a seminar on rabies.. and the newer aspects coming up.

1. Presented by:
Dr. Prabhat Moktan
Moderator:
Dr. v.k.mehta
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2. Content
• INTRODUCTION
• BURDEN OF DISEASE
• EPIDEMIOLOGY
• CLINICAL FEATURES
• DISEASE MECHANISM
• DIAGNOSIS
• Prevention
• CONTROL
• RABIES CONTROL IN INDIA
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3. Introduction:
Key facts
Rabies is a vaccine-preventable viral disease which occurs in more
than 150 countries and territories.
Dogs are the source of the vast majority of human rabies deaths.
Rabies elimination is feasible by vaccinating dogs.
Infection causes many deaths every year, mostly in Asia and Africa.
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4. 40% of people who are bitten by suspect rabid animals are
children under 15 years of age.
Immediate wound cleansing with soap and water after contact
with a suspect rabid animal can be life-saving.
Every year, more than 15 million people worldwide receive a
post-bite vaccination to prevent the disease; this is estimated to
prevent many deaths annually.
(WHO Fact Sheet Updated September, 2015).
Contd..
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5. HISTORY
• Rabies has been derived from the sanskrit word
“Rabhas” which means “to do violence”.
• Latin origin-”Rebere”which means “to rave”.
• “Jalasanthra”- agony caused by water.
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6. Contd..
• Sir Louis Pasteur,french chemist was the first person who
prepared the anti rabies vaccine from the spinal cord of an
infected rabbit.
• On 6th July 1885,Sir Louis Pasteur successfully treated a
9 year old shepherd boy by the name Joseph Meister who
was severely bitten by a rabid dog.
• Consequently, every year July 6th is celebrated as “World
Zoonoses Day “or “World Rabies Free Day”.
• In 1903,Negri,an Italian scientist demonstrated the viral
particles ,as inclusion bodies in the neurons of the rabid
animal,which are named after him as Negri bodies.
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7. Contd..
• In 1911,in India, David Semple, developed a vaccine
from the brain of an infected sheep, popularly known
as “Semple vaccine "or BPL vaccine.
• Later, Flury prepared a vaccine from chick embryo
and duck embryo.
• In 1964, Witkor and Kaprowski, were successful in
preparing a Tissue Culture Vaccine by culturing the
virus in human diploid cells.
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8. 5/23/2016 8
• Human rabies is present in 150 countries and territories and on all
continents, except for Antarctica and Australia.
• 95% of human deaths occur in Asia and Africa.
BURDEN OF DISEASE
WORLD:

9. Contd…
Africa
• Estimates of the burden of rabies in Africa have always been
uncertain because of the lack of good data.
• In 2010 the estimated burden of rabies in Africa was
approximately 23800 deaths.
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10. Contd.
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Latin America and the Caribbean
• Official reports of cases of human rabies transmitted by dogs
decreased from about 250 in 1990 to fewer than 10 in
2010,with concomitant declines in dog rabies.
• The Pan American Health Organization has set a target to
eliminate dog-mediated rabies from America by 2015.

11. Contd..
Asia
• More human deaths from rabies occur in Asia due to endemic
canine rabies exceeding 30000 per annum.
• In 2010 the incidence of human deaths from rabies per 100000
population was estimated to be as given below :
1.Bangladesh-1–1.8.
2.Bhutan- 2.5–7.5 .
3.Cambodia- 2.8–11.5.
• Little information is available on rabies in the Middle East or
Central Asia.
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12. Contd..
INDIA
• India is reported to have the highest incidence of rabies
globally.
• India accounts for 30,000 deaths due to rabies every
year.
• Cases have been reported from all parts of India except
for Andaman Nicobar and Lashadeep islands.
• 3 million people take antirabies treatment every year.
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13. Contd…
Global summary
• About 50,000 deaths occur due to rabies annually.
• Rabies is present in all continents except in Antarctica and
Australia.
• The estimated annual cost of rabies is US$ 6 billion, with almost
US$ 2 billion due to lost productivity after premature deaths and a
further US$ 1.6 billion spent directly on post-exposure
prophylaxis.
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14. EPIDEMIOLOGY
AGENT FACTORS
• The causative agent is a RNA virus,a lyssa virus type
1 belonging to the family Rhabdoviridae.
• It is a bullet shaped virus, single stranded and non
segmented.
• A sheath of lipid covers the body surface.
• The lipid has spikes containing glycoprotein
projecting all over the body surface of the virus.
SEROTYPE 1 is the causative agent of rabies.5/23/2016 14

18. Contd..
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Rabies virus contains two antigens:
• A glycoprotein antigen(G protein).
• An internal nucleoprotein antigen.

