Rabies follies in Massachusetts

A recent news report from Berkshire, Massachusetts that was highlighted by ProMed is a strange and concerning story of rabies exposure.

The story involves two people that were stalked and attacked by an aggressive fox. One man was attacked in his driveway. He fought the fox off with a smoker lid, but several hours later it attacked and attached itself to a woman next door who was outside collecting her recycling bin. The fox bit her multiple times, and it took 20 minutes (with the aid of the same smoker lid - apparently a good fox extractor) to remove the fox from the woman’s leg. The man then killed the fox.

The woman’s sister called the police, who dispatched paramedics and suggested they call Animal Control to get the fox tested for rabies.

So far, so good. Unfortunate attack but managed as well as can be expected.

Anyway, when the paramedics arrived, they told the woman that she didn’t need to go to the hospital. A little more information in the article would have been nice here. Based on the severity of the injury, the response of the paramedics probably makes sense. The fox had bitten her, but the bites didn’t appear to be too serious from a trauma standpoint, and racing her off to the hospital in an ambulance was not required. However, rabies exposure is a major concern and this scenario raises a good question: What is the role of paramedics in thinking about and educating people about the risk of rabies exposure? Ideally, paramedics should know enough to tell people that they should seek medical care when there has been potential exposure to rabies. I don’t know whether this is the case, however. If someone isn’t injured enough to require emergency care, is that all that the paramedic needs to assess?

The woman then had a relative drive her to the emergency room. If this was because of concerns about the severity of bites, then that makes sense. If it’s from a rabies exposure standpoint, then it’s overkill. Assessment of rabies exposure and starting treatment is considered a medical "urgency," but not an "emergency." Basically, that means you don’t need to be treated immediately and you have time to go to a regular physician. In this case, going to her physician the next day would have made the most sense, since emergency rooms are not the ideal place for rabies assessment and exposure treatment.

The fox was rabid in the end, and the woman was started on rabies post-exposure treatment. Even if this was an inefficient way of getting care, the key point is that she was treated. Rabies is almost invariably fatal but is almost 100% preventable with proper post-bite care.

The description of her treatment is strange, however. “On Monday she began the lengthy series of anti-rabies vaccinations, which included injections into each bite mark. She returned to the hospital for another shot on Thursday and learned that she has 10 more vaccinations to endure this month, with each hospital visit at a USD 75 co-pay.” This makes no sense. Current-day rabies post-exposure treatment consists of a series of 4 doses, not 10 or more.

Another strange part of this story is the apparent difficulty the two victims had getting the animal tested. The people who were attacked claim “I called a rabies hotline and nobody picked up." As a result, the fox's body sat on the woman's property for three days until they took it to a local vet clinic, that shipped the fox’s body for testing. In another strange twist, it seems the woman had to pay for testing herself. That makes absolutely no sense. This is clearly an animal with a high likelihood of having rabies and a situation where there has been clear exposure of a person. The rabies status of the animal must be determined and requiring people to pay for that themselves makes no sense.

By the time I posted this story, the Berkshire newspaper had pulled the article from its website. I don’t know why. It could because the story was poorly written or the information was incorrect. Regardless, it raises some interesting issues.

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Bennett - January 3, 2011 10:28 AM

While rabies prophylaxis isn't an emergency, only ER's have a ready supply of the immune globilin and rabies vaccine. Going to the ER is the only part of the management that makes sense!

Scott Weese - January 3, 2011 10:34 AM

Thanks for the comment. That may vary by region, however. In many regions, public health personnel have vaccine and antibody, and arrange for vaccine to be administered or provided to the physician. ERs may have limited or no supply, along with limited experience in rabies exposure.If ERs are the only place where the vaccine is available, that would make sense, but that's not always the case.

Maryn McKenna - January 3, 2011 5:28 PM

This story resonates with me: I had a suspected rabies exposure a few years ago (bat) and had major difficulty getting to the right people and getting the exposure risk-assessed. I did eventually start prophylaxis and got the bat necropsied, but it was surprisingly difficult — phones weren't answered, no one knew where to refer, etc. I persisted mostly because, as a journo covering the CDC, I wrote a few stories every year about occult rabies and bat exposures, and didn't want to end up as a story subject; I wondered though whether someone without my knowledge would have persisted.

Gayle Robison, DVM - January 5, 2011 3:37 PM

It's entirely possible that A)No health department funding was available for rabies testing, given the deplorable state of our economy or B)No local health department existed because no budget for such has ever existed. It's also possible that the woman had no health insurance and therefore calls to physicians' offices about being seen promptly for rabies prophylaxis resulted in her being told that she could not be seen for 3 months (typical if you are a new patient and have no insurance), so she had no choice but to use expensive emergency room resources. This is the US, where we have the best healthcare in the world, after all (insert sercasm smilie here).

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