Caring for a suspected

rabies patient

DR K D S T ABEYWARDANA
MBBS(COL), MD(VIROLOGY), FRCPath(INFECTIOUS DISEASES/VIROLOGY)
CONSULTANT VIROLOGIST
Introduction
 Rabies is a viral illness causing an encephalitis that is almost always fatal.

 Rabies caused by rabies virus (RABV) genotype 1 is one of the most common
fatal infections worldwide.

 Rabies virus is an RNA virus of the family Rhabdoviridae, genus Lyssavirus.

 Rabies virus is labile outside a living host, and does not remain infective for
long periods in the environment.

 Sunlight (ultraviolet radiation), heat, solvents, detergents, and oxidizing

agents have been shown to rapidly inactivate the virus.
Human Rabies deaths
 The World Health Organization (WHO) estimate rabies is responsible for at least 60,000
deaths per annum despite increase in pre- and post-exposure vaccination.
Transmission

 Rabies virus enters the body through wounds or by direct contact with
mucosal surfaces. It cannot cross intact skin.

 The most common form of exposure is virus-laden saliva from a rabid

animal introduced through a bite or scratch (and very rarely into a
pre-existing fresh break in the skin or through intact mucous
membranes)
Human to human transmission

 Human-to-human transmission occurs almost exclusively as a result of organ or tissue

transplantation

 However, human-to-human transmission can occur in the same way as animal-to-human

transmission (i.e., the virus is introduced into fresh open cuts in skin or onto mucous
membranes from saliva or other potentially infectious material such as neural tissue).

 Rabies virus can be found in saliva, tears, and nervous tissues of human rabies cases and
exposure to these body fluids and tissues carries a theoretical risk of transmission

 There is no evidence to suggest that rabies virus is transmitted in either semen or

embryos, or through blood
Clinical Manifestations of Human Rabies

 The incubation period may last for weeks to months, typically about 3 to 12 weeks.

 The initial symptoms of rabies are non-specific. It may present with fever and flu-like
symptoms.

 The patient often complaint of pain or paraesthesia at the bite site at prodromal stage.

 As the condition progress, the patient may start to experience change in behaviour,
altered mental state, hydrophobia, aerophobia and eventually death within 7-10 days
after prodromal stage.
Clinical Manifestations of Human Rabies
 There are two forms of the human rabies:

i. About 2/3 of patients exhibit furious rabies with signs of hyperactivity, excited
behaviour, hydrophobia and sometimes aerophobia.
- After a few days, death occurs due to cardio-respiratory arrest.

ii. Paralytic rabies accounts for about 1/3 of the total number of human cases.
The muscles gradually become paralyzed, starting at the site of the bite or scratch.
Coma slowly develops and eventually death occurs.
 The average time from initial symptom to death is 5.7 and 11 days for furious and
paralytic rabies respectively.
 It is critical to obtain history of exposure to rabid animal when evaluating a case of
acute encephalitis syndrome or acute flaccid paralysis.
Differential diagnosis of human rabies

 Other infective encephalomyelitis, (Japanese encephalitis, Tetanus,

Poliomyelitis)
 Autoimmune encephalitis
 Toxic encephalopathy
 Guillain-Barre Syndrome,
 Cerebrovascular accident
 Acute psychosis
 alcohol withdrawal
 serotonin syndrome
Diagnosis

 Laboratory and image findings are usually nonspecific.

 CSF examination usually showed lymphocytosis (usually less than 30 cell/dL)

 CT scan is usually normal and MRI is usually required for visualisation.

MRI characteristic of rabies are non-enhanced, ill defined mild hyper-intense lesion on
T2-weighted in the brainstem, hippocampus, hypothalamus, subcortical white matter,
deep and subcortical gray matter and cervical cord in both furious and paralytic form.
Enhancing lesion are not typical for rabies.
 Laboratory Diagnosis

 Rabies virus is an exclusively neurotrophic virus. There is no viremia and host immune
response occurs at the late stage of infection. Therefore, no diagnostic test is available to
detect human rabies infection before the onset of clinical symptoms.

 Laboratory confirmation of human rabies can be established through one or more of the
following tests:
1. Detection of viral RNA by real time Reverse Transcriptase Polymerase Chain Reaction (rRT-
PCR).
2. Detection of rabies viral antigens by direct fluorescent antibody (DFA) or
immunohistochemistry (IHC) in nuchal skin biopsy (ante-mortem) or brain tissue (post
mortem).

