Imagine waking up one morning and feeling sick. It starts
with flu-like symptoms, so you do not go to the doctor for treatment. Instead,
you expect to manage the symptoms on your own until it passes. After a few
days, as the symptoms worsen, you begin to experience symptoms that are not
related to the flu—excessive salivation, mental confusion, double vision,
muscle paralysis, difficulty swallowing, light sensitivity, unmanageable
headache, hallucinations, and irritability.
You
decide it’s time to see a doctor and get a ride to the hospital where they
start running tests to determine a diagnosis. After some time, the doctor walks
in with a concerned look on his face and asks if you have traveled outside of
the country or have been bitten by any animals recently. Confused, you answer
“no.” However, you remember that you had gone on a camping trip three months
ago, but you hadn’t been bitten by any animals that you are aware of. The
doctor asks if you have experienced any sensations of pins and needles anywhere
on your body, to which you point toward the back of your shoulder. Even more
concerned now, the doctor orders samples of saliva, serum (blood), and spinal
fluid for a new round of tests.
Two
hours later, the doctor returns to inform you that you have tested positive for
the rabies virus—a death sentence. He explains how he suspects that you had
been unknowingly bitten by a rabid bat while camping three months prior and,
therefore, had no reason to seek post-exposure prophylaxis (PEP) for prevention
of the virus. Unfortunately, he further explains, there is no cure for
full-blown rabies. The only ethical thing they can do for you now is to place
you under a medically-induced coma so you can die peacefully without having to
suffer further.
History
The rabies virus has been a significant and deadly issue
throughout human history. In the 16th century, Girolamo Fracastoro,
an Italian physician, discovered that rabies was a fatal disease and referred
to it as “an incurable wound” (Wnek 1). However, the rabies virus has been
recognized as far back as 300 BC for which Aristotle had acknowledged the
transmission of the virus from stray dogs to people in one of his literary
works (1). In the 18th century, Germany, France, and Spain passed
legislation which called for the extermination of stray dogs in an attempt to
eradicate the virus (Smith 1).
In
1804, Georg Zinke first proved the rabies virus to be infectious by
transmitting the virus from a rabid dog to a non-rabid dog, then from the dog
to a rabbit and a hen via injection of saliva (Pearce 1). In 1885, French
biologist Louis Pasteur created the first rabies vaccine for dogs (Wnek 1).
However, vaccinating dogs for rabies would not become a routine practice until
the 1920s (Smith 1). In 2013, there were 5,865 laboratory-confirmed cases of
animals with rabies in the United States that had been reported to the CDC
(Wilson and Rohdey 1).
The
rabies virus has been able to spread throughout the world due to man’s ability
to travel overseas. Since early history, it has been commonly perceived that
dogs are to blame for the transmission of the virus to humans and other
animals. This may be a valid theory or belief as dogs have been domesticated
and owned by humans for centuries, and dogs who are allowed to spend a lot of time
unsupervised outside are at a greater risk of becoming infected. For this
reason—as well as the large population of stray dogs among various
countries—countries such as Germany, France, and Spain passed legislation in
the 18th century that called for the elimination of stray dogs in an attempt to
eradicate the virus (Smith 1).
According
to the information provided by the Centers for Disease Control and Prevention
(CDC), the number of human deaths caused by the rabies virus has been declining
since the 1970’s due to animal control programs, vaccination programs, outreach
programs, and the availability of modern rabies biologics (“Rabies” 1).
Twenty-three cases of human rabies have been reported in the United States,
however, eight of these had contracted the virus outside of the country (1).
According to the CDC, “each year between 60 to 70 dogs and more than 250 cats
are reported” as rabid, and with 30,000 to 60,000 people having to undergo
rabies post-exposure prophylaxis (1).
Examples
In
2011, a Maryland resident died from organ transplant-related rabies, for which
the donor had unknowingly been infected with rabies prior to death (“Media
Statement” 1). Interestingly, the donor recipient did not develop symptoms
until a year later after receiving the kidney transplant. The typical
incubation period for rabies is about one to three months (1).
