When Rabies Immunoglobulin are not affordable or not available


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Rabies is an acute viral disease that causes fatal encephalomyelitis in virtually all the warm-blooded animals including man. The virus is found in wild and some domestic animals, and is transmitted to other animals and to humans through their saliva (i.e. following bites, scratches, licks on broken skin and mucous membrane).

Guidelines throughout worldwide quote that dogs are responsible for about 97% of human rabies, followed by cats (2%), jackals, mongoose and others (1%). The disease is mainly transmitted by the bite of a rabid dog.

Very often there are cases of bites of stray dogs or mad dogs in Bali. What is often not known even by medical practitioners is whether or not a rabies vaccine and serum rabies vaccine is needed after a rabid dog bite.

Due to the rarity of rabies cases in Bali, there is often a lack of socialization about handling cases of dog bites and other wild animals. Finally, patients only receive wound care and the maximum anti-rabies vaccine. What about the anti rabies serum? In fact, the availability in Bali itself is actually almost non-existent even in the biggest hospitals in Bali though. So important is the anti-rabies serum that we should discuss it?

Rabies vaccine work requires a long time. If we only give the vaccine, it can be said that we are late to prevent the spread of the rabies virus in the body because the vaccine only induces our immunity after 7 days, and only reaches maximum levels after 14 days, even though the virus has begun to spread to the body from the beginning.

Then how do we protect ourselves from the spread of the rabies virus before 7 days? The answer is anti rabies serum or often also referred to as anti rabies immunoglobulin. Anti-rabies serum contains antibodies to the rabies virus so that it can work immediately after being injected, while the anti-rabies vaccine contains rabies antigens that stimulate the body to produce these antibodies. So of course anti-rabies serum works faster.

Anti-rabies serum should be given H-0 (the day when bitten by the wild animal) in addition to cleaning the wound with sterile water or running water and soap if available (as soon as possible before the patient goes to the health service). But if it is not possible to give it on the day of the bite, it is still permissible to give it until the 7th day after the bite. Anti-rabies serum is given intramuscularly and if the wound has not been closed it can be given around the wound, but previously a skin test should be done especially if using horse serum.

In addition, anti-rabies vaccine is still needed because as shown in the picture that the work of anti-rabies serum is only about the first 20 days, even though the virus may still spread until approximately 30 days after entering the body. Anti-rabies vaccine in people who have been exposed to rabies suspect animal bites given 4 times, namely H-0, H-3, H-7, and H-14. Actually, the giving schedule itself has several variations.

The schedule previously mentioned is the schedule issued by the CDC (Centers for Disease Control and Prevention) located in the United States. While in Indonesia there is a schedule issued by IDAI (Indonesian Pediatrician Association), namely 2 doses at 0, 1 dose at 7, and 1 dose at 14. From the vaccine manufacturer Verorab (the only vaccine brand in Indonesia at the time of this writing which was produced by Sanofi Pasteur) suggested 5 doses of administration with schedule H-0, H-3, H-7, H-14, and H-28. The schedule issued by the CDC is accompanied by anti-rabies serum. Health service in Jogja that provides anti-rabies serum. Most anti-rabies serums in Indonesia are distributed to Jakarta, Bali and Eastern Indonesia where rabies cases are still very frequent. Anti-rabies serum with the trademark Favirab (equine anti-rabies serum made by Sanofi Pasteur).

Well, what if the patient has received a complete series of anti-rabies vaccine? One series referred to here is that the patient had been bitten by wild animals and received treatment as explained in the previous paragraph, or the patient had an anti-rabies vaccine as prophylaxis / prevention of rabies even though the patient did not get a bite with a schedule H-0, H-7, H-21 / 28. For cases like this the anti-rabies vaccine schedule is H-0 and H-3 only and it is not recommended for anti-rabies serum administration.

Why is that? Antibody-producing cells in humans have immune memory, so that if someone has been exposed to an antigen in sufficient quantities then when dealing again with the same antigen, the antibodies formed will be faster.

When a person has already been vaccinated completely, when one is vaccinated again the specific antibodies will immediately go up right then so there is no need to wait until the 7th day after being vaccinated. If so, anti-rabies serum is not needed, and instead it will inhibit our immune response which should have been very fast.

The aim of post-exposure prophylaxis is to neutralize viruses that were inoculated before can be moved nervous system.After the wound cleansed, passive antibody administration and active immunization must be done. There are two types immunoglobulin, rabies immune globulin (RIG) which can be given which is human RIG and RIG horse.  HRIG administration for patients with Clinical rabies has a recovery goal against infection. This is achieved by using human rabies immunoglobulin (HRIG) that works by neutralizing viruses rabies both local and systemic in weeks first before the body’s own response to vaccine. HRIG also improves the patient’s T cell response to the vaccine.

The initial dose is 20 IU immunoglobulin /kg of body weight, which must infiltrate around the location of the wound as much as can be reached, because antibody levels against the rabies virus are not high after giving parenteral from RIG, and the neutralization of the local virus is the most important.

The remainder is then injected intramuscularly into areas as far away as possible from the vaccination site. If HRIG not available, WHO recommendations use equine immunoglobulin at a dose 40 IU / kg. Unfortunately HRIG is very expensive (£ 330 for patients with BB 70 kg), and with so it’s not available in countries rabies highest. Active immunization against rabies must be starting with antiserum approval.

Nothing should be done to encourage active immunization and passive immunization at different times, if one product is available before anything else, it must be given immediately, and the second product must be given when is available. However, if RIG is available 11 weeks after vaccination has begun, it might not need as an antibody response to be active start. Schedule 5 post-exposure vaccination doses international, and intramuscular injection is the only route that can be accepted. Doses are given at 0, 3, 7, 14, and 28 days. After the dosage, antibodies are always on there are, usually at titres of 110 IU. Vaccine and Antiserum cannot be mixed or injected in the same limb. In the United States, there are choice of 3 vaccines namely HDCV, cell culture vaccine purified chicken embryos; and cell culture vaccines fetal rhesus lung.

Titers must be accepted in people immunosuppression, including people with HIV infection after vaccination to be sure seroconversion that has occurred. Patient harm HIV with CD41 cell counts below 300 / mL have a bad response, and may need a dose additional vaccines.  The most significant problem is Type I or III reactions consisting of urticaria, arthritis, and angioedema, which are seen in about 6% of patients who receive a dose HDCV amplifier. There is no statement contraindicated, and safe vaccination on Pregnancy

The rabies virus is easily killed by sunlight,soap, and drying. Wound care isthe best prevention of rabies infection. In animal experiments, rabies transmission can almost completely prevented by treatment local injuries given within the first 3 hours after exposure.This does not mean that immunoprophylaxis can be ignored or not done, but the risk and need are very reduced with proper wound care.

If possible, treat injuries must include infiltration under local anesthesia. The wound must then be thoroughly rubbed with water and iodine solution, 40-70% alcohol, or quaternary ammonium compounds (setrimid 0.1% BPC),all of which have a deadly effect proven in rabies virus