Kuduz Saha Rehberi (İngilizce)

REPUBLIC OF TURKEY
MINISTRY OF HEALTH
Turkish Public Health Institution
RABIES FIELD GUIDELINE
TURKEY-2014
Rabies Field Guideline
“This guideline is prepared and printed by Republic of Turkey, Ministry of Health, Turkish Public Health
Institution, Communicable Diseases Control Programmes Vice Precidency, Zoonotic and Vector Borne
Diseases Department . The copyright belongs to Turkish Public Health Institution.
2
Rabies Field Guideline
FOREWORD
Rabies is a zoonotic infectious disease of quite important in terms of public health.
Especially developing to a dramatic status after the emergence of the symptoms of
rabies, this makes people more sensitive to the disease and once again reminds the
importance of taking protection measures for the disease which is invariably fatal.
Thence, studies regarding rabies have been found to be important and have attracted attention at all times. Raising public knowledge and awareness on rabies
and rabies protection activities and pre-exposure and post-exposure prophylaxis
services are included in activities within the scope of preventive health care services
of our ministry.
Possible rabies exposures are known to show two different epidemiological features
in the world. These are the transmission of rabies only from wild animals as in the
USA and transmission of rabies mainly from domestic animals as in India. Rabies
prophylaxis recommendations for Turkey in this guideline has been developed by
taking into account the speciˉc data in Turkey and rabies prophylaxis guidelines of
the WHO and other countries.
Recommendations for possible rabies exposure prophylaxis as well as pre-exposure prophylaxis, general information about the disease, activities to be performed
in case of suspicious situation indicated with this guideline.
Wishing this guideline will be beneˉcial to our country and health personnel, I
thank sincerely to those who contributed in the preparation of this guideline.
Prof. Dr Seçil ÖZKAN
President of the Authority
3
Rabies Field Guideline
Scientiˉc working group members and the personnel of the Turkish Public Health
Institution involved in the preparation of this guideline are listed below in
alphabetical order by last name
6FLHQWLˉF:RUNLQJ*URXSDQG$XWKRUV
)irdevs AKTAČ, MD, Professor of Infectious Diseases and Clinical Microbiology
Orhan AYLAN, Veterinary MD
). Čebnem ERDèN‰, MD, Associate Professor of Infectious Diseases and
Clinical Microbiology
Ateč KARA, MD, Professor of Pediatric Infectious Diseases
Necla TÜLEK, MD, Professor of Infectious Diseases and Clinical Microbiology
*For her contributions at the allergy section, we thank to:
Zeynep MISIRLI*èL, MD, Professor of Allergy and Immunology
7XUNLVK3XEOLF+HDOWK$JHQF\3HUVRQQHO
Ebru AYDIN, MD
èsmet BATTAL, MD, Specialist of Infectious Diseases and Clinical Microbiology
Pénar DUMAN, Veterinary MD
Ayčeg¾l ERDOÜAN, MD, Specialist of Public Health
M. Fatih K܉ÜKÖZTAČ, MD, Specialist of Infectious Diseases and Clinical
Microbiology
Ahmet SAFRAN, Veterinary MD
Mesut SE‰ER, Veterinary MD
5
Rabies Field Guideline
CONTENTS
Foreword
Contents
Abbreviations
Rabies ....................................................................................................................................11
Rabies in Animals ...............................................................................................................11
ȧ 5DELHVLQ'RJV ........................................................................................................13
ȧ 5DELHVLQ&DWV .........................................................................................................14
ȧ 5DELHVLQ+RUVHV ....................................................................................................14
ȧ 5DELHVLQ&DWWOHV .....................................................................................................14
ȧ 5DELHVLQ6KHHSDQG*RDWV.................................................................................14
5DELHVLQ+XPDQV..............................................................................................................15
ȧ ,QFXEDWLRQ3KDVH ....................................................................................................16
ȧ 3URGURPDO3KDVH ..................................................................................................... 17
ȧ $FXWH1HXURORJLFDO3KDVH .................................................................................. 17
R(QFDSKDOLWLF5DELHV ................................................................................ 17
R3DUDO\WLF5DELHV .......................................................................................18
ȧ &RPD ..........................................................................................................................19
0HDVXUHVWREH7DNHQLQWKH)ROORZXSRI3DWLHQWVZLWK5DELHV ......................19
0DQDJHPHQWRI3DWLHQWVZLWK5DELHV .........................................................................19
%XULDO3URFHGXUHVLQ5DELHV5HODWHG'HDWKV............................................................20
/DERUDWRU\'LDJQRVLVRI5DELHV ....................................................................................20
