ANIMAL BITE

MANAGEMENT
AND
RABIES PREVENTION
ANIMAL BITE TREATMENT
CENTER (ABTC)
 ANIMAL BITE TREATMENT CENTER

The ABTC will be situated at the OPD area and

the ER will be an extension
ABTC – Sénior Residents FM, Nurses
ER - Surgery Residents, Nurses
RABIES: The Disease and
Epidemiology
RABIES
• Rabies is a zoonosis, and human infection usually
occurs following a transdermal bite or scratch by an
infected animal.
• Acute. Progressive, incurable viral encephalitis with
a fatal outcome
EPIDEMIOLOGY
• Human rabies is mainly confined to some countries in
Asia and Africa. The Indian Sub continent account
for 80% of the Global human deaths due to Rabies.
• India alone reports about 30,000 human deaths/year
(WHO 1996).
• No age or sex predilections (higher incidence among
children and adult Males).
• 95% of human rabies cases are due to bites from
Rabid dogs
Regions with Highest Number of Human Rabies
Cases, 2015
 Human Rabies Human Rabies Rank
Region 3 29 1
Region 1 25 2
Region 5 24 3
Region 4-a 20 4
Region 11 16 5
Region 6 15 6
Region 2 12 7
Region 12 10 8
CARAGA 10 8
NCR 7 9
Region 7 6 10
Region 8 6 10
Regions with Highest Incidence Rate of Human Rabies
Cases, 2015

Region HR IR Rank
Region 1 25 4.95 1
Region 5 24 4.11 2
CARAGA 10 3.92 3
Region 2 12 3.46 4
Region 11 16 3.24 5
Region 3 30 2.66 6
Region 12 10 2.15 7
Region 6 15 1.97 8
Region 8 6 1.37 9
Region 4-a 20 1.36 10
Region 9 4 1.07 11
Region 10 5 1.05 12
 Provinces with Highest with
Human Rabies Cases, 2015

Province Number of Human Rabies

1 PANGASINAN 15
N. Ecija 13
Camarines Sur 13
Tarlac 7
Quezon 7
CAPIZ 7
DAVAO Norte 7
ISABELA 6
Batangas 6
Bukidnon 6
Misamis Oriental 6
Albay 5
ILOILO PROVINCE 5
Total: Lanao del Norte 5
DAVAO CITY 5
16 LA UNION 4
Cavite 4
 • Treat all diagnosed TB cases
• Eliminate malaria in endemic
provinces
Package
• Improve HIV/AIDS prevention,
of
screening, diagnosis, and treatment
actions
and • Provide rabies vaccine for dog bite
population victims and coordinate with DA for
coverage: dog vaccination
• Eliminate filarial and other intestinal
parasites

CY 2014 2015 2016

Resource
Needs 2.90 3.35 3.48
(billion PhP):

Supporting DSWD, DILG and LGUs, From DOH- OSEC

Agencies: DA (lead for dog vaccination)
 National Goal:
To eliminate human rabies in the
Philippines & declare a rabies-free
Philippines by year 2020 2016
 2014: Rabies Free Zones

Palawan: Quezon:
1. Linapacan Alabat Island
2. Kalayaan 1. Alabat
3. Cagayancillo 2. Quezon
4. Cuyo 3. Perez
5. Magsaysay
6. Araceli

.
Surigao del
Norte:
1. Socorro
RABIES: The Disease
 Transmission
Transplant Aerosol
• Cornea
• Caves
• Solid organs
• Laboratory
• Vascular conduit

Lick Bite/Scratch
• Broken skin
• Mucous membranes
Risk of Developing Rabies
• Around 15 - 20 %

• Influenced by:
1. Virus content of saliva- viral shedding in saliva is
intermittent
2. Severity of the bite
3. Location of the bite
 Brain

Spinal cord

Dorsal root ganglia

Peripheral nerves

Multiplication locally
(in the muscle fibers)
 Incubation Period
IP: 2 wks to 6 yrs
Average IP: 1-3 mos

Length of IP affected by:

• infecting strain
• size of inoculum
• degree of innervation
• proximity to CNS

Moves centripetally from

Rabies Virus replicates in
periphery to dorsal root
the muscle at bite site
ganglia and SC
 Prodrome Duration: 2-10 days
Non-specific S/Sx:
Fever, Malaise/fatigue,
Headache, Anorexia

Attacked by immune
system resulting in
ganglioneuritis (Pain,
itching, numbness at
bite site)

