Have you ever seen a door frame or other wooden object ravaged by termites? For months before, everything seems normal on the surface, but inside, the little critters are eating voraciously away at the structure.
Eventually there is no hiding them, and their massive damage becomes apparent. It nearly always means the total destruction of that object.
I think that’s a perfect analogy for how the rabies virus behaves. Unlike wood though, it replicates and spreads in the nervous systems of otherwise healthy mammals, and needs new hosts once the previous ones die.
This was not the travel article I hoped to write. If the certainty of your mortality scares you, please click away to cute Youtube cat videos now.
The act of writing about traumatic experiences is cathartic. I write this account to record the experiences for myself and remind myself how blessed I am to be alive. But ultimately more importantly, I do it to help others avoid similar emotional trauma after a dog bite.
The idea is to die young, but as late as possible... Paulo Coelho
Normally TRAIL magazine‘s travel articles are upbeat, letting readers know how amazing trail running trips to exotic parts of the world are. Mine, unfortunately, is the opposite. Although my tale opens a door into a dark room filled with moving shadows and monsters that drool, snarl and bite, there is definitely a positive message that I hope will empower you and yours. So don’t slit your wrists midway.
Fateful afternoon run
If you’ve read my editorial letter on page five of TRAIL issue 26, you’ll know that my low-key run to the top of a tourist viewpoint in Quito, Ecuador went pear-shaped.
It happened towards the end of my afternoon run up the 200m-high El Panecillo hillock to view the imposing 45m-tall Woman of the Apocalypse statue. A pack of unfriendly neighbourhood dogs spotted me running down the stairs, and chased me down for their afternoon blood sport. Those seconds would change the tone of the rest of my trip, and my life.
While I faced the biggest one, one of the more agile ones nipped in from my blind side, and bit my lower left calf. Kicking him off, I realised with a renewed surge of adrenalin that I could get bitten by several dogs. ‘Eaten alive!’ did flash in big red letters across my brain panel, so I needed to counter-attack or become prey.
The biter came back for another taste, and I kicked him in the chops, and charged, yelling, at the rest of them. That was enough to stall their feeding frenzy, and I was able to back down the hillside with them still barking aggressively.
One lick, one bite, is enough
Back at my hostel a few minutes later, I cleaned the four puncture wounds with antiseptic, and asked fellow travellers where I could get a rabies jab. There was a public hospital emergency room 250m around the corner, they said. I was being examined within the hour. The doctor looked at my leg and seemed totally disinterested. He said that the bites were superficial and just needed to be cleaned. I asked about rabies in very poor Spanish, and he shook his head like I didn’t need to be concerned.
What I knew about rabies:
- you got it from the bite of another mammal that might or might not show symptoms,
- cleaning the wound was not sufficient to prevent infection,
- once you showed the neurological signs of the disease, the chance of dying from it was 100%,
- it could be a horribly painful death, and if you wanted a decent chance of survival,
- you ideally needed to get your first of several vaccine injections within 24 hours.
There was no guarantee that the dog that had bitten me didn’t have the early stages of rabies, and I wasn’t going to take chances. I checked out of the hostel the next morning and headed into Quito’s business district to get my vaccine.
Remembering a fallen warrior
Graeme Anderson was a world-renowned big water paddler who grew up and lived in Underberg, in KwaZulu-Natal’s Drakensberg region.
I never met him but had heard of his Amazon adventures where he’d shot some of the previously unpaddled rapids in the upper reaches. He’d also travelled to other parts of the world to experience their biggest and baddest rivers. He was back farming with his dad in KZN in 2012 when he noticed a stray dog in Underberg village. An animal lover, he took the dog home to nurse it. It licked his hands, which had cuts on them from farm work. Soon after, it got sick and died, and he buried it without thinking about the possible reasons.
A few weeks later, he was in Mozambique on holiday with his girlfriend when he developed a stiff and tingling neck. They came back to South Africa and he was admitted to Mediclinic in Pietermaritzburg.
After tests, he was diagnosed with acute rabies. A drug-induced treatment called the Milwaukee protocol was started immediately. This had ostensibly saved the life of American teenager Jeanna Giese in October 2004, and possibly another four people out of 36 treated with the protocol. However, there is some controversy in medical science circles around the veracity of the cases. Others debate whether it’s the drug treatments, a genetic resistance to the virus, or a weaker strain of rabies present in bats that results in the claimed survival cases.
I remember reading many messages of support on Facebook as Graeme was put into an induced coma, which can slow down the spread of the virus and protect the brain.
Sadly, five weeks later, he was declared brain dead, said Dr Grant Lindsay, the Director for Mediclinic’s emergency department in Tongaat on the KZN North Coast. Grant would become a much-valued pillar of moral support via email whenever I had concerns.
