DOG BITE ON HUMANS,TREATMENT ,IMMUNIZATION AND LEGAL IMPLICATION

Despite adaptations of dog to human needs, its wild instinct including behavior that often times lead to humans attack remains intact and is a major setback in human‑dog relationship. THIS WAS POSTED IN LOVING MEMORY OFLATE DR RIMAMSKEB JEREMIAH ANUYE

1. DOG BITES, NMA Taraba, CME 23-24 NOV. 2018 DR. Anuye RJ Consider need for radiographs Always perform careful wound cleansing & irrigation Decide if antibiotics & suture closure are in dicated Assess for risk of rabies & tetanus Assure close followup 10/5/2024 1

2. Dog bite injuries Dr. Anuye RJ , MBBS,FCFM,PGHA,MPH. Consultant Family Physician, State Specialist Hospital Jalingo. Taraba State.

3. OUTLINE Introduction Definitions Epidemiology Clinical features Diagnosis Treatment Complications Prognosis Prevention

4. Introduction Human‑dog association came into existence several centuries ago Consequently, humankind has harnessed the resourceful potentials of dogs to meet social, game hunting, security, and healthcare‑related needs. Despite adaptations of dog to human needs, its wild instinct including behavior that often times lead to humans attack remains intact and is a major setback in human‑dog relationship.

5. Definition A  dog bite  is a bite inflicted upon a person or another animal by a dog More than one successive bite is often considered as a  dog attack In small children, most bite wounds are on the head and neck I n older children and adolescents/adults, most are on the limbs. Bite injuries range from trivial ones to major soft-tissue defects with the loss of functionally important structures.

6. Military working dog training to attack by biting

7. Epidemiology In the United States, over 36% of households own at least one dog A study by Amudu et el in Makurdi found 80.8% of residential apartments visited had one or more dogs Important global public health problem, although underreported in the developing countries

8. Epidemiology, cont .., Globally millions of people are bitten by dogs;  Most animal bites are from a dog, usually one known to the victim Incidence of dog bite injury in high-income countries( eg the USA) ranges from 0.73 to 22/1000 per annum Whereas the incidence in low‑ and middle-income countries ranges from 1.03 to 25.7/1000 per annum.

9. Epidemiology, cont. In Nigeria, scanty data In Northern Nigeria, rising incidence of dog bite injuries among the general population A study by Amudu et el in Makurdi showed incidence of 2 per 1000 of ED attendance (1.8/1000 male and 2.3/1000 female ED attendance), and male to female ratio of 1:1.1.

10. Epidemiology cont. 40% of people bitten by suspect rabid animals are children under 15 years of age. Lower limb/buttocks injuries occurred mainly in children while upper limbs and head and neck injuries occurred chiefly in adults. 

11. Symptoms and clinical findings Injuries range in severity from superficial abrasions, tears, and crush wounds to degloving injuries with major tissue loss, sometimes extending to or including the underlying bone. Perforating and even avulsion injuries of the skull have been described

12. A classification of the severity of bite wounds, Rueff et al Grade I Superficial skin lesion Torn skin Scratched skin Bite canal Crushing injury Grade II Wound extending from the skin to the fascia, muscle, or cartilage Grade III Wound with tissue necrosis or tissue loss

13. Classification of the severity of open dog-bite wounds on the face Stage Clinical features I Superficial injury not involving muscle II Deep injury involving muscle III Deep injury involving muscle, with loss of tissue IVA The above, and injury to vessels or nerves IVB The above, and bone involvement

14. Risk of infection A bite can transmit unusual pathogens from the saliva into the wound. The risk of infection after a bite is 10–20%, and about 30–60% of the infections are of mixed aerobic-anaerobic origin.

