Dave Jay S. Manriquez RN.

R A B I E S

FAST FACTS

DEFINITION:
An acute infectious disease of warm-blooded
animals characterized by involvement of the
nervous system resulting in death. It is caused by
the RABIES VIRUS, a rhabdovirus of the genus
lyssavirus.

RHABDOVIRUS: any group of rod-shaped RNA

viruses with 1 important member, rabies
virus, pathogenic to man. The virus has
a predilection for tissue of mucus-
secreting glands and the Central Nervous
System. All warm-blooded animals are
susceptible to infection with these
viruses.

LYSSAVIRUS: Greek – frenzy. A genus of the

family Rhabdoviridae.

There are 2 kinds of rabies. URBAN or CANINE RABIES are

transmitted by dogs. SYLVATIC RABIES are transmitted
from wild animals and bats which sometimes spread to
dogs, cats and livestock.

MODE OF TRANSMISSION:
It is commonly communicated to man through the saliva
of an infected mammal by an exposure to an open
break in the skin such as bites or scratch and
inhalation of infectious aerosols such as from bats.
 In some cases, it is transmitted through organ
transplants (corneal transplant), from an infected
person.

MEDIA OF TRANSMISSION:
Through saliva, tears, urine, serum, liquor and other body
fluids.

INCUBATION PERIOD:
The period between the exposure to the virus to the
occurrence of the first symptom, is usually 2-8
weeks. It may be as short as 4 days or as long as
2 years depending on depth of laceration and site of
wound. The virus moves along nerve axons
passively about 3 millimeters per hour. It is not
known how the virus remains viable or where it is
located during prolonged incubation period.

SUSCEPTIBILITY AND RESISTANCE:

All warm-blooded mammals are susceptible. Natural
immunity in man is unknown.

DIAGNOSIS:
There is yet no way of immediately segregating those
who had acquired rabies infection from those who had been
bitten by non-rabid sources. No tests are available to diagnose
rabies in humans before the onset of clinical disease. The
most reliable test for rabies in patients who have clinical signs
of the disease is DIRECT IMMUNOFLUORESCENT STUDY of a
full thickness biopsy of the skin taken from the back of the
neck above the hair line.
The RAPID FLUORESCENT FOCUS INHIBITION TEST is
used to measure rabies-neutralizing antibodies in
serum. This test has the advantage of providing
results within 24 hours. Other tests of antibodies
may take as long as 14 days.
  True rabies must be distinguished from
RABIES HYSTERIA, a psychological condition
in persons who think they have been bitten
by a rabid animal. In such cases, a patient
ordinarily attempts to emulate convulsive
seizures. Patient receiving rabies vaccine
treatment may develop paralysis
attributable to a sensitization caused by the
rabbit brain material in the vaccine. This
paralysis may simulate paralytic rabies and
may produce symptoms referable to cranial
nerves, such as difficulty swallowing,
paralysis of the masseter muscles and
unilateral or bilateral facial paralysis.
Encephalitis without paralysis may be
caused by the vaccine treatment and in such
cases the disease begins with high fever and
headache with may be followed by
convulsions and coma.

I.EPIDEMIOLOGY

RABIES IN THE PHILIPPINES

Although rabies is not among the leading causes of
disease and death in the country it has become a public health
problem of significance for two reasons: it is one of the most
acutely fatal infections which causes the death of between
200-500 Filipinos annually, and the Philippines ranked number
six among the countries with the highest reported incidence of
rabies in the world.
Based on the report from NCDPC (2004), the six regions
with the most number of rabies cases are Western Visayas,
Central Luzon, Bicol, Central Visayas, Ilocos and Cagayan
Valley. Since the Philippines is highly endemic of rabies,
voluntary pre-exposure prophylaxis among people who are at
risk, like pet owners, animal handlers, health personnel
working in anti-rabies units and children below 15 years old, is
a must. Data shows that 53.7 percent of animal bites patients
are children.
The trend for animal bite cases has increased from 1992
to 2001 but decreased in the year 2002-2004. The increasing
number of patients who are consulting the health centers for
animal bite cases is due to the increasing level of awareness
on rabies. On the other hand, the human rabies cases have
been decreasing from 1995 to 2004. This is due to early
provision of post exposure vaccination to dog bite victims.
Dogs remain the principal animal source of rabies.
Although a great majority of animal bites are non-infected with
the rabies virus, animal control and other public health
measures are undertaken because of the high case fatality
rate for rabies.
It is hard to make a definite early diagnosis of rabies, and
the disease almost always leads to death even when
vaccination and medical management are given as soon as the
symptoms have set in. Further, the cost of post-exposure
vaccination against rabies can be prohibitive.

