Rabies Scare

[jeebusjones]

Five days ago, my cat died from what appeared to be rabies. He matched nearly all of the symptoms of "paralytic" rabies, so understandably I've been a bit terrified since then.

He had been ill for a few days, so my Thai girlfriend and I took him to the vet two days before his death. The vet seemed fairly incompetent, and seemed more interested in bilking as much money as he could out of us than actually helping the animal. No mention of rabies, just administration of some pills to be given twice a day. So, for the next two days the gf and I administered these pills by hand, sticking our fingers in the cat's mouth, getting covered in saliva. He truly hated it, and even bit my girlfriend at one point. Since it appeared not to puncture the skin, we were not particularly worried, especially since we assumed the vet would have recognized rabies.

However, after the cat died I finally went online and did some research of my own. I was shocked to learn that the cat's symptoms exactly matched that of rabies, and more than 48 hours after our first exposure to his saliva we headed to the local hospital for rabies PEP. It was nearly mid-night (we'd been away all day, and discovered the dead cat quite late at night), so we had not choice but to go to the emergency room of the only hospital in town (Kamphaeng Phet).

The place was understandably hectic, and the doctor seemed genuinely uninterested in our case. He practically laughed us out of the ER since we didn't have any open wounds, but wouldn't really let us explain just exactly how we'd been exposed to the cat's saliva, and how my girlfriend had in fact been bitten slightly.

I kept insisting (while my gf translated) that we be given the shots anyway. At one point he said that I could have the vaccines since I was paying in cash, but my girlfriend couldn't, because the doctor assumed she was on the 30 baht program. When she asserted she was paying by cash also, he finally consented to give us the shots.

So we got the rabies vaccine, but the rabies immunoglobin (HRIG/ERIG) was not administered. At the time I hadn't read much about rabies PEP, but they explained that since we didn't have any open wounds the HRIG wasn't necessary. We were told to return after three days for the next round.

Now, during those three days I was, understandably, freaking out. I did a lot of reading online, and I discovered some interesting (frightening?) information. First, our exposure was definitely enough to require rabies PEP, so the doctor was completely out of order (malpractice?). Second, the type of PEP called for varies according to different guidelines. In the US, the CDC states that all potential exposures to the rabies virus receive both the vaccine AND HRIG. The WHO, however, differentiates between Type I, II, and III exposures. Type I is a non-exposure (just petting), so needs no treatment. Type II includes bites/scratches without breaking the skin, as well as direct exposure to saliva. This would be our category (I presume), and according to the WHO it requires only the vaccine but not HRIG. Category III is any transdermal bite/scratch, which requires both vaccine and HRIG.

Now, my concern is that our situation wasn't properly considered, since the doctor didn't let us explain ourselves fully. And since the cat had been living with us, it seems possible that we were exposed to the virus at an earlier stage but didn't remember, since the cat appeared healthy and we thought there was nothing to worry about. The vaccine without HRIG does not grant immunity until at least 7 days have passed, whereas HRIG grants immediate immunity. So I guess until seven days have passed, I'm going to be quite frightened. It doesn't help that today my girlfriend has a fever, so of course my mind is thinking the worst.

I apologize for the rather lengthy post, but hopefully someone else out there has some knowledge in this area, or has had some experience with rabies PEP. Should I go to a different hospital and request HRIG, or is it unnecessary? And should I really be worried, or is my potential exposure quite minimal?

Thanks for reading!

[H2oDunc]

I would think that the first thing you need to confirm for sure rather that just using the internet and a forum is to ascertain just whether your cat did die from rabies. Reading from the internet and postings on open forums will only just fuel the worry and the panic. Get an autopsy done on the cat. Till then try not to worry too much.

[FBN]

Fever at this point has nothing to do with having contracted rabies; it may be from the vaccination or perhaps an infection that may be due to another cause transmitted through contact with the sick cat or another cause.

The Immune globuline given post exposure are antibodies which are immediately protective; it has to be injected at the site of the bite and also intra-muscularly within 24h after exposure. This is "passive immunity" though and does not offer lasting protection. The vaccine allows the body to develop it's own antibodies and should be kicking in at about 7 days but the full course needs to be given for full benefit. There is no indication for the Immune Globuline to be given after having started the vaccination process as this may actually interfere with the development of antibodies.

