Training on Rabies overview:

rabies in a global and national context.

[Ethiopian Public Health Institute/EPHI]

BY
Yimer Mulugeta/Dr
Team lead for zoonoses @ EPHI
 Presentation outline

❑Background information
❑Rabies overview:
✓Transmission, pathogenesis and burden
❑Progresses on rabies P&C strategy towards global
context
❑ Challenges on rabies elimination efforts
EPHI Structure: Background information

PHEM RTT

NLCB NDMC
Background information on Zoonoses and One health

❑Diseases that can spread between animals and humans, called as

Zoonoses/Zoonotic disease

❑61% of human diseases are originated from animals

❑75% of human emerging diseases are originated from
animals

Goal of the ZD program Perform GHSA activity

➢The zoonotic disease program aims to serve as a platform for
preventing, rapidly detecting, and responding to emerging and re-
emerging zoonotic diseases in Ethiopia.
Cont’d… BI on Zoonoses and OH
What is 'One Health'?

OH is a worldwide approach to enhance human, animal &

environmental health through strengthening
interdisciplinary 3C to achieve the best Health outcome.

One Health approach is particularly

relevant include:
✓ Food safety,
✓ Control of zoonoses &
✓ Combatting antibiotic resistance.

Why do we need a One Health approach?

❑Many of the same microbes infect animals and humans, as they share the eco-
systems they live in. Efforts by just one sector cannot prevent or eliminate the
problem. For instance, AMR, anthrax, rabies, brucella
Priority zoonotic diseases in Ethiopia
Disease priority is based on CDC prioritization tool
✓ Criteria used :-

1) Severity of disease in humans,

2) Proportion of human disease attributed to animal exposure,
3) Burden of animal disease,
leptospirosis &
4) Availability of interventions, and echinococcosis
5) Existing inter-sectoral collaboration. replaced by
RVF and HPAI
➢Rabies, anthrax, brucellosis, RVF and HPAI during
reprioritizations
Background information….cont’d

Zoonoses research team of the Ethiopian public health institute in

collaboration with other stakeholders and/or Partners (GHSA, CDC,
WHO…) have done activities to support rabies prevention and control.

Among this:-

❑Support on rabies laboratory capacity building

❑ Professional capacity building/training

❑Workshops and meetings (non-training)

❑ Strengthening of the surveillance system of rabies and response

 Rabies over view
• Rabies is a viral zoonotic disease that causes progressive & fatal (100%)
inflammation of the brain & spinal cord.

• Rabies is Latin Word which means “Madness”

• The first rabies epidemic in Ethiopia was recorded in Addis Ababa in 1903.
Transmission
Mode of rabies transmission
❑Bite ❖Bite -any penetration of the skin by the teeth.
- All bites, regardless of body site or
degree of gross trauma, represent potential risk
❑Non Bite

Infectious saliva or brain material(CNS)tissue from a rabid

animal contacts with mucous membrane (i.e., lining of the
eyes, nose, mouth, genitalia) or fresh, open cuts (wound) in
skin

Source of rabies exposure

❑All mammals
 Transmission …cont’d
❑All mammals are the source for rabies transmission but vary from country to
country or region to region.
In Ethiopia & Africa
❑In Ethiopia and Africa region dog mediated
✓Dogs are responsible for up to 99% of
human rabies cases,
Major source
95% of rabies of human
deaths is rabies death
encountered in In America, In Europe, fox & Bat
Africa &Asia Bat is emerging PHT

❑Human rabies cases have occurred because of bites from cats, bats,
mongooses, jackals, foxes, wolves and other carnivorous animals.
Human Rabies Pathogenesis
1) Virus inoculated by bite/scratch/close contact with open skin or
mucosa .
2) Replication in muscles: virus binds to nicotinic acetylcholine
receptors on post synaptic membranes at NMJ.
3) Spreads centripetally along peripheral nerves towards CNS( 10-
24mm/day) through local dorsal root ganglion,
4) Replicate in motor neurons of the spinal cord & local dorsal root
ganglia and raped ascent of brain .
5) CNS dissemination and neural dysfunction
6) Centrifugal spread along sensory & autonomic nerves to salivary
gland, corneal, kidney,….
Incubation period
✓It is the time interval between exposure to the virus and onset of the
first clinical signs/symptoms of disease.
✓ Incubation period in average 2-3 month & may varies: from 1wks to
years
✓ The length of the incubation period is determined by several factors
including
- site of bite(face, head or neck, finger…)
- travel speed of the virus
- dose of virus
- severity of the bite
- age of the bitten person(children Vs adult)
- the immune status of the victim
 Consider 3 hyper
Rabies in animals key Cl. signs ?