Rabies Virus replicates Rabies Virus travels

in the dorsal root ganglion
along the CNS
 Clinical Signs and Symptoms
• Prodromal phase
• Symptoms
• Non-specific S/Sx (fever, malaise/fatigue, headache,
anorexia) which may be mistaken for flu, ARI, SVI
• Pain, numbness, intense pruritus at bite site
• An intense and progressive local reaction, starting at
the bite site and gradually spreading to involve the
whole limb
• Fever
• Signs
• Healed wound or scar at bite site
• Extensive excoriations at bite site due to pruritus
 Acute Neurologic Phase
Duration: 2-7
days

Rabies Virus infects the brainstem,

thalamus, basal ganglia, and Rabies Virus travels centrifugally
spinal cord from the brain to other organs
Acute Neurologic Phase

Two clinical forms

Acute Neurologic Phase
Encephalitic Rabies
3 Cardinal Signs:
Two clinical forms • Fluctuating consciousness – normal
periods alternating with agitation,
depression and irritability
• Phobic or Inspiratory spasms
 Phobic spasms: Hydrophobia,
Aerophobia
 Inspiratory spasms: occur without
stimulation, are infrequent and less
intense
• Autonomic instability: hypersalivation,
hypertension, hyperthermia,
tachycardia, arrythmia, piloerection,
fixed dilated or constricted pupils,
anisocoria, excessive sweating,
priapism, and spontaneous ejaculations

• Other Sx - hyperventilation,
convulsions, hallucinations, bizarre
behavior
 Acute Neurologic Phase

Two clinical forms

Paralytic Rabies
 Weakness, varied forms of paralysis
• Localized to bitten extremity
• Diffuse, symmetric paralysis
• Ascending paralysis, GBS-like
 Hyperactivity & agitation usually absent
 Aerophobia and hydrophobia in 50 %
 Meningeal signs (headache, neck stiffness)
may be prominent
 Persistent fever from the onset of limb
weakness
 Intact sensory function of all modalities
except at the bitten region
 Bladder dysfunction
Clinical Manifestations of human
rabies cases (n= 320)
Manifestations Number Percent
Hydrophobia 263 82
Aerophobia 251 78.2
Fever 138 43
Dysphagia 90 28
Restlessness 86 27
Dyspnea 79 25
Agitation/combativeness 65 20
Hypersalivation 65 20
Localized paresthesia/itching 32 10
at bite site
RITM human rabies registry
RABIES: Diagnosis
How to diagnose rabies
• Clinical
• History of exposure
• Compatible clinical Sx and symptoms
• Clinical course with Death as outcome
• Neuroimaging techniques
• Laboratory confirmation
• Definite Dx of rabies can only be obtained by laboratory
investigations
• FAT
• PCR – CSF, serial saliva specimens
• RFFIT - CSF
 History
• History of exposure
• Animal bite/scratch – especially dog, cat;
• Non-bite exposure – licks on breaks in the skin or
mucous membranes, exposure to rabid patient,
butchering of infected animal, transplant
• Date of bite and onset of Sx – should fit IP
• Location of bite, number of bite wounds
 History
• Other relevant information
• Status of the biting animal at the time of bite and after
14 days observation period
• Vaccination status of biting animal
• Other victims of the same dog
• News of “mad” dog in the area, animal “found dead”
• Treatment of bite victim – vaccination, traditional
remedies
RABIES PREVENTION
Prevention of Human Rabies:
1. Vaccination of dogs
• Most effective, cost effective
2. Provision of Post- Exposure Prophylaxis (PEP) to
animal bite victims
3. Pre- Exposure Prophylaxis (PrEP) among high risk
individuals
Don’t allow your dogs to stray
in public places

Have your dog vaccinated

with anti-rabies vaccine (fr
age 3 and yearly)

