National Rabies Control and Prevention Program

National Rabies Prevention and Control Program Situationer • Rabies is a public health problem because of the ff. reasons: 1. It is one of the most acutely fatal infections which causes death between 200-500 Filipinos annually 2. The Philippines ranked number six among the countries with the highest reported incidence of Rabies in the world • The National Center for th Disease Prvention and Control reported that in 2004 there were 6 regions with the highest number of rabies cases: 1. Western Visayas 2. Central Luzon 3. Bicol 4. Central Visayas 5. Ilocos 6. Cagayan Valley • 53.7% of animal bite patients are children • The trend for animal bite cases (ABCs) has increased from 1992-2001 but decreased from the year 2002-2004 • Human rabies cases has been decreasing from 1995-2004 • Dogs are the principal source of Rabies • In 2004, there were 95,588 animal bite victims • 88% were bitten by dogs • 58% (55,582) had post0exposure vaccination • 42% (39,980) had no vaccine protection • 0.2% (228) were confirmed Rabies cases based on the appearance of unequivocal signs and symptoms of rabies Implementing Agencies • The NRPCP is jointly implemented by the Department of Agriculture (DA) and the DOH in collaboration with the DECS and DILG DOH – provide human anti-rabies immunizing agents to high risk ABCs DA – lead agency - conducts and supervises dog immunization activities and dog control measures DECS, ILG & LGUs – assist in the promotion of Responsible Pet Ownership Animal Bite Treatment Centers (ABTCs) maximize use of vaccines established in strategic areas where intradermal administration of vaccines is done NCR: RITM, San LAZARO Hospital, MHD in Manila City Hall National Objectives for 2005-2010 Goal: Rabies is eliminated as a public health problem  Rabies is eliminated as a public health problem at less than 0.5 cases per million population 1.

Incidence of Rabies is reduced  Indicator: Incidence rate of rabies per million population  Target: 2.5 cases per million population

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Baseline: 3.4 cases per million population NCDPC, 2002

2. Voluntary pre-exposure coverage is increased  Indicator: Number of volunteers who received prophylaxis  Target: 5 million  Baseline: 50,900 nationwide NCDPC, 2005 3.

Increase dog immunization coverage  Indicator: Number of dogs immunized  Target: 5 million dogs nationwide  Baseline: 1,100,100 dogs nationwide DA, 2004

4.

Rabies elimination level is achieved in endemic areas  Indicator: Number of provinces with < 0.5 cases/million population  Target: 7 provinces  Baseline: 0 province DOH, 2004

Canine Rabies Mean Incidence Rate in 2000 – 24/100,000 dog population Regions with the highest incidence of Rabies • Region 3 = 549 • Region 4 = 386 • NCR = 293 • Region 1 = 289 • Region 6 = 111 Manifestations of Rabies Canine 1. Prodrome Stage – increased alertness or apathy, fever, papillary dilatation, increased muscular tone 2. Excitement Stage – unusual restlessness, biting at inanimate objects, aimless running, difficulty in swallowing, change in bark or growl 3. Paralytic Stage – dog unable to take food or swallow water, paralysis of the jaw and tongue, drooling saliva, paralysis of hindquarters • Death occurs within 3-7 days after the initial symptoms Diagnosis of Canine Rabies Diagnosis of rabies can be based upon the clinical symptoms but should be confirmed by laboratory exams 1. Direct Microscopic Examination – demonstration of Negri bodies diagnostic 2. Fluorescent Antibody Test – rapid and sensitive method of diagnosing rabies 3. Mouse Inoculation Test Prevention and Control of Canine Rabies 1. Mass Dos Immunization 2. Impounding / Elimination of stray dogs 3. Proper Diagnosis and Surveillance 4. Public Information Campaigns • Promotion of Responsible Pet Ownership o Main Thrust of the NRPCP - includes providing pets with proper food and shelter,

5.

vaccination against rabies, regular consultation with vets, keeping pets within our own backyard Quarantine – restriction of movement of dogs

Management of Animal That Bite Human • Healthy dogs and cats that bite a person should be confined and observed for 14 days • If any signs suggestive of rabies develop, the animal should be killed, its head cut off and placed in a sealed styroform under refrigeration for examination at the diagnostic lab • Any stray dogs and cats that bite humans maybe euthanized immediately and the head submitted for rabies examination Human Rabies Definition: • Human Rabies case – an individual manifesting aerophobia / hydrophobia with history of animal bite exposure • Animal Bite case – a person with history of bite or non-bite exposure • Bite Exposure – any penetration of the skin by the teeth of a biting animal • Non-bite Exposure – are scratches, abrasions, open wounds or mucous membrane contaminated by the saliva or other potentially infectious materials such as brain tissues from a rabid dog

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3. 4.

