Title
Guidelines on Management of Animal Bite Patients
Law
Doh Administrative Order No. 164
Decision Date
Oct 16, 2002
The Department of Health establishes revised guidelines for the management of animal bite patients, emphasizing the prevention of rabies through standardized treatment protocols, vaccination, and collaboration among health agencies to achieve a rabies-free Philippines by 2020.
animal bite
rabies prevention
public health

Legal basis, predecessor rules, repeals

  • The order rescinds Administrative Order No. 15-A, s. 1997 dated August 15, 1997.
  • Any other administrative order inconsistent herewith is also rescinded.

Purpose and policy goals

  • The order bases rabies control on the National Objectives for Health 1999–2004, treating rabies as a public health problem.
  • The order emphasizes the prevention of human deaths due to rabies through post-exposure treatment.
  • The order commits the Department of Health to elimination of rabies and to the goal of declaring the Philippines rabies-free in 2020.
  • The order requires continued review and evaluation of the policy and implementation by technical experts.
  • The order requires advocacy, training of health workers, system readiness, and secured funding before full implementation.
  • The order requires support and collaboration among government, non-government, and private organizations.

Coverage and who must follow

  • Government doctors at all levels must follow these guidelines.
  • Private practitioners in the country must also follow these guidelines to ensure uniform management of animal bite patients.

Rabies exposure categories and management

  • The order establishes three (3) categories of exposure to a rabid animal or an animal suspected to be rabid.
  • Each exposure category corresponds to a specific management approach for potential rabies exposure.
  • The detailed exposure-category management framework is provided in Annex A.

Immunization requirements and standards

  • Active immunization is defined as vaccine administration that induces antibody and T-cell production to neutralize rabies virus.
  • The order states active immune response occurs in 7–10 days after vaccination and may persist for one year or more.
  • The order lists the anti-rabies vaccines available in the Philippines:
    • Purified Free Cell Rabies Vaccine (PVRV) at 0.5 ml/vial.
    • Purified Duck Embryo Vaccine (PDEV) at 1.0 ml/vial.
    • Purified Chick Embryo Cell Vaccine (PCECV) at 1.0 ml/vial.
  • The order requires that, for active immunization, any of the three vaccines may be administered intra-muscularly or intrader-mally.

Passive immunization and RIG controls

  • Passive immunization is defined as providing immediate protection with Rabies Immunoglobulin (RIG) combined with anti-rabies vaccine for Category III exposure.
  • The order states RIG has a half-life of approximately 21 days.
  • The order requires only rabies vaccines and RIG evaluated and recognized by WHO and approved by BFAD be used.
  • The order requires national health authorities to evaluate any new vaccine or RIG before use.

RIG types, dosing, and infiltration rules

  • The order recognizes two RIG types:
    • Human Rabies Immunoglobulin (HRIG) derived from plasma of human donors at 20 IU per kilogram body weight.
    • Equine Rabies Immunoglobulin (ERIG) derived from horse serum at 40 IU per kilogram body weight.
  • The order requires HRIG dosing and calculation based on IU concentration:
    • HRIG at 20 IU/Kg with 150 IU/ML example computation.
  • The order requires ERIG dosing and calculation based on IU concentration:
    • ERIG at 40 IU/kg with 200 IU/ml example computation.
  • The order requires RIG as a single dose for all Category III exposures.
  • The order requires RIG infiltration around and into the wound as much as automatically feasible, even if the lesion has begun to heal.
  • The order requires any remaining RIG to be administered intramuscularly at a site distant from the vaccine injection site.
  • The order prohibits giving RIG beyond the calculated dose because it may reduce vaccine efficacy.
  • The order permits dilution with sterile saline 2 or 3 fold for thorough infiltration when the calculated dose is sufficient to infiltrate bite wounds.
  • The order requires RIG administration at the same time as the first vaccine dose.
  • If RIG is unavailable when the first vaccine dose is injected, the order allows giving RIG up to 7 days after the first vaccine dose, assuming the patient received day 3 and day 7 doses.
  • The order requires a skin test prior to ERIG administration and mandates readiness to treat hypersensitivity with adrenaline and antihistamines.
  • The order states a positive interpretation is based on induration of 6 mm or more.

Post-exposure treatment: wound care

  • The order requires immediate and vigorous wound washing and flushing with soap and water preferably for 10 minutes.
  • The order requires application of alcohol, tincture of iodine, or any antiseptic.
  • The order requires avoiding suturing of wounds when possible.
  • If suturing is necessary, the order requires infiltrating anti-rabies immunoglobulin around and into the wound before suturing.
  • The order prohibits applying any ointment, cream, or occlusive dressing to the bite site.
  • The order requires or allows anti-tetanus immunization and anti-microbial if indicated.
  • The order treats animal bites as tetanus prone wounds for purposes of tetanus management (referenced in Annex B).

Post-exposure treatment: vaccine regimens

  • The order requires strict adherence to each treatment schedule to prevent treatment failure.
  • The order recognizes the 2-site intradermal schedule, 2-1-1 intramuscular schedule, standard intramuscular schedule, and 8-site intradermal schedule, with details in Annex C1, Annex C2, Annex C3, and Annex C4.