 Once patient show symptoms, several tests can be used to diagnose rabies ante-mortem
(before death). Preferably, multiple sample types are required for optimal diagnosis.
Samples

 Salivary sampling taken at least 3-6 hr intervals for detection of Rabies RNA
(until 3 consecutive negative results)
 CSF rRT-PCR,

At least 0.5ml.
In sterile plastic container.
Do not add VTM and no preservative
Keep at 4-80C.
Transportation of samples

 Contact local Virology laboratory/Rabies lab prior to sending the samples.

 Packing Specimen for Transportation
- Use three packaging layers
- First layer must be water tight.
- Use absorbent material between primary and secondary receptacle.
 Transport to the laboratory as soon as possible.
 Store all specimens at 4-8 °C before and during transportation within 48
hours.
 Need to store all specimens at -70 °C beyond 48 hours.
 Send all specimens together with appropriately filled request form
Management of Human Rabies Case

 The clinical management of human rabies is primarily palliative in nature.

 Human rabies is almost always fatal. To date there have been few reports of
human survivors, majority of whom had received PEP prior to the symptoms
onset. Nonetheless the survivors have severe neurological sequelae.

 Hence, the management/ prevention of the human rabies case must focus on
good animal bite wound care, post-exposure prophylaxis and prevention of
animal’s bite.
Management of Human Rabies Case

 The aim is to
 Lessen agitation,
 Relieve suffering by the means of sedation, analgesics and antipsychotic.
Nursing care- Aspects to consider

 Ineffective breathing pattern related to asphyxia.

 Imbalanced Nutrition: related to decreased swallowing reflexes.
 Hyperthermia related to infection.
 Risk for injury related to seizures and weakness.
 Risk for infection associated with open wounds
 Anxiety of the family related to exposure to information.
 Nursing care- Interventions

 Improve breathing pattern.

- Place patient with proper body alignment for maximum breathing pattern
- Maintain a clear airway by encouraging patient to mobilize own secretions with successful
coughing; suction secretions, as necessary.

 Improve nutritional intake

- consider six small nutrient-dense meals instead of three larger meals daily.

 Maintain normal body temperature.

- give antipyretic medications as prescribed.
Nursing care- Interventions

 Reduce anxiety.
- Provide a pleasant environment. Patient should be cared preferably in an
isolation room if available or in an area in the ward with minimum
disturbances.
- Use presence, touch, and verbalization, to remind patients that they are not
alone and to encourage expression or clarification of needs, concerns,
unknowns, and questions
- Interact with patient in a peaceful manner
- Accept patient’s defences
- Converse using a simple language and brief statements and explain all
activities, procedures, and issues that involve the patient
Nursing care- Interventions

 Prevent injury.
- Avoid use of restraints; obtain the medical officer’s advise if restraints are
needed
- Eliminate or drop all possible hazards in the surroundings

 Prevent infection.
Maintain asepsis when changing dressing and wound care
 Infection Control Measures:

 Hazard Group 3 pathogen

1. Strict contact precautions

- No direct exposures to the patient’s bodily secretions without personal protective
equipment
- Gloves, gowns and mask
- Eye protection when there is risk of splash of secretions (collecting salivary
samples, suction etc)

2. Number of staff and visitors kept to a minimum

 Infection Control Measures:

3. Secretions and suction containers disposed in clinical waste (incineration)

4. Closed suction catheter system used to remove tracheal secretions in intubated

patients

5. Spillage of secretions or body fluids should be disinfected with freshly prepared 1%

hypochlorite solution for 20 minutes.

6. Use Chlorine dioxide-based disinfectant to clean non-disposable equipment.

(Chlorine-based disinfectants are effective against the rabies virus)
Infection Control Measures:

7. Patient’s clothing, bed linen and other personal items should be boiled and
then washed with soap and water if reused.

8. Following death- terminal clean with a chlorine-releasing agent.

9. HCW does not need any post-exposure anti rabies therapy unless there is
direct contamination of mucous membranes or open wounds with the patient’s
saliva or secretions, or they have been bitten or scratched by the patient while
nursing.
- If there is a suspected high-risk exposure to a HCW, contact Virology and
infection control team for further management.
Thank you