ANIMAL-ASSOCIATED HAZARDS Anak Agung Ayu Yuli Gayatri Tropical and infectious disease division Internal Medicine Department

Sanglah Hospital/ dayana niversity Abstract !a"ies# Herpes $ and envenoming are the diseases that result from "ites "y ra"id mammals or "ites and stings "y venomous animals# especially snakes and scorpions% In all cases# appropriate early treatment# including therapeutic anti&sera# can prevent life&threatening systemic spread of the virus or venom to'ins% Mammals Bite or Scratch Wou !s Animal "ites present a risk for ra"ies# herpes $# tetanus and other "acterial infections% Animals( saliva can "e so heavily contaminated% !a"ies is present on all continents )ith the e'ception of Antartica# "ut more than *+, of human deaths occur in Asia and Africa% !a"ies occurs in more than -+. countries and territories% /orld)ide# more than ++ ... people die of ra"ies every year# and 0. , of people )ho are "itten "y suspect ra"id animals are children under -+ years of age% Dogs are the source of **, of human ra"ies deaths% !a"ies virus# a rha"dovirus present in infected animal(s saliva is inoculated into the "ite )ounds# enter peripheral nerves and spreads to the central nervous system )here it causes a lethal encephalomyelitis% 1ortunately the availa"ility of efficacious and save vaccines and immunoglo"ulin has prevented many fatalities and almost -. million people receive post e'posure treatment annually after potential ra"ies e'posure# mostly follo)ing dogs "ites% In Addition# increase pu"lic and clinician a)areness a"out the risk associated )ith an in2ury from a maca3ue# improved first aid after e'posure# the availa"ility of "etter diagnostic test# and improved antiviral therapeutics have decreased the case& fatality ratio to 4., in treated people% 5nce clinically esta"lished# ra"ies encephalomyelitis is almost invaria"ly fatal# "ut the disease is entirely preventa"le provided that complete post e'posure prophyla'is in implemented promptly% To mitigate the risk of e'posure to ra"ies and herpes $# dogs# monkeys# "ats# and other mammals should "e avoided% Although only maca3ue "ites pose a herpes $ virus# any monkey "ite may

pose a threat for ra"ies% $efore departure# travelers should have a current tetanus vaccination or documentation of having received a "ooster vaccination )ithin the previous +&-. years% Travel health provider should assess a traveler(s need for pre&e'posure ra"ies immuni6ation% In order to prevent infection# all )ounds should "e promptly cleaned )ith soap and )ater# and the )ound promptly de"rided# if necrotic tissue# dirt or other foreigner materials is present% Travelers )ho might have "een e'pose to ra"ies or Herpes $ should contact a relia"le health care provider for advice a"out ra"ies or Herpes $ post&e'posure prophyla'is% S a"e bites 7oisonuos snakes are ha6ards in many locations# although deaths from snake"ites are rare% 1or e'tra precaution# )hen practical# travelers should )ear heavy# ankle&high or higher "oots and long pants )hen )alking outdoors in areas possi"ly inha"ited "y venomous snakes% Travelers should "e advised to seek immediate medical attention any time a "ite )ound "reaks the skin or )hen snake venom is in2ected into their eyes or mucous mem"ranes% Immo"ili6ation of the infected lim" and application of a pressure "andage that does not restrict "lood flo) are recommended first aid measures )hile the victim is moved as 3uickly as possi"le to a medical facility% Specific anti&venoms are availa"le for some snakes in some areas# so trying to ascertain the species of snakes that "it the victim may "e critical% I sect Bites a ! Scor#io Sti $s 8nvenomings "y scorpion stings are also an important health issue in many part of the )orld# particularly in the e'treme 9orthern and Southern parts of Africa# the Middle 8ast# Southren states of SA# Me'ico and parts of South America and Indian su"&continent%:enom from insects can produce severe allergic reactions and lead to life&threatening anaphylactic shock% More commonly# insect "ites and stings are painful and produce local reaction ;redness and s)elling< at the site% Scorpion venoms )hich are especially lethal in young children# release autonomic nervous system mediators causing myocardial damage# cardiac arrhythmias# pulmonary edema# shock# paralysis# muscle spasm and pancreatitis% 8arly administration of anti&venom is highly effective# together )ith intensive care support in severe cases% In addition# infectious diseases can "e spread "y insect "ites# especially in tropical countries%