ȧ )OXRUHVFHQW$QWLERG\7HFKQLTXH ......................................................................21
ȧ ([SHULPHQWDO$QLPDO,QRFXODWLRQ ....................................................................21
ȧ 7LVVXH&XOWXUH ..........................................................................................................22
ȧ 3RO\PHUDVH&KDLQ5HDFWLRQ.................................................................................22
6DPSOLQJLQ5DELHVDQG6KLSSLQJ ...............................................................................22
ȧ $QWHPRUWHP6DPSOHVWREH&ROOHFWHGIURP&DVHV
)ROORZHGZLWK6XVSLFLRQRI5DELHV ..................................................................23
ȧ 3RVWPRUWHP6DPSOHVWREH&ROOHFWHGLQ$XWRSV\IURP
3HRSOH'LHGRI6XVSLFLRQRI5DELHV .................................................................23
5DELHV3URSK\OD[LV ............................................................................................................24
3UH([SRVXUH3URSK\OD[LV ..............................................................................................24
ȧ 3HRSOHWREH$SSOLHG3UH([SRVXUH3URSK\OD[LV .......................................24
ȧ 9DFFLQDWLRQ$SSOLFDWLRQ0HWKRGDQG&DOHQGDULQ
3UH([SRVXUH3URSKOD[LV ...................................................................................24
3RVW([SRVXUH3URSK\OD[LV.............................................................................................25
R5DELHV5LVN([SRVXUH ..........................................................................25
R([SRVXUHV1RW5HTXLULQJ5DELHV3URSK\OD[LV..............................26
R3RVW([SRVXUH$SSURDFK .....................................................................26
7
Rabies Field Guideline
o Wound Care ............................................................................................... 27
o $QWLELRWLFV3URS\OD[LV ............................................................................28
o 7HWDQXV3URS\OD[LV ..................................................................................29
o 5DELHV9DFFLQDWLRQ$SSOLFDWLRQ ..........................................................30
o ,PPXQRJOREXOLQ$SSOLFDWLRQ ..............................................................31
o 3RVW([SRVXUH3URSK\OD[LVIRU7KRVH9DFFLQDWHGLQ
3UH([SRVXUH ............................................................................................34
o &DVHV1RW5HTXLULQJ5DELHV,PPXQRJOREXOLQLQ
&DWHJRU\,,,DQG,9..................................................................................34
$GYHUVH(YHQWV)ROORZLQJ,PPXQL]DWLRQ ..................................................................35
Tables and Figures:
7DEOH5DELHV&DVHV,GHQWLˉHGEHWZHHQE\$QLPDO6SHFLHV ...12
)LJXUH'LVWULEXWLRQRI3RVVLEOH5DELHV([SRVXUHVDQG5DELHV
&DVHVE\<HDUV ..........................................................................15
7DEOH7HWDQXV3URSK\OD[LVLQ3RVVLEOH5DELHVH[SRVXUH ..............................29
7DEOH3URSK\OD[LVLQ3RVVLEOH5DELHV([SRVXUH...............................................32
7DEOH5DELHV3URSK\OD[LVLQ,PPXQRVXSSUHVVHG3HRSOH ...............................34
7DEOH$QLPDO5DELHV'LDJQRVLV&HQWHUV ................................................................36
Annexes:
$QQH[5$%,(66$03/(/$%25$725<'(/,9(5<)250 ................................. 37
$QQH['LVWULEXWLRQRI$QLPDO5DELHV&DVHV
7XUNH\ ..............................................................38
References ...........................................................................................................39
8
Rabies Field Guideline
ABBREVIATIONS
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9
Rabies Field Guideline
RABIES
7KH ˉUVW NQRZOHGJH DERXW UDELHV RQH RI WKH ROGHVW GLVHDVHV LQ KXPDQ
KLVWRU\LVIRXQGLQWKHODZVRIDQFLHQW0HVRSRWDPLDFLYLOL]DWLRQ%DE\ORQLD,Q
WKHVHHSLJUDSKVZKLFKZHUHSUHSDUHGDERXW\HDUVDJRLWLVLQGLFDWHG
WKDWEHLQJELWWHQE\VLFNDQLPDOVZRXOGUHVXOWE\GHDWKDQGWKXVDQLPDOV
VKRXOGEHWDNHQXQGHUFRQWURO
5DELHVLVDYLUDO]RRQRWLFGLVHDVHZKLFKFDXVHVHQFHSKDOLWLVLQPRVWSHRSOH
DQGPDPPDOV$OOZDUPEORRGHGDQLPDOVFDQEHLQIHFWHGZLWKUDELHVYLUXV
EXWQRWDOODQLPDOVDUHHTXDOO\YXOQHUDEOHWRWKHUDELHVYLUXV,QDGGLWLRQWR
WKLVSRVWH[SRVXUHWUDQVPLVVLRQULVNDOVRYDULHVDPRQJVSHFLHV)RUH[DPSOH
DZROIIR[DQGMDFNDOZLWKUDELHVFRPSULVHVWKHKLJKHVWULVNJURXSZKLOHGRJ
H[SRVXUHLVLQWKHPLGGOHJURXSLQWHUPVRIUDELHVULVN+RZHYHUGRJVDUHVWLOO
WKHPRVWLPSRUWDQWUHVHUYRLUVIRUWKHWUDQVPLVVLRQRIUDELHVLQPDQ\UHJLRQVLQ
WKHZRUOGHVSHFLDOO\LQGHYHORSLQJFRXQWULHV
'HYHORSPHQWULVNRIWKHGLVHDVHLVORZLQWKHH[SRVXUHRIDVXSHUˉFLDOZRXQG
WRLQIHFWLRXVVDOLYDZKLOHLWLVDOPRVWLQELWHVLQWKHKHDGDQGQHFNE\DQ
LQIHFWHGZROI%HLQJELWWHQE\DUDELGDQLPDODQGHYHQH[SRVXUHRILQIHFWLRXV
VDOLYDWRLQWDFWPXFRVDUHVXOWZLWKLQIHFWLRQDWDUDWHRIDERXW
5DELHVLVVWLOODIDWDOGLVHDVHWRGD\HYHQWKRXJKLWVDJHQWDQGSDWKRJHQ
HVLVZHUHLGHQWLˉHGDOPRVWDFHQWXU\DJR7KHUHDUHVHYHQFDVHVLQWKHOLWHUDWXUHZKLFKZHUHUHSRUWHGWRKDYHUHFRYHUHGDIWHUFOLQLFDOUDELHVGHYHORSHG
EXWWKHUHDUHGRXEWVFRQFHUQLQJWKHGLDJQRVLVRIVRPHFDVHV
RABIES IN ANIMALS
$QLPDOVSHFLHVWKDWFDQGHYHORSUDELHVLQRXUFRXQWU\DUHGRPHVWLFDQ
LPDOVVXFKDVdog, cat, cattle, sheep, goat, horse and donkey and wild animals
VXFKDVwolf, fox, jackal, pig, bear, marten, skunk and weasel. 7KHUHKDVEHHQQR
UHSRUWHGUDELHVWUDQVPLVVLRQWRKXPDQVWKURXJKPRXVHUDWVTXLUUHOKDPVWHU
