Diary of a Real-Life Veterinarian: September 2013

Wren and Oriole,
my babies.

All of us have to learn some lessons the hard way every once in a while.

I have to remind my clients that I don’t want them to make the same mistakes that I have.

There are even occasions that I find myself begging them to heed my warnings as the lessons learned have dire consequences.

I don’t get much resistance from clients about vaccinating for rabies. Primarily because it is required by Federal and Maryland state law that every pet be vaccinated. But, every once in a while I find myself in an exam room with a client actually having the following discussion. Like the “law” is something I can give your pet a “pass” on.

I think that people want to believe that their pet is immune to disease. I also think that some people are plain old tight wads. With either excuse they are placing not only their pets health and safety, but also their families own health and life, on the line.

How is it so difficult to understand that we vaccinate your kids, yourself, and your pets to try to reduce all of their chances of contracting a disease? Maybe we are all too far removed from the days of polio? Maybe we have forgotten how many millions of people have died from diseases that are almost considered eradicated now?

I have had to learn my lesson the hard way that rabies is NOT one of those mysterious, “heard of, but never seen it, because it doesn't really exist around here,” kind of diseases. Let me say loud and clear that it is alive and well in all areas of the continental Unites States.

My first experience with rabies began my first year out of Vet school. I went into a routine new kitten examination to meet a little 1-1/4 pound (about 5 to 6 weeks old) sweet orange ball of fur and fluff in a brand new Couture pink sparkly bedazzled pet carrier. This little kitten was much more interested in exploring her new world than looking fashionable, but her barely minted proud new mom wanted a transportation device that had style. It was like carrying a WWF wrestler to the fighting ring in Cinderella’s glass coach. That young college aged girl very much the epitome of modern trendy elegance, wanted a cute pet she could accessorize to match her own stylish outfits, but instead had an endless amount of firecracker energy and an all-over the place personality. I was delighted to see them. Even if that kittens mom refused to give up on her attempts to domesticate her new little beast she loved that kitten and I was sure there was a long term bond here, individual personality clashes aside.

That first exam on her kitten “Sunny” was uneventful. We tested her for FeLV/FIV, (both were negative), de-wormed her, and reviewed the protocols for vaccinating. I explained to her that we typically begin vaccines at 8 weeks old, and repeat them every 3 weeks until 16 weeks. We also vaccinate for rabies at 12 to 16 weeks. We made an appointment for Sunny to come back in two weeks to start her kitten shots.

A week went by and I received an urgent phone call from Sunny’s mom that she wasn't eating well. I asked her to bring her in immediately. When she arrived she was still a bright bubbly effervescent kitten. She was however underweight. I often have difficulty understanding what a client is trying to explain to me, whether it be language barriers, social or cultural differences, or because clients don’t always tell you the truth, the whole truth, and nothing but the truth. I have to try to investigate why something is happening, especially because I know my patients can't tell me themselves. For instance, I have seen pets not eat because another pet in the household is eating it first, or, they are feeding a food the pet doesn't like, or cannot eat. About 10 years ago the pet food companies actually had to change the shape of the kibble because smooshy faced kitties couldn't pick up the pieces to get the food in their mouth. If I am feeling stumped about a case, or if something doesn't make sense to me I try to do my own investigative digging. So, for Sunny I did what I have done multiple times before, and hence made my first BIG mistake. I asked Sunny’s owner to leave Sunny with us for a few days for us to observe her. I wanted to know if she was interested in food, but wasn't trying to eat? or, was she eating but not keeping it down? etc. etc.

I brought Sunny back to the hospital and asked the entire staff to keep a close eye on her. Within a few hours she was playing up front with the receptionists and seemed happy, playful and fine. It took the next day for me to start to see that she was in fact acting a little oddly. She didn't have coordinated concise movements. She was clumsy and also started to tremor a little. I then got me big “light bulb” moment and thought worst case scenario, (which I have learned I need to think of first with every case). I scooped her up, brought her upstairs, and placed her in quarantine. I also called Sunny’s owner to update her. Unfortunately, I didn't have much good news for her. Instead of giving her answers I was giving her more questions and I didn't have any idea when I would know any of the answers.

After two days Sunny could barely walk. She was barely functional at all. Her prognosis was grave. I called her mom and asked her to come in and see her. When she arrived all she could do was cry. Her once perfectly animated kitten had turned into a lifeless pathetic shell. I told her that she should be humanely euthanized before she died from respiratory arrest which I thought would happen within the next 24 hours.

Unfortunately, Sunny had bitten and scratched not only Sunny’s mom, but her granddad, and one of my receptionists. I now had to send Sunny to the state pathologist to have her examined for rabies. She tearfully said her goodbye and we all tearfully euthanized her.

