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Is Repetition Of Anti-rabies Vaccination Required For A Dog Bite After 4 Years?
Question: I had taken a full course of rabipur as prescribed of 5 injections in 2012, when a pet dog had bitten me on my arm. Recently yesterday a street dog attacked my let while on a walk. Do I need to take a full course again or a booster.
Brief Answer:
Please take complete 5 dose anti rabies vaccination course
Detailed Answer:
Hi,
Thanks for writing in to us.
I have read through your query in detail.
Please find my observations below.
1. Having taken complete course of rabies vaccination in 2012 is 4 years back and right now you might not be adequately protected.
2. It recommended that you consult as doctor and take complete course of 5 dose anti rabies vaccination.
3. You should take tetanus toxoid if not given before.
Hope your query is answered.
Please do write back if you have any doubts.
Regards,
Please take complete 5 dose anti rabies vaccination course
Detailed Answer:
Hi,
Thanks for writing in to us.
I have read through your query in detail.
Please find my observations below.
1. Having taken complete course of rabies vaccination in 2012 is 4 years back and right now you might not be adequately protected.
2. It recommended that you consult as doctor and take complete course of 5 dose anti rabies vaccination.
3. You should take tetanus toxoid if not given before.
Hope your query is answered.
Please do write back if you have any doubts.
Regards,
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
I am confused and surprised both. The WHO directives in their link http://www.who.int/immunization_standards/vaccine_quality/Rabipur_Product_Insert.pdf
says
c Previously fully immunised individuals:
Patients who have previously received a complete course of primary immunisation
(pre- or post-exposure) should receive two doses of Rabipur; one on each of days 0 and 3, respectively. This is independent of the interval to the last immunisation. No administration of rabies immunoglobulin is required.
While you are advising a complete course of five injections.
Whom should we believe in?
says
c Previously fully immunised individuals:
Patients who have previously received a complete course of primary immunisation
(pre- or post-exposure) should receive two doses of Rabipur; one on each of days 0 and 3, respectively. This is independent of the interval to the last immunisation. No administration of rabies immunoglobulin is required.
While you are advising a complete course of five injections.
Whom should we believe in?
Brief Answer:
Please find clarifications below and guidelines are case dependant
Detailed Answer:
Hi,
Thanks for writing back with an update.
1. I have served in community health centers where I used to come across many cases like yours regularly and I and wish to clarify the reason behind me suggesting you a complete ciourse of 5 injections.
2. The objective of anti rabies vaccination is to generate antoi rabies antibodies in the patient. The antibodies are generated during the course of vaccination. The recommended antibody level in a person who is said to be protected from rabies is titre of at least 0.5 IU/ml. This antibody level is reached after 30 days from initial vaccination.
3. If the antibody level falls below 0.5 IU/ml then the person is no longer protected and requires immunization.
4. There is no definite time limit as to when the anti body level will come below the protected level, it can happen after 2 years or more.
5. When a person is having antibody level above 0.5 IU/ml then it is safe to take two boosters on day 1 or day 3.
6. If it has been a long time since previous vaccination, then the antibody titre is known to go below minimum protecton level.
7. Please see the guidelines of "National Rabies Control Programme 2015 release" which can be downloaded from http://www.ncdc.gov.in/writereaddata/mainlinkfile/File557.pdf
It is mentioned on page 13 that
"Several studies have indicated that persons who have previously received complete pre- or post-exposure prophylaxis will elicit an anamnestic response to
one or more booster doses of rabies vaccine even if the initial series of vaccination was administered several years previously.
This response will occurwhether:
the initial vaccination regimen was administered IM or ID;
the booster dose is given IM or ID
the previously vaccinated person has detectable rabies virus neutralizing
antibodies or not.
Based on the above if re-exposed persons who have previously received and
documented full pre- or post-exposure prophylaxis (either by IM or ID route)
with a cell-culture vaccine or PDEV should now be given only two booster doses
intramuscularly (0.5ml/1ml) or CCVs intra-dermally (0.1 ml at 1 site) on days 0
and 3. Proper wound toilet should be done. Treatment with RIG is not required.
