Revised Guidelines on the Management of Animal Bite Patients

Administrative Order No. 164 DOH , 2002

Management of Potential Rabies Exposure



Category 1
a. feeding/touching an animal b. licking of intact skin (w/ reliable history and thorough PE

Management > Wash exposed skin immediately w/ soap and water. > No vaccine or RIG needed

Category II
a. Nibbling of uncovered skin b. Minor scratches/abrasions without bleeding c. Licks on broken skin

Management:
 Start vaccine immediately  Condition of the animal: 1. Complete vaccination regimen until day 90 if: a. Animal is rabid, killed, died or unavailable for 14-day observation or examination b. If animal under observation died within 14 days and was FAT positive or no FAT testing was done or had signs of rabies

2. Complete vaccination regimen until day 30 if: a. if animal is alive and remains healthy after 14-day observation period b. if animal under observation died within 14 days , was FAT-negative and without any signs of rabies

Category III
a. b. c. d. Single or multiple transdermal bites or scratches Contamination of mucous memb. with saliva Exposure to a rabies patient Handling of infected carcass or ingestion of raw infected meat e. All Category II exposures on head & neck area

Management of Category III Exposures  Start vaccine and RIG immediately  Condition of the animal:
1. Complete vaccination regimen until day 90 if: a. Animal is rabid, killed, died or unavailable for 14-day observation or examination b. If animal under observation died w/in 14 days and was FAT-positive or no FAT testing was done or had signs of rabies 2. Complete vaccination regimen until day 30 if: a. Animal is alive and remains healthy after 14-day observation period b. If animal under observation died within 14 days and was FAT-negative & w/o any signs of rabies

Active Immunization
It induces an active immune response in 7-10 days 7after vaccination and may persist for 1 year or more Types of vaccines available in the Phil.:
a. Purified Verocell Rabies Vaccine (PVRV) .5ml/vial b. Purified Duck Embryo Vaccine (PDEV) 1 ml/ vial c. Purified Chick Embryo Cell Vaccine (PCECV) 1.0 ml / vial

Passive Immunization


Rabies Immune Globulin (RIG) is given together with anti-rabies vaccine to provide immediate antiprotection to patients with Category III exposure. RIG is of two types: 1. Human Rabies Immunoglobulin (HRIG) dose: 20 IU per kg. BW ( 150 IU/ml ) 2. Equine Rabies Immunoglobulin (ERIG) dose: 40 IU per kg. BW ( 200 IU/ml )

Passive Immunization
 

RIG should be given as single dose for all Category III exposures RIG should be infiltrated around and into the wound . Any remaining RIG should be administered IM at the site distant from the site of vaccine injection A skin test must be performed prior to ERIG administration. A positive skin test is based on an induration of 6 mm or more

Post-Exposure Treatment


Local Wound Treatment

> Wash & flush wounds with soap and water preferably for 10 minutes > Apply alcohol, tincture of iodine or any antiseptic > Suturing of wounds should be avoided > Anti-tetanus immunization and anti-microbial Antiantimaybe given if indicated

Treatment Regimen


2-Site Intradermal Schedule ( 2-2-2-0-1-1) 2One dose of ID administration is equivalent to 0.1 ml for PVRV & 0.2 ml for PDEV/PCECV One dose should be given at 2 sites on Days 0, 3, 7 and one site on Days 30 and 90 Injections should be given on the deltoid area of each upper arm in adults and on the anterolateral aspect of the thigh in infants The schedule should be strictly followed to avoid treatment failure

2-Site Intradermal Schedule 2- 2- 2- 0-1-1

Day of Immunization

Day 0 Day 3 Day 7 Day 14 Day 30 Day 90

PVRV PDEV/ Site of Injection PCECV 0.1 ml. 0.2 ml. Left & right deltoids 0.1 ml. 0.2 ml. 0.1 ml. 0.2 ml. None None 0.1 ml. 0.2 ml. 0.1 ml. 0.2 ml.
Left & right deltoids Left & right deltoids

None One deltoid One deltoid

Treatment Regimen


2 1 1 Intramuscular Schedule
One dose is equivalent to 1 vial of 0.5 ml of PVRV or 1 ml. of PDEV/PCECV Should be used in combination with RIG for Category III exposure 2 doses are given IM on day 0 and 1 dose on days 7 & 21 If the dog is alive & healthy after the 14-day observation period, discontinue the last dose

2-1-1 Intramuscular schedule

Day of PVRV Immunization

Day 0 Day 7 Day 21

PDEV/ Site of Injection PCECV Left and Right 0.5 ml. 1 ml.
deltoids

0.5 ml. 1 ml. 0.5 ml 1 ml.