The
donor’s cause of death was unknown and the donor recipient had no reported
animal exposures, which lead to the suspicion of transmission via organ
transplant. Thus, triggering a joint investigation by the Centers for Disease
Control and Prevention (CDC) and Maryland Department of Health and Mental
Hygiene. The CDC tested tissue samples from the donor and recipient which
revealed they had the same type of rabies virus—a raccoon type (1). Therefore,
it was determined that the donor’s cause of death was due to rabies, which also
caused the death of the organ recipient.
In
2004, 15 year-old Wisconsin resident Jeanna Giese became the first person in
documented history to have survived clinical (full blown) rabies without
receiving rabies prophylaxis before or after she became infected:
Jeanna
was exposed to the virus in September of 2004 while at church where she found a
bat and released it outside. The bat had bitten her, but it was so small that
she didn’t worry about it.
Approximately
1 month after the bat bite, the girl complained of fatigue and tingling and
numbness of the left hand. These symptoms persisted, and 2 days later she felt
unsteady and developed diplopia (i.e., double vision). On the third day of
illness, with continued diplopia and onset of nausea and vomiting, she was
examined by her pediatrician and referred to a neurologist. At that time, the
patient continued to have blurred vision and also had partial bilateral
sixth-nerve palsy. Magnetic resonance imaging (MRI) with and without contrast
and magnetic resonance angiography (MRA) studies of her brain were normal, and
the patient was sent home. On the fourth day of illness, the
patient's symptoms continued, and she was admitted to a local hospital for
lumbar puncture and supportive care. On admission, she was afebrile, alert, and
able to follow commands. She had partial sixth-nerve palsy, blurred vision, and
unsteady gait. Standard precautions for infection control were observed…
During
the next 36 hours, she had slurred speech, nystagmus, tremors of the left arm,
increased lethargy, and a temperature of 102oF (38.9oC).
On the sixth day of illness, the bat-bite history was reported, and rabies was
considered in the differential diagnosis. The patient was transferred to a
tertiary care hospital. Because rabies was recognized as a possibility,
expanded infection-control measures, including droplet precautions and
one-to-one nursing, were instituted at time of transport. On arrival, the
patient had a temperature of 100.9oF (38.3oC), impaired
muscular coordination, difficulty speaking, double vision, muscular twitching,
and tremors in the left arm. She was somewhat obtunded but answered questions
appropriately and complied with commands… Clinical management of the patient
consisted of supportive care and neuroprotective measures, including a
drug-induced coma and ventilator support. Intravenous ribavirin was used under
an investigational protocol. The patient was kept comatose for 7 days; during
that period, results from lumbar puncture indicated an increase in antirabies
IgG by immunofluorescent assay from 1:32 to 1: 2,048. Her coma medications were
tapered, and the patient became increasingly alert. On the 33rd day of illness,
she was extubated; 3 days later she was transferred to a rehabilitation unit.
At the time of transfer, she was unable to speak after prolonged intubation. As
of December 17, the patient remained hospitalized with steady improvement. She
was able to walk with assistance, ride a stationary cycle for 8 minutes, and
feed herself a soft, solid diet. She solved math puzzles, used sign language,
and was regaining the ability to speak. The prognosis for her full recovery is
unknown. (“Recovery of a Patient from Clinical Rabies --- Wisconsin, 2004” 1)
The theory behind the
doctor’s decision to place Jeanna under a medically-induced coma, was to
introduce antiviral rabies drugs, allow her body’s immune system to go into
hyper-drive, and see if it could overcome the virus. There is no cure or
treatment for clinical rabies, and Jeanna was fading fast. Therefore, the
doctor asked her parents’ permission to conduct this experiment, since they had
nothing else to lose. Miraculously, the experiment worked for Jeanna Giese and
came to be known as the “Milwaukee Protocol.” Over time, however, this protocol
has failed other patients diagnosed with clinical rabies.
Solutions
“Rabies is 100 percent preventable” and just about all
mammals are able to carry and transmit the virus (“Rabies” 1). In developing
countries, domestic dogs are the primary cause of human transmission. Over
time, various methods have developed in an effort to eradicate and prevent the
spread of rabies worldwide. Some of these strategies have proven effective,
while others have not. As stated by the World Health Organization (WHO):
Past
rabies elimination strategies included the reduction of population density
through culling, based on the rationale that rabies transmission is
density-dependent with disease density increasing proportional to host density.
