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Dog – bite; Frequently Asked Questions (India, 2019)

Q. What should one do immediately after a dog bite?
1. Immediately wash all the wounds with lots of water and soap. Ensure thorough flushing and that all the wounds are washed.
• Washing with soap and water should be started as soon as possible and continued for 15 minutes.
• Such thorough washing will remove a major amount of virus from the wound.
2. Application of antiseptics: Povidone Iodine or any antiseptic with virucidal activity.
• After thorough washing and drying the wound, apply any virucidal agent like Povidone Iodine, alcohol etc.
If soap and/or antiseptic is not available, wash at least with lots of water.
Maximum advantage of washing is gained if it is done immediately after the bite.
• Even if the bite victim informs late, the wound management must still be performed.
• This is because the virus can persist and even multiply at the site of the bite for a long time.
3. Take the victim to nearest clinic where the following can be done:
• RIG (readymade antibodies against rabies) infiltration if required
• Tetanus prophylaxis
• Antibiotic prophylaxis for preventing wound sepsis
• Start the vaccination course against rabies
Washing dog bite wound and applying iodine
Q. Is there any use of: Rubbing chillies, Applying salt, lemon, lime (choona) or mustard oil to the bite wound?
There is NO advantage. On the contrary it poses following dangers:
1. These substances cause local irritation and increase the chances of getting rabies (facilitates virus entry into local nerves and then into the brain).
2. Such application may provide a false feeling of security. This may lead to neglecting the vaccination and is dangerous

Q. I was bitten by a dog 4 months back. The dog is still alive and healthy. Do I still need to get vaccinated?
If the biting dog or cat is healthy after 10 days of observation, vaccination may not be necessary. However, remember that the 10 day observation period is valid strictly for cats and dogs only and no other animal.

Q. I was bitten by a dog 4 months back. The status of the dog is not known. Do I still need to get vaccinated?
The vaccination should be started as soon as the case is reported; irrespective of the time elapsed, if the biting animal status is not known.
Even if the bite victim presents months or years after a bite, it should be evaluated as a recent bite.
This is recommended because of extremely long and variable incubation period of rabies in humans.

Q. The bite is by a young puppy (2 months old). Still do I need the vaccine?
Yes. Vaccination in needed regardless of the age of the biting pup.

Q. A bat bit me. Do I need the vaccine?
Though no case of bat rabies has been reported in India, some bats have been found have anti-rabies antibodies in their blood in the North East. Hence the treating physician needs to evaluate the need.

Q. I am scared of injections. Can I just observe the animal for 10 days and then decide if I should go for vaccination?
NO. Anti-rabies vaccination must be started as soon as possible. If the animal remains healthy after 10 days, one may discontinue/ modify further doses.
Further, the 10 day period is valid ONLY for dogs and cats and not for wild animals.

Q. Can any vaccine provide lifelong immunity against rabies?
NO. Rabies vaccination is needed every time there is a danger of virus exposure. Nevertheless, fewer doses may suffice in case of future bites. Also the need for Rabies Immunoglobulin (RIG) may be eliminated if a previous complete course of vaccination can be documented.

Q. Can one get rabies from bite of a vaccinated dog?
The anti-rabies vaccines in animals may not always provide reliable protection. The dog can be considered protected ONLY if confirmed by a lab report.
Therefore, dog bite victim SHOULD be given the vaccine, irrespective of the vaccination status of the dog.

Q. Are there any dietary instructions for someone receiving anti rabies vaccine?
There are NO dietary restrictions before, during or after vaccination. Nevertheless, alcohol intake should be discouraged.

Q. Should one get the blood tested for the antibody levels after all the doses of vaccine?
Ordinarily, it’s not needed under normal circumstances. There may be a need for this when there is a doubt of low levels of immunity OR if the proper schedule has not been followed

Q. Is there a chance of getting rabies even after complete vaccination?
Extremely few cases have been seen. Following factors may have been the reason:
• Not taken all the doses
• Delayed vaccination
• Vaccine not administered properly
• Not given immunoglobulin in severe bite (category III)
• Immuno-compromised status: HIV/AIDS, steroid use, anti-cancer medication, liver cirrhosis etc.
• Use of chloroquine has been seen to affect the response to vaccine, especially the intradermal doses. If using chloroquine, ensure that ONLY INTRAMUSCULAR schedule is followed.
Very rarely vaccine failure has been reported even if every step was carried out methodically (unexplained failure).

Q. I took full course of vaccine 2 months back. Today another dog bit me. Do I need the vaccine again?
If a documented proof of complete rabies vaccination within LAST 3 MONTHS is provided, all that is needed is adequate washing of the wound as described earlier. Any of the three regimens viz. intradermal, intramuscular or Pre-exposure prophylaxis schedule is protective if completed within last 3 months.
However, if the vaccination was completed more than 3 months earlier, then the following is the recommended course:
Wound management: washing, antiseptic application, no immediate suturing
RIG (readymade antibodies against rabies) is NOT needed
2 doses of rabies vaccine: one – site ID or IM route; on day-0 and day-3
Note: If the former course was with older neural tissue vaccine (NTV) or any unapproved vaccine or if the record is not available; the patient should be evaluated as a new case and a full course should be given.

Q. Who should receive intra-muscular vaccine and not ID (intra-dermal)?
1. Immuno-compromised individuals
2. Individuals receiving:
a. chloroquine/hydroxyl-chloroquine
b. Long term corticosteroids
c. other immune-suppressive therapy

Q. I have taken first 3 doses and the dog is alive and healthy 10 days after bite. Should I discontinue the vaccination?
Once one of the 3 regimens is completed, some immune response persists for decades. This implies that in case of bites in future, only 2 single-site doses would suffice. Therefore:
1. If using ID schedule, one should complete the schedule
2. If using IM regimen, the day 14 dose can be missed, but do get the day 28 dose. This will convert the IM schedule to that of a Pre-exposure one.

Q. Is vaccine safe for pregnant woman?
Rabies is a life threatening disease. Hence pregnancy cannot be a contraindication for vaccination. Moreover, no major adverse effects have been reported in pregnant women.

Q. Can one get rabies from eating the meat of a rabid animal?
Though no case has been reported of such transmission, there is still a possibility. Complete Anti-rabies vaccine schedule should be given in this case.

Q. Is anti-rabies vaccine needed in case of rat bite?
Domestic rats are not known to transmit rabies. Such rat bites do not need the vaccine, but the wound should be thoroughly washed as one would do after a dog bite.
If one is not very sure of the species of the biting animal, it is safer to take the vaccine.

Q. Can the vaccine cause rabies?
NO. Vaccines are made from killed virus and cannot cause rabies. They are safe and effective.

Q. If one dose of vaccination is missed, should the entire course be restarted?
NO. The remaining doses should be given as per the latest recommended schedule.

Q. A cat bit me one year back and I took only 2 doses on days 0 and 3 only. Now a dog has bit me? Do I need the entire course again?
You still need the vaccine but only two doses will suffice.

Reference:
1. Government of India, National rabies control programme, National guidelines on rabies prophylaxis, National Centre for Disease Control, 2019, Delhi, India.

2. Government of Himachal Pradesh: GUIDELINES FOR RABIES PROPHYLAXIS AND INTRADERMAL RABIES VACCINATION IN HIMACHAL PRADESH, 2019. Directorate of Health Service, Swasthya Sadan, Kasumpti, Shimla-171009

Post-Exposure Prophylaxis (PEP): http://www.ihatepsm.com/blog/post-%E2%80%93-exposure-prophylaxis-rabies
Rabies Vaccine: http://www.ihatepsm.com/blog/rabies-vaccine