✓ Any change in its normal behavior suggesting either

undue aggression or depression
✓ Running aimlessly and attacking others without
provocation
✓ Excessive salivation
✓ Refusal to feed or eating unusual object like stone,
paper, wood, metal pieces
✓ Death of animal.
National burden
Rabies: Top_ Zoonotic diseases in Ethiopia
A single confirm case is enough to declare outbreak; we faced a number of ROB

IBCM

40000
Human rabies burden
33145
30000

20000

10000 53 55
0
HUMAN RABIES RABIES _DEATH RABIES _DEATH
EXPOSURE RUMER
National burden …cont’d
❑2700 fatal human rabies report by CDC but by WHO
3800 for SSA like Ethiopia.
16 suspected human rabies deaths and 287 suspected rabies exposures were observed
The highest rabies exposure attack rate was reported from Tembaro woreda
(116.3 per 100000 population at risk); 55.3, 13.6, 12.1, 5.4 per 100000 population at
risk attack rate were found in Hawassa Z, Mareka, Soro &Gena Bossa woreda
respectively.

48 animals rabies death were detected and the

major animal’s species affected were 28 cattle’s,
12 goats, 5 sheep’s and 3equans were identified.
For your surprise out of 10 suspected dog rabies 8
dogs were confirmed at EPHI, rabies national
laboratory. Only 546 dogs were vaccinated
against rabies, the rest dogs were removed in a
mass dog eliminated, via an application of
strickinin.
 Ethiopian Rabies P&C Strategy: A Global strategy
Rabies is classified
Family: Rhabdoviridae
Genus: Lyssavirus

Rabies is a viral zoonotic

disease that causes
progressive & fatal (100%)
inflammation of the brain
and spinal cord.

Clinically, it has two forms:

Furious and paralytic rabies

Human death annually:

✓ 60,000 globally
✓ 2700 national

95% of cases occurring in

Africa & Asia.
Short & long term Goals of rabies prevention strategy

❑Enhance detection of animal rabies through linking animal health professionals with
public health professionals who can assess suspected animals (IBCM)

❑Improve laboratory diagnostic testing for animal rabies by building regional laboratory
capacity

❑Improved access to rabies post-exposure prophylaxis (PEP) by animal bite victims

❑Increased knowledge of animal and healthcare providers in the areas of rabies

prevention, control, and treatment

❑Canine rabies elimination through targeted canine rabies mass vaccination coverage
reaching 70% of the dog population in the select zones of the 3-4 priority regions
Human Rabies Case Definitions
Standard human Rabies Case Definition

• Suspected: a case that is compatible with a

clinical case definition
• Probable: a suspected case plus a reliable
history of contact with a suspected, probably
or confirmed rabid animal.
• Confirmed: a suspected or probable case
that is confirmed in the laboratory.
 Human exposure to rabies
• Possible exposure: A person who had close
contact (usually a bite or scratch) with a rabies
susceptible animal in (or originating from) a
rabies-infected area.
• Probable exposure: A person who had close
contact (usually a bite or scratch) with an
animal displaying clinical signs consistent with
rabies at time of the exposure, or within 10
days following exposure in a rabies-infected
area.
• Exposed: A person who has had close contact
(usually a bite or scratch) with a laboratory
confirmed rabid animal.
Progresses on rabies P&C strategy /Strategic outcomes

1: Strengthen outbreak detection, prevention and response capacity for

rabies
✓Increase access to ARV for human and decrease human death 32k CCV procured
✓PEP service expansion/ strengthen in selected health facilities in Addis Ababa
✓ IBCM centers in AA from 2-15 and planed this additional 10HF
✓Joint rabies operational research’s to wards elimination
✓Work force development particularly frontline HCW(M&V)
2: Advocacy
✓Conduct workshop for concerned stalk holders regarding collaboration on planned
rabies activities in Addis Ababa
✓World rabies day celebration
✓Social media unitization(ETV, FAN, VOA and including LM)
Strategic outcomes …Cont’d
3: Strengthen the surveillance system laboratory capacity for rabid
detection and response of rabies
✓ Increase exposure and case detection rate for rabies
✓Web developed on reporting of rabies lab based surveillance via GAEC

4: Strengthen One Health practice in the country

✓Establish a database to strengthen and improve reporting of all exposure and
cases of human & animal rabies from the local to national
✓Establish a multispectral and linked rabies surveillance and response system
(Integrated bite case management)

5: Information, Education and Communication

✓Increase animal and public health professional’s knowledge on rabies
✓ Increase general public awareness on rabies prevention
Strategic outcomes …Cont’d
6: Control and elimination of dog rabies
• Supporting to new Registration of owned dogs in regions
• Supporting to Improving dog vaccination coverage
• Supporting to Target killing of problematic dogs (animals)
• Supporting to Management of owned and stray dogs in Addis Ababa