However studies have shown that culling is an ineffective means of elimination
and mass vaccination is most efficacious to reduce disease incidence in all
species. (“Control and Elimination Strategies”)
Thus, attempting to kill off animals that pose
the greatest risk of rabies transmission is not an effective strategy. Not to
mention the severe effects on the ecosystem that would correlate with such an
act.
One solution that has been used between Israel and
Jordan, where wild jackals are the primary vehicle for rabies transmissions, is
the scattering of edible pellets that contain the rabies vaccine (Efrati 1).
This method of not only vaccinating domestic animals but wild animals as well,
has successfully limited the spread of the virus by stopping the transmission
process that typically goes from wild animal, to domestic animals, to humans.
However, due to recent political tensions between the two countries, a rabies
epidemic has erupted as a result of their temporarily ceased joint efforts
against the virus (1).
In the United Sates, bats, raccoons, skunks, foxes, stray
animals, and domestic pets are the main carriers of the rabies virus. The
Centers for Disease Control and Prevention (CDC) is largely responsible for the
documentation, management, diagnostic testing, and elimination strategies used
to combat rabies in the United States. The CDC reports:
The
number of human rabies deaths in the United States attributed to rabies has
been steadily declining since the 1970’s thanks to animal control and
vaccination programs, successful outreach programs, and the availability of
modern rabies biologic. Dog rabies vaccination programs have halted the natural
spread of rabies among domestic dogs, which are no longer considered a rabies
reservoir in the United States. Nonetheless, each year between 60 to 70 dogs
and more than 250 cats are reported rabid. Nearly all these animals were
unvaccinated and became infected from rabid wildlife (such as bats, raccoons,
and skunks) … Despite the control of rabies in domestic dogs in the United
States, each year interactions with suspect animals result in the need to
observe or test hundreds of thousands of animals and to administer rabies
postexposure prophylaxis to 30,000 to 60,000 persons. (“Rabies” 1)
Thus, the CDC’s
preventative measures for animals include vaccinating pets, spaying/neutering
pets to prevent growing stray populations, and contacting animal control
suspected rabid animals and for large stray populations that are likely
unvaccinated and ill. For people, medical facilities and pre-exposure and
post-exposure prophylaxis rabies vaccines are readily available. As a result,
human rabies is very rare in the United States with one to three cases per year
(1). However, human fatalities do occur “in people who fail to seek medical
assistance, usually because they were unaware of their exposure” (1). It is
also advised to receive pre-exposure prophylaxis for rabies before traveling
outside of the country, especially to Asia and Africa where the prevalence of
rabies is extraordinary high due to lack of resources and medical facilities
(1). Additionally, the United States has adopted the strategy used by Israel
and Jordan of orally vaccinating wild animals (“RABORAL V-RG: Oral Rabies
Vaccine for Wildlife”).
Absurdity
of Rabies
It is absurd that many people are
unaware of and/or are misinformed about the rabies virus as a whole. Society
has painted a picture that any rabid animal can be identified by two main
characteristics: extreme aggression and foaming at the mouth. A picture that
almost portrays a rabid animal or person as a real-life zombie. However, this
is not always true. In fact, it can be nearly impossible to determine if an
animal is rabid just by observation. One of the reasons this disease can be
difficult to identify is because the rabies virus can manifest itself in two
different ways: furious rabies and paralytic rabies. However, both types have
an incubation period, begin with flu-like symptoms, and cause death within
approximately two weeks of symptom onset.
In the case
of furious rabies, one may become “hyperactive and excitable and may display
erratic behavior” (Johnson 1). One may also experience insomnia,
hallucinations, difficulty breathing, excessive salivation, difficulty
swallowing, and fear of water (1). Although this type of the virus can be
easier to detect through observation, animals displaying what may be perceived
as one of these symptoms may be deceiving. For example, certain dog breeds,
such as those from the bully-family, naturally salivate a lot. Additionally,
aggression from wild animals is not a definitive indication of rabies, either.
Wild animals are wild and will become
aggressive when they feel threatened.
Paralytic
rabies, on the other hand, typically takes longer to set in for, for which one
would “slowly become paralyzed, eventually slip into a coma, and die” (Johnson
1). As noted by Johnson in her article “Rabies: Types, Symptoms & Causes,”
the World Health Organization (WHO) reported 30 percent of rabies cases are of
the paralytic type (1).
