A Rabies Death in Kentucky and Ohio, 2024: A Late Diagnosis and 709 Contacts Assessed

Human rabies is rare in the United States, and most U.S. cases come from wildlife. But people can catch it abroad, usually from dogs where dog rabies is common. This is the story of one such case — and of how a late diagnosis left dozens of health care workers exposed.

The patient

A man moved from Haiti to the United States in April 2024 and began working in a Kentucky warehouse in August. In November he went to a local emergency department (hospital A) with knee and lower back pain:

• First visit: normal knee and spine radiographs; sent home.
• Same day: back with worse pain in both legs, nausea and frequent urination; given fluids and pain medicine and sent home.
• Two days later: dizziness and severe leg weakness. Computed tomography of his head was normal, but magnetic resonance imaging of his lower spine showed a bulging disc, taken as the likely cause. He declined admission.
• Next day (hospital day 1): arrived by ambulance, unable to walk, weakness spreading to his arms, struggling to breathe.

On day 2 he developed excessive saliva, trouble swallowing and agitation; by day 3 he needed a breathing machine.

The patient's timeline, 2024. CDC / MMWR

Why rabies was missed for weeks

Doctors considered rabies as early as day 3. But he was too ill to answer questions, his family knew of no animal exposure, and other explanations seemed plausible: the disc, Guillain-Barré syndrome (he had recently had several vaccines; he got immunoglobulin), and toxoplasmosis (his spinal fluid was positive for toxoplasma antibodies; he was treated for it).

On day 10 he had continuous seizures, and he was later moved to a hospital in Ohio (hospital B) for neurocritical care. A salivary gland biopsy showed only nonspecific inflammation; brain imaging on day 17 showed severe damage, brain stem herniation and no blood flow.

On day 29, hospital B asked the Kentucky and Ohio health departments for rabies testing. CDC received the samples on day 34 and confirmed rabies the same day — antibodies in his blood and spinal fluid, and virus RNA in his saliva. He died on day 34, 40 days after his symptoms began.

Where it came from: the virus matched a variant carried by dogs in Haiti (the Haiti–Dominican Republic variant CAR1a). Haiti has one of the highest rabies risks in the Western Hemisphere. Investigators there could not pin down the source — an unconfirmed report mentioned a cat scratch, and he had traveled widely. The incubation, at 7 months or more, was unusually long (typically 3 weeks to 3 months), which made rabies seem less likely.

Tracing contacts

The infectious period ran from 14 days before symptoms until his death. Exposure meant his saliva, tears or nerve tissue touching someone's eyes, mouth, nose or broken skin — protective equipment that blocked contact meant no exposure.

He had also spent 3 days in New York; the state found his three relatives there potentially exposed. He flew, but had no drooling or agitation then, so fellow passengers were not traced.

Post-exposure prophylaxis (PEP) was one dose of human rabies immune globulin plus vaccine on days 0, 3, 7 and 14. Of the 60, 50 finished the series and six started but did not finish.

The lesson: standard precautions

Standard precautions were used inconsistently before the diagnosis. For all but four of the exposed health care workers, gloves, gowns, masks and eye protection — recommended for every patient — could have avoided the need for PEP; the other four had contact needing enhanced precautions.

• Rabies has only been confirmed to pass between people through organ or tissue donation; spread to health workers has never been documented — but infected people shed virus in saliva.
• Rabies is almost always fatal once symptoms start, so prevention is everything.
• This was one of the largest health care rabies exposure investigations in recent U.S. history.
• Standardized risk assessment targeted PEP to the few truly exposed — sparing others the side effects and cost.
• Most U.S. clinicians have never seen a case. When rabies is suspected, call the state health department right away — its staff know the testing, and early consultation can prevent delays and exposures. Rabies still circulates in wildlife in every state except Hawaii.

Sources

Based on Barger A, Margrey SF, Siu AW, et al., "Imported Human Rabies — Kentucky and Ohio, 2024," MMWR Morbidity and Mortality Weekly Report, volume 75, Centers for Disease Control and Prevention; a work of the United States government in the public domain. The report's summary counts 52 health care workers among those advised to get PEP and its results 53, and it dates the transfer to Ohio both to ten days after admission and to hospital day 13, so neither figure is given here.