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Specific objectives

Prevention and Control of Rabies Wound Management Dr D V Bala Professor & Head Community Medicine Smt NHL Municipal Medical College, Ahmedabad. Specific objectives. 1) Indication of anti rabies treatment 2) Guide for Post-Exposure Prophylaxis 3) Principles of Treatment Wound treatment

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Specific objectives

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  1. Prevention and Control of Rabies Wound ManagementDr D V BalaProfessor & Head Community Medicine Smt NHL Municipal Medical College,Ahmedabad

  2. Specific objectives 1) Indication of anti rabies treatment 2) Guide for Post-Exposure Prophylaxis 3) Principles of Treatment • Wound treatment • Immunoglobulin / anti sera • Vaccination • Advice to Patient 4) Mx of special clinical situations

  3. Specific objectives(cont.) 5) Prevention • Post exposure prophylaxis • Pre exposure prophylaxis • Post exposure treatment who has been vaccinated previously 6) Testing for Rabies 7) Treatment of other animal bites 8) If pet is bitten by a wild animal 9)What approaches have been used to try and control the street dog population?

  4. Animal Bite Management Medical Emergency

  5. INDICATION FOR ANTIRABIES TREATMENT • Antirabies treatment should be started immediately : • If the animal shows sign of rabies or dies within 10 days of observation • Biting animal cannot be traced or identified • Unprovoked bites • Laboratory test are positive for biting animal • All bites by wild animals

  6. CLASSIFICATION OF EXPOSURE • CLASS 1 – - Licks on healthy broken skin. - Scratches with oozing of blood - Consumption of unboiled milk of suspected animal

  7. CLASS -II • Licks on fresh cuts. • Scratches with oozing of blood. • All bites except those on palm, face, head, neck & fingers. • Minor wounds <5 in numbers.

  8. CLASS -III • All bites or scratches with oozing of blood on neck, head, face, palms, fingers. • Lacerated wounds on any part of the body. • Multiple wounds>5in numbers. • Bites from wild animals.

  9. SERIOUS EXPOSURES Bites on the Head, Face, Hands, Genitalia Multiple bites Extensive lacerations Bites by proven rabid animals animals not available for observation more than one animal wild animals

  10. LACERATIONS ON THE SCALP

  11. Bites on the face

  12. MULTIPLE BITES ON THE FACE

  13. Bite on the face in an adult

  14. Multiple bites by more than one dog

  15. EXTENSIVE LACERATION ON THE FOOT

  16. Bite on the Genitalia

  17. Sutured bite wounds

  18. CLASS III EXPOSURE

  19. Category III Exposures

  20. If pet is bitten by a wild animal? • Any animal bitten or scratched by either a wild mammal or a bat that is not available for testing should be regarded as having been exposed to rabies.

  21. Guide for Post-Exposure Prophylaxis CategoryType of contactRecommended Post exposure prophylaxis I Touching or feeding of animals None, if reliable case history Licks on intact skin is available. II Nibbling of uncovered skinWound management,; Administer anti-rabies vaccine immediately Minor scratches or abrasions Convert post exposure prophylaxis to pre exposure prophylaxis if animal remainswithout bleeding. healthy throughout the observation period of 10 days or if animal is euthanized and found to be negative for Rabies by appropriate laboratory techniques.

  22. Guide for Post-Exposure Prophylaxis (Contd…)

  23. Principles of Treatment Always overtreat, but Never undertreat. • Wound treatment • Immunoglobulin / anti sera • Vaccination • Advice to Patient

  24. Decision to treat • Disease is endemic in India • Suspect all animal bites • Treat as per merits of the bite

  25. Observation of animals • Valid only for dogs and cats • Start treatment and observe • Modify PEP

  26. Wound Management DO’S MECHANICAL: Wash under Running tap water CHEMICAL: Soap (Preferably detergent) Disinfectants - Povidone Iodine, Spirit, household antiseptics BIOLOGICAL: Infiltrate immunoglobulins Suturing only if required (1 - 2 loose sutures) and only after administration of RIGs.

  27. DONT’S AFTER A BITE • Don’t apply savlon Cetavlon, chillies, mustard oil, or other irritant chemicals. • Don’t cauterise with carbolic acid, HNO3 • Avoid suturing., infiltrate with RIG first. • (If essential only after 24 hours ) • Don’t cover the wound. • Don’t touch the wound with bare hands

  28. Passive Immunization Human Rabies Immunoglobulin : 20 IU/kg body wt. (HRIG) Maximum of 1500 IU Equine Rabies Immunoglobulin : 40 IU/kg body wt. (ERIG) Maximum of 3000 IU ERIG must be administered only after the Test dose Test dose (ERIG) 0.1 ml of 1:10 dilution of the serumin normal saline Intra Dermal over flexor aspect of forearm or as per Manufacturer guidelines. Observe for : Wheal, Erythema, Induration, Itching, Tachycardia, Fall in Blood Pressure, Feeble Pulse.