II. PATHOPHYSIOLOGY
 Rabies virus

Incubation period
Entry into break in skin
(4 days – 2 years)
(bites, abrasions, mucosa)

§ Pain
§ Fever
INV A SION § Headache
PHA SE § Malaise
Ø Imminent thoraco- § Sore throat
lumbar involvement § Anorexia
(PNS): Pupillary § Increased sensitivity
dilation, lacrimation,
Ø increased thick saliva
production / foaming
of mouth, excessive
perspiration EX CITEM ENT
Ø Anxiety & fear PHA SE Ø Gradual weakness of muscle groups: muscle
Ø Hydrophobia spasms cease , ocular palsy, vertigo, facial &
Ø Pronounced muscular masseter palsy, weakness of muscles of
stimulation & general phonation, loss of tendon reflexes, neck stiffness
tremor Ø (+)Babinski [lesions at pyramidal tract], (-)
Ø Mania & Kernig’s, (-) Brudzinski’s
hallucinations with Ø HR shifting from tachycardia (100-120) to
lucid intervals bradycardia (40-60)
Ø Convulsions Ø Cheyne-Stokes respiration
Ø Local sensation diminshed (pain, heat, cold)
PA RA LY TIC Ø Incoordination
PHA SE Ø General arousal
( D EPRESSIO N PHASE) Ø Bladder & intestinal retention (damage to the
innervation of the musculature of intestine &
bladder)
Ø Hydrophobia disappear but with slight difficulty
swallowing
insomecases, patientshowsperiodofrecovery,
this apparentremissionis followedbyrapid
progressive paralysis
Ø Ascending paralysis,flaccid paralysis of
coma extremities until it reaches the respiratory muscle
Ø Apathy, stupor

Death

III. SIGNS & SYMPTOMS (most common)

• Sensory change on or • Insomnia
near the site of entry • Convulsions
• Fever • Salivation or foaming
• Laryngeal spasm of the mouth
• Sense of apprehension, • Acute attack: fever,
anxiety, irritabilty muscle twitching,
• Headache hyperventilation and
• Delirium excess salivation
The usual duration is 2-6 days without medical intervention.
Death is often due to convulsion or respiratory paralysis.

IV. MANAGEMENT
A. PREVENTION
1. Responsible pet ownership
a) pet immunization, esp. cats, usually
starting at 3 months of age and every year
thereafter
b) don’t allow pets to roam around the streets
c) take care of your pets, keep them in good
health – bathe, feed with clean adequate food
and provide clean sleeping quarters

2. Thoroughly clean ALL BITES AND SCRATCHES

made by any animal with strong medicinal soap or
solution.

3. Responsible awareness. Report immediately

rabid or suggestive of rabies domestic or wild
animals to proper authorities (local government
clinic, veterinarians or community officials).

4. Pre-exposure to high risk individuals.

Veterinarians, hunters, people in contact with
animals (zoo), butchers, lab-staff in contact with
rabies, forest rangers/caretakers.

5. DOH Standard Protocol

a) If dog is apparently healthy, observe the

dog for 14 days. If it dies or show signs
suggestive or rabies, consult a physician.
b) If the dog shows signs suggestive of
rabies, kill the dog immediately and bring
head for lab examination. Submit for
immunization while waiting for results.
 c) If the dog is not available for observation
(killed, died or stray), submit for
immunization.

