A Puppy Bite in India and a Fatal Case of Rabies in Virginia, 2017

This report describes a case from 2017.

On May 9, 2017, the Virginia Department of Health was told of a patient with suspected rabies. Six weeks before her symptoms began, she had been bitten by a dog while traveling in India. On May 11, CDC confirmed infection with a rabies virus that circulates among dogs in India. Despite aggressive treatment she died, the ninth person since 2008 to die of rabies in the United States after being exposed abroad.

The illness

The patient was a 65-year-old woman with no prior health problems.

• May 3: while gardening, she developed pain and tingling in her right arm.
• May 6: an urgent care clinic diagnosed carpal tunnel syndrome and prescribed an anti-inflammatory drug and hydrocodone.
• May 7: at hospital A she had shortness of breath, anxiety, sleeplessness and trouble swallowing water, and worried she had been exposed to something toxic. Tests were normal. She was treated with lorazepam for a presumed panic attack and sent home, then returned almost at once after feeling claustrophobic and short of breath in the car, and was sent home again.
• May 8: an ambulance took her to hospital B with chest discomfort, shortness of breath, spreading tingling in her right shoulder and arm, and worsening anxiety. She was agitated with a fast heart rate, and her electrocardiogram suggested acute cardiac ischemia, but emergency catheterization showed normal coronary arteries. That evening she grew agitated and combative and gasped for air when she tried to drink. Asked about animal contact, her husband said a puppy had bitten her right hand in India about six weeks before her symptoms began. She had cleaned the wound with the tour operator's help but sought no further care. She had no record of a pretravel health visit and had never been vaccinated against rabies.
• May 9: she was placed on a ventilator. An electroencephalogram suggested severe encephalopathy. Because post-exposure prophylaxis (PEP) does not work once symptoms have started, it was not given. Samples went to CDC.
• May 11: CDC confirmed rabies from her saliva and a skin biopsy. Sequencing identified a dog rabies variant associated with India.
• May 13 onward: doctors used the Milwaukee protocol, an experimental treatment with rare and inconsistent success, adding favipiravir and later interferon beta, but her body never produced antibodies against the virus.
• May 21: her family decided to withdraw life support, and she died shortly afterward. Rabies virus was later isolated from her brain.

Tracing exposures

The Thomas Jefferson Health District, which covers both hospitals and the urgent care clinic, led the local investigation with a standard survey tool and national Advisory Committee on Immunization Practices (ACIP) guidance. Of 258 workers identified at the clinic, the ambulance service, both hospitals, the funeral home and the medical examiner's office, 250 were reached and assessed, and PEP was recommended for 72 (29%). Eight declined. The rabies immune globulin and vaccine cost about $235,000, paid by the two hospitals and the health department.

When workers were exposed mattered:

Exposures dropped significantly once rabies was diagnosed. The extra precautions, added after she developed a drug-resistant urinary tract infection, made no significant further difference.

The patient lived in a communal living facility. She was assumed to be contagious from April 19, two weeks before symptoms began. The Piedmont Health District interviewed 13 residents who had close contact with her; four, three who had touched her saliva and one she had bitten, were advised to start PEP.

The tour

From January 28 to April 5, 2017, she had been on a long organized yoga retreat tour of India, with 17 tour members from the United States and Spain and six staff members from the United States and India. Tour members confirmed that a puppy bit her outside her hotel in Rishikesh and that the wound was only washed with water. Three other members had touched the same puppy. Two were found not to have been exposed; the third, a North Carolina resident bitten on the leg, was advised to get PEP. The tour manual told travelers to talk to a doctor about health concerns but listed no specific risks or vaccines. Indian health authorities were notified through WHO and investigated; one rabid dog had been reported in the area in the previous six months, but nothing more was learned about the puppy or its owner.

Lessons

• Rabies is still a global killer. Dog rabies was eliminated from the United States in 2004 but remains endemic in 122 countries and causes an estimated 59,000 human deaths a year, more than any other disease passed from animals.
• Get pretravel advice. CDC recommends rabies vaccination before travel to India, which has the world's highest incidence of human deaths from dog rabies, for travelers doing outdoor activities that risk animal bites. Given how long this tour was and its rural and community activities, pre-exposure vaccination should have been considered. It is recommended for anyone spending long periods in countries where rabies is endemic, going to remote areas, or planning activities that risk exposure.
• After a bite, get PEP quickly. It is highly effective if given before symptoms appear, typically 3 weeks to 3 months after exposure. Previously vaccinated people need two booster doses; unvaccinated people need four vaccine doses plus rabies immune globulin at the wound.
• Standard precautions are enough in hospitals when applied properly: gowns, goggles, masks and gloves, especially during procedures that can splash body fluids. Thinking of rabies early and diagnosing it fast cuts exposures and PEP costs.

Sources

• Murphy J, Sifri CD, Pruitt R, et al. Human Rabies — Virginia, 2017. MMWR Morb Mortal Wkly Rep 67(51–52). https://www.cdc.gov/mmwr/volumes/67/wr/mm675152a2.htm
• CDC travelers' health: https://wwwnc.cdc.gov/travel
• The report was led by the Virginia Department of Health with the University of Virginia, local health districts and CDC; its figure is not reproduced here.