Rabies: More than Just a Dog Bite

By Maricris Q. Aquino, RPh

Rabies, a disease caused by animals widely distributed throughout the world, has been classified by the World Health Organization in 2008 as Neglected Tropical Communicable Diseases. The Philippines, ranking 6^th with highest incidence among countries, apparently belongs to the High Risk Category of the WHO with reported 200 to 300 deaths annually and increasing number of incidences of animal bites every year.

What people do not usually know is that this infection is caused by a virus, which is spread by the infected saliva of an animal that enters through a bite or a broken skin. According to WHO, this virus will then travel from the site of wound to the brain where it will cause inflammation and eventually, and if left untreated, it may become fatal.

On Recognizing the Symptoms: In Dogs and In Humans

The PPD Better Pharmacy has indicated the symptoms, which may vary according to the manifestations of the behavior of the infected animal, predominantly in dogs here in the Philippines. The dog may either appear to be furious: exhibiting marked shift from being tame to wild, unusually restless, evident foaming of the mouth and thick saliva, difficulty in eating and drinking, or on the other hand, may seem to be dumb: being inactive or showing signs of depression, often hiding in dark places, resists eating and posing a “far away look”, jaw dropping, frail, and even sudden death without any sign.

In humans, symptoms may not appear after one has been bitten by an infected reservoir, that is the so-called “incubation period” of the virus for 10-14 days, and may even also last up to 30 days. During this time, prompt treatment is necessary to prevent further progression of the infection. The manifestation of symptoms have two phases: prodromal period, where the patient is experiencing excessive salivation, sensitivity to light, sound and change in temperature, muscle stiffness, loss of appetite, depression, nausea and vomiting and fever; and the neuroleptic phase, where the patient is already showing signs of hallucinations, hyperactivity, seizures and paralysis, difficulty in breathing and feeling of pain when swallowing, and hydrophobia (fear of water).

On Prevention and Treatment

The only thing one should be reminded of is to avoid being bitten by wild and stray animals. People who are at risk of exposure (that is if you are a pet-owner or surrounded by stray animals, or you handle animals, or  even those who explore bat caves) should be given (before exposure) rabies vaccine  for immunization. And to some degree, this vaccine may even protect people for the rest of their life provided the booster shots are administered every 2 years.

What to do when a person is bitten by a rabid animal? One must bear in mind that cases of rabies could be fatal, thus, appropriate measures should be done without delay. The wound should be treated immediately, cleaned with soap and water. People without immunization shots may be given an injection of rabies immunoglobulin (different from the vaccine as this provides immediate protection). This has antibodies against the virus, depending on the state of the animal. The WHO guidelines state that the shot is given initially (day 0), followed by shots of vaccine on days 3, 7, 14, and 28, as it stimulates the body to protect itself from the virus with much longer time.

According to the Merck Manual of Medical Information, if an immunized person has been bitten by a rabid animal, the risk of developing the rabies is reduced. However, it is still advised that the patient should be given immediate wound care and rabies immunoglobulin.

Once the symptoms develop in the victim, neither the vaccine nor the immunoglobulin is effective against the virus. Treatment is only limited, in this case, to relieving the pain and other symptoms making the person comfortable as possible; in most cases, death results due to cardiac or respiratory failure.

Prevention is always the key. Never approach animals or pets you don’t know of. Responsible pet ownership should be promoted as this can reduce the incidence of animal bites in our country. The goal is to make the Philippines a Rabies-Free nation. The world celebrates Rabies Day every 28^th of September.

Image References:

[Rabies: The Facts] n.d. [image online] Available at: http://www.seasidevet.com/rabies-the-facts [Accessed 27 February 2013].

[World Rabies Day: Working Together to Make Rabies History!] n.d. [image online] Available at: http://www.who.int/rabies/worldrabiesday/en/ [Accessed 27 February 2013].

Text References:

Medicomm Pacific, Inc., 2011-2012. PPD Better Pharmacy. 11^th ed. PasigCity: Medicomm Pacific, Inc.

World Health Organization, 2013. Animal Rabies. [online] Available at: http://www.who.int/rabies/animal/en/ [Accessed 27 February 2013].

Corpuz, Niña, 2012. Rabies deaths in PH down, but dog bites up. ABS-CBN News, [online] 28 September. Available at: http://www.abs-cbnnews.com/nation/metro-manila/09/28/12/rabies-deaths-ph-down-dog-bites [Accessed 27 February 2013].

A.D.A.M., Inc., 2012. Rabies. [online] PubMed Health. Available at: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002310/ [Accessed 27 February 2013].

Merck Sharp & Dohme Corp., 2011. The Merck Manual of Medical Information. 2^nd Home ed. USA: Merck Sharp & Dohme Corp.

