Management of dog bite

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Management of dog bite : 

Management of dog bite Prepared by: Dr. Vipin PG 2 MODERATOR : Dr. (Prof.) S.C.Sharma Dr.Dinesh Srivastava Dr.Vipin Mediratta

Slide 2: 

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.

Slide 3: 

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 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, Cost of post-bite treatment is about $25 million. About 20,000 deaths from rabies per year

Dogs in India : 

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 : 

Brief account of rabies Caused by 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 – Through bite of an infected animal (by saliva), Contamination of mucous membranes (i.e., eyes, nose, mouth) with infectious secretions Aerosol transmission, Organ or tissue transplantation (corneal transplantations)

Slide 9: 

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

Diagnosis : 

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 : 

…contd Immunohistochemistry (IHC) In-situ hybridisation Serology Amplification methods (RT-PCR)

Classification of dog bite : 

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 : 

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 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

Slide 20: 

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 : 

Postexposure prophylaxis Anti-rabies vaccine – Human Diploid Cell Vaccine (HDCV), Purified Chick Embryo Cell Vaccine(PCECV), Purified Vero Cell Rabies Vaccine (PVRV) Rabies immunoglobulin(RIG) – Human & Equine Production of nerve tissue vaccine was stopped in 2004 in India

Slide 22: 

Route Intramuscular Intradermal

Slide 23: 

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

Slide 24: 

In category I exposure – no HRIG, no vaccine In category II exposure – wound management, vaccine In category III exposure – wound management, vaccine, HRIG

Slide 25: 

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

Slide 26: 

HRIG 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

Slide 27: 

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 – 20IU/kg (0.133mL/kg) In case of multiple bite wounds, the HRIG can be diluted in sterile NS 2-3 fold & infiltrated around all the wounds

Slide 28: 

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

Slide 30: 

ERIG Source – obtained from hyperimmunized horse Dose – 40IU/ml IM after test dose

CDC Guidelines : 

CDC Guidelines

…contd., : 


Vaccination in re-exposure : 

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 : 

Pre-exposure prophylaxis Recommended for high risk groups – veterinarians, laboratory personnel working with rabies virus medical and paramedical personnel treating rabies patients dog catchers forest staff zoo keepers postmen, policemen, courier boys, and school children in endemic countries

Slide 38: 

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 : 

Adverse effects of rabies biologics HRIG Pain & tenderness at injection site Erythema & induration Headache – most common reported systemic reaction Mostly mild

Slide 40: 

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., : 

…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., : 

…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)

Slide 43: 

PVRV Local reactions – pain, pruritis 3.5% (mc), erythema, lymphadenopathy Serious systemic reaction – very rare

Other animals that can cause rabies : 

Other animals that can cause rabies

Animals that do not cause rabies : 

Animals that do not cause rabies


ID REGIMEN Two site regimen – dose is 0.1 ml, on days 0,3,7 & 28 Eight site regimen – dose is 0.1ml Regimen is – Day 0 – 8 doses Day 7 – 4 doses Day 28 – 1 dose Day 90 – 1 dose

Intradermal route : 

Intradermal route

Not a contraindication : 

Not a contraindication Pregnancy, Lactation, Infancy, Old age & Concurrent illness , Immunocompromised states

If HRIG not available what to give ? : 

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 : 

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

Slide 51: 

PEP includes both passive as well as active immunization HRIG is preferred over ERIG Pre exposure prophylaxis in the high risk individuals

Slide 52: 


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