Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY

October 15, 2019

DEPARTMENT CIRCULAR
No. 2019-_ 0508

TO : BANGSAMORO AUTONOMOUS REGION IN MUSLIM

MINDANAO (BARMM) MINISTER OF HEALTH, ALL
UNDERSECRETARIES, ASSISTANT SECRETARIES,
CENTER FOR HEALTH DEVELOPMENT (CHD)
DIRECTORS, CHIEFS OF MEDICAL CENTERS OF
DOH HOSPITALS, EXECUTIVE DIRECTORS OF
SPECIALTY HOSPITALS, PROVINCIAL HOSPITALS,
DISTRICT HOSPITALS, ANIMAL BITE TREATMENT
CENTERS, PRIVATE HOSPITALS AND OTHERS
CONCERNED

SUBJECT : Adoption of the National Rabies Prevention and Control

Program (NRPCP) Manual of Procedures (MOP) 2019

To strengthen implementation of the National Rabies Prevention and Control Program

(NRPCP) for a rabies-free Philippines, the Manual of Procedures (MOP) was updated to
provide more appropriate and practical guidelines. This is to ensure the safety of all and
eventually end rabies deaths among Filipinos from dog mediated rabies.

The NRPCP MOP shall be posted at the DOH website (www.doh.gov.ph) and adopted
by concerned agencies.

Dissemination of the information and guidance to all concerned is requested.

By Authority of the Secretary of Health:

RNA C. CABOT JE, MD, MPH, CESO

ITI
Undersecretary of Hea}th
Public Health Services Team

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila e Trunk Line 651-7800 local 1113, 1108, 1135
Direct Line: 711-9502; 711-9503 Fax: 743-1829 URL: http://www.doh.gov.ph; e-mail: ftduque@doh.gov.ph
10/23/2019 Study 5.jpg

National Rabies
Prevention and
Control Program

Manual of
Procedures

https://mail.google.com/mail/u/O/#inbox/FMfcgxwDrtvgmqvbvWCVmxXexTfjCFdF ?projector=1&messagePartld=0.1 4/1

 MESSAGE

The DOH, through the National Rabies Prevention and Control Program (NRPCP), and in partnership
with the Department of Agriculture Bureau of Animal Industry (DA-BAI), other government agencies,
and local government units, have jointly reviewed the 2012-2016 National Rabies Manual of Procedures
(MOP) and is pleased to present this revised version for use of all rabies program implementers.

The new MOP aims

to provide all rabies program-involved personnel direction and guidance on the
proper management and control of rabies, with the ultimate goal of ending dog-mediated rabies deaths
among Filipinos by 2027, and a rabies-free Philippines by 2030.

For decades, interventions such as safe and effective medicines, promotion of responsible pet ownership,
early consultation when bitten by animals, and timely administration of anti-rabies vaccines have been
made available to
prevent rabies in both humans and animals. Despite all these efforts, the Philippines is
still burdened by this highly preventable disease.

The statistics are alarming: Animal bite case rates across the country have increased from 2014 to 2018.
In 2018, a total of |.1 million animal bites
were registered. Moreso, in 2018, 276 bite victims died due to
rabies infection, with 42% of bite victims are aged 15 years and below.

As we usher the era of Universal Health Care, may this MOP serve as
atool to strengthen service
delivery through consistency in implementation of the NRPCP among varied providers and stakeholders,
especially at the local level across the country. May this MOP also lead towards effective and efficient
diagnosis of animal bites_and human rabies, ultimately leading to near-elimination levels of rabies-related
morbidity and mortality.

Together, let us reach for a rabies-free Philippines.

FRANCISCO T. DYQUE, Ill, MD, MSc

Secitary
Department of Health
INTRODUCTION TO THE MANUAL
This Manual of Procedures (MOP) for Rabies is a tool designed to facilitate consistency in the
implementation of the National Rabies Prevention and Control Program among clinicians,
health service providers, program managers and coordinators and other stakeholders
nationwide. The manual presents step by step reference guides for all health professionals to
aid in the proper diagnosis of cases of animal bites and human rabies; as well as to deliver
evidence-based management forpatients and special group of people.
While lifesaving in preventing rabies, immunoglobulin and/or vaccine, if administered prior to
onset of
clinical signs, nonetheless share the innate risks of any exogenous pharmaceutical
product. to serious adverse events, though rare, may occur in some patients following
Mild
administration of rabies biologicals. Moreover, inappropriate or injudicious use of biologicals
could lead to shortage of supplies of these products and could compromise efficient Post-
Exposure Prophylaxis (PEP) for patients with higher risk exposures. Lastly, rabies biologicals
and their administration entail significant costs.

It is our aim to strengthen the competencies of our health care workers especially those in the
far flung areas with limited resources towards an effective, efficient and cost-efficient diagnosis
and management of animal bites and human rabies.
In general, it is hoped that the use of this manual will help lower down morbidities and
mortalities related with animal bites. Smart people manage problems but champions prevent
them from occurring. Preventing rabies therefore should be easier and cheaper. The best cure
for rabies is prevention.
CHAPTER
I: INTRODUCTION
I. Rabies: A global concern

The Public Library of Science (PLOS) Neglected Tropical Diseases on the Global
Burden of Endemic Canine Rabies states that globally canine rabies causes
approximately 59,000 (95% confidence intervals: 25-159000) human deaths, over
3.7 million disability-adjusted life years (DALYs) and 8.6 billion USD economic
losses annually. The largest component of the economic burden due to is
premature death (55%), followed by direct cost of post exposure prophylaxis
(PEP 20%) and lost income while seeking PEP (15.5%) with only limited costs to
the veterinary.
(PLOS Neglected Tropical Diseases
| DOI:10.1371 fjournal.pntd.0003709 April 16, 2015

Fig.| Countries or areas at risk for Rabies

Rabies: Countries or areas at risk

~”

‘Data Source: WHO Control of Neglected

The
on
boundaries and names shown and the designations used on this map do notimply the expreasion of any opinion whatsoever
part of the World Health Organization conceming the legal status of any country, tanttory, city or araa or of ts authorities,
the en ‘i

Information
Dresses (NTO)
Systerts (45)
ston
and
Mori Health

or conceming the delimitation of its frontiers or boundaries. Dotted and dashed tines on maps represent approximate border nes
‘World Health Organization ‘SO
WHO 2013. All rights reserved,
for which there may not yet be full agreement.

This map shows that more than 95% of rabies deaths occur in Asia and Africa where the
presence of 3 things are common: poverty, poor sanitation and crowding. The estimated
annual figure of almost 60,000 human rabies deaths is probably an underestimate.
(WHO 2013).

With human rabies mediated by dogs claiming the lives of thousands of people every
year worldwide, the World Organization for Animal Health (OIE) and the World
Health Organization (WHO), in collaboration with the Food and Agriculture
Organization of the United Nations (FAO) and with the support of the Global
Alliance for Rabies Control (GARC), conducted a global conference on rabies in
December 2015.

The conference resulted in a new framework, which was jointly developed from fruitful
discussions among nearly 300 participants — including experts, donors, as well as
veterinary and public health officials. The framework identifies a multi-pronged,
comprehensive approach and feasible actions that are needed to achieve an effective
rabies elimination program.

The conference called for a multi-pronged, comprehensive approach to ensure:

(i) affordable human vaccines and antibodies;
(ii) prompt treatment for bite victims; and
(iii) mass dog vaccination in at-risk areas all supported through
increased communication, awareness and education.

Through this, nations are expected to be liberated from the burdens of this dreaded
infection.

Together with the abovementioned approach, member states are also expected to
effectively implement the five pillars of rabies elimination (STOP-R): socio-cultural,
technical, organizational, political and resources approaches:

e S —-Socio-cultural — The socio-cultural approach will encourage the

promotion of responsible dog-ownership, and dog population management
practices, including dog vaccination.
e T= Technical The technical approach will strengthen animal health and
—

public health systems to ensure sustainable, safe, efficacious and accessible dog
and human vaccines and immunoglobulins, and promote and implement mass dog
vaccination as the most cost-effective intervention to achieve dog-mediated
human rabies elimination.
e O- Organizational — A good organizational set up will ensure sufficient
supply of quality-assured canine rabies vaccines through vaccine banks.
e P= Political commitment will be crucial in promoting the One Health concept
and intersectoral coordination through national and regional networks while
implementation will necessarily require investments in
rabies elimination
strategies.
e R- Resources
The global plan notably calls for three key actions:

e making human vaccines and antibodies affordable;

e ensuring people who get bitten receive prompt treatment;
e implementing mass dog vaccinations in
at-risk areas.

The conference likewise cannot stop overemphasizing the importance of vaccination.

During the conference, WHO Director-General Margaret Chan said, “Rabies is 100%
preventable through vaccination and timely immunization after exposure, but access to post
bite treatment is expensive and is not affordable in many Asian and African countries. If we
follow this more comprehensive approach, we can consign rabies to the history books.”

2. The ASEAN response

There are more than 600 million people who are potentially at risk
of rabies in Southeast Asia. Seven out of its ten ASEAN
(Association of Southeast Asia Nations) Member States (AMS) are
endemically infected with rabies. As early as 2014, the ASEAN saw
the urgency of working as a region to eliminate rabies. It convened
its AMS (Cambodia, Indonesia, Lao PDR, Myanmar, the Philippines,
Thailand, Vietnam, Brunei, Malaysia and Singapore) and initiated a joint strategic
development of rabies elimination. The strategy adapted the STOP-R action pillars.

In September 2014, the ASEAN Rabies Elimination Strategy (ARES) jointly endorsed by the
36th ASEAN Ministerial Meeting on Agriculture with Vietnam as the lead country for rabies
its
control, through Ministers of Agriculture and Rural Development and Health. Anchored on
the “One Health Approach” through the use of STOP-R pillars, the ARES Action Plan
identified and prioritized the regional activities to mobilize technical and financial
support from relevant stakeholders and partners to effectively implement ARES.

The ARES Action Plan was designed to complement the existing sub-regional
frameworks leading to control and eliminate human rabies, such as those developed by
the ASEAN Expert Group on Communicable Diseases (AEGCD) in 2010 and by the
WHO South-East Asia Regional Office (SEARO) in 2012. Each AMS proposed a

strategy in line with their country’s uniqueness, capabilities and capacities to fully
implement
a rabies elimination program especially in high-risk areas. Individual AMS
strategic plans developed likewise aimed to harness and galvanize partner support
through sustained commitment, active involvement and collaboration.
The call to action ‘Towards the Elimination of Rabies in the ASEAN Member States and
the Plus Three Countries’ in 2008 was the
catalyst for the regional elimination of rabies
in ASEAN.

The ASEAN expressed confidence that through ARES, cooperation and collaboration
between and among Member States and other stakeholders will be strengthened.

Other partners who contributed to the development and implementatior of the

strategy are the Food and Agriculture Organization of the United Nations, World
Organization for Animal Health (OIE), World Health Organization, World Animal
Protection, and Global Alliance for Rabies Control.

As the number of human rabies cases from dog bites continues to be alarmingly high at
95%, the global and ASEAN perspectives recognize that eliminating the virus from its
animal host remains to be the most cost-effective way to contain the infection.
Vaccination to cover 70% of dog population at high-risk areas was acknowledged to be
key in successfully eliminating rabies in all endemic areas.

To accomplish this, the action plan encourages the promotion of responsible dog
ownership and dog population management practices, including dog vaccination, in
accordance with OIE intergovernmental standards.

The plan also reiterates the need to strengthen animal health and public health systems,
to ensure sustainable, safe, efficacious and accessible dog vaccines and human vaccines
and immunoglobulins, particularly the underserved. There is a need too, to promote and
implement mass dog vaccination as the most cost-effective intervention to achieve dog-
mediated human rabies elimination.

Thus,
it is essential to ensure availability of quality-assured
canine rabies vaccines. This is
the reason why, the OIE has created a model of dog vaccine bank since 2012. The dog
vaccine bank guarantees the
availability of high-quality vaccines complying with its
intergovernmental Standards as well as their rapid delivery on the ground and an
adequate price obtained after a global competition between potential providers. This
model has already supported the success of several dog vaccination campaigns in some
of its Member Countries of Africa and Asia.

To date, more than I5 million doses of canine rabies vaccines have been ordered or
delivered in many countries through the OIE Vaccine Bank.
 3. The Philippines responds to the global and regional call
Rabies is endemic in the Philippines, and remains to be a public health concern. It
has a
fatality rate of almost 100%. However, being the most fatal among infectious diseases,
rabies too, is 100% preventable. At least one-third of these deaths occur in children
aged 15 years old and below. Data show that the number of animal bite cases reported
in the country increased by 462 %, from 2009 (206,253 bite cases) to 2018 (1,159,711
bite cases). Conversely, the confirmed number of positive human rabies cases increased
by 13.5 % in the last 9 years, from the 243 cases reported in 2009 to 276 in 2018.

In
|,
terms of regions, Il, Ill, IV-A, V and XII reported the most number of
cases from
2008 to 2018. In 2018, there was significant increase in the number of
cases in some
regions.

Table 1: Human Rabies Distribution per Region 2008-2018

2016 3017 2018
Region 2008 2009 2010 2011 2012 2013 2014 2015
18 10 20
i 8 ul 9 14 2 8 15 2I
7 6 16

2 37 25 14 15 19 20 19 12
30 7 58
3 25 7 44 19 20 19 32 29
2B 28 30

4A 31 40 32 2 37 37 38 20
4 4 10

48 2 12 13 8 12 8 3 2
22 18 14
5 38 24 aI 26 15
2 16
4
9 14 16

6 14 14 15 8 4 ' 10 15
8 21 25

7(A) 12 12 13 10 7 4 3 6
10 8 5

8(A)) 20 17 12 ul 6 4 10 6
9 7 12

9 (A) 6 6 6 8 18 19 8 4
17 14 11

10(A) 16 21 23 20 14 17 18 5
13 9 16
11 (A) 5 10 I 19 14 16 2 16
V7 33 2
12(A)) 13 10 2 2 18 19 27 10
8 6 6
CARAGA
(A) 12 2 12 9 3 6 13 10
5 0 0
ARMM 0 0 1

3 i 15
NCR
(A) 8 5 7 7 4 3 2 7
6 3 4
CAR
(P) 3 7 3 {
0 2 0 0

RITM (QU-2)
209 219 776
TOTAL 250 243 257 219 213 205 236 217
Though the number of human deaths has fluctuated over the years, much work still
needs to be done
eliminate canine rabies.
as
there are existing tools and interventions that makeit
possible to

One
of the measures by which rabies could be prevented is through the implementation
of the Republic Act No. 9482; also called the Anti-Rabies Act of 2007 which mandated
the creation of a National Rabies Prevention and Control Program (NRPCP). This is an
inter-sectoral initiative that aimed to strengthen the country’s national rabies prevention
and control program. The National Rabies Prevention and Control Committee
(NRPCC) serves as its
implementing body and is composed of representatives from the
Department of Health (DOH), Department of Agriculture-Bureau of Animal Industry
(DA-BAI), Department of
Interior and Local Government (DILG), Department of
Education (DepEd), Department of Environment and Natural Resources (DENR),
Provincial, City, and Municipal Veterinarians League of the Philippines (PCMVLP), local
government units (LGUs), non-government organizations (NGOs), People’s
Organizations (PO), and academics. Although such a committee was initiated in 1991,
early efforts to eliminate rabies were unsuccessful mainly due to inadequate funding
since no definite budget was allotted for the execution of rabies prevention and control
activities at the national and local levels.

In the call for the global and regional elimination of rabies, the NRPCP
line with
endeavors toeliminate rabies and declare the Philippines as a rabies-free country by the
year 2020. To achieve this, the NRPCP has aligned its program with the ASEAN ARES
(STOP-R framework) and will emphasize implementing the following key components:
based on its Manual of Operations— Pre-Exposure Prophylaxis and Post Exposure
Prophylaxis; dog vaccination; dog population management; health promotion; a central
database system; and responsible pet ownership.

Of these strategies, the DOH would further intensify the vaccination of dogs. The DOH
believes that one of the most viable strategies to curb the alarmingly high rabies cases in
animals and humans is
still massive dog vaccination. Currently, the target is to reach at
least 70% of total dog population. Given that almost all rabies cases are from dogs, the
strategy is seen to reduce the number of
rabies cases among dogs; thereby reducing the
number of human rabies cases.
 Table 2 CY 20/1 to 2015 Species Distribution of Animal Rabies Cases. To copy
Doc nes
2011 2012 2013 2014 15 %

Cat 1.60%
7%
Goat 0.14%
0.14%
Bat
0.
Hamster
0.00%

0.00%
0
0. Source:
Animal Disease and Laboratory Bureau of Animal Industry 2
Animal Disease Diagnostic
Laboratories (RADDL) of the Department of Agriculture, and Research Institute for Tropical Medicine (RITM) of the Department of Health (DOH)

Table shows that among animals, almost all cases (98.01%) were mediated by dogs. The
numbers are
increasing from 2011 to 2015.

As of March 2018 there are 634 animal treatment bite centers in the Philippines that give free
anti-rabies shots.

TABLE 3 Bite Cases per Category of Exposure per Region CY 2015 (change to 2018)
Category Of Exposure
Region
Cat

638
| Cat

25,134
II Cat
It
10,728
Total
36,500
wage
Contribution
5%

2 401 27,737 12,276 40,414 5%

3 13,918 78,892 18,231 111,041 14%

4A 1,578 75,338 18,231 95,147 12%

4B 512 8,551 3,470 12,533 2%

5 249 31,652 10,029 41,930 5%

6 955 27,125 37,007 65,087 8%

7 395 45,609 32,594 78,598 10%

8 188 8,438 7,618 16,244 2%

9 58 1,371 10,094 21,523 3%

10 1,218 27,849 10,723 39,790 5%

I 82 32,932 5,121 38,135 5%

12 438 23,313 6,700 28,451 4%
CARAGA 138 6,065 3,379 9,582 1%

ARMM 34 162 242 438 .

NCR 2,410 88,125 40,973 131,508 17%

CAR 147 11,338 5,473 16,958 2%

TOTAL 23,359 527,631 232,889 783,879 100%

 TABLE 4: Animal Bite Cases Based on Age and Sex of Patients
and Species of Biting Animals CY 2015
Animal Bite Cases Based on Age and Sex of Patients (N= 774,213) Species of Biting Animals (N=593)749
Human
Sex*
x Age *
Rabies
.

Dog Cat Others Total

Male Female Total <I5 >15 Total No.
387,419 386,142 773,56! 342,689 418,028 774,213 217 582,563 160,111 6,919 749,593

(*Discrepancy in the total is due to incomplete entries in the Rabies Exposure Registry)
Source: Infectious Diseases Office, National Center for Disease Prevention and Control, Department of Health)

Additionally, preventing the spread of rabies to humans further complicated by the is

fact that children (below I5 years old) and the marginalized are the most commonly
exposed to canine rabies. These victims are the ones that also lack the resources
necessary to treat or prevent exposure.

The total animal bite cases reported for the year 2018 total a show that the number
of animal bite cases reported in the country increased by 462 %, from 2009 (206,253
bite cases) to 2018 (1,159,711 bite cases). where in 44.26% or a total of 342,689
cases were below years old while 55.73% or 418,028 are ages |5 years old and
[5

above. There is
significant difference as sex of the bite patients male were
no

588,550 or 577,272 were female.

The DOH recognizes that achieving a rabies-free country is a challenging task. One of
the biggest challenge the program needs to address is
the lackluster support and
implementation of RA 9482. Often, and in many areas, the impact of rabies is considered
insignificant by local chief executives. Political will is inadequate, and actions to reduce
the risk of rabies are not taken.

Together the DOH and DA-BAI are working in tandem for human health, as well as
animal health for a more synchronized implementation of strategies and activities to
diminish the number of
animal (canine) bites; ensure enforcement of RA 9482 and
eventually, eliminate rabies in the country.

The NRPCP fully understands that because almost all rabies cases are dog mediated,
elimination of rabies in dog populations through intensive vaccination campaigns will
bring the spread of infection to its end.

10
4. Rabies and its transmission
4.1. Rabies in Humans

Bite and non-bite exposures inflicted by infected humans could theoretically transmit
rabies, but no such case has been documented in
the country. The only documented
human-to-human cases were through corneal as well as through liver, kidney and
other organ transplants.

The rabies virus is not found in human or animal blood and feces thus, these body
fluids do not pose a risk for rabies transmission.

Casual contact, such as touching/talking to a person with rabies or contact with non-
infectious fluid (blood, feces), does not constitute an exposure and does not require
post-exposure prophylaxis (PEP).

Bites from infected animals are the most common mode of

transmission
of rabies to humans. Exposure to rabies may come from bites of infected dogs, cats,
other domestic and wild animals including bats. However, bites from rats, rabbits,
other rodents, reptiles and birds do not pose
a risk for rabies infection.

Non-bite exposures are less important and are infrequent modes of

transmission. However, scratches, open wounds or mucous membranes that are
licked by an infected animal, can be points of entry of the rabies virus and these may
be in the form of the following:

e Contamination of intact mucosa (eyes, nose, mouth, genitalia) with saliva

of infected animal;
e Licks on broken skin; and
e Inhalation of aerosolized virus in closed areas (e.g. caves with rabid bats,
laboratories for rabies diagnosis)

4.2. Incubation period

Incubation period is the period from the time of exposure up to the appearance of
first clinical signs and symptoms of rabies.

11
 The average incubation period of human rabies is between |-3 months. In 90-95 %
of cases, incubation period is less than one year but may be longer 5-10 % cases. in
The duration of the incubation period depends on certain factors:

e The amount of the virus inoculated into the wound or mucosa.

e Severity of exposure - Patients with multiple and/or deep penetrating bite
wounds may have shorter incubation period.
e Location of exposure - Patients with bite wounds highly innervated areasin
and/or close to the central nervous system may have shorter incubation
period.

Incubation Period
«
Usually 1-3 months, rarely > 1
yr
«
Length of IP affected by:
~ infecting strain, size of inoculum, degree of
There are no innervation, proximity to CNS
S/Sx +
Compute date of bite versus date of onset of Sx
- range: 4 days to 10 years
—- 2.5 % within 1 week, 16 % within 1 month

adits
- 76 % within 3 months, 92 % within 6 months
— 96 % within 1 yr, 4% beyond 1 yr
Rabies Virus replicates Moves centripetally
in the muscle at bite from periphery to
site dorsal root ganglia and RITM human rabies registry
RESEARCH INSTITUTE FOR TROPICAL MEDICINE RESEARCH INSTITUTE FOR TROPICAL
q@

MEDICINE

4.3. Pathogenesis

After inoculation, the rabies virus multiplies in the muscle cells (myocytes or may
invade the nerve directly without prior multiplication in the myocytes. is possible It
that the rabies virus may persist locally at the site of inoculation for an unspecified
period of time. This could explain the long incubation period for some rabies
infections.

The virus then penetrates the peripheral nerve cells via viral uptake at neuronal
endings. The virus is transported through both the sensory and motor nerve fibers
to the central nervous system (CNS). In vitro studies show that velocity of axonal
transport of the virus ranges from 25 to 50 mm per day. The spread of the rabies
virus in the coulometer and optic nerves could be as fast as 12 mm/day.

Once the virus reaches the CNS, rabies replication occurs primarily in the neurons
or brain cells through viral budding and the virus spreads and infects the nearby

12
brain cells. Dissemination through the cerebrospinal fluid (CSF) occurs in the late
stages of infection.

While viral dissemination occurs in the central nervous system, the rabies virus
spreads into the peripheral tissues such as muscle fibers, salivary glands, corneas,
adrenal medullae, lacrimal glands, myocardium, kidneys, lungs, pancreas and
epidermis. Infection of salivary glands allows further transmission of the disease to
other mammals.

4.4. Clinical Stages

4.4.1. Prodromal

The prodromal stage occurs when there is initial viral replication at the striated
muscle cells at the site of inoculation just before it enters the brain. The virus then
spreads centripetally up the nerve to the central nervous system through the
peripheral nerve axoplasm.

This stage lasts for 0-10 days with non-specific manifestations, which include
fever, sore throat, anorexia, nausea, vomiting, generalized body malaise,
headache and abdominal pain. Paresthesia or pain at the site of bite is due to
viral multiplication at the spinal ganglion just before it enters the brain.

4.4.2. Acute Neurologic

The acute neurologic stage is the stage when the virus reaches the CNS and
replicates most exclusively within the gray matter. This stage has two types of
presentation: encephalitic or furious type, which is present in 80% of rabies
cases, and paralytic or dumb type, which is seen in 20 %.

Autonomic manifestations such as hypersalivation appear during this stage. The

virus passes centrifugally among autonomic nerves to reach other tissues- the
salivary gland, adrenal medulla, kidney, lung, liver, skeletal muscle, skin and heart.
Passage into the salivary gland facilitates further transmission of the disease
through infected saliva. This stage lasts for 2-7 days, characterized by
hyperactivity, hypersalivation, disorientation, and hallucination, bizarre
behavior interspersed with lucid intervals, seizures, nuchal rigidity or paralysis.

13
 Table 4: Two Types of Presentation of the Acute Neurologic Stage
of Rabies in Humans
Neurologic or Furious type Paralytic or dumb type
Hyperactivity (anxiety, agitation, running, biting, bizarre Acute progressive ascending myelitis, symmetrical
behavior alternating with periods of calm) which may or asymmetrical with flaccid paralysis, pain and
occur spontaneously or may be precipitated by tactile fasciculation in the affected muscles with mild
or auditory, visual or other stimuli. sensory disturbance.

The most characteristic symptom spasm of the

is A complete paraplegia develops eventually with
pharyngeal muscles often triggered by an attempt to fatal paralysis of the respiratory and pharyngeal
drink water (hydrophobia) or by blowing air on muscles.
patient's face (aerophobia). Spasmodic contractions of
the muscles may spread to the respiratory and other
muscles leading to attacks of apnea.

Acute Neurologic Phas

a) wy

Duration: 2-7
days

biby
af yh it LER
Rabies Virus infects Rabies Virus
brainstem, thalamus, travels centrifugally
basal ganglia & spinal cord Ffom brain to other organs
RESEARCH INSTITUTE FOR TROPICAL MEDICINE 15

Coma
- begins within 4-10 days after symptoms start; Cardiac arrhythmiasis is
common. Hyperventilation which leads to perirodic and ataxic respiration to
apnea. Haematemesis is experienced by 30-60% of patients before death.
Pituitary dysfunction is
also present as part of disordered water balance.

Death - without intensive supportive care, respiratory depression, cardio

respiratory arrest, and death occur in almost 100% of cases. 73% die within 3
days of onset of symptoms and 84% die within 24 hours of admission. Outcome
is date and recovery from rabies
if
v ery rare. Cause of death includes
circulatory insufficiency with myocarditis, cardiac arrhythmia or congestive heart
failure (RITM)

14
4.4.3. Differential Diagnosis

Guillain-Barré Syndrome (GBS) is an autoimmune inflammatory disease of

the peripheral nervous system, affecting one or more nerves outside the brain
and spinal cord. This syndrome ischaracterized by the rapid onset of
weakness, sensory loss, and impairment ofreflexes; often paralysis of the legs,
arms, breathing muscles, and face develops in ascending order.

Encephalitis (due to other viruses) isacute inflammatory disease of the

an
brain. Patient experiences fever, a stiff neck and/or back pain, tremors, seizures,
paralysis of extremities, abnormal walk (gait), and abnormal reflex reactions.
Deep loss of consciousness (coma) may occur and last for days or weeks.

4.4.4. Laboratory Diagnosis

Often the diagnosis of rabies is based on the clinical manifestations and a history
of exposure to a rabid animal. In cases where the pathognomonic hydrophobia
and/or aerophobia are present, the diagnosis is straight forward. However,
clinical diagnosis may be difficult in cases of paralytic rabies and atypical
presentations. Thus, rabies laboratory confirmation is necessary. Rabies diagnosis
can be performed on fresh tissue specimens stored at appropriate temperatures,
preferably refrigerated. The specimens to be collected depend on the test to be
performed.

In transporting specimen glycerine preservative (temperature: +4°C or

20°C) or dried smears of brain tissue filter paper (temperature: +30°C)
on
-
enables safe transport.

4.4.5. Ante-Mortem

Samples for Laboratory diagnosis of rabies during life secretions and

biological fluids (saliva, spinal fluid, tears, etc.) can be used to diagnose rabies
during life (intra vitam). They should be stored at -20°C or below. Serum should
be collected from blood samples prior to freezing and stored at - 20°C.

Timing of the collection and interpretation of the sample is very crucial.

