Dr Bikash dot Com

I have just now completed my 3 day posting in Anti Rabies Vaccination Clinic (ARVC)as an intern. This
clinic in our hospital comes under the administration of Department of Community Medicine in which I am
posted for 3 months from 24th October 2008 to 23rd January 2009. ARVC posting is one of the 3 clinics that I have to attend before I go for my PHC and CHC posting in Salipur. The other two are Urban Heal and Traing Center (UHTC) in Jobra and Immunisation clinic Hospital itself. So from 29th October to 31st October I was posted in ARVC. It was a worth while experience.

Bite of any rabid animal is fatal. So it is of paramount importance that any mammal bite should be taken seriously. In India we have plenty of unimmunised dogs and cattles that roam around freely in streets. So it is quite natural that there are plenty of dog bite cases to treat. The rule of thumb that is considered to assess if the dog is rabid or not is to ask the victim if it was an unprovoked or provoked bite. If it is an unprovoked bite then it might have been a rabid one.

So the questionnaire is as follows:

1. What has bitten – mammal or not.
2. Provoked or unprovoked bite – unprovoked might be rabid one.
3. Pet or Stray animal. rabid animal dies within 10 days for sure, so in case of pet animal one can assess.
4. If any local medications has been applied like ointments, lotions etc.

After this assessment of severity of the bite is considered.
WHO categorization for treatment of animal bite is as follows:
Category I: Superficial licking on unbroken skin – No treatment required.
Category II: Wound is deeper but limited to dermis only i.e not deep enough to cause bleeding – Give Anti Rabies Vaccine only.
Category III: There has been bleeding from wound site or there has been a bite i.e teeth mark – Give Anti
Rabies Vaccine and Immunoglobulin both.

Updated Thai Red Cross Regimen is followed for Anti Rabies Vaccination.
The schedule is Intra Dermal vaccination on day 0,3,7,28.
The intra dermal vaccine is given 0.1 ml in each upper arm making the dose on each day 0.2ml.  The vaccine comes as a freeze dried powder form which is reconstituted by 0.5 ml of Normal saline solution. So one vial can be given to 2 and half individuals. This makes vaccination at large centers like ours an ideal option. In our Hospital we vaccinate around 100 patients with Anti Rabies Vaccines every day, 7 days a week, throughout the year.

Preliminary treatment:
Wound care: wash the wound site with soap under running tap water.
Take a Tetnus Toxoid if previously unimmunised.
Intra dermal vaccination on scheduled days i.e on the day of the bite, 3 days after, 7 days and 28 days after on both arms.
If Category III wound then take Immunoglobulins as soon as possible.
2 types of Immunoglobulins are available Horse derived and genetic engineered. Difference is higher cost of human immunoglobulin. advantage is less allergic reactions. Under cover of antihistaminics Horse serum derived immunoglobulis have worked very well in all parts of the world.

Immunoglobulin is given half at the wound site and half else where intramuscularly.
Dose is
Equine immunoglobulin 40 IU/Kg body weight
Human immunoglobulin 20 IU/Kg body weight

If the dog bite has been multiple then Normal saline upto 2/3rd volume of immunoglobulin can be added to dilute it.

Rabies has NO treatment. So take care.
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