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Human rabies case explored

A human case of rabies reported in the Virginia Health Department district that includes Prince Edward, Buckingham and Cumberland is expected to soon be published by the Centers for Disease Control (CDC).

Rhonda Pruitt with the Piedmont District of the Virginia Department of Health investigated the case, where the person tested positive for rabies in May 2017.

The patient, according to a case description from the CDC, was 65 and was a Virginia resident.

Pruitt is a senior epidemiologist with the Virginia Department of Health, meaning that she investigates patterns and causes of disease and injury in people.

Pruitt said she could not disclose the exact locality of the person diagnosed with rabies, saying that the department requires complete anonymity about the person’s location in a case.

“One of our community members was visiting India where they were bitten by a puppy,” Ernest Siva Moore, executive director of Satchidananda Ashram-Yogaville, said in a May 19, 2017, report in the Herald. “More than a month later, the individual had returned to Buckingham and began manifesting symptoms of rabies.”

Pruitt said the case and investigation is expected to be published in the CDC, but is uncertain as to when. She said the case has been cleared for publication.

A highlight of the case was published online on the CDC’s website during World Rabies Day Sept. 28.

TROUBLING SYMPTOMS

Pruitt said in 2017, a patient went to a hospital in Charlottesville.

She said the individual went to an urgent care center a couple of days before that because the patient said she had been gardening and began to experience tingling and numbness in her hand and arm.

The urgent care center diagnosed the patient with carpal tunnel syndrome, was given medication and released.

Pruitt said her symptoms were not improving and they were worsening.

Pruitt said the woman went to a hospital emergency department in Charlottesville and nothing seemed to indicate any serious health problem. Pruitt said the hospital diagnosed her with panic attacks, gave her medication and released her.

She said the following day, “her husband called an ambulance and she was taken to a second hospital in Charlottesville, and she was taken to the emergency department there, and she was just experiencing some odd symptoms. She was very panicky. She was having difficulty breathing, and she mentioned that she was eating well, but she had not been drinking much, and she asked for something to drink and they brought her some water.”

Pruitt said when the medical providers brought her water, the patient began experiencing what Pruitt called a “full-blown panic attack.”

Pruitt said the patient made the comment that she didn’t know when she became so afraid of water.

“That is when they started to really, you know the alarm bells started to go off, because that had never been mentioned in any of the previous medical encounters,” Pruitt said.

Hydrophobia, believed to be caused by a reduced ability to swallow water during the advanced stage of rabies, is one of several symptoms of rabies that include discomfort or prickling at the site of the bite, anxiety, confusion and agitation.

Pruitt said the physician who was treating her in the emergency department asked the patient and her husband about any recent travel or any exposure to animals where she could have possibly been bitten. Her husband said the two of them traveled to India with a tour group back in the winter in the early spring. They had been back in the area for a few months. Her husband said the woman was bitten by a dog while in India.

“That was when they really began to suspect that she possibly had rabies,” Pruitt said about the hospital, and they contacted the local health department about how to send rabies tests to the CDC.

Pruitt said the health department in Charlottesville and other industries worked with the hospital to test the patient for rabies and send the tests to the CDC for analysis.

“The specimen that they collected came back positive for canine-variant rabies,” Pruitt said.

A DANGEROUS TREATMENT

Pruitt said the family elected to pursue the Milwaukee rabies protocol to treat the rabies.

Pruitt said the protocol is an aggressive, experimental treatment.

She said the treatment involves placing the patient into a medically-induced coma and taking the brain off the central nervous system.

“Studies have shown in patients that have contracted rabies and subsequently died that the brain itself was left largely intact but the virus attacks the central nervous system, and eventually makes it impossible for a patient to breathe and maintain normal bodily functions,” Pruitt said, which includes one’s heartbeat, blood pressure and breathing.

While the patient is in a coma, medical representatives administer high doses of anti-viral drugs to try and stop the rabies virus. Pruitt said the treatment has ever only proven successful in one or two cases in the United States. Those people were not bitten by dogs, instead something along the lines of small rodents.

