Pediatrics dog bite

1. DOG BITE MANAGEMENT
Dr. RINU V

2. RABIES
• Rabies is an acute viral disease caused by
Lyssavirus that causes fatal encephalomyelitis in all
warm blooded animals including man.
• Transmission- to humans largely by dogs and cats
(>97%). Wild animals (2%) such as mongoose,
foxes, jackals, wild dogs, wild rodents, and
occasionally by monkeys, horses, donkeys, and
others. Domestic rats, rabbits, and birds are
ordinarily not known to transmit rabies.
• Globally, an estimated 59,000 human rabies deaths
occur every year. In December 2015, the World
Health Organization has set a goal of “Elimination
of dog-mediated human rabies by 2030”.

3. PATHOGENESIS
• Rabies virus is neurotropic- Enters the peripheral
nerves or cranial nerves from the damaged nerve
endings from the site of bite; ascend up through
dorsal route ganglion, spinal cord, and finally reaches
brain where it multiply enormously.
• The rabies virus subsequently descends down to all
secretory glands, salivary glands, mammary glands,
sweat glands, and urine via sympathetic nervous
system.
• All secretions of rabid patients are infectious, But no
human-to-human transmission
• Rabies virus cannot be detected in blood –No viremia
• Average incubation period of 30–90 days

4. There are two forms of rabies in man
1. Classic hydrophobia: Hydrophobia, aerophobia, and
photophobia—clinical course about 1 week to 10 days. More
remarkable abnormalities (agitation, photophobia, priapism,
increased libido, insomnia, nightmares, and depression) may
also occur, suggesting encephalitis, psychiatric disturbances, or
brain conditions.
2. Paralytic rabies: Ascending paralysis—clinical course about 3
weeks; death invariably occurs due to cardiorespiratory failure.
CLINICAL FEATURES

5. • Rabies is a vaccine preventable disease
• In a rabies endemic country like India, where there is sustained dog-to-dog
transmission, every animal bite is suspected as a potentially rabid animal bite, and
treatment should be started immediately after exposure.
Post-Exposure Prophylaxis (PEP) needs to be considered in the following conditions:
Bites by all warm-blooded animals.
Exposure to wild animals: should be treated as Category III exposure.
Rodent Bites: Exposure to domestic rodents, hare and rabbits do not ordinarily
require PEP. However, rodent bites in forest areas necessitate institution of PEP.
Exposure to bats: Bat rabies has not been conclusively proven in India and hence, at
present, exposure to bats does not warrant PEP.
Human-to-human transmission: The risk of human-to-human transmission is minimal
and there are no well-documented cases, other than the few cases resulting from
infected organ/tissue (cornea) transplant
MANAGEMENT

6. VACCINATION STATUS OF BITING ANIMAL
• Irrespective of the vaccination status of the biting animal, the PEP
should be given.
• In the absence of laboratory documentation of immunization
(antibody titre), it cannot be presumed that a vaccinated dog is
actually protected, given the variable efficacy of various anti-rabies
vaccines in animals

7. Type Of Contact, Exposure And Recommended Post-exposure Prophylaxis Category
Category
of
Exposure
Type of Exposure Recommended
Post-Exposure
Prophylaxis
I Touching or feeding of animals
Licks on intact skin
Contact of intact skin with secretions/
excretions of rabid animal/human case
*None, if reliable case
history is available
*Wash Exposed area
with Water & Soap
and apply Antiseptic
II Nibbling of uncovered skin
Minor scratches or abrasions
without bleeding
* Wound management
* Rabies vaccine
III Single or multiple transdermal
bites or scratches
Licks on broken skin
Contamination of mucous
membrane with saliva (i.e. licks)
*Wound Management
*Rabies lmmunoglobulin
*Rabies Vaccine

9. APPROACH TO POST-EXPOSURE PROPHYLAXIS (PEP)
Principles Of Treatment
1. Management of animal bite wound(s)
2. Passive immunization with Rabies Immunoglobulin (RIG)/
Monoclonal antibody(RMabs)
3. Active immunization with Anti-Rabies Vaccines

10. 1. MANAGEMENT OF ANIMAL BITE WOUNDS
• Physical - Wash all wounds with running water - Mechanical removal of
virus from the wound
• Chemical - Wash all wounds with soap and water, apply antiseptic
(povidone iodine, alcohol )- Inactivation of the virus
• Biological - Infiltrate immunoglobulin into the depth Neutralization of and
around the wound(s) in Category III the virus exposures - Neutralization of
virus.
* Antimicrobials and tetanus toxoid should be given if indicated.
* Proper wound care will reduce the viral load by at least 50%.

12. Suturing Of Wounds
• In case suturing can not be avoided, clean the wound and the
wound(s) should first be thoroughly infiltrated with ERIG or HRIG.
• The suturing should be delayed for several hours to allow diffusion of
the RIG through the tissues before minimal suturing are done

13. 2. ADMINISTRATION OF RIGS/RMABS (PASSIVE IMMUNIZATION)
• For individuals with category III (severe) exposures
• Also indicated in category II in immunocompromised patients.
• Vaccine induced antibodies appear only after 7–14 days.
• During this window period of 7–14 days, patient is unprotected, hence,
RIG/RMAbs need to be administered.
• Administered only once, as soon as possible after the animal bite and not
beyond day 7 after the first dose of vaccine

15. There are two classes of rabies passive immunizing agents:
1) Equine rabies immunoglobulin (ERIG): Dosage—40 IU/kg
-It is indigenously manufactured
-To be used only after skin sensitivity test
* As per latest WHO recommendation, skin testing prior to ERIG administration is not recommended as former
does not accurately predict anaphylaxis risk and ERIG should be given irrespective of the test result.
2) Human rabies immunoglobulin (HRIG): Dosage—20 IU/kg
-Imported and expensive
-No skin sensitivity test required
-It is available in prefilled syringe.