15
Table 5. Recommendation of the WHO-CC Reference and Research on Rabies, France Intra-Vitam
Diagnosis of Human Rabies, (Dacheux et al., Plos NTD, 2010)
Intra-Vitam Diagnosis of Human Rabies
Sensitivity Considering
the Clinical Evolution
SAMPLES of the Patient (in days Comments Technique
Storage
.
the Onset of (Reference)
following
Symptoms)
0-8 days >8 days
Saliva (Iml or High High At least three saliva -20°C/- RT-hnPCR
saliva swabs) samples collected at 80°C (3)
intervals of 3-6 hours,
liquid saliva is preferred
to saliva swabs
Urine (atleast Low Low Atleast three urine -20°C/- RT-hnPCR
Iml) samples colleted in an 80°C (3)
interval of 3-6 hours
Skin biopsy High High Skin biopsy collected at -20°C/- RT-hnPCR
(diameter of the nape of the neck, 80°C (3)
4mm, total with hair follicles, using
'

volume of 20 biopsy punch (Stiefel).

mm?)
Serum (500yL) Low Average Sample collection can be +4°C/- RFFIT (31) and/or
repeated, depending on 20°C ELISA (3,6,33)
the length of survival
period (1-2 samples per
week)
CFS (>300yL) Low Average Sample collection can be -20°C/- RT-hnPCR (3);
repeated, depending on 80°C RFFIT (3) and/or
the length of survival ELISA (3,6,33)
period (|-2 samples per
week)

The following laboratory tests can be done to confirm rabies in humans:

Fluorescent Antibody Testing (FA)

The Fluorescent Antibody (FA) technique is the gold standard for rabies
diagnosis. It is a rapid and sensitive test based on microscopic examination
under ultraviolet light. Tissue samples from brainstem, thalamus,
cerebellum and the hippocampus (Ammon’s horn) are recommended for
increased sensitivity of the test. Viral antigen may be detected by using the

16
 FA test on skin biopsies taken from the nuchal area of the neck, with hair
follicles containing nerve endings.

e Polymerase Chain Reaction (PCR)

The Polymerase Chain Reaction (PCR) is a laboratory technique for
"amplifying" a specific DNA sequence. PCR is extremely efficient and
sensitive; it can make millions or billions of copies of any specific sequence
of DNA, even when the sequence is in a complex mixture.

e Serology
Serum Rapid Fluorescent Focus Inhibition Test (RFFIT). Serum
neutralization assays are used to determine the potency of rabies serum
and immunoglobulins used for PEP, and to evaluate the immunogenicity of
human and, to a lesser degree, animal rabies vaccines.
The standard procedures recommended at
the seventh meeting of the
WHO
Expert Committee on Rabies were the mouse neutralization test
(MNT) and the plaque reduction assay. Since then, plaque reduction
methods have been superseded by fluorescent focus inhibition tests, which
is
are more convenient. Although the MNT still widely used as a reference
test, the RFFIT has become the
test of choice in most modern laboratories.

The RFFIT has been shown

to at
be least as sensitive as the in
MNT

measuring virus-neutralizing antibodies. Only 50% of which will give positive

results among rabies cases. Serologic testing is more useful to ascertain the
immune status of immunized animals and humans.

e Histologic Findings
Negri bodies or Cerebral inclusion bodies are round cytoplasmic
inclusions of assembling nucleocapsid are pathognomonic of rabies
infection, but are found in only about 80% of cases. The biting animal
should be examined for rabies.

4.4.6. Post Mortem

Samples for post-mortem diagnosis includes brain tissue that can be

collected through trans-orbital or trans-foramen magnum route if autopsy
cannot be performed.

17
 Table 6. Recommendation of the WHO-CC Reference and Research on Rabies, France Intra-
Vitam Diagnosis of Human Rabies, (Dacheux et al., Plos NTD, 2010)

"Samp es Comments Technique

(Reference)
Brain Biopsy High Brain biopsy collected via the +4°C/- FAT (28); RTCIT
orbital route with Tru-Cut biopsy 20°C (29); WESLYSSA
needles for soft tissues with (26,270;RT-
manual clip (allegiance) or via the hnPCR
(3)
occipital route using lumbar
puncture needles.
Skin biopsy High Skin biopsy collected at the nape -20°C/- RT-hnPCR (3)
(diameter of 4mm, of the neck, with hair follicles, 80°C
total volume of using biopsy punch (Stiefel).
20mm*)

CHAPTER II: NRPCP toward a Rabies Free Philippines

Since the late 1980s, efforts to initiate its prevention and control, the DA and the DOH have
intensified their collaboration on rabies, refocusing strategies through the years toward its
elimination by 2030.

Strategies, activities and supportive components have evolved to become more responsive to
meeting the needs of an increased and sustained public awareness on rabies. Along the way, the
program has also encouraged more commitment, participation and involvement from different
sectors.

The program has likewise standardized treatment and management guidelines of human rabies;
as well as address management of
animal rabies particularly, for dogs. A MOP was developed in
2012 to help standardize program implementation across all agencies. Working in partnership
with the DA, the program has undergone and emphasized massive dog vaccinations as one of the
most effective, cost-efficient strategy to protect and prevent rabies in dogs and in humans.

Despite efforts however, rabies continues to affect many Filipinos, claiming tens of thousands of
lives and putting more people at risk.

Through all these, the NRPCP has been relentless efforts to steer the country closer to
in its
being rabies-free. It rallies partners for a better implementation of RA 9842. It has standardized
data collection through the PIDSR and NARIS that
enabled more accurate reporting from all

18
 2
sQ “S]SAD|

pe8

a
a,
<. 3]
NRPCP Timeline a,
oO
n SMAIADI

2009
9
O°
Philippines, setectedas one wn
of the sites of the World
>
Be
Health Organization
2006 (WHO)- Billand Melinda
SPUD}

1992 Gates (BMG) Foundation

oO

Prevention Program
WHO
Expert Committee on
Rabies
integrated in schoo!
:

project to eliminate human =

Rabies recommends replacing rabies through mass dog ~< PU
Nerve Tissue Vaccine (NTV) vaccination from 2009-
ot
with modern tissue culture 2013. Knownas Philippine
°
vaccine. NTV is less Road Map for National
Rabies Elimination =
Cc

a
immunogenic and caused more
74 Demonstration Project ~ ao
ig ayiy
severeadverse reactions, They
also recommends use of the
of Free
je
pre Rabies Vistas
project was 2 syUsLUdOJBAaP

eal
intradermal (iD) RE
reginen id
DA
through BAI and anti-rabies vaccinal also supported by the Japan
>
jica )
Gevcloping International Cooperation
DOH Communicable especially for World Healt h
Disease Contro! countries. IDregimen
Organization Ageng (JICA)in =
initiate rabies control significantly reduced cost, Catanduanes, Camiguin,
s
efforts in the country efficacy was not compromised. Cebu City and Marinduque.
2
o
UO

7)
o°)
May 1991 March 1999 2012 = UBLUNY

MOA signed between DOH, Pres. joseph E, Estrada signed DOH Infectious Disease Philippines celebrates
=
DA, DILG) and DepEd and
LGUs for inter-sectorai rabies
EO No. $4 dectaring March as
Rabies Awareness Month.
‘Office develops 1*
Rabies Manual of
‘World Rabies Day with
the restof the wortd. o+
elisnination. Rabies Control National Rabies Prevention Operations. 2. pue
Consultative Committee Committee composed of
$
(RCCC) created to guide rabies representatives from the DOH, Program components are =.
program implementation. DA-BAL DILG. DECS (DepEd) Post Exposure Tu
National Rabies Committee and NGOs created. They will Prophylaxis and Pre- Ss sewUe

NRC, composed of technical formulate policies and Exposure Prophylaxis; vy

experts from DA and DOH was - coordinate implementation of health promotion; dog =
“<
also created and served as the National Rabies Prevention vaccination; dog
implementing body. Control Program. Massive population management. 9
NRC drafted rabies elimination
information drive on rabies 2 centrat database
system; and
3
Ss
yyeey

program by 2020: anchored on @ responsible pet Oo

multi-sectoral rabies committees ownership S
—

at the regional, provincial, city

and municipal levels on dog
sommes
-

OE, =
immunization, anti-rabies human
imrounization and rabies
o SuAypouw

awareness. 2
oO
zn
ao
Q
sco so[se7yeys

soO
 I. VISION AND GOAL

Vision: Rabies Free Philippines by 2030

Goal: To eliminate rabies and declare the Philippines
NN
Rabies-free by the year 2030

The NRPCP utilizes a multi-disciplinary Y approach

Pp app that strengthen
8
5 linkage
g with program managers,
prog § Pppublic health workers,
% ace
"Free enitio®™ veterinarians, local executives and other stakeholders including the
general public to achieve rabies elimination.

The Philippines remains committed to accomplish the goal of a rabies-free country by 2030.
With evolving challenges faced by the program however, the NRPCP saw 2030 as the more
feasible, realistic target year. The additional two years will enable the program to implement
appropriate strategies and activities that would best respond to the needs and safeguard human
health from rabies; and be counted among the nations that are rabies-free by 2030.

2. COMPONENTS

Together with partner agencies, the NRPCP implements the following components of the
program as mandated by RA 9482 (Anti-Rabies Act of 2007) should be implemented atall
levels:

2.1. Mass Dog Vaccination

This is the most effective measure to

control canine rabies. The Department of
Agriculture takes the lead in mass dog
vaccination campaigns and provision of
animal rabies vaccine.

20
 2.1.1. Post-Exposure Prophylaxis (PEP) and Pre-Exposure (PrEP)

¢ Post Exposure Prophylaxis (PEP) — anti-rabies prophylaxis should be

administered after an exposure (such as bite, scratch, lick, etc).
¢ Pre-Exposure Prophylaxis (PrEP) — vaccination should be given to
individuals who are
rabies
at
high risk of getting
— =

2.2. Health Promotion

The following are significant activities in the conducting the information and education
campaign on the prevention and control rabies: of
e Celebration of Rabies Awareness Month under Executive Order No.
84, March is Rabies Awareness Month

Rabies Awareness Month is celebrated in the

country all through the month of March.
During this time, mass dog registration and
vaccination drives are conducted in
collaboration with the LGUs, national, regional
and local offices of the DOH, BAI and other

partner agencies.

e Celebration of World Rabies

September 28 has been declared as
Day
- 4>.. D@H

Republic of
‘OtAcricu eet
‘Regional Field Office 10

“TOGETHER.
'
AGAINST #* ~
a
RABIES “as
aaa]
¢ Development of IEC Materials agencies involved in the
-All

implementation of the program are encouraged to conceptualize,

produce/reproduce and distribute IEC materials and collaterals.

21
A
City Government ofValenzuela “9 <,
by)
.

Chy Veterinary Services Office :

i

Marchis Rables Awareness Month Se

oY ONG

at ipa-rehistro angmga
|
£@Pabakunahan mga alagang aso.
@tiewag pabayaans gumala ang alagang hayop
mga pa meu
vei @@
lugar,
‘@

Deaton’

Peron ean!

Aioite bole)
WALANG PRENO
Eteta erect)
Late

LEAT
St Am aT 6)

yearns

Me
ta

¢
Integration of Rabies
Program into the School
Curriculum - The integration
of the program into the
curriculum is a collaborative
effort of DOH and DepEd to
educate school children who are
the most vulnerable to animal
bites.

2.3. SUPPORT SERVICES

2.3.1. Capability -Building

22
 The Department of Health provides the following Training to health personnel
involved in the implementation of the program:

e Management of Rabies Exposure

e Management of Human Rabies
e Training of Traditional Healers on Animal Bite Management

The Department of Agriculture provides the following training to Veterinarians,

Livestock Inspectors/Technician, Laboratory staff and other animal health
personnel involved in the implementation of the Rabies Program:

e Diagnosis and surveillance

of animal rabies
e Training on humane dog catching
and handling
e Methods of restraint and proper
animal vaccination
e Rabies hotspot/ outbreak
investigation and management The DOH and BAI train health personnel,
veterinarians, lab staff, including LGUs and
other personnel involved and engaged in the
implementation of anti-Rabies Programs

2.4. MANAGEMENT AND

IMPLEMENTATION STRUCTURE OF THE
NATIONAL RABIES PREVENTION AND CONTROL PROGRAM

R.A. 9482 (The Anti-Rabies Act of 2007) mandates the establishment of a National
Rabies Prevention and Contro! Program chaired by the Bureau of Animal Industry
of the Department of Agriculture to be implemented by a multi-agency /multi
sectoral- committee at all levels .

23
=
The suggested composition of the Rabies Committee in each level is as follows:

National Level

Bureau of Animal Industry

Department of
Agriculture (DA)

CHAIR

Disease Prevention and Contro! Bureau

Department of Health (DOH)
VICE-CHAIR

MEMBERS |
Department Other Members
of Education * Department of Environment and Natural
( DepE qd) Resources (DENR)
* Previncial, Cay and Municipal Veterinarians
League of the Philippines (PCMLVLP)
° Global Allance for Rabies Control (GARC)
° Philippine Veterinary Medicine Assocation
(PYMA)}
* Philippine Animal Hespial Amocasion (PAHA)
Medina
et Tropical Diseases, Travel Medicine and Vaccines
al.
.
(2016) 2:22 DOI (0.1 186/s40794-01 6-0036-7
College y vcninay Madcine (UPLE-GYM)

At the regional, provincial and local levels, the NRPCC

is structured as follows:

fo |
Regional Province

Taner
Regional Director
Bureau of Animal Industry
Dept of Agriculture (DA)
4
4
:
Governor/Provincial
Veterinarian
=)i

_
CHAIR 4

CHAIR

Provincial Health
ee
Regiona! Director
i;
:

Officer i

ee
VICE-CHAIR
:

of
i

Department
(DOH)
Health
vests
|
‘

VICE-CHAIR :
os,

| i MEMBERS 4

.
+ ©
Department of Interior and 4

MEMBERS Local Government

| F

Department of Interior and i (DILG) i

Local Government (DILG:
Department of
Education.
2»
:
Department of Education
(DepEd)
/
:
(DepEd)
Philippine National Polic
(+ PHTL j

24
—
Municipal
PEAS NR OR
Aa ARTE ROOTS

Mayor/Municipal
BETEE

Agriculturist
CHAIR

Municipal Health
Officer
VICE-CHAIR
nnn

aman
MEMBERS
¢
Dept of Interior and Local Govt
(DILG)
*
Dept of Education (DepEd)
* DOH Rep
* Philippine National Police (PNP)
* NGOs
* Sanitary Inspector (SI)

Barangay

25
=
2.4.1. RESPONSIBILITIES OF GOVERNMENT AND NON-GOVERNMENT
UNITS

Department of Health e Ensure the availability and adequate supply of DOH pre-qualified
human Anti-Rabies vaccine in animal bite treatment centers at all
times and coordinate with other implementing agencies and
concerned NGOs;
e Provide Post-Exposure Prophylaxis at the minimum expense to
individuals bitten by animals suspected of being rabid which will
consist of the initial vaccine and immunoglobulin dose;
e Ensure proper management of logistics to include forecasting,
storage and distribution
e Provide Pre-Exposure Prophylaxis to high-risk personnel, such as,
but not limited to laboratory staff, veterinarians, animal handlers,
vaccinators and other persons working with rabies virus for free;
e Coordinate with the DA in the development of appropriate
health education strategies to inform the public on rabies
prevention and control and responsible pet ownership;
e Develop and maintain a human rabies surveillance system;
e Encourage collaborative activities with the DA, DepEd, DILG,
DENR, NGOs, POs and other concerned sectors; and
e Immediately approve the registration of Veterinary and Human
Barbiturate drugs and veterinary euthanasia drugs in coordination
with the Philippine Drug Enforcement Agency (PDEA).

Department of e Improve and upgrade existing animal rabies laboratory diagnostic

Agriculture capabilities to ensure better services to the people;
e Ensure the availability and adequate supply of animal Anti-Rabies

e
vaccine
at all times;
Undertake free anti-rabies vaccination of dogs giving priority to
high risk and depressed areas;
e Maintain and improve animal Rabies surveillance system;
e Establish and maintain Rabies free zone in coordination with the
LGUs;
e Immediately facilitate for the approval of the sale and use of
Veterinary and Human Barbiturate drugs and veterinary
euthanasia drugs by the DOH and the PDEA;
e Strengthen the training of field personnel and the Information
Education and Communication (IEC) activities on Rabies
prevention and control and responsible pet ownership;
® Conduct research on Rabies and its control in coordination with
other agencies;
e Formulate minimum standards and monitor the effective
implementation of this Act; and
e Encourage collaborative activities with the DOH, DepEd, DILG,
DENR, NGOs, POs and other concerned sectors.

26
 Department Interior
and Local Government
of e Ensure compliance of the roles and responsibilities of the
different LGU’s.
The DILG — Directs LGUs to comply with the government’s anti-
rabies program. Under Republic Act 9482 or the Anti-Rabies
Act of 2007, LGUs play
a vital role in ensuring that
within their jurisdiction are registered, and immunized to
all
dogs

ensure they are healthy. They are also urged to allocate

funds to augment for the implementation of the National
Rabies Prevention and Control Program.

Department
Education
of Strengthen rabies education program through school health
teaching/curriculum;
Assist in the dog mass immunization campaigns in the community;

DepED Encourage collaborative activities with the DA, DOH, DILG,

DENR, NGOs, POs and other concerned sectors; and
Integrate proper information and education on responsible pet
|
DEPARTMENT OF EDUCATION

ownership in the relevant subjects in the Elementary and High

School levels.

Local Government Ensure that all dogs: are properly immunized, registered and
Units (LGUs) issued a corresponding dog tag upon registration and
immunization
Strictly enforce dog Impounding activities and field control to
eliminate stray dogs;
Ensure that dogs are leashed or confined within the premises of
the owner's house or owner's fenced surroundings;
Allocate funds to augment the implementation of the National
Rabies Prevention and Control Program, particularly on the
financing of supplies and human and dog vaccines needed for
immunization;
Ensure the enforcement of Section 6 of Republic Act No. 8485
or "The Animal Welfare Act of 1998";
Enact additional local ordinances that will support the National
Rabies Prevention and Control Program that should include the
regulation of the traditional treatment locally known as "tandok”;
Prohibit the trade of dogs for meat;
With respect to cities and first class municipalities, establish and
maintain a dog pound where impounded dogs shall be kept, and
other municipalities, shall, on their own, establish a dog pound
or opt to share the expense of establishing and maintaining a dog
pound with other adjoining municipalities and/or with private
animal shelters and control facilities;
Prohibit the use of electrocution as a euthanasia procedure;
Appoint a veterinarian and establish a veterinary office in every

27
 province, city and first-class municipality, provided, that the
other municipalities shall, on their own, opt to share the
expense of having a veterinary office;
Require pet shops to post information regarding rabies and
responsible pet ownership; and
Shall collect the fines imposed by R.A. 9482 for the violation any
of its provision.

Animal Bite and Receive allocated immunizing agents from the DOH RO/

z
Treatment Center Provincial Rabies Coordinator;
Ensure proper cold chain management;
Screen all animal bite cases and manage accordingly;
Maintain animal bite registry;
Submit accurate report to the DOH on quarterly basis;
Animal Bite and
Advocate to the LCE additional funds for the program;
Treatment Centers Conduct investigation of reported human rabies cases; and
Conduct health promotion activities.

Non-Government NGOs and academe can or may participate in the following

Organizations (NGO) activities of the program:
and the Academe i. Community mobilization;
ii. Health education/information dissemination on Rabies

e20503 and responsible pet ownership; and

an&ph'n8 iii. Mass anti-rabies campaign

Si
Promotion of the anti-rabies campaign during pet or any animal
shows.
Surveillance/reporting of Rabies cases in animals and humans.
Any other activities geared towards the prevention and
complete
eradication of Rabies.

28
 2.4.2. ROLES AND FUNCTIONS OF HEALTH PERSONNEL

Department of Health Regional Offices (DOH RO) Regional Coordinators

Oversee the implementation of the program at
the regional level
Prepare WFP in coordination with the different partners;
Act as resource person/facilitator during the
training/orientations/workshops;
° Compute vaccine requirement and make the necessary
requisition to the national program;
° Allocate and distribute WHO pre-qualified vaccines and
other logistics needed for the program implementation;
Ensure proper cold chain management;
Ensure efficient accurate and timely submission of report;
Conduct monitoring and evaluation;
Conduct assessment and certification of ABTC/ABC; and
Conduct health promotion activities.

Department of Health Provincial DOH Office and Provincial Coordinators

° Coordinate at the provincial level
Train ABTC personnel
° Act as resource person/facilitator during the
training/orientations/workshops;
° Allocate and distribute FDA approved vaccines and other
logistics needed for the program implementation;

ALLENS»
Ensure proper cold chain management;
Ensure efficient accurate and timely submission of report;
Conduct monitoring and evaluation;
Conduct assessment and certification of ABTC/ABC; and
Conduct health promotion activities.

Animal Bite Treatment Center Personne!

e Receive allocated immunizing agents from the DOH

Provincial Rabies Coordinator;
Ensure proper cold chain management;
all
Screen animal bite cases and manage accordingly;
Maintain animal bite registry;
Submit accurate report to the DOH on a quarterly basis;
Advocate to the LCE additional funds for the program;
Conduct investigation of reported human rabies cases; and e e
Conduct health promotion activities.

29
Animal Bite Center Personnel

Undergo training by the DOH

Buy own vaccine
Screenall animal bite cases and manage accordingly;
Maintain animal bite registry;
Submit accurate report to the DOH on a quarterly basis;
Conduct investigation of reported human rabies cases; and e
Conduct health promotion activities. e

Municipal Health Office

Screen, initiate wound care and refer animal bite cases

to Animal Bite Treatment Center; and
Conduct health promotion activities in collaboration
with MAO and other partners.
'
Pal

DA and LGU Veterinary Personnel

Initiate and coordinateall rabies control activities in the

provinces/ cities/municipalities;
Prepare the yearly regional action plan;
Disseminate program information, guidelines, E.O.
to all provincial/city/municipal coordinators;
Allocate/distribute vaccines from central office (BAI)
to the different provinces/cities/municipalities;
Ensure proper cold storage of vaccines;
Ensure availability of vaccines for the campaign;
Monitor vaccine utilization;
Consolidate reports from the different provincial
coordinator and submit to the central office;
Monitor the implementation of dog ordinance and dog
poundin the Provinces;
Assist the province in overseeing the implementation;
and
Collect empty/used vaccine vials from the provinces and
ensure proper disposal (burning/burying) at the Regional
Office or at the Bureau of Animal Industry

30
Provincial Veterinarian/ Provincial Coordinator

e Prepare yearly provincial action plans and submit to the

6
regional level for consolidation;
° Provide actual dog survey and other monitoring data to
the regional coordinator;
e Allocate and distribute vaccine to the different
municipalities;
@syiNod
° Provide and ensure cold storage for vaccines;
° Monitor proper vaccine utilization during vaccination
campaign;
° Assist in training vaccinators during mass immunization;
e Monitor proper implementation of rabies ordinance and
dog control measures in all municipalities;
° Organize rabies control committees in all
cities/municipalities;
° Initiate and coordinate all rabies control activities in the
cities/municipalities
° Consolidate reports of vaccination to be submitted to
the regional coordinator
° Collect used vaccine vials and return it to the regional
coordinatorfor proper disposal.

Municipal/City Coordinator (City/Municipal Veterinarian/Agriculturist)

e Prepare yearly provincial action plans and submit

6
to the regional level for consolidation;

Oso
e Provide actual dog survey and other monitoring
data to the regional coordinator;
e Allocate and distribute vaccine to the different
municipalities;
e Provide and ensure cold storage for vaccines;
e Monitor proper vaccine utilization during
vaccination campaign;
e Assist in training vaccinators during mass
immunization;
e Monitor proper implementation of rabies
ordinance and dog control measures in all
municipalities;
e Organize rabies control committees in all
cities/municipalities;
e Initiate and coordinateall rabies control activities
in the cities/municipalities
e Consolidate reports of vaccination to be
submitted to the regional coordinator
e Collect used vaccine vials and return it to the
regional coordinator for proper disposal.

31
CHAPTER III: PROGRAM COMPONENTS
Background
NRPCP
is a multi-agency effort to control and eliminate rabies
the country by the Department of
in
Agriculture (DA) and Department of Health (DOH), Department of Interior and Local Government
(DILG), Department of Education (DepEd) in coordination with other Government Organizations (GOs),
Non-Governmental Organizations (NGOs) and People's Organizations (POs).

To more effectivelyimplement the program, the DOH and DA each have their primary focus, roles and
responsibilities, ensuring that efforts are not duplicated and preventive measures for human and animal
infection are taken. Partner agencies DepEd, DILG, other GOs, NGOs and POs
of NRPCP.
are expected toactively
participate in broadening understanding

The following components of the program as mandated by RA 9482 (Anti-Rabies Act of 2007) should be
implemented at all levels.
PART |: HUMAN RABIES

Il. Prevention and Control of Human Rabies

Rabies the oldest and most feared human disease known to man with the highest case fatality rate
is
(CFR) of any infectious disease.Itis the only disease of humans that is treated with a vaccine after

exposure has occurred; a zoonotic disease which is 100% fatal but 100% preventable.

World Health Organization (WHO) states that if symptoms of rabies have appeared, the victim
usually dies in spite of subsequent immunization and treatment with rabies immunoglobulin. There is
no effective treatment once symptoms set in. Rendering treatment versus no treatment makes no
difference in Rabies. Moreover, the rate of mortality for rabies are highest from bites of the face and
neck while the rate of mortality increases with extensive wound. For the virus to be infectious and
for any risk to exists, the person must be exposed to fresh saliva of the rabid animal with a
consideration that the smallest bite with a single drop of saliva can kill.

Rabies also considered a Neglected Tropical Disease (NTD), infecting mostly poor and vulnerable
is

populations whose deaths are rarely reported. Worldwide, rabies occurs mainly in remote rural
communities where measures to prevent dog to human transmission have not been implemented.
Under-reporting of human rabies cases prevents mobilization of resources from the international
community for the elimination of human dog-mediated rabies. Around forty (40%) of people
exposed to dog bites in canine rabies infected areas like the Philippines, are children from 5-15 years
of age. WHO further states that majority of those bites are not reported and go unrecognized.
Much higher proportion of exposed children contract and die of unrecognized rabies than the
estimates from Asia suggest.

32
In 1951, the Daily Mirror newspaper reported that Fernando Poe Sr., a local cinema idol, succumbed
to hydrophobia, at the age of 35, after he let his open wound licked by an infected puppy. He was
diagnosed to have rabies, a disease that is carried and transmitted between mammals via saliva. It’s
well known to be a threat after having been bitten by a wild animal or rabid pet. But it
is also possible

to contract the virus from an infected animal just licking an open cut or wound, and even scratch
from infected wet saliva. Moreover, consumption of raw or improperly cooked infected animal brain
results in direct contact between oral mucous membranes and infected neural tissue. Rarely, rabies
may be contracted by inhalation of virus-containing aerosol or via transplantation of an infected
organ. There are two types of
rabies: (1) the furious type, common in more than 80%, manifests with
hyperactivity, hydrophobia, aerophobia and excited/aggressive behavior while the (2) paralytic type
present in 20% of the cases show ascending muscle paralysis in the absence of aerophobia and
hydrophobia.

At least one-third of human rabies deaths are among children less than 15 years of age (N=399; 2008;
SLH). Dogs are the source of 98.3% ((N=699; 2015; BAI) followed by cats (1.27%), goat ( 0.3%), pig
(0.1%) and carabao (0.1%) in human rabies deaths. The high cost of anti-rabies vaccine and
immunoglobulins, expenditure for medical consultations and the loss of income are an additional
burden to a regular Filipino family confronted with a potential rabies exposure.

However, with improved surveillance and reporting systems, data-based interventions can be
programmed and implemented more effectively, efficiently and economically.

4 R’s in Animal Rabies Risk Assessment: Recognizing, Recording,

Reporting, Referral
Because
it
are both
almost always fatal, rabies continues to be a dreaded disease. Its signs and symptoms
is

disturbing and distressing. But if

if rabies post exposure prophylaxis (PEP) is administered

it
to a bite victim before the virus enters the nervous system, can be prevented.

Rabies’ range of severity is vast and varied, there is

still remains so much the public and at times,
health professionals may not know about it.
There have been many instances where even clinicians
are left bewildered and unsure with their diagnosis of the rabies. This is because its early symptoms
can be very generalized — headaches, fever and weakness. Without a history of a potential exposure
to a rabid animal, these symptoms would not raise the suspicion of rabies as they are very similar to
the common flu or other viral syndromes.

for this reason that an integrated approach

It is to its detection and management can be described
by the four areas, namely:
e Recognition by rabies risk assessment and the clinical signs of rabies in domestic animals
Recording
Reporting
Referral

33
 I.1. Recognition
Recognize by Rabies risk assessment.

I.1.1. Possibility of rabies virus transmission

a. An infected animal

All mammals are susceptible to infection with rabies virus and capable of
shedding and transmitting virus. Only mammals pose a potential risk for rabies
transmission. Rabies virus cannot be be transmitted through bites, scratches, or
other contact with:
¢ Birds
* Reptiles
* Amphibians
¢ Fish/Invertebrates
* Most rodents (rats, mice, hamsters, guinea pigs , rabbits, squirrels,
chipmunks, gophers) with negligible role in propagation of rabies probably
because they fail to survive encounters with rabid carnivores

b. Virus-laden saliva

Rabies virus, once in the brain

Oo spreads to:
Rabies virus innoculation and local ~ Cerebellum
replication occurs in subcutaneous - Hippocampus
or muscle tissue and presents as. - ~ Medulla oblongata
“aching. tinging. itching” sensatic
spares the cerebral cortex
nce, rabid patients present
ucid intervals
virus enters peripheral
Rabies
oO nerves and migrates up the nervy
to the spinal cord with speed 7
Rabies virus undergoes further
of migration from replication and disseination
8 mm > 400 mm/day to other neuros throughout
the CNS.

Rabies virus spreads cut to highly

Innervated tissues, particularly
saliva glands

34
 c. Saliva contact with subdermal tissues or mucus membrane

Rabies virus must be deposited on or near nerve endings for infection to occur

ohaw
sy

\\ Rabies virus must be introduced through a break that exposes

\ subdermal tissue beneath the cutaneous barrier.

@®
The break in the skin can occur at the same time that
infectious saliva is present-as in the classic bite from a
rabid animal.
It may be a pre-existing cut, wound, or lesion on the skin
onto which infectious saliva is subsequently deposited.
Deposition of infectious saliva onto mucus membranes
Animal also represents a potential transmission route for rabies
bite °
virus.
But, deposition of saliva onto intact, healthy skin would
generally not be considered a potential rabies exposure.
'

Rabies virus requires deposition of viable virus onto nerve

endings which lie
below the epidermis.
Superficial scratches that do not penetrate the dermis and draw
blood do not provide an avenue for rabies infection.
Abrasions or scratches inflicted by the claws of an animal do not
constitute a rabies exposure per se.
Deep scratches for which subsequent deposition of fresh saliva
can be ruled out do not represent possible rabies exposures.
if injuries inflicted by an animal’s nails are deep or extensive,
AND subdermal contamination with saliva is likely, the potential
for rabies transmission should be considered.

