revised guidelines on the management of animal bite

Revised Guidelines on the Management of Animal Bite

Patients

Administrative Order No. 164Administrative Order No. 164

DOH , 2002DOH , 2002

Management of Potential Rabies Exposure

Category 1Category 1 a. feeding/touching a. feeding/touching

an animalan animal

b. licking of intact b. licking of intact

skin (w/ reliableskin (w/ reliable

history andhistory and

thorough PEthorough PE

ManagementManagement

> Wash exposed skin> Wash exposed skin

immediately w/ soapimmediately w/ soap

and water.and water.

> No vaccine or RIG > No vaccine or RIG

neededneeded

Category II

a. Nibbling of uncovered skinb. Minor scratches/abrasions without bleedingc. 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. Single or multiple transdermal bites or scratches

b. Contamination of mucous memb. with salivac. Exposure to a rabies patientd. Handling of infected carcass or ingestion of raw infected meate. 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 It induces an active immune response in 7-10 days after vaccination and may persist for 1 year or after vaccination and may persist for 1 year or moremore

Types of vaccines available in the Phil.:Types of vaccines available in the Phil.: a. Purified Verocell Rabies Vaccine (PVRV) .5ml/viala. Purified Verocell Rabies Vaccine (PVRV) .5ml/vial

b. Purified Duck Embryo Vaccine (PDEV) 1 ml/ vialb. Purified Duck Embryo Vaccine (PDEV) 1 ml/ vial c. Purified Chick Embryo Cell Vaccine (PCECV) c. Purified Chick Embryo Cell Vaccine (PCECV)

1.0 ml / vial1.0 ml / vial

Passive Immunization

Rabies Immune Globulin (RIG) is given together Rabies Immune Globulin (RIG) is given together with anti-rabies vaccine to provide immediate with anti-rabies vaccine to provide immediate protection to patients with Category III exposure.protection to patients with Category III exposure.

RIG is of two types:RIG is of two types:

1. Human Rabies Immunoglobulin (HRIG) 1. Human Rabies Immunoglobulin (HRIG)

dose: 20 IU per kg. BW ( 150 IU/ml )dose: 20 IU per kg. BW ( 150 IU/ml )

2. Equine Rabies Immunoglobulin (ERIG)2. Equine Rabies Immunoglobulin (ERIG)

dose: 40 IU per kg. BW ( 200 IU/ml )dose: 40 IU per kg. BW ( 200 IU/ml )

Passive Immunization RIG should be given as single dose for all RIG should be given as single dose for all

Category III exposuresCategory III exposures RIG should be infiltrated around and into the RIG should be infiltrated around and into the

wound . Any remaining RIG should be wound . Any remaining RIG should be administered IM at the site distant from the site of administered IM at the site distant from the site of vaccine injectionvaccine injection

A skin test must be performed prior to ERIG A skin test must be performed prior to ERIG administration. A positive skin test is based on an administration. A positive skin test is based on an induration of 6 mm or more induration of 6 mm or more

Post-Exposure Treatment

Local Wound TreatmentLocal Wound Treatment > Wash & flush wounds with soap and water > Wash & flush wounds with soap and water preferably for 10 minutespreferably for 10 minutes > Apply alcohol, tincture of iodine or any > Apply alcohol, tincture of iodine or any antisepticantiseptic > Suturing of wounds should be avoided> Suturing of wounds should be avoided > Anti-tetanus immunization and anti-microbial > Anti-tetanus immunization and anti-microbial maybe given if indicated maybe given if indicated

Treatment Regimen 2-Site Intradermal Schedule ( 2-2-2-0-1-1)2-Site Intradermal Schedule ( 2-2-2-0-1-1)

One 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 90Injections should be given on the deltoid area of each upper arm in adults and on the anterolateral aspect of the thigh in infantsThe schedule should be strictly followed to avoid treatment failure

