NRPCP PROGRAM

UPDATES
National
s Prevention & Control Program

Ms. Jenny A. Alabado, RMT

Regional Rabies Coordinator
 RABIES

- is a zoonotic disease and human infection caused by

Lyssavirus, usually occurring after a transdermal bite or
scratch by an infected animal.
-highly fatal
Transmission:
-infectious materials, saliva comes into direct
contact with victims mucosa or fresh skin lesions
Very Rarely:
-Inhalation of virus containing aerosol
-via infected organ transplants
 Regional Profile

5 Provinces and 9 cities

30 ABC/ABTCs

Population: 4,768,629
 Locations of ABTCs/ABCs
Misamis
MisamisOccidental
Occidental
Ozamiz
Ozamiz CHO
CHO
Oroquieta

Oroquieta CHO
CHO
Misamis Occidental Provincial Hospital
Misamis Occidental Provincial Hospital
Dona Maria D. Tan Memorial Hospital
Dona Maria
(Tangub City) D. Tan Memorial Hospital
(Tangub
Calamba City)
District Hospital
Calamba
Mayor DistrictA.Hospital
Hilarion Ramiro Sr-RTTH
Mayor Hilarion A. Ramiro Sr-RTTH
 Misamis Oriental
Misamis Oriental
ProvincialHealth
Provincial HealthOffice
Office
GingoogCity
Gingoog CityHealth
HealthOffice
Office
ClaJaVitaILHZ
ClaJaVita ILHZ
ManLuna ILHZ
ManLuna ILHZ(MOPH,
(MOPH,Manticao)
Manticao)
EasternTowns
Eastern Towns ILHZ
ILHZ(Balingasag)
(Balingasag)
El Salvador
El SalvadorCity
CityLying
LyingInIn
 Cagayan de Oro City
CHO
Madonna General Hospital (private)
St. Ignacius Clinic (private)
Maria Reyna-XU Hospital (private)
Justiniano R. Borja General Hospital
 Bukidnon
Bukidnon Provincial Medical Center
BPH- Maramag
Malaybalay CHO
Valencia CHO
Bukidnon Provincial Hospital- Manolo Fortich
 Lanao del Norte
Lanao del Norte Provincial Hospital
(Baroy)
Kapatagan District Hospital
Kolambugan District Hospital
Linamon RHU
 Iligan City
CHO
Iligan Sanitarium Hospital (private)
 Camiguin

Camiguin General Hospital

 SITUATIONAL ANALYSIS MAP OF REGION X
(2016 ,1st qtr)

Human Rabies Cases

1.Bukidnon- 5
2.Misamis Oriental -2
3.Misamis Occidental- 2
4.Lanao del Norte -0
5.Iligan City-1
6.Camiguin-0
7. CDO - 0

TOTAL 10
 1st quarter of 2016 (Human Rabies)
Province Municipality Barangay # of Cases
Bukidnon San Fernando Maglanungay 1
Kitaotao P-2, Digongan 1
P-1, kitubo 1
Maramag Dulogon 1
Manolo Fortich Lunocan 1
Malaybalay San Jose 1
Camiguin
Lanao del Norte
Iligan City
Misamis Plaridel Looc 1
Occidental Tangub Brgy. 5 1
Misamis Oriental Claveria 1
Cagayan de Oro 0
City
 SITUATIONAL ANALYSIS MAP OF REGION X
(2016 ,2nd qtr)

Human Rabies Cases

1.Bukidnon- 3
2.Misamis Oriental -0
3.Misamis Occidental- 1
4.Lanao del Norte -1
5.Iligan City-0
6.Camiguin-0
7. CDO - 1

TOTAL 6
 2nd quarter of 2016 (Human Rabies)

Province Municipality Barangay # of Cases

Bukidnon Kitaotao P7 Kitobo 1
Maramag 2

Lanao del Norte Lala P3 Abaga 1

Baroy 1

Misamis Tangub City Pangabuan 1

Occidental

Cagayan de Oro Cagayan de Oro Zone 5 Bayabas 1

City City
 SITUATIONAL ANALYSIS MAP OF REGION X
(2016 ,3rd qtr)