19. RESERVIOR OF INFECTION
The common reserviors country wise are as
follows:
• DOGS-in most parts of the world mostly in Asia,Latin
America and Africa
• FOXES- Europe ,Arctic and North America,
• RACCOONS-Eastern United States.
• SKUNKS- Western Canada.
• COYOTES- Asia, Africa and North America.
• BATS-Vampire bats in SouthAmerica, Insectivorous bats
in North America and Europe.
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20. 5/23/2016 20

21. 5/23/2016 21

22. Raccoon

23. fox

25. Bats

30. 5/23/2016 30

31. 5/23/2016 31

32. SOURCE OF INFECTION
• The saliva of rabid animals.
• Inhalation of virus containing aerosols.
• Less infectious materials are other body fluids like
serum,urine and milk.
• In humans-saliva,sweat,semen and tears contain the
virus.
• Cornea of human cases constitutes an infective
material.(rabies antigen detected in corneal cells).
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33. Incubation period
• It varies from 3 weeks to 3 months(15 days to 1 year).
Factors influencing the incubation period:
1. Site Of The Bite.
2. Severity Of The Bite.
3. Species Of The Biting Animal.
4. Richness Of The Nerve Supply.
5. Amount Of Saliva Deposited.
6. Protection Through Clothes.
7. Partial Treatment Taken .
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34. Period of infectivity
• The rabid animal is infectious during the last 3 to 5
days of incubation period and also during the entire
peiod of illness,which is about 8 to 10 days.
• Thus the total period of infectivity is about 12 to 15
days.
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35. Host factors
• All warm blooded animals including man.
• Rabies in man is a dead end infection and has no
survival value.
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36. AT RISK
• Veterinarians and animal handlers.
• Hunters and field naturalist.
• Laboratory staff working with rabies vaccine.
• Doctors and Nurses handling rabies patients.
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37. Modes of transmission
• The disease is transmitted from animal to animal and
from animal to humans.
• From wild animals(Sylvatic Cycle) it is transmitted to
domestic animals (Urban Cycle) and accidentally to
humans.
• It is mainly transmitted by bite of rabid animals.
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38. Contd..
• It is also transmitted by bites of insectivorous bats
and by aerosols route by vampire bats.
• Transplacental transmission seen in animals but not in
humans.
• Oral transmission through drinking raw milk of rabid
cattle is less likely.
• Sexual transmission has also not been reported.
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39. pathogenesis
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40. CLINICAL FEATURES
Prodromal Symptoms:
 fever, rhinorrhea, sore throat, myalgias, GI upset.
Back pain and muscle spasms.
 Agitation and anxiety.
 Paresthesias, pain or severe itching at site may be the
first neurological symptom.
 The prodromal stage is followed by
 Widespread excitation and stimulation of nervous
system.
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41. Stage of excitement
In order
I. Sensory system:
 irritable,anxious and nervous.
 sensitive to sensory stimuli like touch,pain
and temperature.
(convulsions on strong stimuli)
II. Motor system:
 increased tone and spasticity of muscles.
 exaggeration of deep reflexes,jerks..
Tremors or tic like movements.
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42. Contd..
III. Sympathetic system:
 excessive perspiration,lacrimation,salivation
and increased libido.
 meanwhile he develops aerophobia and
photophobia.
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43. Stage of paralysis
• Paralysis of muscles of deglutition,resulting in
difficulty swallowing.
• An attempt to swallow results in choking sensation .
• As the condition progresses an attempt to swallow
food and water,reflexly results in painful spasm of
muscles of deglutition.
• Finally even the sight or sound of water causes
painful spasms(hydrophobia).
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44. DUMB RABIES(PARALYTIC RABIES)
• This occurs to about 10-20 per cent humans.
• Seen mostly among partially immunized persons.
• Clinical features:
 gradual ascending paralysis.
 constipation and urinary retention.
 stupor,coma death within 1- 2 weeks.
 hydrophobia is usually abscent.
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46. RABIES IN DOGS
1. “FURIOUS” OR “FRANK” RABIES.
2. DUMB RABIES.
Incubation period varies from 2 weeks to 2 months.
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47. 1. “FURIOUS” OR “FRANK” RABIES:
(MAD DOG SYNDROME).
• It is observed in 80 to 90 per cent of cases.
• In early prodromal stage the dog starts to behave
differently and abnormally.
• It goes to dark corners,becomes restless,unusual
agitation and develops fever.
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48. Contd..
• Later it becomes aggressive and more ferocious.
• Red eyes,runs here and there.
• Develops perversion of taste.
• Bites its own chain,stone, paper, wood,iron etc… in
this procees it can bite humans and other animals
without provocation.
• Later in the clinical stage it develops paralysis of the
lower jaw giving rise to protrusion of tongue, drooling
of saliva, foaming at the angle of mouth and paralysis
of vocal cords leads to change of tone of bark.
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49. DUMB RABIES(PARALYTIC RABIES)
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• It occurs in 10 to 20 per cent of animals.
• The dog becomes silent and withdraws itself from
being disturbed.
• Paralysis of muscles starts from the headand neck
region.
• Difficulty in swallowing.