[wasabi]

I want to add I was once bitten by a monkey in Lop Buri. I have had mixed experiences at Bumrungrad but when I went after the monkey bite I received excellent care. The doctor took my concern seriously and gave me the full course of Verorab vaccine including the immunoglobin.

That said yes Rabbies is a horrible way to die. I would def get the cat checked out by someone competent

[tim armstrong]

I would think that the first thing you need to confirm for sure rather that just using the internet and a forum is to ascertain just whether your cat did die from rabies. Reading from the internet and postings on open forums will only just fuel the worry and the panic. Get an autopsy done on the cat. Till then try not to worry too much.

Agree with H2O. If not too late I would get a post mortem on the cat. If for no other reason than to relieve your understandable worry. Unfortunately many doctors in Thailand are not impressed by non doctors especially farlang, challenging them. But on the other side, it is a bit of a big jump to self diagnose rabies on the basis of an internet search, especially if you have no medical or nursing training. Fortunately it's still quite unusual, so maybe the stats are on your side.But an interesting topic, as rabies is a nasty disease.

I hope all remains well with your girlfriend, and let us know the outcome. Regards.

[jeebusjones]

Thanks for the replies. We're now approaching the seven day mark (in about 6 hours, to be precise) of starting the vaccination process, so I'm starting to relax a bit. As FBN noted, my understanding is also that the vaccine takes about 7 days to help the body build up immunity, so if we've made it this far all should be okay. I'll relax completely in a few more days.

Turns out my girlfriend didn't really have a fever - just overactive imagination and extreme paranoia on our parts. Shortly after writing the original post, we went to a private clinic in town to ask for a second opinion. The doctor was equally dismissive (and rude!); he seemed puzzled by the fact that we didn't just trust the authority of the first doctor we saw. Truly, (some) Thai doctors don't appreciate being challenged, which is a completely different approach to medical treatment than us Westerners are used to.

Unfortunately that cat's body is no longer available for testing. My gf and I disposed of it immediately after discovering it, initially thinking he had been poisoned. And while I admit that I am not a doctor or veterinarian, there were simply too many matching symptoms to not treat his illness as if it were rabies.

Strange thing is, no one we saw, at either hospital, seemed even remotely interested in examining the cat. In the States, that would be the first move taken, but no one here inquired.

Anyway, the statistics about Rabies in Thailand are somewhat reassuring. Although rabies in animals (particularly dogs) is prevalent, there are only about 20-30 rabies deaths per year (down from over 300 ten years ago). And apparently some 400,000 people receive rabies PEP each year, so it would seem the Thai medical "professionals" at least know how to administer it correctly.

Also, I discovered some statistics regarding rabies PEP with and without immunoglobulin. A WHO study I read about (sorry, lost the link) described rabies PEP in France in Poland. In France, only about 11% of those treated also received immunoglobulin, while in Poland the figure was less than 1%. So it would seem that not being given the immunoglobulin is not necessarily cause for concern, depending on one's exposure.

I also spoke with my father about the issue, who was given rabies PEP in Thailand back in 2006 after being bitten by a dog on a beach on Koh Chang. In spite of going to an international clinic with Western staff, he still was not given immunoglobulin.

Hope someone else finds this information useful.

[jeebusjones]

Just had the 7-day follow up jabs. The nurse assured us that having made it this far without developing symptoms we should be in the clear. It's been a scary seven days though. Final series will be on Day 30.

[hhgz]

Doctors love informed patients. Reading a paragraph on Wikipedia does not make anyone an expert on either the transmission of, or the vaccination for, rabies. Worse, vetting every word the doctor says with Wikipedia is bound to lead to a breakdown in communications. Years ago, I was bitten by a cat, and I immediately went to a nearby private hospital:

Me: I need a rabies vaccination. I was bitten by a cat.

Dr: The incidence of rabies is low in Thailand.

Me: I'd prefer to play it safe.

Dr: OK. If it has been 10 years since your latest tetanus vaccination, you should consider getting another.

