What You Must Know and Do About Dog-Bite

Prof JC Sanasam *

Close-up of a dog's face during late-stage "dumb" paralytic rabies
Pix - Wikipedia / Centers for Disease Control and Prevention's Public Health Image Library

Audacity at the spur of the moment with some feelings of nativity, then mistrust, followed by logic and rationality, and finally coming to reasonable senses, realization, repentance and vociferous complaints against all around seem to be in the trait of the people in our land at this age at this corner of the world.

In the past two months we had news in the local newspapers about deaths with dog-bites; evidence of sporadic or low grade endemic outbursts of rabies in Manipur. The World Health Organization (WHO) has been working hard to put an end to rabies, a dangerous killing viral disease. Maybe it is the skeptical attitude of the milieu and lack of input from the end of the health-authorities that diseases, which had already got controlled elsewhere, keep popping out into sporadic cases or endemic assaults in Africa, Asia and not to forget our land Manipur.

Although unofficial, some uneasy reports said that many dog-bite cases came to the health delivery centers when it was already too late. In spite of modern knowledge and education, the enigma of intense faith in myth and mystery, illogical and unrestrained practice in rituals and health delivery system has not stopped in Manipur. Such are still happening in families headed by the so-called intellectuals, socio-politico-economical pundits. It is unbelievable. This write-up does not intend to let down the native or primitive practice.

But it will not be wrong to assert that delivery system of health-care should now be with scientific logic and sound reasons at this modern age. If the native or primitive procedure is believed to be good it needs scientific investigation and verification. With affirmation and general acceptance the so-called primitive or native procedure may become world famous with a renovated treatment of dreaded diseases.

According to the unofficial reports, as many as 40 percent of dog-bite cases, during the recent months, came after about 15 to 20 days of the dog-bite incident (day of exposure to rabies virus, if any) when it was already too late. Luckily rabies did not develop because the virus was not deposited during the bite.

Such victims, as a first line of treatment, went or were taken to local health providers who, in most cases, applied 'teeth-grounded rice' on the sites of the bites or scratches. Then the victim and his or her associates started to mistrust this primitive line of treatment and eventually came to seek the modern logical and well-accepted procedure of treatment. This is not a proper way of looking at things in the modern perspective.

Standard Post-exposure Prophylaxis (Standard Treatment after a Dog-bite)

Treatment after exposure, known as Post-exposure Prophylaxis (PEP), has proved to be highly successful in preventing the killing disease if administered promptly, and it has to be within ten days of the exposure i.e. within 10 days after the day of dog-bite. Thoroughly washing the wound as soon as possible with soap and water for approximately five minutes, that means an intensive thorough washing, is very effective at reducing the virus and its toxic elements.

A virucidal (virus killing) antiseptic such as povidone-iodine, tincture of iodine, aqueous iodine solution or alcohol should be applied after washing. If available, chemical cautery with strong nitric acid or sulfuric acid is advisable.

In the United States, affected patients receive one dose of 'human rabies immunoglobulin' (HRIG), very expensive, not sure if available in this area of the world, and four doses of rabies vaccine over a fourteen day period: the first dose to be started immediately, 1st day, to be followed by subsequent doses on the 3rd day, 7th day and 14th day. Patients that had received pre-exposure vaccination need not have the whole set of the course; but should have post-exposure vaccination on day 1 and day 3.

The old nerve-tissue-based vaccinations requiring multiple painful injections into the abdomen with a large needle although cheap and still being used in remote poor areas of India are being phased out and replaced by affordable WHO ID (intradermal) vaccination regimen, available in this area too.

It is highly recommended that PEP be administered as soon as possible. Begun without delay or with very little delay, PEP is 100% effective against rabies. The treatment should be administered regardless of delay, as it may still be effective if it is not delayed too much.

If the delay has been too long, if the site of the bite is on one of the limbs, and if there is evidence that the dog was a rabid dog (for example if some other person bitten by the dog has developed rabies or had died) such that there is possibility of the virus having penetrated the nervous system it has been recommended that the affected limb should be amputated even, to thwart rabies and should be combined with the PEP regimen at the same time.

Some Key facts about Rabies
o Rabies occurs in more than 150 countries and territories.
o More than 55000 people die of rabies every year mostly in Africa and Asia.
o 40% of people who are bitten by suspect rabid animals are children under 15.
o Dogs are the source of the vast majority of human rabies deaths.
o Wound cleansing and immunization within a few hours after contact with a suspect rabid animal can prevent the onset of rabies and death.
o Every year, more than 15 million people worldwide receive a post-exposure vaccination to prevent the disease- this is estimated to prevent hundreds of thousands of rabies deaths annually.

Rabies is a zoonotic disease (a disease that is transmitted to humans from animals) that is caused by a virus (lyssavirus family). The disease affects domestic and wild animals: dogs, bats, foxes, raccoons, jackals, skunks, mongooses and other wild carnivore animals, and is spread to people through close contact with infectious material, usually saliva, via bites or scratches.

Bats are the source of most human rabies deaths in the USA and Canada. Bat rabies also has become public health threat in Australia, Latin America and Western Europe; dog rabies is rare in these countries and is almost under satisfactory control.

Rabies is present on all continents with the exception of Antarctica, but more than 95% of human deaths occur in Asia and Africa. Once symptoms of the disease develop, rabies is nearly always fatal.

The incubation period (time duration from entry of the virus to the appearance of symptoms) for rabies is typically 1-3 months, but may vary from less than one week to more than one year. The initial symptoms are fever and often pain or an unusual or unexplained tingling, pricking or burning sensation (paraesthesia) at the wound site.

As the virus spreads through the central nervous system, progressive, fatal inflammation of the brain and spinal cord develops.

Two forms of the disease:

Furious Rabies: Patients exhibit signs of hyperactivity, excited behaviour, hydrophobia (fear of water) and sometimes aerophobia (fear of air or wind). After a few days death occurs by cardio-respiratory arrest.

Paralytic Rabies: This form of rabies runs a less dramatic and usually longer course than the furious form. Muscles gradually become paralyzed till coma slowly develops eventually resulting to death. The paralytic form often is misdiagnosed as some other nervous system disorder and so under-reporting of rabies incident occurs. In advanced countries reporting of rabies or similar diseases is very seriously taken; there is very low chance of under-reporting there, not like in our areas. Rigorous preventive vaccination of domestic carnivore animals is a must in these countries.