Rabies op Reis
AML Oude Lashof Internist-infectioloog Maastricht UMC
Casus uit Cambodja
61 jarige man, meldt zich vrijdagmiddag om 15.45u telefonisch dat hij in Cambodja is gebeten in zijn onderbeen door een aap terwijl hij een tempeltrap opliep. Hij zegt dat hij vandaag Rabies vaccinatie nummer 3 moet hebben, volgens zijn rabiesvaccinatiekaartje...
Geschiedenis Eeuwen bekende ziekte “hondsdolheid” Veel mystiek, hondsdagen Religie Verschillende “behandelingen” Rabare, Rabhas, Lyssa => Rabies 1903 intracytoplasmatische inclusies door Negri (Negri-bodies)
Epidemiologie
~55.000 doden / jaar wereldwijd Wereldwijd meeste in Azie (3/5e), rest vooral in Afrika In Frankrijk meeste risico vanuit Noord-Afrika Overdracht alleen door zoogdieren Straathonden meest belangrijk Vleermuizen, vossen, knaagdieren, skunks, wasbeer, katten andere belangrijke vectoren Nederland: hondenbeten in ZuidoostAzie
Gautret 2010, Int j Infect dis, Infectiziektenbulletin juni 2010
www.who.int
Rabies vectoren
Rupperecht, 2002 Lancet inf dis
Mogelijke Rabiesincidenten
Infectieziektenbulletin juni 2010
Tijd tot melding
Infectieziektenbulletin juni 2010
Virologie
Rhabdovirus -> Lyssavirus: ss-RNA virus Verschillende serotypes, allemaal “Rabies”: Rabiesvirus
(type 1): heel de wereld Duvenhage (type 4): (zuidelijk) Afrika European Bat Lyssavirus (type 5 en 6) Australia Bat Lyssavirus (type 7) ...
Kogelvormig
Virologie
Pathogenese
Beet => spiercellen, hechting aan acetylcholinereceptoren Vermenigvuldigt daar, infecteert spierspoeltjes, perifere neuronen** => centraal zenuwstelstel, CZS => rest lichaam, oa speekselklieren (via sensore zenuwcellen)
Duur tot ontstaan ziekte?? Beetplaats, hoeveelheid beten Hoeveelheid speeksel
Kliniek
Incubatietijd: <
30d (25%), 30-90d (50%), 90d-1jr (20%), > 1 jr (5%)
Prodromale verschijnselen: paresthesie
rond wond, koorts, malaise, misselijkheid, braken (duur 2-10 d)
Furieuze rabies (80%): klassieke rabies Geaggiteerdheid,
vreemd gedrag, schreeuwen, hydrofobie, aerofobie, spasmen, delier
Paralytische rabies (20%): paralyse, dd. guillainbarré Geen
klassieke verschijnselen, zwakte, meningeale verschijnselen, coma
Sterfte door cerebraal oedeem of myocarditis
Cambodja-casus
Epidemiologie in Cambodja Jaarlijks
9.000 – 14.500 vragen om rabiesvaccinatie alleen al in Phnom Pehn! In 10 jaar 63 bewezen doden door Rabies, alleen in Phnom Penh: schatting 810 doden/jr Vooral hondenbeten: 1214 onderzocht, 49% positief
Wond uitgewassen Snelle post-expositie profylaxe gekregen Voldoende?
PLoS Negl Trop Dis 2009; 3(9): e511
Nederlands protocol Rabies PEP
“Bij type III accident is ook toediening van Menselijk AntiRabies ImmuunGlobuline” (MARIG) aangewezen: infiltratie rondom beetplaats. Blootstellingstypes Type
I: likken, aaien, speeksel op intacte huid Type II: knabbelen, geen bloed, opp. wondjes Type III: transdermale wond, speeksel op slijmvlies
Contact met GGD!
Post-expositie profylaxe
Vaccinatie intramusculair op dag
0-3-7-14-28: westers model
Bij type III blootstelling: MARIG 20 IU/kg Imogam
/ Berirab In ontwikkelingslanden niet verkrijgbaar Kosten € 1000 / patient
NTvG 2008; 152(9)
Preventie van Rabies
Pre-expositie profylaxe (PrEP) Bij wie? Werkers
in rabies-laboratoria, dierenartsen Niet binnen 24u bij actieve immunisatie / MARIG Werkers in bosgebieden, speleologen Fietsers naar endemische gebieden, etc
Bali: grote uitbraak tot op heden 80 doden, geen toeristen, meeste na beet van hond Reizigers
adviseren
Kinderen! Rabies
Prep aanbieden
Pre-expositie profylaxe 3 vaccinaties: dag 0-7-21/28 Voordeel: geen MARIG nodig* Nadeel: nog steeds 2 post-expositie profylaxe vaccinaties nodig als booster (dag 0-3) Herhaling van vaccinatie: discutabel! Kosten voor im vaccinatie
Casus #2 Verpleegkundige 32 jaar 6 dgn geleden in Monkey-beach, Thailand gebeten door aap die op haar af kwam rennen Aldaar dag 0-3 vaccinatie gehad Belt met vaccinatieburo Telefoniste: rabiesvaccinatie; 3 prikken. U heeft nog maar 1 vaccinatie nodig Ze belt u, want de telefoniste leek niet te luisteren Wat adviseert u haar?
