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Human Rabies -- Kenya
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: 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.
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