Me: OK.

Simple as that. No drama. No hyperactive imagination or paranoia.

[jeebusjones]

My concerns were based on the published guidelines from both the CDC and WHO, not Wikipedia. Both the CDC and WHO guidelines recommend rabies PEP treatment for the kind of exposure I experienced. WHO requires vaccine only, while CDC recommends both vaccine and immunoglobulin.

This doctor was in flagrant violation of WHO standards. Should I have just taken his word for it? Of course I second-guessed him; you would have done the same. And the conversation that took place was far more curt than the conversation you just summarized. Our experience was this:

Thai gf: Our cat has died and it might have been caused by rabies. We're concerned because -

Doctor: Did it bite you?

Gf: Yes, but -

Doctor: Did you see a lot of blood?

Gf: No, but we're worried because...

Doctor: You don't need it.

My girlfriend and I were both calm and extremely polite. But if you were in a similar situation, and actually read the relevant documentation from authoritative sources such as WHO and CDC, you would understandably be as worried as we were, particularly when the standard in your home country differs from that in Thailand. But don't take my word for it, check it out for yourself:

WHO Expert Consultation on Rabies

CDC - Human Rabies Prevention

WHO Rabies Factsheet

CDC Rabies Site

Note the clearly stated guidelines for rabies PEP:

WHO:

Category II – nibbling of uncovered skin, minor scratches or abrasions without bleeding

Treatment: Immediate vaccination and local treatment of the wound

CDC:

Postexposure antirabies vaccination should always include administration of both passive antibody and vaccine, with the exception of persons who have ever previously received complete vaccination regimens (pre-exposure or postexposure) with a cell culture vaccine or persons who have been vaccinated with other types of vaccines and have previously had a documented rabies virus neutralizing antibody titer. These persons should receive only vaccine (i.e., postexposure for a person previously vaccinated). The combination of HRIG and vaccine is recommended for both bite and nonbite exposures reported by persons who have never been previously vaccinated for rabies, regardless of the interval between exposure and initiation of prophylaxis.

This doctor failed to listen to the complete details of our exposure, and then recommended a course of action (i.e. no PEP) that was in clear violation of both CDC and WHO standards.

Would you have trusted him?

[jeebusjones]

And here are the details regarding the cat's illness - bear in mind I am not definitively asserting he was killed by rabies, but there were enough similarities to warrant treating it as such:

1 - The cat was a stray that we stupidly took in some two months ago - initially just feeding outside the house, but after he'd been dewormed and given flea/tick medication, he started coming inside. When we first saw him, he had a wound on his back which was most likely a bite mark.

2 - His initial illness was a high fever.

3 - His behavior became unusual; he was usually quite an amiable cat, but he became withdrawn and avoided contact with us.

4 - He began relieving himself in the house, something he had never done before.

5 - His pupils were noticeably dilated in the days before his death.

6 - There was a dramatic change in his vocalization; his cry became feeble.

7 - He slowly developed problems walking, until in his final days he barely moved at all.

8 - He did not eat or drink, and demonstrated problems swallowing when we tried to hand feed him.

9 - He appeared repulsed by food/water, possibly because of his difficulty swallowing, which is indicative of rabies.

10 - Upon his death, there was a disturbing amount of yellowish foam in his mouth.

11 - The time frame works out perfectly to be rabies - he died about 8 weeks after receiving the mysterious wound, and the time from onset of symptoms to death was well under 10 days.

You will find that all of the above symptoms exactly match paralytic rabies, a lesser known but extremely common course for the disease to take. Contrary to what your doctor said, rabies is highly prevalent in Thailand. An employee at the Thai Red Cross Rabies Center in Bangkok claimed that somewhere on the order of 50% of stray dogs in Bangkok were rabid.

Given this knowledge, wouldn't you have concluded there was a reasonable chance the cat had died of rabies?

[FBN]

Definitely not wrong to consider rabies as the cause of this cat's illness and death given those symptoms; they are fairly typical. The cat's saliva could have been tested while alive and the brain analysed after death but this needs to be done asap after death.