50. Laboratory diagnosis.
1. Antemortem.
2. Postmortem.
1. Antemortem :
– Skin biopsy(nuchal region)from along the hairline of
neck and Fluorescent Antibody Test.
– Corneal impressions and saliva smear for FAT.
2. Postmortem:
– Biopsy of brain and seller’s stain for Negri bodies.
– Fluorescent Antibody Test.
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51. Management of hydrophobia.
• There is no cure or treatment , prevention is the only
intervention.
• Symptomatic with supportive treatment and sedation.
• Admission in a quiet room of the hospital.
• Sedatives,antipyretics,analgesics,antihistaminics and
anticonvulsants.
• IV rehydration,steriods and osmotic diuresis like
mannitol.
• Expert nursing care.
• Mechanical ventilation if required.
• Pre-exposure prophylaxis and PPE.
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52. Prevention of Rabies in Man.
• Two approaches:
1. Post-exposure prophylaxis.
2. Pre-exposure prophylaxis.
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53. Contd..
1. Post –exposure prophylaxis:
 Wound treament
• Gentle washing of wound with soap preferably under
running tap water for at least 10-15 minutes.
• Application of viricidal agents like povidone iodine.
• In deep wounds-thorough exploration with removal
of dirt ,dead tissues and foreign bodies
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54. • Infiltration of rabies immunoglobulin locally
into the wound.
• The animal bite wound is not sutured
immediately,however ,if unavoidable it
should be loose and not occlusive.
• Immunization against tetanus is given .
• Prophylactic antibiotics.
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55. 5/23/2016 55

56. Observation of the animal
• Applicable to dogs and cats.
• The bitten animal should be observed for 10 days.
• Change in behaviour.
• Running here and there.
• Biting without provocation.
• Excessive salivation.
• Change in tone of the bark.
• Eating unusual objects.
• Death of the animal.
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57. Antirabies immunization
Immunization against rabies is not included in
the Universal Immunization Programme,because
• Incubation period is long
• The immunity with antirabies tissue culture vaccines is
hardly 3 years.
• The vaccines are costly.
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58. 5/23/2016 58