2-Site Intradermal Schedule 2- 2- 2- 0-1-1Day ofDay of

ImmunizationImmunization PVRVPVRV PDEV/PDEV/

PCECVPCECV

Site of InjectionSite of Injection

Day 0 Day 0

0.1 ml.0.1 ml. 0.2 ml.0.2 ml. Left & right deltoidsLeft & right deltoids

Day 3Day 3 0.1 ml.0.1 ml. 0.2 ml.0.2 ml. Left & right deltoidsLeft & right deltoids

Day 7Day 7 0.1 ml.0.1 ml. 0.2 ml.0.2 ml. Left & right deltoidsLeft & right deltoids

Day 14 Day 14 NoneNone NoneNone NoneNone

Day 30Day 30 0.1 ml.0.1 ml. 0.2 ml.0.2 ml. One deltoidOne deltoid

Day 90 Day 90 0.1 ml.0.1 ml. 0.2 ml.0.2 ml. One deltoidOne deltoid

Treatment Regimen

2 –1 –1 Intramuscular Schedule2 –1 –1 Intramuscular ScheduleOne dose is equivalent to 1 vial of 0.5 ml of PVRV or 1 ml. of PDEV/PCECVShould 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 Day of ImmunizationImmunization

PVRVPVRV PDEV/PDEV/

PCECVPCECV


Day 0Day 0 0.5 ml.0.5 ml. 1 ml.1 ml. Left and Right Left and Right deltoidsdeltoids

Day 7Day 7 0.5 ml.0.5 ml. 1 ml.1 ml. One deltoidOne deltoid

Day 21Day 21 0.5 ml0.5 ml 1 ml. 1 ml. One deltoidOne deltoid

Standard Intramuscular Schedule


PVRVPVRV PDEV/ PDEV/ PCECVPCECV



Day 3 Day 3 0.5 ml.0.5 ml. 1 ml.1 ml. One deltoidOne deltoid




8-Site Intradermal Schedule


PCECVPCECV No. of No. of doses doses


Day 0Day 0 0.1 ml.0.1 ml. 88 Deltoid (2), anterolateral Deltoid (2), anterolateral thigh (2), lower quadrant of thigh (2), lower quadrant of abdomen (2), suprascapularabdomen (2), suprascapular

region (2)region (2)

Day 7Day 7 0.1 ml.0.1 ml. 44 Deltoid (2), anterolateral Deltoid (2), anterolateral thigh (2)thigh (2)

Day 30Day 30 0.1 ml.0.1 ml. 11 Deltoid (1)Deltoid (1)

Day 90Day 90 0.1 ml.0.1 ml. 11 Deltoid (1)Deltoid (1)

Post-Exposure Treatment under Special Conditions Pregnancy & infancy are not contraindications to treatment Pregnancy & infancy are not contraindications to treatment

with purified cell culture vaccineswith purified cell culture vaccines Avoid Chloroquine , anti-epileptic drugs, systemic steroids Avoid Chloroquine , anti-epileptic drugs, systemic steroids

and heavy alcohol consumptionand heavy alcohol consumption Immuno compromised individuals should be given vaccine Immuno compromised individuals should be given vaccine

using standard IM regimen and RIG for both Category II using standard IM regimen and RIG for both Category II and III exposuresand III exposures

Bites by rodents, rabbits and domestic animals other than Bites by rodents, rabbits and domestic animals other than dogs & cats do not require post-exposure treatment unless dogs & cats do not require post-exposure treatment unless the animal is proven rabidthe animal is proven rabid

Patients bitten by wild animals should be managed similarly Patients bitten by wild animals should be managed similarly as patients bitten by dogs and cats as patients bitten by dogs and cats

