Dog Bite
Management for
State Level
Training
1
Rabies
• Rabies is an acute viral disease which
causes fatal encephalitis in virtually all
the warm blooded animals including man
• Animal bites if managed appropriately
rabies is 100 percent preventable
History
• Rabies in India is known since Vedic periods as
corroborated in Atherva Veda.
• The Latin word “Rabies” - Sanskrit word
“Rabhas” which means “to do violence”.
• Description by the Oriental physicians as far
back as 3000 BC and the Greek physician
Democritus in 500 BC and Celsus in First
Century AD.
Ancient Pictures
Dr.Louis
Pasteur
• Legendary French
scientist
• First vaccine
derived from dried
spinal cord
Human Mortality due to Rabies
Global Deaths : 55000
Deaths in Asia : 31000
Deaths in SEA : 25000
Deaths in India : 20000
India
Rabies is reported
from all states
except Lakshadweep
and the Andaman
and Nicobar Islands.
Rabies in India
• 96% of human rabies cases are due to
bites from Rabid dogs.
• Reported through out the year
• Estimated dog population : 25 Million
• Majority dogs: Stray, Un-owned and
unprotected
• Numerous myths and notions are
prevalent
Magnitude of the PET
requirement
• Estimated 3 million people receive
PET annually in India
• Data based on vaccine utilisation in
both public and private sector
• Many do not seek or do not get PET
Animals transmitting Rabies in India
Domestic Peridomestic
• Dogs • Cows
• Cats • Buffaloes
• Sheep
• Goats
• Pigs
• Donkeys
• Horses
• Camels
Animals transmitting Rabies in India
Wild Not reported
• Foxes & • Bats
Jackals • Rodents
• Monkeys • Birds
• Mongoose • Squirrel
• Bears
Rabid dog
HOME
Furious Rabies Dumb Rabies
Animals transmitting Rabies in
India
• All wild animal bites are considered as
category III exposures.
• Bites by Bats or Rodents do not ordinarily
necessitate rabies vaccination. However,
bites by bats or rodents in unusual
circumstances may be considered for
vaccination in consultation with an expert in
the field of rabies.
Mode of Transmission
Common Rare
• Bites from • Inhalation
infected animals • Organ
• Licks on Broken transplantation
Skin/Mucous • Ingestion
Membranes • ? Sexual
• Scratches
Structure of Rabies Virus
Bullet Shaped.
Enveloped Virus.
Measures 75 nm x 180 nm.
Numerous spikes present
on the envelope, these are
made up of glycoprotein.
Glycoprotein necessary for viral attachment and
also induce protective antibodies.
Inactivation of Rabies Virus
• At 600C within 35 seconds (sensitive to pasteurization
and boiling)
• At pH < 4 or > 10
• By action of oxidizing agents, most organic solvents,
surface acting agents, quaternary ammonium
compounds, proteolytic enzymes, ultraviolet rays and
X-rays
• Soaps and detergents
• Alcohol
Pathogenesis of Rabies
Incubation Period (in man)
Ranges between 6 days to 6 years.
More than 6 months in less than 1%
Bites on the head or face – up to 1 month.
Bites on the extremities - up to 3 months.
Incubation period depends upon
The site of bite
Severity of bite
Number of wounds
Amount of virus injected
Species of biting animal
Protection provided by clothing
Treatment undertaken, if any
Animal Bite Management
Medical
Emergency
Category-I No exposure
• Type of contact
– Touching or feeding of animals
– Licks on intact skin
• Recommended PEP
– None if reliable case history is available
Category-II Minor exposure
• Type of contact
– Nibbling of uncovered skin
– Minor scratches or abrasions without
bleeding
• Recommended PEP
– Wound management
– Anti Rabies Vaccine
Category-III Severe exposure
• Type of contact
– Single or multiple transdermal bites or
scratches
– Licks on broken skin
– Contamination of mucous membrane with saliva
i.e: licks
• Recommended PEP
– Wound management
– Rabies immunoglobulin
– Anti Rabies Vaccine
Serious Exposures
• Bites on the Head, Face, Hands, Genitalia
• Multiple bites
• Extensive lacerations
• Bites by
– proven rabid animals
– animals not available for observation
– more than one animal
– wild animals
Approach to Post-Exposure
Prophylaxis
• Management of animal bite wound
• Passive Immunisation:
–Rabies Immunoglobulin (RIG)
• Active Immunisation
–Anti-Rabies Vaccines (ARV)
Management of animal
bite wound
Wound Management- Do’s
• Mechanical
– Wash the wound with running tap water
• Chemical
– Wash the wound with soap and water
– Apply disinfectants
• Biological
– Infiltrate Immunoglobulins in the depth and
around the wound in category-III exposures
Suturing only if required (1-2 loose sutures) and
only after administration of RIGs.