*see DOH- Revised Guidelines on Management of Animal Bite Patients-

2007 for more complete guide
B. MEDICAL INTERVENTIONS

a. Local wound treatment. Immediately wash wound

with soap and water. Treat with antiseptic
solutions such as iodine, alcohol and other
disinfectants.

b. Antibiotics and anti-tetanus as prescribed by

physician.

c. Rabies – Specific Treatment. Post-exposure

treatment is given to persons who are exposed to
the rabies virus. It consists of active
immunization (vaccination) and passive immunization
(immune globulin administration).

ACTIVE IMMUNIZATION – aims to induce the body to develop antibodies

and T-cells against rabies up to 3 years. It induces an active immune
response in 7-10 days after vaccination, which may persist for one year or
more provided primary immunization is completed
MEDICAL AGENT: Human Diploid Cell rabies Vaccine (HDCV)

PASSIVE IMMUNIZATION – aims to provide IMMEDIATE PROTECTION

against rabies which should be administered within the first 7 days of
active immunization. The effect of the immune globulin is only short term.
Rabies antibodies are introduced before it is physiologically possible for
the patient to begin producing his own antibodies after vaccination.
Some of the RIG is infiltrated around the site and the rest is given
intramuscularly.
MEDICAL AGENT: Rabies Immune Globulin (RIG)

C. NURSING INTERVENTIONS
1. HIGH RISK FOR INFECTION TRANSMISSION
§ provide patient isolation
 § handwashing. Wash hands before and after each
patient contact and following procedures that
offer contamination risk while caring for an
individual patient. Handwashing technique is
important in reducing transient flora on outer
epidermal layers of skin.
§ Wear gloves when handling fluids and other
potential contaminated articles. Dispose of
every after patient care. Gloves provide effective
barrier protection. Contaminated gloves
becomes a potential vehicle for the transfer of
organisms.
§ Practice isolation techniques. To prevent self-
contamination and spread of disease.

2. KNOWLEDGE DEFICIT (about the disease, cause of

infection and preventive measures)
§ assess patient’s and family’s level of knowledge
on the disease including concepts, beliefs and
known treatment.
§ Provide pertinent data about the disease:
a. organism and route of transmission
b. treatment goals and process
c. community resources if necessary
§ allow opportunities for questions and
discussions

3. ALTERED BODY TEMPERATURE: FEVER RELATED TO

THE PRESENCE OF INFECTION. Since fever is
continuous, provide other modes to reduce discomfort.
§ If patient is still well oriented, Inform the
relation of fever to the disease process. The
presence of virus in the body …
§ Monitor temperature at regular intervals
§ Provide a well ventilated environment free from
drafts and wind.
4. DEHYDRATION related to refusal to take in fluids
secondary to throat spasms and fear of spasmodic
attacks.
§ Assess level of dehydration of patient.
 § Maintain other routes of fluid introduction as
prescribed by the physician e.g. parenteral
routes
§ Moisten parched mouth with cotton or gauze
dipped in water but not dripping.

SOURCE:
Taber’s Cyclopedic Medical Dictionary 17th Edition. 1994. Singapore:
Davis Company.

Department of Health.2000. Community Health Nursing Services in

the Philippine Department of Health,
9th Edition.Philippines.DOH

Smeltzer, Suzanne and Bare, Brenda. 2000. Brunner & Suddarth’s

Textbook of Medical-Surgical
Nursing, 9th Edition. Philadelphia: Lippincott Williams and Wilkins

MANAGEMENT OF POTENTIAL RABIES

EXPOSURE
(DOH- Revised Guidelines on Management of Animal Bite Patients- 2007)

I. CATEGORIES OF EXPOSURE TO A RABID ANIMAL OR TO

ANIMAL

CATEGORY I
a. Feeding/ touching an animal
 b. Licking of intact skin (w/ reliable history and thorough
physical examination)
c. Exposure to patient with signs and symptoms of rabies
by sharing of eating or drinking utensils *
d. Casual contact to patient with signs and symptoms of
rabies*

Management:
1. Wash exposed skin immediately w/ soap and water
2. No vaccine or RIG needed

*Pre-exposure vaccination may be considered

CATEGORY II
a. Nibbling/ nipping of uncovered skin with bruising
b. Minor scratches/ abrasions without bleeding**
c. Licks on broken skin

**includes wounds that are induced to bleed

Management:

a. Complete vaccination regimen until day 28/30 if:

1. Animal is rabid, killed, died OR unavailable for 14- day
observation or examination OR
2. Animal under observation died within 14 days and
IMMUNOFLOURESCENT ANTIBODY TEST positive
(IFAT +) OR no IFAT testing was done OR had signs of
rabies

b. Complete vaccination regimen until day 7 if:

1. Animal is alive AND remains healthy after 14- day
observation period
2. Animal under observation died within 14 days but had
no signs of rabies and as IFAT- negative.