15. Risk of infection cont. Factors: Nature of wound: Deep ( punctate ), contaminated wounds Wounds with marked tissue destruction, edema, poor perfusion Wounds on the hands, feet, face, and genitals wounds involving bones, joints, and tendons. Bite wounds near a prosthetic joint implant

16. Risk of infection cont. Characteristics of the patient: Impaired immune response (immune deficiency, chronic hepatic disease, asplenism, age <2 years, diabetes mellitus) Pre-existing venous or lymphatic stasis in the area of the bite Prosthetic heart valve

17. Risk of infection, cont . Characteristics of the patient cont. - Age Characteristics of the biting animal: Healthy Rabid

18. Type of bacteria Aerobic Pasteurella spp. Pasteurella multocida Streptococcus spp. Staphylococcus spp. (incl. MRSA) Neisseria spp. Capnocytophaga canimorsus Anaerobic Fusobacterium spp. Bacteroides spp. Porphyromonas spp Prevotella spp. Infectious pathogens in Dog bite wounds

19. Pathogens that cause systemic infection after dog bites Leptospira Rabies virus Clostridium tetani Francisella tularensis

20. Symptoms and physical findings of infection Redness, Swelling, Purulent secretion, Pain, Fever, and Malaise . 

21. Children are at highest risk for dog bites. Small children should never be allowed to play with dogs unsupervised.

22. Diagnostic evaluation Practical clinical algorithm for initial management History Time, place, and circumstances of the bite, including any provoking factors Animal Species, owner State of health and any unusual symptoms (rabies) Vaccination status

23. Diagnostic evaluation cont. Patient Underlying illnesses Implants (e.g., prosthetic heart valve) Immunosuppression Asplenism Allergies Vaccination status Symptoms (pain, pressure, fever)

24. Diagnostic evaluation cont. Physical examination Symptoms of shock, fever, pain Site, nature, and extent of wound, foreign bodies, inflammation, secretion, lymphadenopathy, hypoperfusion (vascular injury, compartment syndrome), Functional deficits of muscles, nerves, and/or tendons Impaired joint mobility

25. Diagnostic evaluation cont. Ancillary testing Complete blood count (anemia, incipient infection) Tissue swab/secretion sample for bacteriological culture (colonization, infection) Plain films (fracture), CT/MRI (head injury) Documentation Photographic documentation of the wound and comprehensive written documentation of the history and physical findings Medicolegal

26. Diagnostic evaluation cont. NB: Depending on the site and extent of the bite wound, interdisciplinary collaboration may be advisable.

27. Treatment

28. Treatment cont. Wound Care Timely and copious irrigation with normal saline or Ringer’s lactate solution immediately for a minimum of 15 minutes with soap and water, detergent, povidone iodine Explore for tendon ruptures, bone fragments and foreign bodies, such as teeth fragments Wound debridement( Necrotic or devitalized) .

29. Treatment cont. Suture Primary closure in facial wounds(rarely infected cos well vascularized) Done after infiltration of the wound with rabies immunoglobulin (RIG). Sutures should be loose and not interfere with free bleeding and drainage.

30. Wound care cont. Delayed closure Heavily contaminated(dirty) Significant amount of tissue damage Hands or lower extremities Wounds older than 6hrs Results in better cosmetic outcomes.

31. Treatment cont. Limb immobilization Inpatient treatment/outpatient follow-up Avoid covering the wound with dressings or bandages.

32. Treatment cont. Infection prophylaxis Indications for immunization Tetanus Rabies Antibiotics Wounds with a high risk of infection Reporting to the authorities, if legally mandated

33. Prophylactic antibiotics Despite the poor state of the evidence, most experts recommend early antibiotic treatment for fresh, deep wounds and wounds in certain critical bodily areas (hands, feet, areas near joints, face, genitals), for persons at elevated risk of infection, and for persons with implants, e.g., artificial heart valves 

34. Prophylactic antibiotics The duration of antibiotic treatment depends on the severity of the condition, the extent of spread of the infection, the pathogen, and treatment response

35. Prophylactic antibiotics cont. Recommended duration of antibiotic treatment Cellulitis or abscess: 1 to 2 weeks Tenosynovitis : 2 to 3 weeks Osteomyelitis , arthritis: 3 to 4 weeks

36. Antibiotic coverage Prophylactic Antibiotic Dosages for Dog Bites Adults: First-line Amoxicillin/ clavulanate ( Augmentin ), 875/125 mg every 12 hours Alternatives Clindamycin , 300 mg 3 times per day  plus  ciprofloxacin ( Cipro ), 500 mg twice per day

37. Antibiotic coverage, cont. Doxycycline , 100 mg twice per day Penicillin VK, 500 mg 4 times per day  plus   dicloxacillin , 500 mg 4 times per day A fluoroquinolone ; trimethoprim / sulfamethoxazole , 160/800 mg twice per day; or cefuroxime axetil ( Ceftin ), 500 mg twice per day  plus   metronidazole ( Flagyl ), 250 to 500 mg 4 times per day, or clindamycin , 300 mg 3 times per day