16. Rabies Monoclonal Antibody (RMABs)
1) Human RMAb (single MAB—RabishieldTM):
-Dosage—3.33 IU/kg body weight.
-Potency: 40 IU/mL
2) Cocktail of RMAbs (Docaravimab and Miromavimab-TwinrabTM):
-Dosage—40 IU/kg body weight.
-Potency: 600 IU/mL
* No skin sensitivity test required before administration of RMABs.

17. • As much of the calculated dose RIG/RMAb, a should be infiltrated
into and around all the wounds. The RIG/RMAb shall be injected
into the edges and base of the wound(s) till traces of RIG/RMAb
oozes out.
• The remainder of the calculated dose of RIG does not need to be
injected IM at a distance from the wound :but can be fractionated
in smaller, individual syringes to be used for other patients
following aseptic precautions.
• For multiple bites, the calculated dose of RIG/RMAb may not be
sufficient- Dilute the RIG/RMAb in sterile normal saline to a volume
sufficient to inject all wounds.

18. 3. ADMINISTRATION OF ANTI-RABIES VACCINE
Currently available rabies vaccine in India are;
• 1. Purified chick embryo cell vaccine (PCECV)
• 2. Purified Vero cell rabies vaccine (PVRV)
• 3. Human diploid cell vaccine (HDCV)
• 5. Purified duck embryo vaccine (PDEV)

19. Rabies vaccine can be administered by intradermal or intramuscular
route
INTRA-DERMAL (ID)ROUTE
• National Rabies Control Program advocates use of intradermal route
of Rabies vaccine. The use of the ID route leads to considerable saving
in the total amount & reducing the cost of active immunization.
• Intradermal administration is not the preferred route of Rabies
vaccine administration for immune-compromised individuals or
individuals receiving Chloroquine, Hydroxychloroquine or long-term
corticosteroid or other immunosuppressive therapy.

20. Regimen for post exposure prophylaxis - Updated Thai Red Cross Schedule
(2-2-2-0-2)
• 8 Doses - 4 Visits
Days 0, 3, 7, and 28 - 2 x 0.1 mL doses
• Day 0 is the date of administration of the first dose of Rabies
Vaccine.

22. Intramuscular Regimen for Post exposure Prophylaxis –
Essen regimen (1-1-1-1-1):
• Five dose intramuscular schedule- 1 ml for HDCV, PCEC, PDEC
0.5 ML for PVRV
• The course for post-exposure prophylaxis consists of intramuscular
administration of five injections, one dose each given on days 0, 3, 7,
14 and 28.
• Day 0 indicates the date of administration of the first dose of vaccine.

23. • In 2022, WHO published a new guide for the rabies vaccination
• 1-week vaccination schedule on days 0, 3 and 7.
• On each visit, the rabies vaccine is administered through 2-site
intradermal (ID) injections of 0.1 ml of vaccine each, preferably using an
insulin syringe
• This shortened ID regimen is as efficacious as other established
regimens since the antigen-presenting cells in the skin are more
effective than the same cells in the muscle, thus being able to trigger a
high-immune response

24. Site Of Injection
• The deltoid region is ideal for the administration of these vaccines.
• Gluteal region is not recommended because fat present in this region
retards the absorption of antigen and impairs the generation of an optimal
immune response.
• In case of infants and young children, anterolateral part of the thigh is the
preferred site.
• Switching the route of administration from IM to ID or vice versa and
switch over from one type of modern Rabies Vaccines to the other during
PEP is not recommended

25. CONTRAINDICATIONS AND PRECAUTIONS:
• As rabies is a nearly 100% fatal disease, there is no contraindication to
PEP.
• Pregnancy, lactation, infancy, old age and concurrent illness are not
the contra-indications.
• Rabies vaccine does not have any adverse effect on pregnant woman,
course of pregnancy, foetus or lactating mother.

26. • Only two doses of vaccines on days 0 and 3 either by IM/ID.
• No RIG/RMAbs is indicated
-1 site IM vaccine administration on days 0 and 3 or
-1 site ID vaccine (0.1 mL) administration on days 0 and 3
* If repeat exposure occurs within 3 months of completion of PEP, only
wound treatment is required, neither vaccine nor RIG are needed
Re Exposure prophylaxis

27. Pre Exposure Prophylaxis
Pre-exposure vaccination may be offered to High-Risk Groups which
includes:
1. Laboratory staff handling the virus and infected material, clinicians and individuals
attending to human rabies cases.
2. Veterinarians, animal handlers and dog catchers.
3. Wildlife wardens, quarantine officers etc.
4. Travelers from rabies-free areas to rabies endemic areas.
• The Indian Association of Pediatrics (IAP) has recommended pre-exposure
prophylaxis of children. This maybe considered on a voluntary basis.

28. SCHEDULE OF VACCINATION
• Total three doses are recommended for pre-exposure prophylaxis.
• In case of IM route, 1 full vial to be given on days 0, 7 and booster on
either day 21 or 28.
• In case of ID route, 0.1 ml on one site to be given on days 0, 7 and
booster on either day 21 or 28.

29. PROTOCOL FOR RABIES POST EXPOSURE PROPHYLAXIS

31. THANK YOU