7: Creation of strong inter-sectoral and multi-disciplinary

approach for integrated surveillance and response
• Establish national & regional rabies TWG & rabies TF (RRT)
• Scale up rabies diagnostic laboratories at regional level
• MOU, just to strengthen rabies lab based surveillance (AA, Amhara, Tigray,
Oromia(JU), Jigjig U) and GARC as well
Challenges on rabies elimination efforts
✓Short shelf life (NVI) dog rabies vaccine (12 month/year long) and
no/poor routine dog vaccination program
✓Lack of rabies palliative care
✓Weak surveillance system and integration
✓ Limited laboratory capacity
✓Wide use of poorly immunogenic human vaccine NTV
✓Lack of access for ARV (unavailability & unaffordability) CCV
✓Lack of capacity development for animal and public health care providers
(Skill and Knowledge gap)
✓No/poor interoperable reporting mechanisms in place: GARC web page
Way forward

• Strengthen our surveillance system toward our rabies elimination

strategic plan
• Renovate our systems on reporting, implementation
• Improving our capacity building activities in WF and lab setup
Zero human death of rabies by 2030

Thank You!!
FREHIWOT L. (BSc, MPH)

ADAMA OCTOBER, 2022

 Outline

• Introduction to Public health surveillance

• PHEM overview

• Diseases under surveillance in Ethiopia

• Rabies surveillance, outbreak investigation and

response
Public Health Surveillance
 Definition of Surveillance

• Surveillance is derived from the French ‘Sur’ (over)

‘veiller’ (to watch) - hence ‘to watch over’.

• Public health surveillance is an on-going and

systematic health data collection, compilation, analysis,
interpretation and dissemination for public health action.

• It is "Information for Action”

 Uses of PH Surveillance

• To estimate magnitude of the problem

• Early recognition of epidemics - detect sudden
changes in disease occurrence
• To follow secular (long-term) trends
• Projections of future trends
• To evaluate public health programs
• To generate hypotheses and stimulate research

31
Main types of surveillance: Based on the
involvement of Public Health official it can be

1. Passive Surveillance: A surveillance where

reports are awaited and no attempts are made
to seek reports

2. Active Surveillance: Public health officers seek

reports from participants in the surveillance
system

32
 The Surveillance Cycle

Diagnosis / Detection

Reporting /
Evaluation Data Collection

Action! Analysis,
Interpretation

Communicating Information
 PHEM overview, in Ethiopia

• PHEM is the process of anticipating,

preventing, preparing for, detecting,
responding to, controlling and recovering
from consequences of public health threats in
order that health and economic impacts are
minimized.
 Four Pillars of PHEM
Risks to Public Early
Health Need of the Warning
Public to be
protected

Identified Risks

Public Health Emergency

PREPAREDNESS

System, supplies and trained HR

Identified Threats

Public Health
Emergency
Reports/Data RESPONSE

RECOVERY
Corrective Actions

The Public will be protected from

health consequences of
emergencies
Diseases under surveillance
in Ethiopia

36
 Criteria for prioritization

• Diseases which have high epidemic potential

• Required internationally under IHR 2005
• Diseases targeted for eradication or elimination
• Diseases which have a significant public health
importance
• Diseases that have available effective control and
prevention measures
 Immediately Weekly Monthly Quarterly
32. Moderate Acute
1. Anthrax 16. Malaria 26. New HIV cases
Malnutrition (MAM)
17. Diarrhea with dehydration in children 27. Hypertension new
1. Measles
less than 5 years of age cases
1. Human influenza caused by new 18. Acute jaundice syndrome within 14 28. Diabetes new
subtype days of illness cases
1. Adverse events following 19. Severe pneumonia in children under 5
29.Tuberculosis
immunization (AEFI) years age

1. Neonatal s/ non neonatal tetanus 20. Viral Hemorrhagic Fever (VHF) 30. Maternal death

1. Rabies 21. Dysentery 31. Perinatal death

1. Smallpox 22. Relapsing Fever

1. Severe Acute Respiratory

23. Meningitis
Syndrome (SARS)
1. Yellow fever 24. Severe Acute Malnutrition (SAM)
1. Poliomyelitis (acute flaccid
25. Scabies
paralysis)
1. Chikungunya
1. Cholera
1. Dracunculiasis (guinea worm)
1. Dengue fever
1. COVID-19
Rabies surveillance, outbreak
investigation and response
 Case Detection Tools (Case Definitions)

• Community Case Definition • Standard Case Definition

 Surveillance goal for human rabies

• Detect and respond promptly and appropriately to

cases and outbreak of rabies

• Identify high risk areas

• Estimation of disease burden

• Immediate reporting of cases and routine

summary reports
 Case definition for rabies

Standard case definition

• Suspected case
• A person with one or more of the following:
headache, neck pain, nausea, fever, fear of water
(hydrophobia), pharyngeal spasms, aerophobia, anxiety,
agitation, abnormal tingling sensations or pain at the wound
site, when contact with a rabid animal is suspected.

