Rabies & Animal-Bite Guide for Nepal: PEP, First-Aid, Vaccine

The single most important thing you can do after any animal bite or scratch in Nepal is to wash the wound immediately. The World Health Organization (WHO) and Nepal's National Guidelines for Rabies Prophylaxis recommend thorough washing of every bite wound and scratch with soap and running water for at least 15 minutes. This mechanical flushing physically removes and inactivates rabies virus at the wound before it can travel along the nerves, and it measurably reduces the risk of infection.

Do not suture (stitch) the wound immediately if it can be avoided, do not apply irritants such as chilli powder, ash, herbs, oil, or acid, and do not cauterise it, all of which are common but harmful traditional practices. After washing, an antiseptic such as povidone-iodine or 70% alcohol can be applied. Bleeding is usually allowed to flush the wound rather than being stopped too quickly, unless it is heavy.

Washing is first aid, not treatment. Even a wound that looks minor can transmit rabies, and the incubation period can be weeks to months, so you must still go to a health facility the same day to be assessed for post-exposure prophylaxis (PEP). Tell the health worker what animal bit you, whether it was provoked, whether the animal is a pet or a stray, and whether it can be observed or was already killed.

Health workers decide what treatment you need by classifying the exposure into one of three WHO categories, based on how the animal contacted your skin. Getting this classification right is what determines whether you need only wound care, wound care plus vaccine, or wound care plus vaccine plus rabies immunoglobulin (RIG). Because rabies is essentially untreatable once symptoms begin, when in doubt clinicians treat for the higher category.

Category I is contact that does not break the skin: touching or feeding an animal, or licks on intact skin. No PEP is needed for a true Category I exposure, only reassurance. Category II is nibbling of uncovered skin, or minor scratches or abrasions without bleeding; this needs immediate wound washing and a full course of anti-rabies vaccine. Category III is the most serious: single or multiple transdermal bites or scratches, licks on broken skin, contamination of a mucous membrane (eyes, mouth) with saliva, or any contact with a bat. Category III needs wound washing, the vaccine, and rabies immunoglobulin.

In Nepal the great majority of reported bites are from dogs, and bites to the hands, feet and face are treated with particular urgency because the virus reaches the brain faster from wounds near the head and from nerve-rich areas.

Nepal has adopted the WHO-recommended intradermal (ID) route, which uses much less vaccine than the older intramuscular schedules and so stretches limited supplies across more patients. The standard WHO one-week, two-site intradermal schedule gives 0.1 mL of vaccine at two sites on day 0, day 3 and day 7, counting from the first day you receive the vaccine (not the day of the bite). Modern vaccines used in Nepal are safe cell-culture vaccines, not the old nerve-tissue vaccines.

Where the intramuscular (IM) route is used, the Essen regimen gives one dose on days 0, 3, 7, and a final dose between days 14 and 28. A person who has previously completed a full rabies vaccination course and is re-exposed needs only a shortened booster course — for example, a single intradermal site on days 0 and 3 — and does not need immunoglobulin. Keep your vaccination card and follow the exact dates written on it.

Do not skip doses or stop early because the wound looks healed; an incomplete course may not protect you. If you miss a scheduled dose, go as soon as possible and let the health worker adjust the timing rather than restarting. Pregnancy, breastfeeding and young age are not reasons to withhold PEP, because untreated rabies is fatal.

Rabies immunoglobulin gives immediate, ready-made antibodies that protect during the first days before the vaccine can stimulate your own immune response. It is required for all Category III exposures and for Category II exposures in people who are severely immunocompromised. It is given only once, at the start of treatment, together with the first vaccine dose.

The correct way to give RIG is to infiltrate as much of the dose as possible directly into and around the wound(s); any remaining volume is injected at a distant muscle site. The two products are human rabies immunoglobulin (HRIG) at a dose of 20 international units per kilogram of body weight, and the more widely available and cheaper equine rabies immunoglobulin (ERIG) at 40 international units per kilogram. RIG should not be given in the same syringe or the same site as the vaccine.

RIG is expensive and often in short supply in Nepal, so it is prioritised for genuine Category III wounds. If RIG is not immediately available, the vaccine course should still be started without delay and RIG added as soon as possible, ideally within seven days of the first vaccine dose.

The Nepal government has provided anti-rabies vaccine free of charge at government hospitals and health centres since 2007, and switched to safer cell-culture vaccine after local production began in June 2006. In practice, availability varies: government hospitals and district health offices in cities usually stock the vaccine, while remote health posts may not, and periodic national shortages force some patients to buy the vaccine from private pharmacies at their own cost.

Major referral points include Sukraraj Tropical and Infectious Disease Hospital in Teku, Kathmandu, which sees hundreds of animal-bite patients a day, along with large public hospitals such as Bharatpur Hospital in Chitwan and provincial and district hospitals nationwide. If your nearest facility has run out, do not wait — the incubation period gives some time, but you should seek the vaccine at the next facility as quickly as possible, and keep your vaccination card so any hospital can continue your schedule.

If the biting animal is a healthy pet dog or cat that can be safely confined and observed for 10 days, and it remains healthy throughout, PEP may sometimes be stopped early on medical advice; but you should still start PEP immediately and only stop if a doctor confirms it is safe.

Rabies is a serious but preventable public-health problem in Nepal. Government facilities have recorded tens of thousands of animal bites a year — roughly 20,000 to 40,000 reported animal bites annually in the years around 2013–2018, with dogs responsible for more than 90% of them — and the numbers have been rising, with over 56,000 people seeking anti-rabies vaccination at state facilities in fiscal year 2021/22. Reported human rabies deaths in recent years have generally been in the low tens (official records have ranged from single digits to about 32 a year), but experts believe the true toll may exceed 100 deaths annually because many rural cases go unrecorded.

Nepal has committed to the WHO-led global 'Zero by 30' strategy — eliminating human deaths from dog-mediated rabies by 2030 (roughly 2087 in the Bikram Sambat calendar). Reaching that target depends heavily on mass vaccination of dogs, because human PEP alone cannot break transmission while the virus circulates in the stray-dog population. The Epidemiology and Disease Control Division (EDCD) under the Ministry of Health and Population leads the National Rabies Control programme using the 'One Health' approach that links human, animal and environmental health.

The main obstacles are recurring vaccine shortages, under-vaccination of the free-roaming dog population, and under-reporting of rural deaths. Because rabies is nearly 100% fatal once symptoms appear but also nearly 100% preventable with prompt PEP, public awareness of correct first aid and of the free government vaccine is itself a life-saving intervention.