How to make sense of this nonsensical rabies vaccination course?
March 7, 2010 4:43 PM   Subscribe

Much confusion over a rabies vaccination prescription that seems to ignore all official (WHO, CDC) recommendations. Advice appreciated.

Apologies in advance for incoherence. The medical system here is very frustrating, particularly if you are a single woman who shows up alone without male escort.

So, I'm in a developing country and while at the house of friends of friends 48 hours ago, sitting on the floor as one does here, I was climbed over and gnawed on by an eight week old puppy who is in that sharp-toothed biting stage. He chewed on my knuckle and broke the skin.

Only the next day did it occur to me that this might be of some concern. The owners of the puppy claim they got him from a pet store, the name of which they cannot recall -- only the general neighborhood. (I have no particular reason to disbelieve them.) The puppy has not been vaccinated yet, of course (happens at twelve weeks, here). No idea whether the puppy's mom was vaccinated or not, although one would assume she was, provided the puppy actually came from a pet store. The owners have had him for a month. Rabies is a major problem here. I do not know if they have taken him out on the streets (where strays live), but he's so tiny that I doubt it. I also don't know if the apartment in which the puppy lives has a rat or bat problem (quite possible, here).**

A friend suggested I go to the hospital, just to be on the safe side. Off I went yesterday, 24 hours after contact with the puppy. Two doctors listened to my story and suggested the post-exposure treatment for rabies (HRIG + four shots of vaccine). They were overruled by a senior doctor who wrote me a prescription that actually makes no sense for either pre- or post-exposure treatment.

(In short, he simply prescribed vaccine shots at 0, 3, and 7 days. This is two shots short of an effective post-exposure treatment - i.e., it's missing the HRIG on day zero and another vaccine shot on day 14. It's also wrong as a pre-exposure vaccination course -- which requires three shots, but on days 0, 7, and 28.)

I kept asking him about this. (I was already wary of him because he said, "Oh, it's just a scratch! You won't get rabies from that" -- which bespoke a staggering ignorance for a doctor.) He got very irritable and high-handed when I questioned him and finally blew me off by saying, "Well, if you start feeling unwell, come back then."

That doesn't help, though, because according to this prescription, I'm supposed to get the next shot tomorrow.

My question is basically -- what would you do in my shoes? At this point, with one shot already in me, it doesn't seem like a bad idea to follow through with the vaccination course, but the way the doctor has written the prescription, it's NOT the vaccination course I'll be receiving -- it's an incomplete and therefore ineffective portion of the post-exposure treatment.

However, this being the country it is, I could probably convince a pharmacist to ignore the date each shot is supposed to be dispensed, and instead dispense them in a manner that fits with the vaccination timeline suggested by the CDC and WHO.

Can anyone think of any reason this would be a bad idea? (Other than the fact that -- well, if the puppy had rabies, this will screw me over. Then again, if the puppy has rabies, I'm already screwed over by the doctor's refusal to dispense the HRIG.)

I'm definitely worried about doing it the way the doctor said --ie, taking three rabies shots so close together (0, 3, 7). That's a lot of rabies to cram into my body in a single week, especially when this regimen is supposed to FOLLOW the administration of the Human Rabies Immunogobulin shot, a major immune-system booster which I did not receive.

Anyway, I know YANMD, but your advice/thoughts are eagerly solicited. I did try to find another doctor, but for some reason, nobody here is willing to contradict each other (or maybe they're just not willing to contradict this doctor in particular). Unfortunately, I don't have the option of pretending I haven't seen anybody yet, because I *do* have that first rabies shot in my system from yesterday...

** Due to various social mores, I was not able to speak plainly with the puppy's owners and say that I was worried about the health of their puppy. Not only would this be seen as insulting, it would also guarantee that I would NOT get truthful answers to my questions -- especially if the owners thought the answers would displease me. (I don't know these people and don't really have any friends in common, which makes it trickier, even.)
posted by anonymous to Health & Fitness (7 answers total) 1 user marked this as a favorite
Do you have any connection to a doctor back at home? Perhaps you can call your regular doctor at home and try to get a more sane opinion here that you might be able to trust. Alternatively, perhaps there is a "foreigners clinic" around that offers a higher standard of medical care. Your embassy might have a list. A more trustworthy doctor might be able to advise you as to whether it's already "too late" at this point.

