Fact check | After being bitten by a squirrel, I went to the hospital to get 5 shots of vaccine. Is this abuse?

Today there was a news on Weibo that a boy was scratched by a squirrel while feeding it by hand. He received five injections and spent more than 1,000 yuan. It seems that the subsequent actions were correct, but in fact, the right and wrong of the matter may subvert some previous perceptions. Let me first talk about a more embarrassing fact: Although rabies vaccination is usually not required after being bitten by a rodent, there are two countries in the world that have recorded cases of human rabies related to "squirrels".

▌Case 1 is from India

The Department of Pediatrics of SAT Hospital, College of Medical Sciences, Trivandrum, India, reported a 7-year-old boy in Kerala who had "no history of being bitten by any other animal in the past" and presented with fever, cough, irritability, difficulty eating, and aggressive behavior when drinking water. The symptoms had lasted for 2 days. Two months ago, the child was bitten by a squirrel on his right leg and received a tetanus shot and wound treatment at a local hospital, but "did not receive" a rabies vaccine.

The child received "supportive care" in the intensive care unit, but his condition continued to deteriorate, and he eventually died of cardiopulmonary failure "four hours after admission." The corneal immunofluorescence test result was positive for rabies

▌Case 2 is from China

According to the research of the Chinese Center for Disease Control and Prevention, 19,221 cases of rabies were reported in 30 provinces in my country from 2005 to 2012, mainly in rural areas in southern and eastern China, mostly involving farmers, students and preschoolers. In a detailed analysis of the "death cases" reported from 2010 to 2011, it was found that these human rabies cases were mainly caused by exposure to dogs (93.7%) and cats (4.6%), and the rest were related to other domestic animals and wild animals, including horses, pigs, rats and "squirrels".

It is important to note that most reported human rabies cases are "clinically diagnosed" without laboratory testing, and the above information is based on epidemiological and post-exposure treatment data for suspected human rabies cases from 2010 to 2011.

▌Almost happened case 3

According to information released by the State Institute of Health and Family Welfare, Kasupatipalimahal, Shimla, Himachal Pradesh, India, on August 10, 2019, a 9-year-old boy in Colombo, Sri Lanka, was bitten by a squirrel in the middle of his right index finger, but "the wound did not bleed", but a small piece of skin peeled off. The doctor assessed it as a level II exposure and initiated "two-point intradermal (ID) vaccination" as post-exposure prevention (Sri Lanka's immunization program requires a total of 4 injections, 2 intradermal injections each time, which can reduce the use of vaccine antigens).

The squirrel died at noon that day, and its head was sent to the laboratory of the Sri Lanka Institute of Medical Research in Colombo for rabies testing. On August 13, the laboratory confirmed that the squirrel was positive for rabies virus through a fluorescent antibody test (FAT) report (No. H 898, dated 13/08/2019)!

The child's parents "brought the report" to the hospital again to meet with the doctor and negotiate the passive immunization. The doctor said that since the wound was superficial and it was a level II exposure, there was no need to inject rabies immune globulin (RIG) because the risk of side effects of RIG was not worth taking. Although Sri Lankan hospitals are equipped with human rabies immune globulin (HRIG), the doctor still believed that the risk of allergic reactions (such as anaphylactic shock) should not be taken. Therefore, the second dose of intradermal vaccine was administered as planned on the same day, August 13, but RIG was "not used".

After that, the Sri Lankan child’s parents sent an email to the “Indian doctor” and received a positive reply (RIG was needed). At their insistence, the child was injected with RIG, which ultimately significantly reduced the 9-year-old child’s risk of rabies. All of this was due to the parents’ persistence and hard work.

▌Case Analysis

In this case, the victim's fingers bled after being attacked by a wild squirrel. According to the exposure level, it is classified as "Level III exposure". Combined with my country's level of animal rabies virus monitoring and the background of human rabies cases suspected of being exposed to squirrels in the past, the hospital's rabies vaccination can be said to be the "correct" solution.

However, there are a few points worth noting:

① Whether passive immunization agents were used: When facing exposure caused by squirrels, if rabies vaccination is considered necessary, then according to the standard treatment of level III exposure, passive immunization agents (such as immunoglobulin or monoclonal antibody) should also be used. The figure mentioned in the news is "5 injections and 1,000 yuan", so based on the price calculation, passive immunization agents may not have been used;

②Is it a re-exposure? If the injured person has received a full course of rabies vaccine and is not suitable for passive immunization, then he should not receive 5 shots of rabies vaccine, but "2 shots". If the remaining 3 shots are tetanus vaccines, the price is not right.

③Whether tetanus post-exposure treatment was performed: After being injured by a squirrel, in addition to rabies post-exposure treatment, "tetanus post-exposure treatment" should also be performed. However, judging from the number of vaccinations, this does not seem to be true, which means that tetanus post-exposure treatment may not have been performed.

Of course, apart from some doubts, there are still positive aspects.

It is worth praising that the "Informed Consent Form for Rabies and Tetanus Prevention and Treatment" issued by the Affiliated Hospital of Yunnan University in the video is a very good document, because many rabies post-exposure treatments should be accompanied by tetanus post-exposure treatments, but it is rarely mentioned, and this informed consent form is very well done.

Summary

Although the "Guidelines for the Diagnosis and Treatment of Common Animal Injuries" issued by the National Health Commission mentions that "rodents and immunomodulators rarely contract rabies, and there is currently no evidence that they cause rabies in humans", the fact is that although the evidence is limited and of low quality (India does not test animals for rabies virus infection, and China uses case record information rather than virus test results), it also suggests that the statement in the "Guidelines" is "not rigorous."

In summary, although the possibility of rabies caused by exposure to rodents is extremely small, when faced with injuries caused by "wild squirrels", on the one hand, post-exposure treatment should still be considered (including rabies and tetanus vaccination, and the use of passive immunization agents), and on the other hand, rabies virus testing of the injured animals should also be considered to confirm the risk of infection and adjust the treatment plan if necessary.

willing

Disclaimer: This article was created out of personal interest, only to help more ordinary people have a clearer understanding of vaccines. The content and views do not represent any organization, unit, or institution, and it has not accepted any form of sponsorship. All pictures are from public online platforms. If the content is incorrect, please do more self-criticism (not).