Minimal requirements for considering the possibility

of rabies virus transmission in a bite incident:
@®
Arabid mammal
@®
Rabies virus in saliva
@ Saliva deposited beneath the skin or on mucus
membrane

35
1.1.2. Likelihood of rabies transmission

It isimportant to determine whether the biting animal was rabid or likely to be rabid
only at the time the bite was inflicted. Data on the biting animal such as species, size,
health, ownership (e.g. Pet, feral, wild) and rabies vaccination history are necessary for
determining the likelihood that it was shedding rabies virus at the time of the bite.

Domestic dog rabies remains the predominant contributor to rabies incidence

throughout the world.

Younger animals are considered to present a greater risk of rabies than

older animals because:
¢ With their small size and naive immune system, only a smaller amount of virus can
lead to infection
*
However, extremely young animals (<2 weeks old) that bite are unlikely to have had
sufficient opportunity to have been exposed to rabies virus, and for the virus to
replicate, migrate into the CNS, and spread to the salivary glands by the time of the
incident

¢ The risk of rabies transmission

vulnerable sites:
is proportional to the amount of virus deposited in

*
Multiple bites that compromise the cutaneous barrier expand the number of
potential entry for the
virus.

¢ Severe bites that expose large amount of

rabies virus provides greater opportunity
for rabies virus to be deposited on nervous tissue than mild, superficial bites.
* The closer to the CNS the virus is introduced, the shorter may be the incubation
period from infected bite to disease.

* Bites on the following sites are more exigent risk of rabies and need for
rabies prophylaxis than do bites to the arms and legs:
- Face
- Head
- Neck
- Spine

j Highly innervated tissues such as

hands, fingers and genitalia provide a
y rich environment for rabies virus to
invade and replicate.

NOTE: Any deposition of virus-laden saliva on mucous membrane or beneath the dermis
constitute a risk of rabies transmission.

36
Immediate wound treatment is an indispensable component of bite management.
Thorough wound cleansing alone markedly reduces the likelihood of rabies (Dean
1973, Kaplan 1962).

The following bite wounds for which liberal wound irrigation and vigorous
scrubbing are difficult, impossible or delayed allow a greater amount of deposited
rabies virus to remain in place and begin to replicate

- Puncture wounds
- Lacerations resulting in extensive tissue disruption

Vaccination history: a biting animal that has a well-documented history of having

received rabies vaccine, approved for use in that species and administered
consistent with the labeled booster schedule, is
unlikely to be infected with rabies
virus.

Reasons why a history of having received rabies vaccination does not ensure
absolute protection from infection:

- both the magnitude and duration with which the immune

Individuals vary in
systems produce protective antibody following vaccination.

- Rare inconsistencies in manufacture, storage, or handling can compromise a

vaccine’s potency prior to administration.

- Errors in administration of the vaccine (e.g., intradermal rather than

subcutaneous administration) can dilute the functional concentration of
antigen below that necessary to support immunologic memory.

37
 Table 5 Relative Indicators for rabies post-exposure prophylaxis (PEP)
Factor Strong indicators Weak indicators
Animal species Bat, skunk, raccoon, unknown *Dog, cat, other domestic animal
wildlife
Number of bites Single or multiple No
bite
Bite location More urgent: face, head, neck
Less urgent: extremities
Bite severity More urgent: deep lacerations, Superficial; no bleeding
considerable tissue damage;
extensive bleeding
Less urgent: minimal tissue
damage or bleeding
Medical attention No or delayed wound care Immediate cleansing and
irrigation
Bite provoked? No yes
Animal’s health Abnormal behavior No
paralysis or behavioral
abnormalities
Rabies vaccination No documentation of rabies higher: previous rabies
vaccination vaccination but not current
Lower: current on rabies
vaccination
Animal availablefor quarantine? No yes
Rabies recently detected in Higher: yes (Rabies should be considered
region? Lower:no possible in
all regions of the
Philippines, regardless of recent
surveillance data)
Victim’s anxiety about rabies (objective scientific evidence Higher: high
should be the principal
determinant for PEP decisions.) Lower: low
Adopted from the manual on, “Investigation, management and prevention of animal bites in California,” 3°¢ ed.

*BAI reported in 2015 that 98% of animal rabies are from dogs followed by cats in 1.2%.

1.1.3. Recognize the clinical signs of rabies in domestic animals

¢ Withdrawal from and resistance to contact; seeking seclusion

° Wide-eyed; reduced frequency or absence of blinking; dilated pupils;
photophobia
°

¢
Exaggerated, often aggressive, response
Snapping/biting at imaginary objects
to
tactile, visual, or auditory stimuli

¢ Pica (eating or mouthing sticks, stones, soil, clothing, feces, etc)

* Aggressively attacking inanimate objects
* Sexual excitement with attempts to mount inanimate objects
* Compulsive running or circling, often to the point of exhaustion
* Obsessive licking, biting, or scratching at the site of viral inoculation
¢
Dropped jaw, inability to swallow, excessive salivation
* Change in
tone, timbre, frequency, or volume of
vocalizations
¢ Flaccid or deviated tail/penis

38
 * Tenesmus (due to paralysis of the anal sphincter)
¢ Muscular tremors
* Acute onset of mono-para-,or quadri-paresis; lameness
¢ Abnormal, exaggerated gait; ataxia and incoordination
* Convulsive seizures
*
Paralysis, prostration, recumbency
* Death

Ifafter animal examination, some of these signs or any other signs of illness are
present, it is advised to immediately, safely and humanely euthanize the animal,
remove the head and submit the brain to the designated public health laboratory for
testing.

1.1.4. Rabies risk-based response

Rabies infection most quickly and reliably determined through examination of brain
is
tissue removed from an animal shortly after it
is dead or was euthanized.

a. Collection/capture and handling

*
Capture should be conducted only by persons knowledgeable, trained and
skilled in methods appropriate to the species at hand.
¢ All persons charged with capture of a potentially rabid animal should have
been pre-immunized against rabies.
* The number of
persons deployed should be the minimum necessary to collect
the animal.

* Domestic or wild animals collected for the purpose of rabies testing should be
held for a minimum time needed to arrange for euthanasia.
« During the holding period, access to the animal must be limited to the
minimum number of
authorized persons needed to provide for its care.

b. Euthanasia

Must be conducted in a humane and speedy manner, using methods like inhalational
and injectable euthanasia for suspect rabid animals.

Methods that require penetration the skull and interruption of central brain
function to effect death (e.g. Gunshot) should be avoided as these may compromise
brain tissue architecture and result in inconclusive results for rabies virus testing.

39
c. Testing
The public health laboratory should be contacted ASAP to alert them to the
incoming specimens and to ensure that specimens are collected, packaged, and
shipped in strict accordance with their protocol.

A. specimen collection
B. animal heads

d. PPE to be worn during the removal of the:

animal’s head
—~———-==g@ Face shield

Rubber gloves
(heavy duty) Surgical gloves
(disposable)

Plastic aprons

The animal’s head should be severed from the body

at mid cervical vertebrae and placed in a leak-proof inner container.

Place the inner container in

an insulated outer transport container and surrounded
with sufficient coolant (commercial cold pack or dry ice) to preserve the tissue
specimen during transport.

All instruments used removing the head (pruning shears, necropsy knives,
in

scissors) should be disinfected by steam or heat sterilization (autoclaves,

instrument sterilizers, incineration).

brain tissue
* Must be kept cool, using cold packs or dry ice.
* Do not place the brain tissue in formalin or glycerol saline.

40
e. Specimen submission
¢ Cold pack refrigerants are satisfactory when the interval between packaging
the specimen and receipt at the laboratory does not exceed 48 hours.
¢ For longer intervals, the specimen should be placed on dry ice.

¢ Fresh refrigerated specimens are best.

¢ Submission forms and other specimen information should be enclosed in a
properly addressed envelope and fastened to the outside of the mailing
container.
¢ Submit specimens to the local health laboratory by the fastest possible
route, e.g. Messenger or overnight courier service.

f. Test procedure
¢ The Direct Fluorescent Antibody Test (DFA) for detection of rabies virus is
rapid and reliable test.
* The detection of animal rabies in animal tissue and diagnosis of rabies in an
animal should be reported to the local health officer within 24 hours.
¢ Positive rabies test results are reported using the DOH Animal Rabies case
report form.

g. Disposal of animal carcasses

Carcasses of rabid animals are considered biohazardous waste and subject to

restrictions on their disposal.

Carcasses must be placed in a red biohazard bag and carefully labeled with the
words “BIOHAZARDOUS WASTE.”

Ideal factors for permitting home rabies quarantine

* Domestic dog or cat
¢ Written documentation of at least primary and first booster rabies vaccinations
*
Currently healthy; no signs of illness om

¢
Adequate indoor facilities to confine the animal
«
Ability to effectively exclude children and others from
quarantine area

Each bag is securely tied and stored in a leak-proof

container until retrieval by or transfer to the medical
waste hauler.

Use of the carcass as food by any human being,

domestic animal or fowl is prohibited.

41
Table 7 Recognize earliest period (days) prior to onset of clinical signs and prior to
death in which rabies virus is present in the saliva of some mammals
Species Prior to onset Prior to death Reference
7 12 Vaughn 1965
Domestic dogs 7 12 Fekadu | 982*
Domestic cats I 6 Vaughn 1963
Ferrets 2 Undetermined** Neizgoda 1998
Mexican freetail 12 18 Baer 1967
bats
Striped skunks 5 9 Sikes 1962
Gray, red foxes Not reported 3 Sikes 1962

*a single dog in this study that was inoculated with an Ethiopian canine strain of rabies virus had an excessive long shedding
period of 13 days prior to onset and 14 days
prior to death.
** all study ferrets were euthanized after onset of clinical signs.

Because a rabid dog or cat will predictably die within a known period of time,
suspicion of rabies can be eliminated if the dog or cat remains healthy and alive 10
or more days after a bite incident.
Ifthe quarantined animal is not currently vaccinated against rabies, a rabies vaccine
should be administered prior to release from quarantine.

All persons who were bitten or had concerning contact with the animal should be
informed that the animal is healthy and there is no possibility of rabies virus
transmission.

1.2. Recording
Record information in a manner that is accurate, complete, consistent and legible. Write
objective observations efficiently, with photo documentation where possible. These data
serve as the basis for risk assessment of rabies transmission to make an informed decision on
the disposition of the biting animal and appropriate medical management the bitten for
person.
1.2.1. Information
e NOI (nature of bite: dog bite, cat bite, etc)
e POI (place of bite)
e DOI (date bite)
of

e TOI (time bite)

of

e SOI (site of bite)

e EXO (extent of bite wound/s)

e COA (condition of animal)
e ARV
(anti-rabies vaccination history for biting animal and bitten person)
e Pro (provocations/triggering events)
e COB (Category of bite)

42
Reporting Classified by the PIDSR as Category | or immediately notifiable disease,
—

rabies should be reported within 24 hours after a case is suspected to be one. A

standardized reporting form that contains all crucial information on the case (i.e., date,
time and site
of bite, including its diagnosed severity; patient vitals; animal condition,
vaccination record, if
any) is available and should be used when filing the report.

For RHUs The report must be submitted to the facility of a higher level (district,
-
municipal, or provincial hospital) or the nearest ABTC/ABC.

then have to forward the report to the provincial level for

Facilities of higher level will
proper documentation and coordination with appropriate staff who may do further case
investigation and/or confirmation.

Referral

Caution and careful decision must be observed at all times when referring a rabies
patient to another facility. The receiving facility must be able to provide IMMEDIATE
primary management of
bite wounds and as much as possible, obtain a detailed history
of the patient and the biting animal.

The patient’s detailed history must be recorded

should be provided the referral facility.
at the receiving facility, while a copy

For the referral facility, it is

necessary that its staff has the training to handle suspected
rabies cases and the knowledge on the other procedures, especially laboratory
expertise/capabilities to confirm whether the case is rabies or not.

A more thorough discussion on referral is given in the MOP.

43
2. Clinical Diagnosis of Human Rabies

When physicians encounter a patient presenting with an animal-to-human exposure, a proper

history should be taken in order to make a preliminary risk assessment and determine the most
appropriate treatment and or management of the patient.

2.1. History Taking

Clinical history and physical exam are critical to the diagnostic process of rabies and can
provide vital information.

|. Determine the History of exposure to dogs, cats, bats, domestic animals

e bite — Date of Incidence, Place of incidence, Nature of Incidence, Time of
Incidence
e non bite — broken skin or mucous membrane, scratch by paw,
Lick on
unprotected exposure to rabies virus in the lab, transplant of infected tissue,

e
exposure
The
to rabies patient (bite, lick on mucous
following are not considered exposures to rabies
membranes,
— sharing food with

rabies patient, licks on intact skin,

2. Observe the status of biting animal at time of bite and after 14 days
w Determine the vaccination status of biting animal
4. Take note of the incubation period — Incubation period begins on the date of
bite to date the first symptoms appear
5. Watch out for the following clinical symptoms:
e Pain/numbness/itching at bite site
e Encephalitic symptoms— Be sure to note and documentilist them
e Paralytic symptoms — Document/list these as well.
6. Consider other contributory information such as:
e Other victims of the same animal within the past 24 hours
e History of previous rabies vaccination (pre or post exposure prophylaxis,
date)

44
 2.2. Physical Examination

a. Routine

e Include Excoriation at bite site

Look for myxedema
muscle and thigh,
atpercussion sites, usually in the region of the chest, deltoid

e Check patient for possible piloerection and fasciculation

b. Neurologic

Observe for fluctuating

consciousness
Note autonomic stimulation signs
Watch for paralysis
Wait for aerophobia/hydrophobia to manifest

3. Laboratory Diagnosis
3.1. Collection of samples

3.1.1. Saliva collection — Ante-mortem

Collection of the saliva will be done when the patient is in sensible condition. A
minimum of 3 collections, 4-6 hours apart, is required. There are 2 options: the first
is having the patient spit into the collection tube or by aspiration of saliva by the
research staff.

a. Voluntary Spitting

|. are recommended to be done in the morning. The subject

Saliva collections
isrefrained from any oral activities (i.e., eating, drinking, or oral hygiene
procedures) for at least | hour prior to the collection.

45
 N The
patient will be given drinking water and asked to rinse their mouth out
well without drinking the water. Five minutes after this oral rinse, the
patient will be asked to spit whole saliva into the tube.
w The patient will also be asked to hang his/her head down and let the saliva
flow naturally to the front of the mouth; and instructed to hold the
accumulated saliva for a few more seconds and spit into the tube provided.
Patient will spit into the collection tube after saliva is collected in the mouth,
The goal for each whole saliva donation should be about 3 to 5m.
u Require that the tube is placed on ice while collecting whole saliva.
ND
Collected samples are to be placed on ice before processing.
No preservatives or additional material should be added.

b. Aspiration by the Research Staff

| Follow procedures | and 2 above.

2 The subject will be asked to pool saliva for 30 seconds.
3. The research staff will aspirate saliva using a pipette.
4 Aspirated saliva will be flushed in the tube which is placed on ice.
5 Follow Procedures 6 and 7 above.

3.1.2. POST MORTEM COLLECTION

e Collection of the cerebrospinal fluid

1. The patient’s body will be positioned in their left side then will be placed in
a fetal position (the chin is close to the chest, the back is hunched, and
knees are brought toward the chest).
Once the appropriate location is palpated, a spinal needle is inserted
between the lumbar vertebrae L3/L4, L4/L5 or L5/SI and pushed in
until
there is a "give" as it enters the lumbar cistern wherein the ligamentum
flavum is housed. The needle is again pushed until there is a second ‘give'
that indicates the needle is now past the dura mater.
The specimen will be collected in a sterile bottle and will be submitted
immediately for testing; or if cannot be tested immediately, the specimen
may be stored and frozen in -20 °C.

46
e Collection of post mortem nuchal skin biopsy

|. Mark the area to be biopsied using a sterile marker. Clean the area with
alcohol.
2. Prepare the area with betadine swab.
3. Orient the punch biopsy (Formol needle punch) perpendicularly to the
skin’s surface (nape area).
4. Apply more down pressure while turning side to side.
5. Using handskin forcep without teeth and pair of curved iris
scissor, grasp
the specimen at the dermis and cut.
6. To close the biopsy side, use 4-0 suture and needle holder, place |-2
sutures as necessary. Get 2 skin biopsy (one sample in 10% buffered
formalin and the other is
frozen).

e Collection of mixed brain tissue via atlanto-occipital joint

The method of
collecting mixed
brain specimen through the
atlanto-occipital joint works for
dogs. This method is also
recommended if and when specimen
Atlanto-Occipital Joint
from a deceased human is
needed.

|. Place the cadaver in ventral

position. Palpate the atlanto-occipital joint.
2. Make a cross sectional incision and dissect to expose the joint.
3. Open the atlanto-occipital joint by cutting the dorsal atlanto-occipital
membrane and then the meninges. Expose the occipital foramen.
4. Take the brain sample by inserting the straw into the occipital foramen with
a slight twisting movement towards one of the eyes. This will allow samples
to be taken from the medulla oblongata, the base of the cerebellum,
hippocampus (Ammon’s horn) and the cerebral cortex.
5. Before withdrawing the straw, pinch it between the fingers in order to
prevent brain tissues escaping from the straw.
6. After withdrawing the straw, extract the content into a container by cutting
the straw or using stick.

47
 e Collection of hippocampus, brain stem, thalamus and cerebellum
1. The skull vault is opened using two saw cuts- one in front and oneat the

2.
back. These will not show through the scalp
it
when is sewed back together.
The top of the skull is removed, and the brain is very carefully cut free of its
attachments from inside the skull. Remove the brain and place in a tray.
3. Locate the thalamus between thecerebral hemispheres on either side of the
third ventricle.
4. With scalpel make a cut on the cerebral cortex until reaching the
hippocampus which is a tube-like structure. Collect the hippocampus.
5. At the distal part of the brain, locate the flower-like structure. At the distal
part of the cerebrum, this is the cerebellum. Underneath the cerebellum is
the brain stem. Collect the hippocampus, cerebellum and brain stem.

3.2 Handling of Specimen/Transport

Because they are potential biohazards, specimens should be frozen at -20° C. Keeping the
specimen frozen even in transport is necessary to maintain its integrity for accurate analysis.
If specimen needs to be transported through courier, check first with the courier
company
if their delivery vehicles have refrigeration or freezers that can bring the specimen to the
lab.

Table No. Recommended Packing and Handling of Specimens for Transport

Specimen Packaging/Handling Transport Test Results
Saliva Specimen vial, frozen Put in another container and PCR 5-7 days
seal in plastic bag. Transport
with ice/dry ice.
Brain tissue Specimen vial, frozen Put in another container and FAT 48-72 hours
seal in plastic bag. Transport
with ice/dry ice. PCR 5-7 days
Nuchal Skin Specimen vial, frozen Put in another container and PCR 5-7 days
seal in plastic bag. Transport
with ice/dry ice.
Serum Specimen vial, frozen Put in another container and ELISA/FAVN
seal in plastic bag. Transport
with ice/dry ice.
CSF Specimen vial, frozen Put in another container and ELISA/FAVN
seal in plastic bag. Transport
with ice/dry ice.

48
 Table No. Laboratory Diagnosis for Human Rabies Suspects
Specimen Aim Test Volume
Sample
of Where

Ante/Post Mortem
Saliva Virus RNA Detection RT-PCR 1-2 ml in sterile RITM
vial
Serum Antibody Detection RFFIT 2 ml in sterile RITM
ELISA vial
Post Mortem only
Brain ( brain stem and Antigen Detection dFAT | inch ? of the RITM
cerebellum) Viral RNA detection RT-PCR brain. No
formalin
fixation
Nuchal skin biopsy Viral RNA Detection RT-PCR Fresh specimen RITM
(Do not put in
Formalin)
CSF Antibody Detection RFFIT I-2 ml in sterile RITM
ELISA vial
IFAT

Viral RNA detection RT-PCR

4. CLINICAL MANAGEMENT

Considering the fatal outcome and absence of cure for human rabies once signs and symptoms
begin, management should center on ensuring comfort for the patient, using sedation, avoiding
intubation and life support measures.

4.1. Medications

Any
of the following medications may be given:
o Diazepam
o Midazolam
© Haloperidol plus Diphenhydramine

Table 18: Medications that may be given to a Rabies Patient

Drug Dosage Preparation Remarks
Pediatric Adult
Diazepam 0.3-0.5 mg/kg Initial: 2, 5, [0 mg/tablet

every 2-4 hours 10

mg IV at 10-15 minute intervals
not to exceed until a maximum of 30 mg has been 5 mg/ml (2m
20-40 mg/kg/24 given ampule)
hours
Maintenance:
10 mg 3-4x a day
Midazolam 0.1 mg/kg/dose P.O.- 2 tablet 15 mg/ tablet

49
 IM, IVor PO IM- 10-15 mg 5 mg/ml ampule

every 4-8 hours IV-2.5-5 mg

To be given every 4-8 hours
Haloperidol mg/kg IM or IV INITIAL: 5 mg IM/SC every hour for Note: Hypotension and
decanoate hourly as
necessary
3 doses

calm
at least or until patient is dystonic reactions occur

Maximum single
dose: 5 mg
MAINTENANCE: 5
mg IM/SC every
4 to 6 hrs and prn
Diphenhydramine 1-2 mg/kg IV or 50-100 mg every 4-6 hours Note: May cause
IM sedation, especially if
Maximum dose: other sedating agents are
50 mg given
May
cause hypotension

4.2. Supportive care

A patient diagnosed to have rabies should receive adequate sedation and comfort care in a
medical facility.

e Patients should be admitted in a quiet, draft-free, isolation room

e IV fluids
may be given
e Invasive and Heroic procedures must be avoided. (Intubation, Mechanical
Ventilation, Cutdown)
e Provide suitable emotional and physical support.
e Discuss and provide important information to relatives concerning
transmission of disease and indication for post-exposure prophylaxis of
contacts.
e Honest gentle communication concerning prognosis should be provided to
the relatives.

4.3. Isolation room

When appropriate treatment is

not given and rabies patients reach the stage where they
uncontrollable and need to be isolated. Isolation
can no longer be cured, they become
rooms are advised to minimize harm on patients and care givers. Rooms should be
draft-free; with grilled windows and doors that can be locked from outside.

Py
Isolation room in San Lazaro Hospital where
rabies patients are taken during the advanced
stage of the infection
4.4. Referral and transporting of patient to other hospitals

Rabid patients that need to bereferred and transported to hospitals (or facilities of
coordinated with the referral facility. It is important that
higher level) must be properly
the ambulance and the ambulance personnel, including the driver are knowledgeable and
trained on managing a rabid patient.

Family members should be counseled that rabies is 100% fatal. Inform and
explain to them that because rabies is
highly infectious, all precautions must
be taken to prevent the spread of infection.

a. If relatives/family insist on referral, patient should be transported by an

ambulance.
b. Ambulance driver and accompanying personnel have to be informed of risks
of patient. :

c. Hospital of choice must have capability of admitting rabies cases. They must
also be informed beforehand and willing to accept transfer of patient.
d. All precautionary measures must be taken care of.
e. As much as possible, referral of patients with frank symptoms of rabies to
higher facility should be avoided.

When to refer to a higher facility

e When diagnosis is not certain — atypical presentation or paralytic rabies
e Pregnant rabies patients for caesarian section

Referral Forms

When referring a suspected rabies patient, the attending physician from the referring
facility must provide a proper history to enable the receiving facility to do a preliminary
risk assessment and make the necessary management/treatment protocols

Aside from the patient’s basic information,

the following:
a duly filled up referral form should include
e WHERE did the exposure occur? This is important, as the rabies virus is more
prevalent in some areas thanin others.
e WHAT type
ofanimal was involved? In the Philippines, there are more dog-
mediated bites compared to other animals. Whenever possible, include in the
referral form all details about the biting animal (owned or stray; strayvaccinated
or not; if vaccinated, date of vaccination, etc.)
e WHY
did the bite occur? An unprovoked exposure
rabid animal’s behaviour than a provoked exposure.!4
is
usually more typical of a

¢ WHO
is It if
the animal’s owner? is important the animal involved is
a
domestic dog (or cat), as health providers and surveillance unit personnel can
track down the location of the animal for observation purposes. If the animal is
healthy, it may be possible to avoid administering PEP to the exposed patient!

51
4,5. Infection control

Healthcare workers and relatives coming in contact with patients should wear proper
personal protective equipment (PPE) including gown, gloves, mask, goggles
Healthcare workers directly handling rabies patients MUST RECEIVE Pre exposure
prophylaxis and rabies vaccine boosters, if needed, based on monitoring of AB levels
Relatives/watchers/companions of
rabid patients tasked to take care of these patients
(Minimum requirements for “bantays”
4.5.1. Rabies in pregnancy

Ingeneral, pregnant rabies patients should be managed in the same way

non-pregnant patients.
as
Rabid mothers
emergency CS
in
is
the 34 trimester wherein the baby
recommended.
is
already viable, an

Once delivered, the baby should receive PEP (vaccine and RIG)

4.5.2. Disposal of dead bodies

Humans who died of rabies generally present a small risk of transmission to

others. There is evidence that blood does not contain virus but that the
virus is present in many tissues such as the CNS, salivary glands and muscle.
It is also present in saliva and urine.
Embalming should be discouraged. If embalming or autopsy is performed,
should be undertaken carefully, with appropriate precautions and personal
it
protective equipment. Tissues and body fluids should be disposed of in the
same manner as for other infectious diseases.
Wearing protective clothing, goggles, face mask and thick gloves should
provide sufficient protection.
Instruments must be autoclaved or boiled after use.
The Burial Requirement under the Philippine Sanitation Code (PD 856)
Section 91 states that “When the cause of death is a dangerous communicable
disease, the remains shall be buried within |2 hours after death. They shall not
be taken to any place of public assembly. Only the adult members of the family
of the deceased may be permitted to attend the funeral.” It is highly
recommended that early disposal of the body by cremation or burial should
be done depending on their religious practice.

4.5.3. Transmission via Organ Transplantation

Clinical screening of prospective donors is recommended to include a

detailed history, thorough clinical evaluation and analysis of the whole
scenario.

52
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 |
Table 7 Categories of Rabies Exposure with Corresponding Management
Category of Exposure
CATEGORY Management

a) Feeding/touching an animal
1) Wash exposed skin immediately with
b) Licking of intact skin (with reliable
and
soap and water.
history thorough physical
examination) 2) No vaccine or RIG needed
c) Exposure to patient with signs and 3) Pre-exposure prophylaxis may be
symptoms of rabies by sharing of
eating or drinking utensils
considered for
high risk persons.

d) Casual contact (talking to, visiting

and feeding suspected rabies cases)
and routine delivery of health care
to patient with signs and symptoms
of rabies

CATEGORY
Il 1) Wash wound immediately with soap
and water for at least 10 minutes.
a) Nibbling of uncovered skin with or
without bruising/hematoma 2) Start vaccine immediately:
a. Complete vaccination regimen until Day
b) Minor /superficial 28 (see Table 3.2)
if:
scratches/abrasions without bleeding,
including those induced to bleed
i. biting animal is laboratory proven to be
rabid OR

c) All Category exposures on the

II ii. biting animal is
killed/died without
head and neck area are considered laboratory testing OR
Category Ill and should be managed
as such
iii. biting animal has signs and symptoms of
rabies OR

iv. biting animal is not available for

observation for |4 days
b. May omit Day 28 dose if:
i. biting animal AND remains healthy
is alive
after the 14-day observation period, OR
ii. biting animal died within the 14 days
observation period, confirmed by
veterinarian to have no signs and
symptoms of rabies and was FAT-
negative.

54
 3) No RIG needed
e immediately:

CATEGORY Ill 1) Wash wound immediately with soap

and water for at least 10 minutes.
a) Transdermal bites (puncture
wounds, lacerations, avulsions) or 2) Start vaccine and RIG immediately:
scratches/abrasions with a. Complete vaccination regimen until Day
spontaneous bleeding 28 (see Table 3.2)
if:
b) Licks on broken skin or mucous i) biting animal is laboratory proven to
be rabid OR
membrane
biting animal is killed/died without
Exposure to rabies
a_
patient laboratory testing OR
through bites, contamination of
biting animal has signs and symptoms
mucous membranes (eyes, oral/nasal of rabies OR
mucosa, genital/anal mucous
membrane) or open skin lesions with biting animal is not available for
body fluids through splattering and observation for 14 days
mouth-to-mouth resuscitation May omit Day 28 dose if:
d) Unprotected handling of infected i) biting animal is
alive AND remains
healthy after the 14-day observation
carcass
period, OR
Ingestion of raw infected meat biting animal died within the 14 days
observation period, confirmed by
Exposure to bats veterinarian to have no signs and
symptoms of rabies and was FAT-
g) All Category Il
exposures on head negative
and neck areas.

55
Table 8 Management of
patients with category Il and III exposure where the biting
animal cannot be observed or dies within the | 4 days observation period.

FAT Result Signs and symptoms Give 2 ID doses or | IM Give | IM dose on

in
|
of Rabies biting dose on Day zero (D0), Day Fourteen (D1 4)
animal Day three (D3) and Day and 2 ID doses or
seven (D7) IM dose on Day
Twenty Eight (D28)*
+ + Yes Yes
+ - Yes Yes
- + Yes Yes
- - Yes No
Not done + Yes Yes
Not done - Yes Yes
*For Non-WHO Prequalified Vaccines

5.1. Post Exposure Prophylaxis Under Special Conditions

NOT be contraindications to treatment with purified cell

Pregnancy and infancy shall
culture vaccines (PVRV, PCECV) and RIG.

Babies who are born of rabid mothers shall be given rabies vaccination as well as RIG as
at
early as possible birth.
Patients with hematologic conditions where IM injection is contraindicated shall receive
rabies vaccine by ID route.

