Animal Bite Management and

Cold Chain Management

ARMAND JERIC W. MANABAT, MD

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE
DR. PJGMRMC
 Objectives

To discuss the epidemiology of rabies

To discuss the principles of pre and post exposure
prophylaxis
To discuss some key points in cold chain
management
Rabies Epidemiology
 Key Facts

One of the oldest and most feared zoonotic diseases

known to mankind
Dogs are the source of the vast majority of human
rabies deaths, contributing up to 99% of all rabies
transmissions to humans
Rabies is a vaccine preventable disease which occurs
in >150 countries.
Rabies is generally a disease of children.
 Rabies in Asia

Asia has the highest human mortality (due to

endemic canine-mediated rabies)
One Asian dies every 15 minutes.
 40% likely to be a child under 15 years
More than 3B people in Asia are potentially exposed
to dog rabies
 Animal Bite Cases, Philippines

Animal Bites (2007-2018)

1400000
1229607
1200000 1156068
1085611

1000000
783663
800000 683302

600000 522420
410811
400000 328733
216569
176501 190095
200000

0
2007 2008 2010 2011 2012 2013 2014 2015 2016 2017 2018
 Human Rabies Cases, Philippines

Human Rabies Trend (2007-2018)

300
285 276
250 250 257
243 236
219 213 217 209 219
200 205

150

100

50

0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Top 10 Regions with Highest Number of Human Rabies Cases, 2017

Region Human Rabies Rank

Region 3 37 1
Region 12 33 2
Region 4a 28 3
Region 7 21 4
Region 5 18 5
Region 6 14 6
Region 10 14 6
Region 1 10 7
Region 8 8 8
Region 9 7 9
Region 2 6 10
CARAGA 6 10
Provinces with highest number of Human Rabies Cases, 2017

Province Human Rabies Rank

South Cotabato 18 1
Cebu 13 2
Nueva Ecija 11 3
Zambales 10 4
Camarines Sur 10 4
North Cotabato 9 5
Pangasinan 8 6
Negros Occidental 8 6
Bukidnon 7 7
Batangas 6 8
 Animal bite cases in DR. PJGMRMC

In 2019, a total of 1,174 patients were treated in the

DFCM OPD and EACC for animal bite.
 OPD - 394 out of 11,023 (3.57%)
 ER - 780 out of 3307 (23.59%)
 Stages of Rabies

IP
NG
R I
DU
LY
ON
IVE
C T
E
E FE
E P
P
IES
B
RA
 Diagnosis

Usually Clinical
No tests are available to diagnose rabies infection in
humans before onset of clinical disease
 Treatment

None
Many recent treatment failures with the combination
of antiviral drugs, ketamine and therapeutic
(induced) coma
Palliative
 The Key is RABIES PREVENTION

ANIMAL RABIES CONTROL

 Dog vaccination stops canine rabies at source and saves
people’s lives – as well as protecting dogs
HUMAN RABIES CONTROL
 Post Exposure Prophylaxyis (PEP)
 Pre Exposure Prophylaxis (PrEP)
Management of Rabies
Exposures
 Rabies Prevention

2 main strategies
 Dog vaccination to interrupt the virus transmission to humans
 Human vaccination
 PrEP for high risk individuals
 PEP for exposed individuals
 Post exposure Prophylaxis

Components:
 Wound washing and care
 Vaccination: Active Immunization
 Administration of RIG: Passive Immunization
 Wound Care

All bite wounds/scratches should be immediately

and vigorously washed and flushed for 10 minutes
with soap/detergent (as much as 40% reduction in
rabies infection rate)
If soap is unavailable, the wound should be
thoroughly washed with water
Apply Iodine containing similarly viricidal topical
preparation to the wound
DONT”S – garlic, tandok, bato, sucking bite wound
 Wound Care

Give Antibiotics for:

 All frankly infected wounds
 All Category 3 cat bites
 All other category 3 bites that are either deep, penetrating,
multiple or extensive or located on the hand/face/genital area
Recommended Antimicrobials:
 Prophylaxis: Amoxicillin
 Frankly infected wound Coamoxiclav or Cefuroxime or Ampi-
Sulbactam or Cloxacillin
 Alternative Doxycycline
 Suturing

