Family and Community
Medicine 3
AY 2019-2020
1st Shifting Exam
FIRST SHIFTING SUMMARY
02/05/2020
SOLID WASTE MANAGEMENT
LEGEND:
2019 Review Questions
2020 Review Questions
2021 Review Questions
TERMS
DEFINITION
A zoonotic disease and human infection caused by Lyssavirus
Principal Reservoir: dogs
MOT: bite from an infected animal where the infectious material directly contact the victim’s
mucosa or fresh skin lesion.

Incubation Period: 1-3 weeks depends on:
 Amount of the virus inoculated
 Severity of exposure
 Location of exposure

Clinical Stages:
 Prodromal Period (0-10 days)
 Acute Neurologic State

Furious stage

Paralytic/ dumb girl
 Coma
 Death
Worldwide

55,000 deaths every year
 56% of the cases occurring in Asia
 43% in Africa
 mostly in rural areas

Present in all continents except in Antarctica.
Philippines

2014-2018: 1176 cases

Predominantly males (73%)

Affects 3-87 years old

Region 3 comprises 26% of cases followed by Region 4A (16%), and Region 7 (10%)

RA 9482 (Anti-Rabies Act of 2007)

Vision: To declare Philippines Rabies-Free by year 2022

Mission: To eliminate human rabies by the year 2020
 Giving vaccine with or without Rabies Ig (RIG) depending on the level or category of exposure.
Guiding Principle:
 Shared responsibility of the DOH, Local Government Units, animal bite patients and dog/pet
owner
 Epinephrine and antihistamines should be made available for possible hypersensitivity reactions
 All clinically significant Adverse Events Following Immunization (AEFI) shall be reported to the
AEFI Surveillance and Response System.
Management of Rabies Exposure
 Should not be delayed for any reason
 No absolute contraindications to rabies PEP (even pregnancy and infancy)
 Babies who are born to a rabid mother should be given a vaccination as well as RIG as early as
possible
CATEGORY
TYPE OF EXPOSURE
MANAGEMENT
Category 1
 Feeding/touching an animal
 Wash exposed skin immediately with
soap and water.
 Licking of intact skin
 No vaccine or RIG needed
 Exposure to patient (with SSX of
rabies) by sharing of eating or
 Pre-exposure prophylaxis may be
drinking utensils
considered for high risk persons.



Rabies
Epidemiology
National Rabies Prevention and
Control Program (NRPCP)
Strategy 1: Provision of Post
Exposure Prophylaxis to all
rabies exposures/animal bite
victims (Provided by RA 9482)
1st Shifting
MaidenPretty �
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 Wash wound with soap and water.
 Start vaccine immediately:

 Complete vaccination regimen until
Day 28 if:
 Biting animal is laboratory proven
to be rabid OR

 biting animal is killed/died without
laboratory testing OR
 biting animal has signs and
symptoms of rabies OR
 biting animal is not available for
observation for 14 days
 May omit Day 28 dose if:
 biting animal is alive AND remains
healthy after the 14-day
observation period, OR
 biting animal died within the 14
days observation period, confirmed
by veterinarian to have no signs
and symptoms of rabies and was
FAT negative
 RIG is not indicated.
Category 3
 Transdermal bites (puncture
 Wash wound with soap and water.
wounds, lacerations, avulsions) or
 Start vaccine immediately:
scratches/abrasions with
 Complete vaccination regimen until
spontaneous bleeding
Day 28 if:
 Licks on broken skin or mucous
 Biting animal is laboratory proven
membrane
to be rabid OR
 Exposure to a rabies patient
 biting animal is killed/died without
through bites, contamination of
laboratory testing OR
mucous membranes or open
 biting animal has signs and
skin lesions with body fluids
symptoms of rabies OR
through splattering and mouth-to
 biting animal is not available for
mouth resuscitation
observation for 14 days
 Unprotected handling of
 May omit Day 28 dose if:
infected carcass
 biting animal is alive AND remains
 Ingestion of raw infected meat
healthy after the 14-day
 Exposure to bats
observation period, OR
 All Category II exposures on head
 biting animal died within the 14
and neck areas
days observation period,
confirmed by veterinarian to have
no signs and symptoms of rabies
and was FAT negative
 RIG is indicated.

