National Guideline on Rabies Prophylaxis in Nepal 2019

National Guideline on Rabies Prophylaxis in Nepal 2019 will provide a technical guidance to healthcare workers for rabies prophylaxis activities and services.

Background

It is estimated that the annual incidence of human rabies is around one hundred in Nepal. Many human rabies cases are not admitted, or patients leave against medical advice (LAMA). The number of animal bite cases has fluctuated over the past few years. It is estimated that around 50,000 people seek post-exposure prophylaxis in Nepal based on available medical records, vaccine distribution trend and services provided by private clinics.

Human rabies can manifest clinically as either:
• Furious form (classical)- widely recognized form OR
• Paralytic form
Neither form can be correlated with a specific anatomical localization of RABV in the central nervous system.

The consequence of an exposure to RABV depends on several factors, including
• the severity of the wound
• the location of the bite on the body
• the quantity of virus inoculated into the wound(s), and
• the timeliness of post-exposure prophylaxis (PEP)

Signs and Symptoms of Rabies
Initial Symptoms
• Pain or paraesthesia at the wound site
• Fever

Later
• Hyperactivity
• Fluctuating consciousness
• Hallucinations
• Hydrophobia (furious rabies)
• Paralysis and coma (paralytic rabies)
• Followed by death

Standard Case Classification

A case that is compatible with a clinical case definition:

SUSPECTED CASE
“A subject presenting with an acute neurological syndrome (i.e. encephalitis) dominated by forms of hyperactivity (i.e. furious rabies) or paralytic syndromes (i.e. paralytic rabies) progressing towards coma and death, usually by cardiac or respiratory failure, typically within 7–10 days after the first sign, if no intensive care is instituted.

This may include any of the following signs: aerophobia, hydrophobia, paresthesia or localized pain, dysphagia, localized weakness, nausea or vomiting.”

PROBABLE CASE

A suspected case plus a reliable history of contact with a suspected, probable or confirmed rabid animal.

CONFIRMED CASE

a suspected or probable case that is laboratory confirmed (usually post-mortem)

Post Exposure Prophylaxis (PEP)

The indication and procedure for PEP depend on the
• type of contact with the suspected rabid animal and
• immunization status of the patient

Rabies in humans can be prevented, after exposure, by PEP. Proper wound management combined with prompt post-exposure use of Cell Culture Vaccines and Embryonated Egg-based Vaccines (CCEEVs) and simultaneous administration of RIG in severe exposures, is close to 100% effective in preventing rabies.

WHO Classification of Exposures

• Category I: [TYPE OF CONTACT: (Touching or feeding of animals, Animal licks on intact skin (NO EXPOSURE)]- No PEP required
• Category II: [TYPE OF CONTACT: Nibbling of uncovered skin, Minor scratches or abrasions without bleeding (EXPOSURE)]- Wound washing and Immediate vaccination
• Category III: [TYPE OF CONTACT: Single or multiple trans dermal bites or scratches, Contamination of mucous membrane or broken skin with saliva from animal licks (Exposures due to direct contact with bats)]- Wound washing and Immediate vaccination and RIG administration

• World Rabies Day! Rabies: Vaccinate to Eliminate!
• Rabies: Share the message. Save a life. #WorldRabiesDay
• Fast-track efforts to eliminate rabies: WHO
• Rabies: Zero by 30, World Rabies Day 2017
• ”End Rabies Together” : World Rabies Day
• World Rabies Day : Educate. Vaccinate. Eliminate
• World Neglected Tropical Diseases (NTD) Day: Beat NTDs: For Good. For All.
• Epidemiology and Disease Control Division, Department of Health Services