Give adequate care of your

dog
Animal Bite
FIRST AID TREATMENT
What to do if a dog bites you
Do not apply garlic, coffee powder, cow or
any animal dung on the wound
Do not tie a piece of cloth/ bandage above the
bite
Wash the wound with soap under running
water for 10-15 minutes
Apply antiseptic solutions and consult the ER
immediately
What to do if a dog bites you
Take the anti rabies vaccine and injectable
solution of immunoglobulin
Complete the course of the vaccine (four to five
doses) even when the wound heals
Do not consume alcohol while on medication
The Key is to seek medical help IMMEDIATELY
 REMINDER
• The simple local wound treatment
• Not to use procedures that may
further contaminate the wounds (i.e.
tandok, bato, rubbing garlic on the
wounds and other non-traditional
practices)
ANIMAL BITE MANAGEMENT
Specific Guidelines & Procedures
• Management of Potential Rabies Exposure
– Initiation of Post Exposure Prophylaxis (PEP) not
delayed for any reason regardless of interval between
exposure & consultation as it increases the risk of
rabies and it is associated with treatment failure
– No absolute contraindications to rabies PEP. Patients
allergic to a specific vaccine/RIG or its components
shall be given the alternative vaccine/RIG
 Categories of Rabies Exposure with Corresponding Management
Category of Exposure
CATEGORY I
a.Feeding/touching an animal
b.Licking of intact skin (with reliable history and thorough
physical examination)
c.Exposure to patient with signs and symptoms of rabies by
sharing of eating or drinking utensils
d.Casual contact (talking to, visiting and feeding suspected
rabies cases) and routine delivery of health care to patient
with signs and symptoms of rabies
Categories of Rabies Exposure with Corresponding Management

Management of Category I Exposure

1. Wash exposed skin immediately with

soap and water.
1. No vaccine or RIG needed
2. Pre-exposure prophylaxis (PrEP)
- may be considered for high
risk people
Categories of Rabies Exposure with Corresponding Management
Category of Exposure
CATEGORY II
a.Nibbling of uncovered skin with or without
bruising/hematoma
b.Minor scratches/abrasions without bleeding,
including those induced to bleed
* includes wounds that are
induced to bleed

All Category II exposures on the head and neck area

are considered Category III and shall be managed as
such.
Categories of Rabies Exposure with Corresponding Management
Management of Category II Exposures
1. Wash wound with soap and water.
2. Start vaccine immediately

3. RIG is not indicated

Categories of Rabies Exposure with Corresponding Management
Category of Exposure
CATEGORY III
a)Transdermal bites (puncture wounds, lacerations, avulsions)
or scratches/abrasions with spontaneous bleeding
b)Licks on broken skin
c) 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.
d)Unprotected handling of infected carcass
e)Ingestion of raw infected meat
f) Exposure to bats
g) All Category II exposures on head and neck area
Category III
 Categories of Rabies Exposure with Corresponding Management
Management of Category III Exposures
1. Wash wound with soap and water.
2. Start vaccine and RIG immediately:
Treatment:
Post Exposure Prophylaxis
Definition of Terms
• Active Immunization- administration of a
vaccine to induce protective immune
response

• Passive Immunization- administration of pre-

formed antibodies (immune globulins or passive
immunization products) to provide immediate
protection. These antibodies come from either
human or animal source
Definition of Terms
 Pre-exposure prophylaxis- rabies vaccination
administered before an exposure to potentially
rabid animals.
This is usually given to those who are at high risk of
getting rabies such as veterinarians, animal handlers,
staff in the rabies laboratory, hospitals handling rabies
patients and school children from high risk areas, etc

 Vaccine Potency- amount of acceptable active

ingredients in a rabies vaccine which is expected
to provide at least minimum protection
Definition of Terms
• Post Exposure Prophylaxis (PEP) – formerly
post exposure treatment (PET)
– refers to anti-rabies treatment administered
after an exposure (such as bite, scratch, lick,
etc) to potentially rabid animals. It includes
local wound care, administration of rabies
vaccine with or without Rabies Immune
Globulin (RIG) depending on category of
exposure.
Active Immunization
A. Administration
Vaccine is administered to induce antibody and T-
cell production in order to neutralize the rabies
virus in the body.
It induces an active immune response in 7-10
days vaccination, which may persist for years
provided that primary immunization is completed
Active Immunization
B. Types of Rabies Vaccine & Dosages
NRPCP provides anti-rabies tissue culture
vaccines (TCV)

a.Purified Vero Cell Rabies Vaccine (PVRV) –

0.5ml/vial Verorab

b.Purified Chick Embryo Cell Vaccine (PCECV) –

1.0 ml/vial Rabipur
 List of TCV by the NRPCP to
Animal Bite Treatment Centers
with Corresponding Preparation & Dose
Generic Name Preparation Dose
Purified vero cell 0.5 ml/vial ID- 0.1 ml
rabies vaccine IM- 0.5 ml
(PVRV)
Purified chick 1 ml/ vial ID- 0.1 ml
embryo cell IM- 1.0 ml
vaccine
(PCECV)
Recommendation on the intradermal
administration of anti-rabies vaccines:

NRPCP introduces ID use of rabies tissue culture

vaccines in the Philippines 1997.
Phils was among the 1st countries to adopt this
regimen as recommended by WHO, in order to
totally discontinue the use of nerve tissue vaccine
(NTV) which was associate with encephalitis
Recommendation on the intradermal
administration of anti-rabies vaccines:

To mitigate the increase in the cost of PEP with

the shift from NTV to TCV, the ID use of this
vaccines was introduced
According to WHO, the ID use of tissue culture
vaccines can decrease the cost of PEP by as
60-80%
Recommendation on the intradermal
administration of anti-rabies vaccines:

Only limited number of commercially

available rabies vaccines have been
proven, to date, as safe and efficacious
for PEP when administered by the ID
route
 Criteria set by the program to
ensure safe & effective TCVs
1. The vaccine is registered with & approved
by the FDA;
2. The vaccine is WHO prequalified (
http://www.who.int/immunizationstandards/
vaccinequality/PQvaccine_list_en/en/index.
html
);
Vaccination

1.Storage
a. Vaccines stored at +2 to +8 degrees Celsius
NOT freezer
b. Once reconstituted, vaccines is kept in the
refrigerator & used within 8 hours
Vaccination

2. Administration Area
a. Injections be given on the deltoid area of
each arm in adults or at the anterolateral
aspect of the thigh in infants
b. Vaccine shall NEVER be injected in the
gluteal area as absorption is unpredictable.
Treatment Regimen Schedule
1. Updated 2-Site Intradermal Schedule (2-2-2-0-2)
- Modification of the original Thai Red Cross 2-site
ID regimen where day 90 dose has been transferred
to day 28.
- 1 dose for ID administration is equivalent to 0.1 ml
PCECV
- 1 dose shall be given on each deltoid on Days 0, 3, 7
& 28
- 1 intradermal dose shall have at least 0.5 IU vaccine
potency
Treatment Regimen Schedule
1. Updated 2-Site Intradermal Schedule (2-2-2-0-2)
- ID injection shall produce minimum of 3mm
wheal. If inadvertently given subcutaneously or
IM, the dose shall be repeated
- 1 ml syringe with G27 needle- preferably AD
syringe
- Strictly follow the vaccination schedule to
prevent treatment failure
Treatment Regimen Schedule
Day of PVRV PCECV Site of Injection
Immunization

Day 0 0.1ml 0.1 ml Right and Left deltoid

dose 1
Day 3 0.1 ml 0.1 ml Right and Left deltoid
dose 2
Day 7 0.1 ml 0.1 ml Right and Left deltoid
dose 3
Day 28 0.1 ml 0.1 ml Right and Left deltoid
booster
Intradermal Vaccination
Interruption of Treatment
• Delay in second (Day 3) dose:
– 1-2
Day days
0- Jan delay (Day 4-5 from start of vaccination)
1, 2016
DayDay
3- Jan34,given uponforvisit
2016 delayed 2 days&give
follow
Jan 6 the original
Day 7- Jan 8, 2016
Dayschedule of day 7 & 28
28- Jan 29, 2016
– 3-4 days delay (Days 6-7 from start of vaccination)
Day 0- Jan 1, 2016
Day –
3- Day
Jan 4, 3 given
2016 upon
delayed visit,
for 3-4 days adjust
give Jan 8succeeding doses
Day 7- Jan 12, 2016
Day (Day7
28- Feb 1,and
201628) according to prescribed interval
– ->4 days from Day 3 (beyond day 7 from start of
Day 0- Jan 1, 2016
vaccination) – a new course shall be restarted
Day 3- Jan 4, 2016 delayed for more than 4 days CAME ON Jan 12 START
DAY 0
Interruption of Treatment
• Delay in third (Day 7) dose:
 >7 days delay (Days 8-14 from start of vaccination) Day 7
given upon visit & give Day 28/30 done as originally
scheduled
 >7 to 14 days delay (Days 15 to 21 from start of
vaccination) – Day 3 shall be repeated & revised accdng to
prescribed interval
 ->14 days (beyond day 22 from start of vaccination) – a
new course shall be restarted
• Delay in fourth (Day 28) dose:
 Give day 28 dose upon visit; shall be considered as a
booster
2. Standard Intramuscular Schedule
1 dose =1 vial of 0.5 ml PVRV
=1 vial of 1.0 ml PCECV
Day of PVRV PCECV Site of Injection
Immunization