It is also
absurd that, with today’s technology and recourses, researchers have not been
able to find a cure for clinical rabies or develop more reliable testing that
can accurately detect the virus before it becomes clinical or causes death.
According to the CDC, “samples of saliva, serum, spinal fluid, and skin
biopsies of hair follicles around the nape of the neck” can be used to test for
rabies in humans antemortem, however, “no single test is sufficient” (“Rabies”
1). The most accurate way to detect rabies in people and animals is through
testing brain tissue samples postmortem. Perhaps researchers should think
outside of the box and consider a quote by Lewis Carroll, “If you don’t know
where you are going, any road will get you there.” Although this may seem like
an absurd suggestion, many medications that are used today, such as penicillin
and Valium, were discovered by accident.
Another
absurdity spread by the media and society is the misconception that nocturnal
animals seen during the day are very likely to be rabid. This is, also, not
always true. For example, mother raccoons will leave their babies for short
periods of time during the day to forage for food.
Conclusion
Even though rabies is considered
rare in the United States, it is still a major issue. The CDC reported 5,508
rabid animals and three human rabies cases in 2015 in the United States alone
(“Rabies” 1). “Several major health organizations, including World Health
Organization (WHO), World Organization for Animal Health (OIE), and the Food
and Agricultural Organization of the United Nations (FAO),” have come together
and “pledged to eliminate human deaths from [rabies worldwide] by 2030” (“World
Rabies Day” 1). Hence, nations have to work together in order to control and
eliminate the spread of rabies.
Additionally, if you see an animal
that appears to be sick or in distress, do not touch it in an effort to help
it. Instead, contact animal control as they are vaccinated and trained to deal
with potentially rabid animals.
can be quite difficult
Works
Cited
“Control and Elimination
Strategies.” World Health Organization,
World Health Organization, 3
Efrati, Ido. “Israel on the
Brink of a Rabies Epidemic, Thousands of Coyotes Killed.”
Haaretz.com,
24 Jan. 2018, www.haaretz.com/israel-news/.premium-israel-on-the-brink-of-a-rabies-epidemic-1.5762862.
“Human Rabies.” World Health Organization, World Health
Organization, 7 Nov. 2013, www.who.int/rabies/human/en/.
Johnson, Shannon. “Rabies:
Types, Symptoms & Causes.” Healthline, Healthline Media, 19
Oct.
“Media Statement.” Centers for Disease Control and Prevention, Centers for Disease
Control
“Morbidity and Mortality
Weekly Report (MMWR).” Centers for
Disease Control and
Prevention,
Centers for Disease Control and Prevention, 26 Feb. 2010, www.cdc.gov/mmwr/preview/mmwrhtml/mm5907a1.htm.
Pearce, J. “Louis Pasteur
and Rabies: a Brief Note.” Journal
of Neurology, Neurosurgery &
Psychiatry,
BMJ Publishing Group Ltd, 1 July 2002, jnnp.bmj.com/content/73/1/82.
“Rabies.” Centers for Disease Control and Prevention,
Centers for Disease Control and Prevention,
23 Aug. 2017,
“Rabies.” Centers for Disease Control and Prevention,
Centers for Disease Control and
“RABORAL V-RG: Oral Rabies Vaccine for
Wildlife.” RABORAL V-RG: Oral Rabies Vaccine
“Recovery of a Patient from Clinical Rabies
--- Wisconsin, 2004.” Centers for Disease
Control
and Prevention,
Centers for Disease Control and Prevention, 24 Dec. 2004, www.cdc.gov/mmwr/preview/mmwrhtml/mm5350a1.htm.
Smith, Yolanda. “Rabies
History.” News-Medical.net, 28 Apr.
2015,
Walker, Stephen. “Jeanna
Giese First Person to Survive Rabies.” Extraordinary
Children, 15
Wilson, Pamela J., and
Rodney E. Rohde. “8 Things You May Not Know about Rabies – but
Should.”
Elsevier Connect, 28 Sept. 2015, www.elsevier.com/connect/8-things-you-may-not-know-about-rabies-but-should.
“World Rabies Day.” Centers for Disease Control and Prevention,
Centers for Disease Control and
Prevention, 28 Sept. 2017, www.cdc.gov/worldrabiesday/prevention.html.
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