A few days later we received the call from the state lab that Sunny was indeed positive for rabies. My heart sank. I felt awful that so many people now had to go to their doctors and receive post rabies exposure shots. From that day on I have made sure that everyone who works at Jarrettsville Vet is vaccinated for pre-exposure rabies. Thankfully everyone in Sunny's family was fine. And I have learned my lesson. I will always think of “worst case scenario” first, and I will not put my staff at risk.

Every year JAVMA (Journal of the American Veterinary Medical Association) publishes a “Public Veterinary Medicine: Public Health” report on the “Rabies surveillance in the United States.” The September 15, 2011 edition reported the following, “during 2010, 48 states and Puerto Rico reported 6,154 rabid animals and 2 human rabies cases to the CDC, representing a 8% decrease from the 6,690 and 4 human cases in 2009. Hawaii and Mississippi did not report any laboratory-confirmed rabid animals during 2010. Approximately 92% of the reported rabid cases were wildlife.” 36% were raccoon's 24% were skunks, 23% were bats, 7% were foxes, 5% were cats, 1% were cattle, and 1% were dogs.

I think the whole article is worth reading.

And as an end note; the two human fatalities were; a 19 yr old migrant worker from Mexico who entered the US on July 25, 2010, and on Aug 2 reported left arm and shoulder pain. His clinical signs progressed quickly to generalized weakness and he had to be intubated to maintain breathing. He died on Aug 21, 2010. His rabies was tracked back to being bitten by a vampire bat on July 15 in Mexico. The second human fatality was a 70-year-old man who began to experience right shoulder pain on December 24. Two days later he began to have difficulty swallowing. Four days later he had to be intubated. It is unknown how he contracted rabies.

In 2012 the CDC reported the following:

In this century, the number of human deaths in the United States attributed to rabies has declined from 100 or more each year to an average of 2 or 3 each year. Two programs have been responsible for this decline. First, animal control and vaccination programs begun in the 1940's and oral rabies vaccination programs in the 2000's have eliminated domestic dogs as reservoirs of rabies in the United States. Second, effective human rabies vaccines and immunoglobulins have been developed. All human cases in the United States since 1995 are summarized in the Table of Human Rabies Cases from 1995-2011 (see table below). The case histories (if published) of the ten most recent cases can be found using the links below:

*Cases of Rabies in Human Beings in the United States, by Circumstances of Exposure and Rabies Virus Variant, 1995-2011*
Date of Death	State of Residence	Exposure History*	Rabies Virus Variant†
March 15, 1995	WA	Unknown#	Bat, Msp
September 21, 1995	CA	Unknown#	Bat, Tb
October 3, 1995	CT	Unknown#	Bat, Ln/Ps
November 9, 1995	CA	Unknown#	Bat, Ln/Ps
February 8, 1996	FL	Dog bite - Mexico	Dog, Mexico
August 20, 1996	NH	Dog bite - Nepal	Dog, SE Asia
October 15, 1996	KY	Unknown	Bat, Ln/Ps
December 19, 1996	MT	Unknown	Bat, Ln/Ps
January 5, 1997	MT	Unknown#	Bat, Ln/Ps
January 18, 1997	WA	Unknown#	Bat, Ef
October 17, 1997	TX	Unknown#	Bat, Ln/Ps
October 23, 1997	NJ	Unknown#	Bat, Ln/Ps
December 31, 1998	VA	Unknown	Bat, Ln/Ps
September 20, 2000	CA	Unknown#	Bat, Tb
October 9, 2000	NY	Dog bite - Ghana	Dog, Africa
October 10, 2000	GA	Unknown#	Bat, Tb
October 25, 2000	MN	Bat bite - MN	Bat, Ln/Ps
November 1, 2000	WI	Unknown#	Bat, Ln/Ps
February 4, 2001	CA	Unknown# - Philippines	Dog, Philippines
March 31, 2002	CA	Unknown#	Bat, Tb
August 31, 2002	TN	Unknown#	Bat, Ln/Ps
September 28, 2002	IA	Unknown#	Bat, Ln/Ps
March 10, 2003	VA	Unknown#	Raccoon, Eastern US
June 5, 2003	PR	Bite	Dog/Mongoose, Puerto Rico
September 14, 2003	CA	Bite	Bat, Ln/Ps
February 15, 2004	FL	Bite	Dog, Hati
May 3, 2004	AR	Bite (organ donor)	Bat, Tb
June 7, 2004	OK	Liver transplant recipient	Bat, Tb
June 9, 2004	TX	Kidney transplant recipient	Bat, Tb
June 10, 2004	TX	Arterial transplant recipient	Bat, Tb
June 21, 2004	TX	Kidney transplant recipient	Bat, Tb
Survived, 2004	WI	Unknown#	Bat, Unknown
October 26, 2004	CA	Unknown#	Dog, El Salvador
September 27, 2005	MS	Unknown#	Bat, Unknown
May 12, 2006	TX	Unknown#	Bat, Tb
November 2, 2006	IN	Bite	Bat, Ln/Ps
December 14, 2006	CA	Bite	Dog, Philippines
October 20, 2007	MN	Bite	Bat, Unknown
March 18, 2008	CA	Bite-Mexico	Fox, Tb-related
November 30, 2008	MO	Bite	Bat, Ln/Ps
Survived, 2009	TX	Unknown#	Bat, Unknown
October 20, 2009	IN	Unknown#	Bat, Ps
November 11, 2009	MI	Unknown#	Bat, Ln/Ps
November 20, 2009	VA	Bite	Dog, India
August 21, 2010	LA	Bite	Bat, Mexico, Ds
January 10, 2011	WI	Unknown	Bat, Ps
Survived, 2011	CA	Unknown	Unknown
July 20, 2011	NJ	Bite	Dog, Haiti
August 31, 2011	NY	Bite	Dog, Afghanistan

