A&E Clinical Guideline No.

1
Management of Animal Bite Victims & Prevention of Rabies
(Revised June 2005)
Dr C C Lau

I. Introduction

The last local and imported human rabies cases occurred in 1981 and 2001 respectively.

Animal rabies has not been reported in Hong Kong since 1987. Of the 34 animal rabies cases
reported since 1980, 32 cases involved dogs while 2 involved cats. All rabid animals came from the
New Territories. (For details related to rabies epidemiology, please refer to Department of Health
Standing Circular.)

To facilitate medical treatment and disease prevention, the A&E staff should record patient’s
personal data, details of the events and the fate of the offending animal. The degree of suspicion of
the animal being rabid and the availability of the animal for observation will determine the
subsequent medical management.

The essential components of rabies post-exposure prophylaxis are wound management and
assessment for administration of vaccine and rabies immune globulin (HRIG).

The incubation period varies from days to years. When a documented or likely exposure has
occurred, post-exposure prophylaxis is indicated regardless of the length of the delay, provided the
clinical signs of rabies are not present.

Routine delivery of health care to a patient with rabies is not an indication for post-exposure
prophylaxis unless exposure of mucous membranes or non-intact skin to potentially infectious body
fluids has occurred.*

II. Legal Duties

Rabies is a notifiable disease (Section 4, Prevention of the Spread of Infectious Diseases

Regulations (Cap 141B)).

A Person who knows or who may reasonably suspect that an animal is rabid or has been in contact
with a rabid animal shall, without delay, give notice of that fact to an authorised officer (Section 26,
Rabies Ordinance (Cap 421)). An authorised officer is a person authorised by the Director, Deputy
Director or Assistant Director of Agriculture, Fisheries and Conservation.

If the animal is confirmed rabid by laboratory, staff should notify the Central Notification Office
(CENO) of Centre for Health Protection. Please refer to HAHO Operations Circular on ‘Reporting
Mechanism for Notifiable Diseases’ for details.

Page 1 of 6
III. Animal highly suspicious of being rabid

1. the animal is from rabies infected area;

2. the biting incident was unprovoked and the animal has bitten more than one person or other
animal;

3. the animal shows clinical signs and symptoms of rabies, eg increased salivation, shivering,
change in behaviour, paralysis, or restlessness;

4. wild mammals – raccoons, skunks, foxes and coyotes

Notes

a. Rabies infects mammals only. Lagomorphs (rabbits, hares) and most rodents (except
woodchuck) such as squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice are
almost never found to be infected with rabies and have not been known to transmit rabies to
humans.

b. A currently vaccinated dog or cat is unlikely to become infected with rabies.

IV. Principle of Management

A. General
1. Stabilise the patient first.

2. Confirm the patient’s personal particulars :

– name
– age
– sex
– ID card number
– address
– contact telephone number

3. According to the patient’s information, note down the general characteristics of the
biting animal as far as possible, eg species, age, weight, colour, vaccination status, etc.
Enquire whether the biting incident was provoked; whether any other person or animals
have been bitten by this animal; whether any signs and symptoms of rabies shown by
the animal and find out the geographic location of the incident.

4. Advise the patient to report the incident to the Police together with the completed
Part A of MD 1118A (Appendix A). Advise the patient to assist Police by identifying
the offending animal. Arrangement will be made by the police to send the animal
(eg unvaccinated dogs) to a Government Kennel for observation (currently is about
7 days). For dog bite, the dog meeting all the following criteria will be quarantined at
home :
– a licensed dog currently vaccinated against rabies
– on record with Agriculture, Fisheries & Conservation Department (AFCD)
– a locally-kept dog in a rabies-free environment.
A&E Clinical Guidelines No. 1 – Animal Bite / Rabies Page 2 of 6 Revised Jun 2005
IV. Principle of Management (continued)

B. Treatment of Wounds

In studies of animals, thorough wound cleansing alone without other post-exposure

prophylaxis has been shown to reduce markedly the likelihood of rabies.

1. Clean the wound thoroughly with (25%) soap solution, followed by flushing with
copious amount of water. If available a virucidal agent such as povidone-iodine should
be used to irrigate the wound.

2. Foreign bodies should be removed and necrotic tissue should be debrided. Primary
wound closure following proper wound treatment has been successful in wound of the
head and neck, trunk and extremities other than the hands. Delayed suturing is
generally advised for contaminated, large or deep wounds and hand wounds.

3. Give appropriate tetanus prophylaxis.

4. Prescribe other treatments when indicated, eg antibiotics (Appendix B).

C. Immunisation

1. Active immunisation – inactivated rabies vaccine obtained by culture on human

diploid cell (HDCV, HK$165.5 per vial).

The vaccine should be given in the deltoid muscle in adults and in the mid-anterior
thigh muscles of infants and small children on Day 0, 3, 7, 14 & 28.