Revised Guidelines on the Management of Animal Bite Patients Administrative Order No. 164 DOH 2002 Management of Potential Rabies Exposure  Category I o Feeding / touching an animal o Licking of intact skin (with reliable history and thorough PE) • Management Wash exposed skin immediately with soap and water - No vaccine or RIG needed 

Category II o Nibbling of uncovered skin o Minor scratches / abrasions without bleeding o Licks on broken skin • Management Start vaccine immediately Condition of the animal I. Complete vaccination regimen until day 90 if: a. Animal is rabid, killed, died or unavailable for 140day observation or examination b. If animal under observation died within 14 days and was FAT positive or no FAT testing was done or had signs of rabies II. Complete vaccination regimen until day 30 if: a. Animal is alive and remains healthy after 14-day observation period b. Animal under observation died within 14 days, was FAT negative and without any signs of rabies

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Category III o Single or multiple transdermal bites or scratches o Contamination of mucous membrane with saliva o Exposure to a rabies patient o Handling of infected carcass or ingestion of raw infected meat o All Category II exposures on head and neck area • Management: Start vaccine and RIG immediately Condition of the animal I. Complete vaccination regimen until day 90 if a. Animal is raid, killed, died or unavailable for 14-day observation or examination

Mode of Transmission: • Most common: inoculation of virus-laden saliva from the bite of a rabid animal • Other routes: o Contamination of intact mucosa or broken skin with saliva or body fluids of rabid animals o Inhalation of aerosolized virus o Tissue transplant from an undiagnosed rabid donor Incubation Period • Usually between 20-90 days 90-95% of cases = 1 year or less 5-10% = varies from 1-5 years • Variations in length of IP depend on: o Severity of the bite o Distance of the bite to the CNS o Amount of virus introduced o Immune status of the host Clinical Stages of Human Rabies 1. Prodrome lasts for 10 days non-specific symptoms: fever, sore throat, anorexia, nausea, vomiting, body malaise, headache and abdominal pain pain or paresthesia at the bite site 2. Acute Neurologic Phase lasts from 2-7 days

hyperactivity, hypersalivation, hallucination, seizures, nuchal rigidity or paralysis Coma Death

o

2-Site Intradermal Schedule 2-2-2-0-1-1 Day of Immunizat ion Day 0 Day 3 Day Day Day Day

7 14 30 90

Active 



PDEV/PCE CV

Site of PVRV Injection left&right 0.1ml 0.2ml deltoids left&right 0.1ml 0.2ml deltoids left&right 0.1ml 0.2ml deltoids none none none 0.1ml 0.2ml one deltoid 0.1ml 0.2ml one deltoid b. Animal under observation died within 14 days and FAT positive or no FAT testing was done or had signs of rabies II. Complete vaccination regimen until day 30 if: a. Animal is alive and remains healthy after 14-day observation period b. Animal under observation died within 14 days and was FAT negative and without any signs of rabies Immunization It induces an active immune response in 7-10 days after vaccination and may persist for 1 year or more Types of vaccines available in the Philippines: o Purified Verocell Rabies Vaccine (PVRV) 5ml/vial o Purified Duck Embryo Vaccine (PDEV) 1ml/vial o Purified Chick Embryo Cell Vaccine (PCECV) 1ml/vial

Passive Immunization  Rabies Immune Globulin (RIG) is given together with anti-rabies vaccine to provide immediate protection to patients wit Category III exposure  RIG is of two types: o Human Rabies Immunoglobulin (HRIG) Dose: 20 IU / kg BW (150 IU/ml) o Equine Rabies Immunoglobulin (ERIG) Dose: 40 IU / kg BW (200 IU/ml)  RIG should be given as single does for all Category III exposure  RIG should be infiltrated around and into the wound. Any remaining RIG should be administered IM at the site distant from the site of vaccine injection  A skin test must be performed prior to ERIG administration. A positive skin test is based on an induration of 6mm or more Post-exposure Treatment  Local Wound Treatment o Wash and flush wounds with soap and water preferably for 10 minutes o Apply alcohol, tincture of iodine or any antiseptic o Suturing of wounds should be avoided

Anti0tetanus immunization and antimicrobial maybe given if indicated

Treatment Regimen: • 2-Site Intradermal Schedule (2-2-2-0-1-1)  One dose of ID administration is equivalent to 0.1ml for PRVR and 0.2ml for PDEV/PCECV  One dose should be given at 2 sites on Days 0,3,7 and one site on Days 30 and 90  Injections should be given on the deltoid area of each upper arm in adults and on the anterolateral aspect of the thigh in infants  The schedule should be strictly followed to avoid treatment failure •