Human Rabies Cases

1.Bukidnon- 1
2.Misamis Oriental -1
3.Misamis Occidental- 0
4.Lanao del Norte -0
5.Iligan City-0
6.Camiguin-0
7. CDO - 0

TOTAL 2
 3rd Quarter of 2016 (Human Rabies)

Province Municipality Barangay # of Cases

Bukidnon Maramag ____ 1

Misamis oriental Claveria _____ 1

 National Rabies Prevention
and Control Program
2016 Animal Bite Report as
of June 15, 2016
AREAS Animal Bites PEP Coverage PEP % Coverage
NCR 42422 40639 95.80%
CAR 4133 4085 98.84%
REGION 1 9739 9547 98.03%
REGION 2 5902 5834 98.85%
REGION 3 19793 18223 92.07%
REGION 4A 30083 29616 98.45%
REGION 4B 3936 3833 97.38%
REGION 5 6155 6093 99.00%
REGION 6 19370 18522 95.62%
REGION 7 13826 13826 100.00%
REGION 8 2307 2307 100.00%
REGION 9 4006 4045 100.97%
REGION 10 11022 11022 100.00%
REGION 11 8250 7715 93.52%
REGION 12 7251 7161 98.76%
ARMM 207 203 98.07%
CARAGA 3680 3680 100.00%
Total Coverage 192082 186352 97.02%
 Region cases
3 27
4A 22
1 17
10 16
Human Rabies

5 14
by Region
11 14
6 10
7 10
9 10
12 10
8 9
NCR 8
CARAGA 5
2 4
4B 3
ARMM 3
CAR 2
 Top Ten Provinces
Province Cases Rank
Pangasinan 17 1
Bukidnon 11 2
Zamboanga Del Sur 10 3
Camarines Sur 9 4
Leyte 8 5
Bulacan 8
Davao Del Sur 8
Nueva Ecija 6 6
Rizal 6
Cebu 6
Quezon City 6
Cavite 5 7
Laguna 5
Sultan Kudarat 5
 Province Cases Rank
Bataan 4 8
Tarlac 4
Capiz 4
Zambales 3 9
Batangas 3
Quezon 3
Camarines Norte 3
Negros Orriental 3
Misamis Oriental 3
Davao Del Norte 3
Cagayan 2 10
Isabela 2
Iloilo 2
Negros Occidental 2
North Cotabato 2
South Cotabato 2
Maguindanao 2
Agusan Del Sur 2
Marikina 2
 Human Rabies Cases per province
Region casesProvince case
1 17 Pangasinan 17
2 4 Cagayan 2
Isabela 2
3 27 Aurora 1
Bataan 4
Bulacan 8
Nueva Ecija 6
Pampanga 1
Tarlac 4
Zambales 3
4A 22 Batangas 3
Cavite 5
Laguna 5
Quezon 3
Rizal 6
 region Cases Provinces Cases
MIMARO
PA 3 Occidental 1
Oriental Mindoro 1
Romblon 1
5 14 Albay 1
Camarines Norte 3
Camarines Sur 9
Masbate 1
6 10 Aklan 1
Antique 1
Capiz 4
Iloilo 2
Negros Occidental 2
Region Cases Province Cases
7 10 Bohol 1
Cebu 6
Negros Orriental 3
8 9 Leyte 8
Samar 1
Zamboanga Del
9 10 Sur 10
10 16 Bukidnon 11
Lanao Del Norte 1
Misamis
Occidental 1
Misamis Oriental 3
11 14 Campostela 1
Davao Del Norte 3
Davao Del Sur 8
Davao oriental 1
Region Cases Province Cases