Persons who have previously received full post-exposure treatment with NTV or
vaccine of unproven potency or cannot document previous pre- or post-exposure
treatment should be treated as fresh case and given treatment as per merits of
the case."
8. In the above point, it is clearly mentioned that "re-exposed persons who have previously received and documented full pre- or post-exposure prophylaxis (either by IM or ID route) with a cell-culture vaccine or PDEV should now be given only two booster doses intramuscularly (0.5ml/1ml) or CCVs intra-dermally (0.1 ml at 1 site) on days 0 and 3." and this is what you have written in your send follow up in the WHO directive 2007.
9. It is also mentioned that "Persons who have previously received full post-exposure treatment with NTV or vaccine of unproven potency or cannot document previous pre- or post-exposure treatment should be treated as fresh case and given treatment as per merits of the case."
One important fact is that your previous vaccination was in 2012, and it is not sure if your antibody level is above safe limit or not now in 2016 after four years. This brings up the question of potency of the vaccination.
Another point is that in XXXXXXX every dog which scratches or bites is taken as a potentially infected animal wghether it is a stray por pet dog. This is not the case in developed countries.
Therefore keeping in mind that your previous vaccination is long back and the dog is potentially infected, in my opinion your antio body level is to be raised to adequate level immediately and that is the reason I am treating you as a fresh case and suggesting you a complete course of vaccination.
10. Please remember it is better to take precautions because rabies has no cure. Taking a few extra doses of vaccine is better than being vulnerable to the disease and putting yourself at risk. Taking a 5 dose schedule will not do you any harm if you have taken previous vaccination years before.
In conclusion, I have placed accurate medical information and facts before you and this is a forum for discussion and it is strongly suggested to follow advise of your doctor. My suggestion is in the best of your health.
11. Doctors might differ in opinions and if your doctor feels otherwise then you can make a learned choice after going in details through guidelines and facts mentioned by me.
Thanks again for allowing me to clarify your points.
Please do write back if you have any doubts.
Regards,
Please find clarifications below and guidelines are case dependant
Detailed Answer:
Hi,
Thanks for writing back with an update.
1. I have served in community health centers where I used to come across many cases like yours regularly and I and wish to clarify the reason behind me suggesting you a complete ciourse of 5 injections.
2. The objective of anti rabies vaccination is to generate antoi rabies antibodies in the patient. The antibodies are generated during the course of vaccination. The recommended antibody level in a person who is said to be protected from rabies is titre of at least 0.5 IU/ml. This antibody level is reached after 30 days from initial vaccination.
3. If the antibody level falls below 0.5 IU/ml then the person is no longer protected and requires immunization.
4. There is no definite time limit as to when the anti body level will come below the protected level, it can happen after 2 years or more.
5. When a person is having antibody level above 0.5 IU/ml then it is safe to take two boosters on day 1 or day 3.
6. If it has been a long time since previous vaccination, then the antibody titre is known to go below minimum protecton level.
7. Please see the guidelines of "National Rabies Control Programme 2015 release" which can be downloaded from http://www.ncdc.gov.in/writereaddata/mainlinkfile/File557.pdf
It is mentioned on page 13 that
"Several studies have indicated that persons who have previously received complete pre- or post-exposure prophylaxis will elicit an anamnestic response to
one or more booster doses of rabies vaccine even if the initial series of vaccination was administered several years previously.
This response will occurwhether:
the initial vaccination regimen was administered IM or ID;
the booster dose is given IM or ID
the previously vaccinated person has detectable rabies virus neutralizing
antibodies or not.
Based on the above if re-exposed persons who have previously received and
documented full pre- or post-exposure prophylaxis (either by IM or ID route)
with a cell-culture vaccine or PDEV should now be given only two booster doses
intramuscularly (0.5ml/1ml) or CCVs intra-dermally (0.1 ml at 1 site) on days 0
and 3. Proper wound toilet should be done. Treatment with RIG is not required.