59. History of rabies vaccine
Vaccines prepared from animal tissues
1. 1885- Louis Pasteur developed the first rabies vaccine
from the spinal cord of a rabbit.
2. 1911- Semple Vaccine(from sheep and goat brains).
3. 1955- Fuenzalida Vaccine (from suckling mouse brain).
4. 1955- Powell prepared Duck embryo cell vaccine.(from
embryonated eggs)(Flury’s vaccine).
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60. Vaccines prepared from Primary Animal Cells
(modern tissue or cell culture vaccines).
1960-1965- purified chick embryo cell vaccine
• Primary Hamster Kidney Cells Vaccine.(Kissling).
• Primary Dog Kidney Cell Vaccine.
Vaccines prepared from Standardised Cell Lines(Cell Bank).
• 1964- Human Diploid Cell Vaccine (HDCV) by Witkor.
• 1972- HDCV was also prepared by Wistar and Merieux
institute.
• 1985- Purified Vero Cell Rabies Vaccine (PVRV) by Merieux
institute.
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61. Type of vaccines
1. Nerve tissue vaccines.
a) BPL vaccine(Semple vaccine).
b) suckling mouse brain vaccine (Fuenzalida
vaccine).
2. Duck Embryo Vaccine (Flury’s Vaccine).
3. Cell Culture Vaccines
a) Human Diploid Cell Vaccine (HDCV).Rabivax
b) Purified Chick Embryo Cell Vaccine(PCEC-V).
Vaxirab, Rabipur
c) Purified Vero Cell Rabies Vaccine(PVCR).
Verorab,indirab
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62. WHO guideline for PEP
CATEGORY TYPE OF CONTACT WITH A SUSPECT
OR CONFIRMED RABID ANIMAL
RECOMMENDED
TREATMENT
Category I touching or feeding of animals,
licks on intact skin, contact of
intact skin with secretions or
excretions of a rabid animal or
human
no exposure therefore
no prophylaxis if
history reliable
Category II minor scratches or abrasions
without bleeding and/or
nibbling of uncovered skin
use vaccine alone
Category III single or multiple transdermal
bites or scratches, licks on
broken skin, contamination of
mucous membrane with saliva
(i.e. licks) and suspect contacts
with bats
use immunoglobulin
plus vaccine
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63. Intramuscular regimens for rabies PEP
1. Essen’s schedule:
• The 5 dose regimen.
• 0-3-7-14-28.
• 1-1-1-1-1.
2. Zagreb schedule:
• the 3 dose regimen.
• 0---7---21.
• 2-0-1-0-1.
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64. Intradermal regimen for rabies PEP
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• 2 site intradermal schedule.(Thai Red Cross ID
Schedule).
• One dose of vaccine, in a volume of 0.1 ml is given
intradermally at two different sites .
• usually in the deltoid muscle on the left and right
upper arm and suprascapular area
• Given on days 0, 3, 7 and 28.
• 2-2-2-0-2.

65. Contd..
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• 8 site oxford intradermal schedule.
• One dose of 0.1 ml is administered intradermally at
eight different sites :
(upper arms, lateral thighs, suprascapular region, and
lower quadrant of abdomen) on day 0.
• On day 7, four 0.1 ml injections are administered
intradermally into each upper arm (deltoid region) and
each lateral thigh.
• Following these injections, one additional 0.1 ml dose
is administered on days 28 and 90.
• 8-0-4-0-1-1.

66. Passive immunization
• Adminstration of readymade antirabies
antibodies,Antirabies Sera o(ARS) or Human Rabies
Immunoglobulin in all CAT III cases.
• Given at day 0 along with Active Immunization.
• Two types of Rabies Immunoglobulin:
1. Equine Rabies Immunoglobulin
(ERIG/ARS).Ionorab
dose-40 IU/Kg body weight.
2. Human Rabies Immunoglobulin (HRIG).Rabivax
dose- 20 IU/Kg body weight.
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67. Advice to patient
1. Importance of taking the treatment correctly and
completely.
2. To avoid steriods,spicy foods,spirit(alcohol),smoking
and strain(physical and mental ).
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68. Re-exposure to rabies
• History of previous immunization against rabies.
• Has received post exposure or pre-exposure
prophylaxis either IM/ID.
• 2 doses of vaccine on day 0 and 3 by IM.
• If previous immunization is incomplete ,it is treated
as a fresh case.
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69. Contd..
2. Pre-exposure prophylaxis:
• It is given to those people who are at risk for e.g.
Veterinarians,animal handlers,laboratory personnel
working with rabies vaccine..etc..
• WHO recommended 3 doses to be given
intramuscularly on days 0,7 and 28.
Intradermal
• One intradermal injection of 0.1 ml is given on each
of days 0, 7, and 21 or 28. (WHO)
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70. Rabies PEP in immunosuppressed individuals
1. Thorough wound treatment should be further
stressed for immunosuppressed individuals.
2. RIG should be administered deeply into the wound
for both category 2 and 3 exposures.
3. Vaccine should always be administered and no
modification of the recommended number of doses
is advisable.
4. An infectious disease specialist with expert
knowledge of rabies prevention should be consulted.
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71. Control of rabies in dogs
• Elimination of all stray,sick,dead and ownerless dogs.
• Enforcing registration and licensing of pet dogs(collar
for identification).
• Pre-exposure immunization of all pet dogs.
first dose at 2 months of age followed by second dose
after one month.
thereafter, booster dose regularly at once in a year.
• Post exposure prophylaxis. 0-3-7-14-28/30.
• Health education of people about rabies.
• Veterinary vaccines.
NTV,TCV. Nobivac-r
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72. PERSONAL PROTECTION AGAINST RABIES
1. Do not touch animal bitten wounds with
bare hands.
2. Do not touch the chain,food plate of
animals suspected or proven of having
rabies.
3. Do not provoke any animal.
4. Avoid contact with saliva,urine,tears,semen
or vaginal secretion of a rabies patient.
5. Take pre exposure immunization if u fall
under “At Risk” group.
6. Veterinians should wear
gloves,glasses,masks and long sleeved
aprons while examining rabid animals.
7. Protect yourself from dog bites.5/23/2016 72