Anti- tetanus immunization may be given if indicated. History of tetanus immunization
(TT/DPT/Td) should be reviewed. Animal bites are considered tetanus prone wounds.

Intradermal Regimen
 Patients with hematologic
 ID injection should produce a minimum of 3 mm wheal

Updated 2-Site Intradermal Region
Category 2

Casual contact and routine
delivery of health care to patient
with SSX of rabies
Nibbling of uncovered skin with
or without bruising/hematoma
Minor /superficial
scratches/abrasions without
bleeding, including those induced
to bleed
All Category II exposures on the
head and neck area are
considered Category III and
should be managed as such.
Active Immunization

FCM 3
SUMMARY: 1st Shifting
Intramuscular Regimen
 Immunocompromised patients (px with HIV infection, cancer, chronic liver disease
and those taking chloroquine and systemic steroids
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
Standard Intramuscular Regimen – Essen

Rabies Immunoglobulin (RIG)
 ERIG / HRIG
Given to patients with Category III exposures
Indicated for immunocompromised individuals (with HIV Infection, cancer/transplant patients,
patients on immunosuppressive therapy)


Passive Immunization
Administration:

Skin test must be performed prior to ERIG administration (0.02 ml of 1:10 dilution solution)\
 A positive skin test is an induration of >6 mm surrounded by a flare/erythema

Give HRIG

Indications of HRIG:
History of hypersensitivity to equine sera
Multiple severe exposures especially where the dog is sick or
suspected of being rabid
Symptomatic HIV infected patients

In case of anaphylactic reaction, give adrenaline/epinephrine (0.5 ml of 0.1 per cent solution)
 1 in 1000, 1 mg/ml for adults
 0.01 ml/kg body weight for children,

RIG should be administered at the same time with the first dose of rabies vaccine (Day 0).
 If RIG is unavailable on Day 0, it may still be given until 7 days after the first dose of
the vaccine (Day 0).
 Beyond Day 7, RIG is not indicated because an active antibody response has already
started and interference between active and passive immunization may occur
Management of Previously
Immunized Cases

VACCINATED ANIMALS

FCM 3
SUMMARY: 1st Shifting
Vaccinated Animal - Dog/cat must be at least 1 year and 6 months old and has updated
vaccination certificate for the last 2 years.
Updated Vaccination - the last vaccination must be within the past twelve months
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Delays In Schedule
Anti-Tetanus Immunization

Animal bites are tetanus-prone wounds.
Supportive Management
Antimicrobials

most common organism isolated from dog and cat bites is Pasteurella multocida

Indications:
 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




STRATEGY 2: ABTC/ABC
certification as quality PEP
providers

FCM 3
SUMMARY: 1st Shifting
Animal bite treatment centers (ABTC) are government- owned/operated
Animal bite centers (ABC) are private-owned/operated
Department of Health
 Ensures the provision of quality vaccines
 Provides certification using a self assessment form
Guiding principles:
 Established based on CHD recommendations
 Established for every 150,000 population
 Manned by trained physician
 Shall use only FDA approved (RIG)and WHO prequalified vaccines.
 Certified by DOH and accredited by PhilHealth
 Maintain a standardized recording and reporting system.
 Functional two-way referral system.
Requirements:
 Physical set-up (Signage, consultation and wash area, refrigerator, etc)
 Manpower (DOH/CHD trained Medical Doctor and Nurse)
 Supplies (Vaccines and RIG, Syringes, dressing kit, emergency materials, etc)
 Recording and Reporting (Exposure registry, PEP card, quarterly/annual reports,
etc)
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
STRATEGY 3: Provision of PreExposure Prophylaxis (PrEP) to
high risk individuals and
school children in high
incidence area (Provided by RA
1984)
Recommended Booster Schedule:
 1 Booster dose after 1 year of primary immunization:
 0.1 ml ID dose of PVRV or PCEC on D0 OR
 0.5 ml IM dose of PVRV or 1.0 ml PCEC on D0
 Thereafter 1 booster, if Ab titers fall below 0.5 IU/ml OR
 In the absence of serologic testing, 1 booster dose every 5 years

