Rabies has plagued mankind since ancient times. Despite of tremendous progress in the fields of preventive medicine and vaccinology, rabies is widely prevalent in India, causing extensive morbidity and mortality. Estimated annual human mortality in India due to rabies is 25,000 to 50,0001. Though it can strike virtually all mammals, dog is the principal reservoir of this disease in India. Over 95% of human deaths due to rabies are caused by dog bites.1-4
The fear psychosis linked with the bite of a dog is understandable because of the trecherous nature of the disease, which once sets in invariably leads to the death of the victim. Anxious parents seeking medical aid with the history of dog bite in children is not an uncommon feature. Children love to play with dogs and usually get bitten by them as a result of undue provocation5. Though such bites are usually innocuous the risk of rabies can not be totally ruled out. On the other hand bites by stray dogs should always be considered as possibly infectious.
Present study was undertaken to find out the common types of dog bites encountered in children and to study the acceptability of nervous tissue vaccine and its possible common complications.
1630 cases of dog bite in children upto 14 years of age registered in the Anti Rabies Vaccination Centre of Govt. Medical College and Hospital, Nagpur over a period of 6 months from January, 97 to June, 97 constituted the study sample for the present study.
A detailed history was taken and all relevant data pertaining to age, sex, type of dog, site of bite, interval between the dog bite and arrival for vaccination etc. was noted for every study subject. According to the site and severity wounds were classified as class I, II and III. The status of the dog after bite whether alive, taken ill, dead, killed or untraceable were also noted.
Beta-propiolactone inactivated sheep brain nervous tissue vaccine manufactured at Haffkine – Biopharmaceutical corporation Ltd. Parel, Bombay, was administered as per the revised immunization schedule of manufacturer. A detailed record was kept about the doses of ARV recommended and number of doses actually received. Information regarding treatment taken before attending antirabies vaccination centre and their dietary beliefs during vaccination were also noted. All study subjects were judiciously followed for any complications or associated reactions during the treatment period. Recurrence of bite if any was noted and analysed.
In all, 1743 children upto 14 years of age were registered for antirabies vaccination during study period, of which 1630 (93.5%) were cases of dog bite and 113 (6.5%) had bite by other animals 62(3.5%) had pig bite, 36 (2.1%) had cat bite and 15 (0.9%) had monkey bite. Of the 1630 children with dog bite 981 (60.2%) were males and 649 (39.8%) were females. The youngest child to be bitten was one and half months old male child with class III bite. Age distribution is given in Table I.
|CI I||CI II||CI III||Total||CI I||CI II||CI III||Total|
|0 to 1||21||2||4||7||13||1||4||3||8|
Lower limbs (47.2%) were more prone for bite than upper limbs (32.8%). 10.2% children had bite on trunk, 9.3% on face, 6% on head and neck and 3% on genitalia.
In 60.5% cases the bites were by pet dogs and in 39.5% cases bites were by stray dogs. In 36.2% cases bites were by adult grown up dogs and in 13.8% cases bites were by pups. Only in 10.3% cases bites were by vaccinated dogs. In 57% cases the bite was provoked bite.
1266 (77.7%) of cases reported within 3 days of dog bite whereas 364 (22.3%) were late by more than 3 days of which 94 were late by more than 10 days and 8 were late by more than one month. Reasons for coming late were out of station (19.8%); long distance between home and ARV centre (17%); family problems (11.9%); ignorance (7.6%); negligence (6.8%) and performed tantra-mantra (36.9%).
87% of those who were advised the 10 dose + booster schedule completed the full course. 96% of 3 dose schedule children and 90% of 7 dose schedule children took the full course. Thus the acceptance and compliance was fairly good. This may be partly due to fear psychosis linked with the fatal nature of disease.
The commonest reaction following ARV injections were local reactions like redness in 90.9%, swelling in 80.2%, tenderness in 43.1%, pain in 27.4%, and itching in 19.8% cases. General reactions like fever, headache, insomnia etc. were relatively less common. No allergic or neurological complication was reported.
Fate of dogs after bite: 1008 (61.8%) of dogs were alive and healthy following bite whereas 192 (11.8%) were killed and 77 (4.7%) died. 353 (21.7%) dogs were untraceable after bite. 34 (2.1%) subjects had recurrence of dog bite. The bite being by same dog in 14 (41.2%) cases and by different dog in 20 (58.8%) cases. These recurrence cases were vaccinated as per the procedure recommended by the manufacturer of vaccine.
In 12% cases wounds were washed with plain water, in 9% cases with soap and water while in 7.4% cases antiseptic ointment was applied on wound before attending ARV centre. Application of oil and salt, turmeric powder, red chillies, lime, balm, some herbs on wound were carried out in 42.8% cases by their parents while in 14.1% cases their parents took recourse to supernatural methods like going to tantriks, wearing tawiz, beads etc. In 239 (14.7%) cases no prior treatment or first aid was carried out.
Dog bite is one of the most common childhood accidents causing significant morbidity and mortality in paediatric age group6. Rabies, an almost invariably fatal disease continues to be the most serious and most dreaded disease associated with dog bite7.
Very often, children do not realise that their playful behaviour may elicit an angry or defensive reaction from an otherwise friendly well known pet dog. Also, behaviour not generally regarded as provocative may be interpreted by a dog as an invasion of his territory and incite an attack. Therefore young children should never be left unsupervised around any dog. 39.5% of dog bites were by stray dogs. The stray dog menace is rampant due to poor dog elimination activities by municipal bodies. Compounding this, there is also community resistance to dog catching and stray dog elimination. Rabies awareness campaigns should be launched and pet enumeration, licensing and vaccination should be made compulsory.
The commonest reaction following ARV injections were local reactions like redness swelling and tenderness. In general the acceptance and compliance of antirabies vaccination was fairly good. Considering the risk of rabies per se, the risk of complications due to nervous tissue vaccines are not much serious and hence all suspected cases of dog bites should be given the benefit of a recommended full dose of BPL inactivated nervous tissue vaccine.
In the present study, it was observed that many parents applied turmeric powder, chillies, oil and salt etc. on the wound. There were some parents who took recourse to supernatural methods like going to tantriks, wearing tawiz, beads etc. Some parents also had wrong ideas about diet during antirabies vaccination. Hence there is a need for educating people ragarding the correct methods of wound treatment and correcting wrong ideas about diet during vaccination of the children.
This paper demonstrates the need for more lay and professional education and action on the growing problem of dog bite.
Deptt. of PSM, Govt. Medical College and Hospital, Nagpur