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DOG

BITE/RABIES


Introduction
Acute viral disease that causes fatal encephalomyelitis (incurable disease)
ssRNA Virus, Lyssavirus genus of the Rhabdoviridae family.
Transmitted through rabid animals saliva following bites, scratches, licks on broken skin
and mucous membrane
In India, majority of disease transmission is via dogs (97%)
Development of rabies can be prevented if animal bites are managed appropriately

Pathophysiology
From the wound of entry, the rabies virus travels along the peripheral nerves.
The retrograde axonal transport of the rabies virus to the CNS is the key step of
pathogenesis during natural infection. From the CNS, the virus further spreads to
other organs. The salivary glands located in the tissues of the mouth and cheeks
receive high concentrations of the virus, thus allowing it to be further
transmitted through saliva.
Infected animal bite saliva containing infectious rabies virus is deposited in
tissues virus binds to the nicotinic acetylcholine receptors in the muscles
spreads across the motor end plate and ascends and replicates along peripheral
nervous axoplasm to the dorsal root ganglia (DRG), and the central nervous
system (CNS) eventually the virus spreads outward by peripheral nerves to all
the tissues and organ systems.
The risk of developing rabies following a bite or scratch by a rabid animal depends on the
type of wound (bite or scratch), the number of bites, the depth of the bites, and the
location of the wounds


Clinical Features
Incubation Period: 20-90 days (shorter IP when bite is on the head than when it is on an
extremity)
Local pain
Stages of the disease:
1. Prodromal: Pain, paresthesia, headache, fever, nausea and vomiting, anorexia
2. Acute Neurologic Phase: Anxiety, agitation, depression, paresthesia, incoordination,
hyperactivity, confusion, hydrophobia, hyperventilation, aphasia
3. Coma: hypotension, hypoventilation, pituitary dysfunction, arrhythmias, death


Diagnosis
WHO definition: An acute neurological syndrome dominated by forms of hyperactivity (furious
rabies) or paralytic syndrome (dumb rabies) progressing towards coma and death, usually
by cardiac or respiratory failure, typically within 7-10 days of onset of symptoms.

Several tests are necessary to diagnose rabies ante-mortem (before death) in humans; no single
test is sufficient. Secretions (saliva, spinal fluid), skin biopsies of hair follicles, nape of neck can be
used to diagnose rabies. Gold Standard is DFA (direct fluorescent antibody) & in HPE: Presence
of Negris bodies is variable

MANAGEMENT

Categories of Exposure

Category Type of contact
I

Recommended Post
Exposure Prophylaxis

Touching or feeding of animals, Licks on None, if reliable case
intact skin, Contact of intact skin with
history is available
secretions / excretions of rabid animal
/human case

II


Nibbling of uncovered skin, Minor
scratches or abrasions without bleeding



Single or multiple transdermal bites or
scratches, licks on broken skin
Contamination of mucous membrane with
saliva (i.e. licks)

III

Wound management
Anti-rabies
vaccine
(ARV)

Wound management
Anti-rabies
vaccine
(ARV)
Rabies immunoglobulin
(RIG)

Note: Pregnancy, lactation, infancy, old age and concurrent illness are not contra
indications for rabies PEP in the event of an exposure.

1. Wound Care
This is the priority
Do ASAP with running water, use soap and disinfectant
Do it even if the patient presents late
Avoid direct touching of the wound
Local infiltration with RIG (in Cat III, in immunocompromised -> Cat II and III)
Tetanus prophylaxis
Suturing Avoid as far as possible
Antibiotics (Augmentin for 3-5 days)


2. Rabies Vaccine (Active Immunisation, only for Cat II and III exposures)
Same dose and number of injections regardless of age/TBW
a.

Post exposure prophylaxis: IM Regimen

Essen regimen (1-1-1-1-1-1): Five dose IM schedule (sixth dose on day 90 is


optional for immunocompromised and those at extremes of age) for Post

exposure prophylaxis on days 0,3,7,14,28,90 (Day 0 indicated date of


administration of first dose of vaccine). Give in deltoid muscle, not gluteal in
adults and anterolateral thigh for infants and children.
b. Pre-Exposure prophylaxis: IM Regimen
For high-risk groups (veterinarians, animal handlers and catchers, wildlife
wardens, quarantine officers). The Indian Academy of Pediatrics (IAP) has
recommended pre- exposure prophylaxis of children! Schedule of vaccination:
Pre-exposure vaccination is administered as one full dose of vaccine IM on days
0, 7 and 21.
c. Converting Post exposure Prophylaxis (PEP) to pre exposure
vaccination:
Possible only when the dog/cat is available for observation and stays healthy up
to 10days from the day of bite, to convert, give PEP vaccinations on day 0,3,7. If
the dog/cat stays healthy up to 10 days then skip the day 14 dose and give day
28 dose. Advantage of converting is, in case of any subsequent exposure,
treatment with RIG is not required regardless of the category of bite.