Unfortunately, we have both situations here in Thailand. One, the doctor recommends vaccination and the patient declines and where the doctor has a flippant attitude similar to the one in this thread. Rabies is not uncommon in Thailand; a fact that does not seem to be well recognised by either local expatrates and unfortunately, also physicians.

It is generally recommended for long stay expats to have rabies vaccine for Thailand and all pets should be regularly vaccinated.

This situation was par for the course in Bali where the authorities, till quite recently, denied that there was rabies on the island. It is now a proven fact but for years, no rabies vaccines were even available on the island.

Survival rates for rabies in humans that did not get the proper post exposure treatment is small. Unfortunately, your window of opportunity to get the correct treatment is limited so best be well informed as a patient and don't take no for an answer. If the situation is managed calmly, you will probably get what you need. If not in one clinic, then another.

There were a series of mishaps here, starting with the vet that treated the cat. One wonders if he had had his vaccinations (routine for any vet). The second the failure to administer Immune globuline; in cases where there were no severe bites, probably not as important as having the vaccine immediately and for the duration of the post exposure doses.

[jeebusjones]

There were a series of mishaps here, starting with the vet that treated the cat. One wonders if he had had his vaccinations (routine for any vet). The second the failure to administer Immune globuline; in cases where there were no severe bites, probably not as important as having the vaccine immediately and for the duration of the post exposure doses.

As I mentioned, the vet seemed most interested in extracting as much cash from us as possible. He asked very little questions about the cat's history, and after listening to the cat's heartbeat gave him an injection of who-knows-what and prescribed a few pills and some rather expensive vitamins.

The absence of immunoglobulin in my case might not have been a failure per se. Here's the study I mentioned earlier about the statistics from France and Poland:

Is there a need for anti-rabies vaccine and immunoglobulins rationing in Europe?

In France, data from 2007 showed that 3,631 people (47% of all people who sought medical care in anti-rabies centres) received PEP treatment with 11% of them receiving RIG. ...

In Poland, for example, PEP is administered to about 7,000 people every year (54,767 patients in total during the period from 2001 to 2007), and only 0.8% of these patients also receive RIG. In the same time period, 644 individuals received PEP after a contact with bats and only 4.7% of them received RIG.

Clearly Poland might not be the best country to look to for ideal care, but the stats from France are reassuring for my case.

Regarding the pervasiveness of rabies in Thailand, it might be helpful to compare statistics about PEP treatment in different countries. The United States, which has a population of some 300 million people, treats between 16,000 - 39,000 people with PEP each year. Thailand on the other hand, with a population of just 66 million people, treats some 400,000. From these stats alone, it's hard to believe that rabies is uncommon here.

[jeebusjones]

Well it's day 16 from the first exposure (hand-feeding the pills the first day), and day 14 since starting PEP. I'm still freaking out about this, knowing that the vast majority of PEP failures take place during days 14-28. I know the odds are on my side, but I'm still going crazy.

Any words of advice or consolation? I can't get my mind off this.

[simon43]

This doctor failed to listen to the complete details of our exposure, and then recommended a course of action (i.e. no PEP) that was in clear violation of both CDC and WHO standards.

I sympathize with your situation, but do you really think a Thai doctor is aware of WHO, CDC, ethics, responsibility etc?

After you get over this worrying event, perhaps it might be better to relocate to a country where your concerns are taken more seriously.

Simon

[FBN]

Well it's day 16 from the first exposure (hand-feeding the pills the first day), and day 14 since starting PEP. I'm still freaking out about this, knowing that the vast majority of PEP failures take place during days 14-28. I know the odds are on my side, but I'm still going crazy.

Any words of advice or consolation? I can't get my mind off this.

You can have a blood test to determine your immune status after the vaccinations are done; probably not reliable until about 6 weeks or so after the course. Nothing more you can do at this point. Typically bites or exposure sites closest to the central nervous system has a shorter time period before the onset of symptoms; bites in the face have shorter periods than bites on the lower leg whih may take a year or so before symptoms. If you have an adequate antibody level at 6 weeks, you should be protected.

Any physician should definitely be aware of international management protocols for diseases such as rabies; to not be informed is unacceptable especially in Thailand where this is an endemic and prevalent health risk.