Patients with chronic liver disease and those taking chloroquine, and systemic steroids
shall be given standard IM regimen as the response to ID regimen is not optimum for
these conditions. Vaccination shall not be delayed in these circumstances as
the risk of rabies.
it
increases

Immunocompromised individuals (such as those with HIV infection, cancer/transplant

patients, patients on immunosuppressive therapy etc.) shall be given vaccine using
standard IM regimen and RIG for both Category Il Ill
and exposures.

Exposed persons who present for evaluation or treatment weeks or months after the
if
bite shall be treated as if exposure has occurred recently. However, the biting animal
has remained healthy and alive with no signs of rabies until 14 days after the bite, no
treatment is needed.

56
 Interchangeability of modern rabies vaccine brands or types shall not be recommended.
However, in countries such as the Philippines, Thailand, Sri Lanka, France and Germany
it has been practiced for many years without reported untoward events, each time
circumstances made
it
inevitable to interchange vaccine used for administration. Shifting
from one vaccine brand to another shall not be recommended but may be warranted in
the following circumstances, provided that it is one of the WHO recommended cell
culture vaccines:

e Hypersensitivity reaction such as generalized rash, anaphylaxis, severe

generalized pruritus, severe local reaction at injection site (swelling of entire
upper arm).
e Unavailability of the initial vaccine used.

Since no immunogenicity studies have been done regarding change in route of vaccine
administration (i.e. shift from IM to ID or vice versa), shifting from one regimen to
another shall NOT be recommended. As much as possible the initial regimen shall be
completed. In extreme circumstances that shifting has to be done from IM to ID
regimen or vice versa, vaccination shall be restarted from day 0 using the new regimen.

Bites by rodents, guinea pigs and rabbits do not require rabies post- exposure
prophylaxis

Bites by domestic animals (dog, cat) and livestock (cows, pigs, horses, goats etc.) as well
as wild animals (bats, monkeys, etc) shall require PEP.

5.2. Post Exposure Prophylaxis of Previously Immunized Animal Bite Patients

Local wound treatment shall always be carried out.

Persons with repeat exposure after having previously received complete primary
immunization with Tissue Culture Vaccine (TCV) and persons who were exposed to
rabies after completing the Pre-Exposure Prophylaxis against rabies with TCV shall be
vaccinated as follows: (see Table 9)

Table 9. PEP schedule for previously immunized animal bite patients

PrEP/PEP History
(Regardless of type of TCVand route of GIVE RIG MANAGEMENT
administration in previous PrEP/PEP)
Patient received the complete pre-
exposure prophylaxis on Days 0, 7 and
NO Give 0.1 ml ID
site each on
dose
at |

21/28 using TCV DO and D3

OR OR
Patient received at least Days 0, 3, 7 of | vial IM dose at | site

57
ID/IM dose using TCVs each on DO and D3
Patient did not complete the
PrEP
3 doses of Give
if
indicated
Give Full Course of PEP

OR
Patient received only |
or 2 ID/IM dose of
the PEP
c. The following patients are considered to have completed the primary immunization:

e Those who have received day 0, 7, 28 of pre-exposure prophylaxis.

e Those who have received at least day 0, 3, 7 of post-exposure treatment.

d. Booster doses may be given ID (0.1 ml. for PVRV or PCECV) or IM (0.5 ml for
PVRV
or 1.0 ml for PCECV).

e. Patients who have previously received complete primary immunization with rabies
vaccine have the advantage that booster doses will rapidly induce a large
increase in antibody production (a “secondary response”). Therefore, there is
no need to give RIG.

f. Patients who have not completed the primary immunization as described above
shall receive full course including RIG if needed.

5.3. PEP for Potential Rabies Exposure

a. PEP shall not be recommended for all Category | exposures.

b. PEP can be delayed for Category Il Exposures provided that ALL of the following
conditions are
satisfied:

e Dog/cat healthy and available for observation for 14 days.

is

e Dog/cat was vaccinated against rabies for the past 2 years:

> Dog/cat shall be at least | year 6 months old and has updated
vaccination certificate from a duly licensed veterinarian for the last 2
years.
> The last
vaccination must be within the past 12 months, the immunization
status the dog/cat shall not be considered updated
of
vaccinated on the due date of the next vaccination.
if
the animal is not

c. PEP
shall be given immediately for ANY of the following conditions:
e The rabies exposure is
category Ill;
e The dog/cat is proven rabid/sick/ dead with no laboratory exam for rabies/not
available before or during the consultation/dies within observation period.
e The dog/cat is
involved in at least 3 biting incidents within 24 hours or;

58
 e Dog/cat manifests the following behavior changes suggestive of rabies before,
during or after the biting incident: (see Table 10).

d. PEP
shall not be required for bite/s of the following biting animals: rats, mouse, rabbits,
snakes and other reptiles, birds and other avian, insects and fish.

6. Immunization

6.1. Active Immunization

6.1.1. Administration
Vaccine is administered to induce antibody and T-cell production in order to
neutralize the rabies virus in the body. It induces an active immune response 7- in
10 days after vaccination, which may persist for years provided that primary
immunization is completed. The program requires that all ABTCs should use WHO
prequalified vaccines.

6.1.2. Types of Rabies Vaccines

The National Rabies Prevention and Control Program (NRPCP) shall provide the
following anti-rabies tissue culture vaccines (TVC):
- Purified Vero Cell Rabies Vaccine (PVRV) — 0.5 ml/vial
- Purified Chick Embryo Cell Vaccine (PCECV) — 1.0 ml/vial

Table 10 List of TCV Provided by the NRPCP to Animal Bite Treatment

Centers with Corresponding Preparations and Dose
Generic Name Preparation Dose
Purified Vero Cell Rabies 0.5 mi/vial ID -0.1 ml
Vaccine (PVRV) IM —0.5 ml
1.0 ml/vial ID -0.1 ml
IM — 1.0 ml

Purified Chick Embryo Cell 1.0 ml/vial ID -0.1 ml

Vaccine (PCECV) IM — 1.0 ml

To ensure compliance to these recommendations and guarantee that animal bite

patients seeking treatment in government Animal Bite Treatment Centers receive
only Tissue Culture Vaccines (TCVs) that have been proven to be safe and
effective, the program shall utilize for its intradermal regimen only TCVs that
satisfy the following criteria
:
a. The vaccine is registered with and approved by the Philippine Food and
Drug Administration;

59
 b. The vaccine is WHO prequalified (http://www.who.int/immunization
standards/vaccine quality/PQ_ vaccine list_en/en/index.html); Non-WHO
prequalified vaccine which is registered with and approved by the
Philippine Food and Drug Administration may be used;

The vaccine has been proven to be safe and efficacious for PEP when
administered by the ID route using the schedule recommended by the
World Health Organization. Having limited knowledge on and experience
with the ID use of all available anti-rabies vaccines in the country, the
program shall utilize the WHO list of approved TCV for ID use OR the in
case of vaccines not included in the WHO for ID list
use, the vaccine must
comply with WHO requirements for new rabies vaccines and must have
gone through local clinical trials on safety and immunogenicity which are
published in peer-reviewed journals or must be registered with and
approved by the Philippine Food and Drug Administration;

The potency of vaccines for !D use shall be at least 0.5 IU/ID dose as
evidenced their lot release certificate. The potency of the vaccine batch
by

shall be provided by the manufacturer; and

The product insert shall contain the vaccine’s approved ID dose and
consistent with its Certificate of Registration

6.2. Passive Immunization

Rabies immune globulins or RIG (also called passive immunization products) shall be given
in combination with rabies vaccine to provide the immediate availability of neutralizing
antibodies at the site of the exposure before
it
is physiologically possible for the patient

to begin producing his or her own antibodies after vaccination. This is especially
important for patients with Category Ill exposures. RIGs have a half-life of
approximately 21 days.

Human Rabies Immune Globulin (HRIG) derived from plasma of human donors
administered at 20 IU per kilogram body weight. Available preparation is 2
mi/vial; 150 IU/ml.
Highly purified antibody antigen binding fragments [F(ab’)2] produced from
equine rabies immune globulin (ERIG) administered at 40 IU per kilogram body
weight. Available preparation is 5 ml/vial; 200 IU/ml.

Equine Rabies Immune Globulin (ERIG) derived from purified, horse serum administered
at 40 IU per kilogram body weight. Available preparation is 5 ml/vial; 200 IU/ml

60
 Table I1 List of Rabies Immune Globulins

Generic Name Preparation Dose

Human Rabies Immune Globulin 150 IU/ml at
20
01Uikg
|

(HRIG) 2 ml/vial
Purified Equine Rabies Immune 200 IU/ml at 4 01Uikg
Globulin (pERIG) 5 mi/vial

To ensure that only safe and efficacious RIG are provided by the National Rabies
Prevention and Control Program to all ABTCs, the program shall be guided the by
following criteria in procuring the RIG :

e RIG must be registered and approved by FDA;

e RIG must be proven to be safe and effective when used together with anti
rabies vaccine as evidenced by publication on peer reviewed journals. These
include studies on:
© Safety;
o Non-interference when used with anti-rabies vaccine;
o Animal survivorship, if any; and
© Post-marketing surveillance
e Results of RFFIT showing antibody content as claimed by the manufacturer.

6.2.1. Computation and Dosage of Rabies Immunoglobulin

HRIG at 20 IU/kg.
body weight (150
IU/ml)
50 kg. patient x 20 IU/kg,
= 1000 IU

6.2.2. Administration

a. The total computed dose of RIG shall be infiltrated around and into the
wound as much as anatomically feasible, even if the lesion has healed. In
case some amount of the total computed dose of RIG is left after all
wounds have been infiltrated, it shall be administered deep IM at a site
distant from the site of vaccine injection (preferably anterolateral thigh)
using another needle. The total computed dose shall be administered as a
single dose.

61
 b. A gauge 23 or 24 needle, | inch length shall be used for infiltration. Multiple
needle injections into the same wound shall be avoided.
c. A skin test shall be performed prior to ERIG administration using a gauge
26 needle. For skin testing, 0.02 ml of |:10 dilution of solution is
infiltrated
to raise a bleb 3 mm and read after 15 minutes. A positive skin test is an
induration >6 mm surrounded by a flare/erythema. If initial skin test is
positive, repeat skin test on same arm; use distilled water as control on the
other arm. The skin test shall be considered positive if the ERIG skin test is
positive but the control is negative.
d. If a finger or toe needs to be infiltrated, care shall be taken to ensure that
blood circulation is not impaired. Injection of an excessive amount may lead
to cyanosis, swelling and pain
e. RIG shall not exceed the computed dose as it may reduce the efficacy of
the vaccine. If the computed dose is insufficient to infiltrate all bite wounds,
it may be diluted with sterile saline 2 or 3 fold for thorough infiltration of
all wounds.
f. RIG shall always be given in combination with rabies vaccine. RIG shall be
administered at the same time as the first dose of rabies vaccine (Day 0). In
case RIG is unavailable on DAY 0, it may still be given until 7 days after the
first dose of the vaccine. Beyond Day 7, regardless of whether day 3 and
day 7 doses were received, RIG is not indicated because an active antibody
response to the rabies CCV/EEV/TCV has already started and interference
between active and passive immunization may occur.
g. In the event that RIG and vaccine cannot be given on the same day, the
vaccine shall be given before RIG because the latter inhibits the level of
neutralizing antibodies induced by immunization
h. RIG shall be given only once during the same course of PEP. c.4.9. Patients
with Positive skin test to purified ERIG shall be given HRIG.
i. Patient shall be observed for at least one hour after injection of ERIG for
immediate allergic reactions
j. RIG preferred for the following:
is

e History of hypersensitivity to equine sera.

e Multiple severe exposures, especially where dog
is sick or proven rabid.
e Symptomatic HIV infected patients.

Schedule for Delayed Vaccination

The vaccination schedule shall be strictly followed to prevent treatment failure.

In certain instances, when patient fails to come on the scheduled date for his

succeeding dose, the following rules shall apply:

Delay in second (i.e. day 3) dose:

62
 delay is 1-2 days from day 3 schedule (i.e. day 4-5 from start of vaccination)
*
If

— day 3 dose shall be given

upon visit and follow the original schedule of
day 7 and 28.

If delay is 3-4 days from day 3 schedule (ie. days 6-7 from start of
*

vaccination) - day 3 dose shall be given upon visit, adjust succeeding doses
(day 7 and 28) according to the prescribed interval.

*
If delay is > 4 days from day 3 schedule (i.e. beyond day 7 from start of
vaccination) —a new course shall be restarted.

Delay
in third (i.e. day 7) dose
e Ifdelay is <7 days from day 7 schedule (i.e. days 8-14 from start of vaccination)
day 7 dose shall be given upon visit, give day 28/30 dose as originally scheduled.
-
¢ If delay is >7 days from day 7 schedule (i.e. days 15 to 21 from start of
- 14
vaccination)—day 3 dose shall be repeated and revised according to the prescribed
interval.

© If delay is > 14 days from day 7 schedule (i.e. beyond day 22 from start of
vaccination) —a new course shall be restarted

Delay
in fourth (i.e. day 28) dose:
Give day 28 dose upon visit; this shall be considered as a booster.

e If RIG has already been administered, it shall not be given again.

6.4. Management of Adverse Reaction

Hypersensitivity to ERIG/F(ab’)2 may not be predicted by a negative skin test.
Adrenaline and antihistamines shall always be ready for treatment of hypersensitivity.

Anaphylaxis

a. Give 0.1% adrenaline or epinephrine (1:1,000 or Img/ml) underneath the skin or

into the muscle.
e Adults - 0.5 ml
e Children - 0.01 ml/kg, maximum of 0.5 ml
e Repeat epinephrine dose every 10-20 minutes for 3 doses.

63
 b. Give steroids after epinephrine.

Hypersensitivity reactions

a. Give antihistamines, either as single drug or in combination.

b. If status quo for 48 hrs despite combination of antihistamines, may give short
course (5-7 days) of combined oral antihistamines plus steroids.

c. Ifpatient worsens and condition requires hospitalization or becomes life

threatening, may give IV steroids in addition to antihistamines.

Minor/local or induration of
injection site
adache, fev
yi

Nausea, vomiting
Anti emetic, oral rehydration
Hypersensitivity Give antihistamines, either as a single drug (e.g.
Reactions diphenhydramine) or in combination (e.g.
diphenhydramine plus cetirizine).

Major/systemic Ifthe patient’s condition does not improve for 48 hours

despite combination of antihistamines, a short course (5-7
days) of oral antihistamines plus steroids may be given

patient worsens, requires hospitalization or condition

If

becomes life threatening, may give IV steroids in addition

to antihistamines
Anaphylactic or Give 0.1 %adrenaline or epinephrine (1:1000 or | mg/ml)
neuroparalytic underneath the skin subcutaneously) or into the muscle
(intramuscularly) at a dose of 0.5 ml for adults or 0.01
ml/kg or children, maximum dose of 0.5 ml.

Repeat epinephrine dose every |0-20 minutes for 3 doses.

Give steroids after epinephrine.

Hydrocortisone may be administered by intravenous

injection, by intravenous infusion, or intramuscular
injection, the preferred method for
initial emergency use

64
being intravenous injection.

Refer to the next level of care

Hydrocortisone sodium succinate Sterile Powder is given

at 100 to 500 mg intravenously over a period of 30
seconds (e.g, if dose is 100 mg) to 10 minutes (e.g., for
dose 500 mg or more), depending on the specific disease
entity being treated.

In certain
overwhelming,
acute, life-
threatening
situations,
administration in
dosages exceeding
the usual dosages
may be justified
and
may be in multiples
of the oral dosages.

This dose may be repeated at intervals of 2, 4 or 6 hours

as indicated by the patient's response and clinical
condition. In general, high dose corticosteroid therapy
should be continued only until! the patient's condition has
stabilized-usually not beyond 48 to 72 hours.

65
7. Wound Treatment

7.1. Local wound treatment

Bite wounds on the

hand and foot .

Wash wounds immediately and vigorously with soap/detergent

and water, preferrably for 10 minutes. If soap is not available,
the wound should be thoroughly and extensively washed with water.

Apply pressure if wound is bleeding.

Alcohol, povidone or any antiseptic
can also be applied

Wounds shall be immediately and

vigorously washed and flushed with soap
or detergent, and water preferably
for 10 minutes. If soap Avoid suturing at all times is not available, the
wound shall be to prevent the virus from thoroughly and
inoculating deeper into the wound
extensively washed with water.

Apply alcohol, povidone iodine or

any antiseptic.

Suturing of wounds shall be avoided at

all times since it may inoculate virus deeper into
the wounds. Wounds may be coaptated using sterile adhesive strips. If suturing is

66
=
unavoidable, it shall be delayed for at least 2 hours after administration of RIG to allow
diffusion of the antibody to occur through the tissues.

Any ointment, cream or wound dressing shall not be applied to the bite site because it
will favor the growth of bacteria and will occlude drainage of the wound, any. if
Anti-tetanus immunization shall be given, indicated. History of tetanus immunization
if

(TT/DPT/Td) shall be reviewed. Animal bites are considered tetanus prone wounds.
Completion of the primary series of tetanus immunization is recommended.

Table 13. Guide to Tetanus Prophylaxis in Routine Wound

Management
Vaccination History
Indication for TT Unknown or <3
Doses
3 or More Doses
Immunization
Td* TIG/ATS Td* TIG/ATS
All Animal Bites YES YES NO** NO

*Tdap may be substituted for Td if the person has not received Tdap and is | 0 years or
older;DPT may be given for patients < 7 years old; TT
more than 5 years since last dose
may
if
be given Td not available **Yes, if

7.2. Routine Wound Management

The most common organism isolated from dog and cat bites is Pasteurellamultocida.
Other organisms include S. aureus, Bacteroidessp, Fusobacterium and Capnocytophaga.
Antimicrobials shall be recommended for the following conditions:
e All frankly infected wounds
e category Ill cat bites
All
e All other category Ill bites that are either deep, penetrating, multiple or
extensive or located on the hand/face/genital area
Recommended antimicrobials for frankly infected wounds include:
e Amoxicillin/clavulanic
o Adults - 500 mg p.o. TID
o Children - 30-45 mg/kg/day in 3 divided doses

e Cloxacillin
o Adults - 500 mg p.o. QID
o Children - 10-150-100 mg/kg/day in 4 divided doses

e Cefuroximeaxetil

67
 o Adults - 500 mg p.o. BID
o Children - 10-15 mg/kg/day in 2 divided doses

For penicillin allergic patients

o Adults - Doxycycline
o Children — Erythromycin

For those instances where there are no obvious signs of infection, amoxicillin as
prophylaxis may suffice

o Adults - 500 mg p.o. TID

o Children - 30-45 mg/kg/day in 3 divided doses

The public shall be educated in simple local wound treatment and warned not to use
procedures that may further contaminate the wounds (e.g. tandok, bato, rubbing garlic
on the wounds and other non-traditional practices).

7.3. Vaccination

7.3.1. General Principles

Storage
o Vaccines shall be
stored at +2 to + 8 °C ina refrigerator, not freezer.
o Once reconstituted, vaccines shall be kept in the refrigerator and used
within 8 hours.

Administration Area
© Injections shall be given on the deltoid area of each arm in adults or at the
anterolateral aspect of the thigh in
infants.
o Vaccine shall never be injected in the gluteal area as absorption is
unpredictable

7.3.2. Treatment Regimen Schedule

a. Updated 2-site Intradermal Regimen (2-2-2-0-2)

This regimen is a modification of the original Thai Red Cross regimen 2-

site ID regimen where the Day 90 dose has been transferred to day 28.

One dose for ID administration is equivalent to 0.1 ml both for PVRV

and PCECV

68
 One dose should be given on each deltoid (or at the anterolateral
aspect of both thighs in infants) on Days 3, 7 and 28. 0,
One intradermal dose shall have at least 0.5 IU vaccine potency.

Table 14 Updated 2-Site Intradermal Schedule

Day
of
immunizatio| PWRV/PCEV Site of injection
n
Day 0 0.1 ml Left and right deltoids or anterolateral thighs in infants
Day 3 0.1 ml Left and right deltoids or in infants
anterolateral thighs
Day 7 0.1 ml Left and right deltoids or in infants
anterolateral thighs
Day 28 0.1 ml Left and right deltoids or anterolateral thighs in infants

e The ID injection shall produce a minimum of 3 mm wheal. In the

event that a dose of vaccine is inadvertently given
subcutaneously or IM, the dose shall be repeated.
e Aone (I) ml syringe with gauge 27 needle, preferably auto
disposable syringe shall be used for ID injection

b. Standard Intramuscular Schedule

Using the standardregimen, one dose

IM
is
equivalent to vial of
0.5 ml of PVRV
or !.0 ml of PCECV. One(I) dose given is
intramuscularly (IM) on days 0,
3, 7, 14 and 28 (see table 15)

Table 15 Standard Intramuscular Schedule

Day of immunization PVRV PCECV Site of injection

Day 0 0.5 ml 1.0 ml One deltoid or anterolateral thigh
in infants
Day 3 0.5 ml 1.0 ml One deltoid or anterolateral thigh
in infants
Day 7 0.5 ml 1.0 ml One deltoid or anterolateral thigh
in infants

69
 One deltoid or anterolateral thigh
Day 14 0.5 ml 1.0 ml in infants
One deltoid or anterolateral thigh
Day 28 0.5 ml 1.0 ml in infants

c. Alternative Intramuscular Regimen

Zagreb Regimen Schedule (2-1-1 Intramuscular Schedule)

Table 16 Zagreb Schedule

__
Day
immunization
of PVRV PCECV Site of injection

Left and right deltoids or

Day 0 0.5 ml 1.0 ml anterolateral thigh in infants
Onedeltoid or anterolateral thigh
Day 7 0.5 ml 1.0mli in infants
One deltoid or anterolateral thigh
Day 21 0.5 ml 1.0 ml in infants

Shortened Intramuscular Schedule (CDC)

An alternative for healthy, immunocompetent, exposed people who
fully
receive wound care plus high quality rabies immunoglobulin plus WHO-
prequalified rabies vaccines, shall be given a post-exposure regimen
consisting of 4 doses administered intramuscularly on days 0, 3, 7 and 14
(see table | 7)

Table 17 Shortened Intramuscular Schedule (CDC)

Day of
immunization PVRV PCECV
.
Site ee
of injection

Day 0 0.5 ml 1.0 ml One deltoid or anterolateral thigh in infants

Day 3 0.5 ml 1.0 ml One deltoid or anterolateral thigh in infants
Day 7 0.5 ml 1.0 ml One deltoid or anterolateral thigh in infants
Day 14 0.5 ml 1.0 ml One deltoid or anterolateral thigh in infants

70
 PART 2: ANIMAL RABIES

Prevention and Control of Animal Rabies

In order to minimize public health risks due to rabies, and eventually eradicate rabies in dogs, the
following are recommended by the OIE to be implemented according to the standards on disease
control, rabies and animal welfare set by the OIE Terrestrial Animal Health Code:

a. Rabies should be notifiable in the whole country and any change in

the epidemiological
situation or relevant events should be reported accordingly.
b. An effective
system of disease surveillance should be in operation, with a minimum
requirement being an ongoing early detection programme
reporting of suspected cases of rabies in animals.
to
ensure investigation and

Specific regulatory measures for the prevention and control of rabies should be
implemented, including vaccination, identification and effective procedures for the
importation of dogs, cats and other mammals.
A programme for the management of stray dog population should be implemented
and maintained. (OIE)

Mass Registration and Vaccination of Dogs

1.1.1. Estimating Dog Population

e One
is to ten (I dog per 10 humans; 1:10)

Where data on dog population is not existent, the dog population is estimated at a
ratio of one (1) dog per ten (10) humans in
the country for planning purposes. The
estimated human population made by
the National Epidemiology Center (NEC) of
DOH based on
the
formula given by the National Statistics Office (NSO) per DOH
Department Memorandum No. 2014-0008, or the population estimated by the
Philippine Statistics Authority are used as reference. What is recommended is
actual
dog count.

e House-to-house survey or actual dog count/census

This method gives a true number of dog populations in the community. It

is done
before the vaccination campaign commences. In this method, the designated person
lists down all
the dogs per household. While this method gives an accurate count,
should be done yearly and it is costly.
it
e Researches/Projects

This method is usually spearheaded by rabies researches/projects and can be done

through KAP
surveys, etc.

e Listing and dog registration

This method may not depict a true picture of the dog population. It
is usually done
during vaccination campaign. While not all household can bring their dogs for

71
 registration and vaccination, it can somehow give an estimate of how much of the
population is brought for vaccination every year. The LGU
mandatory registration of vaccinated dogs in their
is responsible for
own area pursuant to RA 9482
Section 7 and Rule 4.2.1 of the IRR.

1.1.2. Target population

During the mass vaccination activity, all apparently healthy dogs aged 3 months and
above with no recent bite incident must be vaccinated. All free-roaming dogs and new
inclusions must be prioritized. Pregnant dogs, lactating dams and | to 3 months old
puppies from unvaccinated dams may also be vaccinated depending on the prerogative
of the veterinarian. But vaccination must be repeated when
the case of puppies.
itreaches 3 months old in

Allvaccination must be done annually. Cats and monkeys are also included in the
vaccination when presented.

1.1.3. Priority areas

As envisioned by the DA management, it
is ideal to conduct an intensive vaccination
campaign in a period of three (3) months for the vaccination activity to have an impact;
especially in areas considered high risk for rabies. Prioritization of areas was strategized
for the implementation of the vaccination program.

A. First Priority

High risk depressed areas pursuant to Section 6 No. A (3) of Republic Act No.
9482 or the “Anti-Rabies Act of 2007”, first priority shall be given to provinces
with the highest number of both human and animal rabies cases for the past two
(2) years. Priorities for the distribution of vaccines shall be based on the
incidence of rabies determined through confirmed laboratory reports from the
Animal Disease Diagnosis and Reference Laboratory (ADDRL) or formerly
known
as Philippine Animal Health Center (PAHC), Regional Animal Disease
Diagnostic Laboratories (RADDLs), and the Department of Health- Research
Institute for Tropical Medicine (DOH-RITM). See Risk-based approach

Specialattention shall also be made to 5th class provinces/municipalities and

areas with high animal-human population density and intermingling of these
populations.

B. Second Priority

These are areas being applied by the Local Government Units (LGUs) to be
rabies-free zones.

C. Third Priority

These are provinces/localities already declared as rabies-free zones.

1.1.4. Strategic Plan for Mass Dog Rabies Vaccination

72
 A. Preparation
e Aplan ora strategy must be developed before the activity is carried out.
e A meeting with stakeholders (LGU, NGO, Rabies Committee, DA-RFO)
must be set to discuss the:
o Strategies on how to cover most of the population
o Logistics which include the source of vaccines, where to get the
paraphernalia, human resources and their identification, how to
inform the community about the activity, where to get the dog
population list and the activities on the vaccination day proper.

B. Information drive for the vaccination schedule

A successful vaccination activity is dependent on the information

disseminated in the community. arise if the
More participation will
community
is well informed of the activities.
C. Orientation of the vaccination teams

A team must be supervised by a licensed veterinarian. It is composed of

representatives from the barangay orvillage, vaccinators from the
Veterinary office and/or volunteers from private or non-government and
people’s organizations. Teams of 4-6 persons are a good number and must
be properly identified.

1.1.5. Training of vaccinators, vaccine handlers and dog catchers

“Rabies Vaccination of Dogs refers to the inoculation of a Dog with Rabies vaccine
by a licensed government or
private veterinarian or trained individual under the
direct supervision of a licensed veterinarian. The service of the said trained
individual shall be limited only to Rabies Vaccination Injection in Dogs and only
during government mass vaccination campaigns (Republic Act No. 9482)”.

Trained vaccinators must be equipped

with proper knowledge on Rabies as a
disease and must undergo series of
trainings on proper vaccination
techniques and humane dog.catching.
Designated vaccine handlers must be well
trained on the proper handling and
storage of vaccines, disposal of used
materials and vaccine utilization
reporting.

It is also recommended for

vaccinators, vaccine handlers and dog catchers to
complete the vaccination against rabies through pre-exposure prophylaxis as they
are considered as high risk personnel. This should be on coordination with the
Department of Health (DOH), as stated in RA No. 9482 under Responsibilities of
Government Agencies, Section 6.B.3 “Provide Pre-Exposure Treatment to
high-risk

73
personnel, such as, but not limited to, laboratory staff, veterinarians, animal
handlers, vaccinators and other persons working with Rabies virus for free.”

For consistency, sustainability and support to the limited pre-exposure prophylaxis

provided to vaccinators, it
is recommended that
the hired or volunteer vaccinators
trained and vaccinated with PrEP be the same vaccinators for
at least 3 years.

Conduct of vaccination

A. Approaches in Mass dog vaccination

ee
il. Comprehensive approach
This is done in areas where rabies is endemic, there is high human-
animal population density and where LGUs are active in the
implementation of the rabies program. The goal of this approach
vaccinate all dogs in the community and establish herd immunity.
is to

Risk-based Approach to Mass Dog Vaccination (as developed

with the STANDZ Rabies Project)

This strategic approach takes into consideration the existing rabies risk
when planning for Mass Dog Vaccination to prioritize areas where most
urgent interventions will be needed to effectively interrupt rabies virus
circulation. This approach aims to reduce the overall infection pressure
within the shortest period possible, and maximized available resources
which are often limited. This will allow implementation bodies to
optimize limited human resources and funds, and strategically address
the disease at source, while taking into consideration that proactive
vaccination remains to be critical action needed to eliminate the
disease in the population.

74
 The following are the step-by-step procedure in risk-based approach to
mass dog vaccination: :

i. Classify sub-national components (e.g. Provinces)

Some countries in South-East Asia, like Philippines and Thailand,

have policies in place to declare rabies-free zones within the
country. There are no mechanisms however, to classify areas
where rabies is known to be present. While it is recognized that
all areas, regardless of status, will need appropriate actions in
place to achieve rabies elimination, classification of areas by risk
will help place resources where this will have the most impact in
the process of elimination. This classification will also help draw
political support from local government units which can possibly
expedite implementation of interventions where these will be
most needed.

