Rabies and management

of Dog Bite
 Introduction
 Dog bites account for about 80% of all animal
bites
 In the US the dogs bite about 4.7 million
people each year.
 Any penetration of the skin by teeth
constitutes a bite exposure.
 Introduction
 Most of the dog bites are provoked
 Involves children
 Usually involves lower extremities
 Children may not report minor scratches or
licks
 40 % of people bitten by dogs do not go for
treatment
 Incidence in India
 Incidence of animal bites is 17.4/1000
population
 Most animal bites in India (91.5%) are by dogs
 66% victims are children,
 About 20,000 deaths from rabies per year
 Dogs in India
 India has approximately 27 million dogs,
 Dog:man ratio of 1:40
 Stray dog population is about 80%.
 Brief account of rabies

 Bullet shaped single stranded RNA virus

 Rhabdoviridae family , Genus Lyssavirus
 Incubation period - usually 1–3 months
 But can be as short as 2 weeks or upto several
years
 Mode of transmission –
o Through bite of an infected animal (by saliva),
o Contamination of mucous membranes (i.e., eyes, nose,
mouth) with infectious secretions
o Aerosol transmission,
o Organ or tissue transplantation (corneal transplantations)
 Pathgenesis
• Viral tropism and dissemination
– Prediliction for neural tissue
– Virions amplify near site of inoculation in nerves and
then migrate in retrograde direction 50-100 mm per
day.
– Then virus ascends up rapidly in spinal cord, to
braininitially affecting diencephalon, hippocampus
and brain stem
– Centrifugal spread of virus along somatic and
autonomic nerves
 Pathogenesis
• Host susceptibilty to infections
– Site of bite
– Infecting variant
– Ammount of innoculum
– Host immunity and genetics
 Clinical features
Course
 Non-specific prodromal symptoms – fever,
malaise,headache,nausea,vomiting
 Acute neurologic phase – encephalitic form or
paralytic form
 Coma/death
 Hydrophobia & aerophobia are characteristic
of rabies
 Clinical Features
• Encephalitic Rabies
– Hydrophobia, Aerophobia, opisthotonus,
autonomic instability, dysrthria, dysphagia,
vertigo
• Paralytic (Dumb Rabies)
– 20% 0f cases
– Ascending paralysis (more prominent in bitten
limb)
– Headache and pain in affected limb
 Diagnosis

 Direct fluorescent antibody test (dFA)

 Virus isolation
 General histopathologic examination –
Negri bodies in brain , mononuclear infiltration,
perivascular cuffing of lymphocytes or
polymorphonuclear cells , lymphocytic foci , babes
nodules consisting of glial cells
 …contd
 Immunohistochemistry (IHC)
 In-situ hybridisation
 Serology
 Amplification methods (RT-PCR)
 Classification of dog bite
WHO Classification
 Category I: touching or feeding suspect
animals, but skin is intact
 Category II: minor scratches without bleeding
from contact, or licks on broken skin
 Category III: one or more bites, scratches, licks
on broken skin, or other contact that breaks
the skin; or exposure to bats
 Management of dog bite

 Should not be delayed

 Provoked or unprovoked bite does not matter
 Immunization status of the animal does not
matter
 Management involves – wound management
& post exposure prophylaxis
 Wound management

 Wound should be washed thoroughly with

water & soap
 The wound should be flushed with running tap
water for 10 minutes
 Tetanus toxoid should be given
 Direct touching of wound with bare hands
should be avoided
 Debridement of devitalized tissues
 No suturing or closure of wound
 Irritants such as soil, chilies, oil, herbs, chalk,
betel leaves turmeric etc., should not be
applied
 Cauterization of wound should not be done
 Postexposure prophylaxis