[jeebusjones]

Not exactly the consolation I was hoping to hear. But would you say my exposure was relatively low risk? My fingers came into contact with the cat's saliva on several occasions, but he never bit me. He did lightly bite my girlfriend's finger, but it didn't break the skin. The rabies virus cannot penetrate healthy, intact skin, right?

So do you think there is much cause for worry here?

[Sheryl]

The risk of rabies in this case is very low. A whole series of unlikely things would all have to occur:

1. The cat would have had to have had rabies --possible but by no means sure, all the symptoms described could have other causes.

2. The cat's saliva would have had to get past the skin barrier, through a break in the skin -- from what is described, probably did not.

3. yhe PEP would have to fail, usually does not.

So 3 probabilities, each less likely than the last, would all have to occur. Odds are very much against that.

The human mind is odd in how it calculates risk/reacts to perceived risk. For some reason exotic threats are always given more credence than everyday ones. Truth is, there is probably as much danger of you being injured in a motor vehicle accident in the next month as there is of you developing rabies as a result of this exposure. Probably more.

You are already doing all that you can to address the risk. Best thing is just to trust in the fact that the odds are strongly on your side. Can't go through life worrying about unlikely bad scenarios...well, one can, but it's no way to live. There are an endless array of them and it will just make you miserable.

[jeebusjones]

Thanks, Sheryl. That's exactly what I needed to hear. The human mind does indeed react to fear/stress in strange ways.

I mentioned earlier that my father was given rabies PEP when he first came to Thailand in 2006. At the time and throughout the first few weeks of PEP he was seriously worried about it, in spite of my repeated assurances that he would be fine. His response: "It's easy to say that, but it's different when it happens to you."

So statistically it's easy to conclude that the risk is extremely low, but when any potential risk to your life exists at all -the mind has a tendency to forget about statistics and, in many cases, focus on the slim possibility of a worst-case-scenario.

I hope anyone reading this thread takes away two very important lessons: Always vaccinate your pets, and get the pre-exposure rabies vaccine if you live in place with a high prevalence of rabies - like Thailand.

[jeebusjones]

Well the nightmare continues. Last night my girlfriend was up at 3am with diarrhea and vomiting. She felt extremely hot, so fearing the worst we set out to the hospital emergency room.

The doc said she didn't have a fever, and said it looked like food poisoning. They gave her an IV of some kind then sent us on our way. I repeatedly asked if it might be rabies, and the doc said no because, get this, my girlfriend wasn't afraid of water or air.

Now, I know that hydrophobia and fear of wind are common symptoms in the later stages of the disease, but isn't vomiting one of the earliest symptoms to be exhibited?

We're freaking out here. We're in Bangsaen now, as we were too stressed out up in Kamphaeng Phet and needed to get away in the hopes of relaxing. So much for that.

Does this sound like it could be rabies?

[Sheryl]

Not at all. It sounds like either food poisoning or a viral gastroenteritis, both quite common in Thailand.

Rabies does not present in this manner. And as has been previosuly explained the odds of either of you developing rabies is extremely small.

The odds of one or both of you getting other unrelated illnesses of one sort or another is, on the other hand, fairly high so you need to stop looking at every symptom in terms of possible rabies, or you'll drive yourself crazy.

[jeebusjones]

Thanks again, Sheryl. I know you're absolutely right, but it seems the mere prospect of having been exposed to the rabies virus has brought out my neurotic side. It doesn't help that my girlfriend tends to be a bit of a worrier as well, so we've been feeding off each other's fears.

She is significantly better today though still not 100%, but I suppose that's to be expected with food poisoning. Hopefully we'll be able to put this all behind us once she recovers completely.

[jeebusjones]

This nightmare won't end. My girlfriend is now experiencing strange back pains, enveloping her lower back and towards the hips. This is a symptom she has never experienced before, and it does seem consistent with rabies. I'm freaking out all over again! She has felt the pain since the day after her bout of suspected food poisoning.

What might this be, if not rabies?

[FBN]

Best read Sheryl's post again. Back pain is not consistent with rabies. The incubation period for the (Unlikely) exposure you or she had may be 6mths to 5 years. Clearly not sustainable the way you approach this now so best you can do is get a blood test to determine your immune status and then forget about it.