Day 0 0.5 ml 1.0 ml One deltoid or anterolateral thigh in

infants

Day 3 0.5 ml 1.0 ml One deltoid or anterolateral thigh in

infants

Day 7 0.5 ml 1.0 ml One deltoid or anterolateral thigh in

infants

Day 14 0.5 ml 1.0 ml One deltoid or anterolateral thigh in

infants

Day 28 0.5 ml 1.0 ml One deltoid or anterolateral thigh in

infants
Interruption of Treatment
• Delay in second (day 3) dose
– 1-2 days delay (day 4-5 from start vaccination) day
3 dose shall be given upon visit & follow the
original schedule of Day 7, 14 & 28/30
– 3-4 days delay (day 6-7 from start of vaccination)
Day 3 shall be given upon visit, adjust succeeding
doses (Day 7,14 & 28/30) according to prescribed
interval
– >4 days (Day 7 from start of vaccination) new
course shall be re-started
Interruption of Treatment
• Delay in third (day 7) dose
 < 7 days (day 8-14 from start of vaccination)
Day 7 dose shall be given upon visit, give 28 day dose
as originally scheduled
 7-14 days delay (days 15-21 from start of vaccination)
Day 3 shell be given & revised according to the
prescribed interval
 >14 days delay (beyond day 22 from start of
vaccination)
A new course shall be restarted
Interruption of Treatment
• Delay in fourth (day 14) dose
– Day 14 dose shall be given upon visit & give day
28 dose after 2 weeks
• Delay in fifth (day 28) dose
– Day 28 dose shall be given upon visit.
– If RIG has already been administered, it shall not
be given again
 Alternative IM Regimen
• Zagreb Regimen Schedule (2-1-1 IMSchedule)

Day of PVRV PCECV Site of Injection

Immuniza
tion
Day 0 0.5 ml 1.0 ml Left and right deltoids or
anterolateral thigh in infants
Day 7 0.5 ml 1.0 ml One deltoid or anterolateral
thigh in infants
Day 21 0.5 ml 1.0 ml One deltoid or anterolateral
thigh in infants
 • Shortened Intramuscular Schedule (CDC)
– An alternative for healthy, fully immunocompetent,
exposed people who receive wound care plus WHO-
prequalified rabies vaccines, shall be given a post-
exposure regimen consisting of 4 doses administered
intramuscularly on days 0, 3, 7 and 14
Day of PVRV PCECV Site of Injection
Immunization
Day 0 0.5 ml 1.0 ml One deltoid or anterolateral thigh in infants
Day 3 0.5 ml 1.0 ml One deltoid or anterolateral thigh in infants
Day 7 0.5 ml 1.0 ml One deltoid or anterolateral thigh in infants
Day 14 0.5 ml 1.0 ml One deltoid or anterolateral thigh in infants
Passive Immunization
 Also known as Rabies Immune Globulins (RIG)
 Shall be given in combination with rabies vaccine
 Provides immediate availability of neutralizing
anti bodies at the site of exposure before it is
physiologically possible for the patient to begin
producing his/her own antibodies after vaccination.
 Important for patients with Category Exposures
 Half life of approximately 21 days
 1. Types of RIG
TYPE SOURCE DOSE PREPARATION
Highly Purified Produced from 40 IU/kg BW 5 ml/vial at 200IU/ml
Antibody antigen Equine Rabies
binding immune globulin
fragments (ERIG)
[F(ab’)2]

Provided by NRPCP to ABTCs

Human Rabies Derived from 20 IU/kg BW 2ml/vial at 150IU/ml
Immune Globulin plasma of human
(HRIG) donors

Equine Rabies Derived from 40 IU/kg BW 5 ml/vial at 200IU/ml

Immune Globulin purified, horse
(ERIG) serum
2. Computation & Dosage of RIG

• HRIG at 20IU/kg BW (150IU/ml)

50 kg patient X 20 IU/kg=1000 IU
1000 IU /150 IU/ml= 6.7 ml

• ERIG/F(ab’)2 at 40 IU/kg BW (200IU/ml)