12 10 North Cotabato 2
sarangani 1
South Cotabato 2
Sultan Kudarat 5
ARMM 3 Basilan 1
Maguindanao 2
CAR 2 Abra 1
Baguio 1
CARAG Agusan Del
A 5 Norte 1
Agusan Del Sur 2
Surigao Del
Norte 1
Surigao Del Sur 1
NCR 8 Marikina 2
 NATIONAL GOAL

To eliminate human rabies in the

Philippines and declare rabies-free
Philippines by year 2020.
Lets Help End Rabies
Together for a Rabies-Free
Philippines

Thank you for Listening

Rabies- The Disease
 Rabies- The Disease

Acute. Progressive, incurable viral encephalitis with a fatal outcome

Transmission:
Bite Exposure:
Injection of infectious saliva into a break a skin

Non- Bite
Licking of scratches, abrasions, open wounds or intact mucous
membrane
Inhalation/aerosol- bats in caves
Human to human:
15 documented cases of fatal rabies following transplantation
Corneal transplant- 8
 Exposure

Transplant Aerosol

Cornea Caves
Solid organs Laboratory
Vascular conduit

Lick

Broken skin
Mucous membranes Bite/Scratch
Incubation Period- is the period from the time of exposure up to
the appearance of first clinical signs and symptoms of rabies.
The average incubation period of human rabies is
between one- three (1-3) months. In 90-95% of cases,
incubation period is less than one year but may be longer in 5-
10% cases.
The duration of the incubation period depends on certain
factors:
(1)- The amount of virus inoculated into the wound or
mucosa
(2)- Severity of exposure- patients with multiple
and/ or deep penetrating bite wounds may have
shorter incubation period.

(3)-Location of exposure- patients with bite

wounds highly innervated areas and or close to
central nervous system may have shorter
incubation period.
 Clinical Stages

Prodromal
The prodromal stage occurs when there is initial viral
replication at the striated muscle cells at the site of
inoculation just before it enters the brain. The virus then
spreads centripetally up the nerve to the central nervous
system through the peripheral nerve axoplasm.
This stage lasts for 0-10 days with non-specific
manifestations, which include fever, sore throat, anorexia,
nausea, vomiting, generalized body malaise, headache and
abdominal pain. Paresthesia or pain at the site of bite is due
to viral multiplication at the spinal ganglion just before it
enters the brain
 Acute Neurologic

is the stage when the virus reaches the CNS and replicates
most exclusively within the gray matter. This stage has two
types of presentation: encephalitic or furious type, which is
present in 80% of rabies cases, and paralytic or dumb type,
which is seen in 20 %.

Autonomic manifestations such as hypersalivation appear

during this stage. The virus passes centrifugally among
autonomic nerves to reach other tissues- the salivary gland,
adrenal medulla, kidney, lung, liver, skeletal muscle, skin and
heart. Passage into the salivary gland facilitates further
transmission of the disease through infected saliva.
This stage lasts for 2-7 days, characterized by
hyperactivity, hypersalivation, disorientation, and
hallucination, bizarre behavior interspersed with lucid
intervals, seizures, nuchal rigidity or paralysis
 Two types of Presentation of the Acute Neurologic stage in
Rabies in Human
Neurlogic or Furious Type
Hyperactivity(anxiety, agitation,
running, biting, bizarre behavior
alternating with periods of calm) which
may occur spontaneously or may be
precipitated by tactile or auditory,
visual or other stimuli.
The most characteristic symptom is
spasm of the pharyngeal muscles often
triggered by an attempt to drink
water( hydrophobia) or by blowing air
on patients face.(aerophobia).
Spasmodic contractions of the muscles
may spread to the respiratory and other
muscles leading to attacks of apnea.
Paralytic or Dumb Type
Acute progressive ascending myelitis,
symmetrical or asymmetrical with
flaccid paralysis, pain and fasciculation
in the affected muscles with mild
sensory disturbance.
A complete paraplegia develops
eventually with fatal paralysis of the
respiratory and pharyngeal muscles.
COMA- begins w/in 10 days of onset,
and the duration varies
DEATH- w/out intensive supportive
care, respiratory depression, cardio
respiratory arrest, and death occur in
almost 100% of cases.
Categorization and
Management of
Rabies Exposure
 Categories of Rabies Exposure with
Corresponding Management

