RABIES

Dr. Ahmed Ali Khan

 WHAT IS RABIES
• Rabies may be one of the oldest infectious
diseases known to man. It has been known
since as early as 2000 BC

• Latin word rabere : to rage or rave.

Sanskrit word rabhas : to do violence.

Greeks called it lyssa or lytta : frenzy or

madness.
• Rabies is a viral infection attacking the central
nervous system.

• It causes inflammation of the brain

(encephalitis). This causes pressure on various
areas of the brain, resulting in diverse
symptoms.
• It is usually spread through the bite or scratch
of an infected animal. ( Domestic or Wild)

• The saliva of an infected animal contains high

concentrations of the virus

• It is a zoonotic disease (a disease that is

transmitted to humans from animals).
• Once symptoms of the disease develop, rabies is
nearly always fatal.

• RABIES IS 100% FATAL BUT 100% PREVENTABLE!

• Popular Saying ‘’Prevention is the best medicine’’

 CAUSATIVE ORGANISM
• It is caused by Single-Strand, Negative Sense,
Ran Virus.

• Family : Rhabdoviridae
Genus : Lyssavirus
Species : Rabies Virus
 TRANSMISSION
• Dogs cause > 90% of the Human cases. Other
animals responsible include bats, foxes,
raccoons, skunks, cats
• Human-to-Human transmission also occurs.
Direct or Indirect.

1. Direct : bite ; contact with saliva or other

body fluids of infected person

2. Indirect : transplant related e.g. corneal

transplant, transplantation of solid organs or
vascular conduits
 INCUBATION PERIOD
• In dogs & cats, the virus may be present in the
saliva for 3-4 days before the clinical onset &
during the course of illness till death.

• It is highly variable in man, commonly 3-8

weeks following exposure.

• It can take any where from a few days to even

a few years before symptoms show; but on
average it takes between 30-90 days.
• The closer the site of bite is to the brain, the
shorter the incubation period.

• Rabies virus travels 1 cm per day (inside the

nervous system).

• The virus replicates in the muscle at bite site

• The rabies virus first connects to the receptors
on the muscle cells of the bite wound before it
binds itself to the nervous tissue.

• Other factors that influence incubation period

include : the number of bites, the amount of
transmitted virus, age and health of the
victim.
 SIGNS & SYMPTOMS
In the Animal

Two Forms :

1. Paralytic Type (20-25% cases)

2. Furious Type (75-80% cases)
1. Paralytic Type :

Also referred to as ‘Dumb Rabies’

Weakness and loss of coordination, followed
by paralysis

2. Furious Type :

Extreme behavioral changes, including overt

aggression, attack behavior
 It is also possible, a rabid animal exhibit both
types.

Some animals die due to the infection

without displaying any major symptoms.

It is important to observe the animal for at

least 10 days, if it has not displayed any
signs, to be certain.
 Therefore, following signs should be looked for in
a suspected animal :

• Show no fear for humans

• Act very agitated (without provocation)

• Make strange noises

• Foaming at the mouth ( due to paralysis of throat

and jaw muscles)

• Disorientation, Incoordination and Staggering

( due to paralysis in the legs)
In the Human

• Bite Marks - Pain or tingling at the site of the

bite

• Headache, Fever, Sore throat

• Bizarre behavior

• Nervousness, Confusion , Agitation

• Hallucinations (Seeing things that are not really
there )

• Seizures

• Paralysis

• Difficulty in drinking (due spasms of pharynx,

which produces choking)
• Afraid of water - Hydrophobia (even sight or
sound of water disturbs the patient)

(Hydrophobia in Rabies is described as “Fear

of water" due to spasms in the throat)

• Coma, Respiratory arrest and Death

(Death occurs in 1 - 6 days after signs appear)

 DIAGNOSIS

• Testing the animal

• Labs & Tests
• Imaging
• Testing the animal :

In order to do the test, the animal must be

euthanized and tissue samples are taken from
the brain. On microscopy, ‘Negri Bodies’ are
identified.