3. Rabies Immunoglubolin (RIG - Passive Immunity, (in Cat III, but in
immunocompromised -> Cat II and III))
Provides passive immunity in the form of ready-made anti-rabies antibodies, to
cover the initial phase of the infection. Binds with the virus and causes
neutralization. RIG is administered only once, preferably within 24 hours after
the exposure along with the first dose of anti-rabies vaccine, though it can be
administered up to the 7th day after the administration of the first dose of ARV.
Beyond the seventh day, RIG is not indicated. A full course of ARV should follow
thorough wound cleansing and passive immunization.
Indication: RIG should be administered to all category III exposures. However,
in immune compromised individuals, RIG should be administered in both
category II and III exposures.
Types of RIG:
Equine Rabies Immunoglobulin (ERIG):

Carry a small risk of anaphylactic reaction (1/150,000).


Skin test prior to administering ERIG is not recommended.
Be prepared to manage anaphylaxis (rare)
Dose: 40 IU/Kg BW (max 3000IU). The ERIG produced in India contains
300 IU per ml.

Human Rabies Immunoglobulin (HRIG):

Expensive , approx. 14000INR/235USD


Relatively free from side effects
Dose: 20IU/kg BW (Max 1500IU)

Administration of rabies immunoglobulin:

Bring down to room temperature before administration


Infiltrate as much as possible into and around the wound/s.
Avoid multiple needle injections into the wound/s.
After all the wound/s has been infiltrated, if any volume of RIG is
remaining, it should be administered by deep IM injection at a site distant
from the vaccine injection site.

In cases where extra dose is required due to multiple wounds, the


calculated dose of the rabies immunoglobulin may not be sufficient to
infiltrate. So, it is advisable to dilute the calculated volume of RIG in sterile
normal saline to a volume sufficient to infiltrate all the wounds. (do not
exceed total recommended dose of RIG)

4. Supportive Care
Isolation care
BZD, Opoids to relieve agitation/spasms
Comfort care
Immunise the partners

Other Issues to contemplate:
Observation of the animal: Start PEP immediately after the bite. The
observation period of 10 days is valid for dogs and cats only. Treatment may be
modified if dog or cat involved remains healthy throughout the observation
period of 10 days by converting post-exposure prophylaxis to pre-exposure
vaccination by skipping the vaccine dose on day 14 and administering it on day
28 while using Essen Schedule. (0,3,7,28)
Vaccinated animals: Unvaccinated animals are more likely to transmit rabies,
But, vaccinated animals can also do so if the vaccination of the biting animal was
ineffective for any reason. Appropriate documentation of vaccination status of
dog/cat and proper history should be elicited before deciding to defer post-
exposure prophylaxis after bite by vaccinated dog/cat.
Provoked/Unprovoked bites: PEP should be immediately instituted
irrespective of whether the bite was provoked or unprovoked.
Bites in immunocompromised: Patients on chemotherapy, steroid therapy,
cancer patients, etc. In this subgroup, treat Cat II as cat III (ARV+RIG). Also, anti-

rabies antibody estimation should be done 14 days after the completion of


course of vaccination to assess the need of additional doses of vaccine.
Human to Human transmission: The risk of rabies transmission to other
humans from a human rabies case is very minimal. Offer PEP, to those who have
been exposed closely to the secretions of a patient with rabies.

Re-exposure Prophylaxis in already vaccinated persons: Re-exposed persons who


have previously received full pre- or post-exposure prophylaxis with vaccine should now
be given only two booster doses intramuscularly on days 0 and 3. Proper wound toilet
should be done. Treatment with RIG is not required.


Key Points

Know the categories of dog bite and treat accordingly.
Convert Preexposure prophylaxis to Postexposure if the animal stays healthy after
10 days of observation. (0,3,7,28)
Administer RIG only in Cat III but in immunocompromised, give RIG in both Cat II
and III.
No skin testing is recommended before giving RIG, Adverse effects are rare.


Note: This document represents the treatment of dog bite as per the National Guidelines in
India.

For Further Reading:
1. http://www.ncdc.gov.in/Rabies_guidelines2014.pdf
2. http://www.who.int/rabies/PEP_prophylaxis_guidelines_June10.pdf
3. http://www.cdc.gov/rabies/exposure/index.html
4. http://www.who.int/bulletin/volumes/92/4/14-136044/en/


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Lakshay Chanana
drlakshay_em@yahoo.com
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