Should be avoided as it may inoculate the virus

deeper into the wound
However if suturing is unavoidable:
 RIG should be infiltrated around and into the wound before
suturing
 Delayed for at least 2 hours after RIG administration to allow
diffusion of the RIG to occur
 Sutures – loose and not interfere with bleeding/drainage
Ointments/creams/occlusive dressing shall not be
applied because it favors bacteria growth and may
occlude wound drainage
 Tetanus Prophylaxis

VACCINATION HISTORY
ALL Unknown or <3 doses 3 or more doses
ANIMAL TD TIG/ATS TD if more NO ATS
BITES than 5
years since
last dose
 Categories of Rabies Exposure

Category 1 Category 2 Category 3

- Feeding/ touching an - Nibbling of uncovered - Transdermal bites or
animal skin with or without scratches with spontaneous
- Licking of intact skin bruising/hematoma bleeding
- Exposure to patient - Minor superficial - Contamination of mucous
with signs and scratches/ abrasions membrane with saliva .
symptoms of rabies by without spontaneous - Licks on broken skin
sharing of utensils. bleeding - Unprotected Handling of
- Casual contact to - All category 2 exposures infected carcass
patient with signs and on the head and neck are - Ingestion of raw infected
symptoms of rabies considered category 3 and meat
shall be managed as such
Wash Exposed skin Wash wound with soap Wash wound with soap and
NO vaccine or RIG and water water
needed Start vaccine immediately Start Vaccine and RIG
PrEP may be immediately
considered for high risk
persons
 Passive Immunization

To neutralize rapidly the virus locally in the wound

before it reaches the local nerve endings
To provide the immediate availability of neutralizing
Ab at the site of the exposure before it is
physiologically possible for the patient to begin
producing his or her own Ab after vaccination
(usually 7-14 days)
 Types of Rabies Immunoglobulin

Generic Dose Preparation

Name
HRIG 20iu/kg 150 iu/ml at
2ml/vial
ERIG 40iu/kg 200ml iu/ml
at 5ml/vial
RIG is not indicated for those who can reliably document previous PEP or PrEP
 RIG Guidelines

RIG is given as single dose.

Total computed dose should be infiltrated around
the wound and into the wound as much as
anatomically feasible, even if the lesion has begun to
heal.
The remainder of the computed dose of RIG does
not need to be injected IM at a distance from the
wound but can be fractionated in smaller,
individual syringes to be used for other patients
following aseptic techniques.
 RIG Guidelines

RIG should not exceed the computed dose as it may

reduce the efficacy of the vaccine
If computed RIG is insufficient to infiltrate bite
wounds, it may be diluted with sterile saline 2 or 3
fold for thorough infiltration
Avoid multiple needle injections
Can infiltrate RIG even if wound is infected
 RIG Guidelines

RIG shall always be given in combination with rabies

vaccine
If rig is unavailable when the first dose of vaccine is
injected. It may be given until 7 days after the first
dose of the vaccine. Beyond day 7,RIG is no longer
indicated because an active AB response to rabies
vaccine has already started.
In the event that RIG and vaccine cannot be given on
the same day, the vaccine shall be given before RIG
 Types of Rabies Vaccine

Generic Name Preparation Dosage

Purified Vero 0.5ml/vial ID – 0.1ml
cell Rabies IM – 0.5ml
Vaccine (PVRV)
Purified chick 1.0ml/vial ID – 0.1ml
embryo cell IM – 1.0ml
vaccine
(PCECV)
 Available Rabies Vaccine

Generic WHO PQ Non WHO PQ

PVRV Sanofi Liaoning
Chengda Co, Ltd
Changchun
Changsheng Life
Sciences Ltd
Human
Biologicals Inst
PCECV GSK Cadila
Healthcare
 ARV Guidelines