[jeebusjones]

I appreciate the response, FBN. But let me play devil's advocate (and hope you can reassure me). If the potential exposure was on the finger tip, wouldn't the incubation period be much faster? It's a part of the body that is quite rich in nerve endings.

Also, I have read of cases where rabies did present itself first with back pain.

[FBN]

The "loading dose" of the virus at initial exposure plays a large part to the rapidity of developing the disease and, in your case, the exposure, if any, was minimal.

Rabies disease, by definition, means that the virus is infecting the central nervous system which would present with swallowing difficulties etc.. Migration of the virus along the peripheral nerves is an extremely slow process; this accounts for the long incubation periods with rabies.

[jeebusjones]

Thanks FBN, I appreciate it. Once I make it through this week I'm sure I'll be able to relax. The problem is that, as I mentioned above, I read a CDC report which discussed the fact that the vast majority of PEP failures (minus HRIG/ERIG) occur in days 14-28. We're at day 22 now, so almost in the clear.

Thanks again for bearing with my extreme paranoia.

[taxout]

HRIG is expensive, in limited supply, and has a relatively short useful live. Thus it's not widely stocked in Thailand outside Bangkok.

I'd make a hefty wager that your local community hospital did not have HRIG on hand to offer you no matter the condition of your exposure.

For HRIG it's best to head to Bangkok and the Thai Red Cross, which offers HRIG at far less cost than private hospitals.

[jeebusjones]

They had a poster up in the ER describing the correct administration of ERIG, so they may have had it on hand.

Perhaps a stupid question, but one I'm having difficulty finding an answer to. If the virus has reached the peripheral nervous system, can the immune system (boosted by the vaccine) still fight it? I know once it reaches the central nervous system the answer is no, but what about the PNS? Because it would seem the virus reaches the PNS within days.

[FBN]

They had a poster up in the ER describing the correct administration of ERIG, so they may have had it on hand.

Perhaps a stupid question, but one I'm having difficulty finding an answer to. If the virus has reached the peripheral nervous system, can the immune system (boosted by the vaccine) still fight it? I know once it reaches the central nervous system the answer is no, but what about the PNS? Because it would seem the virus reaches the PNS within days.

The moment skin is broken, the virus is already in contact with the peripheral nervous system; the whole purpose of the post exposure prophylaxis is to prevent multiplication of the virus and progression of the disease and virus to the central nervous system..

So, yes, once you have antibodies, the virus is neutralised.

[jeebusjones]

I'm afraid this story won't end. My girlfriend continues to experience strange symptoms - the lower back pain expanded to include the entire pelvic area. She was noticeably anxious, so we visited a private hospital in BKK where an ultrasound was performed to rule out cysts. Nothing strange was observed, but she was given a load of antibiotics and some painkillers. The next day (yesterday) she seemed fine, but then last night she tossed and turned all night, then woke hours before her usual time and couldn't sleep again.

She's been plagued by a feeling of general malaise all day today, and has been unusually grumpy. The timing and symptoms coincide perfectly with rabies, so again I'm fearing the worst.

I'm also fearing the worst for a few other reasons. One is that the doctor we spoke to at the hospital the other night wouldn't rule out the possibility of rabies. He said based on our exposure the risk was low, but admitted that it was possible. He suggested we get tested (there is a non-invasive test to confirm, apparently), but we were too afraid to do so. He also confirmed, as did some other studies I read about on the web, that the PNS is an immune-protected environment, meaning that once the rabies virus enters a nerve, it is too late.

I also read a US study which suggested that superficial bites on the extremities carry an estimated 5-10% risk of contracting rabies. My girlfriend was bitten on the finger by the cat. It did not appear to break the skin, but isn't there a possibility that the virus was able to gain access to a nerve? We didn't start the vaccine until 36 hours after the bite, so that means if the virus had entered the skin near a nerve, it had about 8.5 days to penetrate the nerve before an immune response could be mounted.

So yes, I may seem paranoid, but isn't there good reason for me to be worried, in light of these unexplained symptoms?