/earing protective clothing# applying insect repellents containing D88T are important preventive measures% The general treatment include= & Ice or cold pack and sting relief s)a"s ;applied topically< )ill help alleviate local pain and s)elling% & Any "ite or sting can "ecome infected and should therefore "e e'amined at regular intervals for progressive redness# s)elling pain or pus drainage & 5ral anti&histamines# such as diphenhydramine 4+ to +. mg every hours are helpful in relieving the itching# rash and s)elling associated )ith many insect "ites and stings & If anaphylactic shock occurs it must "e treated immediately )ith epinephrine and antihistamines% & A specifics antidote is availa"le for those suffering severe symptoms

Re%ere ce -% /orld Health 5rganisation% !a"ies% Geneva> /H5# 4.--% !?> http//)))%)ho%int/ith
2. Susan 8%# @harles 8%# Daniel 1ish"ein# @athleen A% Hanlon# $oonlert ?umlertdacha#

Marta Guerra# et al% Human !a"ies 7revention &&& nited States# 4..A% MM/! !ecommendations of the Advisory @ommittee on Immuni6ation 7ractices% May B# 4..A / +B;8arly !elease<=-&4C#4A
3. /orld Health 5rgani6ation% !a"ies% @urrent strategies for human ra"ies pre and post&

e'posure prophyla'is# Septem"er 4.-. 0% Meslin 1D# Hemachuda T# /ilde H# Gongal G% /H5 Standards for !a"ies @ontrol% At The 5ccasion of the 5I8 Glo"al @onference on !a"ies @ontrol> to)ards sustaina"le prevention at the source# Incheon !epu"lic of Eorea B&* Septem"er 4.-+% /H5 Guide for !a"ies 7re and 7ost Fe'posure prophyla'is in Humans% Department of 9eglected Tropical Disease&9eglected Goonotic Disease Team% !evised -+ Huni 4.-. C% /eiss 8A% A @omprehensive Guide to /ilderness and Travel Medicine% I rd ed% Adventure Medical Eits# 4..+> -4-&-II

Ob&ecti'es Case Male# 0. years old# $adung regency & 7atient referred from $adung District Hospital due to pro"a"le ra"ies% Has complained agitated since 0%+ hour prior to admission% Accompanied "y fear and )on(t drink )ater% 9o fever reported% He has history from !o$ bite about ()* mo th a$o on his right foot# a un&"leeding scratch on dorsal of right foot found% At that time the )ound did not clean or )ash% He did not go to hospital for vaccination% The dog is his o)n pet# not vaccine yet# and one month latter the dog that "it him died )ith unclear cause% & & ?evel of @onciousness> 80:+MC $7> -4./A. mmHg# 7!> --.' / min# )eak# regular# !!> 4. ' / min# regular# Ta' > IC%+ ?a"oratory findings> /$@> I4%A k/Jl# HG$> -+%- g/dl# 7?T> I*A k/Jl% AST> I*%A4 Iu# A?T> --%.4 Iu# $S> -AC%. mg/dl# $ 9> 44%+ mg/dl# S@>.%B4 mg/dl Lear i $ tas"> -% 1ind key )ords related to this case 4% Descri"e condition related to key )ords I% Define organ system that involved in this condition and find pro"a"ly cause of the key )ords 0% Define differential diagnosis and other e'aminations to support the diagnosis To descri"e )hy ra"ies continues to "e a feared 6oonotic disease% To descri"e ho) is ra"ies spread To descri"e disease that !a"ies most commonly mimic To understand ho) !a"ies is diagnosed To descri"e the current recommendation for !a"ies treatment To descri"e pre and post e'posure prophyla'is To descri"e clinical presentation of !a"ies To descri"e the clinical management of snake "ite envenoming To descri"e the clinical management of scorpion sting envenoming