73. National Rabies Control Programme
• Agriculture ministry of india had launched a canine
control program during 6th five year plan.
• Pilot project was launched during the 11th Plan :
Ahmedabad, Bangalore, Pune, Madurai and Delhi.
• The government made it a priority disease for control
under the 12th Five Year Plan.
• All 35 States/UTs will be covered.
• The programme will include :
1. Training health professionals to deal with animal
bites.
2. Awareness creation.
3. Minimizing animal bites.
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74. National Rabies Control Programme
• India’s pilot project under the National Rabies Control
Programme was launched on 13 March 2015 in Haryana.
• Humane Society International/India in collaboration with the
Animal Welfare Board of India and the state Government of
Haryana. undertook the joint initiative.
• It addresses the management of street dog issues through mass
awareness, community engagement, humane catching of street
dogs, effective rabies diagnosis and improving dog bite
management.
• Program entails dog census, mass sterilization and mass
immunization of street and pet dogs to cover at least 70
percent of their population.
• The launch also saw the inauguration of ‘INDIA ONE’; a
convoy developed as a part of the Anti-Rabies Task Force to
conduct sterilization and rabies vaccinations for dogs in rural
locations across India.
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75. World Rabies Day
• September 28 is observed as World Rabies Day, a global
health observance that seeks to raise awareness about rabies
and enhance prevention and control efforts.
• First co-sponsored by CDC and the Alliance for Rabies
Control (ARC) in 2007, World Rabies Day has been
celebrated in countries throughout the world.
• It is an excellent time to take steps that can help prevent
and control rabies, such as vaccinating pets including
dogs and cats and providing education on how to avoid
the animals that typically transmit rabies: raccoons, bats,
skunks, and foxes.
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76. Newer vaccines:
• The new : anti-rabies human monoclonal antibody
(RMAb).
• The final phase of human trials are being conducted in
200 patients at different centres across India.
• Field Trials of New Oral Rabies Vaccine for Use in
Raccoons, Other Wildlife.
• RT-PCR.
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77. References• WHO Technical Report Series No. 982, 2013.
• WHO Expert Consultation on Rabies Second report.
• Communicable Disease Control Chapter I – Management of Specific Diseases Rabies May 2015.
• www.apcri.org
• Institute of Development Studies, University of Sussex, Brighton, England.Public Health Foundation of India,
ISID Campus, 4 Vasant Kunj Institutional Area, New Delhi, 110070, India.
• Role of reverse transcriptase polymerase chain reaction for the diagnosis of human rabies
Manisha Biswal, Radha Kanta Ratho & Baijayantimala Mishra
Department of Virology, Postgraduate Institute of Medical Education & Research,Chandigarh, India
Received February 8, 2010
• WHO Guide for Rabies Pre and Post Exposure Prophylaxis in Humans Updated 2013
• Suryakantha AH.Community medicine with recent advances.epidemioloy of communicable
diseases.rabies,2014,3:489-501.
• Briggs DJ et al. Antibody response of patients after postexposure rabies vaccination with small intradermal
doses of purified chick embryo cell vaccine or purified Vero cell rabies vaccine. Bulletin of the World Health
Organization, 2000, 78:693–698.
• CDC : http://www.cdc.gov/ncidod/dvrd/rabies
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5350a1.htm
• Harverson G, Post-exposure intradermal antirabies vaccine: a cheaper alternative for developing countries,
Trop Doct. 1984 Apr;14(2):67-70.
• Human and dog rabies prevention and control: report of the WHO/Bill & Melinda Gates Foundation
consultation, Annecy, France, 7–9 October 2009. Geneva, World Health Organization.
(WHO/HTM/NTD/NZD/2010.1); http://whqlibdoc.who.int/ hq/2010/WHO_HTM_NTD_NZD_2010.1_eng.pdf.)
• WHO: http://www.who.int/mediacentre/factsheet/fs099/en5/23/2016 78

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