JXLQHDSLJJHUELOOXVUDEELWDQGZLOGUDEELWELWHVLQRXUFRXQWU\DQGLQWKHZRUOG
DFFRUGLQJWRWKHFXUUHQWGDWD7KXVSURSK\OD[LVLVQRWQHFHVVDU\IRUVXFKDQLPDOELWHVXQOHVVLQVWLWXWLRQVGHDOLQJZLWKDQLPDOKHDOWKUHSRUWVSHFLˉFGDWD
:RUOGZLGHGRJVDUHFRQVLGHUHGWREHUHVSRQVLEOHDVWKHVRXUFHRIUDELHVDWD
11
Rabies Field Guideline
UDWHRIZKLOHFDWVDUHRWKHUSHWVDUHEDWVDUHDQGRWKHUZLOG
DQLPDOVDUHOHVVWKDQ,Q7XUNH\LWLVREVHUYHGWKDWRIUDELGDQLPDOV
DUHGRPHVWLFDQLPDOVDQGDPRQJWKHVHGRJVWDNHWKHˉUVWSODFHZLWK
DFFRUGLQJWRWKHDVVHVVPHQWRIODVWWZRGHFDGHVGDWD7DEOH7KHVHFDVHV
DUHJHRJUDSKLFDOO\PRVWO\UHSRUWHGIURP$HJHDQ0DUPDUD(DVWHUQ$QDWROLD
DQG6RXWKHDVWHUQ$QDWROLDUHJLRQV$VRIUDELHVFDVHQRWLˉFDWLRQVIURP
WKH&HQWUDO$QDWROLDQ5HJLRQEHJXQDVZHOO0RUHRYHUVRPHPDPPDOVZKLFK
DUHEURXJKWIURPDEURDGDQGQRWSDUWRIWKHFRXQWU\ȠVIDXQDDOVRSRVHD
ULVNLQWHUPVRIUDELHVPRQNH\HWF5DELHVULVNVKRXOGEHWDNHQLQWRDFFRXQW
LQFRQWDFWVZLWKVXFKDQLPDOV
Table . Distribution of Conˉrmed Rabid Animal Species from Samples
Between 1991- 2013 Collected by Etlik Veterinary Control Central
Research Institute
Animal Species
'RJ
Cat
2WKHU'RPHVWLFDQLPDOV
'RPHVWLF$QLPDOV7RWDO
Wild Animals Total
Total
Number
3156
205
1594
4955
364
5319
%
,Q DQLPDOV WKH LQIHFWLRQ HPHUJHV LQ WKUHH SKDVHV LQ WKH FODVVLFDO UDELHV
FRXUVH
3URGURPDO 3KDVH 7UDQTXLOLW\ SHULRG7KLV SKDVH LV FKDUDFWHUL]HG ZLWK
EHKDYLRUDOFKDQJHV,WGHYHORSVYHU\VORZO\7LPLGLW\DQGQHUYRXVQHVVDUHWKH
PRVWLPSRUWDQWV\PSWRPV$GGLWLRQDOO\HVWUDQJHPHQWIURPKRPHHDWLQJIRUHLJQREMHFWVDQGGLIˉFXOW\LQVZDOORZLQJDUHREVHUYHG7KHSKDVHODVWVIRUWR
GD\V
$WWDFNHU 3KDVH )XULRXV 3KDVH 5HVWOHVVQHVV LQFUHDVHV LQ DQLPDOV
WKHUHVHHPWREHDGHVLUHIRUELWLQJ5DJHLVREVHUYHGLQWKLVJHQHUDOO\VORZO\
SURJUHVVLYHSKDVH
12
Rabies Field Guideline
3DUDO\WLFSKDVH3HULRGRISDUDO\VLV,QWKLVSKDVHZKLFKRFFXUVMXVWEHIRUH
WKHGHDWKSDUDO\VLVGHYHORSVLQIDFLDOPXVFOHVERG\DQGIRRWPXVFOHV7KHDQLPDOEHFRPHVXQDEOHWRWDNHIHHGDQGZDWHUEHFDXVHRIPDQGLEXODUSDUDO\VLV
7KHSKDVHODVWVIRUWRGD\VDQGIROORZHGE\GHDWK
5DELHVFRXUVHZLWKRXWDWWDFNHUSKDVHLVFDOOHGWUDQTXLOUDELHV7KHGLVHDVH
ODVWVIRUWRGD\VDQGGHDWKRFFXUV
In studies investigating the pathogenesis of rabies in dogs and cats, rabies
symptoms appear within 10 days after virus reaches the salivary glands from
central nervous system and animal dies. In other words, if the biting animal
contains virus in its saliva, it would be expected to die within 10 days. (Therefore it is recommended to observe cats and dogs for 10 days.) Such a period
in animals except cats and dogs can not be granted and the observation is not
recommended.
Rabies in Dogs:
$OOWKUHHSKDVHVRIWKHGLVHDVHFDQEHREVHUYHGLQGRJV7KHUHLVQRWDFOHDU
ERXQGDU\EHWZHHQWKHVHSKDVHVWKH\HQVXHHDFKRWKHU$YHUDJHLQFXEDWLRQSHULRGLVWRZHHNV7KHGLVHDVHZKLFKLVFKDUDFWHUL]HGZLWKDSHULRGRIUHSOLFDWLRQRIWKHYLUXVLQWKHFHQWUDOQHUYRXVV\VWHPDQGVSUHDGLQJWRSHULSKHUDO
RUJDQVWKDWGHYHORSVSURJUHVVLYHQHUYRXVV\PSWRPVUHVXOWVLQGHDWKLQWR
GD\V5HVWOHVVQHVVLVWKHPRVWVLJQLˉFDQWV\PSWRPRIWKHUDELHVDFFRPSDQLHG
ZLWKUDJH7KHUDELGDQLPDOJHWVH[FLWHGDVLIVXGGHQO\DURXVHGZKHQH[SRVHGWRIDLQWVRXQGDQGOLJKW,WORVHVLWVGLVWLQFWLYHEHKDYLRUVEHJLQWR
PDNHDEQRUPDOVRXQGVDQGELWLQJJHVWXUHV,WHDWVIRUHLJQREMHFWV,WKDV
GLIˉFXOW\LQVZDOORZLQJGXHWRSDUDO\VLVLQSKDU\QJHDOPXVFOHV7KHUHIRUHWKH
DQLPDOFDQQRWVZDOORZLWVVDOLYDDQGORWVRIVDOLYDFRPHVRXWRILWVPRXWK,ILW
GRHVQRWGLHLQWKLVSKDVHWKHSDUDO\WLFSKDVHEHJLQV7KHSDUDO\VHVVSUHDG
WKHZKROHERG\EHJLQQLQJIURPKLQGOHJV7KHDQLPDOGLHVLQWRGD\VDV
LWFDQQRWHDW
13
Rabies Field Guideline
Rabies in Cats:
&DWVDUHDOVRTXLWHVXVFHSWLEOHWRUDELHVDQGVKRZFOLQLFDOV\PSWRPVVLPLODUWRWKRVHRIGRJV7KHSDUDO\VLVEHJLQVLQWRGD\VDIWHUWKHRQVHWRIˉUVW
V\PSWRPV&RQWLQXRXVKXVNLO\PHRZLQJLVDQRWKHUVLJQRIWKHGLVHDVHLQ
FDWV6LFNFDWVKLGHDQGFURXFKHVDWFRUQHUV5DELGFDWVDUHPRUHGDQJHURXVWKDQ
GRJVWRKXPDQVDQGRWKHUDQLPDOV
Rabies in Horses:
&OLQLFDOV\PSWRPVRIUDELHVLQKRUVHVDUHVLPLODUWRWKHV\PSWRPVRIWHWDQXV
,QWKHHDUO\VWDJHVRIWKHGLVHDVHWKH\JQDZRUUXEWKHZRXQGHGDUHD7KHQWKH\
VKRZDJJUHVVLRQIRUDVKRUWWLPH7KHQLWLVIROORZHGE\SURJUHVVLYHSDUDO\VLV
YRPLWLQJDQGQDVDOGLVFKDUJHFRQWUDFWLRQLQWKHKLQGOHJVDWD[LDDQGˉQDOO\
GHDWK
Rabies in Cattles:
,QIHFWHG FDWWOH XVXDOO\ VKRZ VLJQV RI UHVWOHVVQHVV H[FLWHPHQW DQG DJJUHV
VLRQ&RQVWDQWSDZLQJPRRLQJELWLQJJHVWXUHDQGVWUXJJOHIRUHVFDSLQJWKH
EDUQDUHREVHUYHG7KH\WU\WRHDWDEQRUPDOREMHFWVPDNHELWLQJJHVWXUH7KH\
DWWDFNRWKHUDQLPDOVLQWKHKHUGDQGPRYLQJREMHFWVDQGIDOORYHUWKHLUVWHU
QXPRUVLGH7KHKHDGIDOOVRQWKHVLGHRYHUWKHVKRXOGHU0RUHRYHUVDOLYDWLRQ
DEGRPLQDOSDLQGLDUUKHDGHFUHDVHLQPLONSURGXFWLRQLWFKLQJDQGH[FHVVLYH
ZHLJKWORVVDUHREVHUYHG$IWHUWKHV\PSWRPVRIWKHGLVHDVHIRUPHGWKHGHDWK
RFFXUVLQWRGD\V
Rabies in Sheep and Goats:
&OLQLFDOV\PSWRPVDUHVLPLODUWRWKHV\PSWRPVLQFDWWOHVLFNDQLPDOVDUH
UHVWOHVVDQGDJJUHVVLYH,QDGGLWLRQWRWKLVV\PSWRPVOLNHG\VSQHDOLSOLFNLQJ
DQGLQFUHDVHLQVH[XDOGHVLUHDUHREVHUYHG
&OLQLFDOV\PSWRPVRIUDELHVHVSHFLDOO\LQFDWWOHDQGRWKHUUXPLQDQWVSHFLHV
VKRZJUHDWVLPLODULWLHVZLWKRWKHUGLVHDVHVWKDWFDXVHQHXURORJLFDOV\PSWRPV
6SRQJLIRUPHQFHSKDORSDWKLHVSVHXGRUDELHV$XMHV]N\ȠVGLVHDVHOLVWHULRVLVSDUDVLWHLQIHVWDWLRQVOLNH&RHQXUXVFHUHEUDOLVRUJDQRSKRVSKDWHSRLVRQLQJHWF
14
Rabies Field Guideline
,QFDVHRIVXVSHFWHGUDELHVLQDQLPDOVDQLPDOVSHFLPHQVDPSOLQJDQGVKLSSLQJSURFHGXUHVDUHFDUULHGRXWE\WKHRIˉFLDO9HWHULQDULDQVRIWKH0LQLVWU\RI
)RRG$JULFXOWXUHDQG/LYHVWRFNLQDFFRUGDQFHWRWKHOHJLVODWLRQV
RABIES IN HUMANS
5DELHVLVD]RRQRWLFDFXWHSURJUHVVLYHYLUDOHQFHSKDORP\HOLWLVZKLFKLV
FDXVHGE\DQHXURWURSLF51$YLUXVRIWKH/\VVDYLUXVJHQXVLQ5KDEGRYLULGDH
