Legal basis and related mandates
- The joint guidelines are anchored on Republic Act No. 9482 (Anti-Rabies Act of 2007) for control and elimination of human and animal rabies, prescribing penalties for violations, and appropriating funds for the purpose.
- The guidelines are guided by a 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.
- The guidelines are guided by Batas Pambansa Blg. 97 on the compulsory immunization of livestock, poultry, and other animals against dangerous communicable diseases.
- The guidelines are aligned with DOH Administrative Order No. 2007-0029, which provides Guidelines on Management of Animal Bite Patients.
- The guidelines implement amendments to DOH Administrative Order No. 2009-0027, which amends AO 2007-0029 through the Revised Guidelines on Management of Animal Bite Patients.
- The guidelines also reference WHO Expert Consultation on Rabies, WHO Technical Report Series 931, First Report 2005.
Policy, purpose, and goals
- The guidelines establish operational rules for standardized and rational management of animal bite patients.
- The guidelines aim to ensure effective and efficient management of rabies exposures.
- The guidelines target eventual reduction, if not elimination of human rabies.
- The guidelines support a broader rabies elimination strategy referenced through national goals for rabies elimination.
Definitions of key terms
- Post Exposure Prophylaxis (PEP) (formerly post exposure treatment (PET)) refers to anti-rabies treatment administered after an exposure such as bite, scratch, lick, and similar contacts to potentially rabid animals, and includes:
- Local wound care, and
- Rabies vaccine with or without Rabies Immune Globulin (RIG) depending on the exposure category.
- Updated rabies vaccination requires a dog/cat that is:
- At least 1 yr 6 months old, and
- Carrying an updated vaccination certificate from a duly licensed veterinarian for the last 2 years, with the last vaccination within the past 12 months.
- A Rabid Animal refers to a biting animal showing clinical manifestations of rabies and/or confirmed laboratory findings of rabies.
Scope, coverage, and operational responsibilities
- All government health workers at all levels must adopt the Post Exposure Prophylaxis (PEP) Guidelines for standardized management of animal bite patients.
- Private practitioners in the country are strongly encouraged to adopt the guidelines.
- The Department of Health, in collaboration with LGUs, is responsible for managing animal bite victims and for providing human rabies vaccine to augment LGU supplies.
- The Rabies Control Program must be integrated with regular health services provided by local health facilities.
- PEP must be carried out by both the Department of Health and Local Government Units.
- Funding requirements to operationalize the issuance must be secured prior to its implementation.
- Advocacy through information dissemination and training of health workers must be conducted at all levels.
- Collaboration among government agencies, non-government organizations, and private organizations must be strengthened to ensure successful implementation.
Categorization and management of exposure
- Rabies exposure is categorized into Category I, Category II, and Category III based on the type of contact and risk.
- PEP is not recommended for all Category I exposures.
- PEP can be delayed for Category II exposures if all required conditions are satisfied.
- PEP must be given immediately for exposure situations classified for immediate treatment.
Category I exposures (no routine PEP)
- Category I includes:
- Feeding/touching an animal,
- Licking of intact skin with a reliable history and thorough physical examination,
- Exposure to a patient with signs and symptoms of rabies by sharing eating or drinking utensils, and
- Casual contact (talking to, visiting, and feeding suspected rabies cases) and routine delivery of health care to a patient with signs and symptoms of rabies.
- PEP is not recommended for Category I exposures.
Category II exposures (PEP may be delayed with conditions)
- Category II includes:
- Nibbling of uncovered skin with or without bruising/hematoma,
- Minor scratches/abrasions without bleeding,
- Minor scratches/abrasions which are induced to bleed, and
- All Category II exposures on the head and neck area, which are treated as Category III.
- PEP for Category II exposures may be delayed only if ALL of the following conditions are satisfied:
- The dog/cat is healthy and available for observation for 14 days.
