A bite and rabies risk.

2:57 PM

Disclaimer: this is NOT a post to debate animal rescue, pet care, and healthcare. This is an AWARENESS raising post and a list of info about rabies and it's prevention in India, based on my recent experience. I was planning to tell my story all along, but, Dr Om Shrivastav, who is the Director of department of Infectious diseases at Jaslok Hospital in Mumbai asked me to raise awareness about the need for prompt and accurate rabies treatment and authorised me to publish his name.

With this disclaimer over and hopefully understood by all, I will first share my story and then gives you the guidelines for rabies treatment. Rest assured I'll speak more about my rescue cat in a further post. I just want to keep the two things separated in order to keep this post as short as possible.

On Sunday, I picked up a stray kitten that has been roaming in my society for weeks, and looked like she would not survive much longer outdoor. I am used to be around cats, I know them well enough and this is why I took that chance. You all know however that I have a pet dog as well, and I knew caution was to be exercised which is why I was the one handling the cat all along. Kitty got scared of the dog, and bit me while I was holding her. Knowing what to do in a case of animal bite, I immediately rinsed the wound under water, washed it with soap and applied some antiseptic before heading to the hospital to ask for the rabies preventive treatment. In the hospital I got my first shot of rabies vaccine, and a prescription to come back for a shot on day 3 and again on day 7 being told that it was all that was needed. That already puzzled me slightly because I heard 5 shots was the norm. I googled rabies and prevention extensively only to find out that not only I was right about the 5 shots, but that the hospital also failed to administer a shot of immunoglobulin which is a crucial part of rabies prevention in case of a bite that drew blood. The Indian National Center for Disease Control has a protocol in place which you can read here. It became quite clear to me I had been misinformed. My plan on Monday was to see a physician on Wednesday at the time of my second vaccine dose and bring it up. On Tuesday however, my cat started showing wobbly ness in her hind legs and looked a bit disoriented and weak, which CAN be a sign of rabies in cats. With that new informations I decided not to delay talking to a Physician, and headed back to the hospital. There he first told me that rabies risk was low, added that immunoglobulin should not be administered routinely, but conceded the fact that the 3 doses of vaccine prescribed was incorrect, and upon seeing I got bitten in two places agreed I fell in the category of candidate for immunoglobulin shots. Immunoglobulin dosage varies according to ones weight, for me it was 5 vials that were needed, the hospital had only two and could not find the other 3 in Mumbai. The Physician however told me injecting me with just two would do until the remaining could be found. He asked DH to ask relatives accross the country to hunt the serum down and courier it to us, which shocked me a little. DH spent most of Wednesday trying to find it, the brand we were told to find was a 7k a vial serum of human origin. In his mad search he found that a domestic brand existed at around 400 rupees a unit. I researched it some more and found out the desi version is the Equine Immunoglobulin and wondered if it could be mixed with the human one I received. What became clear at this point was that the physician did not give us all the options and pushed a costly imcomplete treatment on us. DH and I could no longer trust anybody in the hospital and I turned to my network of expats married to Indian friend for the name of a trustworthy Doctor to turn to.

This is how I came to be in the care of Dr Om Shrivastav, who is the director of Infectious diseases in Jaslok Hospital. He is a specialist who knows what to do. I called him immediately, and upon hearing my story on the phone asked to see me. I raced down to South Mumbai immediately, after hearing more of my story he told me that the course of the immunoglobulin treatment should have to be completed with Equine serum, we located the dose I needed and I got injected with it on Thursday. He was shocked to hear the series of mistakes that has been done by healthcare practitioners in my case. Mistakes I will list below:

1) The Casuality department should have injected me with immunoglobulin on Sunday itself, at the site of the bites and then administered the first does of vaccine. This wasn't done, and never even have been explained to me.

2) I got an incomplete prescription for rabies prevention that day too. In case of a bite which drew blood, and without having been immunised previously the post-exposure vaccine doses have to be given on days 0, 3, 7, 14 and 28. It is FIVE doses NOT 3

3) Upon returning and pointing the flaw and asking for immunoglobulin, the physicians was in the wrong suggesting it was not required as rabies risks are low. He should never have agreed to inject only 2 vials out of 5.

4) the same physician should also have offered the equine serum option upon realising there was a shortage of human one.

5) He should NEVER have even asked DH to ask relatives to buy it and courier it our way. Immunoglobulin is a live serum that need to be kept under specific temperatures not to spoil and can't be shipped via DHL. The serum can only be handled by medical professionals. A spoilt serum injected into a human being could pretty much kill said human.

All this happened in a posh, so called "world class amenities" hospital, complete with glitzy lobby and fancy decor. They dismissed the guidelines out into place by the government of India itself, out of ignorance. Their negligence could have cost me my life if I were not proactive and researched things myself.