Category of Exposure
CATEGORY I
a) Feeding/touching an animal
b) Licking of intact skin (with 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 (talking to, visiting and feeding suspected rabies cases) and routine
delivery of health care to patient with signs and symptoms of rabies
 Management of Category I Exposure

1. Wash exposed skin immediately with soap and water.

2. No vaccine or RIG needed
3. Pre-exposure prophylaxis
- may be considered for high risk persons.
 Category II

a) Nibbling of uncovered skin with or without bruising/hematoma

b) Minor scratches/abrasions without bleeding
c) Minor scratches/abrasions which are induced to bleed
d) All Category II exposures on the head and neck area are
considered Category III and should be managed as such.

* includes wounds that are

induced to bleed
 Category III

a) Transdermal bites (puncture wounds, lacerations, avulsions) or

scratches/abrasions with spontaneous bleeding
b) Licks on broken skin
c) Exposure to a rabies patient through bites, contamination of
mucous membranes (eyes, oral/nasal mucosa, genital/anal
mucous membrane) or open skin lesions with body fluids
through splattering and mouth-to-mouth resuscitation.
d) Handling of infected carcass or ingestion of raw infected meat
e) All Category II exposures on head and neck area
Management of Category III exposures

1. Wash wound with soap and water.

2. Start vaccine and RIG immediately:
 Local Wound Care

Wounds should be immediately and

vigorously washed and flushed with soap
and water preferably for 10 minutes
 Local Wound Care

Apply antiseptic
(alcohol, tincture of iodine
etc)
Antibiotics indicated for:
All frankly infected wounds
All category III cat bites
All other category III bites that are either deep,
penetrating, multiple or extensive or located on
the hand/face/genital area
Drugs of choice: Amoxicillin/clavulanic OR
Cloxacillin OR Cefuroxime axetil
 Local Wound Care

Anti-tetanus immunization should be given since animal

bites are considered tetanus prone wounds
 Local Wound Care: Donts

If possible, suturing of wounds should be avoided

(as it may inoculate virus deeper into the wound)
Wounds may be coaptated using sterile adhesives strips
However, if suturing is necessary, anti-rabies
immunoglobulin should be infiltrated around and
into the wound before suturing
If suturing is unavoidable, it should be delayed for at
least 2 hrs after administration of RIG to allow diffusion
of the RIG to occur through the tissues
 Guidelines in Giving RIG

Rabies Immune Globulin (RIG) provides immediate but

short-lived protection against rabies.
Given only to all Category III exposures, in
combination with an anti- rabies vaccine- not affected by
status of dog/animal before and during PEP
RIG should be given as a single dose for all Category III
exposures, in combination with an anti- rabies vaccine
RIG should be given only once during the same course of
PEP;
 In the event that RIG and vaccine cannot be given on the
same day, the vaccine should be given before RIG because it
inhibits the level of neutralizing antibodies induced by
immunization;
RIG may still be given anytime before day7 dose of the
vaccine.
 Guidelines in Giving RIG (3)

RIG requirement is computed base on the patients

body weight :
HRIG : 20 IU/kg BW
ERIG/Fab2 : 40 IU/kg BW

RIG should not exceed the computed dose as it may

reduce the efficacy of the vaccine
 Guidelines in Giving RIG (4)

RIG INFILTRATION
A skin test is performed prior to ERIG
administration
Induration of > 6mm = Positive skin test

Hypersensitivity to ERIG may not be predicted by

skin test. Always be ready with epinephrine and anti-
histamine for treatment of hypersensitivity
OBSERVE the patient for at least 1 hour after
giving RIG
 Guidelines in Giving RIG (5)

RIG should be infiltrated around and into the

wound as much as anatomically feasible, even if
the lesion has begun to heal
 Management of Rabies
Exposure:
Post- Exposure prophylaxis
(PEP)
General Guidelines on the Provision of Post
Exposure Prophylaxis (PEP) to Potential
Rabies Exposure

