A Dog's Bite

A child arrived at our clinic after hours with labored breathing. Possibly just another case pneumonia. But this 10 month-old boy had visited our clinic two weeks prior with a dog bite to the face, and appropriately received both tetanus anti-toxin and anti-rabies vaccines. The health officer, Bezu, visited our house that evening to inform me about the patient’s arrival. “I am worried,” Bezu said, “this patient is sick.” With that, we rushed off to evaluate him together. The boy was unconscious and foaming from the mouth. His lungs were full of fluid, and he gasped for air. As we turned him slightly in the exam, his arms and legs became rigid in a spasm (a common sign of tetanus). “Tetanus!” yelled Bezu, “Get the antitoxin.” But it was too late. Minutes later, the boy was gone.

After the infant’s death, I was confused. Something about the events felt wrong. The child exhibited some signs of tetanus, but the disease progressed so rapidly. What about the foaming at the mouth and gasping for air? After more research we determined that the child must have had rabies–the bite was so near the brain and so deep that the vaccines provided to him weren’t sufficient to prevent the disease.

Since this incident, I’ve had time to read and learn more about rabies—a unique and frightening disease. The disease is universally fatal once it has reached the brain. If someone starts to exhibit the signs of rabies, there is nothing we can do to prevent death. But we also have a unique opportunity to prevent disease progression after exposure (i.e. a bite) by using a vaccine to stimulate the body to produce its own antibodies.

The rabies vaccines that Erin and I received prior to our departure as a prophylactic measure are grown in cell cultures and inactivated. They are the only ones licensed for use in the U.S. Here however, where rabies is enzootic (meaning common in the canine and other mammalian populations), we don’t have access to this tissue-culture vaccine. It’s just too expensive. Instead, we use a neural-tissue vaccine prepared from sheep brain that was first invented in 1911. This vaccine has been called “the crudest biologic material administered to man.” It has also been known to have a high prevalence (0.5%) of severe neurologic side effects and occasionally death. It requires many more shots than the U.S.-approved vaccine (14 rather than 5) because it simply just doesn’t work as well. But even then, the vaccine is not always effective, particularly in wounds to the head and neck where the route of disease travel to the brain is comparatively shorter. The Pasteur Institute notes that according to one study, “rabies vaccines prepared in animal brains were totally ineffectual for preventing rabies in individuals bitten about the head or neck.”

Erin and I had access to a safe and effective rabies vaccine prior to even sustaining a bite. This infant, however, sustained a severe bite to the face in a country where dogs are not vaccinated against rabies. He was given 12 painful shots even though they probably didn’t have a chance of working. His only real chance at living was that the dog that bit him didn’t have rabies in the first place, or that the virus was killed during the cleansing of the wound. Unfortunately, neither turned out to be the case.