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Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor
It is caused by rhabdovirus
TRANSMISSION
Bite of a rabid animal is the commonest route
Contamination of mucous membrane by saliva and potentially infectious material like brain tissue
Aerosol transmission
Exposure while working in lab with rabies virus
Infected organ transplant
Contraction of rabies through consumption of raw meat or animal derived tissue has never been confirmed.
Other contact like patting a rabid animal or contact with the blood, urine or feces of a rabid animal, does not constitute an exposure.
Incubation period: 20 to 90 days
CLINICAL FEATURE
Fever, sore throat, chills
Malaise, anorexia, headache
nausea, vomiting
cough, dyspnea
Autonomic dysfunction: hyperthermia, tachycardia, hypertension & excessive salivation
50% of the cases have classic hydrophobia, in which attempt to drink water results in spasm of pharynx, larynx & diaphragm.
Paralytic rabies is seen in 20% of the cases where paralysis is maximum in the bitten limb,diffuse & symmetric.
Later patient develops coma, hypotension, hypoventilation, apnea, pitutary dysfunction, cardiac arrythmia, cardiac arrest & leads to death.
Diagnosis
Isolation of viral antigen from brain tissue.
PCR of CSF And saliva.
CSF :Lymphocytic pleocytosis. Shows areas of increased signal abnormality in brain stem, hippocampus & hypothalamus.
MANAGEMENT OF BITE WOUNDS
GENERAL CONSIDERATIONS
If rabies immunoglobulin is not available on first visit its use can be delayed by a maximum of 7 days from the date of first vaccine injection.
Pregnancy & infancy are never contraindication to PEP
Persons who present for evaluation & rabies post exposure prophylaxsis even months after having been bitten, should be dealt in the same manner as if the contact occurred recently.
PEP may be discontinued if involved animal is a dog or cat that remains healthy for an observation period of 10days after the exposure occurred.
FIRST AID
Immediate washing & flushing for 15min with soap & water or water alone
Disinfection with etahnol or iodine.
Postpone suturing if possible
Apply antimicrobials & TT
Category | Type Of Contact | Post Exposure Prophylaxis |
Category 1
| Touching, feeding of animals or licks on intact skin. No exposure therefore no prophylaxis if history reliable. | Wound Management |
Category 2 | Minor scratches or abrasions without bleeding or & nibbling of uncovered skin. Use vaccine alone | Wound Management ARV |
Category 3 | Single or multiple transdermal bites or scratches, licks on broken skin, contamination of mucous membrane with saliva & suspect contacts with bats. Use immunoglobulin plus vaccine. All animal bites in forest or wild animals should be treated as category III. | Wound Management RIG ARV
|
POST EXPOSURE PROPHYLAXIS
Intramuscular Regimen
5 dose IM regimen : Day 0,3,7,14,28 in deltoid region or anterolateral part of thigh in childrens.
2-1-1 regimen may also be used. Two doses are given on day 0 over right & left deltoid muscle. Additional dose on day 7 & 21 .
Intradermal Regimen for PEP (2-2-2-0-2)
ID is considered appropriate in settings where vaccine is short of supply as they require considerably less vaccine.
One dose of vaccine, in a volume of 0.1 ml is given intradermally at two different lymphatic drainage sites, usually left & right upper arms, on days 0,3,7 & 28.
Vaccine administrated intradermally must raise a visible & palpable bleb in the skin.
Intramuscular vaccine reduces the volume of vaccine used and cost by 60-80% and is considered appropriate where vaccine or money in short supply.
PCECV Rabipur has been proven to be safe and efficacious. (WHO recommends to use prequalified rabies vaccines that can be used by ID route.)
In India only those anti rabies vaccine approved by DGCI for ID administration should be used for ID route.
Contraindication for Vaccine
There are no absolute contraindications as rabies is fatal disease.
However it may avoided as pre exposure prophylaxis in individuals with acute disorder.
RABIES IMMUNOGLOBULIN (RIG)
It is used in category 3 exposure management.
Infiltrate into depth of the wound and around the wound as much as possible and the remainder into anterior thigh.
DOSE : Human RIG : 20IU/Kg; Equine RIG: 40IU/Kg
IMMUNOCOMPROMISED INDIVIDUALS
No change in regimen
HRIG should be received in categoriy 2 or 3 exposure .
Whether PEP prophylaxis is needed if bitten by a domestic animal ?
Can Post Exposure Prophylaxis converted to preexposure prophylaxis if the animal is healthy even after 10 days?
Administration of rabies immunoglobulin after 1 week is it effective ?
If the bitten dog is vaccinate whether PEP is indicated or not ?
Which are the vaccines approved by DGCI for ID administration ?
|
RABIES PEP OF PREVIOUSLY VACCINATED PERSONS
Local treatment of wound
No RIG
Two PEP schedules are available
One dose on days 0 & 3 0.5ml IM or 0.1 ml ID.
4 site: 4 injections of 0.1ml distributed on each arm,thigh or suprascapular regions on day 0.
PRE-EXPOSURE RABIES VACCINATION
Three doses of vaccine on days 0,7 & 28.
Persons at risk should check rabies virus neutralising antibody titre every 6 mtns.
A booster dose should be taken when titres fall below 0.5 IU/ml.
ADVERSE EFFECT OF VACCINATION
Fever, myalgia, headache, lymph node swelling, fatigue, arthritis.
Pain, redness, swelling.
Updated on 6/11/2016
Reference :
WHO Guide for Rabies pre & post exposure prophylaxis in Humans. Updated 2014.
National Guidelines on Rabies Prophylaxis. NCDC. 2015.
Rabipur vaccine is purified chick embryo cell vaccine.
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emmedonline
Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor