Rage

summary about anger

Rabies is an infectious disease caused by an RNA virus of the genus Lyssavirus. This is an extremely serious disease, and once diagnosed, it has a mortality rate of almost 100%, because there is still no truly effective treatment on a large scale. However, we may know the Milwaukee protocol, a silver lining in rabies treatment, however it applies to a minority of patients.
Vaccination is the only way to limit the development of this disease. There are post-exposure vaccination schemes, that is, after contact with a suspected animal.

In Brazil, the region with the most registered cases of rabies is the Northeast, with around 54%. Transmission to humans is through contact with the saliva of an infected animal, such as wounds, scratches or bites. Between 1980 and 2011, Brazil recorded 157 cases of rabies, most transmitted by domestic animals such as dogs and cats. In the year 2011, 2 cases were registered in the State of Maranhão. Other animals that can also transmit the disease are foxes, wolves, skunks and wild animals.

The main risk groups for the disease are people who live in places close to wild regions that have contact with animals such as bats, wolves, wild cats, etc. Professionals who deal with animals, such as veterinarians and zootechnicians, are also at risk of contracting the disease.

Once the rabies virus is installed in the CNS, it causes symptoms of encephalitis and muscle spasms, with great suffering for the patient, leading to coma and death. The diagnosis is based on the patient’s clinical history and serological tests. Prevention is done through vaccination of humans and animals.

Treatment for the disease, once detected, is almost non-existent and very ineffective. However, there are protocols like Milwaukee’s. With this protocol, a young American woman was successfully treated.

If you are bitten by a suspicious animal, immediately wash the wound and try to obtain as much information as possible about that animal, such as its place of origin and species. Don’t kill the animal, wait to talk to a doctor about what to do about it.

Definition

Rabies, also known as hydrophobia, is a zoonosis (disease transmitted from animals to humans) caused by a virus, whose causative agent can infect any warm-blooded animal. It is a deadly disease for which there is no cure.

However, the disease is only triggered in mammals such as dogs, cats and humans. Due to its lethality and impossibility of cure, the vaccine for prevention is essential.

Rabies and Vampires
Rabies probably gave rise to the myth of vampires, as they bite like a rabid animal and feed on blood. And people who are angry can be very violent and have a high libido, some of the characteristics of a vampire.

Epidemiology

Urban rage vs. wild rabies
There are two main forms of the disease: urban rabies, transmitted mainly by domestic animals such as dogs and cats, and wild rabies, whose reservoir is wild animals and carnivores. In Brazil, rabies has been diagnosed in wild mammals, such as bats, wild dogs, foxes, raccoons, ferrets, various felines, marmosets, monkeys, etc.

Rabies in the world
– According to a study published in April 2015 in the journal PLOS Neglected Tropical Diseases , 59,000 people die every year from rabies worldwide. According to the study, 95% of fatal infections are due to dog bites.
– In India, around 20,000 people die every year from rabies, according to data from early 2017. Most of the victims are children. Almost all cases in India are caused by the bite of a rabid dog.

Brazil and rabies
– In Brazil, according to data from the Ministry of Health, Rondônia is the state with the most occurrences of human rabies. In absolute numbers, the state only loses to Pará (33 cases), Maranhão and Bahia (38 cases), Pernambuco (28 cases) and Minas Gerais (30 cases), as they have a much higher number of inhabitants. In percentages, according to data from the Brazilian government, the Northeast region corresponds to 54% of the cases registered between 1980 and 2008; the North region, in the same period, 19%; Southeast region, 17%; Midwest region, 10%; and the South region, less than 1%. Between 1980 and 2008, dogs and cats were responsible for transmitting 79% of cases; bats, 11%; other animals (foxes, skunks, cattle, horses, goats, pigs, marmosets, wild cats and peccaries), 10%.
– According to recent data from the Brazilian Health Surveillance Secretariat, the total number of cases in Brazil between 1980 and 2011 was 157. In 2010, Brazil recorded 2 cases of the disease, one in the state of Ceará and one in the state from Rio Grande do Norte. Until August 2011, 2 cases of rabies were registered, both in the state of Maranhão.
– In Brazil, five cases of human rabies were recorded in 2012.
– A 14-year-old Brazilian teenager survived rabies, according to Brazilian media (Globo, Record) on January 10, 2018. He was infected by a bat in the rural area of ​​Barcelos, a village located 400 km from the big city of north of Brazil, Manaus, in the Amazon. The teenager, who was suffering from symptoms, went to see a doctor in early December 2017 and then fell into a coma. His 2 brothers were also infected with rabies and unfortunately died from the disease in 2017. On January 10, 2018, the Brazilian Ministry of Health considered that the teenager no longer had the virus in his body, but a complete cure was not yet guaranteed . Indeed, it could present sequelae. He was saved thanks to the Milwaukee protocol, especially using biopterin and amantadine. Rabies, once detected, it is an extremely deadly disease, with some sources talking of a death rate of 98% or more. In Brazil, this is only the second recorded case of a rabies survivor.

Egypt
Between 2014 and 2017, around 200 people died of rabies in Egypt. There are more than 15 million dogs in the country and every year more than 360,000 people are bitten by these animals. This information comes from the Swiss reference website Safetravel.ch from July 2017. The Swiss website states that it is necessary to avoid any contact with animals and that, in case of a bite or scratch, it is necessary to wash the wound well with soap. So, you must urgently disinfect and consult a doctor to receive a specific post-exposure vaccine. It is also important to know that preventive vaccinations are recommended for expatriates and travelers at risk.

Vaccination:
Vaccination against rabies saves 300,000 lives a year. The rabies vaccine is on the World Health Organization (WHO) essential medicine list .

Causes & transmission rabies

Rabies is an infectious disease caused by an RNA virus of the rhabdoviridae family of the genus Lyssavirus with great pathogenicity to humans (about 100%).

In the body, the rabies virus spreads through the nervous system until it reaches the brain.

Streaming

Rabies is a zoonosis, that is, it is transmitted to humans through animals. Transmission occurs when infected animal saliva (such as dogs, cats, bats, wild animals, etc.) comes into contact with humans or other animals through bites, wound licks, scratches, among others. Other rarer forms of transmission are through the placenta and breastfeeding, respiratory route and corneal transplantation in humans.
The dog is the source of 99% of human rabies transmission, according to the WHO.

In urban rabies, the main reservoirs are dogs, followed by cats. The main wild reservoirs are wolves, foxes, bats and coyotes.

See below the table with the main animals, domestic and wild, that can transmit the disease:

Groups of risk

People who deal directly with animals, in urban or wild areas (biologists, veterinarians, grooms, trainers, researchers who work with the virus, firefighters, etc.) should receive anti-rabies vaccination, as they are part of a risk group. In addition, people who live close to wild areas and who have contact with wild animals are at risk.

People traveling to rabies areas are also at risk of catching the disease. If the animal bites the head or neck, the virus can reach the central nervous system more quickly, and this type of patient is at risk of developing more severe symptoms more quickly.

Symptoms

Rabies incubation period
Once installed in the human body, the virus incubation period varies from 2 weeks to 2 months, however, in some cases it can reach more than 1 year. In dogs and cats, this period is from 10 days to 2 months and in cattle, 25 days to 5 months. The time for symptoms to appear depends on how quickly the virus spreads through the nervous system to the brain.