IDPLO\7KHYLUXVLVYXOQHUDEOHWRH[WHUQDOHQYLURQPHQWFRQGLWLRQV6LQFHLWLV
DQHQYHORSHGYLUXVLWLVVXVFHSWLEOHWRPRVWRIWKHOLSLGVROYHQWV
5DELHVLVDZLGHO\GLVWULEXWHGLQIHFWLRQZRUOGZLGHH[FHSWVRPHLVODQGFRXQWULHV,WLVNQRZQWKDWDQQXDOO\DERXWSHRSOHDUHGLDJQRVHGZLWKUDELHV
WKURXJKRXWWKHZRUOG7KHGLVHDVHFDXVHVJUHDWSUREOHPVSDUWLFXODUO\LQ$VLD
$IULFDDQG/DWLQ$PHULFD,WLVHVWLPDWHGWKDWDQQXDO\SHRSOHLQ$VLD
DQGSHRSOHLQ$IULFDDUHLQIHFWHGZLWKUDELHVYLUXV
2XU FRXQWU\ LV VWLOO DQ HQGHPLF UHJLRQ LQ WHUPV RI UDELHV $QQXDO\ DERXW
SRVVLEOHUDELHVH[SRVXUHVDUHUHSRUWHGDQGDQDYHUDJHRIRQHWRWZR
UDELHVFDVHRFFXUV)LJXUH
Figure 1: Distribution of Possible Rabies Exposures and Rabies Cases by
Years (1998-2013)
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+RZHYHUPRVWVLJQLˉFDQWKRVWLQGHYHORSLQJFRXQWULHVLVGRJV:KLOHWKHYLUXV
LV NQRZQ WR EH WUDQVPLWWHG WKURXJK FRUQHDO WUDQVSODQW UDELHV WUDQVPLVVLRQV
WKURXJK VROLG RUJDQ WUDQVSODQWV KDYH EHHQ UHSRUWHG LQ WKH 8QLWHG 6WDWHV RI
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15
Rabies Field Guideline
,WFDQWDNHGD\VRUZHHNVIRUWKHUDELHVYLUXVWRUHDFKWKHFHQWUDOQHUYRXV
V\VWHPDIWHULWVLQRFXODWLRQLQWRWKHZRXQGVLWH)RUWKLVUHDVRQSRVWH[SRVXUH
SURSK\OD[LVFRXOGEHSUHYHQWLYH$IWHUWKHYLUXVXQGHUJRHVUHSOLFDWLRQLQWKH
PXVFOHFHOOVQHDUWKHZRXQGVLWHLWPLJUDWHVWRWKHSHULSKHUDOQHUYHVWKURXJK
DFHW\OFKROLQHUHFHSWRUV$IWHUWKLVVWDJHLWLVLPSRVVVLEOHWRVWRSWKHGLVHDVH
ZLWKYDFFLQDWLRQDQGLPPXQRJOREXOLQ%HIRUHWKLVVWDJHLQHDUOLHUSHULRGWKH
YLUXVFDQEHQHXWUDOL]HGE\QHXWUDOL]LQJDQWLERGLHVGHYHORSHGDJDLQVW*SURWHLQ7KHYLUXVWUDYHOVIURPWKHSHULSKHU\WRWKHFHQWHUZLWKDVSHHGRI
PPGD\$IWHULWUHDFKHVWKHFHQWUDOQHUYRXVV\VWHPLWEHJLQVWRVSUHDG
LQWKHRSSRVLWHZD\DQGVWDUWVWRUHSOLFDWHLQWKHQHUYHVRIDOPRVWDOOWLVVXHV
SDUWLFXODUO\LQVDOLYDU\JODQGV7KXVWKHWUDQVPLVVLRQFLUFOHRIWKHLQIHFWLRQLV
FRPSOHWHGE\WKHH[FUHWLRQRIUDELHVYLUXVZLWKVDOLYD7KHˉUVWLQYROYHGDUHD
LQWKHEUDLQLVOLPELFV\VWHPVRH[FLWDELOLW\DQGDJLWDWLRQDUHREVHUYHG6LQFH
HQFHSKDOLWLVGHYHORSVODWHUWKHSDWLHQWLVFRQVFLRXVZKHQWKHOLPELFV\VWHP
LVLQYROYHGDQGXQOLNHRWKHUHQFHSKDOLWLVH[FLWDELOLW\DQGDJLWDWLRQGHYHORSV
7KHFOLQLFDOSUHVHQWDWLRQRIUDELHVGLIIHUVIURPRWKHUHQFHSKDOLWLVLQPDQ\
DVSHFWV'LVHDVHȠVFOLQLFFDQEHDQDO\]HGLQˉYHSKDVHVDIWHUWKHLQIHFWLRQGHYHORSHG7KHVHSKDVHVDUHUHVSHFWLYHO\LQFXEDWLRQSURGURPDODFXWHQHXURORJLFDOFRPDDQGGHDWK7KHFOLQLFDOSUHVHQWDWLRQLQWKHDFXWHQHXURORJLFDOSKDVH
GHYHORSVLQWZRIRUPVHQFDSKDOLWLFIXULRXVDQGSDUDO\WLFSDUDO\VLVUDELHV
Incubation Phase:
5DELHVKDVWKHPRVWYDULDEOHLQFXEDWLRQSHULRGZLWKLQWKHFHQWUDOQHUYRXV
V\VWHPLQIHFWLRQV7KHLQFXEDWLRQSHULRGYDULHVDFFRUGLQJWRWKHDPRXQWDQG
YLUXODQFHRIWKHYLUXVSUR[LPLW\RIWKHZRXQGWRWKHFHQWUDOQHUYRXVV\VWHP
DQGGHQVLW\RIWKHQHUYHWLVVXHLQWKHVLWHWKHVL]HRIWKHZRXQGDQGSURWHFWLYHPDWHULDOLQWKHZRXQGVLWHVXFKDVFORWKDQGJORYHV:KLOHLQFXEDWLRQ
SHULRGLVUHODWLYHO\ORQJLQPRVWFDVHVWRPRQWKVLWLVWRGD\VLQ
RIWKHFDVHVDQGUDUHO\PRUHWKDQ\HDU+RZHYHUGXUDWLRQVOHVVWKDQ
GD\VDQGXSWR\HDUVKDYHEHHQUHSRUWHGDVFDVHVLQWKHOLWHUDWXUH7KHORQJHVW
LQFXEDWLRQSHULRGSXEOLVKHGLV\HDUV
16
Rabies Field Guideline
Prodromal Phase:
7KHˉUVWDQGHDUO\V\PSWRPVRIWKHUDELHVDUHWKHLQGLFDWRURIYLUXVDUULYDOWRWKHFHQWUDOQHUYRXVV\VWHPDQGGRUVDOURRWJDQJOLRQ7KHVHQRQVSHFLˉF
V\PSWRPVVKRZWKHPVHOYHVXSDVIHYHUDEGRPLQDOSDLQDQGJDVWURLQWHVWLQDOGLVFRPIRUW,WLVLPSRVVLEOHWRGLDJQRVHUDELHVLQKXPDQVXQOHVVFOLQLFDOV\PSWRPV
DSSHDU+RZHYHUQXPEQHVVSDUDHVWKHVLDWLFNOLQJDQGEXUQLQJVHQVDWLRQDW
WKHELWHVLWHRUH[WUHPLW\LVLQYDOXDEOHIRUWKHGLDJQRVLVRIUDELHV7KHVHORFDO
V\PSWRPVLQSURGURPDOSKDVHFDQVSUHDGˉUVWO\LQWRWKHZKROHH[WUHPLW\DQG
WKHQDORQJQHFNDQGIDFH/RFDOV\PSWRPVFDQEHREVHUYHGLQERWKHQFHSKDOLWLF
DQGSDUDO\WLFUDELHVIRUPV7KRXJKQRWVHHQLQHYHU\FDVHLQFDVHRIGHWHFWLRQLWLV
RQHRIWKHPRVWLPSRUWDQWˉQGLQJVWRGLVWLQJXLVKUDELHVIURPRWKHUHQFHSKDOLWLV
Acute Neurologic Phase:
7KHFOLQLFDOV\PSWRPVRISDWLHQWVSURJUHVVWRWKHDFXWHQHXURORJLFSKDVH
IURPSURGURPDOSKDVHLQKRXUVRUDFRXSOHRIGD\V:KLOHDERXWRISD
WLHQWVLQWKLVSKDVHH[KLELWV\PSWRPVRIHQFHSKDOLWLFUDELHVWKHUHPDLQLQJ
KDYHFKDUDFWHULVWLFVRISDUDO\WLFGLVHDVHV\PSWRPVVLPLODUWR*XLOODLQ%DUU«
6\QGURPH*%6:KLOHGHDWKLQSDWLHQWVZLWKHQFHSKDOLWLFV\PSWRPVXVXDOO\
RFFXUVLQGD\VIROORZLQJWKHRQVHWRIFOLQLFDOV\PSWRPVLQDYHUDJHLQWKH
WKGD\WKHDYHUDJHWLPHLVGD\VIRUSDWLHQWVZLWKSDUDO\WLFGLVHDVH7KHUHDOVR
KDYHEHHQFDVHVWKDWWRZHHNVRIOLIHVSDQZDVUHSRUWHGLQHQFHSKDOLWLFIRUP
Encephalitic Rabies:
)LUVWQHXURORJLFV\PSWRPVREVHUYHGLQWKLVFOLQLFDOIRUPRIUDELHVDUHLUULWD
ELOLW\IHDUDQGUXVKZKLFKGHYHORSLQJZLWKLQWHUQDOVWLPXOLVXFKDVWKLUVWDQG
IHDUDQGH[WHUQDOVWLPXOLVXFKDVOLJKWVRXQGDQGQRLVH7KLVSKDVHLVDOZD\V
DFFRPSDQLHGZLWKIHYHUDVWKHFRQVWDQWV\PSWRP,WFRXOGEHJLQLQSURGURPDO
SKDVHDQGFRQWLQXHWRHQFHSKDOLWLFSKDVHRUFRXOGQHZO\GHYHORSHG$QGDGGLWLRQDOO\WKUHHPDLQV\PSWRPVDUHREVHUYHG
1. Changing in Level of Consciousness: 7KHPHQWDOVWDWXVRIWKHSDWLHQWYDULHVEHWZHHQDJLWDWLRQDQGUHODWLYHO\QRUPDORUGHSUHVVLYHVWDWHVSURJUHVVLYHO\
EHFRPLQJPRUHVHULRXVLQIROORZLQJHSLVRGH7KHSDWLHQWVXGGHQO\EHFRPHV
FRQIXVHGDQGGLVRULHQWHGZLWKRXWDQ\UHDVRQRUVWLPXOXV+LVXQGHVLUHG
17
Rabies Field Guideline
XQSOHDVDQWDQGDJJUHVVLYHDFWLRQVODVWIRURQHRUDFRXSOHRIPLQXWHVDQG
WKHQVWRS:KHQKHUHWXUQVWRKLVUHODWLYHO\QRUPDOVWDWHKHGRHVQRWUHPHPEHUVXFKDFWLRQV+LVDJLWDWLRQSHULRGLQFUHDVHVZKLOHWKHSHULRGRIZHOOEHLQJVKRUWHQVZLWKHYHU\SDVVLQJKRXU7KHSDWLHQWIDOOVWLUHGDQGH[KDXVWHG
EHWZHHQDJLWDWLRQSHULRGVEXWKHFDQUHDFWWRVWLPXOL/RVVRIFRQVFLRXVQHVV
DQGFRPDGHYHORSZLWKWKHSURJUHVVLRQRIWKHGLVHDVHFOLQLF
2. Phobic and inspiratory spasm: $HURSKRELDDQGK\GURSKRELDGHYHORSLQ
DOOSDWLHQWVLQHQFHSKDOLWLFIRUPEXWDHURSKRELDLVQRWREVHUYHGLQHDFKSKDVH