 Anti-rabies vaccine –
o Human Diploid Cell Vaccine (HDCV),
o Purified Chick Embryo Cell Vaccine(PCECV),
o Purified Vero Cell Rabies Vaccine (PVRV)
 Rabies immunoglobulin(RIG) – Human &
Equine
 Production of nerve tissue vaccine was
stopped in 2004 in India
 Anti-rabies vaccine
Route
 Intramuscular
 Intradermal
Site
 Deltoid is ideal for IM route
 Anterolateral aspect of thigh in children
 Gluteal region is not recommended
 Eight sites for ID route-both upper arms, both
lateral thighs, both suprascapular regions and
both sides of the lower quadrant region of the
abdomen
 In category I exposure – no RIG, no vaccine
 In category II exposure – wound management,
vaccine
 In category III exposure – wound
management, vaccine, RIG
 In case of bite, keep a watch on the dog for at
least 10 days
 Start PEP immediately
 If the dog developes clinical features of rabies
or dies during the 10 day period PEP should be
completed
 If the dog is healthy, further PEP is not
necessary
 Rabies Immunoglobulin
RIG
 Administered only once on day 0
 Given to previously unvaccinated persons
 If not given on day 0, it can be given till day 7
of PEP series
 Not indicated beyond 7th day
 Full dose should be infiltrated in the area around
the wound
 Any remaining volume should be injected IM at a
site distant from vaccine administration
 Dose – 40IU/kg for eqine and 20 IU/kg for Human
 In case of multiple bite wounds, the HRIG can be
diluted in sterile NS 2-3 fold & infiltrated around
all the wounds
 PEP should be initiated at the earliest
 5 one ml doses of HDCV or PCECV to
previously unvaccinated persons
 On day 0,3,7,14 & 28
ERIG
• Source – obtained from hyperimmunized
horse
• Dose – 40IU/ml IM after test dose
 Vaccination in re-exposure

 If patient has completed full course of either

pre or post exposure prophylaxis
 2 booster doses on day 0 & 3 irrespective of
category or time elapsed
 HRIG or ERIG is not recommended
 In case of h/o incomplete vaccination, treat as
fresh case
 Pre-exposure prophylaxis

 Recommended for high risk groups –

o veterinarians,
o laboratory personnel working with rabies virus
o medical and paramedical personnel treating rabies
patients
o dog catchers
o forest staff
o zoo keepers
o postmen, policemen, courier boys, and school
children in endemic countries
 HDCV & PCECV (1 ml) or PVRV(0.5 ml) by IM
route on days 0, 7 & 28

 Reconstituted tissue culture vaccines (0.1 ml)

by ID route over deltoid on days 0, 7 & 28
 Adverse effects of rabies biologics

HRIG
• Pain & tenderness at injection site
• Erythema & induration
• Headache – most common reported systemic
reaction
• Mostly mild
ERIG
• Local reactions
• Serious adverse-reaction rate < 1–2%.
• Anaphylaxis, may occur in spite of a negative skin
test.
• To be used by medical staff trained and equipped
to manage such an adverse reaction
• Unpurified rabies antisera are not recommended
 …contd.,
HDCV
• Local reactions ( 60-89% )
• Pain at the injection site (mc 21-77%)
• Systemic reactions( fever, headache, dizziness,
& G I T symptoms ) in 6-55%
• Hypersensitivity reactions (5.6%)
• Rare individual case reports of neurologic
adverse events resembling GBS.
 …contd.,
PCECV
• Local reactions (11-57%)
• Systemic reactions less common (0-31%)
• One case report of neurologic illness
resembling GBS from INDIA (Chakravarty et
al., 2001)
PVRV
• Local reactions – pain, pruritis 3.5% (mc),
erythema, lymphadenopathy
• Serious systemic reaction – very rare
Other animals that can cause rabies
Animals that do not cause rabies
ID REGIMEN
Intradermal route
 Not a contraindication
 Pregnancy,
 Lactation,
 Infancy,
 Old age &
 Concurrent illness ,
 Immunocompromised states
 If HRIG not available what to give ?

 ERIG can be given (40IU/ml) after sensitivity

testing

 Double dose of first dose of anti-rabies

vaccination can be given in
 Cat III exposure
 Immunosuppression ( CD 4 count<200/cu mm)
 Malnutrition
 Patients on steroids,& anticancer drugs
 Summary

• Dog bite should be taken seriously

• Any dog can bite – including pet dog
• Provoked or unprovoked does not matter
• Immediate treatment including wound
management & PEP
• PEP includes both passive as well as active
immunization
• HRIG is preferred over ERIG
• Pre exposure prophylaxis in the high risk
individuals