• Confirmed case
• A suspected case confirmed by lab
 Flow of reporting in PHEM
• Detection of cases and reporting starts from health facilities
 Timeliness of Reporting
Health Woreda Zone Region EPHI
Facility

Region to
HF to EPHI
woreda

Zone to
Woreda to
Region
zone

Within 30 Within 30
Within 30 Within Minutes Minutes
Minutes 30
Minutes

Ev
ent Monday Tuesday Wednesday Thursday

Event

0:30 1:00 1:30 2:00

Time The following Week

Immediately notifiable Weekly reportable

44
 Reporting tools

Weekly
aggregated data

Case-Based
Reporting

Line list

Registration book
Human rabies Line -list
Rabies outbreak investigation
 Outbreak Investigation

• A method for identifying and evaluating

people/animal/environment which have been
exposed to an infectious disease or affected by
an unusual health Event.
• The investigation provides relevant information
for taking immediate action and improving
long-term disease prevention activities
 When to conduct an investigation?

• A report of a suspected human/animal rabies

cases received

• Community reports

• A cluster of rabies like cases in animals

 General Phases of an
Outbreak Investigation

Descriptive Explanatory Response

Descriptive Phase
 Explanatory Phase

7. Develop hypotheses
8. Evaluate hypotheses epidemiologically
9. Reconcile epidemiology with laboratory and
environmental findings
10. Conduct additional studies as necessary
 Response Phase

11. Implement and evaluate prevention and

control measures
12. Initiate or maintain surveillance
13. Communicate findings
Investigation form
Investigation….
Investigation form. . .
Response
 Response
• Case management
➢ wound mgt
➢ Prompt administration of post-exposure prophylaxis,
rabies immunoglobulin in severe cases,
• Enhance public health surveillance
• Education and awareness: are key to prevent bites
from rabid Humans/animals, promote dog vaccination
and encourage people to seek timely treatment if
exposed to rabies.
THANK YOU
Animal and Human rabies risk assessment

Mesfin Aklilu (MPH)

October 20 - 22, 2022
Adama, Ethiopia
Contents

1. Benefits of rabies risk assessment

2. Integrated Bite Case Management Components

3. Bite Investigation

4. Key components of IBCM

5. Joint Risk assessment

6. Exposure risk assessment for PEP initiation

7. WHO rabies exposure category (1984)

8. Rabies Algorithm
Benefits of Rabies Risk Assessment

▪ Find rabid animals and remove from community

➢Decrease animal exposures

➢Decrease human exposures

▪ Ensure PEP given to those exposed to confirmed rabid animals

➢Identify additional bite victims

▪ Reduce the unnecessary use of PEP

➢PEP not needed for bites from healthy animals
➢Cost savings to government and citizens
IBCM Definition & Bite Investigation

▪ Integrated Bite Case Management (IBCM) is an approach for

rabies surveillance
▪ That directly and formally links workers in public health and
veterinary sectors
▪ To assess the risk of rabies among animal bite patients and
biting animals,
One Investigation, Major Components (2)
▪ Animal rabies investigation (completed by animal health
workers)
▪ Victim bite investigation (completed by human healthcare
workers
 Key components of IBCM
Key components of IBCM (Joint Risk assessment) 1. Bite and exposure events report
(Bite victim)
2. Bite Investigation (risk assessment
(health professionals)
3. Trigger animal investigation (health
professional}
4. Animal Rabies Assessment
(veterinarian)
5. Laboratory Confirmation
/Quarantine for 10 days /
6. Feed back and investigation of
results (veterinarian).

Risk assessment by health professional

(No. 2)
▪ Site of bite (related with incubation period
(The distance from the bite wound to the CNS)

▪ Size of bite (severity) Related with dose of

virus

▪ Date of bite (related with incubation

period, Important for PEP decision)

▪ Provoked or unprovoked attack

▪ Stray / Owned
 Exposure risk assessment for PEP initiation (Bite investigation by a
health professional)

1. Site of bite

2. Size of bite (Severity of exposure)

3. Date of bite

4. Provoked or unprovoked attack 5. Stray / Owned 6. Type of Exposure

Bite Non bite

Exposure risk assessment ---------- Cont’d.

7. Type of Animal Species Involved

A. Dogs and Cats
▪ (Apparently Healthy ) Confine and observe for 10 days.
▪ Dog or cat unavailable for testing or observation initiate full
course of PEP.
B. Livestock and other Domesticated Animals
▪ Donkeys, horses, cows, sheep, goats, camels, pigs, monkeys
etc. could be infected with rabies.
▪ less likely to be involved in the transmission of rabies.
Animal Species Involved ---------- Cont’d.

▪Any helpful history that might help for decision.

▪If history is unreliable, PEP should be given in full
regimen.

C. Wild Animals
▪Hyena
▪Fox
▪Wolves
▪Mangoose
Animal Species Involved ------- Cont’d.

D. Rodents. (mouse, rat, squirrel. Hamsters, guinea pigs),and

Lagomorph (rabbit, hare)

▪ Rarely need PEP for rabies if they bite.

▪ If not available for testing, rabies PEP shall be considered.

