- anecdote: child walking past a dog and bites it

-short description with epidemiology -short description with epidemiology

Rabies is a zoonotic disease that cause Rabies is a disease humans get from animals
59,000 deaths every year worldwide with with back bones. It is a human infection
56% of caused by Lyssa virus. It may cause a number
the cases occurring in Asia. In the Philippines, of deaths (59,000) every year worldwide.
there are 250-300 deaths every year mostly Most (56%) of this number comes from Asia,
among children below 15 years of age and where Philippines is located. Here, there are
those who are poor. 250-300 deaths every year mostly among
children below 15 years of age.
-transmission How is Rabies transmitted to humans?

Bites from infected animals are the most It is when infected animals bite humans.
common mode of transmission of rabies to
humans.

Exposure to rabies may come from bites of It comes from infected dogs, cats, other
infected dogs, cats, other domestic domestic and wild animals including bats.
and wild animals including bats.

Younger animals are considered to present a Compared to older animals, the younger
greater risk of rabies than older animals. ones are morelikely to transmit rabies.

However, bites from rats, rabbits, other On the other hand, rats, rabbits, other
rodents, reptiles and birds do not pose a risk rodents, reptiles and birds have low chances
for rabies infection of transmitting the virus.

** Non-bite exposures are less important and Other points of entry of rabies virus could be
are infrequent modes of transmission. through:
However, scratches, open wounds or mucous
membranes that are licked by an infected
animal, can be points of entry of the rabies
virus and these may be in the form of the
following: Contamination of some parts of the body
 Contamination of intact mucosa (eyes, known as mucous membranes like those
nose, mouth, genitalia) with saliva of located in the eyes, nose, mouth, and even
infected animal; the private parts with saliva of infected
 Licks on broken skin; and animal;
 Inhalation of aerosolized virus in closed Licks on broken skin; and
areas (e.g. caves with rabid bats, Inhalation of droplets with the virus in closed
laboratories for rabies diagnosis)** areas like caves with rabid bats
**The rabies virus is not found in human or
animal blood and feces thus, these body
fluids Do poop and blood of infected animals &
do not pose a risk for rabies transmission. humans pose risk of rabies transmission?
Casual contact, such as touching/talking to a No.
person with rabies or contact with
noninfectious fluid (blood, feces), does not Not even through casual contact, such as
constitute an exposure. touching/talking to a person with rabies.

- incubation period - How long does it take for the signs &
symptoms of Rabies on humans to show
Incubation period is the period from the time from time of exposure
of exposure up to the appearance of first
clinical signs and symptoms of rabies. On average, it is between 1-3 months. Most
The average incubation period of human of the cases, it takes less than one year but
rabies is between 1-3 months. In 90-95 % of may be longer in rare cases. It depends on
cases, incubation period is less than one year factors like:
but may be longer in 5-10 % cases. The
duration of the incubation period depends on The amount of the virus loaded into the
certain factors: wound, eyes, nose, mouth, and/or private
 The amount of the virus inoculated into the parts
wound or mucosa.
 Severity of exposure - Patients with The severity of the bite wound. If there are
multiple and/or deep penetrating bite multiple and/or deep penetrating bite
wounds wounds, the sooner the signs & symptoms
may have shorter incubation period. appear.
 Location of exposure - Patients with bite
wounds in highly innervated areas and/or The Location of exposure. Signs & symptoms
close to the central nervous system may have of Rabies infection appear sooner if the bite
shorter incubation period. is located on areas of the neck, head, private
parts, hands and toes.