CDC 2012 rabies cases

Wren and Oriole.
My work buddies.
Both rescued as kittens, lucky for me both happy and healthy.

The WHO rabies information;

Key facts

Rabies occurs in more than 150 countries and territories.
More than 55 000 people die of rabies every year mostly in Asia and Africa.
40% of people who are bitten by suspect rabid animals are children under 15 years of age.
Dogs are the source of the vast majority of human rabies deaths.
Wound cleansing and immunization within a few hours after contact with a suspect rabid animal can prevent the onset of rabies and death.
Every year, more than 15 million people worldwide receive a post-exposure vaccination to prevent the disease– this is estimated to prevent hundreds of thousands of rabies deaths annually.

Rabies is a zoonotic disease (a disease that is transmitted to humans from animals) that is caused by a virus. The disease affects domestic and wild animals, and is spread to people through close contact with infectious material, usually saliva, via bites or scratches.

Rabies is present on all continents with the exception of Antartica, but more than 95% of human deaths occur in Asia and Africa. Once symptoms of the disease develop, rabies is nearly always fatal.

Rabies is a neglected disease of poor and vulnerable populations whose deaths are rarely reported. It occurs mainly in remote rural communities where measures to prevent dog to human transmission have not been implemented. Under-reporting of rabies also prevents mobilization of resources from the international community for the elimination of human dog-mediated rabies.

Symptoms

The incubation period for rabies is typically 1–3 months, but may vary from <1 week to >1 year. The initial symptoms of rabies are fever and often pain or an unusual or unexplained tingling, pricking or burning sensation (paraesthesia) at the wound site.

As the virus spreads through the central nervous system, progressive, fatal inflammation of the brain and spinal cord develops.

Two forms of the disease can follow. People with furious rabies exhibit signs of hyperactivity, excited behaviour, hydrophobia and sometimes aerophobia. After a few days, death occurs by cardio-respiratory arrest.

Paralytic rabies accounts for about 30% of the total number of human cases. This form of rabies runs a less dramatic and usually longer course than the furious form. The muscles gradually become paralyzed, starting at the site of the bite or scratch. A coma slowly develops, and eventually death occurs. The paralytic form of rabies is often misdiagnosed, contributing to the under-reporting of the disease.

Diagnosis

No tests are available to diagnose rabies infection in humans before the onset of clinical disease, and unless the rabies-specific signs of hydrophobia or aerophobia are present, the clinical diagnosis may be difficult. Human rabies can be confirmed intra-vitam and post mortem by various diagnostic techniques aimed at detecting whole virus, viral antigens or nucleic acids in infected tissues (brain, skin, urine or saliva).

Transmission

People are usually infected following a deep bite or scratch by an infected animal. Dogs are the main host and transmitter of rabies. They are the source of infection in all of the estimated 50 000 human rabies deaths annually in Asia and Africa.

Bats are the source of most human rabies deaths in the Americas. Bat rabies has also recently emerged as a public health threat in Australia and western Europe. Human deaths following exposure to foxes, raccoons, skunks, jackals, mongooses and other wild carnivore host species are very rare.

Transmission can also occur when infectious material – usually saliva – comes into direct contact with human mucosa or fresh skin wounds. Human-to-human transmission by bite is theoretically possible but has never been confirmed.

Rarely, rabies may be contracted by inhalation of virus-containing aerosol or via transplantation of an infected organ. Ingestion of raw meat or other tissues from animals infected with rabies is not a source of human infection.

Post-exposure prophylaxis (PEP)

Post-exposure prophylaxis (PEP) consists of:

local treatment of the wound, initiated as soon as possible after exposure;
a course of potent and effective rabies vaccine that meets WHO recommendations; and
the administration of rabies immunoglobulin, if indicated.

