A.

MANAGEMENT OF ANIMAL BITE

I. Categorize patients
II. Determine need for hospitalization
III. Determine need for laboratory tests
IV. Initiate treatment

I. Categorize patients
CATEGORY STATUS OF ANIMAL ACTION PLAN
I. Touching, feeding, licking of Healthy, unknown, LOCAL WOUND CARE
healthy skin with no open wound, escaped ,
no mucous membrane contact sick, proven rabid Consider exposure prophylaxis if likely
Key: RELIABLE HISTORY to be re-exposed
II. Superficial scratch/ abrasion Healthy Vaccine
without bleeding, nibbling of Observe 10-14 days
uncovered skin; hematoma only; If animal remains healthy. Discontinue
licks on broken skin or healing vaccination or continue as pre-exposure
wounds; Category I but unreliable prophylaxis
history

CATEGORY STATUS OF ANIMAL ACTION PLAN

II Healthy (continued…)
If animal gets sick or dies; send animal
head for lab exams
If FAT (+): continue vaccination
If (-): may discontinue vaccination or
contribute as pre-exposure prophylaxis

Full course vaccine

Unknown, escaped,
sick, proven rabid
III. Single /multiple transdermal Healthy Rabies Ig + Vaccie
bites; licking of mucous Observe 10 to 14 days
membrane; ALL head and neck
exposure; EXPOSURE to rabid If animal remains healthy, Discontinue
patients (bites, contamination of vaccination or continue as pre-exposure
mucous membranes with saliva/ prophylaxis
fluids (through splattering, mouth
to mouth res, licks of eyes, lips, If animal gets sick or dies, do lab exam
vulva)); handling of infected of animal head
carcass or ingestion or raw (+) continue vaccination
infected meat (-) may discontinue vaccination
orcontinue

Rig + Full course vaccine

Unknown, escaped,
sick, proven rabid

I. Determine need for hospitalization

INDICATIONS
• Secondarily infected bites needing parenteral antibiotics
• Severe adverse reaction to antirabies immunization
 III.Determine need for laboratory tests
• Gram stain
• Culture and Sensitivity

IV.Initiate treatment
• POST-EXPOSURE TREATMENT
• PRINCIPLES:
Minimize the amount of virus at the site of inoculation develop a high titer of neutralizing
antibodies EARLY

PATHOPHYSIOLOGY OF RAIES PREVENTION BY VACCINE

• Amplification of virus in muscle near the site of inoculation
• →CNS infection
• Immunogenic vaccine or specific abs immediately
• →prevent CNS invasion by rabies virus
• Passive immunization: neutralize, lower concentration f the virus, provide time for vaccine to
stimulate active antibody production

IMMUNITY AND PREVENTION

• Only one antigenic type of rabies virus in known
• >99% of infections in human and mammals end up fatally
• Start post-exposure prophylaxis immediately!
• Wound care
• Rabies Ig
• Rabies Vaccine

COMPONENTS:

Passive Immunization

Available Rabies Immunoglobulins

Rabies
Immune Trade Name Pre-paration Dose Precautions
Globulin
Equine
rabies Anti-rabies serum
immune Berna (ARS Berna) or 1000 iu/5ml 40 units/kg Skin test required
globulin Favirab
(ERIG)

Human
rabies
immune Imogam 300 iu/ 2ml vial 20 units/kg No skin test needed
globulin
(HRIG)

Now available:
Fragments of Equine Antirabies Immune globulin (FAVIRAB)

a.HUMAN RABIES IMMUNE GLOBULIN (HRIG)

• 20 u/k on Day 0 mostly infiltrated around wound; remaining, IM gluteal region
• Indications: If skin test (+) to ERIG
Previous reaction to ERIG

b.EQUINE RAIES IMMUNE GLOBULIN (ERIG) – 40 u/k

• Skin test – 0.02ml in 1:10 make a 2-3 mm bleb; read after 15 mins
• Positive: induration is >10mm surrounded by a flare; repeat with control
 GUIDELINES:
• Negative skin test is not an assurance that no anaphylactic reaction will occur: READY WITH
EPINEPHRINE!
• Infiltration of all wounds with HRIG or ERIG is MANDATORY. Dilute with NSS if inadequate.
• RIG – given only anytime within the first 7 days affte initial dose of vaccine

ACTIVE IMMUNIZATION

Purified cell culture rabies vaccine

Rabies Vaccine Trad Prepa ID Dose IM Precautions Contra indications
e ration Dose
nam
e

Purified Vero Cell Rabies

Vero 0.5 ml/
Vaccine 0.1 ml 0.5 ml None
rab vial
(PVRV)
Caution
among
Lyss
Purified Duck Embryo 1.0 ml/ patients with
avac 0.2 ml 1.0 ml None
Vaccine (PDEV) vial anaphylactic
N reaction to
egg