Rabies: know your enemy
- According to World Health Organisation data, more than 2.5 billion people are at risk in over 150 countries. Rabies mortality ranks tenth in all infectious diseases worldwide. There are still up to 60,000 human deaths annually, although effective vaccines for post-exposure treatment are available. Up to 99% of these people have been bitten by a rabid dog, says the WHO’s September 2017 fact sheet.
- Rabies is an RNA virus that causes a form of encephalitis that is nearly always fatal.
- It can be transmitted via bites, licks, and aerosol (sneeze / saliva droplet inhalation from the air in bat caves). It has also rarely been transmitted via human to human organ transplants.
- Post-exposure treatment involves a three or four injection course of virus vaccine such as Verorab, administered in the upper arm. This should be done as soon as possible after exposure. Unfortunately, if free hospital treatment is not available, the cost of the medication often makes treatment for the poor difficult or impossible, and they form the overwhelming bulk of deaths.
- Up to 59,000 people die of rabies every year. Many more could be dying at home, undiagnosed. Most cases (95%) are from India, other parts of Asia, and Africa. Nearly all cases are from dog bites: the World Health Organization says 99% of cases are caused by dogs. Up to 60% of victims are children. So sad!
- For confirmed rabid animal bites, human immunoglobulin (RIG) is also administered via injection, directly into the bite areas. These are active antibodies against rabies, and different from the vaccine. The rabies vaccine is then injected in a part of the body distant from the bites to prevent the two counteracting.
- The human immune system does produce antibodies, but it’s a delayed response, by which time the virus has reached and damaged the brain.
- Since it travels through the nerves, it isn’t directly detectable in blood tests, although antibodies to it can be detected by blood testing.
- There are two forms of rabies: 80% of human patients present encephalitic rabies (furious rabies), characterised by episodes of hyper-excitability. The remainder develop paralytic rabies with quadriparesis (weakness in all four limbs). It is not known why some patients develop the encephalitic form and others paralytic rabies.
- There have been a handful of ‘survivors’ over the years, but unfortunately, after I’ve dug deeper, all cases have been disputed by the greater medical community for various reasons. Watch The Girl Who Survived Rabies on Youtube for a ‘survivor’ account of one such case from 2004. Warning: there is graphic footage of real-life rabies victims.
The three exposure levels to rabies
The World Health Organization (WHO) announced new rabies recommendations in January 2018. Its rabies exposure categories are:
- Category I Touching or feeding animals, licks on intact skin.
- Category II Nibbling of uncovered skin, minor scratches or abrasions without bleeding, licks on broken skin.
- Category III Single or multiple transdermal bites or scratches; contamination of mucous membrane with saliva from licks; exposure to bat bites or scratches.
Preventing rabies after exposure
WHO post-exposure treatment consists of the following steps:
- All bite wounds and scratches must be attended to as soon as possible after the exposure; thorough washing and flushing of the wound for approximately 15 minutes, with soap or detergent and copious amounts of water, is required. Where available, an iodine-containing, or similarly viricidal, topical preparation should be applied to the wound.
- RIG (rabies immunoglobulin) which are active antibodies against rabies, should be administered for severe category III exposures. Wounds that require suturing should be sutured loosely and only after RIG infiltration into the wound.
- A series of rabies vaccine injections should be administered promptly after an exposure.
Dogs and rabies
Veterinarian nurse Dagmar Atkinson of Somerset West told us that she treated a beautiful male German Shepherd when she was studying at Onderstepoort years ago. “He was referred from KwaZulu-Natal, and had been attacking his water bowl. No-one could figure out why he was behaving so oddly. He had been given all his innoculations. It was a really exceptional case, as the rabies vaccines are pretty effective when given correctly.”
“I cannot emphasise enough that dogs in rabies areas should be vaccinated and that by a registered vet clinic. It is rather disturbing that many breeders do their own vaccinations. If a dog is not healthy and has a slight temperature or its immunity is already compromised, the vaccine could be ineffective.
“As students we were shown a video of a person dying from rabies. This was so disturbing and made a huge impact.
“The moral of the story is: protect yourself and your pets. Stay away from stray dogs when running as you never know if they have been vaccinated.
“If you get bitten while running, especially in a rabies area, try to find the owner of the dog. They should be informed that their dog is a nuisance. Remember that they are liable. Secondly, demand to see the vaccination certificate of this animal. All dogs and cats should be vaccinated annually.
“Lastly, rabies alters the behaviour in animals. Tame animals become wild and aggressive and wild animals like meerkat become tame. So beware of strangely tame wild animals that approach you.”