- clinical manifestation on humans - what are the signs & symptoms of an

infected human?
Prodromal
The prodromal stage occurs when there is For up to 10 days, the victim may initially
initial viral replication at the striated experience fever, sore throat, loss of
muscle cells at the site of inoculation just appetite, nausea, vomiting, generalized body
before it enters the brain. The virus then discomfort, headache, abdominal pain, &
spreads centripetally up the nerve to the pricking, tingling or pain at the area of bite
central nervous system through the wound.
peripheral nerve axoplasm.
This stage lasts for 0-10 days with non- Later, the infection will affect the brain and
specific manifestations, which include fever, will manifest as hyperactivity (anxiety,
sore throat, anorexia, nausea, vomiting, agitation, running, biting, bizarre behavior
generalized body malaise, headache and alternating with periods of calm)
abdominal pain. Paresthesia or pain at the which may occur spontaneously or may be
site of bite is due to viral multiplication at triggered by touch or anything the victim
the spinal ganglion just before it enters the hears or sees.
brain.
Acute Neurologic Rabies infected victim will particularly have
The acute neurologic stage is the stage when uncontrolled movement or contraction of
the virus reaches the CNS and muscles at the throat area (spasm of the
replicates most exclusively within the gray pharyngeal muscles) often triggered by an
matter. This stage has two types of attempt to
presentation: encephalitic or furious type, drink water (hydrophobia) or by blowing air
which is present in 80% of rabies cases, on
and paralytic or dumb type, which is seen in patient's face (aerophobia). This may lead to
20 %. a problem in which breathing repeatedly
Autonomic manifestations such as stops and starts (apnea).
hypersalivation appear during this stage. The
virus another type of presentation is that muscles
passes centrifugally among autonomic nerves shrink and become flabby & weak.
to reach other tissues- the salivary Sometimes the victim is unable to move.
gland, adrenal medulla, kidney, lung, liver, Pain, uncontrolled muscle twitching
skeletal muscle, skin and heart. Passage (fasciculation) & problems with senses &
into the salivary gland facilitates further breathing may be experienced by the victim.
transmission of the disease through infected
saliva. This stage lasts for 2-7 days, And ultimately, Coma & death may happen
characterized by hyperactivity, to the infected human.
hypersalivation, disorientation, and
hallucination, bizarre behavior interspersed This disease is 100% fatal but 100%
with lucid intervals, seizures, nuchal rigidity preventable
or paralysis.

Table 4: Two Types of Presentation of the

Acute Neurologic Stage of Rabies in Humans
Neurologic or Furious Paralytic or
type dumb type
Hyperactivity (anxiety, Acute
agitation, running, progressive
biting, ascending
bizarre behavior myelitis,
alternating with periods symmetrical
of calm) or
which may occur asymmetrical
spontaneously or may with flaccid
 be paralysis, pain
precipitated by tactile or and
auditory, visual or other fasciculation
stimuli. in
The most characteristic the affected
symptom is spasm of the muscles with
pharyngeal muscles mild
often triggered by an sensory
attempt to disturbance.
drink water A complete
(hydrophobia) or by paraplegia
blowing air on develops
patient's face eventually
(aerophobia). Spasmodic with fatal
contractions paralysis of
of the muscles may the
spread to the respiratory respiratory
and and
other muscles leading to pharyngeal
attacks of apnea. muscles.

Coma - begins within 4-10 days after symptoms

start; Cardiac arrhythmiasis is
common. Hyperventilation which leads to
perirodic and ataxic respiration to apnea.
Haematemesis is experienced by 30-60% of
patients before death. Pituitary
dysfunction is also present as part of disordered
water balance.

Death - without intensive supportive care,

respiratory depression, cardio respiratory
arrest, and death occur in almost 100% of cases.
73% die within 3 days of onset of
symptoms and 84% die within 24 hours of
admission. Outcome is date and recovery
from rabies if very rare. Cause of death includes
circulatory insufficiency with
myocarditis, cardiac arrhythmia or congestive
heart failure (RITM)

This disease 100% fatal but 100%

preventable
- diagnosis - How to diagnose rabies?
Often the diagnosis of rabies is based on the It is often based on the clinical
clinical manifestations and a history of manifestations and a history of exposure to a
exposure to a rabid animal. In cases where rabid animal. If clinical diagnosis is difficult,
the pathognomonic hydrophobia and/or rabies
aerophobia are present, the diagnosis is laboratory confirmation is necessary.
straight forward. However, clinical diagnosis Samples for laboratory diagnosis of rabies
may be difficult in cases of paralytic rabies from secretions and biological fluids like
and atypical presentations. Thus, rabies saliva, spinal fluid, tears, & etc. of the alive
laboratory confirmation is necessary. Rabies rabid animal or human can be used; but, if
diagnosis can be performed on fresh the rabid animal or human is dead, samples
tissue specimens stored at appropriate for the diagnosis includes brain tissue that
temperatures, preferably refrigerated. The can be collected through autopsy.
specimens to be collected depend on the test
to be performed.

