Do not wait if a dog has bitten you. Rush to the ER immediately! They will wash your wound and provide you with further treatment, as explained at Meri Sehat.

Dog Bite? Run To The ER

Introduction

<a href="https://www.merisehat.pk/disease/rabies-89">Rabies</a>, named after Lyssa (Greek goddess of wrath and fury), is a terrifying disease that can often make the animal or human appear &#39;mad&#39;. In ancient times, not much was known about the causative organism; the physicians just believed the madness was a result of a virus (Latin for poison). Thus, they tried various methods to draw the poison and &#39;madness&#39; out of the person&#39;s body. From cupping to burning the wound, bloodletting, holding the person underwater, and even eating the hair of a rabid dog, they tried it all. Not surprisingly, nothing worked.&nbsp; 
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Later in the 18th century, people turned to mudstones for the treatment of rabies. These calcified hairballs present in the stomachs of cows and goats were thought to have the power to draw out the poison from the body. A lot of the stone&#39;s healing power was of course based on superstition. What they assumed as a cure was just the fact that not everyone that gets bit by a rabid animal develops rabies. Hence, there was never anything to cure. 
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It wasn&#39;t until the 1880s that the first real treatment for rabies came forward. Louis Pasteur&#39;s discovery of the rabies vaccine led to hundreds of people surviving rabid animal bites. Today, vaccines play a significant role in the treatment of the viral disease.

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Rabies is a zoonotic viral disease transmitted via the bite of an infected animal. All mammals can carry the rabies virus, including humans. According to the World Health Organization, 99% of human cases are due to a dog bite<a href="#accordion">[1]</a>. In Pakistan, there is a high incidence of dog bites. In 2010, basic health units across the country reported more than 97,000 cases of dog bites<a href="#accordion">[2]</a>.&nbsp;Moreover, government hospitals in the country receive 50 to 70 new cases per day<a href="#accordion">[3]</a>. Approximately 90% of dog bite cases are from stray dogs rather than pets<a href="#accordion">[3]</a>. As the population of stray dogs increases, this number is expected to rise further, increasing the disease burden.&nbsp; 
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While an animal bite or scratch is the most common mode of transmission, the bullet-shaped rabies virus can also be transmitted via exposure to the animal&#39;s saliva. However, the saliva must come in contact with an open wound, scratch, or cut. Furthermore, inhalation of the aerosolized form of the virus and even organ transplantation can transmit the virus to humans<a href="#accordion">[4]</a>. However, petting a rabid animal or contact with its blood or urine cannot transmit the infection as the virus is stored in the animal&#39;s saliva.&nbsp; 
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The incubation period for rabies can vary between a week to a year. Symptoms typically start as a flu-like illness followed by agitation, hyperactivity, confusion, increased salivation, difficulty swallowing or drinking water, fear of water (hydrophobia), convulsions and eventually death. Some people may not show signs of aggressiveness or hyperactivity; instead, they experience paralysis of the muscles.&nbsp; 
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Understanding Emergency Measures To Treat Rabies

Once symptoms appear, rabies is 100% fatal<a href="#accordion">[1]</a>. In Pakistan, rabies accounts for more than 5,000 human deaths per year<a href="#accordion">[5]</a>. However, timely administration of post exposure prophylaxis vaccine and rabies immunoglobulins can effectively prevent the disease from developing.&nbsp; 
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You will need the rabies vaccine in the following scenarios:

<ul>
	<li>If you got bit, scratched, or had contact with the saliva of a rabid animal</li>
	<li>If the captured animal shows signs of rabies within the 10 days of observation 
	&nbsp;</li>
</ul>

However, if you are unaware of the animal&#39;s rabies status, it is best to assume that the animal was rabid. Especially, if you belong to a rabies endemic region like Pakistan.&nbsp; 
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Emergency treatment for rabies includes immediate washing of the wound with soap and water for at least 15 minutes. If initiated within 3 hours of an animal bite, extensive wound care can be approximately 100% effective at preventing rabies. Moreover, medical care should be sought immediately. In the emergency room, treatment is based on history and exposure.&nbsp; 
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As per the WHO&#39;s guidelines, post exposure prophylaxis (PEP) measures are based on the severity of the contact with the suspected rabid animal<a href="#accordion">[1]</a>.&nbsp; 
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Category I - People in this category are defined as having no exposure. They may have a history of touching or feeding animals, or an animal may have licked their intact skin. 
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Treatment: Washing of exposed skin surfaces only. 
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Category II - This is a category of exposure. People will have a history of an animal nibbling their uncovered skin, minor scratches or abrasions without bleeding. 
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Treatment: Wound washing and immediate vaccination. 
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Category III - Severe exposure characterized by single or multiple transdermal bites or scratches; contamination of mucous membrane or broken skin with animal licks; or direct contact with bats. 
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Treatment: Wound washing, vaccination, and administration of rabies immunoglobulin. 
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Both categories II and III require PEP.&nbsp; 
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If you have never received the rabies vaccine, rabies immunoglobulins are immediately injected at the wound site and a distant site. Moreover, four shots of the rabies vaccine are also administered over a course of 2 weeks (days 0, 3, 7, and 14). Immunocompromised people may require a 5th dose, which is typically given on day 28. 
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In previously vaccinated individuals, 1 mL (2 doses) of the rabies vaccine is injected into the deltoid muscle on day 0 and day 3 of infection. No immunoglobulins are administered in previously vaccinated persons.&nbsp; 
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However, a rabies vaccine is not always needed. In certain situations, you might not require any PEP with the vaccine or immunoglobulins. In the following cases, a rabies vaccine is not needed: 
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<ul>
	<li>If the animal does not show any signs of rabies during the 10 days of observation</li>
	<li>If you got bit or scratched by a vaccinated animal 
	&nbsp;</li>
</ul>