Does
the Province satisfy the
requirements set out for rables-free
zones (see NRPCC Manual of Procedures)

Does the Province report confirmed

animal rabies cases reguta ry?
(almost monthly)

Does the Province submit samples for

rables testing regularly?
(almost menthly or 2.02% of dog pop’n)

a ieumicdg
Elst] Does the Province have human
YES
tables cases?

\s the % positive of these

submission greater than the
national average?

Does the Province have at least

Pree
rr) 70% vaccination coverage?

Reed 9

“LOW-RISK
HIGH
areas with at least one
RISK will automatically
neighbor

be classified as
province classified as
MEDIUM-RISK,
Rts
area ‘i

Eiaiira 1 Sehamatir far cataoonrizing laval af rahiac rick in culh_natinnal eamnanante

75
Figure | shows the schematic diagram for categorizing level of
rabies risk in sub-national components. Each question
corresponds to the next question or answer on what level of risk
that province/area will be classified into.

The objective of high-risk areas will be to reduce rabies

circulation in their area of jurisdiction and work towards
becoming medium- or low-risk areas within 2-3 years. The
objective of medium-risk areas is to identify and address the
remaining problem areas in their area of jurisdiction, and work
towards becoming a low-risk area or become a candidate for
rabies freedom within 2-3 years. The objective of low-risk
areas is to sustain low to zero rabies incidence in their area of
jurisdiction, and work towards declaring freedom within 2-3
years. To achieve these objectives, respective areas will need to
plan and implement interventions following the STOP strategy
(sociocultural, technical, organizational, and political) in
accordance to their standing needs. For example, while high-risk
areas will need to focus on rabies risk reduction, medium-risk
areas might decide to focus on improving surveillance and low risk
areas will work on enhancing dog movement control to prevent
intrusion.

Regardless of the status, areas with limited resources should plan

and implement a risk based approach to MDV where mass
vaccination is deemed necessary. The level of surveillance should
be continually improved, and in the light of changes and progress
following interventions, status should also be continually reviewed
on an annual basis (eg., every Rabies Awareness Month or during
the annual World Rabies Day celebration).

Risk Characterization

Determine the likelihood of rabies virus circulation

Quality surveillance is critical in determining where rabies virus

circulates. As there are no existing laboratory tools to determine
the presence of the infection, tracking rabies events in animals
would be the closest surrogate measure for detecting presence of
virus in the population. Classification of level of certainty of rabies
virus circulation will thus be based with consideration of the
likelihood of rabies case(s) existence in the area as indicated by:
(1) presence of actual dog rabies cases as well as (2) absence of
vaccination or low coverage. Although not
ideal, in situations where animal rabies surveillance is sub-optimal,
(3) human rabies cases can also be an alternate indicator. The long
duration of incubation period however, will need to be taken into
consideration (ie., by the time a human case is detected, the
animal source would have been long dead and removed from the

76
 population). The breadth of reach of infected dogs, particularly for
the free-roaming, should also be taken into account when
assessing an area.

To estimate the level of certainty of rabies of rabies virus

circulation in the area under consideration, Table | below can be
used as a guideline. Ideally, joint assessment of areas under
investigation should be done with inputs from stakeholders if
possible. Because while the descriptions below can facilitate
objective estimation, ultimately, decision will have to be drawn
from the intelligent judgement and internal understanding of the
area’s rabies situation by the local health and animal health
authorities, its local leaders and its
residents.

Table |. Estimating level of certainty that rabies is circulating in the area under evaluation

Animal rabies situation: The area has a

-
confirmed*
or probable* dog rabies
__
case reported in the last few weeks - the area has at least one case
OR nearly every
month in last year
the

Status of vaccination coverage: The area has a very low rabies vaccination
Almost certain ____
coverage in the last 2 years (<40%)
____
Human rabies situation: Reported human rabies cases is greater than the
national average - OR - recorded animal bite cases/patients receiving PEP is greater
than the national average

____
Animal rabies situation: Known to consistently occur but official data is
unclear and shows sporadic pattern because the area has no to very few animal
samples submitted
____
Status of vaccination coverage: The area has a low to moderate vaccination
Highly likely coverage inthe last 2 years (<70%)
Human rabies situation: Reported human rabies cases is greater than the
____
national average - OR — recorded animal bite cases/patients receiving PEP is greater
than the national average

___ Animal rabies situation:

Known to consistently occur but official data is
unclear and shows sporadic
pattern because the area has no to very few animal samples submitted
____
Status of vaccination coverage: The area has a moderate to low vaccination
Likely coverage in the last 2 years
(<70%)
Human rabies situation: Reported human rabies cases is about or lower than
__.
the national average, as
well as the recorded animal bite cases / patients: receiving PEP

____
Animal rabies situation: Animal rabies
policies on stray and roaming
is not known
to occur in the area and
dogsare in place.

Unlikely” ____
Status of vaccination coverage: The area has at least >70% vaccination
coverage in last 2 years.
the

____
Human rabies situation: There is no human rabies case reported in last 2
the

years,

77
 ___
Animal rabies situation: Animal rabies is not known to occur in the area and
policies on stray and roaming
dogsare in place; there is also ‘an ongoing negative surveillance (suspect animal
samples are regularly
submitted, all of which are confirmed:negative)
___ Status of vaccination coverage: The area has at least 70% vaccination
coverage in the last 2 years.
Human rabies situation: There is no human rabies case reported in the last 2
____
years average, as well as the
recorded animal bite cases / patients receiving PEP

iii. Determine the potential impact if action is not taken

The potential consequences or impact of non-vaccination also

need to be considered when prioritizing areas. Areas that has the
potential to have severe consequences once infection enters (eg.,
rapid transmission, higher probability to infect more dogs, and
higher probability to infect more humans and cause mortality due
to limited access to post-exposure prophylaxis) will need to be
dealt more urgently than those where consequences could less be

severe — that is, if resources are limited.

Some indicators that could be considered to approximate

potential impact include: human population density, where dense
population could mean higher dog population density and closer
human-dog interaction; dog movement, where dog movement
not controlled, consequence of infection will be more severe as
is
further spread of the disease is more likely; access to post-
exposure prophylaxis for dog bite victims, where there is limited
or no access to post-exposure treatment due to location or
degree of poverty, consequences of exposure could be more
severe as this could mean equivalence to guaranteed mortality in
the infected human.

To estimate the level of consequences or impact of non-

vaccination, Table 2 below can be used as a guideline. This will
rely largely on availability of accurate demographic data of the
area, and understanding of the local dog ecology.

Table 2. Estimating level of consequences or impact of non-vaccination

Human population density is higher than the national average

___.
___-Dog population and movement is not controlled
Severe Post-exposure for is not easily accessible to residents
'_

prophylaxis humans
___.
___ Highly depressed areas (eg., 4th to 6th
class local government units)

78
 ____ Population
density is higher than the national average
____
Dog population and movement may or may not be controlled
Major is accessible post-exposure prophylaxis for humans
___ There
____ Highly depressed areas
(eg., 4th to 6th class local government units)

____ Population
density is about or. lower than the national average

Moderate _.
___.
Dog population and movement may or may not be controlled
There is accessible post-exposure prophylaxis for-humans
_*
“Area
is
classified atleast as a 3rd class local government unit or higher

Population density is lower than the national average

___
____ Dog population
and movement is
reasonably controlled
Minor
____
There
is
accessible post-exposure prophylaxis for humans
____
Area
is
classified at least as a 3rd class local government unit or higher

Population density is lower the national average

Dog population movement iswell under control
There
is accessible post-exposure prophylaxis. for humans
Area
isclassified at least as a 3rd class local government unit or higher

iv. Rapid Risk Assessment and determination of vaccination

approach inaccordance with the assessed risk

Once the area(s) of interest has been assessed for likelihood of

rabies virus circulation and potential impact of non-vaccination,
the findings can be merged and the level of priority determined
using the assessment matrix (Figure 2 below). The corresponding
actions according to the level of priority is also outlined in Table
3.

Figure 2. Assessment Matrix for Prioritizing Vaccination Initiatives

Almost Priority
certain 3

circulation

virus

rabies

of
Unlikely Priority Priority
3 3

Likelihood

Very Priority | Priority

unlikely 3 2

Minimal Moderate Major Severe

Level of consequence or impact of non-vaccination

v. Implement actions in accordance

risk assessment findings
to the prioritization based on

79
Table 3. Vaccination approach according
to level of priority
Priority Level Description
Mass dog vaccination should be done immediately and rapidly (Start as soon ”

as possible and finish within 2-3 weeks, depending on the size of the area)
Mass dog vaccination can bedone simultaneously or after all Priority |
Priority 2 areas are completed, depending on the number of
available manpower and
resources
Mass dog vaccination can bedone simultaneously or after all Priority 2
Priority 3 areas are completed, depending on the number of available manpower and
resources
Mass dog vaccination can be done simultaneously or after all Priority 3

ee
ea areas are completed, depending on the number
resources
of
available manpower and

vi. Quick Response

This is done when a human or a confirmed canine case is first

reported or in cases of incursions. Backed up by adequate
investigation on the animal case and vaccination history, this shall
cover vaccination of all dogs within 3 km radius then followed by
active surveillance to monitor the possible recurrence of disease

1.1.6. Strategies in Vaccination

A. Fixed post or station

This is conducted in well recognized sites in the barangay and done when there
is lack in manpower. Dog owners bring their dogs in the designated stations.
This is highly dependent on the information drive and the availability of the dog
owners
turnout.
to
have their pets vaccinated. This could result to a low vaccination

B. Mobile or house to house

This done when there
is
is
sufficient manpower to conduct the activity. This
requires more effort, costly and logistically difficult. But this is a good method to
cover most the population.
of

C. Combination

Socio-cultural factors may affect the strategies in vaccination. In most cases, a

combination of fixed post and house to house strategies are employed when
there is enough manpower and resources to do mass vaccination activity to
cover at least 70% of the population.

80
1.1.7. Vaccination day

A. Time of vaccination
Vaccination activity is preferably done during the day. Depending on the
strategy, the team may optto in
do it in the morning or
the safety of the vaccination team is also considered.
the afternoon as long as

Animals for vaccination (please see target population under Mass Dog
Registration and Vaccination)

Duration of vaccination

The prescribed duration for vaccination in a barangay or village must be |-3

days depending on the land area and population density. However, the entire
province should be covered in | to 3 months or as short as possible for the
vaccination strategy to be effective.

Vaccine handling and transport to vaccination site

The vaccine handler must be well informed of the dos and don'ts of vaccine
handling and management (cold chain management). The vaccine must be stored
properly and keptin its proper temperature until the time of administration to
preserve its potency.

Handling of animals for vaccination

Dogs and other animals with owner

e Instruct the pet owner to restrain the dog by carrying the dog with one
hand underthe neck and the other underits abdomen (see Figure 2).
Figure 2. Proper way of holding the dog for vaccination

Ifthe dog is unmanageable, have the pet owner restrain the dog by
holding its head between their legs leaving the dog’s back free (see
Figure 3).

Figure 3. Another way

of restraining the dog for vaccination
Ifthe If the dog seems to bite, tie its mouth shut with plastic twine or
straw by tying around the dog’ snout and tying the loose ends separately
behind the ears (see Figure 4).

Figure 4. Temporary muzzle

82
 B. Free roaming dogs

Free roaming dogs may be difficult to catch or handle by hand. In these

situations, a catching net may be used
activity (see Figure 5).
to assist the vaccinating team for this

Key points to keep in mind when using the catching nets:

Plan before you begin
Use teamwork with one coordinator and one provocateur
First check that there are no surprise exits. If the dog has an owner, ask
them where it is likely to run
Do not allow the dog to run onto a busy road
Work quickly and silently or the dog will become suspicious and may
panic — you will only have | chance
Always allow the dog
to run into the net

Figure 5. Vaccination through the use of catching net

|. Tagging and Identification

Vaccinated dogs must be properly identified. A dog tag or collar must be provided so
that during post vaccination monitoring, vaccinated dogs must be easily identified.
However, not all LGUs have the capability to provide this. As an alternative, spray paint
or animal color marker can be used as identification.
2. Recording
Vaccination form must be completely filled up during vaccination activity and must be
collected after for proper inclusion in the database (Refer to Mass Dog Vaccination
Form). A certificate of vaccination must be accomplished and given to the dog owner as
proof of vaccination.

83
1.1.9. Allotment of vaccines
A. Basis for vaccine allotments

Vaccine allotment isprimarily based on the estimated population, on an equal

percentage basis. Special considerations are given to areas with most cases of human
and animal rabies, known as high risk areas. If provided with a comprehensive
vaccination plan, a Memorandum of Agreement signifying a full commitment of local
chief executive, or a government-private project, vaccines may be given fully to
support the program or mini projects.

B. Timely submission of utilization reports

LGUs that liquidate and send their reports immediately are given opportunity to get
more vaccines.

1.1.10. Distribution of vaccines

A. Vaccine allocation

*
Computed vaccine allocation per region will be released through the
Regional Rabies Coordinator of each DA-RFO. The RRC will be responsible
for the distribution of vaccines per province and city.
* General requirements must be complied by the LGU before the
release of
vaccines.
* For NCR Cities, the request and release of vaccines are made directly by
the City Veterinarian in BAI.

B. Buffer stock

* A buffer stock is maintained by BAI every vaccine tranche delivery. This is

utilized during an emergency situation, committed projects, and any
situation that obligates the need for vaccine.

C. Delivery of vaccines to the Regions and LGUs

Acquisition of vaccines can be made by directly getting the allotted or the

requested vaccines at the Bureau of Animal Industry. Vaccines are released
when
transport box and coolants are provided.
In cases where the recipient is from a distant area, vaccines can be delivered
through a courier or hired forwarders. However, payment for freight charges
must be made by
the
requesting party.

84
 D. Reporting of utilized vaccines

MS. Excel and

All reports (PhiIAHIS or summary of vaccination report (see
Summary of Vaccination Report form) up to the barangay/village level) from the
LGUs (PVO and CVO) must be submitted to the DA-RFO through the RRC.
RRC will collate all reports and a summary will be submitted to the BAI every
quarter.

1.1.11. Post-Vaccination Assessment

Monitoring is an important component of

every mass vaccination activity.
Hitting 70% target coverage is
essential in establishing herd immunity.
Monitoring can be done by third party random evaluation:

e Computing the vaccination percentage reflected after vaccination

activity
Random survey of marked vaccinated dogs
Interview surveys
Serology
Outcome Evaluation of the vaccination program
Revaccination must be done if
the turnout is less than 70%.

1.1.12. Effectivity of vaccination

Effectivity of the program is known when cases have been zero out.

1.2. Dog Population Management

Dog population management (DPM) is

implemented in compliance with the policy of the
Anti-Rabies Act of 2007 and the Animal Welfare Act. Partnerships are established with
other animal welfare organizations to improve dog population management practices to
comply with recommended international standards.

DPM coupled with education on responsible pet ownership, legislative leashing

measures, mandatory registrations are good measures to maintain a health dog
population. At present, LGUs manage the dog population selective elimination of
by

captured stray dogs, impounded dogs unclaimed within three days, and unmanageable
dogs voluntarily submitted by owners.

1.2.1. Stray Dog Management

Stray dog management is

an integral part of disease control. While dogs have
been recognized as a source of rabies in domestic, it
is important that
movement ofdogs must be controlled. Stray dog is defined as any dog leaving its
owner’s place and no longer under effective control of its owner.

85
 . Strict enforcement of penalties and fines
Section 10 of RA 9482 mandates the need to control and minimize unwanted
stray dogs to eradicate rabies. Penalties are imposed to violators. See RA 9482.

° Impounding
Pursuant it
to Section 7 of the RA 9482, is the duty of the LGU to enforce dog
impounding activities and field contro! to eliminate stray dogs. Furthermore,
Local Government Code mandates that LGU must also control stray animals,
not only dogs. As prescribed by the law, cities and first class municipalities
should establish and maintain a dog pound where impounded dogs must be kept.
Other class of municipalities may opt to share the expenses ofestablishing and
maintaining a dog pound with adjoining municipalities or other private animal
shelters and control facilities.

In establishing a dog pound, plan must be carefully evaluated and should register
and comply and with animal welfare requirements. See AO on Dog Pound.

1.2.2. Ways of capturing a stray dog:

Catching a dog by hand. This is done for friendly dogs by trained personnel. This
isnot used in aggressive dogs and suspect rabid dogs.
Dog capture using equipment
Using baits
Catching dogs in confined areas
Catching dogs using nets

> Key Points on Dog Catching

The team should inform the community the reason for dog capture.
Target roaming/ outdoor dogs aspriority
Catching a dog requires coordination between team members.
The team should know how the dog would like to react during capture.
Once thedog has been caught, transfer the dog immediately to the cage.

Precautions:

Avoid getting bitten!

e All staff involved in dog catching and impounding
activities should have
complete course of pre-exposure vaccinations
e Anyone bitten or scratched should wash the wound immediately under
running water for 15 minutes with soap, then disinfect with ethanol or
iodine
if
available, and immediately go to the nearest hospital or bite
treatment center for an assessment
needed
if
post-exposure rabies vaccination is
e dogs are observed
If to show potential signs of rabies, inform the
veterinarian.

86
 1.2.3. Spaying and Castration

Spaying neutering activities are being implemented at the LGU level. Such
initiatives will be collaborated with NGOs and private clinics. It is recommended
to prioritize spaying and castration to free roaming animals.

A. Surgical sterilization by Spaying and Castration

The most effective reproductive control is by surgical sterilization. This

procedure is done using anesthesia, thus, needing a trained personnel,
infrastructure and equipment to execute. Pain should also be managed after
operation. Only licensed veterinarians are allowed to this procedure.

The conduct of spaying and castration activities at the LGU level may be
collaborated with NGOs and private clinics.

B. Non-surgical methods of dog population control

Isolation of females in heat or estrus is the most non-invasive and inexpensive
way of controlling the dog population. However, this requires separate cages for
male and female dogs in the household.

Chemica! sterilization or contraception is now under research.

C. Habitat control

The main driver of this technique is the community. With proper awareness of
garbage disposal, dogs may leave no option of looking for food at the streets.
Underthe Sanitation Code, all wastes must be disposed properly.

1.3. Dog Movement Control/ Management

Cross border movement requires certificate of vaccination, health certificate and

shipping permit.

1.3.1. Inter-provincial and inter-island movement control

Quarantine and border control is being implemented at the provincial level. For
transporting dogs to other provinces or from mainland to an island, the
following are needed:
o Health certificate duly signed by a licensed veterinarian
o Valid vaccination certificate(1 year validity) duly signed by a licensed
veterinarian
o Shipping permit issued by the National Veterinary Quarantine Services (7
days validity)

87
 1.3.2. International Dog Movement

For movement of dogs in and out of the country, the following must be
complied:

o For import

e Veterinary Quarantine Clearance to import issued by BAI

e Rabies Vaccination Certificate issued by country of origin
e Strict quarantine for 30 days in the owner’s premises is a requirement

o For export

e BAI Health certificate / Export Commodity Clearance

e Veterinary Health Certificate and Vaccination Certificate duly signed by
a private Veterinarian
e Test results of serum submitted for antibody detection in laboratories
specified by the recipient country (depending on the recipient country)

1.4. Roles and Functions of DA and LGU Veterinary Personnel

1.4.1. DA-RFU Regional Coordinators

all
Initiate and coordinate rabies control activities in the provinces/
cities/municipalities;
Prepare the yearly regional action plan;
Disseminate program information, guidelines, E.O. to all provincial/city/municipal
coordinators;
Allocate/distribute vaccines from central office (BAI) to the different
provinces/cities/municipalities;
Ensure proper cold storage of vaccines;
Ensure availability of vaccines for the campaign;
Monitor vaccine utilization;
Consolidate reports from the different provincial coordinator and submit to the
central office;
Monitor the implementation of dog ordinance and dog pound in the Provinces;
Assist the province in overseeing the implementation; and
Collect empty/used vaccine vials from the provinces and ensure proper disposal
(burning/burying) at the Regional Office or at the Bureau of Animal Industry.

88
 1.4.2. Provincial Coordinator (Provincial Veterinarian)

Prepare yearly provincial action plans and submit to the regional level for
consolidation;
Provide actual dog survey and other monitoring data to the regional
coordinator;
Allocate and distribute vaccine to the different municipalities;
Provide and ensure cold storage for vaccines;
Monitor proper vaccine utilization during vaccination campaign;
Assist in training vaccinators during mass immunization;
Monitor proper implementation of rabies ordinance and dog control measures
in all municipalities;

Organize rabies control committees in

all cities/municipalities;
Initiate and coordinate all rabies control activities in the cities/municipalities
Consolidate reports of vaccination to be submitted to the regional coordinator;
and
Collect used vaccine vials and return it to the regional coordinator for proper
disposal.

1.4.3. Municipal/City Coordinator (City/Municipal

Veterinarian/Agriculturist)

Coordinate all rabies control activities to other agencies in the local

government unit;
Provide dog population survey to update provincial data;
Receive vaccine allocation from the provincial coordinator for dog vaccination
at the barangay level;
Ensure proper implementation of the rabies ordinance, dog pound and stray dog
control;
Consolidate report of vaccination for submission to the provincial coordinator;
Ensure cold storage of dog vaccine and provide vaccine container (styrofoam) to
maintain and ensure temperature requirement while vaccinating in the area;
Provide mobility for vaccinators during campaign; and
Collect used vaccine vials and return it to the regional coordinator through the
provincial coordinator for proper disposal.

89
Chapter IV. Surveillance of Animal Rabies
1. Surveillance of Animal Rabies

Rabies is a notifiable disease both in the national health and veterinary systems in the Philippines.
Surveillance of canine rabies and submission of laboratory reports of suspected cases essential for is
management of
potential human exposures and for veterinarians to adopt appropriate measures
towards animals who were in contact with the suspected animal case.

I.1. Recognition of Rabies in Dogs

The following are the defined classification of an animal Rabies Case:

Suspect Case Probable Case Confirmed Case

I, An animal that may show any !. Asuspect case with known Any suspect or probable case
of the following clinical signs: exposure to a confirmed rabies confirmed positive for rabies virus
e Sudden behavioral change (e.g. case antigen using Internationally
sudden anorexia, signs of 2. A suspect case that dies within accepted gold standard test such as
apprehension or nervousness, the observation period (14 days Fluorescent Antibody Test
irritability, hypersensitivity) from the time of bite) but no
Hydrophobia laboratory confirmation
Muscle paralysis
Nervous signs
2. An animal involved in a biting
incident

1.2. Data Sources in Capturing the Suspect and Confirmed Cases

Clinical-surveillance based: suspect and probable cases

° Event-based surveillance: news items, rumors, 9| 1, social media, individual messages from
veterinarians, physicians, etc.
° Indicator-based surveillance: routine reports from veterinary laboratory; regular rabies
reports from LGU veterinarians; DOH rabies alerts, ABTCs
—

1.3. Notification
If a suspect or probable animal case dies within the 14 days observation period:
*
Report immediately to the nearest local veterinarian or trained personnel on animal
disease control from the local government unit (ex. barangay/municipal agricultural
office/provincial or city veterinary office).
* The local veterinarian or trained personnel should be informed and should be the one

to supervise/ carry out handling and preparation of the dog specimen for laboratory
confirmation.
* Submit the animal head or carcass for laboratory confirmation of rabies (See Annex for
the list of laboratories and rabies submission form)

90
1.4. Preparation/Handling and Packing of Animal Specimen for Rabies Diagnosis

The animal specimen should preferably be collected by a veterinarian in clinic in order to assure that
the precautionary safety measures in handling potentially infectious materials are strictly followed.
The basic personal protective equipment (PPE) includes a laboratory gown, examination gloves, face
masks and shields and disinfectant for decontamination.

In the household setting, a clean table or bench is needed for the decapitation of the animal. The
following procedures should be followed:

1) The handler should use gloves or wrap their hands with plastic bags to prevent direct
contact with the specimen.
2) Eye protection such as optical glasses should be used to prevent any tissue splatter on the
eyes.
3) An ordinary butcher’s knife or bolo may be used to cut the animal’s head.
4) The head should be cut two (2) inches away from the base in order to include important
tissue components of the brainstem. Dispose the carcass after decapitation by burying or
cremation.
5) No attempt should be made
risk to the processor
to extract the brain tissue because this would cause additional
6) Place the head of the anima in a leak-proof double household plastic bag. This constitutes
the primary container.
7) Do
not put any ice cubes inside
this primary container.
8) No chemical preservative formalin or alcohol should be used as this will render the
like 10%
specimens inappropriate for examination.
9) Utensils/ Instruments, clothing and table used in decapitating the specimen should be
properly and thoroughly cleaned and disinfected with commercially available household
bleaching agent.

1.5. Storage of Animal Specimen before Transport

e Place the primary container into another household plastic bag (secondary container) with
liberal amounts of ice, enough to sustain the cold temperature during transport to the
laboratory.
e The two containers must be placed in a styrofoam box or any leak-proof transport
container and brought to the nearest rabies diagnostic laboratory.
e Label the transport container as “Rabies Suspect”. Affix label with the complete name,
address and phone number of
both the shipper and the laboratory recipient. The head
specimen must sealed
be in a plastic bag and labelled “Handle with Care: Rabies Suspect”.
¢ A fully accomplished Rabies Submission Form should accompany the sample, available in the
BAI website or the nearest accredited rabies laboratory.
e The specimen should be brought to the laboratory immediately and at most within 6 to 8
if
hours post-mortem. However, this is not possible, it should be frozen or stored inside a
leak-proof Styrofoam or ice box container. Add plenty of ice packs into the container to
allow overnight cold storage. Replenish the ice/ice packs as often as needed until is it
transported to the laboratory.

91
 1.6. Specimen Transport

During transport, the specimen should be packed with ice to preserve it.The specimen may be sent
thru air freight or hand carried to the accredited diagnostic laboratories.

1.7. Disposal of Carcass/Disinfection

Dispose the carcass by burying or cremation. Disinfect the working area with commercially available
10% household bleach or 3% Lysol. Consumption of the specimen’s meat is prohibited.

1.8. Laboratory Diagnosis of Rabies in Dogs and Other Animal

The diagnosis of animal rabies is based on laboratory confirmation. Fluorescent Antibody Test (FAT)
is the gold standard for laboratory diagnosis for animal rabies. Direct Microscopic Examination
(DME) is also done, but this is further confirmed by FAT. Please see Annex ___ for the list of
laboratories and available tests.

1.9. Results of Laboratory Examination

A. The diagnostic laboratory should release the results of the examination to the sender of the
specimen immediately.
B. For positive samples, the responsible laboratory should immediately notify the following:
a. Concerned LGU
b. Concerned Regional DA Office cc’d with concerned Regional DOH Office
c. BAl—-AHWD
C. For results of all tested samples, the responsible laboratory should submit a monthly report
to the BAI-ADDRL, who will provide a collated copy to the BAI-AHWD.

1.10. Quality Assurance and Accreditation

A. Regular Proficiency Testing
B. Infrastructure and logistics
C. Capacity Building
D. Minimum International Standards

. Outbreak Response
The main goal in any disease outbreak is to control the spread of the disease. Rabies can spread very
quickly in the dog population through dog bites and will eventually be transmitted to humans.

The control strategies chosen should: (1) protect public and animal health; (2) minimize animal
welfare problems; (3) cause the least possible disruption to local communities, the tourism industry
and visitors; (4) minimize the burden to the public and (5) minimize damage to the environment.

92
2.1. Handling of Dogs and Cats confirmed/Suspected to be Rabid

The management of cases of domestic animals exposed to rabies can difficult because of the lack
be

of immediate perceived threat to human life. The exposure incident obviously could later result in
human exposure if the domestic animal would develop rabies.

Healthy dogs and cats that bite a person should be confined and observed for 14 days. It
is
recommended that rabies vaccine be not administered during the observation period. Such
animal should be evaluated by a veterinarian at the first sign of illness during confinement.
Any illness in the animals should be reported immediately to the local veterinary
department. If signs suggestive of rabies develop, the animal should be euthanized, its head
should be cut off and place in a sealed styrofoam under refrigeration for examination at the
diagnostic laboratory.

Other biting animals, which might have exposed a person to rabies, should be reported
immediately to the local veterinarian and health authority.

Management of animals other thanin dogs and cats, depends on animal

the species, circumstances of
the bite, epidemiology of rabies the area, and the biting history, current health
status and potential for exposure to rabies.

2.3.1. NATIONAL OFFICE (DA-BAIl)

Policy making, memos, Administrative Orders

Provide vaccine support through DA-RFOs
Train Regional Field Persons/LGU Depending on the requirement)
Notify RRCs when ESR
Test head samples /
is received from DoH
PERFORM confirmatory tests
Develop and distribute IEC materials and other support through DA RFOs
Coordinate or share info on rabies in animals in DPCB (Disease Prevention and
Control Bureau)
e Coordinate with other NRPCC Control Bureau (DILG, DOH, DepEd, Private
sector, etc.)
Provide laboratory support to RADDLs
e Perform epidemiological analysis of rabies cases for planning.

‘ee Add requirements for the request of vaccines — guidelines on vaccine requisition,
utilization and reporting
*** Add discussion on Outbreak Investigation form

93
3. SUPPORTIVE COMPONENTS
3.1. Human Rabies Surveillance and Response

Human Rabies surveillance is a systemic collection, analysis and interpretation of data for public health
action. In order for responsible authorities to provide interventions for control and elimination, timely
dissemination of data is very important. This will guide the human and animal health sectors in making
decisions for:
*
interventions for control and reduction of infection transmission
*
provisions of post exposure prophylaxis (PEP) in potentially exposed humans
*
management ofpotentially exposed animals

Rabies surveillance is
done through the Philippine Integrated Disease Surveillance and Response (PIDSR)
by the DOH Epidemiology Bureau (DOH EB) at
the national level. Under PIDSR, dedicated staff from
the Epidemiology & Surveillance Units (ESUs) of the regional, provincial, city & municipal levels
implement the PIDSR.

