What to do after a dog bite or snakebite in Nepal

Wash the wound immediately, thoroughly, with soap and running water. This is not a formality and it is not something to do after you get to the clinic. Thorough wound washing is the first component of post-exposure prophylaxis as WHO defines it, and it physically reduces the amount of virus at the site before it can travel. Do it for several minutes, not a rinse, and do it even if the wound barely bled.

Then go to a health facility the same day. A health post, primary health care centre or district hospital can assess the exposure and start the vaccine course or refer you to where it is held. Do not wait to see whether the wound becomes infected, do not wait for the dog to show symptoms, and do not wait until the next working day if it is a Friday evening.

Do not close the wound yourself. Suturing a bite wound before it has been properly assessed and irrigated is generally the wrong move, and applying local remedies — chilli, oil, herbal pastes — makes the wound harder to clean and does nothing about the virus.

Tell the health worker exactly what happened: what animal, whether it was provoked, whether the animal is known and can be observed, whether the skin was broken, and whether saliva reached your eyes, mouth or an existing cut. Exposure is graded, and the grading determines whether immunoglobulin is needed in addition to the vaccine.

The vaccine is given as a course, not a single injection. Finishing it is the whole point. People routinely take the first dose, feel fine, and stop, which is the same as not starting. Write the dates down and treat the appointments as fixed.

If the animal is a household dog whose vaccination status is known and documented, say so, but do not treat an unvaccinated family dog as safe because it is familiar. Familiarity is not immunity, and the majority of human rabies cases worldwide come from dogs people knew.

Monkeys, cats, jackals, bats and other mammals also transmit rabies. Kathmandu and the temple sites see a steady stream of monkey bites and scratches on both residents and visitors, and a monkey scratch at Swayambhunath or Pashupatinath is an exposure that needs the same response as a dog bite.

Post-exposure prophylaxis, as WHO describes it, consists of three parts: thorough washing of the wound, a course of human rabies vaccine, and rabies immunoglobulin where it is indicated by the severity and site of the exposure. Not everyone needs immunoglobulin; everyone with a genuine exposure needs the vaccine course.

The reason speed matters is mechanical. Rabies travels from the bite site along nerves towards the brain, and the treatment works by stopping it before it arrives. Once the virus reaches the central nervous system and symptoms begin, there is nothing to give. WHO states plainly that at that point rabies is fatal in 100% of cases and that what remains is compassionate palliative care.

The incubation period is typically two to three months but can be as short as about a week or as long as a year, depending on where the virus entered and how much of it there was. This is why a bite that healed cleanly three months ago and has been forgotten is still worth reporting if you never had the vaccine — the window may not have closed, and there is nothing to lose by asking.

Bites on the face, head, neck and hands are more urgent than bites on the leg, because the distance the virus must travel is shorter. If a child has been bitten on the face, treat it as an emergency rather than as something to attend to tomorrow.

Early symptoms are non-specific — fever, pain, and unusual tingling, pricking or burning sensations at the wound site — before the disease progresses to inflammation of the brain and spinal cord. The tingling at an old, healed bite site is the sign that matters and the one people do not recognise.

Vaccine supply varies by facility. A district hospital is more likely to hold it than a small health post, and it is worth asking by telephone where it is available before travelling, particularly outside the main towns. The Epidemiology and Disease Control Division runs the Zoonoses Control Programme under which rabies control sits, and publishes the manuals, guidelines and factsheets health workers use.

Pre-exposure vaccination exists and is worth considering for people at continuing risk: veterinary and animal-control workers, people working with wildlife, and travellers heading to remote areas where reaching treatment quickly would be difficult. It does not remove the need for treatment after an exposure, but it simplifies it.

Move the person away from the snake and keep them as still as possible. Movement pushes venom through the lymphatic system, and a person who walks two kilometres to a road is worse off on arrival than one who was carried. Sit or lie them down, keep the bitten limb below the level of the heart, and stop them walking.

Immobilise the bitten limb the way you would splint a fracture — with a stick or board and a bandage or cloth, firm but not tight enough to stop blood flow. Remove rings, bangles and watches from the limb before it swells, because they become tourniquets on their own once swelling starts.