Rabies symptoms
Centripetal phase: the virus initially multiplies in muscle and connective tissues. From there, it invades nerve endings and is transported to the spinal cord and then spreads throughout the Central Nervous System (CNS).
Centrifugal phase: after reaching the CNS, the virus ends up spreading to other regions of the nervous system, liver, muscles, skin, heart and salivary glands, and may restart the cycle of infection.
Once installed in the brain, the virus begins to damage the nervous system through inflammation (encephalitis). Its mortality rate is very high, being an almost totally fatal disease, with few cases of recovery described in the literature.
Other symptoms of rabies that often appear early on are:
– Muscle spasms
– Hydrophobia (fear of water, patient does not want to drink, as an aversion)
– Aerophobia (fear of air movement)
– Fever (often high)
– Convulsions
– Pains
– Excessive salivation (with formation of drool, as a dog)
In the case of rabies, the patient may also present anxiety, high aggressiveness (violence) and hypersexuality (men with frequent need to ejaculate, strong sexual desire).
Once all symptoms are detected, death occurs within a few days. Furthermore, once the virus is in the brain, the fatality rate is close to 100%. Some sources speak of a survival rate of around 98%, as is the case in particular in the Brazilian media, which highlights the Milwaukee protocol for curing the disease (see Epidemiology in Brazil).
Infected people die from cerebral hemorrhage (due to meningoencephalitis) as well as a heart attack or generalized muscle paralysis. A coma phase often precedes death.

Bite site:
A bite on the hand or near the head, places where there are many nerve endings, can accelerate the development of the disease by affecting the brain more quickly.

Diagnosis

The diagnosis of rabies is made through the clinical history of the patient, in which it is verified if there were bites or contact with animals. Physical examinations are based on the patient’s various symptoms, including neurological, sensory, and muscle disorders.

Laboratory tests are also valid for virus identification, where immunofluorescence of the brain, cornea or oral mucosa is used to detect the infectious agent. Antibody searches are also used for antigen identification.

Other methods include histopathology, also for identifying the virus and checking the state of the affected tissue, and intra-cerebral inoculation in mice, to find out if the virus is in fact the cause of rabies.

Complications

Rabies is a very aggressive disease whose outcome is lethal in the vast majority of cases. The progression of the disease is very painful for the patient who may go into a coma with subsequent death in almost 100% of cases. However, as seen above, in Symptoms , some sources speak of a 98% survival rate, as is the case in particular with the Brazilian media, which presented the Milwaukee protocol to cure the disease (read Epidemiology in Brazil ).

Treatments

There is no treatment for rabies. The measures adopted are for the prevention and vaccination of the population and animals. The medicines administered after the appearance of the symptoms are to alleviate the suffering of the patient.

rabies vaccination

Currently in Brazil, two anti-rabies vaccines are produced: one with the attenuated virus and the inactivated vaccines.

The vaccine can be used for prophylaxis, that is, before the individual is exposed to the virus and is indicated for people belonging to risk groups: veterinarians, trainers, biologists, scientists, etc. In Brazil, the vaccine produced for prophylaxis is the Fuenzalida & Palácios type, whose preparation is made from nervous tissue of suckling mice infected with the virus with subsequent inactivation by ultraviolet radiation and bacteriopropriolactone.

Another type of vaccine is the cell culture vaccine. It has a high immunogenic power, a low rate of adverse events, but a high price.

Anti-rabies serum is obtained from hyperimmunized horses. The application is in a single dose intramuscularly in different sites of the vaccine. Serum can cause anaphylactic, anaphylactoid reactions and serum sickness.

After vaccination, a serological follow-up must be carried out, starting on the 10th day of administration of the last dose, whose antibody titre must be above 0.5 IU/mL. This assessment must be repeated every six months according to the degree of risk that the person is exposed to.

The rabies vaccine can also be used after the patient has been exposed to the virus. In this case, the application must be done after washing the wounds. Passive immunization (serum) can also be used. The application must be made at the site of virus inoculation, that is, in the lesion, so that the antibodies can inactivate the virus.

The therapeutic dose scheme is different from the scheme applied in prophylaxis. Below there is information about the vaccination schedule in prophylaxis and post-exposure.

Prophylaxis:

Scheme with the modified Fuenzalida & Palácios vaccine

4-dose schedule

 – apply on days 0, 2, 4 and 28

 – route of administration: intramuscular, in the deltoid region

 – dose: 1 ml, regardless of age, gender and weight of the patient

Scheme with vaccines produced in cell culture or in duck embryo

a) Scheme with 3 doses by the intramuscular (IM) route

 – apply on days 0, 7 and 28

 – route of administration: intramuscularly, in the deltoid region.