“Rabies has loomed large over Underberg and its surrounding areas in recent years and the community has borne full witness to the tragedy of this deadly virus. Something that wasn’t even on the radar as a child growing up in the area has become so prevalent that it has virtually been accepted as the new normal. Spending a lot of time out on the trails and in the mountains, I have seen an increase in the number of dead jackals, something I hardly ever used to see. I’m fairly sure this is down to the prevalence of the virus. Our children are under strict instructions not to touch any dead animals they might find on the farm and know to report any animal they might see behaving strangely. The manic behaviour associated with a rabid animal is not something that we always see and often a potential carrier animal will simply act in an overly docile and even friendly manner.
“On a personal level, we’ve had a couple of scares via the work my wife does in rehabilitating wild animals. A few years back she raised a Cape clawless otter, Ophelia, who unfortunately died after an encounter with other Otters on one of her trips to the dam. She was attacked by other otters who tried to drown her. She returned home but developed pneumonia from the water in her lungs. When she died we had to send her off to the lab to make sure it wasn’t rabies. Obviously we didn’t want to wait until the results, so our whole family went through a full rabies vaccination process which was a little traumatic for the small kids.
“What has also become a real concern via my work on the farm is that there have been several cases of rabies confirmed in cattle in the area. The big issue is that the symptoms most of these cattle displayed were similar to cattle sicknesses such as redwater and gall sickness. As a result farmers and their staff run the risk of unwittingly exposing themselves to rabies while treating an animal for what they think is a common ailment.
“My advice to anyone who thinks they might have been exposed to rabies is to immediately get access to the vaccine. Don’t take any chances and, if you are in an area where rabies is prevalent, don’t disregard a friendly lick from a stray dog or a nip from a lethargic bat that you cleared off the doorstep.”
Fear and doubt in Quito
Two angels stood between me and a possible Rabies Grim Reaper of Death. Their names were Dr Paulyna Orellana and Mónica Calle and they were the doctor and consultant at a Quito vaccination consultancy.
While I waited, Paulyna called a friend who worked with rabies innoculation in the area I’d been bitten. This contact confirmed that they’d not had rabies in Quito for several years, and local dogs were innoculated.
“Was the dog behaving strangely? Was it drooling?” asked Paulyna. No, it had not, said I.
Still, it was safer to get the vaccine because even if the dog was not rabid, it would help me build rabies resistance should I be exposed in future.
“You’ll need three shots. The first is now. The next is in three days,” said Mónica.
“Ah, that’s not ideal,” I said. “I am booked for a five-day tour in the Amazon and leave today.”
“No problem,” she said. “Go to the Amazon and come back for your second shot in one week. That is still fine for treatment. There are many bats there, and some of them may carry rabies, so at least now you’ll build some passive immunity for any incidents.”
Getting rabies vaccine
The shot was an almost painless jab of Verorab vaccine into the muscle of my upper arm. Verorab is a multi-component vaccine consisting of inactivated rabies particles, to which is added powder and solvent. The blending of components is done at the clinic prior to the injection, and the vaccine must be kept in sterile conditions at 2-8 degrees Celsius to maintain its efficacy. There are sometimes minor side effects, but you cannot get rabies from the vaccine. There are other vaccines available, all manufactured in cultures in laboratories.
How rabies vaccine is made
The cultured virus is rendered inactive, and those particles are mixed with a powder and solvent and injected as the vaccine.
Your body’s immune system thinks the fragments of rabies virus are the actual disease, and your body builds up resistance over several weeks. There may be swelling and pain at the injection site for a while.
I didn’t get those symptoms, but my left hand’s knuckle joints became swollen and slightly painful. As of the writing (three months later) the swelling hasn’t gone down. I cannot say it’s definitively because of the vaccine. However, swelling of joints is listed as one of the side effects in Verorab’s (very) fine print fact sheet.
It’s about R2,000 for the four shot course (including the consultation fee), but if you’re in a pinch after being bitten by a dog, you could possibly get the shots at a state hospital for a lot less. I chose the private clinic option because I didn’t want to take any chances.
Escape from the city
That afternoon I embarked eastward on a seven-hour bus trip that dropped from 2,800m to just 200m in the Amazon, known to Ecuadorians as Oriente (the Orient). I hoped that day was the last I had to be worried about rabies, and lost myself in the beauty of one of the great treasures of the world for those days.
I present you with some of my photos from those carefree days, as a respite from talking about a nasty disease. Scroll past them for the conclusion to my rabies story, and more facts about the disease.
Rabies around the world
- World Rabies Day is an initiative of Global Alliance for Rabies Control (GARC). It started in 2007 to create a global opportunity for people to focus on rabies prevention. 28 September 2015
- The South African Veterinary Association (SAVA) website says: Dogs are also victims of rabies. Not only are they subject to the disease’s horrific clinical symptoms, estimates suggest millions of dogs are killed in culls every year in misguided attempts to control the disease. Dog vaccination stops rabies, culls do not.
- Rabies was found in four jackals and one unvaccinated domestic dog in Muldersdrift, Komdraai and Lanseria in 2016. An intensive dog vaccination campaign was launched by the Department of Agriculture and Rural Development.
