Transcript Slide 1

Systematic review of the health impacts
PREVENTION
OF
RABIES
IN
HUMANS
of mass earth movements
HUMAN DISEASE IS FATAL BUT IS PREVENTABLE BY POST EXPOSURE PROPHYLAXIS (PEP)
ALL ANIMAL EXPOSURES MUST BE ASSESED FOR POTENTIAL RABIES EXPOSURE RISK
RABIES EXPOSURE RISK ASSESSMENT
• Risk assessment is necessary to determine if the animal exposure carries a risk of rabies.
• This assessment is based on species, behavior of the animal, and health of the animal.
• Indicators of high risk attacks include:
•Unprovoked animal attack,
•Animal with abnormal behavior – e.g. domestic animals being aggressive; wild animals may appear ‘tame’,
•Animal appears sick – drooling, wobbling/unsteady, snapping at imaginary objects,
•Animal has died.
• After considering these factors, then consider the category of exposure- see below.
NOTES
• All animal bites are reportable as per district requirements.
• There is NO test to confirm or exclude rabies virus transmission from
animal to human at the time of exposure
• Vaccination history of animal may be unreliable, and as such should be
treated with caution given least weight in the risk assessment.
• Do not delay PEP pending test results for the animal.
•If state vet later confirms animal is rabies free, then PEP can be
discontinued.
• PEP is most effective if given immediately after the exposure.
• Do not withhold PEP when there is a delay PRESENTATION. If PEP is
given, then count the date first vaccine dose is given as Day 0..
MANAGEMENT OF PATIENTS EXPOSED TO POTENTIALLY RABID ANIMAL
GENERAL WOUND MANAGEMENT IS CRITICAL IN ALL PATIENTS:
• Flush very well with soap and water or water alone if soap is not available, for at least 10 minutes, then clean with 70% alcohol solution
• After cleaning apply iodine solution or ointment if available.
• Give antibiotics e.g. amoxycillin clavulanate when indicated.
• Give tetanus vaccination or booster.
• Avoid suturing and use of local anaesthetic agents.
FURTHER SPECIFIC MANAGEMENT DEPENDS ON CATEGORY OF RABIES EXPOSURE AND PREVIOUS VACCIANTION HISTORY:
• Vaccine course in category 2 and 3 exposures.*
• Addition of rabies immunoglobulin in category 3 exposures is critical.** Give rabies immunoglobulin in addition to vaccine for category 2 exposures, if
patient is immunocompromised
CATEGORIES OF EXPOSURE
Category
1
2
3
Description
Action
• Touching or feeding animal
• Licking intact skin
• No action if history of exposure is reliable
• If history of exposure is not reliable treat as category 2
• Nibbling of uncovered skin
• Superficial scratch without any bleeding
• General wound management as above, plus
• Give full course of rabies vaccine*
• Give rabies immunoglobulin in addition to vaccine if patient is immunocompromised
• Bites or scratches penetrating skin or drawing blood
• Licking of mucous membranes (eg eyes, mouth)
• Licking of broken skin or abrasions
• General wound management as above, plus
• Give full course of vaccine*
• Give rabies immunoglobulin**
• Administration of rabies immunoglobulin is critical in category 3 bites
*RABIES VACCINE
**RABIES IMMUNOGLOBULIN (RIG)
Indication: CATEGORY 2 AND 3 EXPOSURES
• Vaccination schedule requires FOUR doses.
• Course: day 0, 3, 7, 14.
• Day 0 = day of first vaccination.
• IMI deltoid muscle in adults, anterolateral thigh in
children.
• DO NOT GIVE INTO GLUTEUS MAXIMUS
• Dose: 1 amp per dose for adults and children.
• Vaccine induces immune response in 7-10 days
• Evidence suggests that immunity from pre-exposure
prophylaxis lasts up to 15 years. If patient has had
two or more rabies vaccines in past, then only give two
booster doses on days 0 and 3.
Indication: CATEGORY 3 EXPOSURES and category 2 exposure if patient is immunocompromised.
• Dose: 20 IU/kg. Infiltrate RIG around wounds, giving as much as anatomically appropriate without compromising blood
supply (especially for extremities).
• Inject any remaining RIG into deltoid in opposite arm to vaccine,
• DO NOT GIVE INTO GLUTEUS MAXIMUS.
• Each 2ml ampoule contains 300 IU of RIG.
• If multiple wounds, dilute RIG in equal volumes of saline and infiltrate all wounds.
• Give RIG at same time as vaccine administration.
• Give RIG and vaccine as soon as possible after exposure for best effect.
• If RIG is not immediately available, it should be sourced and administered as soon as possible, but should not be given
more than 7 days after the first vaccination.
• Omit RIG if past rabies vaccination in the patient can be confirmed.
• RIG is immediately protective. Protection lasts 7-10 days, giving time for vaccine to induce immune response.
