A 23-year-old agricultural extension volunteer working in
Kikima,
Machakos District, Kenya, was bitten by her puppy on May 31, 1983.
She died of rabies on August 27, 89 days after the bite and 20 days
after onset of symptoms. Medical records indicated the patient had
been given three doses of human diploid cell rabies vaccine (HDCV),
0.1 ml intradermally, for preexposure prophylaxis, the last dose of
which she received in late November 1982. She was reportedly
informed
at that time that additional doses of vaccine would be necessary
should a rabies exposure occur. The patient's May 31 diary entry
described a behavior change in her puppy (which was too young to be
immunized against rabies) and her hope that he was not rabid.
The patient was well until approximately August 8, when she
noted
left arm pain. On August 10, she was seen in a Nairobi medical
clinic
with complaints of insomnia and increasing left arm, shoulder, and
neck pain. She was hospitalized on August 11 and placed in the
intensive care unit. When asked about animal exposures, she failed
to
report the bite.
Rabies virus was isolated by CDC from a cervical cord specimen
obtained at autopsy. Rabies monoclonal antibodies indicated that
the
isolate was rabies and not one of the rabies-related viruses, such
as
Mokola or Duvenhage, which have been isolated from humans in
sub-Saharan Africa.
Reported by R Gibbs, MD, K Miller, MD, Peace Corps, Washington, DC,
S
Waterman, Peace Corps, Nairobi; M Warshaw, MD, D Silverstein, MD,
GL
Timms, FRC Path, Nairobi Hospital, Nairobi; C Oster, MD, US Army
Medical Research Unit, Nairobi, B Johnson, PhD, P Tukei, MBCHB,
Virus
Research Center, Nairobi; T arap Siongok, MD, Ministry of Health,
Kenya; Div of Viral Diseases, Center for Infectious Diseases, CDC.
Editorial Note
Editorial Note: This is the first case of human rabies reported in
a
person with a history of preexposure rabies prophylaxis with HDCV.
Investigations are continuing into the circumstances of previous
vaccination, potency of the vaccine used for preexposure
prophylaxis,
and reasons for failure to seek postexposure treatment, since two
1.0
ml intramuscular (IM) booster doses of HDCV are recommended when
rabies exposure occurs in persons who previously received
preexposure
prophylaxis.
Of the last five Americans reported to have died of rabies,
four
(including this patient) were exposed to rabid dogs outside the
United
States (1-3). These cases emphasize that: (1) Protection from
clinical rabies in persons given preexposure prophylaxis requires
that
two IM doses of HDCV be given after exposure, one each on days 0
and
3. Persons who have not received preexposure prophylaxis should
receive five doses of HDCV, one each on days 0, 3, 7, 14, and 28
and
20 IU/kg of human rabies immune globulin on day 0. (2) Laboratory
diagnostic tests are subject to error, and direct microscopic
examination for Negri bodies is less reliable than examination by
fluorescent microscopy.
Human rabies is becoming rare in the United States, primarily
because of effective dog-control programs and adequate access to
excellent rabies biologics. Americans traveling abroad should be
aware of the risk of rabies from dog or cat bites. Most countries
in
Asia (except Taiwan and Japan), Africa, and Latin America have
significant endemic rabies, especially among dogs. Animal vaccines
obtained locally in developing countries sometimes do not appear to
be
immunogenic and may not provide protection for the vaccinated
animal.
CDC continues to recommend that, while traveling, persons
bitten
by animals in countries not known to be rabies-free should seek
immediate advice regarding rabies postexposure prophylaxis.
Although
rabies is almost always fatal once symptoms occur, proper adherence
to
effective preventive and treatment procedures can eliminate the
risk
of human disease.
References
CDC. Human rabies--Rwanda. MMWR 1982;31:135.
CDC. Human rabies acquired outside the United States from a
dog
bite. MMWR 1981;30:537-40.
CDC. Imported human rabies. MMWR 1983;32:78-80, 85-6.
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