BY DR ABDULRAHMAN LOTFY

1. The burden of Animal
Bite in Kuwait
Dr. Abdulrahman Lotfy Amin
Public Health Specialist
Communicable Disease Control Department
Kuwait Ministry of Health

2. Describe rabies disease,
and how it can be transmitted.
Describe the epidemiology of animal
bites in Kuwait
.
Understand the public health burden
of animal bites Our Objectives
To understand purpose of surveillance
of Animal Bite

4. Common Birds in Kuwait
EgretEagle Kingfisher Heron

5. Common Arthropods in Kuwait
Dessert LocustGrasshopper Scorpion
Beetles Ants Butterflies

6. Mammals in Kuwait
Common
Desert
Mammals in
Kuwait
Red fox jerboa
Camels
Other
common
Mammals in
Kuwait
Wild cats
Stray dogs Rats

7. Raccoons
Bats
Dogs & Cats
Skunks
foxes
• Cattle & Sheep & Camels
• Humans
Only Mammals can get rabies
Rabies = Mammals

8. Gerbils
Hamsters
Rats
White Mice
Guinea Pigs
Animals that are not mammals such as
birds, snakes, and fish do not get rabies.

10. Rat bite and rabies
• Rat rabies has been reported from
some Asian countries but is
extremely rare.
• It is not necessary to take PEP in
bite cases by house rats.
• However, it is prudent to take PEP in
consultation with an infectious
disease physician when bitten by wild
rats/rodents.
http://www.who.int/rabies/resources/SEA_CD_278_FAQs_
Rabies.pdf

11. Animal Bite Case Definition
• A bite or
• Scratch or
• the introduction of saliva
from a vector species into an open, fresh wound or mucous
membrane (eye, mouth, or nose) of a human being
http://www.who.int/rabies/resources/SEA_CD_278_FAQs_
Rabies.pdf

12. WHO Case Classification
• Licks on unbroken skin
• Touching/ feeding animals
Category
I
• Nibble, cuts, scratches without
oozing of blood
Category
II
• Licks on mucous membrane or
broken skin
• Bites with breach of skin, bleeding
Category
III

13. Emergency visits
0.2–1.0% of ED visits
(200,000–1,000,000 visits)
Globally
Estimated 3–6 million
mammalian
bites/year
Incidence
True incidence of
animal bites is not
known
Background
Public Health Burden
1%
99%
ED visits
animal bite others
Sutures
• 10
%
Hospitalization
• 1-
2%
Death
• Few
cases

14. Biting species ( Global)
80%
10%
5%
5%
10%
Dogs
Cats
Rodents
Others

15. Biting species in Kuwait
52%
39%
6%
3%
9%
Dogs
Cats
Rodents
Others

16. Animal Bite By Type Of Animal
(2012 – 2016) In Kuwait
1214 1171 1053 1001
1270
715 772
840 830
1125
1 22 121 228
277
46 63 73 57
50
2012 2013 2014 2015 2016
DOGS CATS RODENTS OTHERS
Rat bite
notified
Rat bite
notified
Rat bite
notified

17. COST
750 KD
2185
CASES
1,634,000
KD
Cost Of Treating
One Case PEP of
Animal Bite
AVERAGE
NUMBER OF
CASES l YEAR
Total Cost

18. Infection risk increases with
 Species of animal (cat vs. dog, others)
 Type of wound (puncture bites)
 Delayed treatment (>24–48 hours)
 Patient age >50 years
Risk of infection due to microorganisms
 In the biter’s saliva (rabies virus,
Pasteurella multocida, P. canis, etc.)
 On the victim’s skin (Staphylococcus,
Streptococcus spp., etc.)
 In the environment (Clostridium tetani)
Physical damage/disfigurement
 Avulsions
 Lacerations
 Punctures
 Crushing
Psychological impact
 Lifetime fear of animals
 Nightmares/difficulty sleeping
 Speech defects
 Depression
Potential Health Outcomes