2-1-1 Intramuscular Schedule  One dose is equivalent to 1 vial of 0.5ml of PVRV or 1ml of PDEV/PCECV  Should be used in combination with RIG for Category III exposure  2 dosed are given IM on Day0 and 1 dose on Days7 and 21  If the dog is alive and healthy after the 14day observation period, discontinue the last dose

2-1-1 Intramuscular Schedule Day of Immuniza P PDEV/PCE tion VRV CV Site of Injection 0 left&right Day 0 .5ml 1ml deltoids 0 Day 7 .5ml 1ml one deltoid 0 Day 21 .5ml 1ml one deltoid

Standard Intramuscular Schedule Day of Immuniza P PDEV/PCE Site of tion VRV CV Injection 0.5m Day 0 l 1ml one deltoid 0.5m Day 3 l 1ml one deltoid 0.5m Day 7 l 1ml one deltoid 0.5m Day 14 l 1ml one deltoid 0.5m Day 28 l 1ml one deltoid 0.5m Day 90 l 1ml one deltoid

8-Site Intradermal Schedule Day of Immuniza tion

P CEC V

No. of Dos es

Site of Injection

Day 0

0.1m l

8

Day 7

0.1m l

4

Day 30 Day 90

0.1m l 0.1m l

Deltoid(2), anterolateral thigh(2) Deltoid(2), anterolateral thigh(2), lower quadrant of abdomen(2), suprascapular region(2)

1

Deltoid(1)

1

Deltoid(1)

Post-Exposure Treatment Under Special Conditions • Pregnancy and infancy are not contraindications to treatment with purified cell culture vaccines • Avoid Chloroquine, anti-epileptic drugs, systemic steroids and heavy alcohol consumption • Immuno compromised individuals should be given vaccine using standard IM regimen and RIG for both Category II and III exposures • Bites by rodents, rabbits and domestic animals other than dogs and cats do not require postexposure treatment unless the animal is proven rabid • Patients bitten by wild animals should be managed similarly as patients bitten by dogs and cats Post-Exposure Treatment of Previously Immunized Animal Bite Patients • Local wound treatment should always be done • Persons with a second exposure after having previously received complete pre-exposure prophylaxis and PET with tissue culture vaccine: o < 1 month = No booster dose o > 1 month – 3 years = 2 booster doses (D0,D3) o > 3 years = another full course of vaccine • Booster doses maybe given ID at 0.1ml for PVRV or 0.2ml for PDEV/PCECV or IM at 1 vial of PVRV, PDEV or PCECV. No need to give RIG Pre-Exposure Prophylaxis • Recommended to individuals at high risk of exposure to rabies • Initial Pre-exposure prophylaxis consist of giving 1 dose of vaccine on Days0,7 and 21 or 28 • One booster dose should be given every 2-3 years depending on the risk of work-related exposure Pre-Exposure Prophylaxis Schedule

Intraderm al Intramusc ular

PVRV D0

D7

0 .1ml 0 .5ml

0 .1ml 0 .5ml

PDEV / PCECV D21/2 8 0.1ml 0.5ml

D0

D7

0 .1ml 0 .5ml

0.1m l 0.5m l

D21/2 8 0.1ml 0.5ml

Dispensing of Human Anti-Rabies Immunizing Agents • Patients needing Post-exposure treatment shall be referred to the Animal Bite Treatment Centers where free human anti0rabies immunizing agents are administered • In Category II and III exposures, the patient shall be provided the initial 2 doses of tissue culture vaccine for the 2-1-1 schedule • If intradermal regimen is used, complete course of immunization is given free • If indicated, the patient shall be provided the required dose of RIG, if available. EIG is the first TIG of choice Provision of Free Anti-Rabies Immunizing Agents • The following shall be the program’s order of priority for free vaccine assistance 1. Patients bitten by animals found positive for “Negri Bodies” 2. Patients with Category III exposure 3. individuals exposed to human rabies patients thru bite/non-bite exposure 4. patients bitten by animals that are not available for observation (stray or slaughtered) 5. patients with Category II exposure Rabies Surveillance System (RSS) • Entails systemic collection of pertinent data on rabies, collation, interpretation and dissemination of information to appropriate user groups • Goal: To obtain a comprehensive view of the epidemiologic situation of rabies in the community so that appropriate preventive measures maybe instituted • All government and private hospitals, clinics and health centers shall be directed to notify government health officers or rabies fields coordinators of any human rabies case Specific Uses of RSS • To assess the magnitude and geographical distribution of rabies • To monitor the trends of rabies in the community • To monitor the impact of instituted intervention • To furnish public information on the risk of rabies exposure in an area • To provide indicators for decision on future health care needs