News of rabid foxes or other animals doesn’t make quite as much of a stir here in Western Maryland as it did on Capitol Hill. Here, it seems to be more regarded as a hazard of country living.
This is a sad example of the rabid, anti-fox rhetoric sweeping the nation. Any reports that I’ve been aggressive or inhospitable in any way is just not true!
All I want is to be loved and treated with respect. https://t.co/xmOYPXOdhW
— Capitol Fox (@thecapitolfox) April 5, 2022
Admittedly, my enthusiasm for seeing the beautiful creatures has waned over the years. And I don’t dissect dead animals or road kills as we were taught to do in a mammalogy class I did in college. Too many infections to worry about now, including plague, tularemia, and rabies, and I know most docs don’t have the time (and often the knowledge) to take a detailed exposure history.
The Capitol Hill fox bit “at least” nine people. Sometimes people don’t realize they were bitten. Sometimes ER doctors miss the bites, too.
A friend of mine asked for advice a couple of years ago. That summer evening, she was sitting outside the fire station waiting for a class with her car door open. A coyote tried to jump in the car and bit her as she swatted at it. It then chased her as she ran for help. Over the next several hours, we texted back and forth while she was in the ER waiting to be seen during a high COVID period.
I was reminded of several tips about rabies as I reviewed my notes and literature. For one, early and vigorous cleansing of the wound is with soap and water, and an antiseptic with activity against rabies virus (such as povidone iodine or 2% benzalkonium chloride) is important. These decrease the risk for transmission.
It’s also important to receive rabies immune globulin (RIG) and vaccine as soon as possible after the bite — “timely administration” is the preferred jargon. The shots can be painful because as much of the RIG has to be infiltrated around the wound as possible. The rest is injected into the deltoid muscle. It’s important that the deltoid be used rather than the buttocks, because you don’t get as good an antibody response. What is “timely?” I asked myself. I found that no postexposure prophylaxis failures have been reported in the United States despite an average delay to initiation of approximately 5 days.
While shaken, my friend appeared to have gotten reasonable care. But she got back to me the next day, noting that after she went home and readied for bed, she found a bruised area with broken skin on the back of her calf, likely where the coyote nipped her. She checked with the health department and returned to the ER to receive more RIG around the calf wound.
The coyote bit two people that day, and then searchers found the rabid animal, already dead.
Last year, an Illinois man died of rabies, the first human case there in almost 70 years. The man, in his 80s, had awakened to find a bat on his neck. He refused the necessary medical care. A month later, he developed headaches, difficulty controlling his arms, finger numbness, and difficulty speaking, and subsequently died. Hopefully, healthcare workers knew of this bizarre history and he didn’t expose many of them to the deadly infection before his death.
That case raises another key message: Anyone who awakens with a bat flying around their bedroom should receive prophylaxis. Too many don’t, either because they are unaware that they should be treated, even if they are unaware of a bite, or because they can’t afford treatment.
Another friend was needlessly exposed and required treatment because a woman brought her ill, unvaccinated cat to the veterinary clinic. What kind of person does that to others?
The cost of postexposure prophylaxis with RIG and vaccination can be over $3000. Sometimes, especially if care is given through the emergency room, charges are much higher. An additional problem is that state health departments are less likely to help with the costs than they used to.
People need to know that transmission is only through contact with saliva or brain/nervous tissue. Contact with blood, urine, or stool (.g, bat guano), or simply petting an animal, is not considered a significant exposure, and PEP is not recommended. Also, the rabies virus becomes noninfectious when it dries out or is exposed to sunlight.
I always had a low threshold for treating possible rabies exposures, given that the alternative was inevitable death if the infection was proven. The health department sometimes disagreed with my referrals, leaving the patient with a difficult choice.
This is another reason I am a supporter of universal healthcare.
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About Dr Judy Stone
Judy Stone, MD, is an infectious disease specialist and author of
Resilience: One Family’s Story of Hope and Triumph over Evil and
Conducting Clinical Research: A Practical Guide.
She survived 25 years in solo practice in rural Cumberland, Maryland, and now works part-time. She especially loves writing about ethical issues and advocating for social justice. Follow her at
drjudystone.com or on Twitter