I.   BACKGROUND / RATIONALE

Rabies, present in all continents and endemic in most African and Asian countries, is a fatal zoonotic viral disease, transmitted to humans through contact with infected animals, both domestic and wild. Rabies is estimated to cause at least 55, 000 deaths per year worldwide, about 56% of which occur in Asia and 43.6% in Africa, particularly in rural areas on both continents. In the Philippines, although rabies is not among the leading causes of morbidity and mortality, it is considered a significant public health problem for several reasons: 1) it is one of the most acutely fatal infections; 2) it is responsible for the death if 200 - 300 Filipinos annually and 3) post-exposure prophylaxis (PEP) for victims of animal bites entails considerable expense.

The Department of Health and Department of Agriculture continues to be committed to the fight against rabies and has set the goal of rabies elimination in 2020. An essential part of this strategy is the provision of PEP to bite victims as mandated by the Anti-Rabies Act of 2007. Pursuant thereto, guidelines for the appropriate as well as cost-effective management of animal bite patients have been issued.

Historically the management of animal bite cases had to be updated every five (5) years and the guidelines need to be revised accordingly to incorporate new and better treatment modalities based on research results and recommendations of international bodies. The first revision was made in 1997, the second in 2002 and the 3rd  in 2007 which was amended in 2009.

Since the release of the latest guidelines in 2009, the issue on the management of rabies exposure secondary to bites from vaccinated dogs and cats has not been adequately addressed. This has been consistently raised by veterinarians in many fora, particularly the issue on giving PEP to all bite cases even those involving vaccinated dogs and cats. Given the above situation, a joint DA - DOH Administrative Order is hereby issued.

II.   DECLARATION OF POLICIES

These operational guidelines shall be guided by the following legal mandates and policies:

A. Republic Act 9482 or the Anti-Rabies Act of 2007 - An Act Providing for the Control and Elimination of Human and Animal Rabies, Prescribing Penalties for Violation Thereof and Appropriating Funds Therefor.

B. Memorandum of Agreement entered into by the Secretaries of the Department of Agriculture, Health, Education, Culture and Sports and the Interior and Local Government on May 8, 1991.

C. Batas Pambansa Blg. 97 - An Act Providing for the Compulsory Immunization of Livestock, Poultry and Other Animals Against Dangerous Communicable Diseases.

D. DOH Administrative Order No. 2007-0029: Guidelines on Management of Animal Bite Patients

E. DOH Administrative Order No. 2009-0027: Amendment to AO 2007-0029 regarding the Revised Guidelines on Management of Animal Bite Patients.

1. WHO Expert Consultation on Rabies. WHO Technical Report Series 931 First Report 2005

III.   GOALS AND OBJECTIVES

To provide updated guidelines and procedures to ensure the effective and efficient management of rabies exposures toward eventual reduction, if not elimination of human rabies.

IV.   SCOPE AND COVERAGE

All government health workers at all levels shall adopt these Post Exposure Prophylaxis (PEP) Guidelines to ensure standardized and rational management of animal bite patients. Private practitioners in the country are strongly encouraged to adopt these guidelines.

V.   DEFINITION OF TERMS

A. Post Exposure Prophylaxis (PEP) - formerly post exposure treatment (PET); refers to anti-rabies treatment administered after an exposure (such as bite, scratch, lick, etc) to potentially rabid animals. It includes local wound care, administration of rabies vaccine with or without Rabies Immune Globulin (RIG) depending on the category of exposure.

B. Updated rabies vaccination - Dog/Cat must be at least 1 yr 6 months old and has updated vaccination certificate from a duly licensed veterinarian for the last 2 years with the last vaccination within the past 12 months.

C. Rabid Animal - refers to biting animal with clinical manifestation of rabies and/or confirmed laboratory findings of rabies.

VI.   GENERAL GUIDELINES

A. The Department of Health in collaboration with the LGUs shall be responsible for the management of animal bite victims including provision of human rabies vaccine to augment supplies of the LGUs.

B. The Rabies Control Program shall be integrated with the regular health services provided by the local health facilities.

C. PEP shall be carried out both by the Department of Health and Local Government Units.

D. The funding requirements to operationalize this issuance shall be secured prior to its implementation.

E. Advocacy through information dissemination and training of health workers shall be conducted at all levels.

F. Collaboration among government agencies, non-government and private organizations to ensure successful implementation shall be strengthened.

VII. SPECIFIC GUIDELINES AND PROCEDURES:

A.    Categorization of Rabies Exposure:

Table I. Categories of Rabies Exposure

      Category of exposure  

Type of Exposure

      CATEGORY I   a) Feeding / Touching an animal     b) Licking of intact skin (with reliable history and thorough physical examination)     c) Exposure to patient with signs and symptoms of rabies by sharing of eating or drinking utensils
d) Casual contact (talking to, visiting and feeding suspected rabies cases) and routine delivery of health care to patient with signs and symptoms of rabies       CATEGORY II   a) Nibbling of uncovered skin with or without bruising/ hematoma     b) Minor scratches/abrasions without bleeding     c) Minor scratches/abrasions which are induced to bleed     d) All Category II exposures on the head and neck area are considered Category III and should be managed as such       CATEGORY III
     