Initiation of PEP should not be delayed for any

reason- increases the risk of rabies and associated
with treatment failure.
- There are no absolute contraindications
to PEP.
- Management should depend on the category of
exposure to rabies
 General Principles of PEP

Reduce the quantity of rabies virus at the bite site

Local wound care
Ensure a high titer of neutralizing antibodies
early and maintain it for as long as possible
RIG infiltration (Passive)
Vaccination with anti rabies vaccine (active immunization)
Anti Rabies Vaccination
 Guidelines in Giving Anti- Rabies Vaccine (1)

Anti Rabies Vaccine (ARV) are given to all Category II

and III exposures
Vaccines are needed to provide long term protection
against rabies to individuals exposed to rabies
It confers protection only after adequate levels of
antibodies have been produced
Develops Slowly (10 14 days)
Guidelines in Giving Anti- Rabies Vaccine (2)

2 types of anti-rabies vaccines for both

intradermal and intramuscular use are
available in the Philippines
PVRV (0.5 ml/vial)
PCECV (1.0 ml)

The potency of vaccine for IM use should be

at least 2.5 IU/dose and for ID use should
be at least 0.5 IU/dose
 Guidelines in Giving Anti- Rabies Vaccine (3)

RECOMMENDED REGIMEN
1. Intradermal Regimen
2. Intramuscular Regimen
Patients who are immuno-compromised or who are taking
immuno suppressive drugs as they may not respond to the
reduced antigen in the ID regimen
Patients taking chloroquine, steroids
Children where ID regimen may be technically difficult
 Guidelines in Giving Anti- Rabies Vaccine (4)

Injection should be given in the deltoid area of each arm

in adults or at the anterolateral aspect of the thigh in
infants

Vaccine should never be injected in the gluteal area as

absorption is unpredictable

ID injection should produce a minimum of 3mm wheal in

the event that a dose vaccine is inadvertently given SC, or
IM, the dose should be repeated
INTRADERMAL REGIMEN
Updated 2-site Intradermal Regimen
( 2-2-2-0-2 )
Day 0 Day 3 Day 7

Day 28/30

ID dose = 0.1 ml
PVRV/PCEC
INTRAMUSCULAR REGIMEN
 B1. Standard Intramuscular Regimen
(Essen)
Day 0 Day 3 Day 7 Day 14 Day 28

IM dose = 0.5 ml for PVRV

1.0 ml for PCECV
B2. 2-1-1 Intramuscular Regimen (Zagreb)

Day 0 Day 7 Day 21

IM dose = 0.5 ml for PVRV

1.0 ml for PCECV
Management of Previously Vaccinated
Animal Bite Patients
 Management of Previously Vaccinated Patients(1)

The following patients are considered to have completed the primary immunization:
1. Those who have received day 0, 7 and 21/28 of the
PReP
2. Those who have received at least day 0, 3 and 7 of the
PEP
Persons with incomplete PrEP/PEP should be managed as
if no previous injections have been received
Management of Previously Vaccinated Patients(2)
1. Local wound care must always be carried out
2. All exposure do not require RIG including
category III exposure
3. All exposures must be provided with booster
doses only
 Management
Category of
Local Rabies Immune Anti- Rabies
Exposure Wound Care Globulin (RIG) Vaccine

Category I YES NO NO
Category II YES NO Give Booster
dose every
exposure
Category III YES NO Give Booster
dose every
exposure
Schedule of Booster Dose