E. Human to human transmission

▪ Human-to-human rabies transmission possible but is rare.

(infected tissue and organ transplantation)
▪ If infectious material from a patient such as saliva, gets directly
into their eyes, nose, mouth, or a wound.
Animal Species Involved ------- Cont’d.

▪Urine, blood, and feces does not constitute an exposure

▪Contact with someone who is receiving rabies vaccination
could not be a risk of rabies exposure for others
8. Vaccination Status of the Animal
9. Availability of the Animal for Quarantine or Testing
▪Healthy in the quarantine period, would not have been
shedding rabies virus in its saliva at the time of the
exposure
10. Epidemiology of rabies in the region
▪Endemicity of the disease
Exposure Category Decision

Suspected
Probable Site of bite
Confirmed Site of bite
Not a case of rabies Size of bite
(Animal Bite Date of bite
Investigation by a Provoked or unprovoked
Veterinarian) Stray / Owned
(Bite Investigation by a
Health Professional)

Exposure Category 1,2,

and 3
WHO rabies exposure category (1984)
Cont’d
Cont’d.
Animal Bite Scenarios

Scenario 1

▪ Status of the animal Died

▪ Exposure Type Non bite

▪ Cause of death Unknown

▪ Type of attack None

▪ Ownership status of the animal known / Owned

▪ Animal quarantined, died within 10 days, and rabies confirmed in the laboratory.

▪ Category of exposure 1,2,3

▪ PEP decision Yes / No

Animal Bite Scenarios ------ Cont’d.

Scenario 2

▪ Bite report date Oct., 10/2022 Size of bite

▪ Site of bite

▪ Type of attack provoked

▪ Ownership status of the animal Owned (Unvaccinated)

▪ Date of bite Oct., 6/2022

▪ PEP decision Yes / No

Continue vacc.
▪ Animal quarantined, Healthy at the fifth day PEP decision
Discontinue Vacc.
Animal Bite Scenarios ------ Cont’d.

Scenario 3

▪ Bite report date Oct., 10/2022 Size of bite

▪ Site of bite

▪ Type of attack Un provoked

▪ Ownership status of the animal known / Owned

▪ Date of bite Oct., 10/2022

▪ PEP decision Yes / No

Continue vacc.
▪ Animal quarantined, Healthy at the 7th day PEP decision
Discontinue Vacc.
Animal Bite Scenarios ------ Cont’d.

Scenario 4

▪ Bite report date Oct., 10/2022

Size of bite
▪ Site of bite

▪ Type of attack Unprovoked

▪ Ownership status of the animal Owned (Unvaccinated)

▪ Date of bite Oct., 6/2022

▪ PEP decision Yes / No

▪ Category of Exposure 1,2,3

Continue vacc.
▪ Animal quarantined, Healthy at the fifth day PEP decision
Discontinue Vacc.
Rabies Algorithm
Anti-rabies Vaccines Development: Focus to
CCV

Abebe M. Aga
October, 2022
Outlines

▪ Introduction
▪ Anti-rabies vaccine development
▪ Consideration for vaccination
▪ Regimens for rabies PEP
▪ Discontinuing PEP
▪ Booster vaccination
▪ Rabies Prevention in Animals
 Introduction

❖ Rabies is a viral disease that affect CNS of humans and animals

❖ WHO estimate that 60,000 people and millions of animals
die/year due to rabies,
❖ More than 95% occur in Africa and Asia
❖ Ethiopia is highly endemic for rabies, 2,700 peoples die each
year
❖ The case increase with limited access to high-quality anti-rabies
biologics
 Anti-rabies vaccine development

❖ During 1885; Louis Pasteur isolate rabies virus from rabid dog
➢ Propagate virus on rabbit brain
➢ Attenuated through repeated passage
➢ Perform successful post-exposure treatment of 9 years old Joseph Meister
who was bitten 14 times by rabid dog
 Anti-rabies vaccine development…
Progress in anti-vaccine development
➢ Semple type
➢ Fuenzalida
➢ Avian embryo vaccine (DEV)
➢ Cell culture based vaccine (PVRV)
➢ DNA vaccine
Semple type
➢ Semple type rabies vaccine contains a phenol or ß-propiolactone-inactivated
homogenate of rabies virus-infected goat or sheep brain tissue, NTV
➢ Contains myelin basic protein and is mostly used in Asia and Africa
 Anti-rabies vaccine development…
Fuenzalida

➢ Fuenzalida rabies vaccine is prepared from suckling mouse brain tissue

➢ Mostly used in South America, Brazil

➢ Headache and pain at the injection sites were the most common AE
Other developments:

➢ Purified chick embryo cell vaccine (PCECV)

➢ Purified duck embryo vaccine (PDEV)

➢ Purified Vero cell rabies vaccine (PVRV)

 Production Process
Sheep brain virus propagation/NTV
• Sheep for propagation of the virus in large amount for vaccine production
 Nerve Tissue Vaccine

