(NAR) VOL. 22 NO. 1, JANUARY - MARCH 2011
A. Republic Act 9482 or the Anti-Rabies Act of 2007 – An Act Providing for the Control and Elimination of Human and Animal Rabies, Prescribing Penalties for Violation Thereof and Appropriating Funds Therefor.
B. Memorandum of Agreement entered into by the Secretaries of the Department of Agriculture, Health, Education, Culture and Sports and the Interior and Local Government on May 8, 1991.
C. Batas Pambansa Blg. 97 – An Act Providing for the Compulsory Immunization of Livestock, Poultry and Other Animals Against Dangerous Communicable Diseases.
D. DOH Administrative Order No. 2007-0029: Guidelines on Management of Animal Bite Patients
E. DOH Administrative Order No. 2009-0027: Amendment to AO 2007-0029 regarding the Revised Guidelines on Management of Animal Bite Patients.
- WHO Expert Consultation on Rabies. WHO Technical Report Series 931 First Report 2005
A. Post Exposure Prophylaxis (PEP) – formerly post exposure treatment (PET); refers to anti-rabies treatment administered after an exposure (such as bite, scratch, lick, etc) to potentially rabid animals. It includes local wound care, administration of rabies vaccine with or without Rabies Immune Globulin (RIG) depending on the category of exposure.
B. Updated rabies vaccination – Dog/Cat must be at least 1 yr 6 months old and has updated vaccination certificate from a duly licensed veterinarian for the last 2 years with the last vaccination within the past 12 months.
C. Rabid Animal – refers to biting animal with clinical manifestation of rabies and/or confirmed laboratory findings of rabies.
A. The Department of Health in collaboration with the LGUs shall be responsible for the management of animal bite victims including provision of human rabies vaccine to augment supplies of the LGUs.
B. The Rabies Control Program shall be integrated with the regular health services provided by the local health facilities.
C. PEP shall be carried out both by the Department of Health and Local Government Units.
D. The funding requirements to operationalize this issuance shall be secured prior to its implementation.
E. Advocacy through information dissemination and training of health workers shall be conducted at all levels.
F. Collaboration among government agencies, non-government and private organizations to ensure successful implementation shall be strengthened.
A. Categorization of Rabies Exposure:
Table I. Categories of Rabies ExposureCategory of exposure Type of ExposureCATEGORY I a) Feeding / Touching an animal b) Licking of intact skin (with reliable history and thorough physical examination) c) Exposure to patient with signs and symptoms of rabies by sharing of eating or drinking utensils
d) Casual contact (talking to, visiting and feeding suspected rabies cases) and routine delivery of health care to patient with signs and symptoms of rabiesCATEGORY II a) Nibbling of uncovered skin with or without bruising/ hematoma b) Minor scratches/abrasions without bleeding c) Minor scratches/abrasions which are induced to bleed d) All Category II exposures on the head and neck area are considered Category III and should be managed as such CATEGORY III
a) Transdermal bites (puncture wounds, lacerations, avulsions) or scratches/abrasions with spontaneous bleeding b) Licks on broken skin c) Exposure to a rabies patient through bites, contamination of mucous membranes (eyes, oral/nasal mucosa, genital/anal mucous membrane) or open skin lesions with body fluids through splattering and mouth-to-mouth resuscitation d) Handling of infected carcass or ingestion of raw infected meat
e) All Category II exposures on head and neck area
B. Management
I. PEP is not recommended for all Category I Exposures
II. PEP can be delayed for Category II Exposures provided that ALL of the following conditions are satisfied:i. Dog/cat is healthy and available for observation for 14 days
ii. Dog/cat was vaccinated against rabies for the past 2 years
a. Dog/cat must be at least 1 yr 6 months old and has updated vaccination
certificate from a duly licensed veterinarian for the last 2 years
b. The last vaccination must be within the past 12 months, the immunization status of the dog/cat will not be considered updated if the animal is not vaccinated on the due date of the next vaccination