+% Descri"e la"oratory e'amination to diagnose ra"ies C% Define management of this case B% Define complication and prognosis A% Define prevention "ased on individual# family# and community Sel% assessme t> -% Descri"e kinds of animals get ra"ies 4% Descri"e pathogenesis of ra"ies I% Descri"e diagnosis of ra"ies 0% Define management of animal "ite or scratch )ounds +% Descri"e ho) can ra"ies "e prevented C% Descri"e )ho should get ra"ies vaccine and )henK B% Descri"e the clinical management of snake "ite envenoming A% Descri"e the clinical management of scorpion sting envenoming

+uestio s, A imal associate! ha-ar! . Dr A)A)A/u 0uli 1a/atri2 S#3D4 -% /hy ra"ies does continue to "e a feared 6oonotic diseaseK A. !a"ies encephalomyelitis causes an acute renal failure B. !a"ies causes a spontaneous systemic "leeding C. !a"ies causes an inflammation and tissue damage D. 5nce clinically esta"lished# ra"ies encephalomyelitis is almost invaria"ly fatal E. !a"ies causes shock# paralysis# muscle spasm and pancreatitis 4% Diagnosed of !a"ies> A% The first clue to clinicians of possi"ility of !a"ies is often from history of "itten "y ra"id mammals% $% The first clue to clinicians of possi"ility of skin "iopsy for !a"ies virus antigen% @% A magnetic resonance "rain may "e used for the detection of !a"ies virus% D% All of statements )ere correct% 8% All of statements )ere false%

I% The symptoms of ra"ies are including> A% myocardial damage# cardiac arrhythmias# pulmonary edema $% Hydropho"ia# Aeropho"ia# agitation and coma @% High fever# )atery diarrhea and vomiting D% Spontaneous "leeding and moderate anemia 8% ?ocal reaction ;redness# s)elling and gangrene< at the site% 0% Transmission of ra"ies> A% Ingestion of ra) meat or other tissues from animals infected )ith ra"ies is not a source of human infection% $% $ats are the source of most human ra"ies deaths in the @anada% @% Dogs are the main host and transmitter of ra"ies D% All of statement )ere correct 8% All of the statement )ere false +% The la"oratory test to pro"a"le !a"ies patient includes A% Detect ra"ies virus antigen in the )ound tissue $% Thin "lood smear for detect ra"ies virus @% Detection of ra"ies virus !9A ;"rain tissue# cere"ro&spinal fluids# or saliva< D% Stick rapid diagnostic test 8% All of the statements )ere false% C% 7re&e'posure vaccination should "e offered to persons in high&risk groups# such as> A% veterinarians and their staff $% animal handlers @% ra"ies researchers D% certain la"oratory )orkers 8% All of a"ove B% Management therapy for !a"id mammals "ite or scratch )ound> A% 8ffective treatment soon ;)ithin a fe) days# "ut as soon as possi"le< can prevent the onset of symptoms and death $% 8arly administration of anti&venom is highly effective nited States of America and

@% immediate and thorough flushing and )ashing of the )ound for a minimum of -+ minutes )ith soap and )ater# detergent or povidone iodine D% A L @ )ere correct 8% All of statement )ere correct A% The clinical management of snake "ite envenoming# are as the follo)s> A% It is centred on the intravenous administration of anti&venom $% :entilator support for neuro&to'ic envenoming @% 1luid replacement for hypo&volemic shock D% All of statements )ere correct 8% All of statements )ere false *% Treatment for scorpion stings envenoming are including> A% There are no specific treatment for its $% 8arly administration of anti&venom is highly effective @% 7re and post e'posure prophyla'is is needed D% A#$ L @ )ere correct 8% All of statements )ere false -.% Snake "ites and scorpion stings are related to> A% Snake "ites and scorpion stings are )ell&kno)n medical emergencies in many parts of the )orld $% Agricultural travelers and children are the most affected @% The true incidence of snake "ite and scorpion stings envenoming are not kno)n "ecause many cases do not seek medical attention D% All of statements )ere correct 8% All of the statements )ere false