50 kg patient X 40 IU/kg=2000 IU
2000 IU /200 IU/ml= 10 ml
 Administration

a. Total computed dose of RIG shall be infiltrated around

& into the wound as much as anatomically feasible, even
if lesion has healed.
◦ Left RIG from total amount computed- deep IM at a
site distant from the site vaccine injection (preferably
anterolateral thigh) using another needle
◦ Total computed dose shall be administered as a single
dose

b. G 23 or 24, 1 inch length shall be used for infiltration

◦ Avoid multiple needle injections in the same wound
Administration
c. Skin test shall be performed prior ERIG
administration using G26
– For skin testing, 0.02ml of 1:10 dilution of solution
is infiltrated to raise a bleb 3 mm & read after 15
minutes
– (+) ST is an induration of >6mm surounded by a
flare/erythema
– If ST(+), repeat ST at same arm using distilled
water as control on the other arm
– ST result is (+) if ERIG is (+) and control is (-)
 Administration
d. Finger or toe needs to be infiltrated, care shall
be taken to ensure that blood circulation is not
impaired
e. RIG should not exceed the computed dose- it
may reduce the efficacy of the vaccine.
◦ If computed amount is insufficient to infiltrate all
bite wounds, it may be diluted with sterile saline 2
or 3 folds for thorough infiltration of all wounds
Administration
f. RIG shall be given in combination with rabies
vaccine. Administered at the same time as the
first dose of rabies vaccine (Day 0)
◦ (If RIG is unavailable on day 0), it may still be
given until Day 7 after first dose of vaccine
◦ Beyond day 7, regardless whether day 3 and day 7
doses were received, RIG is not indicated because
an active antibody response to the rabies vaccine
has already started & interference b/n active and
passive immunization may occur
 Administration
g. If RIG and vaccine cannot be given on the same day because
the latter inhibits the level of neutralizing antibodies induced
by immunization
h. RIG shall be given during the course of PEP
i. Patients w/ (+) ST to purified ERIG shall be given HRIG
j. Observe the patient or after injection o ERIG for immediate
allergic reaction
k. HRIG is for the following:
◦ History o Hypersensitivity to ERIG
◦ Multiple severe exposures, esp where dog is sick/ proven
rabid
◦ Symptomatic HIV infected patients
RIG Administration

ERIG (Equine Rabies Igb)

• Wt = 10 kg (ERIG – 40 units/kg; 1000 units/5 ml vial)

• 40 x 10 = 400 units

• 400/1000 units per 5 ml = 0.4 X 5ml = 2 ml

NO ROUND OFF!!!!!
RIG Administration

HRIG (Human Rabies Igb)

• Wt = 10 kg (HRIG – 20 units/kg; 300 units/2 ml vial)
• 20 x 10 = 200 units
• 200/300 units per 2 ml = 0.66 X 2ml = 1.3 ml
NO ROUND OFF!!!!!
 RIG Administation

• Use gauge 23 or 24 needle, 1 in. length for

infiltration
• Avoid multiple needle injections
RIG Administration
Local Wound Treatment
• Immediately & vigorously washed and flushed with
soap or detergent, and water preferably 10 minutes
• If no available soap, wound shall be thoroughly &
extensively washed with water.
• Apply alcohol, povidone iodine or any antiseptic
• Suturing of wounds shall be avoided at all times-
it may inoculate virus deeper into the wounds
Local Wound Treatment
• Wounds may be coaptated using sterile adhesive
strips. If suturing is unavoidable, it shall be delayed for at
least 2 hours after administration of RIG to allow diffusion
of the anti body to occur through the tissues
• Any ointment, cream or wound dressing shall not be
applied to the site because it will favor the growth of
bacteria and will occlude drainage of the wound, if any
• ATS shall be given as indicated. Review tetanus
immunization (TT/DPT/Td). Animal bites are
considered tetanus prone wounds
 Guide to Tetanus Prophylaxis in Routine
Wound Management
Vaccination History
Indication of Tetanus
Immunization Unknown or <3 Doses 3 or More Doses
Td* TIG/ATS Td* TIG/ATS

All Animal Bites YES YES NO** NO

*Tdap may be substituted for Td if the person has not

received Tdap and is 10 years or older;
*DPT may be given or patients <7 years old;
* TT may be given if Td not available
**Yes, If more than 5 years since last dose
 Routine Wound Management
• Pasteurellamultocida most common organism
isolated from dog/cat bites
• Other organisms S. aureus, Bacteroidessp,
Fusobacterium and Capnocytophaga
• Antimicrobials is recommended for the :
– All frankly infected wounds
– All category III cat bites all category III bites that are
either deep, penetrating, multiple or extensive or located
on the hand/face/genital area
Recommended antimicrobials or frankly
infected wounds
• Amoxicillin/Cluvanic
– Adult- 500mg po TID
– Children – 30-45 mg/kg/day in 3 divided doses
• Cloxacillin
– Adult- 500 mg QID
– Children- 10-150-100 mg/kg/day in 4 divided doses
• Cefuroxime axetil
– Adult- 500 mg po BID
– Children- 10-15 mg/kg/day in 2 divided doses
Recommended antimicrobials or frankly
infected wounds
• For Penicillin allergic patients
– Adult- Doxycycline
– Children- erythromycin
• For those instances where there are no obvious signs
of infection: Amoxicillin as prophylaxis
– Adults- 500 mg po TID
– Children- 30-45 mg/kg/day in 3 divided doses
Management of Adverse
Reactions
 WARNING!
• Hypersensitivity to
ERIG/F(ab’)2 may not
be predicted by a
negative skin test