Casus #3 Studente 21 jaar Stage Paramaribo, wordt gebeten door straathond Gaat naar kliniek, vraagt om rabiesvaccinatie Dokter boos! In Suriname komt onder honden geen rabies voor. Ze belt u voor advies. Wat adviseert u? 1. Rabies vaccinatie 2. Dokter geloven 3. Terugkomen voor MARIG
Conclusie
Rabies is dodelijke infectieziekte In het buitenland vooral hondenbeten Elke zoogdierbeet in buitenland = rabies (tot tegendeel bewezen?) Pre-expositie profylaxe bij reizigers met hoog risico Post-expositie profylaxe indicatie? Bij elke beet uit buitenland: contact GGD!
Jeanna Giese “First Person” to Survive Rabies
Willoughby RE Jr, Tieves KS, Hoffman GM, et al. Survival after treatment of rabies with induction of coma. N Engl J Med. 2005;352:2508-14 Follow-up: N Engl J Med 357;9 august 30, 2007
Rabies films, series, etc. Cujo, a Stephen King novel and film about a mother and son being terrorized by a rabid dog. ･I Drink Your Blood, a 1970s cult horror film about a gang of Satanic hippies who get infected with rabies. ･Old Yeller, a novel and film that involves a frontier dog becoming infected by a rabid wild wolf. ･King of the Hill, in the episode 9 of season 4 ("To Kill a Ladybird"), a paranoid Dale Gribble runs away in the woods, afraid that he may have been infected with rabies by a raccoon. ･The Mad Death, a 1983 BBC TV series in which Britain is gripped by an outbreak of rabies after an afflicted pet cat is illegally smuggled into the country. ･Rant, a novel by Chuck Palahniuk in which the main character infects those around him with rabies. ･Rabies, a novel by Borislav Pekic about a genetically engineered rabies virus with a double protein envelope, thus becoming extremely easy to transmit (biting is not necessary any more), which spreads from one victim to another extremely fast. The virus gets turned loose at the London's Heathrow Airport. ･Rabid, starring Marilyn Chambers. ･Q & A, a novel by Vikas Swarup, devotes one chapter to a rabies epidemic in Agra, during which the main character's new friend contracts rabies from a dog bite, and dies. The main character tries to save him, but is unable to obtain the money needed for a vaccine. ･Quarantine, a Hollywood horror movie about mutated variation of rabies. ･In a Season 1 episode of House M.D. titled "Histories," Dr. Gregory House works to diagnose a homeless woman's illness, and it turns out that the woman is infected with rabies, from an untreated bat bite. ･Left 4 Dead and Left 4 Dead 2 by Valve Corporation are both set during an apocalyptic pandemic caused by a rabies-like virus that infects humans and causes them to attack any non-infected on sight . ･To Kill a Mockingbird uses the imagery of a rabid dog to represent the prejudices of the town of Maycomb, Alabama.
･Scrubs season 5 deals with the death of three patients as a result of organ transplant from an infected patient. ･In Their Eyes Were Watching God, a novel by Zora Neale Hurston, the character Tea Cake becomes infected with rabies from a dog bite. ･The Office season 4, Michael Scott, after running Meredith Palmer over with his car, finds out she was infected with rabies. To detract from his own negligence, he subsequently organizes a "5k race for the cure" in her honor. ･The Fantastic Mr. Fox, a movie based on Roald Dahl's famous book Fantastic Mr. Fox. Within the movie the issue of rabies is shown. ･In World War Z, the virus that turns people into zombies is at first thought to be a mutated strain of rabies, and is called "African rabies" throughout the earlier chapters. ･The behavior of the infected characters in the film 28 Days Later was modeled after the effects of advanced rabies in humans even if the virus is, in fact, as stated in the comic book, a carrier of ebola mixed with a calming agent that went rogue. ･Rabies is also the title of albums by Skinny Puppy and Ruoska ･The Gone Dead Train, season 9 of CSI: Crime Scene Investigation, The CSIs are brought in to investigate a series of deaths tied in with rabies. ･Tyra Banks pretended to suffer effects from rabies by collapsing and foaming from her mouth during a monologue segment in her eponymous talk show, to shocked response. ･In Marmaduke, the character Chupadogra (Buster) (voiced by Sam Elliott) was believed to have Rabies and ate owner, however later in the film this turns out to be untrue.･Rage starring Glen Ford and Stella Stevens, doctor in rural Mexico is infected with rabies, desperately struggling to return to civilization and seek treatment, major scene in film shows rabid man restrained by locals exhibiting symptoms ･In the movie The Crazies, a small town in Iowa is infected with a biochemically modified form of the Rhabdoviridae family released accidentally by the United States Army. However, in the movie, the RNA virus begins as a water-borne pathogen and mutates into an air-borne pathogen.