RIWKHFOLQLFDOFRXUVHRIWKHGLVHDVH6XFKSKRELDVFDQEHUHYHDOHGE\EORZLQJ
LQWRWKHIDFHRUFKHVWRIWKHSDWLHQWFUHDWLQJDLUˊRZXVLQJDIDQRUHYHQE\
KROGLQJ D FXS RI ZDWHU 'HYHORSLQJ UHDFWLRQ LV FKDUDFWHUL]HG ZLWK WKH FRQWUDFWLRQRIDFFHVVRU\UHVSLUDWRU\PXVFOHVDQGGLDSKUDJPDQGQHFNˊH[LRQDQG
H[WHQVLRQ5DUHO\RSLVWRWRQXVFDQGHYHORS
3. Autonomic dysfunction: +\SHUVDOLYDWLRQLVVHHQLQDOPRVWHYHU\SDWLHQW
DQGFRQWLQXHVXQWLOSUHWHUPLQDOSKDVH5DWKHUWKDQGLIˉFXOW\LQVZDOORZLQJDQ
LQFUHDVHLQVDOLYDWLRQLVQRWDEOH3XSLOODU\LUUHJXODULWLHVFDQEHGLVFHUQHGZLWK
WKHSURJUHVVRIFOLQLFDOV\PSWRPV1HXURORJLFSXOPRQDU\HGHPDSLORHUHFWLRQ
H[FHVVLYH VZHDWLQJ SULDSLVP DQG HYHQ VSRQWDQHRXV HMDFXODWLRQ FDQ EH REVHUYHG&UDQLDOQHUYHLQYROYHPHQWGRHVQRWRFFXUH[FHSWYHU\UDUHFDVHV
Paralytic rabies:
7KHGLDJQRVLVRISDUDO\WLFUDELHVLVPRUHGLIˉFXOWWKDQHQFHSKDOLWLFIRUPVLQFH
QRDJLWDWLRQDQGFKDQJHLQFRQVFLRXVQHVVDUHREVHUYHG0DLQV\PSWRPVVHHQ
LQHQFHSKDOLWLFIRUPFDQGHYHORSPRUHPLOGO\LQWKHODWHUVWDJHVRIWKHFOLQLF
:KLOHSKRELFVSDVPVDUHREVHUYHGLQKDOIRIWKHSDWLHQWVLQVSLUDWRU\VSDVPVDUH
GHWHFWHGLQDOOSDWLHQWVLQSUHWHUPLQDOVWDJH:HDNQHVVDQGIHHEOHQHVVV\PSWRPVXVXDOO\EHJLQDWWKHELWWHQH[WUHPLW\DQGSURJUHVVLYHO\DIIHFWVDOOH[WUHPLWLHVDQGWKHQUHVSLUDWRU\DQGSKDU\QJHDOPXVFOHV%LODWHUDOIDFLDOSDUDO\VLVLV
FRPPRQSDUWLFXODUO\ZKHQWKHELWHLVLQWKHIDFHDQGKHDGIDFLDOSDUDO\VLVDQG
RFXORPRWRUSDUDO\VLVGHYHORSPRUHRIWHQ+RZHYHUWKHUHLVQRUHODWLRQEHWZHHQ
WKHELWHVLWHDQGGHYHORSLQJRIUDELHVLQSDUDO\WLFRUHQFHSKDOLWLFIRUP3DUDO\WLF
UDELHVFDQEHFRQIXVHGZLWKVSRUDGLF*%6GXHWRVXFKFKDUDFWHULVWLFV
18
Rabies Field Guideline
Coma:
,WLVYHU\GLIˉFXOWWRGLDJQRVHUDELHVZKHQWKHGLVHDVHSURJUHVVHVWKLVVWDJH
$OWKRXJKWZRIRUPVRIUDELHVRFFXULQGLIIHUHQWSHULRGVWKH\UHVXOWLQDVLPLODU
FRPDVWDWH$XWRQRPLFLQYROYHPHQWV\PSWRPVVXFKDVUHVSLUDWRU\GLVRUGHUV
UK\WKPLUUHJXODULWLHVDQGSXSLOODU\V\PSWRPVFDQEHUHPDUNDEOH,QRI
WKHSDWLHQWVKHPDWHPHVLVFDQGHYHORSZLWKLQWRKRXUVEHIRUHGHDWK
MEASURES TO BE TAKEN IN THE FOLLOW-UP OF PATIENTS WITH RABIES
6WDQGDUGLQIHFWLRQFRQWUROPHDVXUHVH[SRVXUHPHDVXUHVLQFDVHVRIFRQWDFW
ZLWK ERG\ ˊXLGV DQG PXFRXV PHPEUDQHV RI SDWLHQW VKRXOG EH WDNHQ LQ WKH
IROORZXSRISDWLHQWVZLWKUDELHVULVN5DELHVLPPXQL]DWLRQVKRXOGEHDSSOLHG
LQFDVHVRIELWLQJVFUDWFKLQJE\DSDWLHQWZLWKUDELHVRUH[SRVXUHRIPXFRVDRU
RSHQZRXQGVWRWKHVDOLYDRIWKLVSDWLHQW
MANAGEMENT OF PATIENTS WITH RABIES
9DFFLQDWLRQDQGLPPXQRJOREXOLQDSSOLFDWLRQLVQRWDGYLVHGDIWHUWKHGHYHORSPHQWRIFOLQLFDOV\PSWRPV
7KHIROORZXSRIVXFKSDWLHQWVVKRXOGEHFDUULHGRXWLQKHDOWKFHQWHUVZLWK
LQIHFWLRXVGLVHDVHVRUSHGLDWULFLQIHFWLRXVGLVHDVHVVSHFLDOLVWDQGQHXURORJ\RU
SHGLDWULFQHXURORJ\VSHFLDOLVWDFFRUGLQJWRWKHDJHJURXSDQGZKHUHSDWLHQWFDQ
EHSURYLGHGZLWKLQWHQVLYHFDUHIDFLOLWLHVLQLVRODWLRQ
6WDQGDUGLQIHFWLRQFRQWUROPHDVXUHVH[SRVXUHPHDVXUHVLQFDVHVRIFRQWDFW
ZLWK ERG\ ˊXLGV DQG PXFRXV PHPEUDQHV RI SDWLHQW VKRXOG EH WDNHQ LQ WKH
IROORZXSRISDWLHQWVZLWKUDELHVULVN5DELHVLPPXQL]DWLRQVKRXOGEHDSSOLHG
LQFDVHVRIELWLQJVFUDWFKLQJE\DSDWLHQWZLWKUDELHVRUH[SRVXUHRIPXFRVDRU
RSHQZRXQGVWRWKHVDOLYDRIWKLVSDWLHQW
7KHUHLVQRWDGLVWLQFWLYHWUHDWPHQWIRUUDELHVDIWHUWKHGHYHORSPHQWRILWV
FOLQLFDOV\PSWRPV
19
Rabies Field Guideline
Burial procedures in deaths due to rabies : ,QWKHGHDWKRISDWLHQWVZLWKUD
ELHVLWLVQRWQHFHVVDU\WRWDNHVSHFLDOPHDVXUHVDQGDSSO\UDELHVSURSK\OD[LV
LQSHRSOHZKRSUHSDUHDQGEDWKWKHGHFHDVHGLQDGGLWLRQWRVWDQGDUGLQIHFWLRQ
SUHYHQWLRQPHDVXUHVLQSUHSDUDWLRQDQGEXULDOSURFHVV%XULDOLQDFFRUGDQFH
WRVWDQGDUGVDQGOHJLVODWLRQV5HJXODWLRQVIRUWKH&RQVWUXFWLRQRI&HPHWHULHV
DQG7UDQVSRUWDWLRQDQG%XULDO3URFHGXUHVLQ)XQHUDOVLVVXIˉFLHQWLQRUGHUWR
SUHYHQWJUDYHVRSHQLQJE\DQLPDOVDQGWRSUHYHQWWUDQVPLVVLRQ
LABORATORY DIAGNOSIS OF RABIES
5DELHVV\PSWRPVDUHFKDUDFWHULVWLFLQPDQ\FDVHVEXWGHˉQLWLYHGLDJQRVLVRI
UDELHVLVGRQHE\ODERUDWRU\FRQˉUPDWLRQ
Tests used in rabies diagnosis;
% +LVWRSDWKRORJLF([DPLQDWLRQ6HOOHUV*LHPVD0DQQ6WDLQ
% )OXRUHVFHQW$QWLERG\7HFKQLTXH)$7
% ([SHULPHQWDO$QLPDO,QRFXODWLRQ
% (OHFWURQPLFURVFRS\
% ,PPXQRSHUR[LGDVH
% 5DSLG7HVWEDVHGRQWKHSULQFLSOHRI(/,6$5DSLG5DELHV(Q]\PH,PPXQR
'LDJQRVLV55(,'
% 5DELHV7LVVXH&XOWXUH5DELHV7LVVXH&XOWXUH,QIHFWLRQ7HVW57&,7
% 3RO\PHUDVH&KDLQ5HDFWLRQ5HYHUVH7UDQVFULSWLRQ3RO\PHUDVH&KDLQ5HDFWLRQ573&5
Serological diagnosis methods;
% 6HUXP9LUXV1HXWUDOL]DWLRQ7HVWLQ0LFH
% ,QGLUHFW)OXRUHVFHQW$QWLERG\7HFKQLTXH,)$7
% &RPSOHPHQW)L[DWLRQ7HVW&)7
% 6HUXP9LUXV1HXWUDOL]DWLRQ7HVWLQ&HOO&XOWXUH5DSLG)OXRUHVFHQW)RFXV
,QKLELWLRQ7HVW5)),7
20
Rabies Field Guideline
% )OXRUHVFHQW$QWLERG\9LUXV1HXWUDOL]DWLRQ7HVW)$91
% +DHPDJJOXWLQDWLRQDQG+DHPDEVRUSWLRQ7HVWV
,QWKHODERUDWRU\GLDJQRVLVRIUDELHVLQRXUFRXQWU\PHWKRGVDFFHSWHGDQG
UHFRPPHQGHGE\WKH:RUOG+HDOWK2UJDQL]DWLRQ:+2DQG:RUOG2UJDQL]DWLRQIRU$QLPDO+HDOWK2,(DUHXVHG)OXRUHVFHQW$QWLERG\7HFKQLTXHDQG([SHULPHQWDO$QLPDO,QRFXODWLRQ7HVWVDUHXVHGDVURXWLQHGLDJQRVLVPHWKRGVLQ
WKHODERUDWRULHVIRUUDELHVGLDJQRVLVLQDQLPDOVLQODERUDWRULHVLQFKDUJHRIUDELHVGLDJQRVLV9HWHULQDU\&RQWURO,QVWLWXWHVRIWKH0LQLVWU\RI)RRG$JULFXOWXUH
DQG/LYHVWRFNLQWKHSURYLQFHVRI$QNDUD,VWDQEXO,]PLU$GDQD(OD]éÝ.RQ\D
(U]XUXP DQG 6DPVXQ LQ RXU FRXQWU\ ,Q DGGLWLRQ WR WKHVH WHVWV 3RO\PHUDVH
&KDLQ5HDFWLRQDQG6HTXHQFH$QDO\VLVDQG)$91DPRQJVHURORJLFDOWHVWVDUH
URXWLQHO\FDUULHGRXWDQG7LVVXH&XOWXUH,QIHFWLRQ7HVWLVXVHGLQH[SHULPHQWDO
VWXGLHVLQ(WOLN9HWHULQDU\&RQWURO&HQWUDO5HVHDUFK,QVWLWXWH5DELHVGLDJQRVLVLQKXPDQVLVSHUIRUPHGRQO\LQ$QNDUD(WOLN9HWHULQDU\&RQWURO&HQWUDO
5HVHDUFK,QVWLWXWH
Fluorescent Antibody Technique:
7KHSXUSRVHRIWKLVWHFKQLTXHLVEDVHGRQG\HLQJWKHSUHSDUDWHVWDNHQIURP