Post-Exposure Treatment of Previously Immunized Animal Bite Patients

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

Pre-Exposure Prophylaxis

Recommended to individuals at high risk of Recommended to individuals at high risk of exposure to rabies exposure to rabies Initial Pre-exposure prophylaxis consist of Initial Pre-exposure prophylaxis consist of giving 1 dose of vaccine on Days 0, 7 and giving 1 dose of vaccine on Days 0, 7 and 21 or 2821 or 28One booster dose should be given every 2-3 One booster dose should be given every 2-3 years depending on the risk of work-related years depending on the risk of work-related exposureexposure

Pre-Exposure Prophylaxis

ScheduleSchedule PVRVPVRV PDEV/PCECPDEV/PCEC

D0D0 D7D7 D D 21/2821/28

D0D0 D7D7 D D 21/2821/28

Intra-Intra-dermaldermal

0.1 0.1 ml ml

0.1 0.1 mlml

0.1 0.1 mlml

0.1 0.1 mlml

0.1 0.1 mlml

0.1 0.1 mlml

Intra-Intra-

muscularmuscular

0.5 0.5 mlml

0.5 0.5 mlml

0.5 0.5 mlml

1.0 1.0 mlml

1.0 1.0 mlml

1.0 1.0 mlml

Dispensing of Human Anti-Rabies Immunizing agents

Patients needing Post-exposure treatment shall be referred Patients needing Post-exposure treatment shall be referred to the Animal Bite Treatment Centers where free human to the Animal Bite Treatment Centers where free human anti-rabies immunizing agents are administeredanti-rabies immunizing agents are administered

In Category II and III exposures, the patient shall be In Category II and III exposures, the patient shall be provided the initial 2 doses of tissue culture vaccine for the provided the initial 2 doses of tissue culture vaccine for the 2-1-1 schedule2-1-1 schedule

If intradermal regimen is used , complete course of If intradermal regimen is used , complete course of immunization is given freeimmunization is given free

If indicated, the patient shall be provided the required dose If indicated, the patient shall be provided the required dose of RIG, if available. EIG is the first RIG of choiceof RIG, if available. EIG is the first RIG of choice

Provisions of Free Anti-Rabies Immunizing Agents

The following shall be the program’s order of The following shall be the program’s order of priority for free vaccine assistance:priority for free vaccine assistance:

1. Patients bitten by animals found positive for “negri bodies” 2. Patients with Category III exposure3. Individuals exposed to human rabies patients thru bite/non-bite exposure4. 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, Entails systematic collection of pertinent data on Rabies, collation, interpretation and dissemination of information collation, interpretation and dissemination of information to appropriate user groups to appropriate user groups

Goal : To obtain a comprehensive view of the Goal : To obtain a comprehensive view of the epidemiologic situation of rabies in the community so that epidemiologic situation of rabies in the community so that appropriate preventive measures maybe institutedappropriate preventive measures maybe instituted

All gov’t. & private hospitals, clinics & health centers All gov’t. & private hospitals, clinics & health centers shall be directed to notify gov’t. health officers or rabies shall be directed to notify gov’t. health officers or rabies field coordinators of any human rabies casefield coordinators of any human rabies case

Specific Uses of RSS

To assess the magnitude & geographical To assess the magnitude & geographical distribution of rabiesdistribution of rabies

To monitor the trends of rabies in the communityTo monitor the trends of rabies in the community

To evaluate the impact of instituted interventionTo evaluate the impact of instituted intervention

To furnish public information of the risk of rabies To furnish public information of the risk of rabies exposure in an area exposure in an area

To provide indicators for decision on future health To provide indicators for decision on future health care needscare needs

Constraints

1.1. Local ordinances that enforce compulsory Local ordinances that enforce compulsory dog immunization and RPO are either not dog immunization and RPO are either not enacted or weakly enforced by the LGUs enacted or weakly enforced by the LGUs

2.2. The Rabies control program has not been The Rabies control program has not been integrated among the regular health integrated among the regular health services provided by local health facilitiesservices provided by local health facilities

revised guidelines on the management of animal bite

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