Pruitt said the doctors began to administer the protocol and that the patient was on that treatment for several days.

She said the doctors were continuing to do repeat testing to see if the patient was producing any antibodies to the virus, a sign that the treatment was working. Pruitt said the patient never did. Pruitt said on May 21, the decision was made that they would bring her out of her coma and stop administering the treatment. She died shortly after.

THE CAUSE

Pruitt said the investigation of the individual’s case involved contacting the tour company the person went to while in India.

Pruitt said the patient, nor any other people on the tour were aware of canine rabies’ prevalence in India, describing it as “endemic.”

“Here in the United States, we have really good vaccine campaigns, and we have practically eradicated canine rabies in the United States,” Pruitt said, noting that most of the rabies in the U.S. is from wild animals. Pruitt said the health department encourages people to avoid wildlife and to even vaccinate their livestock if they live in rural areas close to wildlife populations.

Pruitt said over the course of their investigation, they discovered a person who lived in North Carolina who was bitten by the very same dog that the Virginia patient was bitten.

“I worked with the family to get her contact information and I contacted her and let her know that she had been identified by other people on the tour as having been bitten by this dog and she recalled it,” Pruitt said.

She said the North Carolina resident said she was bitten the day before the Virginia patient was bitten.

“I told her, I said it’s very important, right now, right this minute, whatever you’re doing, go to your local emergency room, let them know that you’ve been bitten by a dog in India, and that another person bitten by the same dog has developed rabies.”

Pruitt said the Virginia patient was bitten on her hand. The person from North Carolina was bitten on her ankle.

Pruitt said the rabies virus travels up the central nervous system. The further away the wound is from the central nervous system, the better.

Pruitt said the patient got to the emergency room, and they went ahead and started to administer treatment to her.

Pruitt asked the North Carolina patient to contact her as soon as she began receiving treatment.

“She thanked us for saving her life,” Pruitt said, adding that the North Carolina patient received treatment in enough time that she never developed rabies.

Pruitt said the health district worked with the tour company in India, identified all of the tourists and everyone on staff at the tour company and followed up with each one of them.

“The dog was owned by a homeless man, and he had a little makeshift shelter set up right across the street from the hotel where they were staying,” Pruitt said. “The CDC and the India Health Ministry was able to track down the homeless man based on the information that we received.”

Pruitt said the homeless man who owned the dog had no indication of illness. However, he said the dog ran away and he had not seen the dog in a while.

Pruitt said no one could confirm, but she suspected that the dog eventually died.

Pruitt said upon talking to the tour company, the company said they had provided information to the tourists about rabies. Pruitt said everyone she spoke with who attended the tour were never cautioned about rabies.

“The lady in North Carolina said that had she known that, she would have definitely gotten a rabies vaccine before going on the tour,” Pruitt said.

She said the CDC and the India Health Ministry are working with the tour company to provide education for future tours.

‘EXTENSIVE’ INVESTIGATION

Pruitt said the investigation, and the responses to the case were “extensive.”

Pruitt said she had to contact everyone in the patient’s community who may have had contact with her in the weeks she began presenting symptoms of rabies. Pruitt said the health department locally interviewed 13 people who identified themselves as having had close contact with the patient.

Pruitt said of those 13 individuals, four of them met the criteria to begin post-exposure prophylaxis treatment, a treatment for rabies. She said all four of those individuals completed their course of the prophylaxis treatment and did not present rabies symptoms.

At the hospitals, urgent care center and funeral home the patient was treated, Pruitt said the health department had to do risk assessments for all of the health care providers that treated the patient who were potentially exposed to the patient’s saliva.

“That was quite an undertaking,” Pruitt said.

Pruitt said she talked to the patient’s husband several times. She said she kept a calendar of when his rabies vaccine were due and would follow up with him to make sure he received them all.

Pruitt said the health department also went out to the community and we did a town hall meeting to answer their questions.

Pruitt said for weeks she fielded calls from concerned people who knew the patient.

“Unfortunately the patient did pass away, but I think that we were able to really provide good information to the people in our district and in our communities as to things that they can do to protect themselves against that risk,” Pruitt said.