38. Antibiotic coverage, cont. Children First-line: Amoxicillin/ clavulanate , 25 to 45 mg per kg divided every 12 hours Alternative: Clindamycin , 10 to 25 mg per kg divided every 6 to 8 hours  plus trimethoprim / sulfamethoxazole , 8 to 10 mg per kg ( trimethoprim component) divided every 12 hours Pregnant women who are allergic to penicillin Azithromycin ( Zithromax ), 250 to 500 mg per day Close monitoring is needed because of high failure rate

39. Indications for Tetanus Prophylaxis History of tetanus immunization Clean, minor wounds All other wounds Vaccine Immune globulin Vaccine Immune globulin Uncertain or < 3 doses Yes No Yes Yes ≥ 3 doses No, unless > 10 years since last dose No No, unless > 5 years since last dose No

40. Assessing the risk of rabies Immediately High risk Unprovoked bite Dog not vaccinated The exposure occurs in a geographical area where rabies is still present The animal looks sick or displays abnormal behaviour A wound or mucous membrane was contaminated by the animal’s saliva The animal has not been vaccinated. Low risk bite provoked

41. Post-exposure prophylaxis (PEP) Post-exposure prophylaxis (PEP) is the immediate treatment of a bite victim after rabies exposure. PEP consists of: thorough washing and flushing of the wound; a series of rabies vaccine administrations promptly started after an exposure, and if indicated RIG infiltration into and around the wound, promptly after exposure.

42. Indications for postexposure rabies prophylaxis (PEP) The WHO Expert Consultation on Rabies (2018) has categorized rabies risk based on category of exposure and made recommendations for PEP,

43. Categories of contact and recommended post-exposure prophylaxis (PEP) Categories of contact with suspect rabid animal Post-exposure prophylaxis measures Category I – touching or feeding animals, licks on intact skin None Category II – nibbling of uncovered skin, minor scratches or abrasions without bleeding Immediate vaccination and local treatment of the wound Category III – single or multiple transdermal bites or scratches, licks on broken skin; contamination of mucous membrane with saliva from licks, contacts with bats. Immediate vaccination and administration of rabies immunoglobulin; local treatment of the wound

44. Post-exposure prophylaxis measures, cont. Cat1= None Cat2= Immediate vaccination and local treatment of the wound Cat3= Immediate vaccination and administration of rabies immunoglobulin; local treatment of the wound All category II and III exposures assessed as carrying a risk of developing rabies require PEP.  

45. Post-exposure prophylaxis (PEP) by category of exposure Immunologically naive individuals of all age groups – A. Category I exposure – Washing of exposed skin surfaces No PEP required

46. Post-exposure prophylaxis measures, cont . Immunologically naive individuals of all age groups cont. B. Category II exposure – Wound washing and Immediate vaccination: -2-sites ID on days 0, 3 and 7 or -1-site IM on days 0, 3, 7 and between day 14–28 or -2-sites IM on days 0 and -1-site IM on days 7, 21 RIG is not indicated.

47. Post-exposure prophylaxis measures, cont. Immunologically naive individuals of all age groups, cont. C. Category III exposure – Wound washing and immediate vaccination – 2-sites ID on days 0, 3 and 7 or 1-site IM on days 0, 3, 7 and between day 14–28 or 2-sites IM on days 0 and 1-site IM on days 7, 21 3. RIG administration is recommended

48. Post-exposure prophylaxis measures, cont. Previously immunized individuals of all age groups A. Category I exposure Washing of exposed skin surfaces No PEP required.

49. Post-exposure prophylaxis measures, cont. Previously immunized individuals of all age groups B. Category II exposure Wound washing and vaccination:* – 1-site ID on days 0 and 3 or At 4-sites ID on day or 3. RIG is not indicated.