While dogs may get all the blame for spreading rabies to humans, cats are the most common rabid domestic animal in developed countries<a href="#accordion">[7]</a>. However, both cats and dogs typically acquire the virus from contact with a wild animal. In developed countries, domesticated animals like cats and dogs account for only 10% of cases while the rest are due to wild animals<a href="#accordion">[6]</a>. These include raccoons, bats, skunks, and foxes. In 2019, bats accounted for 57.4% of rabies cases in Canada, followed by skunks (19.1%), dogs (8.7%), and raccoons (7.8%)<a href="#accordion">[7]</a>.&nbsp;

Therefore, it is important to note that not all dogs are rabid, Moreover, dogs aren&#39;t the only ones you should be wary of.&nbsp; 
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Conclusion

In 2018, Getz Pharma Private Limited joined hands with Indus Hospital &amp; Health Network (IHHN) to establish &#39;Rabies Free Pakistan&#39;. The project aims to eradicate rabies from Pakistan by 2030. So far, the Rabies Free Pakistan team has vaccinated more than 30,000 dogs and neutered around 7,000 dogs. Through mass vaccinations and controlling the dog population, the program aims to reduce the disease burden.&nbsp; 
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However, rabies is a neglected disease in Pakistan. Despite the high prevalence, a huge majority of people are unaware of the disease, its cause, and ways of prevention<a href="#accordion">[8]</a>.&nbsp;Moreover, many people in Pakistan do not vaccinate their pets against rabies. Another barrier to rabies elimination is the heavy distribution of stray dogs in rural areas. These dogs carry a higher risk of infection as they are unvaccinated. Therefore, implementing canine vaccination programs in rural areas, increasing awareness of first-aid practices, and controlling the dog population can help decrease the incidence of rabies in the country. 
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Key Points

<ul>
	<li>Rabies is a zoonotic viral disease that results from an infection with the rabies virus. Symptoms typically begin 1-3 months after exposure to an infected animal. These include fever, headache, burning sensation at the wound site, anxiety, agitation, hydrophobia, hyperventilation, paralysis, coma, and eventually death.&nbsp;</li>
	<li>Humans can contract rabies via the bite or scratch of a rabid animal. Moreover, exposure to the animal&rsquo;s saliva with an open wound, scratch or cut can also transmit the virus to humans.&nbsp;</li>
	<li>Although dogs account for the greatest number of human rabies cases, cats can also spread the disease.&nbsp;</li>
	<li>Emergency treatment for a rabid animal bite includes extensive wound washing followed by administration of the rabies vaccine and immunoglobulins. In previously vaccinated individuals, only 2 doses of the rabies vaccine are given intramuscularly, at day 0 and day 3.</li>
	<li>Effective rabies control programs, which include mass vaccination of dogs, spreading awareness about rabies among the masses, better distribution of rabies vaccines, and increasing surveillance in rural areas can help reduce the disease burden in the country.&nbsp;</li>
</ul>

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[1].WHO, 2021. Rabies. [Online]

[2].World Health Organization, n.d. Pakistan - Rabies Control Programme.

[3].Ali MI, Jamali S, Ashraf T, Ahmed N. Patterns and Outcomes of dog bite injuries presenting to emergency department in a tertiary care hospital at Karachi. Pak J Med Sci. 2021;37(3):794-799. doi: https://doi.org/10.12669/pjms.37.3.3464

[4].Lu, Xue-Xin et al. “Rabies virus transmission via solid organs or tissue allotransplantation.” Infectious diseases of poverty vol. 7,1 82. 15 Aug. 2018, doi:10.1186/s40249-018-0467-7

[5].Ahmed T, Asghar MW, Mushtaq MH. A short report on epidemiological investigation of dog bite cases in association with temperature rise as a part of climate change. Advancements Life Sci. 2019;6(3):106–9

[6].Koury R, Warrington SJ. Rabies. [Updated 2021 Nov 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-

[7].Ma, X., et al. (2021). Rabies surveillance in the United States during 2019, Journal of the American Veterinary Medical Association, 258(11), 1205-1220.

[8].Ahmed, T., Hussain, S., Zia, UuR. et al. Knowledge, attitude and practice (KAP) survey of canine rabies in Khyber Pakhtunkhwa and Punjab Province of Pakistan. BMC Public Health 20, 1293 (2020).

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