Wednesday, February 29, 2012

Playing Doctor

It was a lovely sunny day at the VBB hospital. The trees were getting some new green as the spring rolled in and there was the slight scent of wet earth that remained from an early morning shower. My day was ticking by, surgery in the morning, followed by afternoon appointments, when suddenly a gaunt figure in a large flowered hat careened into the front lobby.
By large flowered hat, I mean it was a hat with HUGE fuzzy flowers on it, worn by the famous "hat lady" in our little town in recognition of the first official day of spring. This particular lady had hats for all sorts of occasions, all worn as a partial jest and partial personality tic of the wearer.

On this day, the normally sunny countenance of Hat Lady was marred by a look of horror. She was holding an equally flowered handkerchief wound around her wrist. As I walked into the reception area, I could hear her demanding to know the rabies vaccination status of one of our patients. I explained that we were not allowed to release that information to her since she was the owner. However, after looking at the record and seeing that the patient, Teeth, had his last rabies vaccination within the year, I felt pretty comfortable telling her that I didn't think she had anything to worry about with regards to rabies. I advised her to go to the doctor to have the wound looked at and maybe a tetanus shot.

It was at this point that the Hat Lady started yelling that I had to give her a rabies vaccination. I told her that A) I didn't have vaccines for humans and B) I was not licensed to give a vaccine to a human. She kept saying that a rabies vaccine is a rabies vaccine and that she "demanded" that I give her one. When I told her that she would need to talk with her doctor and animal control about that, she got super dooper mad. She threatened to call my boss...I offered to dial the number for her. She threatened to call the board...again, I offered to dial the number for her.

When the police showed up (she had called them about the dog bite), both the officer and I were finally able to get her to calm down. As the dog in question was current on vaccines, he was quarantined for 10 days in the home of his owner and the Hat Lady never required a rabies vaccine (at least not yet).

This brings up some important things: One, a vaccine approved for dogs, cats, goats, cows, horses, etc is not necessarily approved for humans. In fact, I am struggling to think of one off of the top of my head. Two, most vets would rather you call the vet board because they refused to work on you rather than to have a board report for working on you. Hell, the vet at my undergrad even refused to pull a splinter out of the hand of a fellow student because he didn't want to get in trouble for working on a human.

The last thing to let everyone know is that rabies vaccines are important. It is against the law to not have your dogs and cats vaccinated and it is a bad idea to not vaccinate other animals. In the US, there are not large numbers of animals identified as being rabid nor are there large amounts of people dying from rabies. However, in places like China and India, those numbers increase exponentially. We can thank our relatively low rabies incidence to the efforts of the public health departments and veterinarians. That does not mean that we can relax our attitudes towards rabies. We have global travel of animals, including the adoption and importation of animals from places in the middle east, where soldiers are falling for homeless animals and trying to help them. Some of these animals can come to the US with rabies. So, thinking that you can extend the time between rabies vaccines beyond the scope of the vaccine is both illegal and dangerous.

A family in Florida just found this out. Their dog came in contact with a raccoon. The dog had not been vaccinated for rabies within the allotted time. Most rabies vaccines are either considered to be effective for 1 year or for 3 years. This dog had been vaccinated 7 years prior to the incident. Because of the lack of protection from the rabies vaccination and the contact with a raccoon, this dog contracted rabies. Rabies is diagnosed post mortem (after death) via a certain test on the brain cells. Once this dog was diagnosed with rabies, the humans in the household had to be vaccinated and the other family dogs were euthanized. In reality, after the unvaccinated dog came into contact with a raccoon, an animal species known to harbor rabies, the dog should have been euthanized or at the very least quarantined for 6 months or so. Rabies viral particles have to travel up the nerves from the site of the bite/contact into the brain, which can take a long time. Thus an animal can be infected, but not start showing signs or being able to transmit rabies for weeks to months, depending on the site of the bite.

As for the 1 year versus 3 year protocol, I am split on this. For animals that are likely to come into contact with wild life regularly, I would stick with the yearly protocol. I have read a report of a dog that contracted rabies in spite of being within the 3 year interval per his rabies vaccine. For those patients that are less likely to see hot wild life action (like my indoor, couch potato old lady dog), I would go with an extended, 3 year protocol. And just because your cat does not go outside, do not assume it is safe. There are enough people that find random bats in the house...and a bat bite often goes unnoticed, even when they bite a human. So, obey the law....and use some common sense. Some of my colleagues might disagree and they are welcome to do that. However, a classmate of mine told me that they just had a dog diagnosed with rabies in Virginia and there was also a recent report of a horse that was diagnosed with rabies in Tennessee.