Human Rabies is
classified by PIDSR as category I, which is an immediately notifiable disease and must
be reported within 24 hours.

For Animal Rabies, the National Animal Disease Diagnostic Laboratory (NADDL) was established to
confirm rabies in animals as part of the surveillance of the Department Of Agriculture.

3.1.1. Case Definition

It is veryimportant for rabies that the same case definition be used in and by all reporting units. This is
to ensure a consistent and accurate identification of rabies cases throughout the system. Cases are
further classified to indicate whether they are suspect, probable or confirmed:

*
Suspect — Indicative clinical picture without being a confirmed or probable case
¢ Probable — Clear clinical picture, or linked epidemiologically to a confirmed case (Note: A
"case with an epidemiological link" is a case that has either been exposed to a confirmed case, or
has had the same exposure as a confirmed case (e.g., history of exposure to animal suspected
with rabies)
*
Confirmed - Verified by laboratory analysis

Case definition for rabies requires laboratory confirmation based on a positive result for the direct
fluorescent antibody test (FAT). Table below is a guide to determining whether
probable or confirmed:
a
case is suspected,

94
 Table No Classification of a Human Rabies Case
Suspected Probable Confirmed
A person presenting with an A suspected case plus history of A suspected case that is
acute neurological syndrome contact with suspected rabid laboratory confirmed
(encephalitis) dominated by animal.
forms of hyperactivity (furious
rabies) or paralytic syndromes
(dumb rabies) that progresses
towards coma and death,
usually by respiratory failure,
within 7 to 10 days after the
first symptom if no intensive
care is instituted.
Note: Bites or scratches from a suspected animal can usually be traced back in the patient medical history.
The incubation period may vary from days to years but usually falls between 30 and 90 days

3.1.2, Reporting and Notification

of Rabies

Rabies is considered by the PIDSR as an cum

immediately notifiable disease and should be Community

reported simultaneously to the PHO/ PESU, | |

CHD/RESU and NEC within 24 hours of Barangty Heath Barangay Heath

detection by the fastest means possible. J

Initial reporting can be done using the
Cases from moavean
ural Heal

telephone or radiophone, or written via [focstnorstas Heath

Oee
ae or email. It will be followed by
facsimile . . airports hon-cha
cities

!
case-based reporting form using the
standard PIDSR case investigation form.
. . .
‘Cases from in
“tnd Sureance,
aan
tsechs,

|
a
Epidemiology and

pes)
[stevincia
fale, ports, chartered eles sirports
Reports received by the NEC will be
,
ports

reported to World Health Organization

possibly within 24 hours also.
|
sain
“Peurveltence
Units (RESU)
ae
petuinat be
pitals, ports,
alrports
J
referral noapis
National
fea port, a ocenter
Flow of weekly reporting of notifiable ports

diseases
Any person in the community or in
a health facility attending to a suspect rabies case should report to
the next higher level authority (MHO/PHO/ PESU and ROV) within 24 hours by the fastest means
possible. Report may be done by telephone, facsimile or email.

Once PIDSR detects human rabies outbreak, response will be conducted with the ESUs
in coordination
with theDA, following the response protocol of PIDSR.

Human rabies surveillance should be the basis for the DA to initiate their outbreak response.

95
—
3.2. Data Sources in Capturing the Suspect and Confirmed Cases

The following may be referred to as data sources in capturing both suspect and confirmed cases:

* Clinical-surveillance based: suspect and probable cases

* Event-based surveillance: news items, rumors, 911, social media, individual messages from
veterinarians, physicians, etc.
* Indicator-based surveillance: routine reports from veterinary laboratory; regular rabies reports
from LGU veterinarians; DOH rabies alerts, ABTCs

4. OUTBREAK RESPONSE

The main goal in any disease outbreak is to control the spread of the disease. Rabies can spread very
quickly in the dog population through dog bites and will eventually be transmitted to humans.

The control strategies chosen should: (1) protect public and animal health; (2) minimize animal welfare
problems; (3) cause the least possible disruption to local communities, the tourism industry and visitors;
(4) minimize the burden
to
the public and (5) minimize damage to the environment.

4.2. Trigger Points for Rabies Outbreak Response

¢ Dog showing rabies symptoms
e Dog that died of rabies or died with no known cause
¢ Dog involved in an unprovoked biting case
e Laboratory —confirmation of animal rabies
e Human Rabies case

CHAPTER V. HEALTH PROMOTION AND ADVOCACY

The NRPCP recognizes that raising awareness on rabies prevention, control and elimination is an
essential component in the overall rabies prevention strategy. Through a communication plan that
presents strategies and activities to heighten awareness about rabies, this section is intended to guide
implementers in adapting a strategic communication plan that would not only heighten awareness about
rabies prevention and control, but more importantly, drive the community to practice desired behaviors
on prevention and seek the most appropriate treatment at
their level

As the program gears towards a Rabies-Free Philippines, the NRPCP sees the need to intensify the
campaign on Responsible Pet Ownership (RA 9482). The proposed health promotion and
communication plan in this section outlines strategies and activities that involve consultation with
communities, health and allied services and all other stakeholders seen crucial to implement solutions.
The plan likewise
conveys that everyone has their part to play, and engaging all
stakeholders even at the
earlier stages of implementation is expected to help them take ownership of their part of the solution.
Hopefully, this will ensure that rabies prevention remains a priority with them well into the future.

96
The proposed plan adheres to the DOH health promotion process in five action areas, namely: by
building healthy public policy, creating supportive environment, strengthening community action,
developing personal skills and reorienting health services complemented with various approaches. These
approaches are advocacy, communication and social mobilization (ACSM), Communication for
Behaviour Impact (COMBI), Social Marketing and Risk Communication among others.

This chapter is designed to guide health care providers and other stakeholders in the planning and
implementation of their health promotion activities that will improve LGU, stakeholder and community
understanding of rabies and RA 9482; as well as improve health seeking behaviour on rabies
prevention — thus, ensure support for the National Rabies Prevention and Control Program.

The campaign’s overarching objective is to achieve a Rabies-free Philippines by 2020.

Specific objective/swere crafted for each identified target audience group, taking into account each
target audience’s knowledge level of rabies, capacity to act towards its prevention and control, access to
information and socio-cultural contexts. (Refer to proposed plan)

¢ The NRPCP, inclose coordination with all LGUs and allied agencies especially the DA-BAI shall
intensify health promotion activities of RA 9482 to complement all program efforts
¢ The NRPCP shall initiate the refinement of guidelines and assist in the proper implementation of
PhilHealth eligibility claims of bite victims (patient does not claim PHIC reimbursement) and
regulation of claims by animal bite treatment centers and animal bite centers (ABTCs/ ABCs)
¢ All involved agencies shall develop relevant IEC materials approved by the NRPCC and HEPO
* The DOH shall initiate integration of Rabies program into various allied partner programs:
o Level-appropriate Incorporation of rabies in the school curriculum in collaboration with
DepEd
© Joint conduct of mass dog vaccination including provision of annual booster doses with
K-9 corps of the AFP, PNP, BFP
o Sponsorship of mass dog vaccination and consistent information dissemination
(reminders) on RA 9482 among faith-based organizations at the communities
o Inclusion of RA 9482in all possible forums and channels for information dissemination

by media practitioners

I. STRATEGIES

1.1. Building Healthy Public Policy

It isimportant for health workers to realize that promotion goes beyond health care.
Promotion puts health on the agenda of policymakers in all sectors and at
all levels, leading them
towards being aware of the health consequences of
their decisions and accepting their
responsibilities for health.

.
97
 It requires advocacy for the development and issuance of the following policy instruments to
support health like laws, local resolutions and ordinances; executive orders, memorandum
circulars; administrative orders and memorandum of agreement.

1.2. Creating Supportive Environment

Creation of a supportive environment could be physical or organizational. Physical environment

can be improved or enhanced by making animal bite treatment centers more accessible to
clients. On the other hand, organizational environment can be the creation of coalitions,
networks and inter-agency committees to increase the number of people promoting particular
health actions where social mobilization is the major action to be undertaken.

1.3. Strengthening Community Action

Health promotion works through concrete, simultaneous and effective community action in
setting priorities, making decisions, planning strategies, and implementing them to eliminate
rabies in their respective areas. A concerted effort of the community is necessary in the,
prevention, surveillance and elimination of rabies. Likewise, initial gains of rabies free
provinces should be supported and sustained. Collective. Integrated approach.

1.4. Developing Personal Skills

In the prevention, surveillance and elimination of rabies, the need for developing
personal skills is very important. This can be done by enhancing the capability of health care
providers through interpersonal communications training, seminars, briefings/ orientation and
provision of IEC materials. Health promotion must be carried out in all possible opportunities
and places (e.g. home, school, market, etc.) by different concerned institutions or groups of
stakeholders given the mandates and the expertise.

1.5. Re-Orienting Health Services

The responsibility for health promotion in health services is shared among. individuals,
community, groups, health professionals, health service institutions, and governments. They
must work together towards a health care system which contributes to the pursuit of health.

The role of the health sector must move increasingly in a health promotion direction, beyond its
responsibility for providing preventive and curative services.

Health services need to embrace an expanded mandate that is sensitive and respective of the
cultural differences. This mandate should support the needs of individuals and communities for a
healthier life, and should open channels between the health sector and broader social, political,
economic, and physical environmental components.

98
 1.6. Strategic Activities

Elimination of rabies can be done through mass dog vaccinations highlighted in the
observance of two important national events namely:

e Celebration/Observance of Rabies Awareness Month - March

e Celebration/Observance of WORLD RABIES DAY — September 28

Conceptualization, production/ reproduction and distribution of IEC materials.

e Conduct (National) initiatives in the integration of Rabies Program:

a. DepEd — Implement K-12 Curriculum Integration of Rabies Prevention and Control.

b. DILG — Development of ordinance for Rabies prevention and control at the
Provincial, Municipal and Barangay Level.
c. DA-— Develop IEC materials on Responsible Pet Ownership, Rabies Transmission to
domesticated dogs, and quarantine measures in
collaboration with DENR.
d. Other Organizations
a. NGO's
i. International Organizations
ii. Local NGO’s
b. Animal Welfare Groups
c. Veterinary Organizations
i. Vets
ii. Animal Hospitals
d. Academe

2. Key Messages

With the intensified health promotion and communication campaign, the following are the key messages
for each identified target audience that will be highlighted:

2.1. Pet owners

e Bea responsible pet owner.
o Have your pet dog registered, vaccinated three (3) months old and yearly booster
doses while dog alive
is
o Deo not allow your pet
to roam the streets or any public place without a
leash
o Ensure your pets are properly fed and cared for
o As the (pet) owner, you are responsible for your pet’s bite victim’s treatment and
management; including all expenses to be incurred for treatment
o Should your pet bite a victim, it is your responsibility to ensure that your dog
is
properly confined during the 14-day observation period.
0 Itis also your responsibility to inform and consult the Municipal
Agricultural officer/ City veterinarian if your pet gets sick or died within

99
 the | 4-day observation period for proper sample submission to
designated laboratories for rabies confirmation.

2.2. Dog-bite Victim/Care giver

e Know and apply the proper bite wound management
© Proper wound washing with soap for 10 minutes in a flowing/ running water
o Immediately seek medical care from trained health providers in animal bite
treatment centers and/or animal bite centers and not from traditional healers/
tandoks to avoid further infection of the wound
e Continue and complete the prescribed vaccination dosages

2.3. LGUs/LCEs
e Support to rabies elimination is good investment for health
e Rabies is a 99.9% fatal disease but also 100% preventable
e RA 9482 should be immediately and properly implemented inall barangays

o Local Rabies Prevention and Control Committees have to be established and/or

revitalized for active surveillance and monitoring of dog movements (especially
stray)
Mass dog vaccination should be conducted regularly at specified times
© Provision of booster doses should also be given every year (after mass dog
vaccination)
2.4. Health Service Providers
e Rabies is a fatal disease/infection transmitted through an infected dog’s saliva
e Rabies is a preventable disease

e Dog
bite victims
should receive complete number and dosage of rabies vaccines
e Biting animal should be confined through caging or leashing and observe for 14 days for any
change in behavior and signs of rabies.

2.5. Animal Bite and Treatment Center/Animal Bite Center Health Providers
e ABTCs are sources of FREE rabies vaccines for human victims
e Warning signs to watch out for in a bite victim:
o Check other parts of the manual
e Warning signs to watch out for in suspected dog:
o Check other parts of the manual
e Continue and complete the prescribed vaccination dosages

2.6. Community/General public

e Basic information on Rabies as a disease, its prevention and control and elimination.
o Rabies is
a fatal disease/infection transmitted through an infected dog's saliva
e Basic information on proper management of human bite victims.

100
 o Thorough washing of bite wounds with soap and clean water and application of
antiseptic (povidone) are the first steps to prevent the spread of rabies
o It is best to seek immediate medical treatment from trained health service providers
rather than tandoks
e Basic information on how to manage/handle the biting animal
© Biting animal should be kept confined in a cage AND alive and given appropriate
care while being observed for |4 days
o Do not eat dog meat

2.7. Other stakeholders (Media, Faith-based Organizations, other GOs and NGOs)
e Rabies is
a fatal disease/infection transmitted through an infected dog’s saliva
e Rabies is a preventable disease

STRATEGIC HEALTH PROMOTION AND COMMUNICATION PLAN 2017-2020

Program Title: National Rabies Elimination Program

Behavioral Objectives:

By the end of 2020:

e 90% or more of pet owners are practicing responsible pet ownership

o Registration of all pet dogs including owned unleashed (any better term?) dogs.
o Vaccination of all pet dogs inthe first three months of each dog; and annual booster for
each dog while the dog
is alive
© Provision of proper care, grooming, shelter and management/control
o Assumption of responsibility for the care and treatment of dog bite victim including
medical expenses to be incurred
o Containment of dog for observation during possible incubation period (keeping dog
alive) of 14 days.
© Submission of dog head to DA animal laboratory of national, subnational level and those
LGUs with local animal diagnostic center or in RITM for animal rabies analysis and
confirmation
e Ideally, 90% or more of LGUs are supporting RA 9482 through the following:
o Conduct of proper mass dog vaccination and registration regularly
o Allocation of funds for the procurement for rabies vaccines for both humans and dogs
o Organization of a functional multi-sectoral Local Rabies Prevention and Control
Committee including budget for rabies
o Enforcement ofregulation on the treatment of
bite victims by tandoks
o Prohibition of the trade of dogs for dog meat
o Allocation of funds for health promotion and communication campaign that includes
reproduction and distribution of IEC materials and media air time
e Health care providers at the local health unit are providing information through IPC, community
assemblies and other available effective medium of communication on proper bite management
and always refer bite victims to ABTCs for PEP

.
101
Health care providers in animal bite and treatment centers (ABTCs) and animal bite centers
(ABCs) are complying with treatment protocols
Bite victims are practicing proper and immediate bite management
o Immediate proper washing of bite wound/s with soap and water
o Applying alcohol/povidone iodine and other antiseptic on the bite wound
o Seeking immediate medical advice and treatment at the ABTC or ABC.
All community stakeholders are supporting RA 9482
o Identifying and reporting stray dogs to designated office/unit (MVAO, CVAO, barangay?)
o Support implementation of campaigns on proper mass dog vaccination, including stray
dogs.
o Disseminating correct information on rabies (i.e., other GOs, media, church, PAWS,
in
NGOs present the area)
=
Dispel myths and misconceptions on rabies
=
as
LRPCC
target so that a multi-sectoral action can be implemented like the
municipal, city and provincial veterinary and agriculture

102
 Target Audience and Locus of
Year Key Messages Strategies/ Activities Tools
Communication Objective Responsibility
2017- Pet owners
2018 e To create awareness on Basic facts on rabies IEC development flyers, comics, e NRPCP
the basic facts of rabies Importance of mass Information dissemination Posters, e HPCP
(about the disease, signs dog vaccination for and popularization of RA billboards, radio,
and symptoms and dogs from 3 months 9482 through mass, social plugs, social
prevention) old and yearly and non-traditional media media- based
e To create awareness on booster doses for 3 vectors
their roles and years and while
alive
dog
is
responsibilities as dog
owners in compliance to
RA 9482
Dog
bite victim
e To educate bite victims on Basic facts on rabies IEC development flyers, comics, e NRPCP
the proper bite Proper bite wound Information dissemination Posters, e HPCP
management (washing with management and popularization of RA billboards, radio,
soap and water; application Continue and 9482 through mass, social plugs, social
of antiseptic; seeking complete the and non-traditional media media- based
immediate medical prescribed vectors
treatment) vaccination dosages
LGUs/LCEs/Barangay
e To reiterate LGU roles Basic facts on rabies IEC development Advocacy kit e NRPCP
and responsibilities in the Proper Building Healthy Public Approved local e HPCP
implementation of RA implementation of Policy ordinance/s e LGU (PIO,
9482 and other related mass dog vaccination Advocacy with DA and MHO
and
laws (RA 8485 and RA
7160)
should be conducted
regularly at specified
BAI on animal policy Mun
or
Vet)
City
component
To advocate for logistical times Strengthen partnership
support on the Active surveillance of with Phil. inter-agency
procurement of supplies rabies in dog Committee on Zoonosis

103
and provision of services population and (PhICZ)
for human and animal monitoring of dog Strengthen community
rabies movement action
To issue and implement Provision of booster o Revitalize and/or
additional ordinances doses every year organize the barangay
which include organization (after mass dog rabies elimination
of multi-sectoral LRPCC, vaccination) team
dog rabies surveillance Support to rabies Conduct of mass dog
monitoring of dog elimination is good vaccination
movement in the area, investment for health Observance of World
implementation of mass Rabies Day
dog vaccination and
elimination of rabies in
both animal and human
population.

104
 Target Audience and
Year Communication Key Messages Strategies/ Activities Tools Locus of
Responsibility
Objective
o as

2017- Health Care Providers

2018 (local health units)
To re-orient and update
HCPs on rabies and the
Rabies
is
a fatal
disease/infection
e Developing Personal Skills Updated training
module
NRPCP
e Reorienting Health Services
importance of: transmitted through
e providing proper bite an infected dog’s
wound management saliva

_
e recognizing what is Rabies
is a
preventable disease
the category the bite
.

wound
Dog
bite victims
:
should receive
e immediate referral to complete number
ABTCs/ABCs and dosage of rabies
e giving complete doses vaccines
of rabies vaccines to Biting animal should
be confined through
dog
bitevictims
caging or leashing
and observe for 14
days for any change
in behavior and signs
of rabies.
ABTC and ABC Provider
To educate providers on the
following: Warning signs to e Developing Personal Skills Updated training NRPCP
e Proper observation of watch out for in bite e Orientation modules
warning signs and victim o Reorienting Health
changes on bite Warning signs to
Services
victims
e Schedule of PEP
watch out for in
Need to observe suspected dog
biting animal, take Continue and
care and keep them complete the
confined or leashed
105
 during |4 days prescribed
incubation period vaccination dosages

Community or general
population Basic information on Development of materials Multi-media NRPCP
To be responsible pet Rabies as a disease, applicable to the LGUs
owners. its prevention and population. and LRPCC
To gain knowledge on control and area.
elimination.
the proper
Basic information on
management of dog
proper management
or any animal bite of human bite
To gain knowledge on victims.
how to manage the Basic information on
biting animal. how to
manage/handle the
biting animal.

106
 Target Audience and Locus of
Year
Communication Objective Key Messages Strategies/ Activities Tools
Responsibility
2017- Other stakeholders
2018
Media
To update media practitioners
on rabies
Rabies
is
a fatal e Information dissemination Information e NRPCP
disease/infection on rabies kits e HPCS
transmitted through © Popularization of RA Strengthening
Church an infected dog’s saliva 9482 in various media communi YY
To update leaders on rabies Integration in columns,
the
©
and how congregation can Rabies is a preventable actions
programs, etc
help remind followers/owners disease o Community-based
to be responsible pet owners health classes

Other GOs: o Sponsorship of mass

To Advocate for support in the dog vaccination
= Reminders of
implementation of RA 9482 as
schedules on mass
appropriate for the agency
mandate (DENR, DILG, DepEd, dog vaccination
= Provision of other
PNP, AFP, etc)
logistical support
during mass dog
vaccination (PNP
and AFP K9 corps,
etc)
e Inclusion of level-
appropriate discussion
of rabies in existing K-
12 school curriculum
and teaching guides

107
 its
For 2017 to 2018, alongside the conduct of mass dog vaccination, the NPRCP will also focus
intensified Responsible Pet Ownership campaign and distribution of IEC efforts among GIDA areas

a
where greater number of people have limited access to information.

108
 Target Audience and
Year Communication Key Messages Strategies/ Activities Tools Responsibili
ty
_

Objective
2019- Pet owners
2020 e To sustain awareness Rabies
isa fatal Information
dissemination on rabies
Reminder NRPCP
and knowledge of their disease/infection materials on HPCS
roles and transmitted through Sustained popularization
y
responsibilities as dog an infected dog’s of RA 9482in various pooster shor
MH
(PIO/MHO/Mun/City
,

in
Y
owners compliance saliva media pet owners have P

to RA 9482 Rabies
is a and can access vaccinated
dogs
Vet)
preventable disease
To keep (my) pet
rabies-free, booster
doses are necessary
every year
Politicians/LGUs
e To sustain and/increase It is worth investing Information NRPCP
support to RA 9482 in rabies prevention. dissemination HPCS
it safeguards the o Regularly provide LGU
health of updates, especially (PIO/MHO/Mun/City
constituents and “progress” data on Vet)
increases their rabies
economic Sustain/continue
productivity. Advocacy to support RA
9482
Sustain campaign on the
benefits of supporting
rabies prevention
Documentation of best
practices
Identify success stories
and spokespersons to
champion Rabies
prevention with other
LGUs
o For areas with high

109
 index of cases,
fund/support to
strengthen ABTCs
(ensure vaccines,
supplies, etc)
o: Ensure that vaccines
inABTCs are
provided FREE
o For other areas,
-establish ABTCs and
ensure availability of
trained health
providers and
vaccines
Continue observance
and celebration of
World Rabies Day

110
—
Year Target Audience and Key Messages Strategies/ Activities Tools Locus of Responsibility
Communication Objective
2019- Monitoring and Review e -NRPCP
2020 Conduct external review on e EB
NRPCP policy, operations and HPCS
implementation to determine:
o. Number of
LGUs
effectively implementing
and supporting RA 9842
o Number dogs vaccinated
for the first time
o Number of dogs given
booster shots
o Number of stray dogs
(and cats) newtered and
spayed as part of animal
population management
and control
o Number of
ABTCs
providing FREE vaccines
and properly complying
with PhilHealth claims
policies
Health Care Providers (local e NRPCP
health units)
To update HCPs on new
is a fatal
Rabies
disease/infection
e Developing personal skills
Re-orientation of health
Updated training
manuals
e LGUs
e
developments on rabies transmitted through an services
To refresh HCPs on the following: infected dog’s saliva e Capability building
e importance of providing Rabies is a preventable o Conduct refresher
proper bite wound disease course/s and updates on
management
Dog
bite victims should rabies prevention,
receive complete number treatment and
e recognizing what is the
and dosage of rabies management
category the bite wound vaccines
e immediate referral to Biting animal should be
ABTCs/ABCs confined through caging
© giving complete doses of or leashing and observe
rabies vaccines to dog for 14 days for any change
in behavior and signs of
bite victims
rabies.

111
 Year Target Audience and Key Messages Strategies/ Activities Tools Locus of Responsibility
Communication Objective
2019- ABTC and ABC Provider
2020 To sustain providers’ knowledge on
the following: Warning signs to watch e Developing Personal Skills Updated training NRPCP
° Proper observation of out for in bite victim (especially new ABTC and modules LGUs
warning signs and changes Warning signs to watch ‘ABC personnel)
on bite victims
out for in suspected dog Orientation
. . .
®
Schedule of PEP
Conti
ontinue and complete o _Reorienting Health
Need to observe biting Services
animal, take care and the prescribed vaccination
keep them confined or dosages
leashed during |4 days
incubation period
Community or general
population Basic information on Development of materials Multi-media NRPCP
e To reinforce knowledge as
Rabies its
a disease, applicable to the
population and area.
LGUs
LRPCC
and practice of prevention and control
and elimination.
responsible pet owners.
Basic information on
e To practice proper
proper management of
management of dog or humanbite victims.
any animal bite Basic information on how
e To practice proper to manage/handle the
management of the biting biting animal.
animal.

112
CHAPTER VI: MONITORING AND EVALUATION

Monitoring and evaluation is needed to verify the progress of NRPCP at

the municipal,
provincial, regional and national levels e.g. to verify whether program guidelines, strategies and
activities have been implemented as planned, to ensure accountability, and to detect any
problems and/or constraints. This in turn can provide feedback to the relevant authorities for
them to take remedial measures thus promote better planning through careful selection of
strategies for future action.

Under PIDSR, evaluation is a periodic review of the relevance, effectiveness and impact of
activities in the context of surveillance and response systems.

A program review is also an opportunity for the NRPCP to:

e Identify possible areas for refinements
e Determine if there is a need to redirect program
e Determine possible next steps

The complementary strategic campaign will likewise be part of the review to help the program
determine:
e awareness and knowledge levels of target audience groups on RA 9842
e number ofpet owners who are
voluntarily registering and having their 3-month old dogs (and cats)
vaccinated for rabies
e number of pet owners who present their pets for booster shots every year for the next three years
and annually while the dog
is alive

113
|. Logistics Management

One
of the components of a successful program like NRPCP is adequate supply of Tissue Culture
Vaccine (TCV) and Rabies Immunoglobulin (RIG). Therefore, all ABTCs should have free and adequate
supply of human rabies vaccine to give the complete dose (until supply last) of TCV to
all
animal bite
cases but of of
ensure completion required number doses including RIG to prevent human rabies. The
ABCs when procuring their own vaccines shall be required to follow the procurement guidelines as per
AO 2014 s 0002. ABTCs augmenting their vaccines and the RIGS aside from the supplies delivered from
the DoH procured supplies, shall likewise procure said vaccines and RIGS following the same AO.

Adverse Effects Following Immunization (AEFI) shall follow the procedures set by the EPI Program (For
discussion with the EPi, EB, FDA).

Supplies of TCV and RIG are procured annually by DOH following the procurement management
system. Once the TCV and RIG are delivered, inspected by the Food and Drug Administration (FDA)
and DOH inspection committee, these will be allocated and distributed to the Department of Health
Regional Offices (DOH RO) for distribution to the different provinces/CHOs/ABTCs on a quarterly
basis, subject to availability of anti-rabies vaccine. All PHOs/CHOs/ABTCs must submit quarterly
utilization and vaccine inventory report to the DOH. The local government units are encouraged to
enact and strictly enforce ordinance/s relevant to rabies control and to provide fund allocation for anti-
rabies vaccines for bite victims.

These vaccines and RIG require cold chain management. A cold chain is a temperature-controlled
supply chain which consists of uninterrupted series of storage and distribution activities. This aims to
maintain a given temperature range (2-8°C) to ensure the potency of vaccines and rabies
immunoglobulins from the manufacturer to the person who will receive the vaccine.

-114
 Human Vaccine Requirements

Rabies vaccine needs for one course of intradermal regimen:

Table 21: Vaccine Need for Intradermal Regimen

No. of Vials per
patient for full
:
Vaccine Per Vial
: Intradermal No. of ID doses
ss
No. of doses No.of course of
D ose per visit per vial
. eo
Visits i ntradermal
administration
Purified 0.5 ml 0.1 ml 2 doses 5 doses 4 2
Verocell
Rabies
Vaccine
Purified Chick 1.0 ml 0.1 ml 2 doses 10 doses 4 |

Embryo
Vaccine
(PCEC)

1.2. Computation of Human Rabies Vaccine using the Intradermal Regimen and
Rabies Exposure Category

Computation of human rabies vaccine requirements at the national and regional level
of
_

may be based on the number Category Il and Ill rabies exposures with consideration
of the available resources from the national government and other sources.

Estimated number of Category II and

Ill exposures expected to require TCV:

of
sed
Category Il and Ill Exposures
m_Annual Report)
|

115
National Level

FOR PVRV FOR PCEC

No. Of ID doses required No. Of ID doses required
Cat Il + Cat Ill = number of patients requiring Cat Il + Cat Ill = number of patients
requiring
TCVs/CCVs base on annual report base from TCVs/CCVs base on annual report base from
previous year previous year

No. of patients requiring CCVs X 8 doses = total No. of patients requiring CCVs X 8 doses =
ID doses required for all patients total ID doses required for all patients
Sample computation:
Sample computation:
1,000 Cat Il + 1,500 Cat Ili = 2,500 total
1,000 Cat Il + 1,500 Cat Ill = 2,500 number of patients requiring CCVs
total number of
patients requiring CCVs 2,500 x 8 = 20,000 ID doses required for all
2,500 x 8 = 20,000 ID doses required for all patients
patients
No. Of vials required No. Of vials required
Total ID doses / 5 ID per vial X 1.2* = total Total ID doses / per vial X 1.2* =
10 ID
number of vials required total number of vials required
*(.2 or 20% is the allowable wastage) *(.2 or 20% is the allowable wastage)

Sample computation: Sample computation:

20,000 + 5 x 1.2 = 4,800 vials required 20,000 = 10 x 1.2 = 2,400 vials required

1.3. Waccine Requirements at the level of Animal Bite Treatment Centers

Estimated number of Rabies Exposures per Year

Computation of the cell culture vaccine for the Local Government Units (LGU)
through the Animal Bite Treatment Centers may be based on the number of
Category
Il
and Ill rabies exposures with consideration of the available resources
from the LGU and augmentation from the national government and other sources.