CATEGORY III
a. Transdermal bites or scratches ( to include puncture
wounds, lacerations, avulsions)
b. Contamination of mucous membrane with saliva (i.e.
licks)
 c. Exposure to a rabies patient through bites,
contamination of mucous membranes or open skin
lesions with body fluids (except blood/feces) through
splattering, mouth-to-mouth resuscitation, licks of the
eyes, lips, vulva, sexual activity, exchanging kisses on
the mouth or other direct mucous membrane contact
with saliva.
d. Handling of infected carcass or ingestion of raw infected
meat
e. All Category II exposures on head and neck area

*Does not include sharing of food/ drink/ utensils and casual contact
with rabid patient
Management:

a. Complete vaccination regimen until day 28/ 30 if:

1. Animal is rabid, killed, died OR unavailable for 14 day
observation or examination OR
2. Animal under observation died within 14 days and was
IMMUNOFLOURESCENT ANTIBODY TEST (IFAT)-
positive OR no IFAT testing was done OR had signs of
rabies

b. Complete vaccination regimen until day 7 if:

1. Animal is alive AND remains healthy after 14-day
observation period.
2. Animal under observation died within 14 days but had
no signs of rabies and was IFAT- negative

II. POST- EXPOSURE TREATMENT

CONCEPT OF THERAPY/ REMEDY: removal or neutralization of
infectious virus before it enters
the Nervous System

1. Local Wound Treatment

- Soap and water
- Alcohol, povidone iodine or any antiseptic
- Suturing of wounds should be avoided
- Don’t apply any ointment, cream/ dressing
- Anti-tetanus immunization
 2. Antimicrobial
- Amoxicillin/ clavulanic
- Cloxacillin
- Cefuroxime axetil

3. Vaccination
- Updated 2- Site Intradermal Schedule
- Standard IM Schedule

MANAGEMENT OF RABIES PATIENTS

(DOH- Revised Guidelines on Management of Animal Bite Patients- 2007)

Considering the fatal outcome and lack of cure for human

rabies once symptoms start, treatment should center on
comfort care, using sedation and avoidance of intubation and
life- support measures once the diagnosis is certain.

1. Medications – any of the ff. Regimens may be used:

 a. Diazepam
b. Midazolam
c. Haloperidol plus Dipenhydramine – this regimen has
been used at San Lazaro Hospitald

2. Supportive Care
Patients with confirmed rabies should receive adequate
sedation and comfort care in an appropriate medical
facility.

a. Once rabies diagnosis has been confirmed, invasive

procedures must be avoided.
b. Provide suitable emotional and physical support.
c. Discuss and provide important information to relatives
concerning transmission of disease and indication for
post- exposure treatment of contacts
d. Honest gentle communication concerning prognosis
should be provided to the relatives

3. Infection Control

a. Patients should be admitted in a quiet, draft- free,

isolation room.
b. Healthcare workers and relatives coming in contact
with patients should wear proper personal protective
equipment (PPE) including gown, gloves, mask,
goggles

4. Disposal of dead bodies

a. Humans who have died of rabies generally presents a

small risk of
transmission to others. There is evidence that blood does
not
contain virus but that the virus is present in many tissues
such as
the CNS, salivary glands and muscle. It is also present in
saliva and urine.
b. Embalming should be discouraged
c. Performing necropsies carelessly can lead to mucous
membrane and inhalation exposures
d. Wearing protective clothing, goggles, face mask and
thick gloves should provide sufficient protection.
e. Instruments must be autoclaved or boiled after use.
f. Early disposal of the body by cremation or burial is
recommended.