virus • A zoonotic disease • Neurotrophic • Rhabdovirus (bullet shaped virus) Dr. Ramakrishna HK Rabies

  4. Introduction • Only disease with 100% mortality • Incidence maximum in India (36% of world) • Causes of high mortality Ignorance Non availability of vaccine Cost of treatment Dr. Ramakrishna HK Rabies

  5. Dr. Ramakrishna HK Rabies

  6. Reservoir for Virus • Dog: 90% cases • Others: cat, other domestic animals and wild animals • Transmitted by bites and licks mainly Person to person Aerosol Dr. Ramakrishna HK Rabies

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  10. At risk • All worm blooded animals • Persons working in laboratory with rabies virus, veterinarians, dog handlers, hunters, naturalists, forest deportment workers etc… Dr. Ramakrishna HK Rabies

  11. Pathogenesis • Virus multiplies near the bite site • Enters peripheral nerves • Ascends to CNS • Spreads centrifugally in peripheral and autonomic nerves • Involves the organs: Salivary gland, myocardium, adrenal etc… Dr. Ramakrishna HK Rabies

  12. Clinical Feature • Incubation period: Long and variable 1 week to many years: Usually 3-8 weeks • Depends on many factors Site, severity, number of wounds, amount of virus injected, species of animal, clothing, treatment etc… Dr. Ramakrishna HK Rabies

  13. Initial Symptoms • Prodromal symptoms: Head ache, malaise, sore throat, fever etc… • Specific: Tingling or pain at the site of bite • Excitation & Stimulation: All parts of NS Dr. Ramakrishna HK Rabies

  14. Later Phases • Aerophobia • Hydrophobia • Intolerant to noise, light • Violent spasms of pharyngeal and neck muscles Dr. Ramakrishna HK Rabies

  15. Examination • Increased reflexes • Dilatation of pupils • Increased perspiration • Increased salivation • Lacrimation • FEAR OF DEATH, anger, irritability depression Dr. Ramakrishna HK Rabies

  16. Duration of illness • Usually 2 – 3 days • May be prolonged 5 – 6 days • Death: Convulsion or paralysis, coma Dr. Ramakrishna HK Rabies

  17. Diagnosis • H/O animal bite • Pain at bite site • Hydrophobia • Aerophobia • Confirmation: Skin biopsy (Immunoflorescence for antigen) Virus isolation in saliva Dr. Ramakrishna HK Rabies

  18. Treatment • First Aid • Active immunization • Passive immunization Dr. Ramakrishna HK Rabies

  19. WHO Recommendations Dr. Ramakrishna HK Rabies

  20. Dr. Ramakrishna HK Rabies

  21. First Aid • Wash: Copious amount of running water • Mild soap • Ethanol or iodine solution • Avoid suturing: If must, infiltrate with RIG Dr. Ramakrishna HK Rabies

  22. Active Immunization: • VACCINE: Intra deltoid: Anterolateral thigh • Nervous tissue based vaccines are no more used • Vaccine: Cell culture is the best VERO CELL CULTURE Dr. Ramakrishna HK Rabies

  23. WHO Schedule • 0, 3, 7, 14, 28 • 90 optional • Should not overlap antimalarial treatment • Serum antibody titre > 0.5 IU/ml Dr. Ramakrishna HK Rabies

  24. Passive Immunization Dr. Ramakrishna HK Rabies

  25. RABIES IMMUNOGLOBULINS • Passive Immunization • Neutralize virus on contact • Gives a coating to the virus so that it cannot enter the nerve ending Dr. Ramakrishna HK Rabies

  26. TYPES • Human Rabies Immunoglobulin (HRIG) • Equine Rabies Immunoglobulin (ERIG) Dr. Ramakrishna HK Rabies

  27. HUMAN RABIES IMMUNOGLOBULINS • Immunoglobulins mainly IgG obtained from plasma or serum of donors immunized against rabies • Plasma pooled from more than 1000 donors – previously immunized. • Passive protection immediately Dr. Ramakrishna HK Rabies

  28. HRIG: Advantages • Purity • Minimal or no foreign protein • Minimal risk of hypersensitivity • Negligible side effects Dr. Ramakrishna HK Rabies

  29. HRIG : Disadvantages • Expensive • Risk of viral agents – (HIV, Hepatitis-B, Hepatitis-C) • Shortage because of low yield Dr. Ramakrishna HK Rabies

  30. EQUINE RABIES IMMUNOGLOBULINS • Immunizing horses with rabies vaccines • Serum processed by modern automated ultra filtration technology • Contains purified antibodies against Rabies Dr. Ramakrishna HK Rabies

