What is the management protocol for a dog bite in an Indian setting?

Dog Bite Management in an Indian Setting

Immediately wash all dog bite wounds thoroughly with soap and water, then initiate post-exposure prophylaxis (PEP) with both rabies vaccine and rabies immunoglobulin (RIG) within 24 hours for Category III wounds, while observing healthy dogs for 10 days to determine if prophylaxis can be discontinued. 1

Immediate Wound Management

All bite wounds must be washed immediately and thoroughly with soap and water—this is the single most effective measure for preventing rabies. 1 This local wound cleansing has been shown in experimental models to markedly reduce the likelihood of rabies transmission. 1

• Administer tetanus prophylaxis as indicated 1
• Control bacterial infection with appropriate antibiotics 1
• Do not suture wounds initially unless absolutely necessary for cosmetic or functional reasons

Risk Assessment: Critical Factors

Animal Status and Observation Protocol

If the biting dog is healthy and available, confine and observe it daily for 10 days. 2 This is the cornerstone of determining whether PEP can be discontinued:

• Do NOT vaccinate the animal during the observation period to avoid confusing rabies signs with vaccine side effects 2
• If the dog remains healthy for 10 days, discontinue PEP 1
• If the dog develops any illness, report immediately to local health authorities and have a veterinarian evaluate 2
• If signs suggestive of rabies develop, euthanize the animal immediately and submit the head for laboratory testing 2

For stray or unwanted dogs that cannot be observed, treat as rabid and initiate full PEP immediately. 2, 1

Exposure Category Classification

Category III exposures (any bite breaking skin, scratches/abrasions with bleeding, or mucous membrane contamination with saliva) require both vaccine AND immunoglobulin. 1

• Bites to face and hands carry highest risk but should not influence the decision to treat 1
• Non-bite exposures (scratches, abrasions, mucous membrane contact with saliva) also constitute rabies exposure 1
• Casual contact (petting, contact with blood/urine/feces) does NOT constitute exposure 1

Post-Exposure Prophylaxis Protocol

For Previously Unvaccinated Individuals

Administer both rabies vaccine AND rabies immunoglobulin (RIG) as soon as possible, ideally within 24 hours but can be given up to day 7-8 after first vaccine dose. 1

• RIG dosing: Infiltrate as much as anatomically feasible around the wound site; administer remainder intramuscularly at a site distant from vaccine 1
• Vaccine schedule: Follow tissue culture vaccine protocols (modern cell culture vaccines, NOT neural tissue vaccines which have serious side effects) 3
• Beyond day 7, RIG is not indicated as antibody response to vaccine is presumed to have occurred 1

For Previously Vaccinated Individuals

Those with documented adequate rabies antibody titers should receive vaccine only—no immunoglobulin needed. 1

Indian Context-Specific Considerations

Critical Gaps in Current Practice

In India, dogs are responsible for up to 95% of animal bites requiring antirabies treatment, with stray dogs accounting for approximately 80% of cases. 3, 4 However, significant management deficiencies exist:

• Only 46% of Category III victims receive the life-saving immunoglobulin they require 4
• Two-fifths of patients do not wash wounds with soap and water 5
• One-fifth do not receive anti-rabies vaccine at all 5
• A majority (79%) do not receive anti-rabies serum when indicated 5

Vaccine Considerations

Tissue culture vaccines should be used exclusively; neural tissue vaccines (still used in Indian public sector) have serious side effects and should be phased out. 3

• WHO recommends intradermal route for tissue culture vaccines, which is highly economical 3
• However, this route is not yet approved by India's Drug Controller General 3
• Intramuscular administration remains the standard approved route

Common Pitfalls to Avoid

Do not delay treatment waiting for animal observation results if the animal is unavailable or shows any signs of illness. 1 Rabies is 100% fatal once clinical symptoms appear.

Do not omit RIG in Category III exposures—this is a critical gap in Indian practice where only 46% receive it despite indication. 4 The combination of active and passive immunization is essential for adequate protection.

Do not assume rodent bites require prophylaxis—squirrels, rats, mice, hamsters, and similar rodents almost never require antirabies treatment in most geographical areas. 1 However, consult local health authorities as regional variations exist.

When to Consult Local Health Authorities

• Unknown or escaped animals 1
• Wild animal bites (regard as rabid unless proven negative) 1
• Livestock or unusual animal bites 1
• Questions about regional rabies epidemiology 1
• Unprovoked attacks (more likely to indicate rabid animal) 1

The decision to treat must account for: animal species, bite circumstances, vaccination status of animal, and regional rabies presence. 1 In India's high-endemicity setting, err on the side of treatment when in doubt given the disease's 100% fatality rate.