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CALL BACK STUDY 118 VOLUNTEER SUBJECTS, PREVIOUS PEP OR PREP WITH ANY TISSUE CULTURE VACCINE 5 – 21 YEARS PREVIOUSLY METHOD COLLECT SERUM DAYS 0, 5, 7,

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Presentation on theme: "CALL BACK STUDY 118 VOLUNTEER SUBJECTS, PREVIOUS PEP OR PREP WITH ANY TISSUE CULTURE VACCINE 5 – 21 YEARS PREVIOUSLY METHOD COLLECT SERUM DAYS 0, 5, 7,"— Presentation transcript:

1 CALL BACK STUDY 118 VOLUNTEER SUBJECTS, PREVIOUS PEP OR PREP WITH ANY TISSUE CULTURE VACCINE 5 – 21 YEARS PREVIOUSLY METHOD COLLECT SERUM DAYS 0, 5, 7, 14 FOR NEUTRALIZING ANTIBODY BOOSTERS VERORAB ID 0.1 mL DAYS 0 AND 3 RESULTS VACCINE YEARS PREVIOUSLY (PEP,PREP) 65 VACCINE YEARS PREVIOUSLY (PEP.PREP) 53 DETECTABLE TITERS ON DAY ANAMNESTIC RESPONSE ON DAY HIGH TITERS ON DAYS 7 AND ( Suwansrinon K, Wilde H, Benjavongkulchai M, et al. Vaccine 2006;24: )

2 CALL BACK STUDY DATA (NABs done by RFFIT test at QSMI. Cut off: > 0.03 ) Group IU/mL Day 0 Day 5 Day 7 Day 14 PREP 5-10 Y GMT Range PEP 5-10 Y GMT Range PREP Y GMT Range PEP Y GMT Range

3 PEP FAILURE, MANAGEMENT ERROR 1985 DAY 0: THAI MALE 41 YEARS, DOG BITE UPPER LIP DEEP Day 0: WOUND CARE, HDCV IM gluteus DAY 2: HRIG IM INTO GLUTEAL REGION. WOUND NOT INFILTRATED HDCV 1 AMP IM DELTOID DAY 4: HDCV IM DAY 7: HDCV IM DAY 14 HEADACHE, FEVER, HDCV GIVEN AT 8 SITES 0.1 Ml ID DAY 15: PROGRESSION TO HYDROPHOBIA, AEROPHOBIA, SPASMS DAY 16: DEATH. NO AUTOPSY. ERRORS: CAT III, WOUND NOT INJECTED. HDCV GLUTEUS FROM QSMI COLLECTION

4 PEP FAILURE, MANAGEMENT ERROR 1987 THAI MALE 53 Y (BANGKOK) DAY 0: BITTEN BY DOG WHICH DIED 4 DAYS LATER AND FAT POSITIVE FOR RABIES. DEEP WOUNDS BOTH HANDS AND FINGERS. APPROPRIATE WOUND CARE GIVEN. DAY 6: DOG FAT POS. START PVRV ID. ERIG PASTEUR INTO WOUNDS REST IM ( GLUTEUS) DAY 9: PVRV ID 0.1 Ml x 2 Day 12: PVRV ID 0.1 Ml x 2 Day 26: FEVER, HEADACHE, NUMBNESS OF RT ARM AND SHOULDER, LATER WEAKNESS OF HAND AND DYSARTHRIA. DAY 27: STILL COHERENT. NOW DYSEASTHESIA OF LT ARM. ADMISSION TO CUH. START PHOBIC SPASMS, AEROPHOBIA, SEIZURES, AND RAPID PROGRESSION. DAY 28: DEATH. FAT POSITIVE ERROR: CAT III. DELAY 6 DAYS QSMI COLLECTION

5 PEP FAILURE, MANAGEMENT ERROR 1994 THAI GIRL AGE 2.5 (BANGKOK ) DAY 0: BITTEN BY STREET DOG MULTIPLE DEEP WOUNDS FACE. APPROPRIAT WOUND CARE SUTURES UNDER KETAMINE ANESTHESIA PCEC VACCINE BY TRC ID REGIMEN DAY 1: ERIG (BERNA) 40 IU/KG HALF INTO WOUNDS AND REST IM ( GLUTEUS). NOT ALL WOUNDS INJECTED DAY 3: PCEC ID 0.1 X 2 DAY 7: PCEC ID 0.1 X 2 DAY 10: ONSET OF TYPICAL FURIOUS RABIES WITH PHOBIC SPASMA, AEROPHOBIA, HYDROPHOBIA. HOSPITALIZED FOR COMFORT CARE. DAY 17: DIED. NO AUTOPSY. ERROR: CAT III, SUTURE OF WOUNDS BEFORE RIG QSMI COLLECTION

6 PEP FAILURE, MANAGEMENT ERROR 1987 THAI BOY AGE 9 Y (CHACHINGSAO) DAY 0: BITTEN BY STREET DOG. SEVERE WOUNDS AT 12 SITES OF FACE, HEAD, ARM. APPROPRIATE WOUND CARE NOT ALL WOUND INJECTED WITH 4.2 mL ERIG (BERNA) UNDILUTED PVRV ( PASTEUR MERIEUX) 1 mL IM DELTOID DAY 3: PVRV IM DAY 7: PVRV IM DAY 14: PVRV IM DAY 21: ONSET OF ENCEPHALITIC RABIES DAY 25: DEATH. AUTOPSY POSITIVE FOR RABIES ERROR: CAT III, NOT ALL WOUNDS INJECTED WITH ERIG QSMI COLLECTION