RESPONSIBLE PET OWNERSHIP (RA 9482 or the Anti Rabies Act of 2007)
 Have their dog regularly vaccinated against Rabies and
 mandatory registration
 Maintain control over their dog and not allow it to roam
 Provide dog with proper grooming, adequate food, and clean shelter
 Report immediately any dog biting within twenty-four (24) hours
 Assist the dog bite victim

Stray Dog Management
 Impounding
 Field Control
Surgical Sterilization through spaying/castration
Non-surgical Sterilization
 Chemical sterilization
 Isolation of females
Habitat Control
 Proper garbage disposal
STRATEGY 4: Strengthened IEC
(Information, Education, and
Communication) campaign
Dog Population Management
 Policies and Procedures (cold chain management, waste management, etx )
Pre-exposure prophylaxis (PrEP)



Dog Movement Control
FCM 3
SUMMARY: 1st Shifting
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

STRATEGY 5: Advocacy
Campaign
STRATEGY 6: Training of
Medical Doctors and Registered
Nurses of ABTCs/ABCs







STRATEGY 7: Disease-Free Zone
STRATEGY 8: Integration of
Rabies Curriculum in Elementary
Curriculum
STRATEGY 9: Post-Mortem
Review




STRATEGY 10: Support to
Department of Agriculture on
Dog Vaccination
FCM 3
SUMMARY: 1st Shifting
Rabies Awareness Month (March)
World Rabies Day (September 28)
Main Stakeholders
 Building Healthy Public Policy
 Animal bite victims
 Legislators, local chief executives, NGOs, and POs
5 Key Strategies for Health Promotion
 Building Healthy Public Policy
 Creating Supportive Environment
 Strengthening Community Action
 Developing Personal Skills
 Re-orienting Health Services
Required for certification of Animal Bite Treatment Centers by the DOH and accreditation
by PhilHealth
Training is conducted by the Research Institute for Tropical Medicine
See p.12 of Trans S2T2 (3A) for discussion of Training Program
Local ordinance on the prevention and control of rabies.
Localized comprehensive Rabies Prevention/Control and Elimination Program.
Specific Requirements: Human Rabies-Free Zone
 No case of indigenously acquired infection by a Lyssavirus should be confirmed in
any human at anytime for at least two (2) years through monthly zero-case reporting
from the Municipal Health Office.
 Comprehensive rabies vaccination program in a place for two (2) years
 Adequate laboratory-based surveillance system
 Enforcement of control measures to eliminate, destroy and dispose straydogs as
per existing ordinance.
 Effective dog movement control measures
 Information, education and communication campaign
Sustaining Rabies-Free Zones
 Local Level

The Governor and City/Municipal Mayors takes charge for implementation
of guidelines

“BantayRabis Sa Barangay” headed by the Barangay Captain

The Rabies Control Committees oversee the implementation of the rabies
control program components

Epidemiology and Surveillance Units (ESU) under the Philippine
Integrated Disease Surveillance and Response System
 Regional Level

Regional Rabies Control Committees must regularly supervise and
assess the implementation of the Rabies-Free zones

Regional Animal Disease Diagnostic Laboratory (RADDL) must continue
to conduct routine animal surveillance and must investigate the
occurrence of animal rabies
 National Level

Department of Health (DOH) and Department of Agriculture(DA-BAI)

The DILG Regional/Provincial Directors shall monitor the compliance of
the Local Chief Executives

The DOH shall refer to RITM all rabies cases for confirmation when
possible
DepEd is involved in Rabies control as mandated by RA 9482
Memorandum 34 s. 2017
 Requires schools to propagate Rabies awareness and prevention through
BrigadaEskwela
Aims to to review the diagnostic history, clinical aspect, and outcome of the patient, status of
the biting animal, and location of biting incidence of human death cases
Mass Dog Vaccination
 Dogs aged 3 months old and above
 Registration and permanent identification of vaccinated dogs is recommended,
annual vaccination against rabies is mandatory
 One dose of 1 ml is given to them IM or SQ, regardless of weight
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Surveillance of Human Rabies