• Always be ready with

Adrenaline
(Epinephrine) and
Antihistamines for
treatment of
hypersensitivity
 Types of Adverse Reactions

• Anaphylaxis
• Hypersensitivity
reaction
 Anaphylaxis
• Most Serious Type of Reaction
• Very Rare (occurs in 1 in 3 million population (1:3
million)

• Detection and Management is

the same as in all types of
anaphylaxis secondary to
drugs, foods & Antigens.
• Occurs in a few minutes after
injection.
• Health worker should be
prepared to detect and
manage it properly
• Early recognition of the
signs and symptoms should
lead to early treatment to
prevent loss of lives.
 How to detect Anaphylaxis
Time Scale Signs and Symptoms Severity

Early warning signs Dizziness, perineal burning, Mild

warmth, pruritus

Occurs within a few Flushing, urticaria,nasal Mild to moderate

minutes congestion, sneezing,
lacrimation, angioedema
Moderate to severe
Hoarseness, abdominal cramps.
subternal pressure

Late, life-threatening Laryngeal edema, dyspnea, Severe

symptoms abdominal pain

Bronchospasm, stridor collapse,

hypotension, dysrhythmias
Fainting is more commonly observed in older children. Anaphylaxis should
be distinguished from a faint..
 How to Distinguish Anaphylaxis from a Faint
Items Faint Anaphylaxis
Onset Usually at the time or Within the first few minutes
soon after the injection after injection
System
Skin Pale, sweaty, cold and Red, raised and itchy rash;
clammy swollen eyes, face;
generalized rash
Respiratory Normal to deep breaths Noisy breathing from airways
obstruction (wheeze or
stridor)
Cardio-vascular Bradycardia Tachycardia
Transient hypotension Hypotension
Gastro-intestinal Nausea/ vomiting Abdominal cramps
Neurological Transient loss of Loss of consciousness, little
consciousness, response once in prone
Good response once position
in prone position
 How should Anaphylaxis be managed?
When and where anaphylaxis occur cannot be
predicted.
If and when it does occur, it happens within
the first few minutes after immunization.
Thus the vaccination team should be ready to
respond to incidence of anaphylaxis.

Initial management entails the following

measures:
1. Place the patient in the recumbent position to
ensure that the airway is clear.
2. Assess breathing and pulse. If there is strong
carotid pulse, then it is not anaphylaxis.
3.If appropriate, begin with cardiopulmonary
resuscitation.
4. Give epinephrine by deep intramuscular injection at the deltoid
area according to the following areas:
Age (in years) Dose of Epinephrine (1:1000)
Less than 1 year 0.05 ml
1 year 0.1 ml
2 years 0.2 ml
3-4 years 0.3 ml
5-8 years 0.4 ml
Adult 0.5ml

• Repeat epinephrine dose every 10 to 30 mins for 3 doses

• Give steroids after epinephrine

vcgfrjr 02182010 1730

5. If patient is conscious after
the epinephrine, place the head
lower than the feet and keep
the patient warm.

6. Give oxygen by facemask, if

available.

7. Transfer the patient to the

emergency room for further
management, but never leave
the patient alone.
Management of Hypersensitivity Reaction

• Give antihistamines, either as

single drug or in combination

• If status quo for 48 hrs despite

combination of antihistamines,
may give short course (5-7 days)
of combined oral antihistamines
plus steroids

• If patient worsens and condition

requires hospitalization or
becomes life threatening, may
give IV steroids in addition to
antihistamines
 
 Indications for Use of HRIG
• positive skin test to
ERIG/F(ab’)2
• history of hypersensitivity to
equine sera
• multiple severe exposures
(especially where dog is
sick or suspected of being
rabid) on head and neck
area
• symptomatic HIV infected
patients
 Precaution

The patient must be

asked to wait for at least
one hour after injection
of ERIG/F(ab’)2 in order
to observe for allergic
reactions which usually
consist of itchiness,
rashes or aching joints.
 
