What are the Indian guidelines for dog bite management, focusing on active and passive immunization?

Indian Guidelines on Dog Bite Management: Active and Passive Immunization

Critical First Step: Immediate Wound Management

All dog bite victims must immediately wash wounds thoroughly with soap and water for at least 15 minutes, as this single intervention markedly reduces rabies transmission risk more than any vaccine or immunoglobulin. 1, 2, 3

• Apply povidone-iodine solution after soap and water irrigation if available 2, 3
• Do NOT apply traditional remedies like chillies, salt, turmeric, lime, ash, or other substances—these practices are common in India but provide no benefit and may delay proper treatment 4
• Tetanus prophylaxis should be administered if the last dose was >10 years ago for clean wounds or >5 years ago for contaminated wounds 2

Exposure Classification and Treatment Algorithm

Category III Exposures (Require Both Active AND Passive Immunization)

Any bite that penetrates skin or contamination of mucous membranes with saliva requires both rabies immunoglobulin (RIG) and vaccine, regardless of delay in presentation. 1, 3

• Category III includes: single or multiple transdermal bites, scratches, or contamination of broken skin/mucous membranes with saliva 3
• Face and hand bites carry highest risk but should not influence the decision to treat 3
• In India, 63% of dog bite victims present with Category III exposures 4

Passive Immunization: Rabies Immunoglobulin (RIG)

Administer RIG at 20 IU/kg body weight on day 0, infiltrating the full dose around and into the wound(s) if anatomically feasible, with any remaining volume given intramuscularly at a site distant from vaccine administration. 1, 3

• RIG must be given within 7 days of starting vaccine; beyond day 7, it is contraindicated as antibody response to vaccine is presumed to have occurred 1, 3
• RIG should NEVER be administered in the same syringe or anatomical site as vaccine 1
• Critical pitfall in India: RIG availability is severely limited—only 2 of 6 surveyed centers had RIG available, representing a major gap in proper post-exposure prophylaxis 4
• If human RIG is unavailable, equine antirabies serum may be used, though human RIG is strongly preferred 3

Active Immunization: Anti-Rabies Vaccine (ARV)

Previously unvaccinated persons should receive a 4-dose intramuscular vaccine regimen on days 0,3,7, and 14 in the deltoid muscle (or anterolateral thigh in children), never in the gluteal area. 1

• The 4-dose schedule (days 0,3,7,14) is now recommended over the older 5-dose schedule (which included day 28), as no rabies failures have been documented with the reduced schedule and it saves costs without compromising safety 1
• Tissue culture vaccines (HDCV, RVA, PCEC) are the standard of care globally 1
• Major concern in India: Neural tissue vaccine (NTV) is still widely used in the public sector despite serious neurological side effects, though tissue culture vaccines are available in some centers 5, 6
• WHO recommends intradermal administration of tissue culture vaccine as a cost-effective alternative, but this route is not yet approved by India's Drug Controller General 5

Previously Vaccinated Persons

Individuals with documented prior complete rabies vaccination (pre- or post-exposure) should receive vaccine ONLY on days 0 and 3, without RIG. 1, 3

• RIG is contraindicated in previously vaccinated persons as it may suppress the anamnestic antibody response 1

Common Pitfalls in Indian Context

• Wound washing compliance is poor: Only 54.4% of patients wash wounds with soap and water, and 89.6% wash for <5 minutes (far below the recommended 15 minutes) 7
• Vaccine compliance is inadequate: Only 47.8% complete the full vaccine course, with 45.5% non-compliant 7
• Delayed presentation is common: Patients often seek traditional healers first or apply home remedies before presenting to anti-rabies clinics 4, 8
• RIG is critically underutilized: Most public sector centers lack RIG, meaning the majority of Category III exposures receive incomplete prophylaxis 4
• Wound washing at clinics is neglected: Only 1 of 6 surveyed centers practiced wound washing at the facility itself 4

Special Considerations

• Dogs cause 92-96.9% of animal bites requiring treatment in India 5, 4
• 64.3% of bites are unprovoked, and 64.7% are from stray animals 4
• Children (age 2-18 years) comprise 47.5% of victims, and males represent 72-78% of cases 4
• Post-exposure prophylaxis should be initiated regardless of time elapsed since exposure, as incubation periods >1 year have been documented 1