2-site intradermal schedule (2-2-2-0-1-1)

  • The order identifies the 2-site intradermal schedule as (2-2-2-0-1-1).
  • The order defines intradermal dosing units:
    • 0.1 ml per dose for PVRV.
    • 0.2 ml per dose for PDEV/PCECV.
  • The order requires one dose at two sites on Days 0, 3, and 7, and one site on Days 30 and 90.
  • The order requires injections on the deltoid area of each upper arm in adults, or in infants at the anterolateral aspect of the thigh.
  • The order requires use of a one (1) ml. insulin syringe with gauge 25 or 26 needle for intradermal injection.
  • The order requires vaccine storage within 4°C and 8°C and after reconstitution use within 8 hours.
  • The order sets rules for missed doses:
    • If only day 0 was given and the time between day 0 and the day 3 dose is more than one week, repeat the first dose and do not repeat RIG.
    • If at least day 0 and day 3 doses were given, adjust missed doses while giving remaining doses according to the original schedule.
    • If the day 30 dose is missed, it may be given when the patient comes, and the day 90 dose may be given as originally scheduled or at least 1 month after the day 30 dose, whichever is longer.
    • If day 90 is missed, it may be given when the patient comes.

2-1-1 intramuscular schedule

  • The order identifies the 2-1-1 intramuscular schedule as 2-1-1.
  • The order defines dosing equivalence:
    • One dose equals 1 vial of 0.5 ml PVRV or 1 vial of 1.0 ml PDEV/PCECV.
  • The order requires two (2) doses intramuscularly on Day 0, and one dose in the deltoid area of each upper arm in adults (or anterolateral thigh in infants) on Day 7 and Day 21.
  • The order provides that treatment does not need restarting if a patient misses a scheduled succeeding date; the prescribed interval is followed.
  • The order requires using the 2-1-1 regimen with RIG for Category III exposure.
  • The order requires the patient be informed that 2-1-1 IM is not the optimum regimen for Category III exposures when RIG is not available.
  • The order requires discontinuing the last dose if the dog is alive and healthy after a 14-day observation period.

Standard intramuscular schedule

  • The order identifies the standard IM regimen with doses on days 0, 3, 7, 14 and 28.
  • The order defines one dose as one vial of 0.5 ml PVRV or 1.0 ml PDEV/PCECV.
  • The order requires administration into the deltoid muscle in adults and the anterolateral thigh in infants.
  • The order provides that missed doses do not require restarting; prescribed intervals between injections are followed.

8-site intradermal schedule (8-site ID)

  • The order identifies the 8-site intradermal regimen as involving intradermal dosing on day 0, day 7, and days 30 and 90.
  • The order defines one dose as 0.1 ml of PCECV.
  • The order requires eight (8) doses intradermal on day 0, four (4) doses on day 7, and one (1) dose on days 30 and 90.
  • The order specifies injection sites:
    • Day 0: two injections each on the deltoid muscles, anterolateral thigh, lower quadrant of the abdomen, and suprascapular region (back).
    • Day 7: two injections each on the deltoid muscles and anterolateral thigh.
    • Day 30: one injection on the deltoid.
    • Day 90: one injection on the deltoid.
  • The order requires using the 8-site ID regimen when RIG is not available and requires informing the patient that it is not the optimum regimen for Category III exposures.

Special conditions and special management rules

  • Pregnancy and infancy do not contraindicate treatment with purified cell culture vaccines (PVRV, PDEV, PCEC).
  • The order directs avoiding chloroquine, anti-epileptic drugs, systemic steroids, and heavy alcohol consumption during rabies immunization because these may interfere with the immune response.
  • If avoiding these drugs is not possible, the order requires using the standard IM regimen.
  • The order requires immuno-compromised individuals (including HIV infection, cancer/transplant patients on immunosuppressive therapy, and similar) be given vaccine using the standard IM regimen and RIG for both Category II and III exposures.
  • The order requires that exposed persons presenting weeks or months after the bite be treated as if exposure occurred recently.
  • The order permits no treatment if the biting animal remained healthy and alive until 14 days after the bite.
  • The order provides that bites by rodents, rabbits, and domestic animals other than dogs and cats require no rabies post-exposure treatment unless the animal is proven rabid; anti-tetanus prophylaxis must be given.
  • The order requires monkey bites and other wild animal bites to be managed similarly to dog and cat bites.

Previously immunized patients and pre-exposure prophylaxis

  • The order requires local wound treatment for previously treated and previously immunized animal bite patients.
  • The order provides vaccination rules for second exposure after previously receiving complete pre-exposure prophylaxis or post-exposure treatment with tissue culture vaccine:
    • If second exposure occurs < than 1 month after completion: no booster dose.
    • If second exposure occurs 1 to 3 years after completion: two booster doses on D0 and D3.
    • If second exposure occurs > than 3 years after completion: another full course of active immunization.
  • The order states booster doses may be given intradermally at 0.1 ml for PVRV or 0.2 ml for PDEV/PCECV or intramuscularly at 1 vial of PVRV, PDEV, or PCECV.
  • The order states no rabies immunoglobulin is needed for these booster situations.