50. Post-exposure prophylaxis measures, cont Previously immunized individuals of all age groups, cont. C. Category III exposure – Wound washing and immediate vaccination:* – 1-site ID on days 0 and 3 or At 4-sites ID on day 0 – or At 1-site IM on days 0 and 3 – 3. RIG is not indicated. * Immediate vaccination is not recommended if complete PEP already received within <3 months previously

51. Post-exposure prophylaxis measures, cont. Previously immunized individuals of all age groups, cont. C. Category III exposure Wound washing and immediate vaccination- 2-sites ID on days 0, 3 and 7 or 1-site IM on days 0, 3, 7 and between day 14–28 or 2-sites IM on days 0 and 1-site IM on days 7, 21 3. RIG administration is recommended. –

52. Postexposure rabies prophylaxis Three types of rabies vaccine: Human diploid cell vaccine ( HDCV ) Rabies vaccine adsorbed ( RVA ) and Purified chick embryo cell vaccine ( PCEC ).

53. Post-exposure prophylaxis measures, cont. For both PEP and PrEP , vaccines can be administered by either the ID or IM route. One ID dose is 0.1 mL of vaccine; one IM dose is 0.5 mL or 1.0 mL depending on the product, i.e. the entire content of the vial ID schedules offer advantages through savings in costs, doses and time.

54. Post-exposure prophylaxis measures, cont. ID injection sites for all age groups: Deltoid region E ither the anterolateral thigh or suprascapular regions. IM administration sites: Adults/children aged ≥2 years, deltoid area of the arm for and Children aged <2 years. anterolateral area of the thigh NB: Rabies vaccine should not be administered IM in the gluteal area.

55. Suspected animal When possible, suspect animals should be humanely euthanized and tested for rabies. PEP can be discontinued if the suspect animal is proved by appropriate laboratory examination to be free of rabies or, in the case of domestic dogs, cats or ferrets, the animal remains healthy throughout a 10-day observation period starting from the date of the bite. Consumption of meat or milk from a rabid animal is strongly discouraged and should be avoided but if it occurs, PEP is not indicated.

56. Administration of rabies immunoglobulins (RIG) Administered only once, preferably at, or as soon as possible after, the initiation of PEP. Should not be given after day 7 following the first rabies vaccine dose, because circulating VNAs will have begun to appear. Highest priority to receive RIG are: Category III exposed Patients with severe bites Immunodeficiency;

57. Administration of rabies immunoglobulins (RIG),cont Maximum dose calculation for RIG is 40 IU/kg body weight for equine derived RIG ( eRIG ), and 20 IU/kg body weight for human derived RIG ( hRIG ).

58. Pre-exposure prophylaxis ( PrEP ) PrEP which is the administration of several doses of rabies vaccine before exposure to RABV

59. Pre-exposure prophylaxis ( PrEP ) Indications: Individuals at high risk of RABV exposure. sub-populations in highly endemic settings with limited access to timely and adequate PEP Individuals at occupational risk Travellers who may be at risk of exposure

60. Pre-exposure prophylaxis ( PrEP ) PrEP schedule: 2-site ID vaccine administered on days 0 and 7. If IM administration is used, WHO recommends a 1-site IM vaccine administration on days 0 and 7.

61. Dog bite lacerations of the face

62. Same patient after primary suture repair

63. Complications Soft tissue injury-scratches/punctures to avulsion and crush injuries Traumatic amputation Local and systemic wound infections and rabies Disfigurement, Posttraumatic stress disorder Wound healing complications such as hypertrophic scar and keloid

64. Prevention of Dog Bites Dog-owners should: Responsible dog ownership Keep dogs with a known history of aggressive behavior out of households with children Train dogs properly (hierarchical behavior: the owner is boss) Avoid aggressive play with dogs Seek professional advice if a dog starts to behave aggressively

65. Prevention of Dog Bite cont. Children should: Keep well away from strange dogs Not play with dogs unless supervised by an adult Never disturb a dog while it is sleeping, eating, or caring for puppies Parents should: Teach children early how to behave with their own dog Teach them what to do if approached by a strange dog

66. Medicolegal aspects “It is inevitable that many more people will visit their GPs after a bite from a dog or another animal. If not properly managed, animal bites can have serious repercussions for the patient, including infections, scarring, nerve damage, psychological effects and even death, take particular care in assessing trauma caused by dog bites.” Allegations of failure to treat or refer such patients appropriately

67. Conclusion Always perform careful wound cleansing & irrigation Decide if antibiotics & suture closure are indicated Assess for risk of rabies & tetanus Consider need for radiographs/litigations Assure close follow-up

68. Thank you

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