Get them to a health facility that holds antivenom, as fast as safely possible. This is the entire treatment. Antivenom is on WHO's essential medicines list and is the only effective treatment for envenoming; nothing done at the roadside substitutes for it. If you know which local facility stocks it, go there rather than to the nearest building with a red cross on it.

Do not apply a tourniquet. Do not cut the wound. Do not try to suck out venom, with your mouth or with any device sold for the purpose. Do not apply ice, and do not give alcohol. Every one of these is common practice in Nepal and every one of them causes additional harm — tissue death, extra bleeding, infection, and a delay while the wrong thing is being done.

Do not go to a traditional healer first. WHO records that many victims opt for traditional practices rather than hospital care and that this contributes directly to deaths, and in Nepal it is the single most consequential decision the family around a snakebite victim makes. If a household is going to consult a healer, someone should be driving to the hospital at the same time.

Try to describe the snake if you saw it — size, colour, markings, whether it reared — but do not go back to find it, catch it, or kill it and bring it. People are bitten a second time doing this, and treatment does not depend on identifying the species.

Watch for the signs of envenoming on the way: drooping eyelids, difficulty speaking or swallowing, difficulty breathing, blurred vision, drowsiness, bleeding from the gums or the bite site, and severe swelling. Tell the receiving staff exactly what you have seen and when it started.

Snakebite in Nepal concentrates in the Terai and peaks during the monsoon, when flooding drives snakes out of burrows and into fields, courtyards and houses. The bites that kill disproportionately happen at night and indoors, to people sleeping on the floor, and the krait is the reason — a snake that enters houses, bites while people sleep, and produces a bite that can be almost painless at the time.

The most effective single measure in a snakebite district is sleeping off the floor, on a raised bed, under a tucked-in mosquito net. The net is not primarily about snakes, but a properly tucked net is a physical barrier and it works for the exact scenario that produces the worst outcomes. It also deals with the mosquito-borne disease burden that peaks in the same season.

Keep the area around the house clear. Grain stores, woodpiles, rubbish heaps and thick vegetation against the wall attract rats, and rats attract snakes. Sealing the gaps under doors matters more than most people think.

Use a torch after dark, always, and wear shoes outdoors. A large share of bites are to the foot and ankle of somebody who stepped on a snake they could not see. Rubber boots during field work in monsoon are the cheapest protective equipment available.

For dogs, the equivalent prevention is vaccination coverage. Rabies control works by vaccinating dogs rather than by treating people, and the national zoonoses programme exists for exactly this. Where community dog vaccination campaigns run, supporting them protects children more effectively than anything an individual household can do afterwards.

Teach children the rules directly: do not approach or feed street dogs, do not chase or corner monkeys, do not reach into holes or under stones, and tell an adult immediately about any bite or scratch, however small. Children conceal bites because they expect to be scolded, and a concealed bite is the most dangerous kind.

Not every health facility holds rabies vaccine and not every facility holds antivenom, and the map of who holds what is not intuitive. A district hospital is a better first assumption than a health post, but the only reliable answer is a local one.

The practical preparation is a five-minute phone call made on an ordinary day: ask your district hospital whether it holds rabies vaccine and snake antivenom, and whether that changes at night or at weekends. Write the answer down and put it where the household can find it. This is the same category of preparation as an earthquake go-bag and it is far cheaper.

The Epidemiology and Disease Control Division publishes outbreak and situation updates, notices, manuals and factsheets, and runs the disease surveillance system through which unusual clusters are reported. If you want to know whether something is happening in your district — an outbreak, a supply issue, a campaign — that is where it is announced.

Cost is a genuine barrier that people should plan around rather than discover. Ask what the treatment will cost and whether any exemption or free treatment provision applies at that facility. Families who do not ask sometimes leave without completing a vaccine course, which is the worst possible outcome because it costs money and delivers nothing.

If you are bitten while travelling or trekking, the calculation changes. Reaching definitive treatment may take a day or more from a remote area, which is a strong argument for pre-exposure rabies vaccination before a long trip into places with dogs and no hospital, and for treating any bite as a reason to end the trip and descend rather than to continue and deal with it later.

Finally, report animal bites even when you are certain the animal is healthy. Surveillance data is what drives vaccination campaigns and antivenom distribution, and the reason a district gets supplies is that the district reported the need.