Stored at 2-8’C
Once reconstituted vaccines should be kept in
refrigerator and used within 8 hours
Injections: Deltoid area for adults. Anterolateral
aspect of thigh in infants. Never given in gluteal area
as absorption is unpredictable.
ID injection should produce a minimum of 3mm
wheal.
 PEP regimens- IM

IM Day 0 Day 3 Day 7 Day Day Day

14 21 28
5 dose
IM
4
dose
IM
2-1-1
dose
IM
 PEP Regimens - ID

ID Day 0 Day 3 Day 7 Day 28

OLD

New
(PQ)
 Guidelines

Initiation of PEP shall not be delayed for any reason

regardless of interval between exposure and
consultation
Immunocompromised individuals should be given
vaccine using either IM or ID regimen and RIG for
both Category II and III exposures.
Patients with hematologic conditions where IM
injections are contraindicated, should receive rabies
vaccine via ID route.
 Guidelines

Delay in consult
 Treat as if the exposure occurred recently
 If the biting animal has remained healthy and alive with no
signs of rabies until 14 days after the bite, no treatment is
needed.
Babies born of rabid mothers shall be given rabies
vaccination and RIG as early as possible at birth
Changes in the human rabies vaccine product during
the same PEP course if unavoidable are acceptable to
ensure PEP course completion. Restarting in not
necessary.
 Guidelines

As much as possible, the initial regimen/route should

be completed. However, in unavoidable circumstances,
changes in route of administration during PEP course
is acceptable.
 There is no need to restart
 The schedule of the new regimen should be adapted
Should a vaccine dose be delayed for any reason, the
PEP regimen should be resumed (not restarted)
Patients with chronic liver disease and those taking
chloroquine and systemic steroids shall be given
standard IM regimens
 Guidelines

Bite by other animals other than dogs/cats

NO PEP – rodents, rabbits and guinea pigs. Anti
tetanus prophylaxis should be given.
GIVE PEP
 Other domestic – cattle, pigs, horses etc
 Monkeys, bats, and other wild animals
 Bites by vaccinated dogs/cats

Category 1 , PEP not recommended

Category 2 exposures, no vaccine as long as ALL of
the following conditions are satisfied:
 Dog/cat is healthy and available for observation for 14 days
 Dog/cat was must be at least 1 ½ years old and has updated
vaccination certificate from a duly licensed veterinarian for the
last 2 years
 The last vaccination must be within the past 12 months; the
immunization status of the dog/cat will not be considered
updated if the animal is not vaccinated on the due date of the
next vaccination.

Joint DA-DOH AO 2011-002

 Bites by vaccinated dogs/cats

Bites by vaccinated dogs and cats.

 If biting animals starts to show signs of rabies, immediately
give vaccine and RIG
 If biting animal remains healthy within 14 days observation
period, there is no need to administer rabies vaccine
Category 3 give RIG and PEP

Joint DA-DOH AO 2011-002

 PEP for Previously Immunized Patients

2018 Guidelines PrEP/PEP History Give RIG MANAGEMENT

Patient received
PrEP/PEP the complete Prep prophylaxis on (Days 0,
History

(Regardless of type of TCV7)

and route of Give RIG MANAGEMENT
Determine if high or low
administration in previous PrEP/PEP No
OR risk bite

Patient received
Patient received at
theleast Day
complete 0 and Day 3 of PEP ID/IM
pre-exposure Give 0.1ml ID dose at 1 site eaxh on D0
prophylaxis on Days 0,7and 21/28 using TCV and D3
Patient received the complete Prep prophylaxis on (Days 0,
OR No OR
7) OR
Patient received at least Days 0,3,7 of ID/IM dose 1 vial IM dose at 1 site each on D0 and
using TCVs
Patient received at least Day 0 and Day 3 of PEP ID/IM GiveD3
if
Give full course of PEP
indicated
AND
Patient did not complete the 3 doses of PrEP

OR Patient is immunocompromised
Give if indicated Give full course of PEP
Patient
Patient received onlydid
1 or not complete
2 ID/IM dose of thePrep
PEP