Pre-exposure prophylaxis (PrEP)

  • The order recommends pre-exposure prophylaxis for individuals at high risk of rabies exposure, including personnel in rabies diagnostic laboratories, veterinarians, animal handlers, and others directly involved in rabies control.
  • The order sets PrEP dosing:
    • 0.1 ml for all vaccine types given intradermally (ID), or
    • 1 vial of 0.5 ml for PVRV or 1 vial of PDEV/PCEC given intramuscularly (IM) at one site.
  • The order sets initial PrEP schedules as one dose of either vaccine on Days 0, 7 and 21 or 28.
  • The order requires a booster dose every two or three years depending on risk of work-related exposure.

Laboratory confirmation and handling

  • The order requires animals for laboratory testing to be placed in a leak-proof double plastic bag, then placed in a bigger container with liberal amounts of ice.
  • The order provides that if an animal can be brought to the laboratory within 12 hours of death, no ice is needed.
  • The order prohibits adding chemical disinfectants or preservatives such as formalin or alcohol.
  • The order requires bringing specimens to the nearest rabies diagnostic laboratories whose addresses are detailed in Annex E.

Biting animal management

  • The order advises consulting a veterinarian on biting animal management when possible.
  • The order provides specific observable signs supporting concern for rabies:
    • Sudden change of behavior.
    • Hoarse howl.
    • Watchful, apprehensive expression; staring; blank gaze.
    • Drooling of saliva.
    • Paralysis or uncoordinated gait of forelimbs.
    • Marked restlessness and pacing.
    • Aimless running and biting anything in its way.
    • Depraved appetite and self-mutilation.
    • Quiescence with biting when provoked.
    • Snapping at imaginary objects.
    • Paralysis of lower jaw and tongue; inability to drink.
    • Sudden death without associated signs and symptoms.

Dispensing and free treatment mechanisms

Referral and dispensing function

  • The order requires referring patients needing post-exposure treatment to an Animal Bite Treatment Center where free human anti-rabies immunizing agents (vaccines and RIG) are administered.
  • The order requires the assessment of animal bite patients and dispensing of vaccine and RIG through the following procedures:
    • Thoroughly assess the victim and record in the Municipal/City/Hospital Rabies Surveillance Form (Facility-based form).
    • Decide whether to initiate treatment using the Guide for Rabies Post-Exposure Treatment as reference.
    • For immunization warranting Category II and Category III, provide the initial 2 doses of tissue culture vaccine for the 2-1-1 schedule; succeeding doses are the patients’ responsibility, except that when the intradermal regimen is used, the complete course of active immunization is given for free.
    • Provide the required dose of rabies immunization (RIG) if indicated and available.
    • Prefer the first RIG of choice as EIG.
    • Explain decisions with emphasis on adherence to treatment schedules.
    • Observe courtesy and tactfulness toward patients, particularly those who do not need immunization.
    • Provide advice on Responsible Pet Ownership.

Government responsibility for free vaccine

  • The order makes dispensing free anti-rabies immunizing agents the sole responsibility of government health agencies if available.
  • The order requires providing vaccine for free to Category III patients who lack capacity to buy succeeding vaccine doses, if available.
  • The order requires restricting free vaccine to properly assessed animal bite patients who are physically present.
  • The order prohibits giving vaccine to non-patients.

Priority order for free vaccine assistance

  • The order sets the program’s order of priority for free vaccine assistance:
    • Patients bitten by animals found positive for "negri bodies", regardless of exposure category.
    • Patients with Category III exposure.
    • Individuals exposed to human rabies patients through bite/non-bite exposure (mouth-to-mouth resuscitation, licking of intact mucosa such as eyes, lips and vulva).
    • Patients bitten by animals that are not available for observation (stray/slaughtered).
    • Patients with Category II exposure.

Free PrEP for rabies personnel

  • The order requires government veterinarians and laboratory technicians working for rabies diagnosis, prevention and control be provided free pre-exposure prophylaxis using the intradermal technique if available.

Vaccine allocation and distribution roles

  • The order assigns vaccine procurement to the National Center for Disease Prevention and Control.
  • The order requires the National Center for Disease Prevention and Control to ensure Regional Health Offices receive vaccine allocation every quarter, subject to availability.
  • The order assigns distribution to the Centers for Health Development, acting through the Director and the Rabies Control Program Coordinator, for delivery to Provincial/City Health Offices.
  • The order assigns local distribution to Provincial Rabies Control Coordinators to establish Animal Bite Treatment Center(s) for administering free human anti-rabies immunizing agents (vaccines and RIG).

Summary schedule annex references and integration

  • The order integrates detailed exposure categorization in Annex A, tetanus-prone bite guidance in Annex B, and regimen schedules in Annex C1, Annex C2, Annex C3, and Annex C4.
  • The order integrates delivery and dosing structure for pre-exposure prophylaxis in Annex D.
  • The order integrates laboratory location details in Annex E.

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