Ante-Mortem
Samples for Laboratory diagnosis of rabies
during life secretions and biological fluids
(saliva, spinal fluid, tears, etc.) can be used to
diagnose rabies during life (intra vitam).

Post Mortem
Samples for post-mortem diagnosis includes
brain tissue that can be collected through
trans-orbital or trans-foramen magnum route
if autopsy cannot be performed.

-management & treatment What to do if there is possible exposure to

rabid animal?
1. Take note of the ff details regarding the
exposure to dogs, cats, bats, & domestic
animals Take note of the details regarding the
 bite – Date of Incidence, Place of incidence, exposure to dogs, cats, bats, & domestic
Nature of Incidence, Time of Incidence animals
 non bite – Lick on broken skin or mucous
membrane, scratch by paw, For the exposure is through a bite wound,
unprotected exposure to rabies virus in the take note of the date, place, nature, & time
lab, transplant of infected of incidence.
tissue, exposure to rabies patient (bite, lick
on mucous membranes, It is also important to take note that non bite
 The following are not considered exposures exposure, aside from what was mentioned,
to rabies – sharing food with rabies patient, include scratch by paw, unprotected
licks on intact skin, exposure to rabies virus in the lab, transplant
__________________________ of infected
tissue or organ; however, sharing food with
2. Observe the status of biting animal at time rabies patient & licks on intact skin are not
of bite and after 14 days considered exposures to rabies

How to recognize clinical signs of rabies in Observe the status of biting animal at time of
domestic animals? bite and after 14 days. How to recognize
clinical signs of rabies in domestic animals?
• Withdrawal from and resistance to contact;
seeking seclusion There may be some or any of the ff:
• Wide-eyed; reduced frequency or absence
of blinking; dilated pupils; Withdrawal from and resistance to contact;
photophobia seeking seclusion;
• Exaggerated, often aggressive, response to Wide-eyed; reduced frequency or absence of
tactile, visual, or auditory stimuli blinking; dilated pupils; photophobia
• Snapping/biting at imaginary objects Exaggerated, often aggressive, response to
• Pica (eating or mouthing sticks, stones, soil, tactile, visual, or auditory stimuli
clothing, feces, etc) Snapping/biting at imaginary objects
• Aggressively attacking inanimate objects Pica (eating or mouthing sticks, stones, soil,
• Sexual excitement with attempts to mount clothing, feces, etc.)
inanimate objects Aggressively attacking inanimate objects
• Compulsive running or circling, often to the Sexual excitement with attempts to mount
point of exhaustion inanimate objects
• Obsessive licking, biting, or scratching at Compulsive running or circling, often to the
the site of viral inoculation point of exhaustion
• Dropped jaw, inability to swallow, excessive Obsessive licking, biting, or scratching at the
salivation site of viral inoculation
• Change in tone, timbre, frequency, or Dropped jaw, inability to swallow, excessive
volume of vocalizations salivation
• Flaccid or deviated tail/penis Change in tone, timbre, frequency, or volume
• Tenesmus (due to paralysis of the anal of vocalizations
sphincter) Flaccid or deviated tail/penis
• Muscular tremors Tenesmus (due to paralysis of the anal
• Acute onset of mono-para-,or quadri- sphincter)
paresis; lameness Muscular tremors
• Abnormal, exaggerated gait; ataxia and Acute onset of mono-para-,or quadri-paresis;
incoordination lameness
• Convulsive seizures Abnormal, exaggerated gait; ataxia and
• Paralysis, prostration, recumbency incoordination
• Death Convulsive seizures
If after animal examination, some of these Paralysis, prostration, recumbency
signs or any other signs of illness are or Death
present, it is advised to immediately, safely
and humanely euthanize the animal, Determine the vaccination status of biting
remove the head and submit the brain to the animal.
designated public health laboratory for
testing. Take note of the incubation period, which
begins on the date of bite to date the first
symptoms appear.
_________________________
Watch out for & take note of the mentioned
3. Determine the vaccination status of biting signs & symptoms of Rabies on humans
animal specially presence of pain/numbness/itching
4. Take note of the incubation period – at bite site, behavior & uncontrolled muscle
Incubation period begins on the date of contraction & weakness
bite to date the first symptoms appear
5. Watch out for the following clinical Take note other contributory information
symptoms: such as other victims of the same animal
 Pain/numbness/itching at bite site within the past 24 hours & history of
Encephalitic symptoms– Be sure to note and previous rabies vaccination of the victim.
document/list them
 Paralytic symptoms – Document/list these
as well.
6. Consider other contributory information
such as:
 Other victims of the same animal within the
past 24 hours
 History of previous rabies vaccination (pre
or post exposure prophylaxis,
date)

