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LETTER TO EDITOR  
Year : 2017  |  Volume : 42  |  Issue : 4  |  Page : 248-249
 

“Scratches/Abrasions without bleeding” cause rabies: A 7 years rabies death review from medical college Shimla, Himachal Pradesh, India


1 Department of Epidemiology, IDRV, DDU Zonal Hospital, Shimla, Himachal Pradesh, India
2 Department of Hospital Administration, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
3 Department of Veterinary, Dog Sterilization Centre, Animal Birth Control Programme, Municipal Corporation, Shimla, Himachal Pradesh, India
4 State Correspondent, The Statesman and Alumni of HP Agriculture University, Palampur, Himachal Pradesh, India

Date of Web Publication25-Oct-2017

Correspondence Address:
Omesh Kumar Bharti
IDRV, DDU Zonal Hospital, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcm.IJCM_37_17

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How to cite this article:
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;42:248-9

How to cite this URL:
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 [serial online] 2017 [cited 2020 Nov 25];42:248-9. Available from: https://www.ijcm.org.in/text.asp?2017/42/4/248/217236


Sir,

Rabies annually causes 20,000 deaths in India and this figure has not changed for the last decade. This review was done retrospectively to analyze the reasons for deaths due to rabies, registered at Indira Gandhi Medical College Shimla since 2009. We investigated 19 deaths due to rabies in the past 7-year period. Of these, five were caused by “scratches/abrasions without any bleeding” and no postexposure prophylaxis (PEP) was sought. All injuries were caused either by unvaccinated pups below 3 months of age or by stray unvaccinated dogs. Four deaths were of patients who received proper wound care along with minimum 3 doses of intramuscular rabies vaccination, but rabies immunoglobulins (RIG) were not given or were not available. In eight cases, no PEP was sought as the patients were either not aware of its need or the PEP facility was far away or the PEP cost was not affordable or deceased believed that pups below 3 months of age do not carry a risk of rabies. In one case, the patient was bitten by a cat 2 years back. Majority patients belonged to rural and remote areas. Five of the deaths in our study were because of not seeking prophylaxis as abrasions/scratches without bleeding were not thought to carry a risk of rabies. In the Philippines, a rabies death review of 1839 patients demonstrates that all deaths were due to dog related injuries including bites and scratches.[1] In Iran [2] four people having scratches on their hands were infected with the saliva of rabid animals and died due to rabies, there was no history of bites. In our death review also, deaths caused by “scratches/abrasions without blood” amply demonstrate the ability of the rabies virus to enter nerves through dermis due to broken skin and its capacity to cause rabies. In our settings, the minimum incubation period was 22 days due to scratches on the face in front of Lt Tragus and maximum incubation period was 102 days due to a trivial scratch on right Forearm by a furious rabid dog. Rabies due to bat scratches [3] is known and hence can happen due to rabid dog/animal scratches as well. Pathogenesis studies by Kuzmin et al.[4] state that after delivery into a wound, rabies virus can infect several types of cells and replicate at inoculation site, as has been shown for skeletal muscle cells and fibroblasts. Human skin dermal layer is populated with fibroblasts that may allow the entry of the rabies virus and subsequent infection if left unattended [5] and needs further evaluation. Latest guidelines of the WHO (2014) prescribe that the type II wounds, that include minor scratches or abrasions without bleeding, need to be given only rabies vaccine whereas additional local RIG infiltration may be required.[6] The confusion of scratches with blood or without blood need to be rectified in the type II classification of the WHO bite wounds and need to be replaced by “Bruises that don't involve breach of the skin surface.” Breach of skin surface can easily be identified with spirit test, if there is burning sensation, breach of skin is likely. Many national guidelines, for example, USA,[7] Canada, and Switzerland do not make a difference between category II and III wounds and recommend rabies vaccination alongwith RIG administration on potential exposure to rabid animals irrespective of the type of wounds. More such rabies death reviews may throw light on this unusual phenomenon of deaths due to scratches/abrasions by rabid animals, especially on the head, neck, shoulder region, hands and arms, in rabies endemic countries like India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
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. International Journal of Infectious Diseases 2011;15:e495-9. Available form: http://www.sciencedirect.com/science/article/pii/S1201971211000889. [Last accessed on 2015 Jan 05].  Back to cited text no. 1
    
2.
Simani S, Fayaz A, Rahimi P, Eslami N, Howeizi N, Biglari P, et al. Six fatal cases of classical rabies virus without biting incidents, Iran 1990-2010; J Clin Virol. 2012;54:251-4. Doi: 10.1016/j.jcv.2012.03.009. Available form: https://www.ncbi.nlm.nih.gov/pubmed/22554714. [Last accessed on 2015 Jul 12].  Back to cited text no. 2
    
3.
Robertson K, Lumlertdacha B, Franka R, Petersen B, Bhengsri S, Henchaichon S, et al. Rabies-Related Knowledge and Practices Among Persons At Risk of Bat Exposures in Thailand. Carabin H, ed. PLoS Neglected Tropical Diseases. 2011;5:e1054. Doi:10.1371/journal.pntd.0001054. Available form: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3125144/. [Last accessed on 2015 Sep 15].  Back to cited text no. 3
    
4.
Kuzmin IV, Rupprecht CE, Rabies Virus, Encyclopedia of Virology. Vol. 5. Mahy BWJ, Van Regcnmortel MHV, ed. Oxford: Elsevier. p. 367-73. Available form: https://www.researchgate.net/publication/316345100_Rabies_Virus. [Last accessed on 2017 Apr 22].  Back to cited text no. 4
    
5.
Rittié L, Fisher GJ. Isolation and Culture of Skin Fibroblasts. In: Varga J, Brenner DA, Phan SH. ed. Fibrosis Research. Methods in Molecular Medicine, Humana Press: 2005;117:83-98. Available form: http://link.springer.com/protocol/10.1385%2F1-59259-940-0%3A083. [Last accessed on 2014 Jun 11].  Back to cited text no. 5
    
6.
Bharti OK, Narayan MadhusudanaPyare Lal Gaunta S, Yajaman Belludi A. Local infiltration of rabies immunoglobulins withoutsystemic intramuscular administration: an alternative cost effective approach for passiveimmunization against rabies. Hum Vacc Immunother 2016;12:837-42, Doi:10.1080/21645515.2015.1085142; Available form: https://www.ncbi.nlm.nih.gov/pubmed/26317441. [Last accessed on 2014 Jul 17].  Back to cited text no. 6
    
7.
Use of a Reduced (4-Dose) Vaccine Schedule for Postexposure Prophylaxis to Prevent Human Rabies: Recommendations of the Advisory Committee on Immunization Practice; Morbidity and Mortality Weekly Report (MMWR) Recommendations and Reports 2010;59;1-9; Available form: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5902a1.htm. [Last accessed on 2014 Sep 22].  Back to cited text no. 7
    




 

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