What should I do if I am bitten by a dog?

Bitten or scratched by a dog, cat or monkey is a common problem seen in our travel clinic. Most important concern in this scenario is a rabies risk. Since it is a serious and untreatable disease. Once someone develop symptoms of rabies, it will always fatal.  So we have to do everything we can to prevent rabies virus when they have been bitten/scratched by a mammal. Here are some useful information and advice

1. Once you exposure to any mammal (dog, cat, monkey, etc), the first step is to clean your wound immediately with antiseptic or just soap and water. This is an important step that could minimize the risk of getting rabies. Do not forget to do this.

2. You can get rabies only when you ‘expose’ to an infected mammal. The keyword ‘expose’ is important and should not be confused. The World Health Organization (WHO) has classified the possible rabies exposure in three categories as followed;

Category Type of contact Post-exposure treatment
I Touching or feeding animals, licks on intact skin No vaccine is needed if history is reliable
II Nibbling of uncovered skin, minor scratches or abrasions without bleeding Immediate rabies vaccination
III Single or multiple transdermal bites or scratches, licks on broken skin; contamination of mucous membrane with saliva from licks, contacts with bats. Immediate vaccination and administration of rabies immunoglobulin

3. You’ll see, in most cases, if you’re bitten you are likely to have a category III exposure which require rabies vaccine and immunoglobulin. Rabies immunoglobulin, in simple word, is just a rabies antibody that could neutralize the virus at the wound. So the concept is, if someone has transdermal bite (bite that break to the deep layer of the skin); it is possible that rabies virus could find its way to the nervous system. So we immediately need something to neutralize it. We cannot just give a rabies vaccine and wait for the protection since it could take more than a week before a series of vaccine will become effective. And unfortunately, the incubation period of rabies could be as short as 7 days. No one would take that risk.

4. If you has been scratched by an animal, the wound is not deep and there is no bleeding. We could categorize as category II exposure. In this case, you just need a series of rabies vaccine i.e. 5 shots on Day 0,3,7,14,28.

5. However it is not always easy to categorize the exposure in the real life. Someone might get bit; the wound is small but there is some minimal bleeding or bruise. Should we categorize into category II or III. Sometimes it is difficult to say. However, giving that rabies is 100% fatal, so in the grey zone case, most doctors prefer to give ‘over’ treatment to ‘under’ treatment. We also agree, we prefer to err on the side of caution.

6. There is a common scenario that traveler has category III exposure, but rabies immunoglobulin is not available on the first visit. On that case, you still need to get the vaccine and should find the place where you can get the immunoglobulin without delay.

7. If you have already completed rabies pre-exposure series i.e. 3 shots, it is not necessary to receive immunoglobulin. You just need two shots of rabies vaccine on day 0 and day 3 once you exposure to animal.

8. If you’re not sure, whether you should go to see a doctor or not; or whether the scratch is severe or not. DO NOT try to consider it by yourself. You need a qualified medical doctor to assess for you. Visiting a doctor is an urgent issue after possible exposure to rabies virus.

9. In the standard recommendation, we do not use the ‘behaviour’ or the ‘looking’ of the dog/cat to consider the necessary of the rabies post-exposure treatment. Since even healthy-looking dog/cat could transmits rabies. So we will consider all exposure to animal is a rabies risk. We could be sure that there is no rabies risk when that dog/cat survive more than 10 days after exposure. However, the rabies post-exposure treatment must begin immediately on the day of exposure.

10. Once you get bitten/scratched, you should seek for medical care as soon as possible. No one knows the safe time-frame that you can delay, i.e. we have always been asked whether it is ok to delay the treatment for 12 hours/24 hours/48 hours, etc. Unfortunately, no one know the answer. Generally speaking you should do it as soon as possible.

Place where you can get rabies vaccine

Most hospitals in Thailand can provide rabies vaccine. However rabies immunoglobulin is available only in big/referral hospital only. If you’re in Bangkok, you may get rabies vaccine and immunoglobulin in our hospital.

Thai Travel Clinic (www.thaitravelclinic.com)
Hospital for Tropical Diseases
Faculty of Tropical Medicine, Mahidol University
420/6 Rajvithi Rd, Rajthewi
Bangkok 10400, Thailand

Remark:

* Rabies post-exposure treatment is costly especially when rabies immunoglobulin (RIG) is required. In our clinic, the cost of rabies vaccine is around 400 baht per shot and the rabies immunoglobulin (ERIG) is approx 2500-5000 baht (depend on the body weight).

* Pre-exposure prophylaxis is recommended and should be considered in some travelers. Please refer to this article: Rabies vaccine in Southeast Asia. Is it necessary?

Why we don’t set any vaccine bundle-package or promotion in our clinic?

Some travelers might wonder that why we do not set a vaccine-bundle package or any promotion in our clinic. Although it may be a good marketing idea for any clinics, we simply don’t do it.  Why? Here are some reasons/explanation:

1. We believe that the reasonable pre-travel vaccines for all travelers are not the same even they travel to the same destination. Risk of acquiring infectious diseases are different between person to person. So we need a proper risk-assessment in order to give a sound recommendation.

For example, a businessman who plan to visit Bangkok for only a week come to see me and ask for a vaccine, we may recommend none. In contrast to a backpacker who plan to traveling in Thailand for 2 months, in this case, we may recommend rabies vaccine, JE vaccine, HepA/B and tetanus vaccine. So we could not just develop a ‘vaccine-list’ that would fit for all.

2. Let’s say, if we could create a table like this for travelers to India, what do you think?

Recommended vaccine for India  Cost
Vaccine A 300 Baht
Vaccine B 700 Baht
Vaccine C 1,200 Baht
Package (A+B+C) 2,000 Baht (Save 200)

This table is easy to understand and will make some travelers feel great. Since if they choose to get all three vaccines they even get some discounts. But we will not do it.

Why??  We train our doctors to do their best risk assessment for each individuals and give sound and straightforward recommendation. Such as we have Mr. X in our clinic and his itinerary do not cause any risk from disease C, so we will recommend only vaccine A+B, not include C. On the other hand, if we see Mr Y and he will go to some remote area where disease D is common, so we will recommend vaccine A+B+C and also vaccine D.  You’ll see if we have a package like that, it may impact the doctors and travelers’ decision.

3. Although package and promotion is commonly used in many clinics/hospitals as a marketing tool, we  do think that marketing should not play any role in medicine. Otherwise it may distort the ethics and professionalism. So in order to maintain our ‘integrity’ we do not use any marketing tools in our clinic. You will never see somethings like: Buy 2 vaccines and get 20% discount, or Get these three vaccines for only 2,000 baht (save 200 baht). We will never do that.