Application of antiseptics
• Povidone iodine
• Alcohol
• Chloroxylenol (Dettol)
• Chlorhexidine gluconate
• Cetrimide solution (savlon)
Wound Management- Don’ts
• Do not touch the wound with bare
hands
• Do not apply irritants like soil,
chillies, chalk, betel leaves etc
Passive Immunisation
Passive Immunization
•Human Rabies Immunoglobulin (HRIG)
–20 IU/kg body wt. Maximum of 1500 IU
–Does not require any prior sensitivity testing
•Equine Rabies Immunoglobulin (ERIG)
–40 IU/kg body wt. Maximum of 3000 IU
–ERIG must be administered only after the
Test dose
Anti-rabies sera should be brought to
room temperature before administration
Infiltration of RIG in wounds
Infiltrate as much as possible into and around the wounds;
remaining if any to be given Intra Muscularly at a site away
from the site where vaccine has been administered.
Inject RIGs into all wounds (anatomically feasible).
If RIGs is insufficient (by volume) dilute it with sterile
normal saline (up to equal volume).
Presently available preparations are very safe. However,
equine serum must be administered with full precautions.
RIG infiltration
Active Immunisation
for
Post-Exposure
Prophylaxis
Good Bye to Nervous Tissue Vaccine
Production stopped since December 2004
Intramuscular ARV
Essen Regimen (Intra-Muscular)
Day 0 : 1st dose
Day 3 : 2nd dose
Day 7 : 3rd dose
Day 14: 4th dose
Day 28: 5th dose
Day 90: 6th dose (optional)
IM vaccination site
• Deltoid or antero-lateral aspect of
thigh
• Gluteal region not recommended due
to poor absorption
Points to remember
Day 0 (D0) - Day of 1st dose of vaccine given,
not the day of bite.
All modern Tissue Culture Vaccines (TCVs)
are equally effective and safe.
Never inject the vaccines into the gluteal
region.
Points to remember
Interchange of vaccines acceptable in special
circumstances but not to be done routinely.
Reconstituted vaccine to be used immediately
within 6 hours
Vaccine dosage is same for all age groups.
Approach to a patient requiring rabies
vaccine when none is available
Double the Ist dose in the following situations if antirabies
serum is not administered.
Category III Exposure
Malnourishment, Patients on steroids, anti cancer
drugs and anti-malarials.
HIV / AIDS patients (CD4 count < 200) RIGs are life
saving.
Double dose of vaccine is not a substitute for RIGs.
Intradermal ARV
Intra Dermal Regimens
for Post Exposure Treatment
Approved by the WHO.
Cost effective.
Viable alternative to replace Nerve Tissue
Vaccine in India.
Studies in India confirm safety and efficacy.
Approved by DCGI for use in India.