OR YES, if indicated Give full course of PEP

Patient received only 1 dose of PEP

2018 New Guidelines on the Management of Rabies Exposures AO 2018-0013

PEP of Previously Immunized Animal Bite
Patients
RISK OF CRITERIA RECOMMENDATI
EXPOSURE ON
HIGH risk Any one of the following: Immediate
Biting animal cannot be observed, dies or is Provide booster
sick injection
Bite site is highly innervated parts of the body:
neck, head, genital area, hands and toes
Multiple deep bites
Patient from GIDA ( area of infrequent
transportation)
* Geographically isolated and disadvantaged
areas
LOW risk Last dose within 3 months AND Observe biting
Biting animal is healthy , owned, kept animal for 14 days
AND ANY ONE OF THE FOLLOWING: If animal remains
1. Biting animal is same animal at bit patient healthy, withhold
previously or booster
2. Biting animal previously immunized or
3. Bite is on the proximal extremity

2018 New Guidelines on the Management of Rabies Exposures AO 2018-0013

 Pre exposure Prophylaxis

Given prior to exposure

Benefits
 The need for RIG is eliminated
 PEP vaccine regimen is reduced from 5 to 2 doses
 Protection against rabies is possible if PEP is delayed
 The cost of PEP is reduced
 Pre exposure Prophylaxis

Target Population
 Personnel in rabies diagnostic or research laboratories
 Veterinarians and veterinary students
 Animal Handlers
 HCW directly involved in care of rabies patients
 Individuals directly involved in rabies control
 Field workers
 PrEP Regimens

Immuno- Day 0 Day 7 Day

competent 21/28
OLD
IM – 1 site
ID – 1 site
NEW
IM – 1 site
ID – 2 sites
 PrEp Regimens

Immuno- Day 0 Day 7 Day

compromised 21/28
OLD
IM – 1 site
NEW
IM – 1 site
ID – 2 sites
Cold Chain Management

THE KEY TO POTENT VACCINES

 What are VACCINES?

Vaccines are sensitive biological substances which are

susceptible to heat, light and/or freezing
Lose their potency with time; more rapid if not
continuously stored at the temperature appropriate for
them (recommended range +2 to +8 °C)
Once open and diluted, stable for 6 hours under +2 to +8
°C
Damage due to successive exposures to heat or light is
CUMULATIVE
Once potency is lost, PERMANENT and
IRREVERSIBLE
 Vaccine Appearance after Exposure to Inappropriate Storage
Conditions

Can you spot the difference?

Properly stored Inappropriately stored

vaccine vaccine
Full Potency Diminished Potency

Vaccine appearance is NOT a reliable indicator that vaccines have

been stored under appropriate conditions
 Cold Chain

System used to
maintain optimal
temperature
conditions during the
transport, storage and
handling of vaccines
starting at the
manufacturer and
ending with the
administration of the
vaccine to the patient
 Cold Chain

3 major elements
 Well trained personnel
 Reliable transportation and storage equipment
 Efficient management procedures
 Why do we need to maintain a Cold Chain System?

Vaccine potency
 Ability of the vaccine to induce protective immunity after its
administration
Consequences:
 Failure in immunization program
 Increase in vaccine preventable diseases
 Expensive mistake
 To Facilitate Cold Chain Management:

Prepare storage and handling plans

 Written routine plan
 Written emergency vaccine plan retrieval and storage
Designate personnel
 Primary vaccine coordinator
 Back-up Vaccine coordinator
Make summaries of storage requirements for each
vaccine in your inventory
 Essential cold chain equipment

Dedicated refrigerator(s) for storing biological

products
A freezer
Temperature monitoring devices
Insulated containers (coolers)
Ice packs (frozen)
Gel packs (stored at biological refrigerator
temperatures)
Insulating materials
 Refrigerator

Purpose built refrigerator (lab style unit)

Alternatively, Domestic/household refrigerators can
be used if:
 Freezer and refrigerator compartments each have a separate
external door.
 Frost free model
Dormitory style – Do not use for permanent storage
 When using refrigerator as vaccine storage:

1. For “Vaccine use only”

2. Ensure that rubber seal of the ref is not broken and that door
closes properly
3. Maintain the refrigerator temperature between +2 to +8 °C
(temperature of +5 °C is a safety margin for temperature
fluctuations
4. Place water bottles on empty shelves and in the door to
provide temperature buffer
5. Position refrigerator properly
 At least 1 foot from the wall
 40cm space above
 Wheels or leveling legs sit 2.5-5cm above the floor
 At least 1 foot away from the next refrigerator
 When using refrigerator as vaccine storage:

6. Protect from sunlight

7. Connected to a power supply point or a voltage
regulator
8. A refrigerator not in use may be turned off but
should not be unplugged.
9. Back-up generators should be provided to provide
power in the event of power outages
10. A back-up refrigerator prepared and ready all the
time for any cold chain break or emergency
 Temperature Monitoring Device

Monitoring devices that help measure, control and

record temperature.
Designed to be irreversible indicators of
inappropriate temperatures
Used to keep track of the temperature to which
vaccine and diluents are exposed during
transportation and storage
 Insulated Containers

Used to transport or store quantities of vaccine

needed for immunization on site during a working
day to avoid frequent opening of the refrigerator.
Temperature inside the cooler is maintained with
ice/gel packs and insulating materials
 Ice packs

Flat, square plastic bottles that can be filled with

water and frozen.
Set ice packs on their edge and allow space between
them for air circulation in the freezer.
Condition ice packs before use (lay at room
temperature for 30 minutes)
 Vaccine Storage

1. Put vaccines in the middle of the compartment away

from coils, walls, floor and cold air-vent
2. Should not be stored in the refrigerator door.
3. Vaccine batches should be rotated:
 FEFO “First Expiry First Out” (different expiry dates)
 FIFO “First In First Out” (same batch)
4. Observe proper vaccine spacing. (2-3cm)
 Vaccine Storage

5. make sure not to overstock the unit

6. Similar type vaccines should be placed together
 Label shelves or boxes clearly
 Place diluents at the bottom shelves (if diluents are supplied
separately from the vaccine)
7. Fill the bottom part of the ref with full water
container
8. Monitor temperature twice daily. Use calibrated
thermometers
 Monitoring the temperature

Post the temperature log on the vaccine storage unit

door
Read the temperatures both the refrigerator and the
freezer and record on the temperature log at least
twice a day
Have the person reading and recording the temp
initial the temperature log
Review the temperature log weekly
 Maintenance of Equipment

Daily
 Twice daily temperature monitoring and recording of all unit
compartments and room temperature
Weekly
 Defrost you freezer if the frost is ¼ inch thick
 Check the rubber seals – that they fit securely and tightly
 Review and file temperature logs
Monthly
 Examine and clean the coils
 Arrange for regular technician check-ups
Annually
 Calibration of temperature monitoring devices
 Breakdowns and Emergencies

Cold chain breaks

 Failure to maintain the temperature required to ensure
potency of vaccine
 Deviation from the safe temp. range +2 to +8 °C
Cold chain emergency
 Mainly due to:
 Technical faults in the refrigerator
 Power failures or power outages
 Breakdowns and Emergencies

If there is an ongoing POWER OUTAGE or FAILURE:

 Do not allow vaccine to remain in a non functioning unit for an
extended period of time!
 If you are unsure how long the power will be interrupted/not in
time to maintain temp within the recommended range,
 “ACTIVATE YOUR COLD CHAIN EMERGENCY PLAN”
 If you are certain that power will be restored:
 Take the temperature of the refrigerator when the outage started
 Keep the refrigerator door closed until power is restored
 Record the number of hours power was out
 Take the temperature of the refrigerator every hour until power is
restored.
 Breakdowns and Emergencies

Points to remember during cold chain emergency:

 Keep all refrigerators/freezers CLOSED.
 Vaccines can be stored in domestic refrigerators without power
approximately 2 hours
 If power is not restored after 2 hours, TRANSFER vaccines to
an alternative storage unit or to cold boxes with adequate ice
packs
 Upon resumption of power supply, do not return vaccines to
the refrigerator until proper temperature is restored
“The Best OFFENSE is a strong
DEFENSE!”

KEEP IT COOL
Thank You!!