13 comments:

  1. I heard a story about a vet school professor and students getting called out to work on a cow (I forget what for). As part of their workup there was oral examination/palpation sans gloves. Cow turned out to be rabid. Moo.

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  2. I'm in Afghanistan and I really wish the Soldiers would just leave the dogs alone. A returning Soldier recently DIED of rabies after he did not seek care after being bitten while he was deployed. Please stop helping these guys bring these dogs back to the US. In addition to rabies, they are often harboring leishmaniasis, echinoccoccus hydatid disease, screwworm, and many other diseases that we do not see in the US or see very infrequently. When I'm not deployed I live in Texas...rabies is all over the place!

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  3. "Lady, you're more like to have caught rabies from whatever rodent is living in your hideous hat."

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    1. Well, I swear she almost caught salmonella from the huge "roasted turkey" hat she wore during the thanksgiving season. Imagine a hat that looks like a cooked turkey...ass up and the wearer's head stuck up the stuffing hole.

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  4. I was bit by a mouse when I was five. My mom had told me to leave it alone, but I ignored her. The kleenex wrapped around my bit finger did not conceal what I had done.

    She took me to the hospital, where they gave me my first shot. In my stomach. It hurt. For the remaining 13 shots, the doctor who lived down the hall from us came over to our apartment. My mom had to drag me out from under the bed, where I was clutching the bedposts. She would sit on my hands and Dr J would sit on my legs, then poke my stomach. It was excruciatingly painful and I don't know why anyone would WANT a rabies shot.

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    1. I imagine someone would WANT a rabies shot because they DON'T want to DIE...as rabies is almost 100% fatal once clinical signs develop.

      You likely received rabies immunoglobulin...a very thick solution that is painful when injected. A 'rabies shot' is a vaccination that hurts no more than your annual flu shot. Not sure why you would receive rabies IgG for a rodent bite as there has never been a documented case of rabies transmission by a rodent. In theory, because they are mammals, infection and transmission may be possible. However, if you think about it, the mouse would have to survive an attack by a rabid animal in order to become infected with rabies and live long enough after it's injuries to be able to transmit the disease. Not likely as most rodents which are unlucky enough to be attacked and wounded are promptly eaten or die of their wounds.

      Thankfully, rabies IgG is no longer a series of many shots given in the stomach. Half the volume is infused in and around the site of the wound (still painful, especially if bitten on the hand as is the most likely place) and the other half in a distant location such as the gluteal muscle. The victim is also started on rabies prophylaxis (rabies vaccination) in the deltoid muscle or intradermally in the deltoid. Even after exposure to a known rabid animal, rabies is almost 100% preventable if the above treatment is sought as soon as possible. It's also been shown that thoroughly washing the wound with soap and water reduces transmission of the virus as well.

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    2. My guess is that the poster above was commenting about not understanding why someone would want a rabies post exposure vax if they didn't really need one. And I agree, getting vaccinated for shits and giggles is not a good idea. As a member of the VBB recently experienced in her post exposure vax, some people end up in the hospital due to a reaction with the vaccine.

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  5. The raccoons around here came up positive for canine distemper last year, and they're shockingly good at getting into houses. Getting your animal ALL of their vaccinations on schedule should be common sense.

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  6. Personally I hate 3 year vaccines b/c the client thinks they only need to see a vet every 3 years, to chance to talk about hw prevention, do a physical exam, etc. if the health department puts on a rabies vaccine clinic in our state they require a 3 year vaccine to be used. It just sends a bad message and is almost impossible to convince clients of any different.

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  7. I would refer your health department to the case of the dog that became infected with rabies after a TWO year interval using the 3 year vaccine. It helped convince ours.

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  8. Hmmm... This post reminds me that my cat's rabies vaccination is overdue. Bad vet!

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  9. Just so the non-vets reading this blog will know. In Georgia we get reports of confirmed rabies cases frequently. Just last month we had three such reports in our county alone (GA has 159 counties).

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  10. I asked once why the rabies vaccine for animals is a one-shot thing, whereas humans require a series of 3 or 4? (Might have been seven at the time, I don't remember.) The answer I got was that the animal vaccine is a live, attenuated virus, whereas the one licensed for humans is a killed virus. So why not use the attenuated virus on humans? "Well, in a disease in which thus far nobody who has been infected has yet failed to die, they don't want to take the slightest chance that the virus will mutate back to a virulent strain." Guess that makes sense.

    (Since that conversation, which was with one of my professors of pharmacy back in the '90s, two things have changed: 1, someone actually survived an active rabies infection for the first time ever, and 2, the Sabin live polio vaccine was de-licensed, because it did tend to back-mutate.)

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