- The dog/cat was vaccinated against rabies for the past 2 years, and vaccination is “updated” under the required standard:
- The dog/cat must be at least 1 yr 6 months old, and
- The dog/cat must have an updated vaccination certificate from a duly licensed veterinarian for the last 2 years, and
- The last vaccination must be within the past 12 months.
- The animal’s immunization status is not considered updated if it is not vaccinated on the due date of the next vaccination.
- If the biting dog/cat becomes sick or dies within the observation period, PEP should be started immediately.
Category III exposures (immediate PEP)
- Category III includes:
- Transdermal bites (puncture wounds, lacerations, avulsions) or scratches/abrasions with spontaneous bleeding,
- Licks on broken skin,
- 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,
- Handling of infected carcass or ingestion of raw infected meat, and
- All Category II exposures on the head and neck area.
- PEP must be given immediately for ANY of the following conditions:
- The rabies exposure is Category III,
- The dog/cat is proven rabid/sick/dead with no laboratory exam for rabies or where laboratory results are not available before or during consultation,
- The dog/cat is involved in at least 3 biting incidents within 24 hours, or
- The dog/cat manifests behavior changes suggestive of rabies before, during, or after the biting incident.
Clinical signs supporting rabies suspicion
- The guidelines identify clinical signs of animal rabies in stages, including behavioral and neurologic features such as:
- Changes in attitude/behavior/temperament, including unusual shyness or aggressiveness and escalation from friendly to aggressive behavior,
- Solitude, restlessness, snapping at imaginary objects, apprehension, nervousness, anxiety, and barking/vocalization at slight provocation,
- Dilated pupils with myotic changes in advance state, mydriasis, and sluggish palpebral or corneal reflexes,
- Slight rise in body temperature (slight fever),
- Signs in the furious stage and paralytic (dumb) stage including paralysis beginning at the bite area and progressing to CNS involvement, photophobia, hyperaesthesia, eating unusual objects, aggression, hypersalivation/frothing and drooling, licking/chewing of bite site, dysphagia, cage biting, wandering/roaming, excitability, jaw drop due to masseter muscle paralysis, irritability/viciousness, eyelid changes, self-mutilation, progressive paralysis with terminal-stage manifestations, ataxia, seizures, coma/respiratory paralysis leading to death within 2-4 days, and disorientation with roaming and biting.
- If behavior changes suggestive of rabies appear before, during, or after the biting incident, PEP must be given immediately.
Exemptions from PEP requirements
- PEP is not required for bite/s from the following animals:
- rats,
- mouse,
- rabbits,
- snakes and other reptiles,
- birds and other avian,
- insects,
- fish.
Implementation mechanisms and dissemination
- The National Center for Disease Prevention and Control (NCDPC) disseminates the joint administrative order to all Centers for Health Development (CHD).
- The CHD, through the Directors and the Rabies Control Program Coordinators, ensure dissemination to:
- all Provincial/City/Municipal Health Offices,
- Animal Bite Treatment Centers, and
- private practitioners, hospitals, and animal bite clinics in their respective regions.
- The Bureau of Animal Industry (BAI) disseminates the joint administrative order to all DA Regional Field Units.
- DA-RFUs, through Regional Executive Directors and Rabies Control Program Coordinators, ensure dissemination to:
- all Provincial/City/Municipal Veterinary Offices (or their equivalents) in their respective regions.
- Provincial Health Offices disseminate to:
- all City/Municipal Health Offices, Animal Bite Treatment Centers, and private practitioners, hospitals, and animal bite clinics in their respective provinces.
- Provincial Veterinary Offices disseminate to:
- all City/Municipal Veterinary Offices (or their equivalents) in their respective provinces.
Repeal and effect on prior rules
- The provisions of the National Rabies Prevention and Control Program Manual of Operations, National Rabies Committee CY 2001 are rescinded.
- Any other issuances inconsistent with the joint guidelines are rescinded.