❖Not recommended by WHO due to:

➢ Neuroparalytic reactions

➢ Low immunogenicity

➢ Painful injection

➢ Volume and dosage, 2-5cc, 17 injection

➢ Short shelf life,

➢ Thus, WHO supports the trend to stop production and

use of NTV and SMB
 Cell Culture Vaccine Production

Virus propagation in cell lines

❖ Virus propagated on Vero cell line

❖ Vaccine formulation performed using purified Ag

❖ QC tests performed on vaccine pool

 QC/QA
❖ Safety test for presence of residual virus

▪ volume of 0.03ml of vaccine inoculated

intracerebrally into a group of mice IC
▪ Observation for 14 days, any mice should not
die showing rabies sign
▪ Specific death confirmed by FAT techniques
❖Sterility test (bacterial/fungal contamination)
▪ Crude vaccine incubated with bacteriological
media to detect any contamination present
❖ Potency test
Why cell culture anti-rabies vaccine preferred?

➢ Increased safety, no severe complication

➢ Increase tolerability, IM/ID

➢ Increase efficacy

➢ Number of doses reduced, 1ml, only 4/5 injection (PEP)

➢Longer shelf life

➢ Mass production is possible

 Considerations for vaccination
Risk level
❖ Risk level depends on:
❑ Extent or severity of the exposure
❑ Type of animal species involved
❑ Circumstances (provoked vs. unprovoked)
❑ Availability of the animal for observation or testing
❑ Vaccination status of the animal
❑ Epidemiology of rabies in the region
 Regimens for rabies PEP... CCV

Two intramuscular schedules with CCV:

Follow local health regulatory and manufacturers guideline
❖ The 5 dose intramuscular regime (0.5/1ml)
• One dose of the vaccine administered on day 0, 3, 7, 14 and
28 in deltoid region or, in small children, into the antero-
lateral area of thigh muscle;
❖ The 2-1-1 regimen (0.5/1ml)
• Two doses are given on day 0 in the deltoid muscle, right
and left arm
• In addition, one dose in the deltoid muscle on day 7 and one
on day 21
❖ If RIG used, vaccine should be inoculated at distant from that of
RIG
 Regimen...

Intradermal
❖ Intradermal route require considerably less vaccine than the
intramuscular regimens
❖ 0.1 ml is given intradermal at left and right upper arm
❖ Method is particularly appropriate where vaccine or money is
in short supply, emergency response
❖ Intradermal injections reduce the volume of vaccine required
and vaccine cost
 Regimen...

Intradermal
❖ Administered in the deltoid muscle on the left and right upper
arm
❖ Two dose given on days 0, 3, 7 and 28
❖ Decision to implement ID route should be endorsed by National
Health Authorities
 Discontinuing PEP

❖ Post-exposure prophylaxis may be discontinued if the

animal involved remains healthy for an observation period

of 10 days
❖ If the animal is killed and proven to be negative for
rabies by a reliable diagnostic laboratory
❖ Data from laboratory and field experience indicate that
there is no infection in the species involved
 PEP for previously vaccinated persons

Booster vaccination
❖ Standard intramuscular dose, 1/0.5 ml depending on vaccine type
❖ One dose on days 0 and 3
Pre-exposure rabies vaccination
❖ Persons at high risk of exposure to live rabies virus (laboratory
staff, veterinarians, animal handlers and wildlife officers)
❖ Three doses of vaccine on days 0, 7 and 28 (0.5 or 1 mL)
 Booster vaccination (PrEP)

❖ Persons working with live rabies virus in diagnostic laboratories,

research laboratories, vaccine production laboratories and others
professions (veterinarians, animal handlers, wildlife officers...)
• Serum sample taken every six months
• One booster dose given when the antibody titre falls below
0.5 IU/ml
 Rabies Prevention in Animals

• No post-exposure prophylaxis for animals

• Routine vaccination is the only way to prevent animal
rabies
• Vaccination schedule for dogs and cats
• First vaccine at 3 months of age
• Booster vaccine 1 year later
• Vaccinate every 3 years after 1st booster
• Mass vaccination of 70% dog population
• Prevention and control strategy
• The concept of herd immunity
Vaccine Cold Chain Management
Outlines

▪ Importance of vaccine cold chain management

▪ Vaccine handling and transportation requirements
▪ Vaccine storage requirements
▪ Case scenario group work
 Vaccine handling and storage

Why is the cold chain important?

