EPIDEMIOLOGICAL
EXERCISE- RABIES
A boy of 7 year was brought to you with history of dog bite on
the hand and fingers with bleeding, 2 hours back. How do you
manage this case as a medical officer?
• Solution:
• Taking history in detail
• Name, age, address, locality
• Time and place of bite
• Type of dog: Pet, street, domestic, stray, wild
• Other persons bitten by the same dog
• Provoked or unprovoked bite
• Possibility of watching the bitten dog for 10 day
• Animal showing signs of rabies.
CONT.,
• Wound details
• Site of wound, distance from the brain
• Type of Bite—Superficial, deep or mere lick
• Number of bites
• Bite—Bare skin or interposing cloth.
• Classification of bite
• As bite is on hand and fingers, bite is considered as class III bite.
CONT.,
• Management
• Wound management
• Antibiotics and tetanus toxoid: To prevent infection and tetanus
• Antirabies immunoprophylaxis
• Watching the dog for 10 days
• Wound management
• Aim
• Removal and destruction of rabies virus in the wound
• To remove the saliva remains, dirt and foreign bodies
CONT.,
• Methods adopted
• Physical
• Chemical
• Immunological.
• Physical
• Wound treatment is of paramount importance
• Wound treatment is given as early as possible
• Wound is cleaned
• Flushing and washing the wound and adjoining area with plenty of soap and water, under
running tap water for at least 15 minute
• Punctured wound is irrigated by using catheters.
CONT.,
• Chemical
• To inactivate remaining virus, following chemicals are used-
• Tincture, Iodine- 0.01%, Povidone iodine
• To inactivate/destroy remaining virus in the wound spirit, alcohol tincture iodine
can be used as they act by dissolving the lipid membrane of the virus.
• Quaternary ammonium compounds like Savlon, Cetavlon should not be used.
Cauterization by using carbolic/nitric acid should not be done.
• Suturing causes further trauma, and helps in spread of virus into deeper tissues.
Hence, suturing should not be done immediately. If necessary, suturing is done
after 48 hour of applying immunoglobulin.
• Bandage: Wound is left open, unbandaged.
CONT.,
• Immunological: Immunoglobulin
• Immunoglobulin is the best prophylaxis for rabies exposure
• Prevents the replication of virus
• Prolongs the incubation period
• Given after sensitivity test
• Complete protection is ensured only by giving immunoglobulins immediately
after exposure, followed by complete course of vaccine
CONT.,
Passive immunization
Immunoglobulin schedule
Rabies Immunoglobulin Preparation concentration Dose/kg body weight Maximal dose
per ml
HRIG 150 IU 20 IU 1500 IU
ERIG 300 IU 0.134 ml 10 ml
HRIG - Human rabies immunoglobulin, ERIG-Equine rabies immunoglobulin
Major part of the dose is administered around the wound as palm and finger bite is class III bite.
Rest is injected intramuscularly to the gluteal region.
CONT.,
• Active immunization
• Cell cultured vaccine like purified inactivated duck embryo vaccine (PDEV) or
human diploid cell vaccine (HDCV) or purified chick embryo vaccine (PCEV),
purified vero cell cultured vaccine (PVCV) is used
• Vaccine is given as prophylactic, prevents establishment of virus in peripheral
nerve
• Intramuscular injections are given to deltoid region
• Dose—0.5 to 1 ml
• Schedule—0, 3, 7, 14, 28
CONT.,
• Advice to patient/attendant
• Take complete treatment timely.
• There is no contraindication for Rabies vaccine
• Avoid steroid, chloroquine, and immunosuppressive drugs
• Avoid physical and mental strain, late nights and alcohol
• Report immediately in case of fever, pain, stiffness in neck and limbs
• People are educated to seek treatment for all dog bites, even if it is a small pup.
• There is no secondary prevention, except ensuring a comfortable death.
