Brief Report :

Observation of a stray animal can be fatal sometimes Dr . Amlan Goswami
Consultant Physician , Kolkata

Almost everyone working in anti-rabies clinics advise patients to observe the animal biting the patient for ten days . Some patients do not take any dose of the vaccine and keep watching it for ten days. After ten days, if the biting animal was normal, then the patients are advised that they do not require any vaccination.This is a very common practice. Sometimes it can be fatal .

During my long experience in managing animal bites in humans I can remember a few cases where the biting animal was a stray dog, and the patients reported that it was healthy and normal for more than ten days after the incident, and as a result the vaccination was stopped, but the said two patients had received five doses of 5 ml each of the BPL inactivated NTV on their anterior abdominal wall. These patients had not received any RIGs infiltration in their wounds. Both the patients were very confident about identifying the stray dogs which bit them.

In the first case, A 32 years old male was bitten on his left leg by a stray dog, which he claimed to have identified. The incident occurred at about 11 pm in the night when he was returning home after his days work as a shopkeeper. He received the five shots of the “Semple Vaccine”. After 12 days of the incident he returned to the OPD and got it recorded in the OPD ticket that “the dog biting him has been observed to be normal and healthy for 12 days after the incident”. As a result the vaccination was stopped . About Two months after the incident his relatives came to the OPD for post-exposure vaccination because of handling a Rabies patient. The said person was admitted to the Infectious Disease Hospital (IDH) and had died of Rabies after showing all the typical symptoms of Aerophobia and Hydrophobia.

The second case was a police officer, about 45 years old, who was very fond of dogs, and used to feed stray dogs regularly in the mornings. One day he was bitten by a Stray Dog on his right hand which he claimed to have identified. He came to the OPD that same morning itself. His wound in the right hand was attended by the Surgery OPD personnel, cleaned and bandaged. The attending surgical consultant prescribed antibiotics and pain killers. He came to the anti-rabies clinic and started getting the prescribed five doses of “Semple Vaccine”, one shot a day. He did not get RIGs infiltration of the wounds. His injuries recovered uneventfully. On the 14th day following the incident he came to the OPD and got it recorded in his OPD ticket that the dog biting him was observed after the incident and was seen to be normal and healthy for 14 days after the incident. About three months after the incident he was brought to the OPD with symptoms of Aerophobia and Hydrophobia. He was immediately sent to the IDH for isolation and treatment. He told that he could not see the dog after about one and a half months of the incident. He died two days later and was diagnosed to have died due to Rabies. The close contacts of this patient came to the OPD for post-exposure prophylaxis.

There are things common to both, in the incidents mentioned above. In both the cases the patients were bitten by stray animals, and there is a possibility of mistaken identity of the animals. In both the cases the wound washing with soap and water was not done properly. In both the cases RIGs were not infiltrated into the wounds as per WHO recommendations. Not following the “WHO guidelines for Post-exposure Management” can sometimes be fatal.

A report appeared in JAPI, 1987, Vol 35 , No : 5, in the form of Letters to the Editor, by Dr. V. D. Charan. In that report he mentions about a person bitten by a stray dog over his left leg for which the patient did not take any post-exposure prophylaxis against rabies. The biting animal was observed after the incident and was seen to be alive till one month after the incident. Subsequently the fate of the dog was not known as the patient left that place for another place of posting.

Similar reports have appeared in the medical literature from time to time2. The common concept is that excretion of rabies virus in the saliva of dogs occurs after the onset of the disease. If the biting animal is a known dog or a known cat and can be reliably kept under observation and is normal and healthy for more than ten days after the incident, then most possibly rabies virus was not present in the saliva, on the day the exposure took place. The WHO guidelines on post-exposure prophylaxis is based on this concept.

However, reports have been published in scientific literature both in India and Internationally of intermittent salivary excretion of rabies virus in apparently healthy dogs3&4. This phenomenon has however not been reported in cats.

In conclusion I have made this observation that the tendency to treat patients seeking post-exposure treatment following an animal bite by not vaccinating the patient due to any reason what-so-ever, and asking him/her to observe the animal can be very risky. The animal, if it is a stray animal might not be correctly identified and a different animal might have been observed leading to fatality. Delayed initiation of post-exposure vaccination will lead to delayed onset of seroconvertion which may be risky. It is a very safe practice to follow the WHO TRS 931 guidelines meticulously.

References :

  1. Charan, V. D. Letters to the editor, Rabies – an unusual observation, JAPI, 1987, Vol 35 , No : 5.

  2. Yurkovsky, A.M. Hydrophobia following the bite of apparently healthy dogs. J Hyg Epidemio Microbiol Immu (Praha) 1962 : 6, 73-8.

  3. Veeraraghavan, N. Studies on the salivary excretion of rabies virus by the dog from Surandai. Pasteur Institute of Southern India, Coonoor, Diamond Jubilee Souveneir, 1967, pp 28-33.

  4. Fekadu, M. Atypical rabies in dogs in Ethiopia. Eth Med J, 1972, 10, pp 79-86.