Purified Chick Embryo Cell

Rabi 1.0 ml/
Vaccine 0.1 ml 1.0 ml None
pur vial
(PCECV)
* ID dose for 8-site regimen is 0.1 ml per dose

Summary Schedule of Active Immunization against Rabies

Dose No. of doses on specified days

Regimen PVRV PDEV PCECV

D
Veror Lyssavac Rabipu D0 D3 D7 D 14 D 21 D 90
28 -30
ab N r

2-site ID 0.1 ml 0.2 ml 0.1 ml 2 2 2 0 0 2

Standard
0.5 ml 1.0 ml 1.0 ml 1 1 1 1 1 1 0
IM

0.1ml
8-site ID* - 0.1 ml 8 0 4 0 0 1 1
**
2-1-1 IM 0.5 ml 1.0 ml 1.0 ml 2 0 1 0 1 0 0

* 2 injections each over the deltoid, lateral thigh, suprascapular area and lower quadrant of the abdomen
on day 0 and over the deltoid and thigh on day 7
** 8- site ID regimen with PVRV used only in RITM
SITES
NEVER GIVE IN THE GLUTEAL AREA

Intradermal:
• If no satisfactory papule results, repeat on opposite side
• Requires skilled health worker
• In health facilities seeing more animal bite cases

Intramuscular: No special training required

Front Back
GUIDELINES IN GIVING PET
1. Persons with prior complete pre- or post-xposure prophylaxis
For subsequent exposures:
a.Local wound care
b.If category I or II and bite is
• within one month of last dose: no booster
• between 1 to 3 years of last does: two boosters, NO Rig
• >3 years: repeat full course, NO Rig
2. Person with incomplete pre- or post-exposure prophylaxis:
REPEAT FULL COURSE
3. Pregnant woman and infants may receive vaccination
4. Exposed person who consult late
Treat as if exposure were recent; if >14 days and biting animal remains healthy, NO TREATMENT
5. Missed doses
• If D0 dose given for >1 week: repeat first dose without RIG
• If D0 and D3 given: adjust missed doses; give remaining according to original schedule
• If D30 missed: give when patient comes; give D90 dose as scheduled or at least one month after
D30 dose
• If D90 missed: give anytime the patient come
6. NEVER give vaccine in the gluteal area
7. AVOID chloroquine, systemic steroid, anti-epileptics, heavy alcohol intake especially if receiving ID
vaccination
8. AVOID shifting brands except because of hypersensitivity reaction or inavailability of the drug
9. AVOID changing route of administration
10. ENCOURAGE complete pre-exposure prophylaxis (D20 or D30) even if the animal is proven non-rabid
or healthy
11. Immunocompromised persons: standard IM regimen
PLUS RIG for category I and II
12. All healthy cat and dog bites – observe for 14 dys
13. Cat, monkey, wild animal bites – treat as dog bites
14. Bites of rats, rodents, other domestic animals –
PET not needed unless proven rabid; give anti-tetanus prophylaxis

SUPPORTIVE MANAGEMENT
1. LOCAL WOUND CARE – the cornerstone of rabies prevention; reduces risk of 90%
• VIGOROUS washing with soap and water
• Irrigate with virucidal agents like povidone iodine
2. DELAY WOUND SUTURING – after RIG infiltrated into the wound
3. AVOID creams, ointments or occlusive dressing
4. ANTIBIOTIC PROPHYLAXIS
• >50% of cat bites and 15% to 20% of dog bites become secondarily infected
• Give to all category III cat and dog bites
• NO obvious infection: Amoxicillin
• Frankly infected: Cloxacillin or Co-amoxyxlavulanic acid
5. CONSIDER ANTI-TETEANUS PROPHYLAXIS – all anima bite wounds are considered tetanus-prone
Table 2. Guide to Tetanus Prophylaxis in Routine Wound Management

Non-immune Immune**
Type of Injury
Incomplete Booster >10 yr Booster <10 yr

Clean minor wound DT/DPT Tetanus Toxoid NONE

(start active
Immunization series

Tetanus prone DT/DPT +TIG* Tetanus Toxoid >5 yrs since booster give Tetanus Toxoid; <5 yrs
NONE

Neglected wound DT/DPT + TIG* Tetanus Toxoid + Tetanus Toxoid + TIG*

TIG*

* ATS may be used in the absence of TIG

** Immune Individual – has received at least 3 doses of DPT or TT
MANAGEMENT OF THE BITING ANIMAL
1. DON’T SACRIFICE A HEALTH ANIMAL
2. Observe for 10 to 14 days
• Sudden change in behaviour
• Hoarse howl
• Watchful, apprehensive expression of the eyes, staring, blank gaze
• Drooling of saliva
• Paralysis or uncoordinated movement of hind legs
• Marked excitability and restlessness; pacing in cage
• If restrained, attacks objects within range, bites cage
• If at large, runs aimlessly, biting anything in its way
• Snaps at imaginary objects
• Quiescent, bites when provoked
• Depraved appetite
• Self-mutilation
• Paralysis of the lower jaw ad tongue, inability to drink
• Sudden unexplained death
3. If animal is sick at time of bite or during observation period but no signs of rabies → veterinarian
4. Sacrifice animal if it poses grave danger to the public. DON’T DAMAGE THE HEAD