     
        a) Transdermal bites (puncture wounds, lacerations, avulsions) or scratches/abrasions with spontaneous bleeding     b) Licks on broken skin     c) Exposure to a rabies patient through bites, contamination of mucous membranes (eyes, oral/nasal mucosa, genital/anal mucous membrane) or open skin lesions with body fluids through splattering and mouth-to-mouth resuscitation     d) Handling of infected carcass or ingestion of raw infected meat    

e) All Category II exposures on head and neck area

B.   Management

I.   PEP is not recommended for all Category I Exposures

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

i.   Dog/cat is healthy and available for observation for 14 days
ii.   Dog/cat was vaccinated against rabies for the past 2 years
a.   Dog/cat must be at least 1 yr 6 months old and has updated vaccination
certificate from a duly licensed veterinarian for the last 2 years
b.   The last vaccination must be within the past 12 months, the immunization status of the dog/cat will not be considered updated if the animal is not vaccinated on the due date of the next vaccination

^* If biting dog/cat becomes sick or dies within the observation period, PEP
should be started immediately

III. PEP should be given immediately for ANY of the following conditions:

i.   The rabies exposure is category III;
ii.   The dog/cat is proven rabid/sick/dead with no laboratory exam for rabies/not available before or during the consultation;
iii.   The dog/cat is involved in at least 3 biting incidents within 24 hours or
iv.   Dog/cat manifests the following behavior changes suggestive of rabies before, during or after the biting incident:

Table 2. Clinical Signs of Animal Rabies

Prodromal Stage (usually lasts 2-3 days; sometimes only a few hours)

A. Changes in attitude/behavior/temperament such as unusual shyness or aggressiveness

a.  Friendly animal becomes aggressive
b. Solitude
c.  Restlessness
d.  Snapping at imaginary objects
e. Apprehension
f.  Nervousness
g. Anxiety
h.  Barking/vocalization at the slightest provocation

B. Dilated pupils; become myotic in advance state
C. Mydriasis and/or sluggish palpebral or corneal reflexes
D. Slight rise in body temperature (slight fever)

Clinical Rabies
 

Furious Stage (usually lasts 1-7 days) Paralytic (dumb) stage (develops 2-10 days after clinical signs; usually last 2-4 days)       I. Increased response to auditory and visual stimulation such as: Paralysis   -Restlessness - Paralysis may begin at the bite area and progress until entire CNS involvement   -Photophobia - Following paralysis of the head and neck, the entire body becomes paralyze   -Hyperaesthesia   -Eating unusual objects   -Aggression - Change in tone of vocalization/barking (indicative of laryngeal/pharyngeal paralysis)   -Attacking any live or inanimate objects         II. Erratic behavior           -Biting or snapping -Hypersalivation or frothing; drooling/slobbering of saliva (indicative of laryngeal/pharyngeal paralysis)   -Licking or chewing of wound/bite site -Dysphagia/difficulty/inability to swallow (indicative of laryngeal pharyngeal paralysis)   -If caged, biting of their cage     -Wandering and roaming     -Excitability - Jaw drop /Dropped jaw due to masseter muscle paralysis (suspects foreign body in mouth or esophagus)   -Irritability     -Viciousness -Pupil dilation or pupil constriction     -Protrusion of third eyelid       III. Self-mutilation -Ataxia, progressive paralysis and cannibalism (terminal stage)       IV. Muscular in-coordination and seizures - Coma and/or respiratory paralysis resulting in death within 2-4 days       V. Disorientation           Roams and bites inanimate object and also other animals including man         VI. PEP is not required for bite/s of the following biting animals: rats, mouse, rabbits, snakes and other reptiles, birds and other avian, insects and fish.

VIII.    IMPLEMENTING MECHANISM:

a. Roles and Responsibilities

i.  Department of Health

1.  The National Center for Disease Prevention and Control (NCDPC) shall be responsible for disseminating this Joint AO to all Centers for Health Development.

2. All Centers for Health Development (CHD) through the Directors and the Rabies Control Program Coordinators shall ensure that this Joint AO is disseminated to all Provincial/City/Municipal Health Offices, Animal Bite Treatment Centers and private practitioners, hospitals and animal bite clinics in their respective regions.

ii. Department of Agriculture

1. The Bureau of Animal Industry (BAI) shall be responsible for disseminating this Joint AO to all DA - Regional Field Units.

2. The Department of Agriculture - Regional Field Units (DA-RFUs) through the Regional Executive Directors and the Rabies Control Program Coordinators shall ensure that this Joint AO is disseminated to all Provincial/City/Municipal Veterinary Offices or their equivalents in their respective regions.

iii. Local Government Units

The Provincial Health Offices shall be responsible for disseminating this Joint AO to all City/Municipal Health Offices, Animal Bite Treatment Centers and private practitioners, hospitals and animal bite clinics in their respective provinces. Likewise, the Provincial Veterinary Offices shall be responsible for disseminating this Joint AO to all City/Municipal Veterinary Offices or their equivalents in their respective provinces.

IX.   REPEALING CLAUSE

The provisions of the National Rabies Prevention and Control Program Manual of Operations, National Rabies Committee CY 2001 and any other issuances inconsistent herewith are hereby rescinded.

X.   EFFECTIVITY

This Order shall take effect immediately.

Adopted: February 2, 2011
   
 

(SGD) ENRIQUE T. ONA, MD, FPCS, FACS	(SGD) PROCESO J. ALCALA
Secretary of Health	Secretary of Agriculture