Estimated number of vials to be used by the number of patients per day.

The number of patients with rabies exposures seeking anti-rabies vaccination per
day could not be predicted. The risk of rabies infection as a consequence should
prevail over wastage of vaccine. Unused doses of vaccine may be provided for pre-
exposure prophylaxis of individuals within the area.

116
 The table below shows the estimated number of vials to be opened as based on the
number of
patients seeking PEP in one day (estimate based on <10 patients/day
only).

Table No: Estimated Number of Vials to be Open Based

on the Number of Patients
Number of vials to be opened
Number of Number of ID according to vaccine type
patients per day Doses
PVRV PCEC
I 2 I |

2 4 | I

3 6 2 I

4 8 2 |

5 10 2-3 | -2
6 12 3 2
7 14 3 2
8 16 4 2
9 18

10 20 4-5 2-3

1.4. Vaccine Allocation

The kind of vaccine (PVRV or PCEC) to be allocated to ABTCs must be based on the
following factors:
* Number of patients per day; and
* Availability of the vaccine in the local market

Ideally, PCEC shouldnot be given to small ABTCs (with 2 or less patients per day to
avoid huge wastage rate (>60%.) PVRV can be given to both small and big ABTCs (with
>3 patients per day)

1.5. Rabies Immunoglobulin

Computation of the RIG yearly requirement may be based on the number of Category
lll rabies exposures with consideration of available resources from the national

government, LGUs and other sources.

Computation of Rabies Immunoglobulin Supply:

COMPUTATION EXAMPLE: For

Equine Rabies
Immunoglobulin
Number of Category Ill Exposure x average number 86,982 patients x 2* vials /patient (for a 26-50
of vials of RIG per patient kg patient) = 173,964 vials/year

*N 0. of vials per patient depends upon the weight of patient. For patients < 25 kgs shall require (1) onevial; > 51 to 75kgs shall require (3) threevials; >75
shall require (4) four vials

117
 Animal Rabies Vaccine

Computation of Animal Rabies Vaccine is based on 10:1 human: dog population ratio.
Herd immunity when mass dog vaccination coverage of 70% is reached within a short
period of time and yearly vaccination thereafter every two years.

Number of animal rabies vaccine required:

Example:
National: 89 Million x 10% = 8.9 Million (Estimated dog population)
8.9 Million x 70% coverage x 0.1 vial/dog = 623,000 vial

1.7. Vaccine Wastage

Wastage is defined as loss by use, decay, erosion or leakage or through wastefulness.

Vaccine usage isdefined as the proportion of vaccine issued and administered.

Vaccine wastage is the opposite of vaccine usage and

is calculated as follows:
Vaccine Wastage Rate = Number of doses supplied* - doses administered
x 100
Number of doses supplied
Example:

*Doses supplied is calculated from stock records for a given time period by adding the starting balance
of usable vaccine doses to new doses received during the period and subtracting the ending balance

118
 Some wastage is unavoidable. It is impossible to get all the doses in a multi-dose vial. A |

ml-dose vial does not yield 10 doses for PCEC or a 0.5 ml vial does not yield 5 doses for
PVRV.

In one day, one vial of vaccine could cover the (2) two ID doses of two patients for
PVRV or (2) two ID doses of (4-5) four to five patients for PCECV in one visit.
However, there are instances that a lesser number of patients come in one day to
consume all the available doses of vials that have been opened within the day.

Unused doses may be used for pre-exposure prophylaxis and may be counted as
administered doses to minimize wastage.

Wastage rates higher than 20% may indicate problems such as poor stock
management, cold chain failure incorrect mixing of freeze-dried vaccine and
incorrect dosage.

1.8. Physical Inventory

A regular physical check ensures stock records, and accurate and complete running balances.
Regular inspection should be done to check on damaged, expired, heat or cold-exposed vaccines
that need to be kept outside of the cold chain and clearly labelled “Damaged/expired vaccine —
do not use”.

An
inventory report should be properly filled up and submitted to next higher administrative
level every quarter.

1.9. Minimum Requirement for ABTC

1.10. Responsibility of Cold Chain Manager

e Monitor cold chain practices.

e Ensure all
vaccines and biologics are handled correctly and procedures are documented
e Ensure that vaccines and biologics storage and handling protocols are up to date
e Provide information to new immunization providers regarding storage and handling.
e Ensure rescue and transport supplies (coolers, freezer packs, flashlight, protocols, etc.) are
in close vicinity of the fridge.
e Review the temperature log for vaccines and biologics weekly to ensure proper
temperature recording.
e Follow up on recommended actions following a cold chain failure.
e Complete monthly inventory counts and checks.
e Weekly refrigerator maintenance.
e Annual thermometer or data logger maintenance.

119
Animal Rabies Vaccines

4.1. Introduction

On major component of the Rabies Program is dog vaccination which is recognized as the most
effective strategy to protect humans from rabies by cutting the infection at its source. There has
been several mass vaccination strategy developed including ring vaccination covering 3 km radius
from the areas with human and/or animal cases, north to south or vice versa and outer to inner
vaccination. Whether what strategy is being employed, the ideal mass vaccination strategy should
cover at least 70% of the total dog population and should be completed in shortest time possible
within a month.
or

4.2. Estimating Dog Population

Thefirst step towards approximating the number of vaccines needed in an area is to estimate the
dog population or
attaining the actual dog count in that specific area. Please see Chapter Ill, Part C
for more information on this.

4.3. Procurement of Vaccines

4.3.1. Vaccine qualifications

The animal rabies vaccines to be used during the mass dog vaccination must be
inactivated,
met the OIE criteria and must be registered to BAI to ensure quality.

4.3.2. Budget Resource

4.3.2.1. Department of Agriculture
Annually, the Department of Agriculture allots budget for the National Rabies
Prevention and Control Program. This includes the budget for vaccine
procurement and operating expenses for the program.

4.3.2.2.Local Government Unit

Other LGUs have allotted budget to support the NRPCP. Budget may come
from 20% development fund, 5% calamity fund and CSRs.

4.4. Forecasting of vaccines

4.4.1. International bidding

Animal rabies vaccines are procured through the assistance of Bureau of International
Health Cooperation and World Health Organization who then subjects the purchase
request to the bidding process. Once the bidding process is done and quotation for
vaccines are released, the WHO notifies the BAI for the amount of vaccines to be
purchased based on the program budget. See Algorithm on Process of Forecasting
Vaccines through International Bidding

120
 4.4.2. Local bidding
Local procurement of vaccines is
subjected to the bidding process set by the government.
Once purchase request has been made, bidders may post quotations online through
Philippine Government Electronic Procurement System (PhilGEPS). A contract is forged
once a bidder
Local Bidding
is
finally chosen. See Algorithm on Process of Forecasting Vaccines through

4.5. Delivery Schedules of Procured Vaccines (Tranches)

After transfer of payment has been made, through the

assistance of Bureau of Import Services
and Land bank of the Philippines, vaccines are delivered in tranches usually in March — in time
for Rabies Awareness Month and September — in time for World Rabies Day (September 28).

4.6. Allotment of Vaccines

Vaccine allotment is
primarily based on the estimated population, on an equal percentage basis.
Special considerations are given to areas with most cases of human and animal rabies, known as
high risk areas. If provided with a comprehensive vaccination plan, a Memorandum of
Agreement signifying a full commitment of
local chief executive, or a government-private
project, vaccines may be given fully to support the program or mini projects.
4.7. Timely submission of utilization reports
LGUs that liquidate and send their reports immediately are given opportunity to get more
vaccines.

4.8. Distribution of Vaccines

4.8.1.Vaccine allocation

¢ Computed vaccine allocation per region will be released through the Regional Rabies
Coordinator of each DA-RFO. The RRC will be responsible for the distribution of vaccines
per province and city.
e General requirements must be complied by the LGU before the release of vaccines.
e For NCR Cities, the request and release of vaccines are made directly by the City
Veterinarian in BAI.

4.8.2. Buffer stock

A buffer stock is BAI every vaccine tranche delivery. This is utilized during an
maintained by
emergency situation, committed projects, and any situation that obligates the need for vaccine

4.9. Delivery of Vaccines to the Regions and LGUs

Acquisition of vaccines can be made by directly getting the allotted or the requested vaccines at
the Bureau of Animal Industry. Vaccines are released when transport box and coolants are
provided.

121
 In cases where therecipient is from a distant area, vaccines can be delivered through a courier
or hired forwarders. However, payment for freight charges must be made by
the requesting
party.

4.10. Cold Chain Management

Manufacturer
4.10.1. Stages of cold chain management raspansibility manufacturing ‘

Vaccine is the most important commodity in the

implementation of the program. To guarantee good quality
Manufacturer/distributor Vaccine
and effectiveness, vaccines must be handled carefully responsibility distribution
ensuring optimum temperature and conditions during
transport and storage from the procurement
vaccination proper.
up to the
Provider
;
Vaccinearrival 4
responsibility at provider
facility
4.10.2. Elements of effective cold chain management

¢ Awell trained staff or designated vaccine handler Vacdne

storage
e Reliable storage and temperature monitoring equipment 4 and handling
atprovider
Vaccine refrigerator or bio-ref
3

o Thermometer
o Temperature record ledger A Vaccine
e Accurate vaccine inventory administration

Proper Vaccine Storage and Handling

Animal rabies vaccines must be stored between 2° to 8° Centigrade. Precautions must be made
the
regarding stability of temperature. Temperature below 2°C and higher than 8°C or any fluctuations
may destroy the vaccine potency and will result to losses.

During the vaccination day, it

is important that target population to be vaccinated is known so
that enough vaccines are being prepared. Furthermore, vaccines can be transferred in small cold
packs to increase portability, yet maintaining the optimum vaccine temperature. During vaccine
withdrawal, it is better to utilized one bottle at a time. Once a vial of vaccine is opened, all of
the vaccine must be used as recommended by the manufacturer. It is best to use the vaccine on
the same day
itis opened.

4.10.3. Managing remaining vaccines and waste disposal

e All used needles and syringes should be placed in the safety box for correct and safe
disposal.
¢ All unused vaccine that has not been maintained at 2° C to 8° C and other sharps must
be incinerated.
e Any unopened vaccine in small cold box can be returned to the refrigerator if the
temperature has been remained between 2° C to 8° C
e Any remaining vaccine should be returned to local storage & must be used the following
day or within 24 hours, otherwise, it will be discarded.

122
 4.11. Reporting of Vaccine Utilization

All reports (PhiiAHIS or MS Excel and summary of vaccination report (see Summary of Vaccination
Report form) up to the barangay/village level) from the LGUs (PVO and CVO) must be submitted to
the DA-RFO through the RRC. RRC will collate all reports and a summary will be submitted to the
BAI every quarter.

1.1.1. Recording and Reporting

Records are related

information or evidences collected over a period of time. The availability of records
is the successful implementation of the program. These will make sure that patient’s data and
critical in

management are monitored and appropriately documented.

Reports are accounts of events, situations, or episodes. These are evidences of the efficiency and
effectiveness of program implementation. Program reports can also be used as basis for planning and
improvement of implementation.

|. Policies

I.1. The NRPCP shall utilize the Rabies Exposure Registry and PEP Card as its official recording
forms.
1.2, Quarterly reports on animal bite cases, cohort analysis and Summary of Human Rabies shall be
submitted all levels to the DOH through channels.
by

1.3. Recording. and reporting shall be implemented at all ABTCs/ DOH recognized ABCs the in
country
1.4. Recording and reporting shall include all animal bite cases categorized according to NRPCP
guidelines.
1.5. The NRPCP shall adopt the official DOH recording and reporting system.
1.6. Records and reports shall verify the accomplishment of the program.

2. Procedures

2.1. Rabies Exposure Registry

The Rabies Exposure Registry is maintained at the ABTC/ DOH recognized ABC. contains It
data on personal information, patient history of exposure, post-exposure prophylaxis, and
previously immunized patients.

123
 OU
_National Rabies Prevention and Control Program
inet vee

RIG and
Name of Patient Age|Sex] Addrass* Where” When
Animal Date |Date Route Yes} No Started

The ABTC/ABC nurse fills up the registry as follows:

2.1.0.1.
2.1.1.2.
-
Registration Number chronologically assigned to each patient.
Registration Date- indicated the date of consultation.
2.1.2. Under Personal Information
a. Name
of
Patient- Write the family name followed by the first name and
middle initial
b. Address- state complete address, including landmarks or contact numbers
(if available)
c. Age- Patient’s completed age in years
d. Sex- Write M for male and F for female
2.1.2.1. Under history of Exposure
e Date-indicate the date when the patient was bitten.
e Place- indicate the complete address where the patient was bitten.
e Type of Animal- Write PD if Pet Dog; SD if Stray Dog owned or ownerless
freely roaming the community; C if Cat; O if Other than those previously
stated.
e Type of Bite- Write B if Bite and NB if Non Bite to include all non-biting
rabies exposure like eating raw meat, splattering, kissing, etc.
e Site- Indicate the body part/s bitten
2.1.2.2. Under Post Exposure Prophylaxis (PEP) Category of Exposure
e Washing of Bite- Write Y if Yes or N if Not done
e RIG - indicate the date when the RIG was given
e Route- indicate the route of injection ( Write IM if Intramuscular or
Intradermal)
ID

if
e Brand- indicate the brand name of TCV/CCV given
e Under Tissue Culture Vaccine/CCV-indicate the date when the following
doses was given
Tissue Culture Vaccine (TCV) Date Dose was Given
Ist Dose
2nd Dose
3rd Dose

124
__
4th Dose
5th Dose

Outcome

Patients who receive either PrEP or PEP may be classified according to the following outcomes:

Code Description
Completed (C) Patient received at least day 0, 3 and 7 doses of PEP or day 0, 7 and 21/28
of PrEP

Incomplete (INC) Patient with less than 3 doses of either PEP or PrEP

Died (D) Patient who died of whatever cause while undergoing PEP
None (N) Category Il and Ill exposures who did not received any TCV dose

2.1.2.3. Status of Biting Animal

After the |4th day of observation period, assess the status of the biting animal. Write A if
Alive; D if the animal Died or L if the animal was not available for observation.

2.1.2.4. Under Previously Immunized Patients

e Day indicate the date the dose was given

O-

e Day
3- indicate the date the dose was given
2.1.2.5,.Remarks- indicate other significant information if available.
2.2. Flow of Reporting

Regular reporting is crucial to better understanding and addressing rabies situations in the whole
country, particularly in regions and provinces where rabies is endemic. It contributes to the provision of
timely and appropriate actions to control the spread of infection, and safeguard both human and animal
health. Through reports, rabies program implementers, particularly those in GIDAs are provided
broader perspectives, timely feedback and relevant data. >

Data gathered from reports may be used for various analytical purposes, i.e., review of current
strategies and activities; resource and budget allocation, progress and status of patients provided PEP,
number of dogs (and other animals) vaccinated, etc.

125
The timely submission of all reports would ensure data relevance and rapid response to emerging rabies
situations. The NRPCP recommends that all rabies program personnel adhere to the reporting flow in
the table below:

Table (no) Flow and schedule of reporting from different units

Responsible FLOW TIMELINE

Program Manager DPCB-DOH

Ist week of the ant d month
the succeeding quarter
of

. .
Every 30¢ following month
Program Officer
.
Regional
of the quarter
City/provincial Coordinator
. . : Every 20% following month
City/Provincial of the quarter

ABTC MD/nurses ABTC/ABC

Every 2"4 day of the Ist
month of the succeeding
quarter
*** Partial report should be given every 15“ day of the succeeding month of
the following
quarter

2.3. National Rabies Information System (NaRIS)

To effectively implement all prevention and control interventions, the NRPCP requires reliable
information on the incidence of rabies across the country. Reliable information is made even
more crucial given the virulent nature of rabies — and the urgency to stop the spread of its
infection. One of the ways by which the NRPCP is able to accomplish this is through the
National Rabies Information System (NaRIS), a data collection mechanism designed for
continuous and systematic collection, reporting and analysis of rabies data.

NaRIS
is apatient-based rabies program accessible to
all
stakeholders- DOH, DA, WHO, LGUs,
RHUs, CHOs, ABTCs, NGOs, and the private sector- through the internet. It facilitates data
collection, aggregation, and utilization, and has the capacity to perform drug inventory.

It is a standards-based website that was developed for 3 levels of users namely, the public,
animal bite treatment center personnel, and managers/ decision makers.

As an information portal, the public can access various information on rabies, i-e., first aid
tips, locations of animal bite centers. The public may also use it as a notification portal where
any person can report a possible rabies case.

Trained personnel from the reporting health facility will input patient-based data, ideally at the
point of care.

Decision makers can reference the NaRIS website to access data that are important to decision-
making.

126
 The NRPCP office encourages that all ABTCs and ABCs use
the NaRIS for reporting of animal
bites. ABTCs and ABCs in geographically Isolated and disadvantaged areas (GIDAs) where internet
access may be difficult, staff may continue to submit their manually-encoded quarterly reports.

It serves asthe online bite and rabies registry and inventory card where trained animal
bite treatment center personnel will input patient-based data ideally at the point of care.
The website is a dashboard and database where decision-makers can easily retrieve data
important for decision-making.

This project was initiated by the DOH Infectious Disease Office through funding from the Bill
and Melinda Gates Foundation through the World Health Organization Philippines.

2.4. Post Exposure Prophylaxis Card (PEP CARD)

Each patient receiving post-exposure prophylaxis will be provided with a Post Exposure
Prophylaxis Card (PEP Card). This will be properly the filled out by the ABTC/ABC Nurse based
on the Rabies Exposure Registry data. The front page should clearly state the name and address
of the ABTC/ABC. This can also be used as reference in cases of transfer/continuation of
treatment and future management by other ABTC/ABC.

2.5. Report of Animal Bites

The Quarterly Report of Animal Bites will be filled out by the ABTC/ABC Nurse. The report on
animal bite victims, which includes distribution of animal bite cases as to age, sex, geographic
location, site of bite (lower or upper extremity, head/neck, trunk), category of exposure,
vaccine and immunoglobulin use is submitted by the Animal Bite Treatment Centers to the
Provincial and City Coordinators for consolidation and submission to the Regional Rabies
Coordinator on a quarterly and yearly basis for program analysis and submitted to the National
Rabies Prevention and Control Program Coordinator.

DEPARTMENT OF HEALTH
. National Rabies Prevention and Control
Program

Form

Provinces/ ~~
Cities/ABTCs No. PR TCV HRIG! ERIG Dog} Cat

127
 2.6. Summary of Human Rabies

The Summary of Human Rabies will be filled out by the Provincial/ City Medical or Nurse
Coordinators. It provides information on patients’ personal data, biting history, pre exposure
prophylaxis and rabies history of human deaths.

gee
a [
_...DepartmentofHealth
geen
Form 3 gece openness
el cng ee QuartefAnma
oe H Rabies Reporting Form

Reporting Unit:
py
i
!

Li
-

Pati Personal Data Biting History Post Exposure Prophylaxis Rabies History
Biting |Category RIG Anti- Rabies Vaccination Signs and Symptoms investigated
Name of Patient Age] Sex| Address where when
Animal |Exposure| Date |Date Started] Vaccine Used] Route Yes Started Sy/Sx Yes No

2.7. All reports for submission should be reviewed, analyzed and signed by the ABTC/ABC
physician.

One
of the recent measure in the implementation of the rabies program is the data collection
surveillance and diagnostics of human and dog populations an cases of animal rabies; establishment of a
central database system for registered and vaccinated dogs to impound unregistered, stray and
unvaccinated dogs; linked the National Rabies Information System (NaRIS) with the Philippines Animal
Health Information System (PhiIAHIS) to capture dog rabies data in order to maintain a One Health
Approach.

Part B: Animal Rabies Recording and Reporting

4.12. Introduction

4.13.Procedures
4.13.1. Animal Rabies Vaccination Reporting
4.13.2. Case Investigation Reports
4.13.3. Animal Rabies Cases

4.14.Practical Linking

128
 1.1.2. Monitoring, Supervision and Evaluation

Monitoring is the routine collection and tracking of key program data over time. Monitoring is a process
that helps to identify problems early so that they can be corrected quickly. This requires that data be
collected, compiled, and analyzed on a routine basis. Monitoring will provide information about the
status and trends of the program that can help:

e Assess whether the

program is meeting its targets
e Identify and improve problem areas in the implementation of NRPCP
e Check records and reports
e Ensure most effective and efficient use of resources

Supervision is an essential management tool to ensure the ABTC/ABC staff carry out the program’s
policies, standards, and procedures correctly, effectively, and efficiently. It is also an opportunity for
supervisor to do the following:

e Discuss with ABTC/ABC staff important issues related to the program;

facility
e Acknowledge and reinforce good performance;
e Help ABTCs/ABCs staffidentify and correct inadequacies or weaknesses in
its performance;
e Give feedback and solicit ideas on how to improve program implementation; and
e Provide mentoring to the ABTC/ABC staff.
e Ensure compliance to DOH standards for certification
While monitoring helps look at progress in indicators and helps in knowing if targets are reached,
evaluation examines the process in greater depth and helps evaluators understand what the
indicators
are really telling.
Evaluations are typically conducted at specific time periods (for example, at the end of the year),
whereas monitoring happens on
a
daily, monthly, and quarterly basis.

An evaluation of NRPCP will demonstrate how well the program has met the expected goals and
targets.

2. POLICIES
¢ Monitoring of ABTC/ABC shall be done by Provincial /City/ DOH NRPCP Coordinators every
quarter. They shall see to it that ABTCs/ABCs follow the standards/directions and technical policies.
¢
The Provincial/City/DOH/ DOH NRPCP Program Coordinators shall regularly conduct monitoring
using the prescribed forms. They shall analyze data from quarterly reports and provide feedback of
findings with corresponding recommendations to
the staff or authorities concerned.
* Continuous advocacy efforts to secure commitment of LGUs to purchase anti rabies vaccine, RIG
and other supplies and for the implementation of responsible pet ownership.

129
3. PROCEDURES
3.1. Monitoring and Supervision Activities for ABTCs

Identify which ABTC/ABC should be visited regularly based on results of previous monitoring and
supervisory visits. Use the following guidelines for monitoring and supervisory visits:

a. Verify records such as PEP cards and Rabies Exposure Registry for accuracy and
completeness of data entries.
For PEP card, randomly verify/inspect the card of patients whether schedule of next visits
are written at the back of the card while actual date of visit/actual ARV administration are
recorded inside the card. Should be consistent with the Rabies Exposure Registry Data.
In the Rabies Exposure Registry, bites due to rats, rabbits, snakes and other reptiles, birds
and other avian, insects and fish should not be included.
Calculate completion rate of last quarter’s total number of registered cases. Verify reasons
of non -completion of treatment.
Observe ABTC/ABC staff administering ID dose and RIG infiltration if correct dose
and procedures are done correctly.
is
given

sy Observe ABTC/AEC staff giving correct and relevant health education to the patients,

PT
Conduct interview ABTCstaff and patients to ensure that guidelines are being observed.
Conduct physical inventory of vaccines and other supplies including proper storage.
Compute supplied/distributed drugs and the number of doses given and check the remaining
doses/vials in the refrigerator.
Coordinators/supervisors must share relevant information and recommendations arising
from the visit in writing preferably in the supervisory logbook, with the ABTC/ABC staff
concerned. Courses of actions to address deficiencies or mistakes must be thoroughly
discussed and solutions agreed upon by the supervisor/coordinator and staff. Make sure the
issues and recommendations written have been addressed in the next visit.

For areas declared as Rabies Free Zone, monitoring should include the following in order to sustain free
rabies zone:

Activities to be conducted to sustain rabies free zone

Use of a checklist and monitoring for assessment and evaluation

The ABTC physician/nurse

prepares, analyzes, and must submit the Quarterly report on
Animal Bite Victims, Quarterly Report of Human Rabies Case, Quarterly Cohort Analysis
and vaccine utilization report.

Every ABTC/ABC must seek for certification to ensure that quality rabies exposures
management services is implemented in both public (Animal Bite Treatment Centers) and
private (Animal Bite Centers) facilities. The certification provides an assurance to all
animal bite cases that these facilities are capable of providing quality, safe, affordable and
effective rabies exposures prophylaxis services. Furthermore, certification ensures
standardization of the provision of bite exposures management and treatment services
through a uniform set of standards.

130
 SAMPLE MONITORING TOOLS USED BY REGION 4b AND
Region 10

Republic of the Philippines

Regional Office Vi
Department of Health
ci
KALUSUGAN
PANGKALAHATAN

Q. Abeto St., Mandurriao, Iloilo City

RABIES PREVENTION AND CONTROL PROGRAM

Monitoring Checklist

Province:
City / Municipality:
Date:

Parameters Y Rema
e rks
s
|.Animal Bite Treatment
Centers
With trained staff
WN
With available vaccines
Intradermal technique used
Guidelines for Animal Bite
Management (AO 164) available
With designated space identified by a
signage
Cold chain management in
place (with
alternative plan in case of brownouts)

{]. Provincial / City / Municipal

Ordinance
Functional Rabies Control Committee
a. Regular meetings
b. With ordinances /
resolutions passed
With dog pound
w With dog vaccination center / dog
vaccination done in
the area
DS
Registration of dogs done
Includes dog owners liability
NOW
With stray dog control
Functional Brgy. Rabies Brigade

131
 Above provisions enforced (if yes, pls.
indicate corresponding no.)

Budget for Rabies Control

Ill.
Included in the Animal Development
Plan
With specific funding scheme

IV. Response to Reported

Human Rabies Cases
Surveillance System
a. Case investigation of human
rabies cases
b. Contact tracing
Vaccination of high risk contacts
Dog vaccination in the area (15 km

radius)
Household and community education

Parameters Rema
rks

V. Referral System
Referral slips from ABTCs / RHUs
filed
Referral slips from referred hospitals /
RHUs filed

Recording / Reporting
VI.

System
Reports filed and submitted
|. Quarterly reports
2. Case Investigation Reports
3. Annual records

Vil. Advocacy
> Agenda in LHB meetings
wn
Agenda in ILHZ
meetings
Orientation League of Mayors
—

Tri-media campaign
uk
Celebration of Rabies Awareness

132
 Month
6. Multi-sectoral advocacy
7. Others

Comments
/ Suggestions:

Submitted by: Noted by:

~

Rabies Coordinator
PHO/CHO/MHO/COH

Republic of the Philippines

Department of Health
REGIONAL OFFICE IV- MIMAROPA
QMMC Compound Project 4, Quezon City

MONITORING TOOL
NATIONAL RABIES PREVENTION AND CONTROL PROGRAM

Name :

:
Facility :

Municipality / Province

133
Date of Monitoring :

I. Efficiency of PEP Coverage

Percentage of PEP given

to date
Cohort report of PEP
Coverage to date
No. of reported rabies
patient to date

li. Cleanliness, Orderliness and Infection Control

CRITERIA YES NO

Clean and health-promoting environment

ismaintained within and outside the
premise
Adequate clean water is available for
wound washing
General and infectious waste
appropriately segregated, handled and
disposed

Ill. Rabies Program Policies and Vaccine Storage

CRITERIA YES NO

Trained physician and/or nurse on duty at

the facility
RER
and PEP
card adequately and
accurately filled up
Medical record of patients available and
filled-up appropriately
Quarterly reports of human and animal
bite cases recorded and updated
Rabies education and management advised

Defaulters logged in a separate logbook,

follow-up system in place
Referral system to other ABCs/ABTCs
(should services are not available)
effectively implemented
Passive and active ARVs available for
patient administration
Vaccines adequately stored in a
temperature-regulated environment

134
 Vaccine contingency plan available in case
of power interruption

IV. Social Mobilization/IEC

IEC Activities Conducted

Places of Conduct
Dates of Conduct
No.of Participants
IEC Materials Given
Type of IEC Materials given
No. of IEC materials given

Other Findings
:

_
Monitored by

: Facility Staff/Chief
:

135
1.1.3. Capability Building

1.1}. Human Capability Building

Training health care personnel as well as allied health professionals on the importance of proper
management and treatment of
animal bite wounds is
essential in preventing and containing the
spread of rabies; and most importantly, saving the lives of victims.

As health care standards and medicine continue to grow, rabies responders have the duty to be
apprised and keep up with the times. They are, after all the first to meet a possible rabies
patient, so it is important that they are knowledgeable and up to date on rabies protocol. Those
that have been previously trained may do well to have a refresher course, as there have been
changes on clinical management and treatment of
rabies.

Similarly, there are updates

medical technology, providing healthcare professionals from both
in
the public and private sectors with new or additional materials that they may need on daily
basis.

For human health, The DOH, through the NRPCP, will provide training on the clinical protocols
and other equally-important and relevant components. Human rabies data management;
information, communication and advocacy; logistics and capability building needs will be handled
by the respective DOH unit (i.e., data management by the EB; health promotion and advocacy
by the HPCS, etc).

Laboratory capability will be handled by the RITM.

The DA-BAI and their agencies will handle training on animal health.

|. ABTCs
2. NARIS

3. Rabies Prevention Control Module

a. for Health Providers

b. for Community Health Workers / Volunteers

Note: GARC Rabies Educators Certificate (E-Learning) Course to be reviewed by NRPCP

and Health Promo for possible roll out to BHW’s and non-medical implementers.

4, Laboratory

B. Animal Capability Building

|. Laboratory Training for Vets

a. Continuing Medical Education

2. Dog Catchers and Vaccinators

136
 C. Other Stakeholders
|. Broadcasters/ Media/ Tri-Media (Orientation)

1.1.4. Supporting Policies — Responsible Pet Ownership

|. RA9482

2. Department Orders/ Memo / AO/ Circulars

3. Local ordinances

4. Quarantine Policies

Chapter VII MYTHS AND MISCONCEPTIONS

Despite progress on medical research and the national government’s efforts on rabies prevention
and control, many Filipinos still believe in the myths and misconceptions and follow old remedies
that are ineffective. Myths abound, false beliefs continue and inappropriate practices on dog/bite
wound management persist in many parts of the country. These include making the bite wound
bleed profusely; applying garlic directly on the wound and opening up the wound to
further facilitate
bleeding. It is believed that making the wound bleed more helps remove the
rabies virus.