IMMUNOCOMPROMISED PATIENTS
•Give RIG and vaccines in category 2 and 3 exposure.
•Give 5th dose of vaccine on day 28.
NICD Hotline for Clinical Advice: 082 883 9920
Updated June 2013
Adapted from Rabies: Guide for medical, veterinary and allied professions, Second edition
Department of Agriculture
PREVENTION OF RABIES IN HUMANS
ADDITIONAL INFORMATION FOR HEALTH CARE WORKERS
FACTORS TO CONSIDER FOR DETAILED RISK ASSESSMENT
Animal species
At risk of carrying rabies
Dogs
Cats
Livestock
Bats
Bat-eared fox
Mongoose
Cane rats
These lists are for example only – if you are unsure of risk
for a particular species seek expert advice
Not a risk for rabies
Birds
Reptiles
Mice and rats (other than cane rats)
Animal Behaviour
Factors which indicate higher risk of exposure:
The attack was unprovoked - teasing an animal, trying to take an animals food or guard,
dog attacking an unfamiliar person entering their territory are provoked attacks,
The animal has bitten multiple people,
Domestic animal being aggressive, wild animal appearing tame.
Animal Health
If the animal has died or is sick this increases the risk of rabies exposure
Typical rabies symptoms include:
Dogs: aggression, drooling, wobbling, snapping at imaginary insects, muscle paralysis.
Cats: aggression, uncoordinated, frothing, abnormal vocalisation and response to owners.
Cattle and goats: choking – “bone in the throat”, knuckling of fetlocks and hind-quarters.
Wild animals: lose fear of humans. Jackals and badgers more aggressive. Kudu and
yellow mongoose tend to be more tame.
If the patient presents more than 10 days since exposure, and the animal is still alive and
healthy, then risk of rabies exposure is very low.
Figure 1. A map illustrating the distribution of the main rabies vectors in South Africa
GEOGRAPHY
Consider where the exposure occurred and where the animal is from.
Higher risk areas include KwaZulu-Natal, and parts of Eastern Cape, Free State,
Mpumalanga and Limpopo, However outbreaks have occurred in all provinces and
there are no areas of zero risk.
CATEGORIES OF EXPOSURES
Picture of large/deep bite
wound
Picture of bleeding scratch
Wounds do not have to be large or bleed
profusely to be considered category 3. A
single drop of blood drawn from the wound
indicates a category 3 exposure. All three
pictures show category 3 wounds
Picture of bat bite.
Category two exposures only occur when
there has been no break in the skin or
bleeding at all.
There are no category 2 bat exposures
should always be considered category 3, as
WOUND MANGEMENT AND ADMINISTRATION TECHNIQUE
Step 1: Thoroughly clear the wound for 10 minutes with
soap and water, then clean with 70% alcohol solution.
Finally apply iodine solution.
diagram of wound cleaning.
Step 2: If indicated, infiltrate rabies immunoglobulin
around wound at a dose of 20IU/kg
diagram of RIG infiltration.
Step 3: Administer vaccine by IM injection into deltoid
muscle in adults, anterolateral thigh in children. Give
further doses as per PEP schedule
diagram of vaccine
administration.
PICTURE OF VACCINE ADMINSITRATION
Examples of
vaccine (left and
centre) and RIG
(right) packaging
rabies vaccine
packaging 1
rabies vaccine
packaging 2
rabies vaccine
packaging 3
DO NOT USE LOCAL ANAESTHETIC AND
AVOID SUTURING IF AT ALL POSSIBLE.
If suturing of wound which is a high risk of rabies
exposure suturing is unavoidable, RIG must be
infiltrated around the wound first, and suturing delayed
for as long as possible.
OTHER CONSIDERATIONS
Veterinary services
• If you give PEP then the state vet/animal health practitioner should be contacted
to inform them of potentially rabid animal.
• This contact should be made urgently if there is a risk of other citizens being
exposed, for example the animal has attacked multiple people and it is still alive.
Supply of biologicals
• Procedures should be in place to ensure access to adequate supplies of vaccine
and immunoglobulin (either local stocks or robust referral systems).
• Each facility should have a process in place to resolve stock outs quickly.
• Provincial Department of Health should be contacted if there are any difficulties in
sourcing rabies immunoglobulin.
Non-compliance:
Most cases of rabies in those receiving PEP occur when the protocol has not been
followed correctly:
• It is therefore critical to follow the protocol.
• Patients should be actively followed up to ensure completion of vaccination
schedule.
• If the patient does not comply fully, they should be informed that they are placing
themselves at higher risk, and staff should make every effort to ensure PEP is
completed.
Pregnancy:
• No contraindication to vaccine or RIG.
A human rabies case constitutes a public health system failure so it is important to confirm all
suspected rabies cases and to investigate as to the reason for the failure.