QuestionsQuestions (DOH ADMINISTRATIVE ORDER NO. 164)
It provides revised, uniform guidelines for managing animal bite patients to prevent human rabies deaths after exposure, supports the DOH rabies prevention/control program, and aims to eliminate rabies in the Philippines.
It applies to both government doctors nationwide and private practitioners; they are advised to follow the guidelines to ensure uniform rabies post-exposure management.
The Order states there are three categories (Annex A) and that each category corresponds to a corresponding management plan (including whether to give vaccines and/or RIG). The key difference is the required treatment level for each exposure category.
Active immunization induces antibody and T-cell production to neutralize the rabies virus; it may take 7–10 days to induce response and can persist for one year or more. Available vaccines listed are PVRV (0.5 ml/vial), PDEV (1.0 ml/vial), and PCECV (1.0 ml/vial).
Yes. For active immunization, any of the three vaccines may be administered either intramuscularly (IM) or intradermally (ID).
Passive immunization provides immediate protection via RIG combined with anti-rabies vaccine; it is given in combination with vaccine for Category III exposure.
Only rabies vaccines and RIG evaluated and recognized by WHO and approved by BFAD should be used.
HRIG is derived from plasma of human donors at 20 IU/kg; ERIG is derived from horse serum at 40 IU/kg.
Give RIG as a single dose; infiltrate around and into the wound as much as feasible even if healing started; if any remains, administer intramuscularly at a site distant from vaccine injection; give at the same time as the first vaccine dose (or up to 7 days after first vaccine if unavailable).
Do not exceed the calculated dose because it may reduce vaccine efficacy.
A skin test must be performed prior to ERIG administration; hypersensitivity may not be predicted by skin test, so be ready with adrenaline and antihistamines. A positive result is based on induration of 6 mm or more.
Immediately and vigorously wash and flush with soap and water preferably for 10 minutes; apply alcohol/tincture of iodine or any antiseptic; avoid ointment/cream/occlusive dressings; suturing should be avoided; if suturing is necessary, infiltrate anti-rabies immunoglobulin around and into the wound before suturing.
Anti-tetanus immunization and anti-microbial may be given if indicated; animal bites are considered tetanus-prone wounds.
One dose is equivalent to 0.1 ml for intradermal administration for PVRV and 0.2 ml for PDEV/PCECV. One dose at two sites on Days 0, 3, and 7; one site on Days 30 and 90.
If only Day 0 was given and the lapse between Day 0 and Day 3 is >1 week, repeat the first dose (do not repeat RIG). If at least Day 0 and Day 3 were given, adjust missed doses but keep remaining doses according to the original schedule. If Day 30 is missed, give when patient comes; Day 90 may be scheduled as originally or at least 1 month after Day 30 dose—whichever is longer. If Day 90 is missed, give when patient comes.
Using 2-1-1, one dose equals one vial (0.5 ml PVRV or 1.0 ml PDEV/PCECV). Two doses are given IM on Day 0, and one dose each on Day 7 and Day 21. For Category III, it should be used in combination with RIG; if RIG is not available, it may be used but is not the optimum regimen and the patient must be informed.
If the dog is alive and healthy after the 14-day observation period, discontinue the last dose.
Pregnancy and infancy are NOT contraindications to purified cell culture vaccines. Immunocompromised individuals must receive vaccine using standard IM regimen and RIG for both Category II and III exposures. If patients present weeks/months after the bite, treat as if exposure occurred recently unless the biting animal remained healthy and alive up to 14 days after the bite, in which case no treatment is needed.
Local wound treatment always applies. If second exposure occurs: (1) <1 month—no booster dose; (2) 1 to 3 years—give two booster doses on D0 and D3; (3) >3 years—give another full course of active immunization. There is no need to give RIG. Booster doses may be given ID at 0.1 ml for PVRV or 0.2 ml for PDEV/PCECV or IM as 1 vial for PVRV/PDEV/PCECV.
Dispensing free vaccines/RIG is the sole responsibility of government health agencies if available; Category III patients who cannot buy succeeding doses get free vaccine if available; vaccines are only for properly assessed animal bite patients physically present (no non-patients). Priority: (1) Negri bodies-positive animals regardless of bite exposure category; (2) Category III; (3) exposure to human rabies patients (bite/non-bite like mouth-to-mouth, licking intact mucosa); (4) animals not available for observation (stray/slaughtered); (5) Category II.