Wounds shall be immediately Know and apply the proper bite wound
and vigorously washed and management
flushed with soap or detergent,
and water preferably for 10 Immediately and vigorously wash and
minutes. If soap is not available, flush the bite wound with soap or detergent,
the wound shall be thoroughly and water preferably for 10 minutes. If soap
and extensively washed with is not available, the wound shall be
water. thoroughly
Apply alcohol, povidone iodine or any and extensively washed with water.
antiseptic.
Suturing of wounds shall be avoided at all Apply alcohol, povidone iodine or any
times since it antiseptic.
may inoculate virus deeper into the wounds.
Wounds Suturing of wounds shall be avoided at all
may be capitated using sterile adhesive times since it may inoculate virus deeper into
strips. If suturing is unavoidable, it shall be the wounds.
delayed for at least 2 hours after
administration of RIG to allow diffusion of the Wounds may be capitated using sterile
antibody to occur through the tissues. adhesive strips.
Any ointment, cream or wound dressing shall
not be applied to the bite site because Any ointment, cream or wound dressing shall
it will favor the growth of bacteria and will not be applied to the bite site because it will
occlude drainage of the wound, if any. favor the growth of bacteria and will occlude
drainage of the wound, if any.

Warning: Do not use procedures that may

further contaminate the wounds (e.g.,
traditional healers/tandoks, bato, rubbing
garlic on the wounds and other non-
traditional practices)

Immediately seek medical care from trained

health providers in animal bite
treatment centers and/or animal bite
centers.

Animal Bite Treatment Center Schedule:

Tacloban City Hospital – Mon & Thu
EVMC – Tue & Fri
LPH – Wed & (half day) Sat

Continue and complete the prescribed

vaccination dosages.

Key Messages Key Messages to the pet owners

With the intensified health promotion and Be a responsible pet owner. Have your pet
communication campaign, the following are dog registered, vaccinated three (3) months
the key old and yearly booster doses while dog is
messages for each identified target audience alive. Do not allow your pet to roam the
that will be highlighted: streets or any public place without a leash.
2.1. Pet owners Ensure your pets are properly fed and cared
  Be a responsible pet owner. for. As the (pet) owner, you are responsible
o Have your pet dog registered, vaccinated for your pet’s bite victim’s treatment and
three (3) months old and yearly booster management; including all expenses to be
doses while dog is alive incurred for treatment. Should your pet bite
o Do not allow your pet to roam the streets a victim, it is your responsibility to ensure
or any public place without a leash that your dog is properly confined during the
o Ensure your pets are properly fed and 14-day observation period. It is also your
cared for responsibility to inform and consult the
o As the (pet) owner, you are responsible for Municipal Agricultural Officer/ Municipal
your pet’s bite victim’s treatment and Veterinarian/City Veterinarian if your pet
management; including all expenses to be gets sick or died within the 14-day
incurred for treatment observation period for proper sample
o Should your pet bite a victim, it is your submission to designated laboratories for
responsibility to ensure that your dog is rabies confirmation.
properly confined during the 14-day
observation period.
o It is also your responsibility to inform and
consult the Municipal Agricultural
Officer/ Municipal Veterinarian/City
Veterinarian if your pet gets sick or died
within the 14-day observation period for
proper sample submission to designated
laboratories for rabies confirmation.

Kagat
Lagnat
ingat