19. Animal Bite Surveillance
in Kuwait

20. Monitor PEP
use/misuse
.
Mitigate human risk of
rabies Purpose of Surveillance
Monitor epidemiology of
animal bites

21. Epidemiology of Animal Bites Reported in Kuwait,
2012–2016

22. Number of potential rabies exposure
in Kuwait ( 2012 – 2016) by sex
0
500
1000
1500
2000
2500
3000
2012 2013 2014 2015 2016
1517 1537 1567 1584
1963
460 494 520 532
759
1977 2031 2087 2116
2722
male female total

23. Number of potential rabies exposure in
Kuwait ( 2012 – 2016) by governorate
412
465
440
127
558
393
453 472
572 584590
560
639
746
824
318
341
321
385
440
264
212 215
286
315
2012 2013 2014 2015 2016
Capital Hawally Farwaniya Ahmadi Jahra

24. % of persons completed full dose vaccination
due to potential risk in Kuwait ( 2012 – 2016)
by governorate
89%
86%
85%
82%
85%
2012 2013 2014 2015 2016

25. Blood results to evaluate immunity PEP
against rabies virus in Kuwait (2012 – 2016)
0
10
20
30
40
50
60
70
80
90
100
2012 2013 2014 2015 2016
8 8 7 7 5
92 92 93 93 95
% NOT IMMUNE % IMMUNE
>1 IU = Non-immune < 1 IU = Immune

26. CAUSES OF VACCINE FAILURE
delayed
vaccination
non-use of
rabies
immuno-
globulin in
category III
exposure
incomplete
course of
vaccination
Immuno-
compromised
status
Unexplained
failure

27. Health Education
4
Animal Quarantine
3
Management
2
Reporting
1
Steps of Animal Bite
Surveillance process

28. Reporting to:
Concerned Preventive Health Center
Name and address of
the owner of the animal
Date, time and location
of the incident
Location on the body
and severity of the bite
General description of
the biting animal
Reporting

29. Reporting to:
Public Authority For Agriculture Affairs And Fish Resources
Quarantine
for 10 days
.
Any animal involved
in a bite or a scratch
Animal
available
If the animal
remains healthy, it
cannot have been
shedding the rabies
virus in its saliva at
the time of the bite
If animal
died
Animal
lost
Continue
shotsStop
shots

30. Recommended management
• None
Category
I
• Local Rx of wounds
• Anti rabies vaccine
Category
II
• Local Rx of wounds
• Anti rabies vaccine
• Rabies immunoglobulin
Category
III
• Licks on
unbroken skin
• Touching/
feeding
animals
Category
I
• Nibble, cuts,
scratches
without oozing of
blood
Category
II
• Licks on mucous
membrane or
broken skin
• Bites with breach
of skin, bleeding
Category
III

31. Lines of
management
Wound
management
Local
General
Immuno-
prophylaxis
Anti-rabies
vaccine
Rabies
Immunoglobulin
Health
Education

32. STAGE 5
5
STAGE 4
Wound not to be dressed or
bandaged
4
STAGE 3
Local administration of Anti-
rabies Immunoglobulin
3
STAGE 2
Apply pressure if wound
is actively bleeding
2
STAGE 1
Immediately wash the wound
with soap and water
1
WoundManagement
Suturing after 24-48hrs with
antiserum locally
Local
General
AntibioticsTetanus
toxoid Oral amoxicillin-clavulanic acid
= Augmentin for 5-7 days

33. Immuno-prophylaxis 2
3
Active
Immunization
Passive
Immunization
Human Diploid cell Anti-
rabies vaccine
Rabies Immunoglobulins
0
3
7
14
28
90
45
Blood
sample
Infiltrated around the wounds as much as possible and
any remaining volume should be administrated IM at an
anatomical site distant from vaccine administration

34. Should not
inject RIG
• Later than 7 days after the
initiation of post-exposure
vaccination.
• Previously immunized
as this may reduce the
immunologic response to the
vaccine.
Rabies immunoglobulin
• Passive antibody is present 24 hours
after injection
• Half-life is approximately 21 days.
• Dosage
– HRIG 20 IU/kg
admin as soon as possible at the same time
as vaccine, or up to 7 days after vaccine
inj.