Soal $ahasa Indonesia

1. Mengapa rabies berlanjut menjadi penyakit zoonosis ditakuti? A. Rabies encephalomyelitis menyebabkan gagal ginjal akut B. Rabies menyebabkan perdarahan sistemik spontan . Rabies menyebabkan peradangan dan kerusakan jaringan !. "etelah tegak diagnosis klinis# rabies encephalomyelitis hampir selalu $atal

%. Rabies menyebabkan shock# kelumpuhan# kejang otot dan pankreatitis

2. !alam mendiagnosis Rabies& A. 'etunjuk pertama untuk dokter# kemungkinan Rabies sering dari ri(ayat digigit oleh mamalia. B. 'etunjuk pertama untuk dokter# biopsi kulit untuk antigen )irus Rabies. . "ebuah resonansi magnetik otak dapat digunakan untuk mendeteksi )irus Rabies. !. "emua pernyataan di atas benar. %. "emua pernyataan adalah salah.

3. *ejala+gejala rabies meliputi, A.kerusakan miokard # aritmia jantung# edema paru B. -ydrophobia# Aerophobia# agitasi dan koma . !emam tingg#i diare cair dan muntah !. perdarahan spontan dan anemia sedang %. reaksi lokal .kemerahan# pembengkakan dan gangren/ di tempat gigitan.

0. 'enularan rabies, A. Makanan yang mengandung daging mentah atau jaringan lain dari he(an terin$eksi rabies bukanlah sumber in$eksi pada manusia. B. 1elela(ar adalah sumber penularan rabies paling mematikan pada manusia di Amerika "erikat dan 1anada. . Anjing adalah host utama dan penularan rabies !. "emua pernyataan di atas benar %. "emua pernyataan adalah salah

2. 3es laboratorium untuk pasien yang dicurigai Rabies meliputi A. !eteksi antigen )irus rabies pada jaringan luka B. hapusan darah untuk mendeteksi )irus rabies

. !eteksi )irus rabies R4A .jaringan otak# cairan cerebro+spinal# atau air liur/ !. "tik tes diagnostic cepat %. "emua pernyataan di atas salah

5. 6aksinasi sebelum paparan harus disarankan kepada orang+orang kelompo risiko tinggi# seperti, A. dokter he(an dan sta$ B. 'emelihara he(an . 'eneliti Rabies !. 'ekerja laboratorium tertentu %. "emua di atas benar

7. Manajemen terapi untuk gigitan mamalia Rabid atau goresan luka, A. 'engobatan e$ekti$ segera .dalam beberapa hari# sesegera mungkin/ bisa mencegah timbulnya gejala dan kematian B. 'emberian anti+racun sedini mungkin sangat e$ekti$ . 'embilasan dan mencuci luka selama minimal 12 menit dengan yodium sabun dan air# deterjen atau po)idon# segera setelah gigitan !. A 8 yang benar %. "emua pernyataan itu benar

9. Manajemen klinis gigitan ular berbisa# adalah sebagai berikut, A. -al terpenting adalah pemberian intra)ena anti+racun B. 6entilator untuk mendukung untuk gejala neuro+toksik . airan pengganti pada kondisi hipo+)olemic

!. "emua pernyataan itu benar %. "emua pernyataan adalah salah

:. 'engobatan untuk sengatan kalajengking berbisa meliputi, A. 3idak ada pengobatan khusus

B. 'emberian a(al anti+bisa sangat e$ekti$ . 'ro$ilaksis sebelum dan pasca paparan diperlukan !. A# B 8 yang benar %. "emua pernyataan adalah salah

1;. *igitan ular dan sengatan kalajengking terkait dengan, A. *igitan ular dan sengatan kalajengking dikenal sebagai kondisi darurat medis di berbagai belahan dunia B. <isata(an pertanian dan anak+anak adalah yang paling terkena dampak . kejadian sebenarnya dari gigitan ular dan sengatan kalajengking beracun tidak diketahui dengan pasti karena banyak kasus tidak mencari pertolongan medis !. "emua pernyataan itu benar %. "emua pernyataan yang salah

Ans)er/Ha)a"an > -% D 4% A I% $ 0% D +% @ C% 8 B% D A% D *% $ -.% D