Med Journal February 2021_Joomag - Page 6

Scientific article by Elton r . cleveland , md , dvm

Associate Professor , UAMS Associate Program Director , Baptist Health-UAMS Family Medicine Residency

Rabies : What is Going On ?

Rabies is a fatal viral zoonosis and a serious public health problem 1 , 2 . Laboratory testing is necessary to confirm infection . Any exposure is a concern to all parties involved . Medical professionals must be aware of the issues surrounding rabies . They must possess a cogent plan to evaluate and care for the exposed patient or allay the fears of the non-exposed . A common-sense approach to caring for pets and their interaction with wild animals is critical in the fight against rabies . Arkansas Department of Health officials are available and are knowledgeable about rabies diagnosis and treatment .
Year- 1981 The clinic radio in my truck suddenly sounded without the normal call signs . It was my wife . She said , “ The health department called . They said you have been exposed to a horse with rabies , and they are sending the rabies immune globulin and vaccine on the bus tomorrow . You are to meet the bus and have your physician start the rabies immune globulin and vaccine . What is going on ? Is this true ?”
Fortunately , I was miles away from the ire of this sweet woman . Questions of “ What is going on ” are frequent when we hear the numerous scenarios of possible rabies exposure .
Rabies is an ever-present danger . A friend from Mena would often tell me stories of seeing 30-40 rabid dogs a day during an outbreak that took place in the 1940s and 1950s . This was prior to animal-vaccine availability . When I began veterinary practice , most exposures were from men trying to vaccinate their dogs and mistakenly injecting a modified live vaccine into themselves instead of the dog , thus needing prophylaxis . There is no known effective treatment for rabies ; subsequently , most of the people who contract it die
. The rare few that survive do so by an unexplained phenomenon . Although the disease has a poor prognosis , rabies is generally preventable with proper wound cleansing along with post-exposure prophylaxis ( PEP ).
Potential in Arkansas
In 2019 , the Arkansas State Public Health Laboratory tested 807 samples , and 26 were positive for rabies . The species breakdown of positive tests : 15 skunks , seven bats , two horses , one cat , and one cow 3 . From 1960 to 2018 , a total of 125 rabies cases in humans were reported in the U . S ., with roughly one-quarter resulting from dog bites during international travel . Of the infections acquired in the U . S ., 107 were attributed to bats 4 . In domestic animals , cats will have more cases of rabies than dogs or ferrets . This is thought to be due to lower vaccination rates of cats and their frequency of being outside with more likely exposure 5 . In Arkansas , skunks are the most frequent positive wild animal .
Initial Evaluation
Suppose your nurse takes an urgent call from a concerned patient regarding an animal bite . What do you do ? Whom do you contact or consult ? Have they cleansed the bite wound ?
Wound care is the first step in the treatment of any individual with a feared rabies exposure . Appropriate wound care alone has been noted to be almost 100 % effective if initiated within three hours of inoculation . Recommendations include scrubbing the wound and surrounding area with soap and water ( solutions include 20 % soap solution , povidone , and alcohol solutions ) and swabbing deeply for puncture wounds , with ample irrigation . After cleansing the wound thoroughly , the application of a virucidal agent such as benzalkonium chloride or povidone-iodine is recommended 6 .
Prior to the initial evaluation , gather the following information :
• What is the species of the exposing animal ?
• What type of contact – bite or nonbite ?
• Animal behavior – vaccinated ? Unprovoked attack ? Any behavioral changes in the animal ? Recent bite wounds on animal ?
• Ascertain the location of bite – leg versus face , neck , etc .; are there multiple bites ?
• What age is the person ? A child may be at higher risk than an adult .
• Is the person a transplant recipient or immunocompromised ?
• If non-bite , is there a scratch or mucous membrane exposure ?
• Is the animal available for observation or testing ? Dogs , cats , and ferrets appear to begin to sicken and die within 10 days ( generally within 5-7 days ).
• Was it a bat exposure ? Any exposure to bats is a potential rabies exposure , with an estimated 1 % of bats being positive for rabies 4 .
• Was the person outside the U . S . when bitten ?
• Has the exposed person been previously vaccinated ?
Plan and Process
Since the incubation period is 1-3 months with a range of several days to up to 8
174 • The Journal of the Arkansas Medical Society www . ArkMed . org