The Updated Guideline on the

Management of Animal Bite Patients

RAFFY A. DERAY, MD, MPH

National Program Manager
National Rabies Prevention and Control Program

National Rabies Prevention and Control Program

National CenterDepartment
for DiseaseofPrevention
Health and Control
 Management of Rabies
Exposure:
Post- Exposure prophylaxis
(PEP)

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 General Principles of PEP
A. Reduce the quantity of rabies virus at the bite site
• Local wound care
B. Ensure a high titer of neutralizing antibodies early
and maintain it for as long as possible
• Rabies Immune Globulin (RIG) infiltration (Passive)
• Vaccination with anti rabies vaccine (active
immunization)
• - There are no absolute contraindications to PEP
• -should not be delayed for any reason.

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 Categorization and
Management of Rabies
Exposure

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 Category of Exposure Management
CATEGORY I
a) Feeding/touching an animal 1. Wash exposed skin
immediately with soap and
b) Licking of intact skin (with reliable
water.
history and thorough physical
examination) 2. No vaccine or RIG needed
c) Exposure to patient with signs and 3. Pre-exposure prophylaxis
symptoms of rabies by sharing of may be considered for high
eating or drinking utensils risk persons.
d) Casual contact (talking to, visiting and
feeding suspected rabies cases) and
routine delivery of health care to patient
with signs and symptoms of rabies

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 Category of Exposure Management
CATEGORY II
a) Nibbling of uncovered skin with 1. Wash wound with soap
or without bruising/hematoma and water.
b)Minor/superficial 2. Start vaccine
scratches/abrasions without immediately:
bleeding, including those 3. RIG is not indicated
induced to bleed
c) All Category II exposures on
the head and neck area are
considered Category III and
should be managed as such.

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 Category of Exposure Management
CATEGORY III
a) Transdermal bites (puncture wounds, 1. Wash wound with
lacerations, avulsions) or scratches/abrasions soap and water.
with spontaneous bleeding 2. Start vaccine and
b) Licks on broken skin RIG immediately:
c) Exposure to a rabies patient through bites,
contamination of mucous membranes (eyes,
oral/nasal mucosa, genital/anal mucous
membrane) or open skin lesions with body
fluids through splattering and mouth-to-
mouth resuscitation.
d) Unprotected Handling of infected carcass or
ingestion of raw infected meat
e) All Category II exposures on head and neck
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 Category III

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 A. Components of PEP
1. Local Wound Care 2. Anti Rabies
Vaccination 3. RIG Infiltration

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1. Local Wound Care/First Aid for Animal Bites
1.Wounds should be
immediately and vigorously
washed and flushed with soap
and water preferably for 10
minutes.
2. Bring animal bite patient to
the nearest Health Center
/Animal Bite Treatment
Center.
3.Observe dog for 14 days.
4.Be a Responsible Pet
Owner.
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Local Wound Care
 Apply antiseptic
(alcohol, tincture of iodine, etc)
 Antibiotics if indicated
 Drugs of choice: Amoxicillin/clavulanic
 OR Cloxacillin OR Cefuroxime axeti
 Anti-tetanus immunization
should be given since animal
bites are considered tetanus
prone wounds

National Rabies Prevention and Control Program

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Local Wound Care
 Anti-tetanus immunization should be given since animal bites are
considered tetanus prone wounds
Remember:
 Bring animal bite patients to nearest Animal Bite treatment Center as
soon as possible for Antirabies Immunization.

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 Local Wound Care: Don’ts
 If possible, suturing of wounds should be avoided (as
it may inoculate virus deeper into the wound)
Wounds may be coaptated using sterile adhesives strips
 However, if suturing is necessary, anti-rabies
immunoglobulin should be infiltrated around and into
the wound before suturing
If suturing is unavoidable, it should be delayed for at least 2
hrs after administration of RIG to allow diffusion of the RIG
to occur through the tissues

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 RIG Infiltration

National Rabies Prevention and Control Program

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3. ACTIVE IMMUNIZATION
• Giving of Anti- Rabies Vaccination
– Vaccine is administered to induce antibody and T-cell
production in order to neutralize the rabies virus in the body.
It induces an active immune response in 7-10 days after
vaccination and protection is only conferred after
adequate levels of antibodies have been produced,
which may persist (detectable but may no longer be
protective) for years provided that primary is
completed.

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Anti Rabies Vaccination

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 Management of Rabies Exposures Secondary to Bites by
Vaccinated Animals (2)
PEP can not be delayed for ANY of the following
conditions :
1. The rabies exposure is category III;
2. The dog/cat is proven rabid/sick/ dead/not available for
observation before or during the consultation;
3. The dog/cat is involved in at least 3 biting incidents within 24
hours or
4. Dog/cat manifests behavior changes suggestive of rabies before,
during or after the biting incident:

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Special Conditions
1. Pregnancy and infancy:
Pregnancy and infancy are not contraindications to
treatment with modern Tissue Culture Vaccines (TCVs);
Nerve Tissue Vaccine
is not recommended during pregnancy

2. Drugs and Chronic Liver Disease

Patients with chronic liver disease and those taking
chloroquine, and systemic steroids should be given
standard IM regimen as the response to ID regimen is not
optimum for these conditions.
conditions

National Rabies Prevention and Control Program

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Special Conditions
3. Babies of Rabid Mothers
Babies who are born of rabid mothers should be given
rabies vaccination as well as RIG as early as possible at birth.

4. Patients with Hematologic Conditions:

Patients with hematologic conditions where IM injection is
contraindicated should receive rabies vaccine by ID.

National Rabies Prevention and Control Program

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Special Conditions
5. Immunocompromised individuals:
Such as those with HIV infection, cancer/transplant patients on
immunosuppressive therapy etc) should be given vaccine using
standard IM regimen and Rabies Immune Globulin (RIG) for both
Category II and III exposures.
6. Delay in Consult:
Exposed persons who present for evaluation or treatment weeks or
months after the bite
 Treat as if the bite was recent
 If the biting animal has remained healthy and alive until 14 days
after the bite, PEP is not needed

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Special Conditions
7. Bites by other animals:
 rodents, guinea pigs, rabbits, snakes and other cold blooded animals do not
require rabies PEP.
 Bites by domestic animals other than dogs and cats (cattle, pigs, horses,
etc), monkeys and other wild animals require rabies PEP.

8. Shifting from one vaccine brand:

Shifting from one vaccine brand to another is not recommended but
may be warranted for the following situations provided that it is one of the
WHO recommended cell culture vaccines:
 hypersensitivity reaction
 unavailability of initial vaccine used

National Rabies Prevention and Control Program

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Special Conditions
9. Shifting from one regimen
Shifting from one regimen to another (IM to ID, ID to IM) is
not recommended. As much as possible the initial regimen should be
completed.

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Pre- Exposure Prophylaxis (PrEP)

National Rabies Prevention and Control Program

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Pre- Exposure Prophylaxis (1)

Pre Exposure Prophylaxis (PrEP) - refers to rabies vaccination

administered before an exposure to potentially rabid animals. This
is usually given to those who are at high risk of getting rabies.

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Pre- Exposure Prophylaxis (2)
Recommended for persons at high risk for rabies exposure:
- Veterinarians and veterinary students
- Animal handlers/pet owners
-Laboratory staff handling rabies virus
-Health care workers caring for rabies patients
- Individuals directly involved in rabies control
- Young children (5-14 years)

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 National Rabies Prevention and Control Program
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