Persons who have previously received full post-exposure treatment with NTV or
vaccine of unproven potency or cannot document previous pre- or post-exposure
treatment should be treated as fresh case and given treatment as per merits of
the case."
8. In the above point, it is clearly mentioned that "re-exposed persons who have previously received and documented full pre- or post-exposure prophylaxis (either by IM or ID route) with a cell-culture vaccine or PDEV should now be given only two booster doses intramuscularly (0.5ml/1ml) or CCVs intra-dermally (0.1 ml at 1 site) on days 0 and 3." and this is what you have written in your send follow up in the WHO directive 2007.
9. It is also mentioned that "Persons who have previously received full post-exposure treatment with NTV or vaccine of unproven potency or cannot document previous pre- or post-exposure treatment should be treated as fresh case and given treatment as per merits of the case."
One important fact is that your previous vaccination was in 2012, and it is not sure if your antibody level is above safe limit or not now in 2016 after four years. This brings up the question of potency of the vaccination.
Another point is that in XXXXXXX every dog which scratches or bites is taken as a potentially infected animal wghether it is a stray por pet dog. This is not the case in developed countries.
Therefore keeping in mind that your previous vaccination is long back and the dog is potentially infected, in my opinion your antio body level is to be raised to adequate level immediately and that is the reason I am treating you as a fresh case and suggesting you a complete course of vaccination.
10. Please remember it is better to take precautions because rabies has no cure. Taking a few extra doses of vaccine is better than being vulnerable to the disease and putting yourself at risk. Taking a 5 dose schedule will not do you any harm if you have taken previous vaccination years before.
In conclusion, I have placed accurate medical information and facts before you and this is a forum for discussion and it is strongly suggested to follow advise of your doctor. My suggestion is in the best of your health.
11. Doctors might differ in opinions and if your doctor feels otherwise then you can make a learned choice after going in details through guidelines and facts mentioned by me.
Thanks again for allowing me to clarify your points.
Please do write back if you have any doubts.
Regards,
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Brief Answer:
If it was low risk then probably you can take only boosters.
Detailed Answer:
Hi,
Thanks for writing back with an update.
1. In my opinion, it is important to know if it was a high risk attack or low risk attack and if the animal was provoked or it came to attack you spontaneously.
2. If the dog was provoked like you stepped over it or came in the way of dog and the injury was mildest nature like scratch without bleeding in your leg, then you can probably stop after two boosters. Since you have written lightly therefore I am considering this a low risk exposure.
3. On the other hand, if the dog came to you purposefully and tried biting you with bleeding in injury area then it is to be considered a high risk injury and should be managed accordingly with more doses.
However, since you have received immunization in 2012 there is no need to take immunoglobulin. Other than above you do not require any extra treatment.
Hope your query is answered.
Please do write back if you have any doubts.
Regards,
If it was low risk then probably you can take only boosters.
Detailed Answer:
Hi,
Thanks for writing back with an update.
1. In my opinion, it is important to know if it was a high risk attack or low risk attack and if the animal was provoked or it came to attack you spontaneously.
2. If the dog was provoked like you stepped over it or came in the way of dog and the injury was mildest nature like scratch without bleeding in your leg, then you can probably stop after two boosters. Since you have written lightly therefore I am considering this a low risk exposure.
3. On the other hand, if the dog came to you purposefully and tried biting you with bleeding in injury area then it is to be considered a high risk injury and should be managed accordingly with more doses.
However, since you have received immunization in 2012 there is no need to take immunoglobulin. Other than above you do not require any extra treatment.
Hope your query is answered.
Please do write back if you have any doubts.
Regards,
Note: For more detailed guidance, please consult an Internal Medicine Specialist, with your latest reports. Click here..
Above answer was peer-reviewed by :
Dr. Sonia Raina
Answered by
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