Rabies vaccine before a dog bite: Which children actually need it?

Rabies is one of the few infections that is almost invariably fatal once symptoms appear, yet it is also almost entirely preventable if exposure is managed correctly.

Despite new figures suggesting that rabies deaths in the country have gone down, India still has the highest disease-related mortalities in the world with the majority of the victims being kids– and therefore whether children should be vaccinated before any dog bite is particularly important in the local context.

The Indian Academy of Paediatrics (IAP), the largest network of paediatricians in the country, in 2022 recommended pre-exposure prophylaxis, or PrEP, for all children.

India continues to carry a substantial burden of animal bites.

A study by the Indian Council of Medical Research-National Institute of Epidemiology (ICMR-NIE) estimated around 9.1 million animal bites every year, more than three-fourths caused by dogs, with an estimated 5,726 human rabies deaths annually.

Yet the wording by the IAP was rather cautious and the body has not publicised this recommendation much either.

So which kids then need rabies PrEP?

Most experts agree that children living with pets and those considered more likely to encounter or be bitten by dogs, can be considered for the same.

India's national rabies guidelines also describe PrEP as something that may be offered to high-risk groups, while noting that the IAP recommendation for children can be considered on a voluntary basis.

Dr Khan Amir Maroof, a community medicine specialist and rabies researcher at University College of Medical Sciences and GTB Hospital, said he does not believe PrEP is necessarily appropriate for every child despite the IAP recommendation.

“I feel it still may not be appropriate for every child to get vaccinated before a dog bite,” he told India Today.

“As it is, kids are already being given multiple vaccines as part of the government’s Universal Immunisation Programme (UIP) and including one more vaccine at programmatic level needs robust scientific evidence to justify an additional prick,” he said.

The National Centre for Disease Control (NCDC), under the Union health ministry, has, in the past, deliberated on the possibility at an initial stage, but it is not being pursued actively as of now, say sources.

According to Dr Maroof, the decision should be guided by the likelihood of exposure. He said the World Health Organisation’s (WHO) approach considers PrEP in settings where the risk of exposure is particularly high – 5 % or more in a community – and pointed to available Indian data suggesting that in most places in the country, the proportion of people experiencing dog bites is around 2–2.5 %.

WHO recommends PrEP for people with continual, frequent or increased risk of exposure because of where they live or what they do. It can also be considered for people travelling to high-risk areas or those living in remote, highly rabies-endemic areas where access to rabies treatment may be limited.

India's national guidelines describe three doses for PrEP, with the traditional schedule being days 0, 7 and 21 or 28, depending on the applicable regimen.

A recent Indian study involving children is also examining simplified intradermal PrEP schedules, reflecting continuing interest in making preventive vaccination easier to deliver in endemic settings.WHY CHILDREN ARE VULNERABLE

The concern over children is not misplaced.

Government estimates have previously indicated that very high-as much as over 90 % according to some estimates – of rabies morbidity and mortality in India is associated with dog bites.

Children are particularly vulnerable because they are more likely to come into close contact with dogs and may not recognise warning signs in an animal or report a bite or scratch.

According to Dr Sanjay Wazir, director of paediatrics at Motherland Hospital in Gurugram, their short stature makes bites to the hand or face, typically category3 or deep bites, more likely.

“Also, they often do not tell an adult about a minor scratch. In India, where freeroaming dogs are common, preexposure vaccination deserves discussion with parents. But whether all kids should go for it is a difficult decision and I advise parents on a case-to-case basis,” he said. .

The WHO also notes that children make up a large proportion of dog-bite victims and face a greater risk of serious injury because bites to the head and neck are more common in children than adults.

Dogs are therefore central to rabies control. WHO estimates that dogs are responsible for 99 per cent of human rabies cases globally and says mass dog vaccination is one of the key interventions needed to interrupt transmission.

For this reason, says Dr Maroof, primary focus should be on vaccinating the dogs, a public health intervention that is necessary as well as easier to do- a fact that has also been reinforced in a study published in The Lancet Regional Health based on a project in Kerala.PrEP DOES NOT REPLACE PEP

This is perhaps the most important point for parents.

Dr Ashu Khajuria, paediatrician with Kailash Hospital & Neuro Institute, said even a child who has received PrEP must seek medical attention after a potentially risky bite or scratch.

“PrEP does not eliminate the need for medical evaluation after a potential exposure,” Khajuria said.

That applies even when the animal is a household dog or cat that has been vaccinated. A bite or significant scratch should not simply be ignored.

The reason is that PrEP primarily primes the immune system. If an exposure subsequently occurs, the management is simpler because a previously vaccinated person generally needs fewer vaccine doses and does not require rabies immunoglobulin as part of re-exposure management under the applicable guidelines.

For someone without a previous vaccination, however, post-exposure prophylaxis can involve wound management, rabies vaccine and, for severe bites, rabies immunoglobulin.

Whether or not a child has received PrEP, the immediate response after a suspicious bite or scratch remains critical.

The wound should be washed thoroughly with soap and running water for at least 15 minutes, followed by prompt medical assessment. The WHO also recommends wound washing and immediate vaccination for Category II (moderate) exposures, while Category III exposures require vaccination plus rabies immunoglobulin or an appropriate monoclonal antibody where indicated.

Experts emphasise that properly delivered PEP is highly effective at preventing death.

The world health body, too, describes appropriate wound management and timely, quality-assured PEP as almost 100 per cent effective in preventing human rabies deaths.

A recent study led by the National Institute of Mental Health and Neurosciences (NIMHANS) had reinforced why correct PEP matters as much as access to the vaccine. Among 89 laboratory-confirmed rabies deaths in people who had sought care and received at least one vaccine dose, researchers found that only three appeared to represent genuine PEP failures.

Most involved missed, delayed or incorrectly administered components of treatment.- Ends

Sumi Sukanya Dutta writes on health and pharma for India Today - Health and Wellness. With over 17 years of experience in journalism, she has extensively covered a wide spectrum of issues-from pandemics and public health crises to the growing obesity epidemic and advancements in medical science.

Prior to her current role, Sumi held reporting positions at ThePrint, Moneycontrol, The New Indian Express, The Telegraph, and The Times of India, where she focused on governance and public policy at both state and national levels. She has also contributed to The British Medical Journal (BMJ).