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Dog Bite - Rabies

Dog Bite – Rabies

Rabies is an acute viral disease which causes fatal encephalomyelitis in virtually all the warm blooded animals including man. The virus is found in wild and some domestic animals, and is transmitted to other animals and to humans through their saliva (i.e. bites, scratches, licks on broken skin and mucous membrane). 
Rabies has terrified man since antiquity. The fear is by no means unfounded since the disease is invariably fatal and perhaps the most painful and horrible of all communicable diseases in which the sick person is tormented at the same time with thirst and fear of water (hydrophobia). Fortunately, animal bites, if managed appropriately and timely the disease is preventable to a large extent. In this regard the post-exposure treatment of animal bite cases is of prime importance.

In the past, why was injection administered in the stomach for dog bite?

ANSWER I: This is the only disease where the vaccine is given after the exposure (post-exposure). Nervous tissue vaccine (NTV), is one of the vaccines administered for dog bite.

This vaccine is prepared from a fixed virus grown in the brain of adult sheep or other animal. The final vaccine is a 5 per cent emulsion of infected sheep’s brain containing the inactivated virus.

These viruses do not cause the disease but still retain the antigenecity, i.e., capability of producing the antibodies when injected.

After the bite, about 2-5 ml of the vaccine is administered depending upon the bite severity. More vaccine is administered for a longer duration for severe bites. Bites in the neck, head, face, palm, fingers and multiple wounds are categorised as class three bites.

They require injection for 10 days daily with two booster doses. For such volume of vaccine and duration, the ideal injection site is the anterior abdominal wall. This is preferred as there is a wide area and injection can be given at different points to avoid pain, swelling and discomfort.

Moreover the injections are to be given subcutaneously (below the skin) in the fatty layer. It is a misconception that it is given in the stomach. The needle does enter the abdominal cavity or, for that matter, any of the abdominal organs.

On the abdominal wall skin is held in a fold and elevated. A 1.5 cm needle is used to inject the vaccine in the subcutaneous tissue. After the fold is elevated and such a needle is used there is no possibility of going beyond the subcutaneous layer of the anterior abdominal wall.

This anterior abdominal wall is divided into ten quadrants and injections are given in different quadrants each time. This again results in less pain and swelling.

ANSWER II: The vaccine is given in the stomach region because of the presence of large subcutaneous layer there. Earlier version of this injection needs slower absorption and prolonged activity. Only injection given to a subcutaneous layer can achieve this.

Buttocks and arm region contain larger area of muscle and less of subcutaneous layer.

Hence they are not suitable sites. One more reason is that the stomach region can also accommodate large doses and avoid any complication.

In children despite the subcutaneous layer not being thick and stomach not being large pose no problem as the quantity of injection given is less.

The improved version is a cell cultured vaccine and acts the same way as any other vaccine. In other words it does not require a subcutaneous layer. Hence, it can be given in the buttocks or arm region.

SOME HINTS

1.  NEVER disturb any dog who is sleeping, eating, or caring for puppies.  


2.  NEVER pet a dog, even your own, without letting him see and sniff you first. 


3.  Children must always ASK PERMISSION from the owner and their parents BEFORE petting any dog. I never allowed my children near strange dogs much less pet them.


4.  If the owner cannot control the dog and have it SIT nicely for the child to pet, WALK AWAY.


5.  NEVER approach a dog who is confined behind a fence, within a car, or on a chain.


6.  NEVER TEASE any dog by poking at them through fences or car windows or reaching your arm through to pet them.


7.  NEVER approach a strange dog you don’t know or a dog who is not with his owner.


8.  NEVER RUN away from a dog that is chasing you. STOP, STAND STILL, REMAIN CALM, ARMS AT YOUR SIDES, be quiet and DO NOT SCREAM. Walk away SLOWLY FACING THE DOG BUT NOT STARING AT its eyes.


9.  If a dog attacks, “feed” him your jacket, a school book, a bicycle, or anything else that you can get between you and the dog. 


1 0.  If you are attacked, STOP, CURL UP IN A BALL LIKE A TURTLE, COVER YOUR HEAD WITH YOUR ARMS AND HANDS.


11. Attacking (or perceived attacking) a dog or its companions, or encroaching on its territory.


12. A sick or injured dog, or an older animal, like people, may become “cranky” or over-reactive, and may develop a tendency to become “snappish”.


13. When dogs fight, a human stepping in between, or seeking to restrain one of them without due care, may be badly bitten as well.Do not interfere in the fight.


14. Staring: Especially including direct staring (an act of aggression/perceived as threatening by dogs) or a person not known to the dog moving their face very close to the animal’s own snout (may be perceived as a challenge, threatening, or imposing). Staring is more dangerous when on the same visual level as the dog (such as small children), or when the human is unfamiliar.


15. Like humans, dogs react when fearful, and may feel driven to attack out of self defense, even when not in fact being “attacked”. Speed of movement, noises, objects or specific gestures such as raising an arm or standing up may elicit a reaction. Many rescued dogs have been abused, and in some dogs, specific fears of men, women, skin coloring, and other features that recall past abusers, are not uncommon.