Give 0.1 ml ID dose of PCEC or PVRV at 1 site

each on D0 and D3
OR
1 vial IM dose PCEC or PVRV at 1 site each on
D0 and D3
Management of Rabies Exposures
Secondary to Bites by Vaccinated
Animals
(Joint DOH- DA AO s. 2011)
Management of Rabies Exposures Secondary to
Bites by Vaccinated Animals (1)
I. PEP is not recommended for all Category I exposures.
II. PEP can be delayed for Category II Exposures provided that
ALL of the following conditions are satisfied:
Dog/cat is healthy and available for observation for 14 days
Dog/cat is vaccinated against rabies for the past 2 years:
Dog/cat must be at least 1 yr and 6 months old and has updated
vaccination certificate from a duly licensed veterinarian for the last 2
years
The last vaccination must be within the past 12 months, the
immunization status of the dog/cat will not be considered updated if
the animal is not vaccinated on the due date of the next vaccination
* If biting dog/cat becomes sick or dies within the
observation period, PEP should be started immediately
Management of Rabies Exposures Secondary to
Bites by Vaccinated Animals (2)

PEP can not be delayed for ANY of the following

conditions :
1. The rabies exposure is category III;
2. The dog/cat is proven rabid/sick/ dead with no laboratory
exam for rabies/not available before or during the
consultation;
3. The dog/cat is involved in at least 3 biting incidents within 24
hours or
4. Dog/cat manifests behavior changes suggestive of rabies
before, during or after the biting incident:
 Special Conditions

1. Pregnancy and infancy:

are not contraindications to treatment with
modern
Tissue Culture Vaccines (TCVs); Nerve Tissue Vaccine
is not recommended during pregnancy
2. Drugs and alcohol
Avoid chloroquine, systemic steroids and heavy
alcohol consumption during rabies immunization as they
may interfere with the immune response. If this cannot
be avoided, the standard IM regimen should be used
 Special Conditions
3. Immunocompromised individuals (HIV
infection, cancer/transplant patients on
immunosuppressive therapy etc) should be given
vaccine using standard IM regimen and Rabies
Immune Globulin (RIG) for both Category II and
III exposures.
4. Delay in Consult:
Exposed persons who present for evaluation or treatment
weeks or months after the bite
Treat as if the bite was recent
If the biting animal has remained healthy and
alive until 14 days after the bite, PEP is not
needed
 Special Conditions
5. Bites by other animals:
rodents, guinea pigs, rabbits snakes and other cold blooded
animals do not require rabies PEP unless the animal is proven
rabid.
Bites by domestic animals other than dogs and cats (cattle,
pigs, horses, etc), monkeys and other wild animals require
rabies PEP.

6. Shifting from one vaccine brand:

Shifting from one vaccine brand to another is not recommended but
may be warranted for the following situations provided that it is one of
the WHO recommended cell culture vaccines:
hypersensitivity reaction
unavailability of initial vaccine used
 Special Conditions
7. Shifting from one regimen
Shifting from one regimen to another (IM to ID, ID to IM) is
not recommended. As much as possible the initial regimen
should be completed.
Pre- Exposure Prophylaxis (PrEP)
 Pre- Exposure Prophylaxis (1)
Pre Exposure Prophylaxis (PrEP) - refers to rabies
vaccination administered before an exposure to
potentially rabid animals. This is usually given to
those who are at high risk of getting rabies.
 Pre- Exposure Prophylaxis (2)
Recommended for persons at high risk for rabies
exposure:
- Veterinarians and veterinary students
- Animal handlers/pet owners
-Laboratory staff handling rabies virus
-Health care workers caring for rabies patients
- Individuals directly involved in rabies control
- Young children (5-14 years)
 Pre- Exposure Prophylaxis (3)

Consist of three doses of 0.1 ml of PCEC or PVRV

given intradermally (ID) or 1 vial of 1 ml of PCEC or 0.5
ml of PVRV given intramuscularly (IM) on the following
days:

Day 0 Day 7 Day 21/28

 REMEMBER !!!!!!
Pre- Exposure Prophylaxis
- Does not eliminate the need for Post- Exposure
Prophylaxis (PEP) after a rabies exposure.

- Simplifies the PEP requirement for previously

vaccinated persons by eliminating the need
for RIG and decreasing the number of doses of
vaccine needed !!!
Lets End
Rabies
Together

THANK YOU
FOR LISTENING