Test results are usually ready within 24 to 72

hours.
• Labs & Tests

No single test is considered sufficient in

diagnosing rabies in a living person,

• Lumbar Puncture (for CSF analysis)

• Saliva Direct Fluorescence Antibody Test
(DFA test)
• ELISA, RT-PCR

The presence of antibodies to rabies virus

indicates an infection.
• Imaging

Certain imaging tests can aid in the diagnosis

of rabies encephalitis (i.e., acute inflammation
of the brain resulting from rabies infection)

• Head MRI
• Head CT Scan
 MANAGEMENT
There is no known treatment of Rabies.

Management is based on Post-Exposure

Treatment (PET).

PET is divided into two phases :

1. Before Symptoms Have Appeared

2. After Symptoms Have Appeared
1. Before Symptoms Have Appeared :

• Local wound treatment, Wash lesions well with

soap and water (tetanus booster)

• Avoid suturing wounds. Don’t apply ointment,

cream or wound dressing

• Apply alcohol, povidone iodine or any antiseptic

• Tetanus Vaccine
• Infiltrate rabies immune globulin (20 IU/kg)
into and around the margin of the bites.
( for immediate passive immunity, until active
immunity begins 7-10 days after vaccination )

• Administer Anti-rabies vaccine on days

0,3,7,14, and 28. (Post-Exposure Prophylaxis)

• Prophylactic Antibiotics for high-risk wounds,

or people with immune deficiency.
( e.g. Amoxicillin, Cloxacillin or Cefuroxime )
2. After Symptoms Have Appeared :

• Once symptoms start, treatment is supportive.

• It should center on comfort care, in an

appropriate medical facility. Patient should be
admitted in a quiet, draft-free, isolation room.

• Supportive care includes :

• using sedation ( e.g. Diazepam, Midazolam,
Haloperidol + Dipenhydramine)

• avoidance of intubation (invasive procedures

must be avoided )

• life support measures

• Doctors, nursing staff & relatives in contact
with the patient should wear proper personal
protective equipment (gown, gloves, mask,
goggles)
 COUNSELLING
• Provide suitable emotional support

• Discuss & provide important information to

relatives concerning transmission of disease &
indication for PET of contacts

• Honest gentle communication concerning

prognosis should be provided to relatives of
patient
 PREVENTION & CONTROL

• PRE-EXPOSURE PROPHYLAXIS
• POST-EXPOSURE PROPHYLAXIS
• WHO CATEGORISATION OF EXPOSURE
PRE-EXPOSURE VACCINATION

• Provided to subjects at risk before occupational

or vocational exposure to rabies.

• Subjects include diagnosticians, laboratory &

vaccine workers, veterinarians, cavers, hikers, etc.

• Simplifies post exposure management.

• Only vaccines used.

POST-EXPOSURE PROPHYLAXIS

• Provided to subjects after rabies exposure.

• Consists of :

a. Wound care
b. Rabies immune globulin
c. Anti-rabies vaccine
d. Prophylactic Antibiotics
WHO CATEGORISATION OF EXPOSURE
TREATMENT ACCORDING TO WHO
CATEGORIES OF EXPOSURE
 DOSAGE SCHEDULE
Intramuscular Schedule ( Deltoid/ Thigh )

1. Essen Schedule (Day 0, 3, 7, 14, 28 )

One Dose per Visit. Total 5 Visits.

2. Zagreb Schedule ( Day 0, 7, 21 )

Two Doses on First Visit, Then One Dose per
Visit. Total 3 visits.
Intradermal Schedule (Updated 2-Site Regimen)

• Day 0, 3, 7, 28 – Two doses per visit. Total 4 Visits

Pre-Exposure Schedule

• Day 0, 3, 7, 21/ 28 – IM or ID. One Dose per Visit.

Total 3 Visits.
 VACCINES USED
• HDCV ( Human Diploid Cell Vaccine) Rabivac

• PVRV ( Purified Vero Cell Rabies Vaccine )

Verorab

• PCECV ( Purified Chick Embryo Cell-Culture

Vaccine) Rabipur
 COMPLICATIONS
• Always fatal, once symptoms of the disease
develop. Very poor prognosis.

• Complications If not Treated or Treatment

Failure : Death is Certain

• Early initiation and proper treatment

increases the chances of survival.
General Safety Measures

• Be careful and act responsibly around stray

animals
• Get your pets vaccinated against rabies
• Learn how to recognize an animal with rabies
• Know how to avoid dog bites
• Learn about dog body language
• Contact Animal Control Services if you suspect
an animal of rabies or too many stray dogs in
the locality