*If biting dog/cat becomes sick or dies within the observation period, PEP
should be started immediately
III. PEP should be given immediately for ANY of the following conditions:i. The rabies exposure is category III;
ii. The dog/cat is proven rabid/sick/dead with no laboratory exam for rabies/not available before or during the consultation;
iii. The dog/cat is involved in at least 3 biting incidents within 24 hours or
iv. Dog/cat manifests the following behavior changes suggestive of rabies before, during or after the biting incident:Table 2. Clinical Signs of Animal Rabies
Prodromal Stage (usually lasts 2-3 days; sometimes only a few hours)
A. Changes in attitude/behavior/temperament such as unusual shyness or aggressivenessa. Friendly animal becomes aggressive
b. Solitude
c. Restlessness
d. Snapping at imaginary objects
e. Apprehension
f. Nervousness
g. Anxiety
h. Barking/vocalization at the slightest provocation
B. Dilated pupils; become myotic in advance state
C. Mydriasis and/or sluggish palpebral or corneal reflexes
D. Slight rise in body temperature (slight fever)
Clinical Rabies
Furious Stage (usually lasts 1-7 days) Paralytic (dumb) stage (develops 2-10 days after clinical signs; usually last 2-4 days) I. Increased response to auditory and visual stimulation such as: Paralysis -Restlessness - Paralysis may begin at the bite area and progress until entire CNS involvement -Photophobia - Following paralysis of the head and neck, the entire body becomes paralyze -Hyperaesthesia -Eating unusual objects -Aggression - Change in tone of vocalization/barking (indicative of laryngeal/pharyngeal paralysis) -Attacking any live or inanimate objects II. Erratic behavior -Biting or snapping -Hypersalivation or frothing; drooling/slobbering of saliva (indicative of laryngeal/pharyngeal paralysis) -Licking or chewing of wound/bite site -Dysphagia/difficulty/inability to swallow (indicative of laryngeal pharyngeal paralysis) -If caged, biting of their cage -Wandering and roaming -Excitability -”Jaw drop”/Dropped jaw due to masseter muscle paralysis (suspects foreign body in mouth or esophagus) -Irritability -Viciousness -Pupil dilation or pupil constriction -Protrusion of third eyelid III. Self-mutilation -Ataxia, progressive paralysis and cannibalism (terminal stage) IV. Muscular in-coordination and seizures - Coma and/or respiratory paralysis resulting in death within 2-4 days V. Disorientation Roams and bites inanimate object and also other animals including man VI. PEP is not required for bite/s of the following biting animals: rats, mouse, rabbits, snakes and other reptiles, birds and other avian, insects and fish.
a. Roles and Responsibilitiesi. Department of Health
1. The National Center for Disease Prevention and Control (NCDPC) shall be responsible for disseminating this Joint AO to all Centers for Health Development.
2. All Centers for Health Development (CHD) through the Directors and the Rabies Control Program Coordinators shall ensure that this Joint AO is disseminated to all Provincial/City/Municipal Health Offices, Animal Bite Treatment Centers and private practitioners, hospitals and animal bite clinics in their respective regions.ii. Department of Agriculture
1. The Bureau of Animal Industry (BAI) shall be responsible for disseminating this Joint AO to all DA – Regional Field Units.
2. The Department of Agriculture – Regional Field Units (DA-RFUs) through the Regional Executive Directors and the Rabies Control Program Coordinators shall ensure that this Joint AO is disseminated to all Provincial/City/Municipal Veterinary Offices or their equivalents in their respective regions.iii. Local Government Units
The Provincial Health Offices shall be responsible for disseminating this Joint AO to all City/Municipal Health Offices, Animal Bite Treatment Centers and private practitioners, hospitals and animal bite clinics in their respective provinces. Likewise, the Provincial Veterinary Offices shall be responsible for disseminating this Joint AO to all City/Municipal Veterinary Offices or their equivalents in their respective provinces.
(SGD) ENRIQUE T. ONA, MD, FPCS, FACS | (SGD) PROCESO J. ALCALA |
Secretary of Health | Secretary of Agriculture |