Updated Thai red Cross Schedule (2-2-2-0-2)
• Dose
– 0.1ml/ID Site
– injection of 0.1ml of reconstituted vaccine
per ID site and on two such ID sites
• Site
– Upper arm over each Deltoid area, an inch above
the insertion of deltoid muscle
Schedule (2-2-2-0-2)
Day 0
Day 3
Day 7
Day 28
Materials required
• A vial of rabies vaccine approved for IDRV
and its diluent
• 2 ml disposable syringe with 24 G needle for
reconstitution of vaccine
• Disposable 1 ml (insulin) syringe (with
graduations upto 100 or 40 units) with a fixed
28 G needle
• Disinfectant swabs (e.g: 70 % ethanol,
isopropyl alcohol) for cleaning the top of the
vial and the patient’s skin
ID Injection technique
• Using aseptic technique, reconstitute the
vial of freeze-dried vaccine with the diluent
supplied by the manufacturer
• With 1 ml syringe draw 0.2 ml (upto 20
units if a 100 units syringe is used or 8 units
if 40 units syringe is used (o.1 ml per site in
2 sites)
• Expel the air bubbles from the syringe
carefully
ID Injection technique
• Using the technique of BCG inoculation, stretch
the surface of the skin and insert the tip of the
needle with the bevel upwards, almost parallel to
the skin surface
• Inject half the volume at one site and the
remaining half at the other site
• An inch above the insertion of deltoid muscle is
the preferred site
• If the needle is correctly placed inside the dermis,
considerable resistance is felt while injecting the
vaccine
Intra Dermal Administration of ARV
Correct technique
for ID injection
General guidelines for IDRV
Must be administered by trained staff
Reconstituted vaccine should be used as
soon as possible or at least within 6-8
hours
Vaccine when given intra-dermally should
raise a visible and palpable bleb in the
skin
General guidelines for IDRV
In the event that the dose is given
inadvertantly given subcutaneously or
intramuscularly or in the event of spillage,
a new dose should be given intradermally
in nearby site
Animal bite victims on chloroquine therapy
should be given ARV by IM route
Medical advice to Vaccinee
No dietary restriction.
No restriction of physical exercise.
Avoid immune suppressants (Steroids, anti-
malarials) if possible.
Best to avoid consumption of alcohol
during the course of treatment.
Medical advice to Vaccinee
Complete the course of vaccination.
Address and contact details should be
collected from every client and followed
up
Client should be informed that Inj.
Tetanus toxoid should not be counted as
ARV dose
Class III exposures
Transdermal injury on the
back
Lacerations on the scalp
Extensive lacerated bites
on the face
Bites on the face of a child
Multiple bites on the face of a child
Bite on the face in an adult
Multiple bites by many dogs
Severe laceration caused by dog bite
Extensive laceration of the foot
Bite on the genitalia
Sutured bite wounds
Apply loose stitches
Clinical Findings
• Bizarre behavior.
• Agitation
• Seizures.
• Difficulty in drinking.
• Patients will be able to eat solids
• Afraid of water - Hydrophobia.
• Even sight of sound disturbs the patient.
• But suffer with intense thirst.
• Spasms of Pharynx produces choking
• Death in 1 -6 days.
• Respiratory arrest / Death / Some may survive.
68
Symptoms
• Headache, fever, sore throat
• Nervousness, confusion
• Pain or tingling at the site of the bite
• Hallucinations
– Seeing things that are not really there
• Hydrophobia
– “Fear of water" due to spasms in the throat
• Paralysis
– Unable to move parts of the body
• Coma and death
69
CLINICAL MANIFESTATIONS
1 – Non specific prodrome
2 – Acute neurologic encephalitis
Acute encephalitis
Profound dysfunction of brainstem
3 – Coma
4 - Death ( Rare cases recovery ) 70
CLINICAL MANIFESTATIONS
1 – Non specific prodrome
1 - 2 days 1 week
Fever, headache, sore throat
Anorexia, nausea, vomiting,
Agitation, depression
Parenthesis or fasciculation's at or
Around the site of inoculation of
virus.