7 PEP FAILURE, MANAGEMENT ERROR Day 0: THAI GIRL 7 YR, CHACHINGSAO DOG BITE : FACE LEFT CHEEK, EYE BROW, ARM WOUND CARE, STARTED PET WITH 8-SITE ID REGIMEN (PCEC –CHIRON) NO RIG AVAILABE DAY 7: 4-SITE ID GIVEN. CHILD WELL DAY 12: HEADACHE, FEVER, PAIN OVER LEFT EAR, HOSPITALIZED DAY 13: WORSE, CONFUSED, AEROPHOBIA, SPASMS, AGGITATED, ENT NEG, CT NEG, ROUTINE LAB, SPINAL FLUID UNREMARKABLE. DAY 14: COMATOUS, INTUBATED DAY 15: DIED, NO AUTOPSY. ERROR: CAT III, 8-SITE IN PLACE OF RIG SRIAROON C. VACCINE 2003

8 PEP FAILURE, MANAGEMENT ERROR 2005 DAY 0: BURMESE FEMALE AGE 44, NORMAL HOST, DOG BITE IN BURMA, LACERATIONS FACE INCLUDING NOSE. WOUND CARE IN BURMA WITH SUTURE. TRANSFER TO THAI SIDE SAME DAY. WOUND INJECTED WITH ERIG (THAI RED CROSS PEPSIN DIGESTED). STARTED ON PCEC IM DELTOID DAY 3: PCEC IM DAY 7: PCEC IM DAY 14:PCEC IM DAY 15: ONSET OF FURIOUS RABIES SYMTOMS DAY 17: DEATH (Potencies of vaccine and ERIG checked at US-CDC, all meet standards) ERROR: CAT III, SUTURE BEFORE RIG INJECTION QSMI COLLECTION

9 PEP FAILURE 1997 THAI FEMALE 72 Y (BANGKOK) DAY 0: BITTEN BY UNKNOWN DOG. SMALL DEEP WOUND CHEEK IMMEDIATE WOUND CARE. WOUND INJECTED WITH ERIG (PASTEUR ) REST DELTOID PVRV (PASTEUR-MERIEUX) IM DELTOID DAY 3: PCEC (CHIRON) IM DELTOID DAY 7: PCEC (CHIRON) IM DAY 14: PCEC (CHIRON) IM DAY 20: ONSET OF PARALYTIC RABIES. FULL ICU CARE DAY 29: (SERUM ANTIBODIES 27 IU SERUM AND DETECTABLE IN CNS DAY 31: DEATH. AUTOPSY POSITIVE FOR RABIES T. HEMACHUDHA ET AL. CID. 1999; 28:

10 PEP FAILURE 1997 THAI BOY 9 (BANGKOK ) DAY 0: DOG BITE. SUPERFICIAL BLEEDING SCRATCH OF NOSE AND CHEEK WITHOUT BLEEDING. APPROPRIATE WOUND CARE. WOUNDS INFILTRATED WITH ERIG PASTEUR REST IM. PCEC CHIRON IM DELTOID. DAY 3: PCEC IM DELTOID DAY 7: PCEC IM DELTOID DAY 14: PCEC IM DELTOID DAY 30: ONSET OF FURIOUS RABIES DAY 37: DEATH. AUTOPSY POSITIVE FOR RABIES T. HEMACHUDHA ET AL. CID. 1999; 28:

11 WHY PEP FAILURES? POOR OR NO WOUND CARE VACCINE OF POOR QUALITY RIG OF POOR QUALITY NO RIG GIVEN AT ALL NOT ALL BITE WOUNDS INJECTED EXCEPTIONALLY LARGE VIRAL LOAD VIRUS CLOSE TO NERVE 0R RAPIDLY NVASIVE VIRUS STRAIN UNRELIABLE REPORTING

12 Child face

13 Hand bites

14 WHAT ARE WE MISSING? Old data indicate as much as 40% rabies infection rate can be avoided by energetic wound cleaning [1]. Wound cleaning and antisepsis is enshrined in WHO guidelines [2] 3 rabies PEP centers in India and Pakistan were visited Each treated over 100 animal bites daily. None had facility to clean wounds We may many PEP failures by just washing wounds 1) Kaplan MM, Cohen D, Koprowski H, et al Studies on the local treatment of wounds for the prevention of rabies. Bull WHO 1962;26: ) WHO. Expert Committee on Rabies, Technical Report Series 824. Geneva 1992.

15 AN ARGUMENT FOR PREP IN RABIES HYPERENDEMIC REGIONS WHERE DOG CONTROL IS FAILING FOR CHILDREN WHERE PEP NOT READILY AVAILABLE OR WHO LIKELY NOT REPORT EXPOSURES CAN BE DONE USING ID METHOD AND MULTIPLE DOSE VIALS.


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