  31. ERIG: Advantages • Massive Yield • Low cost • Widely available • Modern purification and ultra filtration technologies has made it safer. Dr. Ramakrishna HK Rabies

  32. ERIG: Disadvantages Presence of foreign protein Risk of immediate hypersensitivity Dr. Ramakrishna HK Rabies

  33. INDICATIONS FOR RIG • Category III bites (WHO classification) • Licks on mucous membranes by wild or pet animals • AIDS : Category II & III bites • Varicella (Chicken pox) Dr. Ramakrishna HK Rabies

  34. INDICATIONS FOR RIG Cont’d 5. Long term Corticosteroids 6. Long term Chemotherapy 7. Radiation Therapy 8. Wound suturing (pre-infiltration) Dr. Ramakrishna HK Rabies

  35. Dosage • Human Rabies Immunoglobulin 20 Units per kg of body weight • Equine Rabies Immunoglobulin 40 Units per kg of body weight • Maximum dosage: HRIG 2000 IU ERIG 4000 IU Dr. Ramakrishna HK Rabies

  36. Administration • Infiltrated into and around the wound. • The remaining portion if any, to be injected in to the opposite deltoid Never give intravenously Dr. Ramakrishna HK Rabies

  37. NEVER EXCEED CALCULATED DOSE • Partially suppresses active production of rabies antibody. • Only once: Not beyond the 7th day of bite Interferes with antibody production Dr. Ramakrishna HK Rabies

  38. Administration: Precautions • Warm before intramuscular injection. • Site & syringe – different from ARV. • Avoid RIG seeping out of wounds. If so, the volume should be estimated and replaced. • Caution is needed if injecting into a tissue e.g. finger pulp, excess fluid can result in increased compartmental pressure and lead to necrosis. Dr. Ramakrishna HK Rabies

  39. RIG TREATMENT - CHILDREN • The same calculated dosage • If insufficient to infiltrate all wounds, dilute with sterile NS 2 to 3 fold • Total dose of RIG should not be increased Dr. Ramakrishna HK Rabies

  40. RIG • Provides immediate passive antibodies • Protects the patient until the patient can produce own antibodies from the rabies vaccine. • Adequate titre of passive antibody is present 24 hours after RIG administration. Dr. Ramakrishna HK Rabies

  41. Duration of Protective Effect: Short Half-life: Approximately 21 days. Dr. Ramakrishna HK Rabies

  42. Cross sensitivity Patients sensitive to other human immune globulin products may be sensitive to Rabies Immunoglobulin also. Dr. Ramakrishna HK Rabies

  43. SIDE / ADVERSE EFFECTS • Rare. • Local: Pain, tenderness at injection site • Systemic: Headache, Fever, Chills, Flushing, Backache, Nausea • Sensitization and subsequent reaction to IgA containing material, such as blood and plasma Dr. Ramakrishna HK Rabies

  44. Drug Inter actions • Can impair the efficacy of live attenuated virus vaccines such as Measles, Mumps, Rubella and Varicella (for a period of at least 6 weeks and up to 3 months). • Vaccines should be administered 14 days prior to or 3 months after administration of RIG. • Over dosage: Significant depression of active immunity. • Avoid repeated doses: prevents full development of the active immunity expected from the vaccine. Dr. Ramakrishna HK Rabies

  45. Intradermal Test • Intradermal test: mandatory • Test: 0.1 ml of RIG: intradermally on the left forearm. • Observation: observed for 30 minutes for local: 24 hours for systemic reactions Dr. Ramakrishna HK Rabies

  46. Reactions • Local: Erythema, Wheal, Severe pain at the local site. • Systemic: Giddiness, mild circulatory collapse with fall of BP. • Precaution: Keep Resuscitation set ready History of sensitization to other vaccines or immunoglobulins, give anti- histamines prior to administration. Dr. Ramakrishna HK Rabies

  47. Management Mild Local Reaction: Anti histamines Systemic reaction: Adrenaline 1:1000 (Aqueous) – 0.01ml/Kg/ dose repeated every 10 – 20 minutes. • Usual Doses: Infants – 0.05ml – 1ml Children – 0.1 0.3 ml Adolescents – 0.3 – 0.5 ml Dr. Ramakrishna HK Rabies

  48. Management: Cont’d SEVERE CASES: HYDROCORTISONE : I.V 100 – 200 Mg Dr. Ramakrishna HK Rabies

  49. CHILDREN, PREGNANCY AND LACTATION Not a Contra indication Dr. Ramakrishna HK Rabies

  50. Previously Immunized • Do not use RIG • Active immunization: 0, 3, 7. • If antibody titre > 0.5 IU/ml 0, 3. Dr. Ramakrishna HK Rabies

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