71
More Dangerous Rabies
• Furious Rabies
• Dumb ( Rage
tranquille )
(Landry/Guillain-
Barre Syndrome
72
Acute Neurologic Encephalitis
• 1 – 2 days to < 1 week
• Excessive motor activity, Excitation, Agitation
• Confusion, Hallucinations, Delirium,
• Bizarre aberrations of thought, Seizures,
• Muscle spasms, Meningismus,
• Opisthotonic posturing
• Mental aberration ( Lucid period coma )
• Hypersalivation, Aphasia, Pharyngeal spasms
• Incordination, Hyperactivity
73
Acute Neurologic Encephalitis Phase
• Fever T > 40.6
• Dilated irregular pupils
• Lacrimation, Salivation & Perspiration
• Upper motor neuron paralysis
• Deep tendon reflexes
• Extensor plantar responses ( as a rule )
• Hydrophobia or Aerophobia (50 -70% )
74
75
76
Diagnosis of Rabies
• In most cases, human rabies is diagnosed
primarily on the basis of clinical symptoms
and signs, and a corroborative history of or
evidence of an animal bite, death of an
animal, and incomplete or no vaccination
following exposure.
77
Post mortem Diagnosis
• The standard premortem test is a
fluorescent antibody test to
demonstrate the presence of viral
antigen. The standard postmortem
test is biopsy of the patient's brain
and examination for Negri bodies.
Autopsies are rarely performed.
78
Diagnostic methods
• Antigen detection by specific Immuno
fluorescence.
Ante-mortem - Conjunctival,skin biopsy from
nape of neck.
Postmortem impression from surfaces of
salivary glands Hippocampus,
Histological examination
ELISA specific antibody detection.
PCR
79
Negri bodies
in Brain Tissue
• Negri bodies round or oval
inclusion bodies seen in the
cytoplasm and sometimes
in the processes of neurons
of rabid animals after death.
• Negri bodies are
Eosinophilic, sharply
outlined, pathognomonic
inclusion bodies (2-10 µm in
diameter) found in the
cytoplasm of certain
nerve ..
80
DIFFERENTIAL DIAGNOSIS
Other viral encephalitis
Hysteria reaction to animal bite
Landry/Guillan-barre syndrome
Poliomyelitis
Allergic encephalomyelitis ( rabies vaccine )
81
Frequently Asked
Questions (FAQs)
If a person bid by an animal comes
after several days, what to do?
• ARV should be started at the earliest to
ensure that the individual will be
immunised before the rabies virus
reaches the nervous system.
• However, people who present for
treatment even months after a possible
rabies exposure should be evaluated and
treated as if the event had occurred
recently.
Pregnant woman bitten by a dog.
Shall the pregnancy be terminated?
• Pregnancy, lactation, infancy, old age and
concurrent illness are no contra-indications for
rabies post-exposure prophylaxis.
• PEP takes preference over any other
consideration since it is a life saving
procedure.
• Rabies vaccine does not have any adverse
effect on fetus, mother to be and the course
of pregnancy
• There is no need to terminate the pregnancy.
What is the dose of ARV for children?
• All age groups of animal bite victims
require the same number of injections
and dose per injection.
• The dose of RIG is based on body weight
I was bitten by a vaccinated dog.
Do I need to be vaccinated?
• There is no guarantee that the
vaccination was effective in that animal
(animal vaccine failure) and also the
reliability of history of vaccination
• A person bitten by a vaccinated animal
should receive the full course of PET as
per the category of exposure.
A dog had bitten me when I provoked it.
Do I need to be vaccinated?
• Whether a dog bite was provoked rather
than unprovoked should not be
considered a guarantee that the animal is
not rabid.
• We don’t know what an attacking dog
considers provocation for an attack
What is the relevance of 10 days
observation of the animal?
• Practically it is not possible to go behind
the animal.
• Since we have a vaccine without side
effects, it is always safe to give the full
course of vaccination.
A man was bitten by a jackal.
Does he require RIG?
• All wild animal bites should be
considered as categoty-III bite and
treated accordingly.
I fed my cow by holding its
mouth. The animal died later due
to rabies. Do I need vaccination?
• Yes. Contact with saliva necessitates
PET.
A Doctor unwittingly examined
the oral cavity of a patient who
complained difficulties in
drinking. What to do?
• The doctor needs full course of PET.
• Continuing medical education on
rabies prevention to be organised.
Investigation of Rabies deaths
• Investigate all deaths due to
rabies by using the prescribed
case investigation sheets
• The insights gained in
understanding what went
wrong, will help to prevent
further loss of lives
Together we can
prevent rabies
THANK YOU