- South Africa uses instant messaging for daily mapping and dissemination of cases.
That burning tingling!
When I got back to Quito, I headed back to Monica to get my second vaccine jab. The day later, out of curiosity, I read up about the first symptoms of rabies on my smartphone.
One of the sites said something like this: “A tingling or burning sensation in area of bite, anything from 10 days to three months or years after exposure. Weakness or numbness at bite area. When symptoms appear, it is too late to prevent the spread of the disease.”
Phew! Hectic, that must be awful to know if you realise what’s happening, I thought. The next morning, I went for my first real run in over two weeks, running for an hour on tar in one of Quito’s commercial areas that looked like a hilly Sandton.
My legs felt it afterwards. I’d lost quite a lot of fitness, and Quito is at 2,800m after all! That afternoon, I felt a tingling, burning, and stinging sensation in my left calf, near where the bite wound was. It was 10 days since the bite.
Noooo! Could it be? My insides turned to cold mercury. If that could happen, that’s what I felt in that moment!
Was this really happening to me? Had the vaccine failed? Should I have postponed the Amazon trip and waited for the immunoglobulin shot, despite the advice that the city was rabies-free? Was I going to die because of one small but very wrong decision?!
The tingling and a sense of numbness stayed all day while I forced myself to think of other things (and work on parts of TRAIL issue 26 – it was not all a holiday you know!)
My left foot has always felt a little different, maybe because of a touch rugby ankle sprain in my twenties, and several trail running sprains since then. So was this just my mind playing tricks on me, turning up the sensory volume dial, or was I in real trouble here?
Pondering my mortality
All I could think about was my family, and how my dying would affect them. This could not happen, I needed to keep it together. I wanted to live a long life still, and be a positive light to help many people through the magazine and a healthy lifestyle example. Dying of rabies was not a good way to do this!
I dreaded falling asleep that night. What would I feel like in the morning? Would the tingling be even worse? I didn’t expect to be foaming at the mouth and chasing people in the traffic on all fours, but the future did seem very uncertain.
Getting rabies advice
The next day I reached out to my friend Claire Lindsay, who was a friend of Graeme Anderson. She immediately suggested Dr Grant Lindsay, the director for Mediclinic’s emergency department in Tongaat on the KZN North Coast. I kicked myself (figuratively) as I’ve know Grant for several years from events like Giant’s Cup Trail Run. He’s a popular and experienced race doctor (you should consider hiring him!).
He came back to me immediately and put my mind at ease. I should be fine as Quito was high altitude and rabies was not typically present that high. And I had learned previously of course that Ecuador had very few cases of canine rabies as there was an extensive dog immunisation programme. “Just get a third shot in Ecuador, and a fourth when you’re back in Durban, and we’ll sort you out,” he said. Phew. What a legend in a time of need.
Note: There are various protocols for the timing of shots. Some are three-shot [0-3-7 days], and revised ones seem to be four-shot [0-7-14-28 days]. There are even five-shot protocols. Consult a medical professional trained in rabies immunology. My guidelines are based purely on information I’ve gleaned from a few professionals as well as internet searches on reputable websites.
The story ends well, at least in my case. The dog that bit me almost certainly didn’t have rabies to begin with. Rabid dogs tend to be avoided by other dogs. Ecuador has a low rate of the disease, and my research and confirmation from medical professionals was that the city of Quito is rabies-free. Last and most important, I was fortunate to get the first vaccine shot within 24 hours, just in case my biter was carrying rabies.
The tingling was possibly a combination of a muscle strain from the run and/or the bite itself, coupled with localised healing from the bite.
So, good for me. But I cannot stop thinking of the people, mainly underprivileged, and already struggling under the yoke of poverty, who are at this moment being bitten by a rabid dog, or suffering through the awful symptoms of rabies. And although we see dogs as the cause of rabies, they are also innocent victims.
Can we eliminate rabies in humans?
I do hope that we see an end to this horrible scourge, just like we did with the equally awful smallpox virus, which was declared eradicated in 1980. What a triumph! There are programmes in place to eradicate rabies transmission from dogs by 2030. Read about the development of the human rabies vaccine as well as innovative technology to vaccinate wildlife on Wikipedia.
Let’s be part of that vision.
Safety starts at home. Get your cats and dogs vaccinated by an approved vet.
Equally important: get your rabies vaccine jabs. It will be three or four trips to a clinic in 30 days, and then you have peace of mind.
You never know when you’re running in a faraway place and a village dog jumps into your path and bites you. It takes just a few seconds to change the course of your adventure, believe me.
If you do get bitten by a dog suspected of having rabies, and you’ve had your vaccinations done beforehand, you’ll still need one or two booster shots to be completely safe. But you’ll be so glad you were better prepared. Peace of mind is priceless!
Please be safe out there.