• Assurance/confidence in potent product and vaccine
quality
• Vaccine should be handled only by HPs
• Professional responsibility, Prevent risk of vaccination
failure
• Confident the vaccines you give will be effective
• Public Health responsibility
✓ Public confidence in vaccination programmes
 Vaccine handling …

Light Sensitive
• Sensitive to strong light, sunlight, ultraviolet,
fluorescents
•Vaccines should always be in their original
packaging until point of use to protect them
from light
 Transporting vaccines

• Use appropriate cool box and ice packs from recognised

medical supply

• Monitor temperature at regular intervals and change ice

pack

• Vaccines should be wrapped in bubble wrap or similar

insulation material to prevent direct contact with ice packs

• Use insulating material to fill any spaces within the cool box

• Only take enough vaccine for particular session and

minimise exposure of the vaccines to room temperatures
 Vaccine Storage
• Do not mix vaccine with • Use a dedicated vaccine refrigerator
food or other medicine

• Safeguard electricity supply

• Do not place refrigerator in
direct sunlight or near heat
source • No more than 50% full

• Do not remove vaccines • Group vaccines by type

from original boxes until (lyophilized, solution)
ready to use

• Defrost/calibrate refrigerator
• Do not store vaccines in
refrigerator doors or in solid regularly
plastic trays/containers
within the refrigerator
• Ensure backs up are available in the
event of refrigerator failure
• Keep vaccines away from
refrigerator walls and cold
air vents
Storage Units

NO DORMITORY STYLE UNITS

Single exterior door with an interior freezer compartment
 Temperature Monitoring

• Use max/min thermometer

• Probe should be placed in the centre of
refrigerator
• Temperature should be recorded twice a day
• Never exceed 8ºC or fall below 2ºC
• aim for 5ºC
• Calibrate refrigerator as recommended
• Take immediate action if temperature is
outside recommended range
Vaccine Storage

• 2-3 inches between vaccine and the walls

• Store each type of vaccine or diluent in a separate container
• First in, first out… specially for multiple dose container like NTV
• When possible, store diluent with the corresponding refrigerated
vaccine
• Labels shelves and containers to clearly identify vaccine and diluent
Vaccine Storage

• Store vaccines with similar packaging or names on different shelves

• Clearly label vaccine type/users
• Keep vaccines in original packaging with lids closed
• Do not pack a unit too tightly
• restrict air circulation
• impact vaccine temperature
Storage Unit Power Supply

• Protect unit’s power supply by

• Plug directly into wall outlet
• Install plug guard
• Install DO NOT UNPLUG sign
• Install DO NOT DISCONNECT
Managing the Cold Chain
Compromised cold chain:
• no physical indication of compromise
• not effective in protecting
• increase in disease cases
 Cold Chain management flow

• Exposure to heat, cold, or light can

result in loss of vaccine potency
• Potency cannot be restored
• Continued exposure to improper
conditions reduces potency further
• Improper handling results in loss of
potency
Thank you!
 Rabies post-exposure prophylaxis
(Anti-rabies treatment, Fermi vaccine)
By Mekoro Beyene
October 20-22, 2022
Adama
 Outline

1. Training objective
2. Fermi-type rabies vaccine, NTV
3. Rabies post-exposure prophylaxis
4. Storage & shelf life
Training Objective

• The purpose of this training is to create awareness among health

professionals in anti-rabies vaccine handling and utilization.
/the locally produced brain tissue rabies vaccine/.
Fermi-type Rabies Vaccine

❖ In Ethiopia, Fermi-type rabies vaccine has been

used
for rabies post-exposure prophylaxis for more
than
60 years.

❖ A 5% suspension of nerve tissue vaccine that is

prepared
from adult sheep brain.

❖ The vaccine is used for post-exposure

prophylaxis(PEP)
for humans. i.e. Anti-rabies vaccination is given
Rabies post-exposure prophylaxis
/Anti-rabies treatment/

❖First Aid Treatment:-

➢Local treatment of wounds is very important.

➢must be performed promptly after the bite.

➢It is recommended firstly to wash the wound with running water and
soap or detergent
Rabies post-exposure prophylaxis…

❖ Rabies post-exposure vaccination:-

• This indication must be based upon a number
of factors to be assessed.

If the rabies suspected animal is known and

followed up by a veterinary surgeon for ten
days following the incidence, there are then
three possibilities:-
 Rabies post-exposure prophylaxis…

i. If the bites are not severe, treatment should

not be given unless the veterinary surgeon
gives a contrary opinion upon observation of
the animal.

ii. If the bites are severe, treatment should be

started as soon as possible, but may be stopped
if the animal is seen to be healthy five days after
the bite.
Rabies post-exposure prophylaxis…

iii. If for any reason the rabies suspected animal

is disappeared during the observation period
before the 10th day, treatment must be started
immediately.
iv. If the rabies suspected animal is killed,
treatment is started as soon as possible and
may be interrupted only after examination of
brain has eliminated all suspicion of rabies.
Rabies post-exposure prophylaxis…