One deltoid One deltoid

Standard Intramuscular Schedule

Day of Immunization PVRV PDEV/ PCECV

Site of Injection One deltoid One deltoid One deltoid One deltoid One deltoid

Day 0 Day 3 Day 7 Day 14 Day 28

0.5 ml. 0.5 ml. 0.5 ml. 0.5 ml. 0.5 ml.

1 ml. 1 ml. 1 ml. 1 ml. 1 ml.

8-Site Intradermal Schedule

Day of PCECV No. of Immunization doses Site of Injection Deltoid (2), anterolateral thigh (2), lower quadrant of abdomen (2), suprascapular region (2) Deltoid (2), anterolateral thigh (2) Deltoid (1) Deltoid (1)

Day 0

0.1 ml.

Day 7 Day 30 Day 90

0.1 ml. 0.1 ml. 0.1 ml.

4 1 1

Post-Exposure Treatment under Special Conditions

  

Pregnancy & infancy are not contraindications to treatment with purified cell culture vaccines Avoid Chloroquine , anti-epileptic drugs, systemic steroids antiand heavy alcohol consumption Immuno compromised individuals should be given vaccine using standard IM regimen and RIG for both Category II and III exposures Bites by rodents, rabbits and domestic animals other than dogs & cats do not require post-exposure treatment unless postthe animal is proven rabid Patients bitten by wild animals should be managed similarly as patients bitten by dogs and cats

Post-Exposure Treatment of Previously Immunized Animal Bite Patients

Local wound treatment should always be done Persons with a second exposure after having previously received complete pre-exposure preprophylaxis & PET with tissue culture vaccine: a) < than 1 month : no booster dose b) > 1 month 3 years : 2 booster doses (D0,D3) c) > than 3 years : another full course of vaccine Booster doses maybe given ID at 0.1 ml. for PVRV or 0.2 ml for PDEV/PCECV or IM at 1 vial of PVRV, PDEV or PCECV. No need to give RIG

Pre-Exposure Prophylaxis
Recommended to individuals at high risk of exposure to rabies Initial Pre-exposure prophylaxis consist of Pregiving 1 dose of vaccine on Days 0, 7 and 21 or 28 One booster dose should be given every 2-3 2years depending on the risk of work-related workexposure

Pre-Exposure Prophylaxis
Schedule

PVRV
D0 D7 D 21/28

PDEV/PCEC
D0 D7 D 21/28

IntraIntradermal

0.1 ml

0.1 ml 0.5 ml

0.1 ml 0.5 ml

0.1 ml 1.0 ml

0.1 0.1 ml ml 1.0 1.0 ml ml

IntraIntra0.5 muscular ml

Dispensing of Human Anti-Rabies Immunizing agents



 

Patients needing Post-exposure treatment shall be referred Postto the Animal Bite Treatment Centers where free human antianti-rabies immunizing agents are administered In Category II and III exposures, the patient shall be provided the initial 2 doses of tissue culture vaccine for the 2-1-1 schedule If intradermal regimen is used , complete course of immunization is given free If indicated, the patient shall be provided the required dose of RIG, if available. EIG is the first RIG of choice

Provisions of Free Anti-Rabies Immunizing Agents

The following shall be the programs order of priority for free vaccine assistance: 1. Patients bitten by animals found positive for negri bodies 2. Patients with Category III exposure 3. Individuals exposed to human rabies patients thru bite/non-bite exposure 4. Patients bitten by animals that are not available for observation ( stray or slaughtered) 5. Patients with Category II exposure

Rabies Surveillance System (RSS)

Entails systematic collection of pertinent data on Rabies, collation, interpretation and dissemination of information to appropriate user groups Goal : To obtain a comprehensive view of the epidemiologic situation of rabies in the community so that appropriate preventive measures maybe instituted All govt. & private hospitals, clinics & health centers shall be directed to notify govt. health officers or rabies field coordinators of any human rabies case

Specific Uses of RSS

To assess the magnitude & geographical distribution of rabies To monitor the trends of rabies in the community To evaluate the impact of instituted intervention To furnish public information of the risk of rabies exposure in an area To provide indicators for decision on future health care needs

Constraints
1.

2.

Local ordinances that enforce compulsory dog immunization and RPO are either not enacted or weakly enforced by the LGUs The Rabies control program has not been integrated among the regular health services provided by local health facilities