WHO Needs to Re-look at Animal Bite Wound Classification for Rabies Post Exposure Prophylaxis to Save People from Deadly Rabies!
Abstract
Rabies is a deadly zoonotic disease that is largely caused by bites or scratches of an infected dog. WHO has defined wound classifications for taking decisions on Rabies Post Exposure Prophylaxis (PEP) after bites. Some experts have suggested a change in WHO classification to include another category IV in severe wounds. As we work in the rabies endemic country contributing the highest number of rabies deaths annually, we discuss what changes in Rabies PEP classification are actually required based on our clinical practice. We discuss here how the lives of victims of rabid animals were saved and what factors led to the failures of PEP. We also discuss why there is no need to expand existing wound classification to category IV and no need to use higher concentrations of RIG for severe wounds like those on the head and neck. We recommend omitting category II and keeping only categories I and III for wound classification for rabies PEP based on our clinical experience with rabid dog bites and scratches i.e. either there is exposure or no exposure using spirit test in doubtful abrasions without bleeding. Moreover, because the rabies virus attaches to the nerve at the site of the bite and there is no viraemia in rabies infection, therefore, to classify a scratch or abrasion with or without bleeding is not rational.
How to cite this article:
Bharti OK. WHO Needs to Re-look at Animal Bite Wound Classification for Rabies Post Exposure Prophylaxis to Save People from Deadly Rabies!. Epidem Int. 2022;7(3):28-32.
DOI: https://doi.org/10.24321/2455.7048.202219
References
Hampson K, Coudeville L, Lembo T, Sambo M, Kieffer A, Attlan M, Barrat J, Blanton JD, Briggs DJ, Cleaveland S,
Costa P, Freuling CM, Hiby E, Knopf L, Leanes F, Meslin FX, Metlin A, Miranda ME, Muller T, Nel LH, Recuenco
S, Rupprecht CE, Schumacher C, Taylor L, Vigilato MA, Zinsstag J, Dushoff J; Global Alliance for Rabies Control
Partners for Rabies Prevention. Estimating the global burden of endemic canine rabies. PLoS Negl Trop Dis.
;9(4):e0003709. [PubMed] [Google Scholar]
Sudarshan MK. Rabies. In: Parthasarathy A, Kundu R, Agrawal R, editors. Textbook of pediatric infectious
diseases. 1st ed. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd; 2013.
Raina P, Sharma GK, Barwal KC, Kumar M, Chauhan S. Male genital injuries in infants caused by the bite of
pet pups: case series and literature review. J IndianAssoc Pediatr Surg. 2022;27:491-4. [PubMed] [Google
Scholar]
World Health Organization. WHO expert consultation on rabies. Third report. WHO Technical Report Series,
No. 1012. Philippines: World Health Organization; 2018. [Google Scholar]
Bharti OK, Madhusudana SN, Wilde H. Injecting rabies immunoglobulin (RIG) into wounds only: a significant
saving of lives and costly RIG. Hum Vaccin Immunother. 2017;3;13(4):762-5. [PubMed] [Google Scholar]
Bharti OK, Sood RK, Ramachandran V, Phull A. A scratch with hind toes by rabid dog causes rabies-some case
studies. Indian J Appl Res. 2015;5(2):576-7.
Bharti OK, Chand R, Chauhan A, Rao R, Sharma H, Phull A. “Scratches/abrasions without bleeding†cause rabies: a 7 years rabies death review from Medical College Shimla, Himachal Pradesh, India. Indian J Community
Med. 2017;42(4):248-9. [PubMed] [Google Scholar]
Dimaano EM, Scholand SJ, Alera MT, Belandres DB. Clinical and epidemiological features of human
rabies cases in the Philippines: a review from 1987 to 2006. Int J Infect Dis [Internet]. 2011 [cited
Jan 5];15:e495-9. Available from: http://www.sciencedirect.com/science/article/pii/
S1201971211000889 [PubMed] [Google Scholar]
Ghosh S, Rana M, Chowdhury S. Trends and clinicoepidemiological features of human rabies cases in
Bangladesh 2006–2018. Infect Control Hosp Epidemiol. 2020;41(S1):S416.