❖Dosage and Administration:-

a. Infants less than 2 years of age, 2cc daily subcutaneous injections
around the umbilicus for 14 consecutive days. Booster doses on the
10th, 20th and 30th days following the last injection.
Rabies post-exposure prophylaxis…

b. For children 3 years of age 3cc daily subcutaneous injections for 14

consecutive days. Booster doses on the 10th, 20th and 30th days
following the last injection.
Rabies post-exposure prophylaxis…

c. For children 4 years of age, 4cc daily subcutaneous injections for 14

consecutive days. Booster doses on the 10th, 20th and 30th days
following the last injection.
Rabies post-exposure prophylaxis…

d. For children 5 years of age, and above, 5cc daily subcutaneous

injections for 14 consecutive days. Booster doses on the 10th, 20th
and 30th days following the last injection.
Rabies post-exposure prophylaxis…

❖Side Effects:-
• As for any active product, the nervous tissue vaccine may induce
undesirable effects to a varying degree in certain subjects: -

➢Minor local reactions: - pain, erythema, oedema, pruritus and

induration at the injection point.
Rabies post-exposure prophylaxis…

❖ Systemic reactions:

➢moderate fever, headaches, dizziness,

gastrointestinal disorders(nausea, abdominal
pains). Exceptionally, sometimes might cause
partial paralysis.
Rabies post-exposure prophylaxis…

➢Report to the doctor any unwanted and disturbing effects which

might not be mentioned in this leaflet.
Storage and Shelf life

➢The expiry date is five months from

the date of issue, provided that the vaccine
is kept at a temperature between 20C and 80C
throughout this time.

➢N.B:- Freezing destroys the antigenicity of

phenolized vaccine and hence the vaccine
should not be used if frozen.
 Fermi-type Anti-Rabies Vaccine for Human Use

Nervous Tissue /Fermi-type/ Anti-Rabies ii. If the bites are severe, treatment
Vaccine for Human use should be started as soon as
possible, but may be stopped if the
1. Preparation:- animal is seen to be healthy five
The vaccine consists of a 5% aqueous days after the bite.
suspension of brain tissue from sheep iii. If for any reason the rabies suspected
inoculated with fixed rabies virus, animal is disappeared during the
observation period before the 10th
inactivated with Phenol.
day, treatment must be started
2. Amount:- immediately.
Vial contains 100 ml.
3. Action:- iv. If the rabies suspected animal is
The vaccine works by causing your killed, treatment is started as
body to protect itself against rabies. soon as possible and may be
The body makes substances which interrupted only after examina-
fight the rabies virus. i.e ensure the tion of brain has eliminated all
production and maintenance of high suspicion of rabies.
levels of virus neutralizing antibodies. 5. First Aid Treatment:-
4. Indications /intended use/:- The treatment of wounds is very
The vaccination is given to people important and must be performed
after they have been exposed to rabies
promptly after the bite. It is
infection. i.e given after a bite.
recommended firstly to wash the
This indication must be based upon a
wound with running water and soap
number of factors assessed by an or detergent and then apply 70%
experienced physician. alcohol, tincture of iodine or a 0.1%
4.1 If the rabies suspected animal is quaternary ammonium solution
known and followed up by a (provided that no soap remains as
veterinary surgeon for ten days
these two products neutralize each
following the incidence, there are
then three possibilities:- other). Curative vaccination must be
administered under medical superv-
i. If the bites are not severe, treatment ision and only in a rabies treatment
should not be given unless the
veterinary surgeon gives a contrary centre.
opinion upon observation of the
animal.
6. Dosage and Administration:-
a. Infants less than 2 years of age, 2cc
daily subcutaneous injections
 a. around the umbilicus for 14 date of issue, provided that the vaccine
consecutive days. Booster doses on is
the 10th, 20th and 30th days kept at a temperature between 20C and
following the last injection. 80C throughout this time.
b. For children 3 years of age 3cc
daily subcutaneous injections for N.B:- Freezing destroys the antigenicity
14 consecutive days. Booster doses
of phenolized vaccine and hence the
on the 10th, 20th and 30th days
following the last injection. vaccine should not be used if frozen.
c. For children 4 years of age, 4cc
daily subcutaneous injections for 3. Name and address of the producer
14 consecutive days. Booster doses Ethiopian Public Health Institute
on the 10th, 20th and 30th days
following the last injection. Gulelle Sub-city, Arbegnoch Street
d. For children 5 years of age, and
P.O.Box: 1242
above, 5cc daily subcutaneous
injections for 14 consecutive days. Addis Ababa, Ethiopia
Booster doses on the 10th, 20th and
30th days following the last Tel: 011 2 13 34 99/0112758330
injection.
http://www.ephi.gov.et

1. Side Effects:-
As for any active product, the nervous
tissue vaccine may induce undesirable
effects to a varying degree in certain
subjects: - Minor local reactions: - pain,
erythema, oedema, pruritus and
induration at the injection point.
Systemic reactions: moderate fever,
headaches, dizziness, gastrointestinal dis
orders (nausea, abdominal pains).
Exceptionally, sometimes might cause
partial paralysis. Report to the doctor
any unwanted and disturbing effects
which might not be mentioned in this
leaflet.
2. Storage and shelf life:-
The expiry date is five months from the
THANK YOU!