In a follow-up on report from last May, a Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWRpublished this week gave some more details of the rabies death of a Virginia woman.

Close-up of a dog's face during late-stage "dumb" paralytic rabies/CDC
Close-up of a dog’s face during late-stage “dumb” paralytic rabies/CDC

According to the report,  the 65-year-old woman aged 65 years with no preexisting health conditions sought medical attention in May 2017 for arm pain following a dog bite 6 weeks prior while traveling in India on a months log yoga retreat.

Members of the tour confirmed that the patient was bitten by a puppy outside her hotel in Rishikesh, India, and that the wound was washed with water, but no further treatment was administered. Additional member had contact with the puppy, including one person from another state that was also bit and rabies postexposure prophylaxis (PEP) was recommended.

As her symptoms progressed, various medical intervention were performed including endotracheal intubation and mechanical ventilation.

Rabies death reported in Utah, First since 1944

Laboratory tests were performed–Electroencephalography results suggested severe encephalopathy. Rabies was confirmed by the detection of rabies virus RNA by real-time reverse transcription polymerase–chain reaction (real-time RT-PCR) in saliva and skin biopsy specimens, and rabies virus antigen by direct fluorescent antibody testing of the skin biopsy.

Several days later the full Milwaukee protocol was attempted to no avail. Approximately three weeks after symptom onset,  the family decided to withdraw advanced medical support, and the patient died shortly thereafter. Rabies virus was isolated from brain tissue postmortem.

Vaccination is the most cost-effective way to reduce rabies deaths in India: Study

The authors write that travelers to India, which has the world’s largest incidence of dog-mediated human rabies deaths, are recommended to receive pretravel rabies vaccination if they will be involved in outdoor activities (such as camping, hiking, biking, adventure travel, and caving) that put them at risk for animal bites.

In the case of the yoga retreat tour, given the extended length of the tour and the rural and community activities involved, pretravel rabies vaccination should have been considered. In the event of a suspected rabies exposure, PEP is recommended as soon as possible and has been shown to be highly effective at preventing rabies if administered prior to symptom onset (typically 3 weeks to 3 months after exposure).

Persons with a history of vaccination should receive a 2-dose booster vaccination series if exposed, whereas persons with no history of vaccination require a 4-dose vaccination series with rabies immune globulin administered at the site of exposure.

Read more at MMWR