More often, a tandok is called on to perform the task of removing rabies from the wound. The
It
tandok scorches the antler of a deer and places this over the wound. is believed that if the horn
sticks, the patient is infected with rabies. The wound is
then packed with garlic to stop the infection and
kill the disease.

Prevalent attitudes and malpractices like these could actually cause more harm and worsen the wound
and the bite victim’s condition. These practices are followed by many people for a long time and are
perpetuated to next generations; thus hampering the right health seeking behaviors for rabies (and
animal bite wounds).

Tandoks have also been long sought for their folk knowledge and are considered by the people as the
better alternative to obtaining premium priced anti-rabies vaccines. Another reason why far-flung
communities seek traditional or alternative measures is their distance from health facilities. Many still
lack access to hospitals because of distance and transportation costs.

The NRPCP has intensified its efforts in strengthening further their rabies prevention efforts
through health promotion campaigns and information, education and communication (IEC)
activities.

137
The following table shows other myths and misconception on rabies, a very misunderstood fatal
disease.

MYTHS AND FACTS ON RABIES

MYTHS FACTS
The public health significance Rabies is of public health importance because of the high mortality
of rabies is related to the rate, which is 100% when people have no natural resistance to rabies.
number of cases in an area. Fortunately, humans have
a
virus compared with other hosts.
relatively lower susceptibility to the rabies

Only one rabies virus is No, because rabies-related viruses belonging to the genus Lyssavirus
known
to cause the disease. can all cause rabies-like disease. Rabies-related viruses include Mokola
virus, Lagos bat virus and Duvenhage virus in Africa, European bat
viruses | and 2, and Australian bat lyssavirus.
Rabies is only transmitted by Rabies can be transmitted through a wound or broken skin when in
the bite of an animal. contact withthe saliva of a rabid animal, e.g. even when there is saliva
on an animal’s claw when
transmission can also occur
itin scratches a victim’s skin. Airborne rabies
rabid bat caves.
Human rabies is only The dogis the major carrier of rabies in the urban setting. Rarely,
transmitted by dogs. rabies virus is transmitted by cats. In the countryside, people are at
risk of contracting rabies when in contact with rabid wild animals such
as foxes and jackals. Although extremely rare, it is possible for the
rabies virus to be transmitted from rabies-infected livestock, such as
cattle, to humans.
There are no asymptomatic A small percentage (5%) of rabies-infected dogs remain asymptomatic
carriers of rabies. carriers. There can also be cases where the rabies virus is present in
tonsils and absent in the central nervous system (CNS).
Human rabies is transmitted In general, rabies can be transmitted to humans by unvaccinated stray
by stray dogs. and also domesticated dogs.
‘Do not worry; the dog has
had its shots. It has no
This is true ONLY
if the dog has had a booster shot.

rabies.’
Rabid dogs seem to have a Wrong. Humans infected with rabies have painful muscle spasms when
fear of water. they try to swallow. This leads to a morbid fear of water
(hydrophobia). In contrast, rabid dogs have no sign of hydrophobia
but are very sensitive to external stimuli.
Only rabid dogs froth at the
mouth.
a. Not necessarily. Dogs can be affected by two forms of
rabies, the
furious form and the paralytic form. In the latter form, because of jaw
muscle paralysis the dog’s tongue hangs out of its mouth and
experiences excessive salivation. Paralytic rabies occurs in
it
approximately 20% of rabid dog cases. Consequently, in 80% of rabies
no sialorrhea is present.
b. Frothing at the mouth may also be a symptom of conditions that
are more common than rabies, such as canine distemper, coccidiosis,
helminthiasis, ticks, etc.

If a
is
dog bites, it means that
infected by rabies.
it a. Adog with the furious stage of rabies can act in that manner.
at strangers. As the rabies
Initially, a dog with furious rabies snaps
progresses, the infected dog bites at inanimate objects, such as tires

138
 and chairs. If it
a furious-phase dog escapes, will run long distances,
snapping at any creature that it encounters, before it enters the final
paralytic stage and dies.
b. Even a healthy dog bites but there is always some reason for the
biting, i.e. it is normal for a dog to bite a person who steps on itstail
or a stranger who pats its head. In contrast, a rabid dog bites for NO
REASON
at all.
A friendly dog is not infected a. During the incubation period of rabies, a dog can act in.a friendly or
by rabies. aggressive manner, depending on its character and training
b. In the early clinical stage of rabies, dog behavior shifts: a previously
aggressive dog can behave in a friendly way, whereas a previously
sociable dog can react aggressively.

Rabies post-exposure This was true in the past, when rabies PEP shots were given large- by

prophylaxis (PEP) shots are circumference needles through the abdominal wall, which
tender area. Now, in adults, rabies PEP shots are administered
is a very
very painful.
intradermally or intramuscularly in the deltoid area. In children, shots
can also be administered in the anterolateral aspect of thigh.
Rabies post-exposure Rabies immunoglobulin (RIG) is infiltrated around and into the
prophylaxis (PEP). consists
only of an injection of rabies
wounds
to achieve passive immunization aimed at neutralizing the
rabies virus. RIG is ALWAYS followed by the administration of
.

immunoglobulin (RIG). vaccine (active immunization).

First aid is not helpful for It is necessary to clean the animal bite wound promptly and
those who have been bitten thoroughly. The wound and surrounding tissue should be flushed with
or scratched by an animal a strong stream of water and washed well using soap or detergent for
suspected of having rabies. at least 10 minutes. Virucidal disinfectant (povidone iodine) should be
This is the reason why they applied carefully under skin flaps. Then the animal bite patient should
should immediately go to the immediately go to the nearest bite center or health facility so that
nearest bite center or health rabies immunoglobulin (RIG) can be infiltrated around and into the
facility. wounds, if needed, and PEP can be administered.
Any animal that has bitten Any canine or wild host of rabies that has bitten humans or other
humans should be killed domestic animals must be kept. under quarantine or killed humanely. If
because of the danger of kept under quarantine, the suspected rabid animal should be observed
rabies. for a reasonable period of time, usually 10 to 14 days. If killed, the
intact head of the suspected rabid animal should be submitted for
necropsy and examination to check for the presence of rabies virus in
the brain tissues.
There is.a
fixed observation No, because the observation. period of suspected rabies hosts is
period for suspected rabies
hosts that have bitten
related to when the virus made
symptomatic phase. Thus it
it into the saliva during the pre-
depends on the species of rabies animal
humans or other hosts. host. Canine hosts excrete the virus in their saliva 3-14 days prior to
the appearance of symptoms, depending on the infectious dose and
viral strain. Consequently, an observation period of up to 2 weeks for
suspected rabid dogs could be recommended.
Rabies vaccines for animals There are also oral rabies vaccines for animals. In rabies enzoonotic
are only injectable. areas, vaccines are incorporated into edible baits to vaccinate dogs
and wild hosts such as foxes and jackals.
A pet that
is bitten by an Rabies has an incubation period usually ranging from | to 3 months.
infected animal doesn't The time it takes for the infection to reach the brain, muscle tissues,

139
develop rabies until the peripheral nerves, or central nervous system depends on the severity
infection reaches the brain. If
and location of the bite. an infected animal bites your pet, he or she
already has rabies before symptoms appear.
The only way to contract Your pet only needs to come intocontact with the saliva of an
rabies is through the bite of infected animal to be at risk for rabies. It can be transmitted just as
an infected animal. easily through a scratch or an open wound when the carrier has saliva
on
its claws.
Rabies is only transmitted by Domesticated pets that are unvaccinated pose the same riskas stray
stray dogs
nations.
in
industrialized dogs when it comes to spreading rabies.

Rabies vaccinations are A rabies vaccination is over quickly, just like any other preventive
painful and have many side shot. Your pet may have mild side effects the day of the injection,
effects. such as sleepiness or lethargy. However, this is far preferable to an
inevitable death that comes with rabies.
Only dogs carry the rabies Dogs AND other animals can carry the virus. ANY mammal can
virus. spread the rabies virus. In the Philippines, the most common source of
infection is stray, unvaccinated dogs. Cats and livestock such as cows,
goats, horses and carabaos can pass it on as well. Wild animals like
bats and monkeys are known
rabies virus.
to also potentially be infected with the

Rabies is not fatal to humans. Rabies is nearly always fatal to humans

hours after
if immediate treatment is not
given within 24-48 being bitten or scratched. Shots can be
administered to prevent the rabies virus from infecting the bitten or
scratched person. One shot is called “rabies immunoglobulin” to
prevent the virus from infecting the person, and the other
of vaccines to produce antibodies and fight the virus.
is a series

A person does not need first First aid is a MUST. The wound must be immediately and thoroughly
aid when he
is
bitten or cleaned with soap and generous amounts of water for
at least 10
scratched by a rabid animal. minutes to help wash the virus away. Then the person must be
brought to the nearest bite center or health facility.
“Tandok” is enough Patients who received “tandok” died either from
treatment when
a
bitten or scratched by a
person is rabies or tetanus. Tandok is a form of folk medicine used by
traditional healers. A deer horn is placed over the wound, believing
rabid animal. that it sucks out the virus. All victims should be seen by a doctor so
they are given immediate and proper medical treatment.
in
|
If I’m unsure | was bitten or Never assume you weren't bitten or scratched. This can happen
scratched, shouldn’t worry. cases whenthe is
person asleep. Perhaps a dog or cat entered or bat
flew into the room, which could bite or scratched a person without
waking him up. Children or those with disabilities who are unable to
communicate should also be checked.
An animal that is suspected
of rabies should be shot in
The animal should be captured and contained if it’s not seen to cause
more injury. It should then be brought to the laboratory and be tested
the head. ‘for the virus.
If I'm okay a few hours after
I’m bitten, | don’t have
Symptoms of having the disease manifest very late, often days before
death. This is why if there’s a chance that you may have contracted
rabies. the virus, immediate medical treatment needs to be sought.
Rabies can be spread Rabies is NOT transmitted through the blood, urine, or feces of an
through feces or blood.
is
infected animal, nor it spread airborne through the open
environment. Saliva provides the primary transmission medium when

140
 the animal is inthe clinical stage of rabies. For the rabies virus to get
to the salivary glands, it has to travel first from the site of entry
(usually a bite wound) through the animal’s nervous system, then to
the brain. This is what causes most rabid animals to exhibit abnormal
behaviors, depending on whatpart of the brain is
infected. Finally, the
virus travels to the salivary glands during the terminal stage of rabies,
prior to death. It is this later stage of rabies when an animal is most
infectious because the virus is in the saliva.

Appendix
Primary Bite Trauma and Severity
Factors that can contribute to the severity of animal bite wound(s)

a. Species of animal
e Canine teeth can create cutting and crushing damage to tissues
e Needle-like dentition of cats leave discreet puncture wounds.

b. Agel/size of victim

Children are more likely than teenagers and adults to sustain bite injuries that require medical attention.
Children less than or equal to 14 years of age comprised 30% of bite related emergency department
visits (CDC 2003).

Because of the smaller stature, children are more likely to suffer bites to the head and face (Lung 2005;
Harris 1974; Daniels 2009).

Injuries to the head and face represented nearly two-thirds of bite injuries among children aged <4 years
in one study (CDC 2003) and nearly three-quarters of bite injuries among children aged 0 to 9 years in
another (Weiss 1998).

c. Number of animals
Most animal bites are bitten by a single animal only.

Unusual circumstances such as persons attempting to intervene in a fight between two or more dogs
might increase their vulnerability to bites from multiple animals.

Communication cues operational between dogs during normal circumstances are often ignored during a
fight, animals may persist in frenzied biting behaviour and inflict more bites per animal than would occur
in an altercation between
a
single dog and the human victim.

d. Behavior

141
A fearful or aggressive dog
reflected aggression.
is unlikely to back down
if its initial aggressive threats are challenged with

A person who responds to canine aggression in a dominant, violent and loud manner rather than
assuming a calm and submissive posture, is more likely to sustain multiple wounds as the dog persists in
its attack.

Appendix 2.

Secondary Complications and adverse health Events

Factors associated with bite wound complications include:

a. Species of animal

Wound infections are frequently observed in bites from cats (28% to 80%) than from dogs (3% to 18%)
(Douglas 1975; Rhea 2014)

Deep puncture wounds resulting from cat bites are superficially less severe than the typical crushing
wounds from dog bites, but are also less amenable to thorough cleansing, irrigation and debridement
rendering them more vulnerable to infection.

The period from infliction of the bite to the first symptoms of infection is shorter (7-18 hours) for cat
bites compared to dog bites (12-48 hours) (Talan 1999)

Cat bites are more frequently associated with severe systemic sequelae such as:

¢ Meningitis
¢
Osteomyelitis
¢ Endocarditis
¢ Septic arthritis
¢ Septic shock

b. Tissue Trauma

Dog bites that create dead space-- whether from lacerations or puncture wounds--were nearly three
times as likely to be infected (32%) as similar wounds that did not create dead space (11%) (Myers
2008).

c. Anatomic location

Bites to the hands are more susceptible to infection due to the proximity to the skin of underlying
bones, joints and tendons (Smith 2000, Brook 1989, Thomas 2011).

Bites over or near joint can lead to osteomyelitis and septic arthritis.
Bites to the cranium may result in infections or abscesses in the brain or supporting structures.

142
Wounds and resultant scars to the face are more likely to be considered “disfiguring” than similar
wounds
tothe trunk or extremities.

d. Health of bite victim

Pre-existing conditions that may precipitate complications and sequelae of animal bites:

° Elderly
¢ immunosuppressed
¢ Have sub-optimal hepatic or splenic function
¢ Diabetes
¢ Cardiovascular disease

The above conditions may also complicate the therapeutic options available to treat the sequelae.

e. Timeliness and appropriateness of medical attention

Immediate wound care can significantly reduce the chances of secondary infection, loss of devitalized
tissue, and irreparable disfigurement.

Persons who delay seeking medical attention until later (>12 hours after incident) are more likely to
already be experiencing symptoms and signs of infection or neuromuscular damage, often from grossly
less significant wounds.

Appendix 3. Infection
Chief medical concern of animal bites is infection.

Studies have identified contamination with potentially pathogenic bacteria in > 85% of fresh bite wounds,
however only 15-20 % of bite wounds develop frank infection (Goldstein 1992).

a. Bacterial infection

Pasteurella spp. are the most common microbial isolates from infected bites, occurring in more than 75%
of cat bites (P. Multocida ssp multocida and ssp septica) and approximately 50% of dog bites (P. canis)
(Talan 1999).

Anaerobic bacteria recovered in 75% of infected dog and cat bite wounds (Brook 1987; talan 1999):

¢ Porphyromonas spp.
¢ Fusobacterium
¢ Bacteroides
° Prevotella

143
—
Possible infections from cat and dog bite complications (Goldstein 1989; Luchansky 2003):

* Cellulitis (develops rapidly, often within 24 hours)

¢ Abscess formation
¢
Osteomyelitis
¢ Septic arthritis
¢ Endocarditis
¢ Meningitis
° Sepsis
Bacteria most commonly isolated from horse, pig and primate bite wounds:

¢ Staphylococcus
* Streptococcus
¢ Enterococcus
¢ Neisseria
Bacterial pathogens found
in oral cavity of terrestrial reptiles:

¢ Pseudomonas aeruginosa
¢ Proteus spp.
* Coagulase negative staphylococci
* Salmonella groups Ila and Illb
¢ Clostridium spp.
Bacterial pathogens from bites of fish and aquatic reptiles:

¢ Vibrio
¢ Aeromonas spp

Bartonella henselae is the causative agent of cat scratch disease, which can follow a bite or scratch from a
cat. It does not cause obvious illness in cats, and up to half of domestic cats carry the organism at some
point in their lives, usually as kittens.

Manifestations of cat scratch disease:

¢
Regional lymphadenitis
* Systemic infections like osteomyelitis and encephalopathy can occur particularly in

immunocompromised individuals

Clostridium tetani, causing tetanus, is a concern for contamination of any wound, including animal bites.

A person protected against tetanus and does not require a tetanus-toxoid containing vaccine:

* Ifhe/she has had a primary series of 3 previous immunization with tetanus toxoid (Td) or
tetanus-diphtheria-acellular pertussis (Tdap) vaccine,
¢ with the last dose or the last booster within the last 5 years

144
—
Person who has completed the 3-dose series but the last vaccine or booster was >5 years ago should
receive a booster dose.

Person whose primary tetanus immunization is unknown or incomplete should receive the full 3-dose
primary tetanus vaccination series.

Person whose primary tetanus immunization history is unknown or incomplete should receive tetanus
immune globulin (TIG), in addition to the 3-dose primary series if wound is:
¢ particularly large
¢
penetrates into muscle
¢ is dirty
¢ or results in visible devitalized tissue, (CDC 2006).

Capnocytophaga canimorsus is part of the normal canine oral flora, can contribute to severe systemic
infections such as: (Lion et al 1996)

° Sepsis
¢ Septic arthritis
¢ Meningitis
¢ Endocarditis
¢ Renal failure
e DIC
* Cutaneous manifestations (maculopapular, petechial or ecchymotic
"
rashes)
¢ Cellulitis, necrotizing eschar and gangrene can lead to amputation of
digits/limbs
®

Up to a third of infection due to Capnocytophaga canimorsus may be fatal despite the organism’s
susceptibility to penicillins, fluoroquinolones and cephalosporins.

Apparent risk factors for Capnocytophaga canimorsus systemic infection:

e Liver disease
e —Asplenism
¢ —Immunocompromising disease or pharmacotherapy
¢ Advanced age

Rodent bites can also lead to bacterial infection.

Streptobacillus moniliformis (less commonly Spirillum minus) is the cause of ratbite fever--a rare acute

145
=
illness, most commonly associated with bites from laboratory or pet rats, is characterized by:

¢ Fever
¢ Chills
e Myalgia
Recurrent arthralgia/arthritis
¢

Maculopapular rash
¢

Severe manifestations include:

° Endocarditis
° Meningitis
° Sepsis
° Death (10% of untreated patients)
Appendix4. VIRAL INFECTION
Rabies
is the chief viral pathogen of concern in bites from a mammal, but other viruses can be
transmitted in bites from selected species.

Lymphocytic choriomeningitis virus is found in many rodents, most commonly house mice, ans
transmitted to humans through direct contact, infected aerosols, or bites. Infected rodents are
asymptomatic but in humans the
virus causes:

¢ Fever
¢ Headache
e Myalgia
¢ Meningitis or meningoencephalitis in rare instances

Cercopithecine herpesvirus |, also known

as B virus or Herpesvirus simiae, is a herpes virus.

The prevalence of virus infection is low among immature macaques, but approaches 90%
B or higher
among sexually active adults (Holmes 1995).

Humans who have direct contact with monkeys can be infected with B virus. Bites and scratches are
most common, but other contact with tissues and secretions can effect transmission.

Infected person with B virus experience the

ff 1-3 weeks after the incident:

* Vesicular lesions and abnormal sensation at the bite site

e Fever
* Headache
Fatigue ¢

More severe systemic symptoms include:

* Lymphadenitis

146
 e Nausea and vomiting
¢ Abdominal pain
¢ Spread of virus to CNS leads to increased sensitivity to stimuli, uncoordinated
movements, double vision, agitation and ascending flaccid paralysis, contributing to
fatal respiratory paralysis
Appendix 5

PRACTICAL STEPS IN DESIGNING A COMMUNICATION PLAN

2.1. Define the problem. Identify the communication barriers gaps between the
existing and desired behaviours
the gap. can be a problem
It in
of the target group. Identify the factors that caused
knowledge/information, skill, attitude or resource. Problem
identification methods include observation, Knowledge Attitude Practice and Behaviour
(KAPB) surveys, group discussions, analysis of records, results of tests and special studies;

2.2. Behavioral Objectivel/s

2.3. Formulate communication objectives. Objectives are goals to aim for or desire to
achieve within a time limit through the use of strategies and resources. It
is important to have a
clear idea of the health program to be communicated and the action to be taken by the
identified target audiences;

2.4. Identify/Analyze and segment the audience. It is very important to know the target
audience and study their needs, interests and level of comprehension;

2.5. Identify strategies and activities

The template below may be used as guide and reference in adapting the national health promo
and communications plan:

Target Audience
Year
and
Communication Key Messages
Strategies/
Activities
Tools
Locus of
Responsibility
Objective

Program planners and implementers at the local level are encouraged to develop their own
health promotion and communication plan according to the socio-cultural context of the local
situation to increase chances of messages to be better understood and accepted; and hopefully
being practiced.

2.6. Design effective messages. A message should awaken the interest of the target audience
which are in consonance with their needs and values. Messages on Rabies Campaign should

147
10/8/2019 odtis.doh.gov.ph/docregistryprint.php?route_no=R2019-001169893

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RIGINATING OFFICE: DPCB - IDO

2019-000133405 oe DATE: 10/08/2019

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OF DOCUMENT: Memorandum

BJECT: Atty. Laperal - Request for Signature of Sec. Duque on the Attached Manual of Procedure (MOP) of the
Rabies Prevention and Control Program (2018)

ACTION
REQUIRED/ACTION DUE DATE
TAKEN/REMARKS

2019-10-08 |DPCB - IDO DPCB-Director For Signature 2019-10-15

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odtis.doh.gov.ph/docregistryprint.php?route_no=R2019-001169893 1/1
 Republic of the Philippines
Department of Health
OFFICE OF THE SECRETARY

October 8, 2019
MEMORANDUM

FOR : ATTY. FATIMA P, LAPERAL

Head Executive Assistant

FROM :
Nangiids L. AREVALO, MD, MPH, CESO IV
f Diregtor IV
Disease Prevention and Control Bureau

SUBJECT : Request for Signature of Secretary Francisco T. Duque III on

the Attached Manual of Procedures (MOP) of the National
Rabies Prevention and Control Program (2018)

Endorsing to your Office the attached 2018 Manual of Procedures (MOP) for Rabies which
designed to facilitate consistency in the implementation of the National Rabies Prevention and
Control Program (NRPCP) among clinicians, health service providers, program managers and
coordinators, for signature of the Secretary.

Thank you.

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila e Trunk Line 651-7800 local 1108, 1111, 1112, 1113
Direct Line: 711-9502; 711-9503 Fax: 743-1829 e URL: http://www.doh.gov.ph: email: ftduque@doh.gov.ph
 October 8, 2019

MEMORANDUM

FOR : ATTY. FATIMA P. LAPERAL

Head Executive Assistant

FROM : NAPGLEON L. AREVALO, MD, MPH, CESO IV

Direqtor IV
Disease Prevention and Contro! Bureau

SUBJECT : Request for Signature of Secretary Francisco T. Duque III on

the Attached Manual of Procedures (MOP) of the National
Rabies Prevention and Control Program (2018)

Endorsing to your Office the attached 2018 Manual of Procedures (MOP) for Rabies which
designed to facilitate consistency in the implementation of the National Rabies Prevention and
Control Program (NRPCP) among clinicians, health service providers, program managers and
coordinators, for signature of the Secretary.

Thank you.
 Republic of the Philippines
Department of Health
OFFICE OF THE SECRETARY

October 15, 2019

DEPARTMENT CIRCULAR
No. 2019-

FOR : BANGSAMORO AUTONOMOUS REGION IN MUSLIM

MINDANAO (BARMM) MINISTER OF HEALTH, ALL
UNDERSECRETARIES, ASSISTANT SECRETARIES,
CENTER FOR HEALTH DEVELOPMENT (CHD)
DIRECTORS, CHIEFS OF MEDICAL CENTERS OF
DOH HOSPITALS, EXECUTIVE DIRECTORS OF
SPECIALTY HOSPITALS, PROVINCIAL HOSPITALS,
DISTRICT HOSPITALS, ANIMAL BITE TREATMENT
“YU
CENTERS, PRIVATE HOSPITALS AND OTHERS

\\ SUBJECT :
CONCERNED

Adoption of the National Rabies Prevention and Control

Program (NRPCP) Manual of Procedures (MOP) 20 20-2025

management-and
=
fobte+
0

N
To strengthen implementation of the National Rabies Prevention and Control Program
(NRPCP) for a rabies-free Philippines, the Manual of Procedures (MOP) was updated_to—
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pum og adopted -

The NRPCP MOP shall be posted at the DOH website (www.doh.gov.ph) and
Selig:
by concerned agencies. 4

rs
Dissemination of the information and guidance to all concerned,requested.

By Authority of the Secretary of Health:

MYRNA
C. CABOTAJE, MD, MPH,
Undersecretary of Health
CESO
III
Public Health Services Team

have bn aylow2s
*

of arog 2
Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila e Trunk Line 651-7800 local 1113, 1108, 1135
Direct Line: 711-9502; 711-9503 Fax: 743-1829e URL: http://www.doh.gov.ph; e-mail: ftduque@doh.gov.ph
 October 15, 2019

DEPARTMENT CIRCULAR
No. 2019-

FOR : BANGSAMORO AUTONOMOUS REGION IN MUSLIM

MINDANAO (BARMM) MINISTER OF HEALTH, ALL
UNDERSECRETARIES, ASSISTANT SECRETARIES,
CENTER FOR HEALTH DVELOPMENT (CHD)
DIRECTORS, DIRECTORS OF DOH RETAINED
HOSPITALS, CHIEFS OF MEDICAL CENTERS,
EXECUTIVE DIRECTORS OF SPECIALTY AND
SERVICE HOSPITALS, PROVINCIAL HOSPITALS,
DISTRICT HOSPITALS, ANIMAL BITE TREATMENT
CENTERS, PRIVATE HOSPITALS AND OTHERS
CONCERNED

SUBJECT ss:
Adoption of the National Rabies Prevention and Control
Program (NRPCP) Manual of Procedures (MOP)

To strengthen implementation of the National Rabies Prevention and Control Program

(NRPCP for a rabies-free Philippines, the Manual of Procedures (MOP) was updated to
presents appropriate and practical guidelines. The National Rabies Manual of Procedures
(MOP) 2020-2025 is
intended to provide all rabies-involved personnel guidance the proper on
management and control of rabies to ensure the safety of all
and eventually end dog-mediated
deaths among Filipinos.

The NRPCP MOP shall be posted at the DOH website (www.doh.gov.ph) and adopted
by concerned agencies.

Dissemination of the information and guidance to all concerned requested.

By Authority of the Secretary of Health:

MYRNA
C. CABOTAJE, MD, MPH, CESO III
Undersecretary of Health
Public Health Services Team

DPCB PHST-ASEC PHST-USEC

{ waefigon L. AREVALO, MD, MPH, CESO IV MARIA ROSARIO S. VERGEIRE, MD, MPH, CESO IV
tk.
ra
Minn Director IV Wf Assistant Secfetary of Health Execyftive Assistant
| TI
INTRODUCTION TO THE MANUAL
N
consistency in the implementation of the National Rabies Prevention and Control Program
among clinicians, health service providers, program managers and coordinators and other
stakeholders nationwide. The manual presents step by step reference guides for all health
professionals to aid in the proper diagnosis of cases of animal bites and human rabies; as well as
to deliver evidence-based management for patients and special group of people. roduet
While lifesaving in preventing rabies, immunoglobulin and/or vaccine, if administered prion
of
onset of clinical signs, nonetheless share the innate risks of any exogenous pharmaceutical/Mild
to serious adverse events, though rare, may occur in some patients following administration of
vd oe'
rabies biologicals. Moreover, inappropriate or injudicious use of biologicals could lead
shortage of supplies of these products and could compromise efficient to.
S f
for patients with
higher risk exposures. Lastly, rabies biologicals and their administration entail significant costs.

It isour aim to strengthen the competencies of our health care workers especially those in the
far flung areas with limited resources towards an effective, efficient and cost-efficient diagnosis
and management of animal bites and human rabies.

In general, it is hoped that the use of this manual will help lower down morbidities
mortalities related with animal bites. Smart people manage problems but champiohobevend
them from occurring. Preventing rabies therefore should be easier and cheaper, hd
the best

cure for rabies is prevention.

CHAPTER
|:
I. Rabies: A global concern
INTRODUCTION

The Public Library of Science (PLOS) Neglected Tropical Diseases on the Global
Burden of Endemic Canine Rabies states that globally canine rabies causes
approximately 59,000 (95% confidence intervals: 25-159000) human deaths, over
3.7 million disability-adjusted life years (DALYs) and 8.6 billion USD economic
losses annually. The largest component of the economic burden due to is
premature death (55%), followed by direct cost of post exposure prophylaxis
(PEP 20%) and lost income while seeking PEP (15.5%) with only limited costs to
the veterinary.
(PLOS Neglected Tropical Diseases
| DOI!:10.1371 ljournal.pntd.0003709 April 16, 2015

Fig.1 Countries or areas at risk for Rabies

Rabies: Countries or areas at risk
on ni

contact wilh !

dogs and other rabies

o e445 2000 3800 Kemelers

ets
Data Source: WHO Control of Neglected Bs
World Health
NTO) 0 "9 niga ion
be
‘The boundaries and names shown and the designations used on this map do notimply the expression of any opinion whatsoever Tropical
Diseases
and
»
on part af the World Heaith Organization conceming the legat status of any country, territory, city or area or of ts authorities,
the -

‘of conceming the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border ‘ines
Woald Health Orgenization © WHO 2013, Allights ed.

This map shows that more than 95% of rabies deaths occur in Asia and Africa where the
presence of 3 things are common: poverty, poor sanitation and crowding. The estimated
annual figure of almost 60,000 human rabies deaths is probably an underestimate.
(WHO 2013).

With human rabies mediated by dogs claiming the lives of thousands of people every
year worldwide, the World Organization for Animal Health (OIE) and the World
Health Organization (WHO), in collaboration with the Food and Agriculture
Organization of the United Nations (FAO) and with the support of the Global