World Health Organization. Weekly Epidemiological Record [Internet]. 2018 [cited 2022 Aug 10];93(16):201-
Available from: https://apps.who.int/iris/bitstream/handle/10665/272371/WER9316.pdf?ua=1
World Health Organization [Internet]. Request for reinstatement of equine rabies immune globulin to
the EML and EMLc; [cited 2022 Aug 12]. Available from: https://cdn.who.int/media/docs/default-source/
essential-medicines/2021-eml-expert-committee/applications-for-addition-of-new-medicines/a.12_
equine-rabies-ig.pdf?sfvrsn=772b7a5d_6
Bharti OK, Thakur B, Rao R. Wound-only injection of rabies immunoglobulin (RIG) saves lives and costs less
than a dollar per patient by “pooling strategyâ€. Vaccine. 2019;37(S1):A128-31. [PubMed] [Google Scholar]
Cai L, Wang L, Guan X, Wang L, Hu X, Wu Y, Tong Y, Wang P. Epidemiological analysis of rabies in
Central China from 2013 to 2018. Infect Drug Resist. 2021;17;14:2753-62. [PubMed] [Google Scholar]
Susilawathi NM, Darwinata AE, Dwija IB, Budayanti NS, Wirasandhi GA, Subrata K, Susilarini NK, Sudewi RA,
Wignall FS, Mahardika GN. Epidemiological and clinical features of human rabies cases in Bali 2008-2010. BMC
Infect Dis. 2012;12:81. [PubMed] [Google Scholar]
Scholand SJ, Quiambao BP, Rupprecht CE. Time to revise the WHO categories for severe rabies virus
exposures–category IV? Viruses. 2022;14(5):1111. [PubMed] [Google Scholar]
Guzman FD, Iwamoto Y, Saito N, Salva EP, Dimaano EM, Nishizono A, Suzuki M, Oloko O, Ariyoshi K, Smith
C, Parry CM, Solante RM. Clinical, epidemiological, and spatial features of human rabies cases in Metro Manila,
the Philippines from 2006 to 2015. PLoS Negl Trop Dis. 2022;16(7):e0010595. [PubMed] [Google Scholar]
Bharti OK, Tekta D, Shandil A, Sharma K, Kapila P. Failure of postexposure prophylaxis in a girl child attacked by rabid dog severing her facial nerve causing possible direct entry of rabies virus into the facial nerve. Hum
Vaccin Immunother. 2019;15(11):2612-14. [PubMed] [Google Scholar]
Madhusudana SN, Ashwin BY, Sudarsahan S. Feasibility of reducing rabies immunoglobulin dosage for passive immunization against rabies; results of in vitro and in vivo studies. Hum Vaccine Immunother. 2013;9:1914-7. [PubMed] [Google Sholar]
Bharti OK, Anderson DC, Kishore J, Katoch P, Sharma P. Small volume of Rabies Immunoglobulin (RIG) is
effective for local wound infiltration in rabies postexposure prophylaxis whereas intramuscular RIG is
just a wastage. J Adv Res Med. 2021;8(3):8-12. [Google Scholar]
Zhu Z, Huang S, Lu S, Zhang M, Meng S, Hu Q, Fang Y. Severe multiple rabid dog bite injuries in a child
in central China: continuous 10-year observation and analysis on this case. Hum Vaccin Immunother.
;2;16(4):904-6. [PubMed] [Google Scholar]
Rupprecht CE, Briggs D, Brown CM, Franka R, Katz SL, Kerr HD, Lett SM, Levis R, Meltzer MI, Schaffner W,
Cieslak PR. Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human
rabies: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep.
;59:1-9. [Google Scholar]
Gongal G, Mudhusudana SM, Sudarshan MK, Mahendra BJ, Hemachudha T, Wilde H. “Commentary. What is the risk of rabies transmission from patients to health care staff?†Asian Biomedicine. 2017;6(6):937-939. https://
doi.org/10.5372/1905-7415.0606.142; https://sciendo.com/article/10.5372/1905-7415.0606.142
Shankar V, Dietzschold B, Koprowski H. Direct entry of rabies virus into the central nervous system without
prior local replication. J Virol. 1991;65(5):2736-8. doi: 10.1128/JVI.65.5.2736-2738.1991. PMID: 2016778;
PMCID: PMC240640. Available from: https://www. ncbi.nlm.nih.gov/pmc/articles/PMC240640/
Copyright (c) 2022 Omesh Kumar Bharti
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