EUDLQWLVVXHDQGRWKHUWLVVXHV>VDOLYDU\JODQGFRUQHDGHUPLVIURPKDLU\SDUWV
RQWKHQDSH@ZLWK)$7DQGVXEVHTXHQWO\VHDUFKLQJIRUYLUDODQWLJHQVE\ˊXRUHVFHQWPLFURVFRS\5HVXOWVFDQEHREWDLQHGZLWKLQKRXUVDIWHUWKHGHOLYHU\
RIWKHPDWHULDO
Experimental Animal Inoculation:
1HJDWLYHWHVWUHVXOWVRI)$7FDQQRWEHDVVHVVHGDVDEVROXWHO\UDELHVQHJDWLYH,QVXFKFDVHV([SHULPHQWDO$QLPDO,QRFXODWLRQLVSHUIRUPHGDVWKHPRVW
UHOLDEOHPHWKRGLQWKHGLDJQRVLVRIUDELHV7KHPRVWVXVFHSWLEOHDQLPDOIRU
LQRFXODWLRQWHVWLVEUHDVWIHGPLFH,QDGGLWLRQWRWKLVWRZHHNVROG:KLWH
6ZLVV 0LFH FDQ DOVR EH XVHG ,Q UDELHV SRVLWLYH FDVHV LQ PLFH UDELHV VSHFLˉF
V\PSWRPVEHJLQWRDSSHDUIURPWKHVL[WKGD\RQZDUG$QRWKHU)$7LVDSSOLHG
LQWKHEUDLQVRIPLFHG\LQJZLWKV\PSWRPV
21
Rabies Field Guideline
Tissue Culture:
0RXVHPXULQHQHXUREODVWRPDDQG&KLFN(PEU\R5HODWHGDQG%DE\+DPVWHU
.LGQH\FHOOVDUHXVHGLQYLUXVLVRODWLRQ,QSULQFLSOHFHOOFXOWXUHDQGˊXRUHVFHQWODEHOHGK\SHULPPXQHVHUXP),76DUHXVHGLQVLGHDQGUHVXOWVDUHH[DPLQHG
LQˊXRUHVFHQWPLFURVFRS\IRUWKHLVRODWLRQRIHWLRORJLFDJHQWLQFHOOFXOWXUH
7KHWHVWLVDSSOLHGLQH[SHULPHQWDOVWXGLHVLQ$QNDUD(WOLN9HWHULQDU\&RQWURO
&HQWUDO5HVHDUFK,QVWLWXWH
Polymerase Chain Reaction:
,WLVDPROHFXODUEDVHGPHWKRGXVHGWRGHWHFWYLUXVHVEDVHGRQDPSOLI\LQJ
QXFOHLFDFLG$VUDELHVYLUXVKDVD51$JHQRPHYLUDO51$VKRXOGEHH[WUDFWHGIURPVXVSHFWHGPDWHULDOVDQGF'1$VKRXOGEHV\QWKHVL]HGUHYHUVHWUDQVFULSWLRQIURPLW1RUPDO3&5FDQEHSHUIRUPHGRQO\DIWHUWKLVVWDJH7KXVWKH
PHWKRGXVHGIRUYLUXVHVZLWK51$JHQRPHOLNHUDELHVYLUXVLVFDOOHG573&5
$OO UHVHDUFKHUV XVLQJ 3&5 IRU WKH GLDJQRVLV RI UDELHV XVH V\QWKHWLF ROLJRQXFOHRWLGH'1$SULPHUVWKH\GHYHORSRUSUHYLRXVO\GHYHORSHGSULPHUVE\RWKHU
UHVHDUFKHUV6HTXHQFHDQDO\VLVDQGQXFOHRWLGHSRVLWLRQVRI3DVWHXUYLUDOVWUDLQ
DUHWDNHQDVUHIHUHQFHLQWKHSUHSDUDWLRQRIGHYHORSHGSULPHUV)RUWKHHIˉFDF\
RI3&5SULPHUVHOHFWLRQLVYHU\LPSRUWDQW
Serologic Tests:
5)),7 DQG )$91 WHVWV DUH XVHG WR LGHQWLI\ DQWLERGLHV SURGXFHG DJDLQVW
UDELHVLQKXPDQDQGDQLPDOEORRGVHUXPV7KHVHWHVWVDUHEDVHGRQVHUXP
QHXWUDOL]DWLRQWHVWWKDWFHOOFXOWXUHDQG)7,&DUHXVHGLQVLGHDQGUHVXOWVDUH
DVVHVVHGE\ˊXRUHVFHQWPLFURVFRSH7HVWVDUHXVHGERWKLQPHDVXULQJRILP
PXQHUHVSRQVHDIWHULPPXQL]DWLRQDQGLQGLUHFWO\GLDJQRVLVRILQIHFWLRQSURYLGHGSDLUHGVHUXPVDPSOLQJLQVXVSHFWHGFDVHV,WLVSHUIRUPHGRQO\LQ$QNDUD
(WOLN9HWHULQDU\&RQWURO&HQWUDO5HVHDUFK,QVWLWXWHLQRXUFRXQWU\
SAMPLING IN RABIES AND SHIPPING
'LYHUVHVDPSOHVFDQEHXVHGLQWKHGLDJQRVLVRIUDELHVLQKXPDQVIROORZHG
XSZLWKDQGRUGLHGRIVXVSLFLRQRIUDELHV
22
Rabies Field Guideline
Ante-mortem samples collected from cases followed with suspicion of rabies;
1. 6DOLYDDWOHDVWP/SODVWLFSLSHWWHLWFRXOGEHFROOHFWHGZLWKGURSSHU
2. &HUHEURVSLQDOˊXLGDWOHDVWP/
3. %LRSV\VSHFLPHQWDNHQIURPWKHSRVWHULRUUHJLRQRIWKHQHFNDWWKHKDLUOLQH
FRQWDLQLQJDPLQLPXPRIKDLUIROOLFOHVDWOHDVWPPLQGLDPHWHUDQG
RIVXIˉFLHQWGHSWKWRLQFOXGHWKHFXWDQHRXVQHUYHVDWWKHEDVHRIWKHIROOLFOH
4. %ORRGVHUXPDWOHDVWP/IRUHDFKVHUXP
7KHVHVDPSOHVVKRXOGEHUHSHDWHGLQSHULRGVRIWRGD\VDVWKHLQFXEDWLRQSHULRGRIWKHGLVHDVHSURJUHVVGLIIHUHQWO\6DPSOHVVKRXOGFRQWDLQVDOLYD
cerebrospinal ˊuid (CSF)EORRGVHUXPDQGELRSV\VSHFLPHQ
Post-mortem samples collected in autopsy from people died of suspicion of
rabies;
1. $WOHDVWFP3 RIWLVVXHVDPSOHVIURPWKHFRUWH[WKHFHUHEHOOXPDQGWKH
KLSSRFDPSXVFRUQXDPPRQLVLQWKHEUDLQ
2. $WOHDVWFP3 RIWLVVXHVDPSOHIURPVDOLYDU\JODQGLIQHFHVVDU\IRUHQVLF
VSHFLDOLVWRWRODU\QJRORJLVWRUSDWKRORJ\VSHFLDOLVWFDQEHFRQVXOWHGIRU
VDPSOLQJ
6DPSOLQJVKRXOGEHSHUIRUPHGVLPLODUO\WRDQWHPRUWHPVDPSOLQJZKHQDX
WRSV\LVQRWSRVVLEOH$X[LOLDU\OLTXLGRUPHGLXPIRUPDOGHK\GHJO\FHULQFHOO
SURGXFLQJPHGLXPHWFVKRXOGQRWEHXVHGIRUSUHVHUYDWLRQRIVDPSOHV6WHULOHVFUHZFDSWXEHVZLWKVHDOLQJJDVNHWVVKRXOGEHSUHIHUUHGIRUSUHVHUYDWLRQ
6DPSOLQJDQGVKLSSLQJVKRXOGEHSHUIRUPHGZLWKLQWKHNQRZOHGJHRI
WKH3URYLQFLDO3XEOLF+HDOWK'LUHFWRUDWH6DPSOHVVKRXOGEHSDFNHGDQGVKLSSHG
DFFRUGLQJWRWKHFROGFKDLQFRQGLWLRQV6KLSSLQJVKRXOGEHLQWKHTXLFNHVWZD\
DQGE\SHUVRQLISRVVLEOH7KHSDFNHWVKRXOGFRQWDLQSDWLHQWLQIRUPDWLRQLQIRUPDWLRQDERXWH[SRVXUHWRWKHELWHRIGRPHVWLFRUZLOGDQLPDOLQIRUPDWLRQ
DERXW YDFFLQDWLRQ DQG LPPXQRJOREXOLQ DSSOLFDWLRQ DQG LQIRUPDWLRQ DERXW
VDPSOLQJWLPH5DELHV6DPSOH/DERUDWRU\'HOLYHU\)RUP
23
Rabies Field Guideline
RABIES PROPHYLAXIS
6LQFHUDELHVLVDIDWDOGLVHDVHSUHYHQWLRQDSSURDFKHVDUHOLIHVDYLQJ7KXV
pre-exposure prophylaxis VKRXOGEHDSSOLHGWRSHRSOHZKRDUHRIWHQH[SRVHG
WRDQLPDOVZLWKUDELHVULVNZKLOHpost-exposure prophylaxis VKRXOGEHDSSOLHG
WRDOOSRVVLEOHUDELHVH[SRVXUHV
PRE-EXPOSURE PROPHYLAXIS
3UHH[SRVXUHSURSK\OD[LVLVUHFRPPHQGHGIRUSHRSOHZLWKLQFUHDVHG
H[SRVXUHULVNEHFDXVHRIRFFXSDWLRQDORURWKHUUHDVRQV
People to be applied pre-exposure prophylaxis;
ȧ3HRSOHZRUNLQJLQRFFXSDWLRQVZLWKKLJKUDELHVULVN5DELHVUHVHDUFKODERUDWRU\VWDIISHRSOHZRUNLQJLQUDELHVYDFFLQHSURGXFWLRQHWF
ȧ3HRSOHZRUNLQJLQRFFXSDWLRQVZLWKUDELHVULVNYHWHULQDULDQVDQLPDOKDQGOHUVDQLPDOVKHOWHUZRUNHUVFDYHUVVSHOXQNHUVDQGSHRSOHZRUNLQJRQEDWFRORQLHVHWFDQGRWKHUSHRSOHZKRDUHRIWHQH[SRVHGWRDQLPDOVZLWKUDELHVULVN
ȧ3HRSOHHQJDJHGLQQDWXUHVSRUWVZLWKDKLJKULVNRIH[SRVXUHWRZLOGOLIH
ȧ3HRSOHWUDYHOOLQJLQDUHDVZKHUHGRJUDELHVLVHQ]RRWLFDQGLPPHGLDWHDFFHVVWRDSSURSULDWHPHGLFDOFDUHLVLPSRVVLEOH
Vaccination Application and Schedule for Pre-Exposure Prophylaxis
3UHH[SRVXUHSURSK\OD[LVVFKHGXOHUHTXLUHVLQWUDPXVFXODUGHOWRLGDSSOLFDWLRQDQWHURODWHUDOWKLJKIRULQIDQWV\RXQJHUWKDQ\HDUVROGRIWKUHHGRVHVRIYDFFLQHJLYHQRQGD\VDQGRUDQG5DELHVYDFFLQHVKRXOG
QHYHUEHDGPLQLVWHUHGLQWKHJOXWHDODUHDDQGDURXQGWKHDEGRPHQ
Vaccination is applied in muscles in deltoid area in adults and in
anterolateral thigh in infants.
