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