Rabies FAQs
 Can rabies be acquired by eating
meat of rabid dog?
• The rabies virus is very sensitive to heat. Cooking dog
meat will kill the virus
• If eaten, the rabies virus is also killed by the acids in the
stomach
• However, the one preparing the dog meat for food may be
exposed through breaks in the skin, splatters

• It may be possible to get rabies from eating raw dog’s

brain but this has not yet been reported
 Can one get rabies from a rabid
person?
• Yes, infected persons can transmit rabies through:
- Organ transplantation
- Bites
- Contamination of open skin lesions or mucous membranes with
body fluids (except blood and feces) through licks, splattering, mouth-
to-mouth resuscitation, sexual activity, exchanging kisses on the mouth

• This is a rare occurrence and has only been documented from organ
transplants

• One cannot get rabies from sharing food or drink with an

infected person
 Can household pets also transmit
rabies?

• Yes, all dogs/cats can transmit rabies even if

they are kept as pets
• In fact, as much as 88% of human rabies
patients were bitten by pets
 What other animals are able to
transmit rabies?

•All warm blooded animals can transmit rabies. This

will include dogs,
cats, other domestic
animals ( cows, pigs, horses, goats, etc.
 Are puppies more “rabid” than
adult dogs?

•No, the risk of getting rabies is the same for

those bitten by puppies and adult dogs
 Will all dog bite patients develop
rabies?
• No, not all dog bite patients will get rabies
• The risk of developing clinical rabies is around
15 – 20% and depends on:
– Amount of virus in saliva
– Severity of the bite
– Location of the wound
Are traditional remedies effective?

•No, traditional remedies are not effective

•May delay proper treatment because bite victim

has false sense of security that the bite has been
adequately treated

•May cause secondary bacterial infection

Is rubbing the wound with garlic or
salt effective?
• No, rubbing the wound with garlic or salt or applying
vinegar are not effective in removing the virus

•Rubbing garlic on the wounds may cause abrasion of

the skin around the bite wound, resulting in a bigger
bite wound and possible secondary infection
Does rabies vaccine cause neurologic
damage?
• The nerve tissue vaccine (Sample vaccine)
was associated with neurologic side
effects, but is no longer in use

•The currently available purified vaccines

are considered safe and effective with no
neurologic side effects
Does we give anti-rabies vaccination
to rat bites?

• Theoretically, rodents can transmit rabies.

However, there are no documented reports of
human rabies from rodents
Is it safe to give anti-rabies vaccination during
pregnancy
•Yes, rabies vaccine and RIG can be given
safely during pregnancy

•The risk of teratogenicity is less than the

risk of rabies

•Nerve tissue vaccine is not recommended

during pregnancy
 Can you give anti-rabies vaccination to
patients with fever?

•Yes, rabies vaccine and RIG can be given safely even

if the patient has fever or other illness

•There is no contraindication to rabies

vaccination
 Can you give anti-rabies vaccination to
newborns?

•Yes, rabies vaccine and RIG can be given safely to

newborns
What should be avoided while undergoing
anti-rabies immunization?

• Avoid chloroquine, systemic steroids and heavy

alcohol consumption during rabies immunization

•These may interfere with antibody formation

Does anti rabies vaccination provide lifelong
immunity?
•Although the antibodies from the vaccine persist for a
long time, the immunity is not considered life long

•Since the disease is highly fatal, every exposures

should be treated either with a full vaccination course
or booster dose/s
 Are wounds that are induced to bleed
considered Category III?

•Wounds that do not bleed spontaneously are

categorized as Category II

•This includes wounds that are induced to

bleed
 Why is it necessary to vaccinate the patient if
the dog is vaccinated?
Reasons:
• At least 80% of dog population need to be vaccinated to cut the
transmission of rabies among dogs
• Animal vaccine failures may occur (improper administration or poor
quality of the vaccine, poor health status of the animal, one vaccine dose
does not always provide long-lasting protection against infection in
dogs)
• Whether a dog bite was provoked rather than unprovoked should not be
considered a guarantee that the animal is not rabid as it can be difficult to
understand what an attacking dog considers provocation for an attack
• Some dog owners may claim their dog is vaccinated even if they are
not
Is it better to sacrifice all biting animals even
if they are healthy?
• No, sacrificing healthy animals is against animal rights

• Animals that are healthy at the time of the bite should be

observed for 14 days

• Only those animals that are sick at the time of the bite or
become sick during the observation period should be sacrificed
and the head tested for rabies