Since antibody response is not sufˉcient, vaccination should not be applied
in gluteal area.
24
Rabies Field Guideline
,QSHRSOHDWKLJKULVNJURXSVXFKDVUDELHVODERUDWRU\UHVHDUFKHUVDQGODERUDWRU\ZRUNHUVZKRZRUNZLWKUDELHVYLUXVRUYDFFLQHDQWLERG\VFUHHQLQJVKRXOG
EHSHUIRUPHGHYHU\PRQWKV$QWLERG\VFUHHQLQJIRURWKHUULVNJURXSVVKRXOG
EHSHUIRUPHGHYHU\\HDUV,IDQWLERG\OHYHOLVVXIˉFLHQWYDFFLQDWLRQLVQRWQHFHVVDU\,IFRPSOHWHQHXWUDOL]DWLRQLVEHORZVHUXPGLOXWLRQGHWHUPLQHGE\
5)),7RU)$91LQ5HIHUHQFH/DERUDWRU\DERRVWHULVUHFRPPHQGHG:KHQDQWLERG\VFUHHQLQJFDQQRWEHSHUIRUPHGLQULVNJURXSDVLQJOHGRVHRIERRVWHUFDQ
EHUHFRPPHQGHGHYHU\\HDUV6LQFHDQWLERG\UHVSRQVHFDQQRWEHIRUHVHHQ
LQLPPXQRVXSSUHVVHGSHUVRQVLWLVQRWSRVVLEOHWRGHWHUPLQHDQH[DFWSHULRG
VRDQWLERG\VFUHHQLQJLVVWULFWO\UHFRPPHQGHG
POST-EXPOSURE PROPHYLAXIS
3RVVLEOHUDELHVH[SRVXUHVVKRZVWZRGLIIHUHQWHSLGHPLRORJLFDOFKDUDFWHULVWLFVLQWKHZRUOG7KHVHDUHWKHWUDQVPLVVLRQRIUDELHVRQO\IURPZLOGDQLPDOV
DVLQWKH86$DQGWUDQVPLVVLRQRIUDELHVPDLQO\IURPGRPHVWLFDQLPDOVDVLQ
,QGLD5DELHVSURSK\OD[LVUHFRPPHQGDWLRQVIRU7XUNH\LQWKHVHJXLGHOLQHKDV
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SURSK\OD[LVJXLGHOLQHVRIWKH:+2DQGRWKHUFRXQWULHV
Possible Rabies Exposure: %LWHVRIUDELHVVXVFHSWLEOHDQLPDOVSRVHULVNIRU
UDELHVUHJDUGOHVVRIWKHELWHVLWH2SHQZRXQGVLQFLVLRQVH[SRVXUHRIPXFRVD
PHPEUDQHV WR SRWHQWLDOO\ LQIHFWHG PDWHULDOV VXFK DV VDOLYD GURRO DQG RWKHU
QHXUDOWLVVXHDQGOLYHRUDOYDFFLQHEDLWVXVHGLQDQLPDOVDQGVFUDWFKHVDUHDOVR
FRQVLGHUHGDVQRQELWHSRVVLEOHUDELHVH[SRVXUH
Post-exposure vaccination should be initiated as soon as possible.
Since incubation period is variable in rabies, exposure should be categorized
and appropriate prophylaxis treatment should be initiated regardless of time
elapsed since exposure.
25
Rabies Field Guideline
Exposures Not Requiring Rabies Prophylaxis1, 2
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)HHGLQJDUDELGDQLPDOXQNQRZLQJO\H[SRVXUHRILQWDFWVNLQWRLWVEORRG
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PDGHRIWKLVPLON
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RIDUDELHVSDWLHQW
Prophylaxis is not applied.
Steps in Post-exposure Approach covers:
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1
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FDVHVQRWUHTXLULQJSURSK\OD[LVLQFOXGLQJKXPDQELWHV
2
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26
Rabies Field Guideline
H5DELHVLPPXQJOREXOLQDSSOLFDWLRQ
a) Wound care
Wound care is the most important step in possible rabies exposure prophylaxis. A good wound care is the most important method to reduce the transmission of rabies virus. It must be administered as soon as possible.
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VWUHDPDVPXFKDVSRVVLEOHZLWKSUHVVXUL]HGZDWHURUE\VTXHH]LQJWKHHQGRI
KRVHDQGVRDSLPPHGLDWHO\LQDOOLQMXULHV7KHZRXQGFDQDOVREHZDVKHGZLWK
VDOLQHZLWKODUJHLQMHFWRUVLQKHDOWKIDFLOLWLHV
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EHDSSOLHG
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DQWLVHSWLFWUHDWPHQWGRHVQRWUHSODFHZDVKLQJZLWKSOHQW\RIUXQQLQJZDWHU
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DVSRVVLEOH&RVPHWLFIDFWRUVDQGLQIHFWLRQULVNVKRXOGEHFRQVLGHUHGLQGHHS
DQGZLGHZRXQGV,IVXWXULQJLVXQDYRLGDEOHLQDGGLWLRQWRUDELHVSURSK\OD[LV
PLQLPXPQXPEHURIVXWXUHVVKRXOGEHDSSOLHGDWOHDVWRQHKRXUDIWHUUDELHV
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LQRFXODWLRQULVNWRWKHQHUYH
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PHDVXUHVGXULQJWKHDSSOLFDWLRQ
Suturing of wound or similar practices prefered not be performed as far
as possible. Cosmetic factors and infection risk should be considered in deep
and wide wounds. If suturing is unavoidable in addition to rabies prophylaxis,
minimum number of sutures should be applied at least one hour after rabies
immunoglobulin
is applied in and around the wound in order to reduce virus
b) Antibiotics Prophylaxis
inoculation risk to the nerve.
27
Rabies Field Guideline
b) Antibiotics Prophylaxis
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$QWLELRWLFVSURSK\OD[LVLQDQLPDOELWHVLVUHFRPPHQGHGLQEHORZFDVHV
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DSSOLHGLIWKHSDWLHQWDSSOLHVLQWKHˉUVWKRXUVHYHQZLWKRXWFOLQLFDOV\PSWRPV,I
WKHUHLVQRFOLQLFDOV\PWRPVIRULQIHFWLRQDIWHUWKHˉUVWKRXUVDSSOLFDWLRQVDQWLELRWLFWUHDWPHQWLVQRWQHFHVVDU\
Antibiotics preferred in prophylaxis:
In adults:
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,QSHQLFLOOLQDOOHUJ\
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FDQEHDOVRFRQVLGHUHG
In children:
$PR[LFLOOLQFODYXODQDWHPJNJGD\LQGRVHVSR
28
Rabies Field Guideline
AlternatiYHWUHDWPHQWV
o 'R[\F\OLQHIRUWKRVHROGHUWKDQ\HDUVROGPJNJGD\LQGRVHVSR
o &HIXUR[LPHPJNJGD\LQGRVHVSR0HWURQLGD]ROHPJNJGD\
LQGRVHVSR
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Antibiotic prophylaxis is applied for 3 days in children and adults. All patients
including immunosuppressed ones should be re-evaluated after 3 days.
Tetanus prophylaxis:
c) Tetanus prophylaxis:
$OOSDWLHQWVVKRXOGEHDVVHVVHGLQWHUPVRIWHWDQXVSURSK\OD[LV
Tetanus SURSK\OD[LVVKRXOGEHDGPLQLVWHUHGZLWKZRXQGFDUHDIWHULQMXU\DVLV
VKRZQLQ7DEOH7HWDQXVLPPXQRJOREXOLQFDQEHXVHGLQSURSK\OD[LVZKHQQHFHVVDU\+XPDQWHWDQXVLPPXQRJOREXOLQLVDSSOLHGDV,8,0ZKLOHKRUVHWHWDQXV
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Table2. Tetanus Prophylaxis in Possible Rabies exposure
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Unknown or
< 3 dose
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29
Rabies Field Guideline
d) Rabies Vaccination Application
Schema for 4 Doses of VaccineFourGRVHVRIYDFFLQHDUHDSSOLHGLQGD\V
DQG
Schema for 5 Doses of VaccineFiveGRVHVRIYDFFLQHDUHDSSOLHGLQGD\V
DQG
Schema 2.1.1. Vaccination: FourGRVHVRIYDFFLQHDUHDSSOLHGGRVHVLQGD\
DQGGRVHLQGD\DQG
9DFFLQDWLRQVFKHPDVDUHFKRVHQDFFRUGLQJWRWKHDSSURDFKHVUHFRPPHQGHG
LQ7DEOHIRUKHDOWK\LQGLYLGXDOVDQG7DEOHIRULPPXQRVXSSUHVVHGLQGLYLGXals.
Each of two doses in day 0 in schema 2.1.1 should be applied in different
extremities.
,IYDFFLQDWLRQLVDSSOLHGLQWKHVDPHH[WUHPLW\PRUHWKDQRQFHGLVWDQFHEHWZHHQVLWHVVKRXOGEHDWOHDVWFP
If vaccination is dicontinued after a single or couple of doses of vaccine
application, vaccination continues where it left off according to schedule in
case of patients.
Rabies immunization is applied with the same schedule and dose in infants,
children, adults and pregnant women.
6LQFH DQWLERG\ UHVSRQVH GHYHORSV LQ ZHHNV LQ KHDOWK\ SHUVRQV ZKRVH
SRVWH[SRVXUHLPPXQL]DWLRQLVDSSOLHGSURSHUO\URXWLQHDQWLERG\WHVWLQJLVQRW
QHFHVVDU\
If a new possible rabies exposure occurs during his post-exposure
vaccination , vaccination schedule is continued in the same manner.