Victim who has been previously immunised either with a five-dose course or as
prophylaxis against rabies within the past 5 years should receive 2 doses of HDCV on
Day 0 and 3. HRIG is not recommended.

5-dose full course is recommended if vaccination is incomplete or received more than

5 years ago. Consider passive immunisation.

Adverse reactions are usually minor and transient but it should be used with care in
patients with allergy to neomycin. Persons who have a history of serious
hypersensitivity to rabies vaccine should be revaccinated with caution.

a. local reactions (30-74%) : pain, erythema, swelling, itchiness at injection site

b. systemic reactions (5-40%) : headache, nausea, abdominal pain, myalagia,
dizziness
c. 3 cases of neurological illness resembling Guillain-Barre syndrome that resolved
without sequelae in 12 weeks have been reported.

A&E Clinical Guidelines No. 1 – Animal Bite / Rabies Page 3 of 6 Revised Jun 2005
IV. Principle of Management (continued)

C. Immunisation (continued)

2. Passive immunisation – Human Rabies Immune Globulin, HRIG (300 IU/2 ml,
HK$650 per vial)

The recommended dosage is a single administration of 20 IU / kg body weight. If

anatomically feasible, the full dose should be infiltrated around the wound(s) and any
remaining volume should be administrated IM at an anatomical site distant from
vaccine administration.

Adverse reactions – local pain and low grade fever

Studies conducted in the United States by CDC have documented that a regimen of one dose
of HRIG and five doses of HDCV over a 28-day period was safe and induced an excellent
antibody response in all recipients.

The efficacy of regimen deviated from the recommended one is unknown. Beyond the 7th day,
antibody response is presumed to have occurred. A few days variation is not important.
Vaccine of HDCV type but from different manufacturers may have different protective
activities and should be considered individually. In case of doubt, a new course should be
commenced.

Corticosteroids, other immunosuppressive agents, anti-malarials, and immunosuppressive

illnesses can interfere with the development of active immunity after vaccination.

Pregnancy is not a contraindication to post-exposure prophylaxis. Foetal abnormalities have

not been associated with rabies vaccination.

A&E Clinical Guidelines No. 1 – Animal Bite / Rabies Page 4 of 6 Revised Jun 2005
V. Post-exposure prophylaxis against rabies

A. Animal highly suspicious of being rabid

1. Give HRIG and start full course of HDCV.

2. Stop HDCV when there is no histological evidence of rabies in the brain tissue of the
offending animal.

B. Animal not highly suspicious of being rabid

1. Animal cannot be captured

Explain to patient the risk of contracting rabies and start full course of HDCV.

2. Animal not yet captured

HDCV is usually not required immediately unless the wounds are extensive or over the
head and neck regions.

Explain to patient the need to return for treatment if the offending animal cannot be
made available for observation in a Government Kennel within 48 hours. Ask patient to
sign Part B (II) of the Consent Form MD 1118A.

Follow up the case in 48 hours.

3. Animal available for observation

HDCV is not required at this stage. Explain to the patient the need to return for
treatment if the offending animal dies during observation period. Ask the patient to
sign Part B (II) of the Consent Form MD 1118A.

The AED will be informed immediately over the phone about the result of laboratory
test and/or the death of the animal under observation by the AFCD. A written
confirmation will also be forwarded to the concerned AED.

4. Animal status confirmed

a. Animal dies during observation

Call back patient immediately to start HDCV and wait for laboratory
confirmation.

b. Animal confirmed rabid by laboratory

Call back patient immediately to start or to continue the full course HDCV.

HRIG should be administered and can be given up to the seventh day after the
first dose of HDCV. Beyond the seventh day, an antibody response to HDCV is
presumed to have occurred.

A&E Clinical Guidelines No. 1 – Animal Bite / Rabies Page 5 of 6 Revised Jun 2005
References

1. Department of Health. Standing Circular No. 3/2002. Guidelines on the management of

animal bite victims and prevention of rabies.

2. Human Rabies Prevention - United States, 1999 Recommendations of the Immunization

Practices Advisory Committee (ACIP).

3. Emergency management of dogs and cat bite wounds. Emergency Medicine Clinics of
North America. Vol. 10 No. 4 719-736 (Nov 1992).

4. Emergency Medicine: A Comprehensive Guide. 4th Edition. American College of

Physicians.

5. Wilderness Medicine: Management of Wilderness and Environmental Emergencies.

3rd Edition, Paul S. Auerbach.

Appendices

A Report on Animal Bite (MD 1118A)

B Antibiotics Treatment for Dog Bite Wound

C Flow Chart for Management of Animal Bite Patients

A&E Clinical Guidelines No. 1 – Animal Bite / Rabies Page 6 of 6 Revised Jun 2005
 Appendix A
REPORT ON ANIMAL BITE
PART A

Sub-Divisional Inspector i/c Station Report No

Name of Person Bitten Age Sex M/F

Address _____________________________________________________________________________________________

Tel Date when bitten

Description of Animal __________________________________________________________________________________

Locality where biting occurred ___________________________________________________________________________

I request your assistance in the tracing and delivery of the animal concerned to the Senior Veterinary Officer.