 – dose: 0.5 or 1 ml, depending on the manufacturer. The dose recommended by the manufacturer is independent of the patient’s age and weight.

b) Scheme with 3 doses by the intradermal route (ID), for HDCV, PVCV and PCEV vaccines (but not for PDEV)

 – apply on days 0, 7 and 28

 – intradermal route of administration, in the deltoid region

 – dose: 0.1 ml, regardless of manufacturer

Post-exposure:

Schemes with the modified Fuenzalida & Palacios vaccine

a) 3 doses of vaccine and clinical observation of the dog or cat

 – apply on days 0, 2 and 4

 – route of administration: IM, in the deltoid region; in children under 2 years of age, it can be administered in the region of the vastus lateralis muscle of the thigh

 – dose: 1 ml, regardless of age, gender and weight of the patient

b) vaccination 7 + 2 (9 doses)

 – apply 1 dose, daily, on 7 consecutive days, and 2 booster doses, 10 and 20 days after the administration of the 7th dose

 – route of administration: IM, in the deltoid region; in children under 2 years of age, it can be administered in the region of the vastus lateralis muscle of the thigh

 – dose: 1 ml, regardless of age, gender and weight of the patient

c) sero-vaccination 10 + 3 (13 doses)

Vaccine:

 – apply 1 dose, daily, on 10 consecutive days, and 3 booster doses, 10, 20 and 30 days after the administration of the 10th dose

 – IM administration route, in the deltoid region; in children under 2 years of age, it can be administered in the region of the vastus lateralis muscle of the thigh

 – dose: 1 ml, regardless of age, sex and weight of the patient

Rabies serum or human rabies immunoglobulin:

 – apply on the first day of treatment (day 0)

route of administration: infiltrate the site of injury; if the amount is insufficient to infiltrate the entire lesion, they can be diluted in saline solution; if there is no anatomical possibility for the infiltration of the entire dose, a part, the smallest possible, should be applied in the gluteal region

 – Dose: anti-rabies serum (SAR – 40 IU/kg of weight), human anti-rabies immunoglobulin (HRIG – 20 IU/kg of weight)

Schemes with vaccines produced in cell culture or in duck embryo

a) 3 doses of vaccine and observation of the dog or cat

 – apply on days 0, 3 and 7

 – route of administration: IM, in the deltoid region; in children younger than 2 years old, it can be administered in the vastus lateralis region of the thigh

 – dose: 0.5 or 1 ml, depending on the manufacturer. The dose indicated by the manufacturer is independent of the patient’s age.

b) vaccination (5 doses)

 – apply on days 0, 3, 7, 14 and 28

 – route of administration: IM, in the deltoid region; in children younger than 2 years old, it can be administered in the vastus lateralis region of the thigh

 – dose: 0.5 or 1 ml, depending on the manufacturer. The dose recommended by the manufacturer is independent of the patient’s age and weight.

c) sero-vaccination

Vaccine:

 – apply on days 0, 3, 7, 14 and 28

 – route of administration: IM, in the deltoid region; in children younger than 2 years old, it can be administered in the vastus lateralis region of the thigh

 – dose: 0.5 or 1 ml, depending on the manufacturer. The dose recommended by the manufacturer is independent of the patient’s age and weight.

Rabies serum or human rabies immunoglobulin:

 – apply on the first day of treatment (day 0)

 – route of administration: infiltrate the site of injury; if the amount is insufficient to infiltrate the entire lesion, they can be diluted in saline solution; if there is no anatomical possibility for the infiltration of the entire dose, a part, the smallest possible, should be applied in the gluteal region

 – Dose: anti-rabies serum (SAR – 40 IU/kg of weight), human anti-rabies immunoglobulin (HRIG – 20 IU/kg of weight)

There are also vaccination schemes in case it is necessary to interrupt treatment with the Fuenzalida & Palácios vaccine. In that case, treatment should be continued with vaccines produced in cell cultures or duck embryos. It is also important to emphasize that there are different vaccination procedures for patients who were re-exposed to the virus and used prophylactic or post-exposure treatment.

Table 1: schedule for patients who received modified Fuenzalida & Palácios vaccine for post-exposure treatment and were re-exposed to the virus.