Rabies is a virus that is fatal. Once you develop clinical symptoms of the disease it is too late, you are doomed to die. However, the incubation period in humans allows the vaccine to prevent the disease from developing IF and ONLY IF the protocol is followed to the T. 20k people DIE of rabies in India annually due to lack of treatment and negligence from both patients and healthcare specialist. There NO low risk with rabies! you do NOT take any chances with an animal bite! domesticated or wild? Dr Om Shrivastav told me himself that earlier in the month he got a patient who died of rabies after her pet dog bit her. She felt she was safe and didn't get prompt treatment, the price was sadly her life. You get bitten by any animal, domesticated or not, vaccinated pet or not you GO get your rabies shot. The vaccine is 318 rupees a shot, you need 5, Equine immunoglobulin might set you at a thousand rupees or such depending on your weight. I might seem pricey, and a bit of a hassle to get, but remember, all these are far far far FAR cheaper than loosing your own life.

If you get bitten by an animal, again, any animal, here is what you should do in this order :

1) Wash the wound under running water with soap. Washing can remove 60% of the rabies infected saliva at the site of the bite. Pat the wound dry and put antiseptic on it. Head to the hospital as soon as you can.

2) I. The hospital, if you haven't been immunised for rabies before, they should inject you with human or equine rabies immunoglobulin at the site of the bite, then give you the first dose of the rabies vaccine in the arm.

3) After the first shot of vaccine you will need to return for a vaccine dose on day 3, 7, 14 and 28. Which will bring you to a total of 5 rabies vaccine shots. This will keep you immunised for 3 years...however if bitten again in that time span, it does NOT dispense you from not going to the hospital for the next bite. previously immunised people will still need a few shots as a booster, but will be exempted from receiving the immunoglobulin serum.

If in doubt about how you have been treated at a hospital, refer to the Governement of India guidelines and show them to your doctor...INSIST on proper treatment, do not let them dismiss your concern. This protocol has been put into place to save lives and make rabies a preventable disease. If you are living in Mumbai, Dr Om Shrivastav has asked me to let you know he sits at the Jaslok Hospital in Pedder Road, do not hesitate to contact him about rabies, or any other infectious diseases for that matter.

This informations apply to all living or travelling through India. Do not become a statistic and be one of the 20 thousand rabies death India see a year. Know that an animal cannot be tested for rabies while alive, there are no blood test to confirm it. An animal that bit you should be kept confined for 10 days, if it shows a change in behaviour and it's condition deteriorate rapidly, the chance of rabies increases. Once the animal died of a natural death, it should be sent for examination to a laboratory. Only a test performed on the brain of the deceased animal can confirm rabies, but by the time this is done, it could be too late for yourself. In this light, we can all agree that a few jabs in the arms is really a very small price to pay and that the motto should be " Better Safe than Sorry"

As for myself, I am now in the safe and back on track with the treatment, my wrists are a bit sore from the injection of equine immunoglobulin I got yesterday. But the error that could have potentially cost my life in the first hospital I visited is rectified and all I am to do now is get my days 7, 14, and 28 shots which are the one left.

As for the cat? She seems fine, her leg weakness was due to an old injury and a little anaemia, she hasn't deteriorated, but is still being observed by me in my home for any changes, the date at which it can be determined she was not infectious when she bit me is next Tuesday, and of course I am keeping her, but as I said, this is part of another post.

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  1. This is a really good post. I'm glad you were able to find a good doctor who got you the right treatment. Hopefully spreading some awareness will help others should they find themselves in a similar situation.

  2. Thank you, awareness is definitely needed, many people in India die because they can't afford the treatment which is bad enough, but a good percentage die after getting improper treatment or thinking they were not at risk evenif paying for the treatment was not a problem and could be afforded. It seems the hospital that made the blunder regularly dismiss the immunoglobulin part of the treatment, which in the case of a first time bite in a non immunised person is a non negotiable, it HAS to be administered.

  3. Sharmishtha4:09 AM

    You should send a print out of this post to the idiot doctor and medical establishment that is clueless about a major malpractice in treatment. Maybe they will learn something about proper treatment protocol. If you had contracted rabies, you might have, God forbid, died. And think about the millions who trust people like him as a demi-God.

  4. I plan to write a serious letter to the management of the hospital, because it is the negligence of several doctors that occurred. And I came to know from various friends that also got bitten that depending who treated them it was 3 or 5 shots, but never the immunoglobulin shot. Clearly they are clueless about the protocol and yes their mistake could have killed me which is a very scary thing. It makes me wonder how many of the 20k annual rabies death in India are due to doctors doing their job improperly.

  5. If you plan to write to a letter to the hospital, do enclose the Indian National Center for Disease Control guidelines, quoting the relevant portions. You must also send a copy of the letter to National Center for Disease Control bringing this to their notice that some hospitals are not following their protocols in this matter. Once it is brought to the notice of the National Center for Disease control, they may undertake a review of their policies for stricter compliance of their directions. The hospital may not may not rectifiy their mistake but what about other medical establishments in the country. The best thing to do is to write e mail to the highest officials at the hospital and the National Centre for Disease Control as it is more direct and quick.

  6. Thanks! This is a great idea, I haven't thought of writing directly to the NCDC in the first place but it makes a lot of sense.

  7. Alexandra Madhavan11:36 AM

    That is SO SO SCARY!!!!!!! I am just in shock of the negligence of that so-called doctor!!!!!!! what the hell!!!
    That would have angered me so much. I would complain to the hospital and whoever granted him his physician certificate. Do they have rateMDs.com there?


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