Please inform us at Tel , whether the animal is captured. This information would assist us in the
management of the patient.

Hospital or Clinic MO

Date _____________________________

··············································································································································································································

PART B A&E/Hospital No
REPORT ON ANIMAL BITE
PATIENT ADVICE AND CONSENT FORM

Name of Person Bitten Age Sex M/F

Address Tel

* (I) (for patient to whom anti-rabies vaccine is recommended)

I, myself/parent/guardian of the above-named person acknowledge that the risk of

contracting rabies and the risk of having reactions to anti-rabies vaccination have been clearly explained to me. I wish/do not
wish* myself/my child/my ward* to receive a complete course of anti-rabies vaccination.

* (II) (, myself/parent/guardian of the above-named person*, understand

that I/my child/my ward* should attend this Hospital or Clinic again for further treatment if the biting animal cannot be
captured for observation or dies during observation period in a Government Kennel.

Witnessed Signed
Patient/Parent/Guardian of Patient *

Designation Date

Notes: 1. * Delete as appropriate.

2. A person leaving Hong Kong in less than two weeks should leave a reliable address at which he/she may be
immediately contacted abroad.
A&E Clinical Guidelines No. 1 – Animal Bite / Rabies Appendix A – Page 1 of 1 Revised Jun 2005
 Appendix B
Antibiotics Treatment for Dog Bite Wound

A. Organisms

• Organisms inoculated into wound by animal’s teeth, originated form the animal’s oral
cavity, often polymicrobials

1. Aerobes
• α-haemolytic streptococci, Staph. aureus, Pasteurella multocida & Staph.
intermedius

2. Anaerobes
• Actinomyces species, Bacteroides species, Fusobacterium species &
Peptostreptococcus species, Capnocytophaga species

B. Antibiotics

1. Increased risk of infections if

y delayed treatment for 8 hours without proper wound management
y full thickness puncture
y hand wounds or lower extremity wounds
y wounds requiring surgical debridement
y wounds in patients with high risk of infection
♦ documentation of or high suspicion for bone or joint penetration and pathogen
inoculation
♦ a bite wound in any immunocompromised patient, especially in the setting of
mastectomy, chronic liver disease, or corticosteroid or other
immunosuppressive therapy
♦ a bite wound adjacent to a prosthetic joint
♦ a bite wound around the genital area

2. Prophylaxis
y instituted when clinical circumstances predict a high likelihood of infection after a
bite-wound injury
y oral amoxicillin-clavulanic acid
y for patients with penicillin allergy, choices may include oral clindamycin plus a
fluoroquinolone (eg ciprofloxacin, levofloxacin), clindamycin plus a tetracycline,
and clindamycin plus trimethoprim-sulfamethoxazole. Cefuroxime plus
metronidazole may be considered in patients with non-life-threatening reaction to
penicillin.
y for paediatric patients with penicllin allergy, clindamycin plus
trimethoprim-sulfamethoxazole may be considered
y suggested prophylactic therapy duration : 3 – 5 days

A&E Clinical Guidelines No. 1 – Animal Bite / Rabies Appendix B – Page 1 of 2 Revised Jun 2005
 Appendix B
Antibiotics Treatment for Dog Bite Wound (continued)

B. Antibiotics (continued)

3. Infected wounds

y obtain wound culture prior to antibiotics if possible; empirical therapy before

culture results available
y oral amoxicillin-clavulanic acid
y for patients with penicillin allergy, oral clindamycin plus a fluoroquinolone,
clindamycin plus a tetracycline, and clindamycin plus
trimethoprim-sulfamethoxazole. Cefuroxime plus metronidazole may be
considered in patients with non-life-threatening reaction to penicillin
y Antibiotics choice in paediatric patients with penicillin allergy follow the same
suggestions as for prophylactic use
y the duration of antibiotic therapy for a bite wound depends on the severity of the
infectious process

Reference

Myers JP. Bite wound infections. In Tan JS (ed). Expert guide to infectious diseases.
Philadelphia. American College of Physicians; 2002: 645-667.

Gilbert DN et al. The Sanford guide to antimicrobial therapy. 34th ed. Antimicrobial Therapy,
Inc. 2004.

Red Book 2003. Report of the Committee on Infectious Diseases. American Academy of
Paediatrics.

A&E Clinical Guidelines No. 1 – Animal Bite / Rabies Appendix B – Page 2 of 2 Revised Jun 2005
 Appendix C
Flow Chart for Management of Animal Bite Patients

A&E Clinical Guidelines No. 1 – Animal Bite / Rabies Appendix C – Page 1 of 1 Revised Jun 2005