According to Washington State University, it’s important to take the first dose within 24 hours of the sting.

Immunoglobulin administration is usually concurrent with post-exposure rabies vaccination.

Rabies vaccine storage, example of Nobivac
According to a study conducted by Washington State University and published in October 2016 in the specialist journal Vaccine, the rabies vaccine for dogs seems to remain effective even when not cold-preserved. In fact, WHO recommends that the vaccine be transported (“cold chain”) and stored at temperatures between 2°C (35.6°F) and 8°C (46.4°F). In Africa and South Asian countries where rabies exists, ensuring a “cold chain” and storage at the correct temperature is not always easy. But Dr. Lankester of Washington State University found that Nobivac vaccine, a widely used rabies vaccine, produced the same level of protective antibodies in dogs after being stored for 6 months at 25°C (77°F) and for 3 months at 30°C (86°F). In other words, the vaccine appears to be heat resistant. Vaccinating dogs against rabies is the best way to prevent rabies in humans.

Milwaukee Protocol (experimental rabies treatment)

The Milwaukee protocol is an experimental treatment against rabies, and consists of placing the patient in a state of induced coma, administering antiviral drugs, anesthetics, sedatives and replacing enzymes. According to this protocol, a young North American woman managed to be treated in 2004/2005. The Doctor. Rodney Willoughby, a pediatrician from the US state of Milwaukee, came up with the idea of ​​putting a 15-year-old patient suffering from rabies into a coma, because he thought the body could then use the energy normally used in the brain to fight. against the virus in other parts of the body. This brilliant idea saved the girl and confirmed her intuition, the body was able to fight the virus before it reached the brain and destroyed it.

In Brazil, in 2008, in a 15-year-old male patient, the Milwaukee protocol was a success and was the first case of cure of the disease in Brazil. A second successful case occurred in January 2018 in the Amazon, in a 14-year-old teenager (see also above in Epidemiology >> Brazil).
In 2018, it is estimated that 5 patients were cured by this protocol or by other identical treatment schemes, 2 in Brazil (2008 and 2018), 2 in the United States (2004 and 2011) and 1 in Colombia (2008). 🇧🇷In Colombia, however, the person later died, but from causes other than rabies.

Tips

Important
– In case of contact with a suspicious animal (e.g. bite), immediately wash the affected area with water and alkaline soap for 15 minutes and then disinfect with alcohol or iodine. A post-exposure prophylaxis vaccination against rabies should be given as soon as possible1.

Some tips about the disease:

1 – Wash the wound with soap and water, disinfect it with alcohol and tincture of iodine,

2 – Whenever possible, stop the simultaneous use of corticosteroids, antimalarials and immunosuppressants,

3 – Always remain vaccinated if you belong to a risk group,

4 – Look for a health center as soon as possible if you are bitten or scratched or come into contact with the saliva of an infected animal.

5 – Try to write down as much information as possible about the transmission of the disease. Try to find out what kind of animal bit you, whether it was domestic or wild, and whether that animal is in the vicinity.

6 – If the animal that bit you can be captured without causing any further injury to anyone, it is important that this is done.

7 – Do not kill the animal with blows or shots in the head, as this can make tests that identify whether or not the animal has rabies difficult. Wait to talk to a doctor and he will contact your local health departments to find out what should be done with the animal.

Prevention

– Prevention of rabies is through vaccination and periodic serology tests to verify antibody levels, which must be above 0.5 IU/mL.

– It is also important to vaccinate your pet (dogs, cats, etc.), since most of the transmission of rabies to humans is through dogs and cats.

– Never touch a wild animal that behaves abnormally, that appears sick or injured. The basic rule is to call the forest guard who will take care of the situation.
In case of a bat bite, it is always necessary to consult a doctor who will take the necessary prophylaxis measures.

Jeanne Kenney
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I’m a stylist trainer, a content creator, and an entrepreneur passion. Virgo sign and Pisces ascendant, I move easily between my dreams, the crazy world I want, and my feet on the ground to carry out my projects.

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