DOG BITE management in pediatrics # for Pediatric pgs# topic presentation # for exam # for md dnb

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 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. 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

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

9. 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%.

10. 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

11. 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

12. 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.

13. 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.

14. 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.

15. 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 )

16. 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.

17. 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.

18. 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.

19. 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

20. 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

21. 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.

22. 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

23. 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.

24. 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.

25. PROTOCOL FOR RABIES POST EXPOSURE PROPHYLAXIS

26. THANK YOU