A. Wound management

B. Passive immunization (inj. of immunoglobulin/anti-sera)

C. Active immunization i.e. inj. of anti-rabies vaccine (ARV) General Considerations in rabies PEP (Post-Exposure Prophylaxis) If rabies immunoglobulin (RIG) is not available on first visit, its use can be delayed by a maximum of 7 days from the date of first dose of vaccine. Pregnancy and infancy are never contraindications to PEP. If the patient comes even months after having been bitten, he/she should be dealt with in the same manner as if the bite has occurred recently.

PEP is not required in case of consumption of milk of a rabid animal no matter the milk is boiled or raw. No such incident has been reported where exposure to milk of a rabid animal has caused rabies. Although it is not desirable to consume milk from an infected animal, it is to be kept in mind that rabies virus is not excreted in milk (of a rabid mammal) in concentration sufficient to cause infection. Moreover, boiling of milk destroys rabies virus. Consumption/handling of raw meat of a rabid animal requires PEP. Cooking kills rabies virus.

A.            Wound management:

Wash the wound immediately (as early as possible) under running tap water for at least 10 minutes.

Use soap or detergent to wash the wound (if soap is not available then use water only to wash the wound).

After thorough washing and drying the wound apply disinfectant – e.g. povidone iodine, spirit etc.

Don’t apply irritants viz. chilli, soil, oils, turmeric, lime, salt, plant juice etc.

Don’t touch the wound with bare hands.

Wound washing must be performed even if the patient reports late.

Postpone suturing if possible; if suturing is at all necessary, it should be performed after cleaning and infiltrating RIG at the depth of wound and only minimum number of loose sutures should be applied.

Don’t cauterize. Administer systemic antimicrobial and tetanus toxoid if necessary (follow usual norm of wound management in this regard).

B.            Passive immunization (immunoglobulin/anti-sera): Human Rabies Immunoglobulin (HRIG):

Local infiltration of rabies immunoglobulin: RIG should be infiltrated in the depth and around each of the wounds to inactivate the locally present rabies viruses. Infiltrate as much as possible in the depth and around the wounds.

C.            Active immunization: Route of inoculation: Intramuscular or Intradermal.  Site of inoculation:

Deltoid muscle or anterolateral part of thigh. Not recommended in gluteal region, since there is chance of low absorption due to presence of fatty tissue. Dosage as per various standard guidelines/regimens.

Dr Khalid Ur Rehman

MD physician, Medical Officer J&K Health Services