35. Rabies Virus
Rabies virus is a neurotropic virus, has a cylindrical
morphology and is the type species of the
Lyssavirus genus of the Rhabdoviridae family
Clinical Types of Rabies
There are two clinical manifestations of rabies – frantic and
paralytic. Frantic rabies is most common form of human rabies
Rabies
Rabies is a disease transmitted from animals to
humans, which is caused by a virus
What is rabies?

36. Globally, rabies is the tenth leading cause of death
due to infection in humans.
Rabies is present on all continents with the exception of
Antartica, but more than 95% of human deaths occur
in Asia and Africa

37. Abrief overview on the disease is provided below:
Indian Population
Estimated deaths due torabies
Stray dog population
Estimated animal bites
Frequency of bite
: 1 billion plus
: 20,000annually
: 25 million
: 17.4 million.
: 1 bite per 2 seconds.
1 per 30 minutesFrequency of Humanrabies deaths :
approx.
The post-bite treatment costs the Indian economy
over $25 million a year *
*India’s ongoing war againstrabies.
Bull WHO2009; 87(12):885-964
National Journal of Community Medicine .
Volume4, Issue 1, Jan–Mar2013
India contributes to the highest number of
human deaths due to rabies in the world
Nearly 50% of total human deaths due to
rabies in the world is contributed by India

38. April 15, 2017
Individuals or professionals who slaughter
rabies infected animals and handle brain
and other infected material may be at risk
5
April 15, 2017
There are no evidence-based reports of
human rabies occurring due to
consumption of milk OR cooked meat.
4
April 15, 2017
Although rabies patients are extremely
unlikely to bite other people, caregivers
should be watchful and alert when looking
after them, and avoid contact with the
patient’s saliva
3
April 15, 2017
Human-to-human transmission of rabies
through corneal or other organ
transplantation is rare but possible.
2
April 15, 2017
from the rabid animal’s saliva when it
bites or scratches, Licks to wounds or
grazed and broken skin, or to the lining of
the mouth and nose,
1
of Rabies
Modes of transmission

39. After entering the human body, the
rabies virus progresses from
subcutaneous tissue, or from
muscle, into peripheral nerves.
The virus migrates along nerves to
the spinal cord and brain at an
estimated speed of 12–24 mm a
day.
The infected person exhibits
behavioral changes and clinical
signs when the virus reaches the
brain
The incubation period ranges from a
few days to several months, and
can be as long as 1 year.
Incubation Period

40. site of the bite – head and neck
wounds, and wounds in highly
innervated areas such as fingers,
generally have shorter incubation
periods due to the proximity of
the viral inoculation to nerve
tissue.
5
the immune status of the victim
4
the animal responsible for the
bite
3
the amount of rabies virus
introduced
2
type of exposure and severity of
the bite
1
of Rabies
factors that influence
development

41. excessive salivation or foaming at
the angles of the mouth – but not
hydrophobia.5
a change in sound e.g. hoarse
barking and growling or inability
to make a sound4
running for no apparent reason3
eating abnormal items such as
sticks, nails, faeces, etc.
2
biting without any provocation1
of Rabies in dogs
clinical features

42. SIGNS AND SYMPTOMS OF
RABIES IN HUMANS
pain or itching at the site of the bite wound
fever, malaise, headache lasting for 2–4
days
hydrophobia (fear of water)
intolerance to noise, bright light or air
fear of impending death
anger, irritability and depression
Hyperactivity
at a later stage the mere sight of water
may provoke spasms in the neck and
throat
the duration of illness is usually 2–3 days

43. - Globally: Estimated 3–6 million mammalian
bites/year
- Most animal bites are caused by dogs & cats
- There are more than 2000 animal bites in
Kuwait every year mostly due to dogs & cats
- To prevent rabies, animal bite can be managed
ASAP by vaccine, IG, antibiotic, TT and wound
management
- Globally, rabies is the tenth leading cause of
death due to infection in humans.
- Rabies is 100% fatal if not treated immediately