A repeat vaccination is given to them yearly for continuous protection for 3 years
70% of the dog population must be vaccinated within 3 months, but coverage may
vary
Philippine Integrated Disease Surveillance and Response (PIDSR)
 Classified human rabies as an immediately-notifiable disease (must be reported
within 24 hours)
The National Animal Disease Diagnostic Laboratory (NADDL)
 Established to confirm animal rabies as part of the surveillance of the Department
of Agriculture
Case Definition



Case Investigation and
Reporting


Laboratory Confirmation



Surveillance of Animal Rabies

FCM 3
SUMMARY: 1st Shifting
Conducted by CHD program coordinator along with the RSU staff
Suspected patients who went home against medical advice, they should be reported
NOTIFICATION shall be consolidated by the RESU and the NEC describing the distribution
of human rabies cases by:
 Age
 Sex
 Geographic location
 Time of occurrence
PCR or viral culture
Samples:
 Brain samples (taken after death)
 Skin samples (taken before death)
 Saliva
 Urine
 CSF
Rabies is a notifiable disease both in the national health and veterinary systems in the
Philippines
Surveillance of canine rabies and submission of laboratory reports of suspected cases is
essential for the management
Recognition:
 animals directly noted to have manifestations of rabies
 Dogs or cats that have bitten a person and are being observed for manifestations
Notification:
 If animal died after biting a person or while being observed, report immediately
 Trained personnel shall carry out handling and preparation of the dog specimen
for laboratory confirmation
 Submit the dog for laboratory confirmation of rabies Preparation/Handling and
Packing of Animal Specimens for Rabies Diagnosis
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
Animal Specimens for Rabies
Diagnosis
Outbreak Response
Evaluation Indicators
Preparation/Handling and Packing
 Collected by a veterinarian in a clinic
 Use of basic personal protective equipment (PPE)
 For household setting, a clean table or bench is needed for the decapitation of the
animal
 The head should be cut two (2) inches away from the base
 Placed in a leak-proof double household plastic bag
 Do not put any ice cubes inside this primary container
 No chemical preservative

Storage of Animal Specimens before transport
 liberal amounts of ice on the secondary container
 placed in a styrofoam box or any leak-proof transport container and brought to the
nearest rabies diagnostic laboratory
 Label the transport container as “Rabies Suspect”.
 Affix Complete name, Address, Phone number of shipper and laboratory recipient
 If specimen cannot be transported at once, it should be frozen or stored inside a
leak-proof Styrofoam or ice box container.

Specimen Transport
 through air freight or hand carried

Disposal of Carcass/Disinfection
 Burying in a pit or burning
 Working area = 10% household bleach (Chlorox) or 3% Lysol

Laboratory Diagnosis of Rabies in Dogs and other animals
 Fluorescent Antibody Test (FAT)

Results of laboratory examination
 laboratory diagnosticians should inform the AHD-BAI immediately of all specimens
examined positive for rabies
 Collate all DA-BAI-DOH Form I using the standardized DA-BA I-DOH Form two (2)
and should submit the filled-up forms to AHD-BAI on or before the 7th day of the
succeeding month.

Main goal in any disease outbreak: to control the spread of the disease
RECORDING AND REPORTING
 NRPCP shall utilize the Rabies Exposure Registry and PEP Card as its official
recording forms
 Quarterly reports on animal bite cases, cohort analysis and Summary of Human
Rabies shall be submitted
 Recording and reporting shall be implemented at all ABTCs/ DOH recognized ABCs
 Shall include all animal bite cases categorized according to NRPCP guidelines
 NRPCP shall adopt the official DOH recording and reporting system
 Records and reports shall verify the accomplishment of the program.

Rabies Exposure Registry

Post-Exposure Prophylaxis (PEP) Card

Report of Animal Bite

Summary of Human Rabies
MONITORING, SUPERVISION, AND EVALUATION

done by Provincial/City/CHD NRPCP Coordinators every quarter

analyze and provide feedback of findings with corresponding recommendations to the staff
or authorities concerned

Continuous advocacy efforts to secure commitment of LGUs to purchase anti-rabies
vaccine, RIG and other supplies.
Treatment Outcomes
FCM 3
SUMMARY: 1st Shifting
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FCM 3
SUMMARY: 1st Shifting
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