Patients who are found to be infected with viral and bacterial infection during
vaccination are properly treated and vaccination is continued. Drug treatment
continues.
30
Rabies Field Guideline
Immunoglobulin Application; GRVHVKRXOGEH,8NJIRUKHWHURORJRXV
HTXLQHRULJLQRU,8NJIRUKXPDQRULJLQ,QFUHDVLQJWKHGRVHLVQRW
XVHIXODQGFRXOGVXSSUHVVDQWLERG\UHVSRQVH,IDQDWRPLFDOO\DSSURSULDWHLP
PXQRJOREXOLQVKRXOGEHDGPLQLVWHUHGDURXQGDQGLQWKHZRXQG7KHUHPDLQLQJ
VKRXOGEHDGPLQLVWHUHGLQDGLIIHUHQWH[WUHPLW\ZKLFKYDFFLQH
WKHPXVFOHV,IUHFRPPHQGHGGRVHLVQRWHQRXJKIRUWKHZKROHZRXQGDSSOLFDWLRQLWVKRXOGEHGLOXWHGZLWKVWHULOHVDOLQHDFFRUGLQJWRWKHVL]HRIWKHZRXQG
DQGDSSOLHGLQDQGDURXQGWKHZRXQG
In cases when rabies immunoglobulin cannot be applied immediately,
immunoglobulin is applied in seven days following the ˉrst dose of vaccine.
If it is more than seven days, immunoglobulin is not applied.
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UHDFWLRQV ZHUH IRXQG WR EH ORZ 7HVW LV DOVR QRW UHFRPPHQGHG E\ WKH :+2
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DOOHUJLF UHDFWLRQV GXULQJ UDELHV YDFFLQDWLRQ DQG LPPXQRJOREXOLQ DSSOLFDWLRQ
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LQPLQXWHVRILQWHUYDOVLIQHFHVVDU\,WXVXDOO\UHVSRQGVDIWHUGRVHV
7KHSDWLHQWVKRXOGEHJLYHQR[\JHQ/PLQXWHLVRWRQLFVROXWLRQLQWUDYHQRXVO\DQGXUJHQWO\UHIHUUHGWRDPHGLFDOFHQWHUIRUIROORZXS
Immunoglobulin is not administered in the same anatomical area with the
vaccine or with the same injector .
31
32
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Category
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Type of Exposure
Table 3. Prophylaxis in Possible Rabies Exposure
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Recommended Approach
Rabies Field Guideline
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,QWKHHYHQWRIDSSHDUDQFHRIUDELHVV\PSWRPVRUGHDWKRIDQLPDOEHFDXVHRIDQXQNQRZQUHDVRQGRVHVRIYDFFLQDWLRQLQGD\VDQGDQGLPPXQRJOREXOLQDUHDSSOLHG
,IWKHDQLPDOGLHVIRUDQ\UHDVRQHVFDSHVRUGLVDSSHDUVLQFOXGLQJDSSHUDQFHRIGLVHDVHV\PSWRPVLQDQLPDOSRVWH[SRVXUHSURSK\OD[LVGRVHVRIYDFFLQHRUVFKHPDLVDGPLQ
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Rabies Field Guideline
33
Rabies Field Guideline
Table 4. Rabies Prophylaxis in Immunosuppressed People
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Recommendations for Post-Exposure Prophylaxis for Those Vaccinated in
Pre-Exposure
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Cases Not Requiring Rabies Immunoglobulin in Category III and IV Injuries:
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YDFFLQHVEHIRUHIRUDQ\UHDVRQSUHH[SRVXUHRUSRVWH[SRVXUHUHJDUGOHVVRI
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34
Rabies Field Guideline
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0 and 3.
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RI+HDOWK
35
Rabies Field Guideline
Table 5. Animal Rabies Diagnosis Centers
NAME OF INSTITUTE
FAX NO
TELEPHONE NO
&HQWUDO9HWHULQDU\
&RQWURODQG5HVHDUFK,QV
Etlik / Ankara
0312 3211755
0312 3260090
%RUQRYD9HWHULQDU\
&RQWURODQG5HVHDUFK,QV
,]PLU
0232 3885052
6DPVXQ9HWHULQDU\
&RQWURODQG5HVHDUFK,QV
6DPVXQ
0362 4370399
(OD]éÝ9HWHULQDU\&RQWURO
DQG5HVHDUFK,QV(OD]éÝ
0424 2338720
(U]XUXP9HWHULQDU\
&RQWURODQG5HVHDUFK,QV
(U]XUXP
0442 3170733
3HQGLN9HWHULQDU\&RQWURO
DQG5HVHDUFK,QV,VWDQEXO
0232 3880010
0362 4370399
0362 4370836
0424 2181958
0424 2181834
0442 3170732
0442 3168142
0216 3540249
0216 3901280
0216 3547692
0216 3900600
$GDQD9HWHULQDU\&RQWURO
DQG5HVHDUFK,QV$GDQD
0322 2390495
.RQ\D9HWHULQDU\&RQWURO
DQG5HVHDUFK,QV.RQ\D
0332 3203798
* +XPDQUDELHVFDVHVDUHDOVRGLDJQRVHG
36
0232 3881062
0322 2390489
0322 2390490
0332 3200332
0332 3224741
E - MAIL
HWOLN#YHWJRYWU
ERUQRYD#YHWJRYWU
VDPVXQ#YHWJRYWU
HOD]LJ#YHWJRYWU
HU]XUXP#YHWJRYWU
SHQGLN#YHWJRYWU
DGDQD#YHWJRYWU
NRQ\D#YHWJRYWU
Rabies Field Guideline
ANNEXES
ANNEX - 1. RABIES SAMPLE LABORATORY DELIVERY FORM
This section will be filled out by the laboratory when sample has been delivered.
Sample No:
Laboratory Arrival Date:
/
/
Lab Notes: (current status of sample , etc. )
This section will be filled by health care provider / clinician who obtains and sends the sample.
SENDING INSTITUTION / PERSON
HOSPITAL INFORMATION
Name-Surname:
Date of admission to hospital: .
../
..
./
Institution:
Province:
Date of hospitilization: .
Phone:
Date of discharged:
../
...../
./
..
..
./
Fax:
PATIENT IDENTITY INFORMATION
Name-Surname:
Date of birth: ..
TR Identity No:
Gender:
Residence (home) address:
Profession / job:
../
..../
...
Male
Female
Phone (Home):
Town and province:
Phone (Mobile):
INFORMATION OF RABIES RISK EXPOSURE
Animal that cause rabies risk exposure
Owned
Unowned
Wild
Body region of rabies risk exposure ;
Species of the animal that cause rabies risk exposure;
characteristics of the lesion:
animal's fate, etc:
Date of rabies risk exposure: ...../...../
Onset date of clinical symptoms: ..
Clinical symptoms:
Information on the application status of
vaccination and immunoglobulin:
LABORATORY REQUEST FORM
Sent sample type:
1.
2.
3.
4.
5.
Date of sampling: .. ../ ..../
...
Period of samples
were taken
Antemortem
../
..../
...
Notes from the sender (if any):
Date: ..
Postmortem
../
..../
...
Signature
37
Rabies Field Guideline
ANNEX-2. Distribution of Animal Rabies Cases
* (Turkey, 01.01.2013-12.11.2013)
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38
Rabies Field Guideline
REFERENCES
1.
*ROGVWHLQ(-&%LWHV,Q0DQGHOO*/%HQQHWW-('ROLQ5HGV3ULQFLSOHV
DQG3UDFWLFHRI,QIHFWLRXV'LVHDVHVWKHG3KLODGHOSKLD(OVHYLHU&KXUFKLOO/LYLQJVWRQH
2.
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DQG,PPXQSHUR[LGDVHLQWKHGLDJQRVLVRIUDELHV,Q.XUWVDN(0RULVVHW
5HGV9LUDO,PPXQRGLDJQRVLV$FDGHPLF3UHVV1HZ<RUN
3.
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4.
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HGV)LHOGV9LURORJ\5DYHQ3UHV1HZ<RUN
5.
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77.
6.
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7.
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8.
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9.
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10.
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11.
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12.
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.RSURZVNL+HGV/DERUDWRU\7HFKQLTXHVLQ5DELHV:+20RQRJUDSK
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Rabies Field Guideline
13.
.LQJ$$7XUQHU*65DELHV$5HYLHZ-&RPS3DWK
14.
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15.
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16.
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18.
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21.
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22.
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23.
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24.
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26.
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HGV9LURORJ\QGHG1HZ<RUN$FDGHPLF3UHVV
40
Rabies Field Guideline
27.
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29.
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30.
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41
Rabies Field Guideline
WEBSITES ON THE SUBJECT
1.
ŚƩƉ͗ͬͬǁǁǁ.ǁŚŽ.ŝŶƚͬƚŽƉŝĐƐͬƌĂďŝĞƐͬĞŶͬ
2.
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3.
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ĞƌͲŐĞŶĞůŐĞƐŝͲ 2ϬϬϵ.Śƚŵů
4.
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ŶĂnjĞͲŶĂŬŝůͲ ǀĞͲĚĞĮŶͲŝƐͲ.Śƚŵů 5.
ŚƩƉ͗ͬͬǁǁǁ.ĐĚĐ.ŐŽǀͬƌĂďŝĞƐͬ
6.
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Rabies Field Guideline
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43
Rabies Field Guideline
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44
Rabies Field Guideline
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45
Rabies Field Guideline
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46
Rabies Field Guideline
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47
Rabies Field Guideline
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48