  29. Rabies Immunoglobulin

  30. RIG : Infiltrate in wounds • Infiltrate as much as possible into and around the wounds; remainingif any to be given Intra Muscularly at a site away from the site where vaccine has been administered. • Inject RIGs into all wounds (anatomically feasible). • If RIGs is insufficient (by volume) dilute it with sterile normal saline (upto equal volume). • Presently available preparations are very safe. However, equine serum must be administered with full precautions.

  31. RIG Infiltration

  32. Dr. Louis Pasteur1883 Rabies vaccine

  33. VACCINES FOR IMMUNIZATION OF MAN CLASSIFICATION: • Nervous tissue vaccine : sheep , suckling mouse brain (NTV X) • Chick & Duck embryo vaccine (PCEV) • Cell culture vaccines : 2 types • Human diploid cell vaccine (HDCV): • 2nd generation tissue culture (animal cell) vaccine

  34. Currently Available Anti-rabies Vaccines In India

  35. Vaccines approved for ID use in India • PVRV – Verorab, Aventis Pasteur (Sanofi Pasteur) India Pvt. Ltd. • PCECV – Rabipur, Chiron Behring Vaccines Pvt. Ltd. • PVRV – Pasteur Institute of India, Coonoor • PVRV – Abhayrab, Human Biologicals Institute

  36. Vaccines

  37. Nervous tissue vaccine • BPL inactivated vaccine prepared from fixed virus grown in brains of adult sheep • Disadvantage is it is a crude vaccine so can cause fatal neurological reaction. • Discontinued since December 2004

  38. Good Bye to Nervous Tissue Vaccine • Annual production 35-40 million ml • Utilized to immunize 450,000 people/annum • Efficacy 90 – 95% • Neuroparalytic accidents : 1:4000 – 1:11000 • Production stopped since December 2004

  39. DUCK EMBRYO VACCINE • Developed in attempt to eliminate neuroparalytic factors contained in brain tissue vaccine • Allergic risk is present though . • No to be given to person sensitive to egg protein • Not available in India

  40. CHICK EMBRYO VACCINE • Purified chick embryo cell vaccine or PCEV is also called RABIPUR • Very popular all over the country.

  41. CELL CULTURE VACCINE • Newer vaccines • More potent safer, • Requires less dose small volume few injections, few side effects: • Two types : • Human Diploid Cell Vaccine (HDCV ) and • 2ND Generation Tissue Culture Vaccine : Cheaper than HDCV

  42. HUMAN DIPLOID CELL VACCINE (HDCV) • Prepared by propagating the “FIXED” virus in human diploid fibroblast cells. • Safe & highly potent. • In INDIA used for both pre & post exposure immunization.

  43. 2nd GENERATION TISSUE CULTURE VACCINE • Derived from “Non Human” sources like foetal bovine kidney, chick embryo fibroblast, dog kidney cells, hamster kidney cells. also from Non tumogenic continuous cell lines (vero cells). • Highly potent & Low cost. • Preferred over HDCV vaccines.

  44. Materials required for IDRV • A vial of rabies vaccine approved for IDRV and its diluent. •  2 mL disposable syringe with 24 G needle for reconstitution  of vaccine. •  Disposable 1 mL insulin syringe (with graduations upto 100  or 40 units) with a fixed (28 G) needle. •  Disinfectant swabs (e.g. 70% ethanol, isopropyl alcohol) for cleaning the top of the vial and the patients’ skin.

  45. Routes of Administration of Anti-rabies Vaccines • Intramuscular • Intradermal

  46. Site of Inoculation : Intramuscular • Deltoid muscle • Or • Anterolateral part of thigh • Notrecommended in • Gluteal region • due to poor absorption

  47. Intramuscular route • (if antimalarial chemoprophylaxis is applied concurrently, intramuscular injections are preferable to intradermal) • 􀃈 adults: deltoid area of the arm; • 􀃈 children: antero-lateral area of the thigh acceptable

  48. Essen intramuscular Regimen Standard intramuscular regimen. One dose into deltoid on each of days: 5 vials 5 visits day 0 3 7 14 28 Rabies immunoglobulin Post Exposure Vaccination Schedule

  49. Two intramuscular schedules for modern vaccines: “Essen” regimen”:Classical 5 dose IM (intramuscular) regime one dose of the vaccine should be administered on days - 0, 3, 7, 14 and 28, in deltoid region. or, in small children, into the antero-lateral area of the thigh muscle; As an alternative, the 2-1-1 regimen may be used. 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 7and one on day 21.

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