If all of the above failed, I think my personal inclination would be to strongly consider obtaining the HRIG and follow the CDC/WHO guidelines yourself if no doctor could provide any reasonable evidence for the protocol you were prescribed.
posted by zachlipton at 5:19 PM on March 7, 2010

I feel for you and hope this whole thing is moot because the dog doesn't have rabies.

But follow the WHO / CDC on their recommendations. Rabies is nothing to trifle with. If you are bitten by an infected animal and you don't get the (first) treatment shot within 72 hours of exposure it is 100% fatal in humans. This is what a CDC travel specialist MD told me while convincing me (and my GF) to get the shots before we left. So by the time you'd be feeling unwell, you'd really be in a bad place.

So I'd escalate as necessary to find a doctor who will give you what the CDC prescribes for post-exposure. Go to a different hospital if necessary, or go to the travel medicine / "foreigner" section of the same hospital. Make a huge ruckus and get a hospital administrator. A bitchy, hysterical foreigner is still a living foreigner.

Of course it's unlikely that the dog has rabies. But it's better to be safe than dead.
posted by zpousman at 5:19 PM on March 7, 2010

I had PEP after a bat exposure. I know what you're going through.

Well, it doesn't sound like you're in the most professional of hands, but what they're doing seems consistent with the beginning of the "Essen" vaccination schedule: live vaccine only, on days 0, 3, 7, 14, and 28. This is considered appropriate for a Category II exposure, "Minor scratches or abrasions without bleeding or licks on broken skin and nibbling of uncovered skin". [European Center for Disease Prevention & Control] The HRIG is part of the protocol for a Category III exposure, which would be a real bite vs. a "gnaw". In the developed world, they might take a better-safe-than-sorry approach and treat a borderline case as Category III. Personally, I would insist on the last two shots. It's likely, though, that he's following a pragmatic approach of giving prophylaxis up through the point at which most bite victims might be symptomatic (and thus fatally ill).

zpousman, it isn't so much the 72 hours as that you need the prophylaxis to begin well before you become symptomatic, because once you are symptomatic, your odds of survival drop near zero.

Just for safety's sake, make sure that if you go in your doctors have a copy of the Milwaukee protocol -- which saved an unvaccinated girl in Wisconsin a few years ago after infection via a bat bite -- but has only worked one other time last I heard.

I suppose what you should probably do, given your experience here, is follow up with a primary-care physician in your home country. I would consider flying home and getting the regimen there, but I'm not entirely sure that would be ethical or even legal.

Bottom line: don't worry about what you've already had and what is prescribed, that seems OK. It's continuing the full prophylaxis that you should focus on.
posted by dhartung at 5:33 PM on March 7, 2010

If you do decide to get the HRIG, do note that it's extremely hard to find in a lot of places. It may not be easily procurable, even if you head to the capital of wherever you are right now. So you might really have to look hard -- or leave the country.
posted by SpringAquifer at 8:23 PM on March 7, 2010

What would I do in your shoes? Nothing, honestly. I wouldn't get the shots. If the dog is rabid, then your hosts have already been exposed to it, right? And they're fine, right? I believe it takes about ten days to two weeks for the first symptoms to show, so your hosts would already have contracted it.

I lived in Egypt for a couple of years, in Cairo, where there is rabies, and I actually rescued a street pup. Total craziness, right? But I also knew that although rabies is rampant in Cairo, there hadn't been many cases in our neighborhood. Also, the dog didn't seem rabid, right? Puppies chew, .as you know.

Since you started the series, I guess it makes sense to continue with it. But I might call my doctor back in the US or wherever... but ultimately, yeah, if WHO and CDC say the same thing, go with that.

Good luck!
posted by bluedaisy at 10:46 PM on March 7, 2010

I had PEP from a bat scratch 4 years ago now, it was stressful enough to deal with without worrying that the course hadn't been completed. Contrary to bluedaisy's comment it can take two years for symptoms to develop. Not to dramatise, but If you start to fell unwell then it's too late. Insist on the last two shots, and do what needs to be done to get the proper treatment if only for your own peace of mind.
posted by poissonrouge at 9:21 AM on March 8, 2010

Call your embassy.

In Armenia, at least, there is a 'French' doctor that all serious medical issues are turned to. I'd imagine there is something similar where you are.

Also look at your travel insurance. There may be a collect callable doctor.

Good luck! I know how tough it is dealing with medical care in a developing country and when working in another language. As much of a PITA the Embassy can be, this is a time to use it.
posted by k8t at 11:59 PM on March 8, 2010

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