Precautions when Handling a Suspected Rabid Animal

1. Only one person without open wound
2. Keep a safety barrier or distance from the animal
3. Wear protective clothing
4. Be armed with restraining device
5. Confine animal in an isolated area inaccessible to unauthorized persons
6. Disinfect or sterilize the areas that get in contact with the animal’s body fluids
- Soap and wter
- Detergent soutin
- 1:500 benzalkonium chloride or sodium hypochlorite
- 45% to 70% alcohol
- 7% iodine

How tocut the head of the Dead Animal

1. If animal is <5kg send intact to the laboratory
2. Large animals: you need protective covers, sharp knife, solid table top and disinfectants
3. Slowly cut tissues of the neck near the base of the head
4. Break bones to separate the head by striking back of knife with a hammer or heavy wood or metal.
AVOID aerosolization and scattering tissue debris.
5. DO NOT ATTEMPT TO EXTRACT BRAIN OUT OF THE BRAIN CAVITY
6. Place head in a leakproof container. DO NOT PUT ANY PRESERVATIVES OR DISINFECTANT.
7. Disinfect all contaminated surface

Preparation and Transport of Animal’s Head

1. Place leakproof container with animal’s head in a bigger container with ice/ dry ice
2. Label: pet owner’s name, date of preparation
CAUTION: RABIES SUSPECT
3. Freeze if transit time is >48 hours
4. Avoid keeping at room temperature for > 12 hours
B. MANAGEMENT OF A PATIENT WITH RABIES
a.DIAGNOSIS
• Clinical
• Laboratory confirmation
- PCR of saliva
- Corneal imprint for Fluorescent Antibody Test (FAT)
- CSF for FAT or Mouse Inoculation Test

b.THERAPY
• MORTALITY rate is almost 100%
• Rabies is better prevented than treated
 • No specific chemotherapy for clinical rabies
• Supportive care: IV fluids, sedation with midazolam or diazepam

c.PRECAUTIONS
• Immediate isolation of suspected and confirmed cases. Rabies is communicable.
• Restrain patient
• Healthcare givers in direct contact with patient should be equipped with goggles, face mask,
gowns, gloves
• Pay special attention to patient’s saliva, sputum, CSF, and other body secretions. Dispose of
equipment or instruments which may harbour rabies virus properly -> disinfect
• Sterilize equipment: 60ᵒC, at least 30 minutes
• HANDWASHING

C. MANAGEMENT OF CONTACTS OF RABID PATIENT

EXPOSURE TO RABID PATIENTS

I. REQUIRE PROPHYLAXIS (vaccine PLUS RIG)
1.Exposure to body fluids (EXCEPT blood and stool) or other potentially infectious material in
direct contact with mucous membranes (oral, conjunctival or genital) or broken skin (cut,
scratch abrasion) when patient already has symptoms
2.Needlestick injuries if needles is exposed to CSF, nervous tissue, ocular tissue or internal
organs
3.Bites
4.Licks of open wounds or mucous membranes

II.NO PROPHYLAXIS REQUIRED

1.Sharing food, drink, utensils
2.Casual contact, interviewing patient, doing physical examination
3.Caring for patient without exposure of mucous membranes or open wounds to patient’s
secretions
4.Exposure to blood as in needlestick injuries
*contact may opt to have pre-exposure prophylaxis

PRE-EXPOSURE PROPHYLAXIS
Indications:
1.Individuals at high risk for rabies: veterinarians, animas handlers, laboratory workers
2.Hospital staff involved in management of rabies patients

Regimens: day 0, 3, 28
• IM - PVRV 0.5ml or PDEV 1.0ml or PCECV 1.0ml
• ID – PVRV 0.1 ml or PDEV 0.2ml or PCECV 0.2ml
• Booster: every 1 to 3 years

Whats the trick? HEALTH PERSONEL

• VACCINATE before you teach your dog new • Handwashing
tricks • Barrier precautions
• Knowledge • Careful handling of body secretions and
• Sound judgement potentially infected tissues, instruments
• Immediate decisions and equipment
NOT ALL patients and contacts require
SUMMARY treatment
VICTIM • Know WHOM, WHEN, and HOW to treat
• Immediate wound care – cornerstone of • Consider: biting animal, site and severity
prevention of wound, degree of contact
• Early medical consult – PET, Anti-tetanus, • Consider: local wound care as essential,
antibiotics immediate treatment
• Observing biting animal • Categorize patient for action plan
• For category III: NO COMPROMISE!
(Vaccine + RIG)
• Human bites?