Effective treatment soon after exposure to rabies can prevent the onset of symptoms and death.

Local treatment of the wound

Removing the rabies virus at the site of the infection by chemical or physical means is an effective means of protection. Therefore, prompt local treatment of all bite wounds and scratches that may be contaminated with rabies virus is important. Recommended first-aid procedures include immediate and thorough flushing and washing of the wound for a minimum of 15 minutes with soap and water, detergent, povidone iodine or other substances that kill the rabies virus.

Recommended PEP

PEP depends on the type of contact with the suspected rabid animal (see table).

Table: Categories of contact and recommended post-exposure prophylaxis (PEP)

*Categories of contact with suspect rabid animal*	*Post-exposure prophylaxis measures*
Category I – touching or feeding animals, licks on intact skin	None
Category II – nibbling of uncovered skin, minor scratches or abrasions without bleeding	Immediate vaccination and local treatment of the wound
Category III – single or multiple transdermal bites or scratches, licks on broken skin; contamination of mucous membrane with saliva from licks, contacts with bats.	Immediate vaccination and administration of rabies immunoglobulin; local treatment of the wound

All category II and III exposures assessed as carrying a risk of developing rabies require PEP. This risk is increased if:

the biting mammal is a known rabies reservoir or vector species;
the animal looks sick or has an abnormal behaviour;
a wound or mucous membrane was contaminated by the animal’s saliva;
the bite was unprovoked; and
the animal has not been vaccinated.

In developing countries, the vaccination status of the suspected animal alone should not be considered when deciding whether to initiate prophylaxis or not.

Who is most at risk?

Dog rabies potentially threatens over 3 billion people in Asia and Africa. People most at risk live in rural areas where human vaccines and immunoglobulin are not readily available or accessible.

Poor people are at a higher risk, as the average cost of rabies post-exposure prophylaxis after contact with a suspected rabid animal is US$ 40 in Africa and US$ 49 in Asia, where the average daily income is about US$ 1–2 per person.

Although all age groups are susceptible, rabies is most common in children aged under 15. On average 40 % of post-exposure prophylaxis regimens are given to children aged 5–14 years, and the majority are male.

Anyone in continual, frequent or increased danger of exposure to rabies virus – either by nature of their residence or occupation – is also at risk. Travellers with extensive outdoor exposure in rural, high-risk areas where immediate access to appropriate medical care may be limited should be considered at risk regardless of the duration of their stay. Children living in or visiting rabies-affected areas are at particular risk.

Prevention

Eliminating rabies in dogs

Rabies is a vaccine-preventable disease. The most cost-effective strategy for preventing rabies in people is by eliminating rabies in dogs through vaccination. Vaccination of animals (mostly dogs) has reduced the number of human (and animal) rabies cases in several countries, particularly in Latin America. However, recent increases in human rabies deaths in parts of Africa, Asia and Latin America suggest that rabies is re-emerging as a serious public health issue.

Preventing human rabies through control of domestic dog rabies is a realistic goal for large parts of Africa and Asia, and is justified financially by the future savings of discontinuing post-exposure prophylaxis for people.

Preventive immunization in people

Safe, effective vaccines can be used for pre-exposure immunization. This is recommended for travellers spending a lot of time outdoors, especially in rural areas, involved in activities such as bicycling, camping, or hiking as well as for long-term travellers and expatriates living in areas with a significant risk of exposure. Pre-exposure immunization is also recommended for people in certain high-risk occupations such as laboratory workers dealing with live rabies virus and other rabies-related viruses (lyssaviruses), and people involved in any activities that might bring them professionally or otherwise into direct contact with bats, carnivores, and other mammals in rabies-affected areas. As children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites, their immunization could be considered if living in or visiting high risk areas.

WHO response

For at least three decades WHO has fought to break the "cycle of neglect" affecting rabies prevention and control particularly in low- and middle-income countries through advocacy, surveys and studies and research on the use of new tools .

The Organization continues to promote human rabies prevention through the elimination of rabies in dogs as well as a wider use of the intradermal route for PEP which reduces volume and thereby cost of cell-cultured vaccine by 60 to 80%.

WHO supports targets for elimination of human and dog rabies in all Latin American countries by 2015 and of human rabies transmitted by dogs in South-East Asia by 2020. In this latter region a five-year plan (2012–2016) aims to halve the currently estimated number of human rabies deaths in endemic countries.

WHO rabies article

Related posts. MD man dies from rabies

If you have any pet related questions you can find me at Pawbly or in person at the clinic Jarrettsville Vet.

Diary of a Real-Life Veterinarian

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Friday, September 27, 2013

Rabies. Your Pets And Your Life On The Line.

World Rabies Day. September 28, 2013