Rabies supertable TERMS 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 � 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. Casual contact and routine delivery of health care to patient with SSX of rabies Category 2 Nibbling of uncovered skin with Wash wound with soap and water. or without bruising/hematoma Start vaccine immediately: 1 of 9 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 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 Intramuscular Regimen Immunocompromised patients (px with HIV infection, cancer, chronic liver disease and those taking chloroquine and systemic steroids Standard Intramuscular Regimen – Essen Passive Immunization 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) 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 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 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 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) 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 Dog Movement Control Policies and Procedures (cold chain management, waste management, etx ) Pre-exposure prophylaxis (PrEP) 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 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 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 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 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