The Diagnosis and Treatment of Rabies

Sarah M. Dolitsky

Virginia Military Institute

Word Count: 1,389 words

Author Note

Help Received: References

The Diagnosis and Treatment of Rabies

            The virus that causes rabies is known as lyssavirus, named after Lyssa, the Greek Goddess of rage (Evans, 2017). This is fitting considering that later symptoms of the one type of the disease are aggressiveness, hallucinations, seizures, and delirium. Initial symptoms for both types of rabies include discomfort, an itching sensation, anxiety, confusion, fear of water, difficulty swallowing, and agitation (CDC, 2011). Rabies is transmitted when the saliva of an infected animal comes into contact with another animal or human, typically through a bite. Rabies, which can be a fatal disease if left untreated, can be prevented and treated. The current paper will examine the various methods of diagnosing as well as treating the infectious disease known as rabies.

First off, diagnosing rabies is critical since, as previously states, the disease can be fatal. Since rabies, is so rare it is sometimes difficult to treat without conducting tests especially since the infected person may be unaware of a bite mark from an infected animal. This is because the incubation period of rabies typically one to three months but could be as short as a few days or as long as a year. As for diagnosing rabies, there are two clinical forms: encephalitic, known as furious, and paralytic, known as dumb. The former makes up for 80% of cases while the latter makes up the remaining 20% of rabies cases (Jackson, 2009). The symptoms for furious rabies are exactly how it sounds and how many typically stereotype rabies; aggression, madness, hallucinations, and rage. On the other hand, the symptoms for dumb rabies are less known, which are paralysis, coma, multiple organ failure, and eventual death. The laboratory tests should focus on detecting the virus antigen or RNA in tissues or fluids of the human infected. For example, Cerebrospinal fluid or CSF, often shows abnormal results for those infected with rabies. To be more specific, the white blood cell count detected in a CSF sample tends to be less than 100 cells/μL (Jackson, 2009).

Further methods for diagnosing rabies include taking a skin biopsy or a brain biopsy. A skin biopsy can be taken from the nape of the neck which contains hair follicles making it more detectable. This method is more useful than a brain biopsy since a brain biopsy can only be used to assess rabies postmortem or after the infected person has already died. However, the brain biopsy can still be used to give information on the victim’s extent and/or type of rabies. More so, the brain biopsy is specifically useful for its accuracy. Rabies cannot be excluded due to negative tests unless it’s a brain tissue test. This means that if a CSF sample or skin biopsy comes up negative for rabies, the patient could still have rabies, but if a brain biopsy comes up negative, there’s no chance the person had rabies (Jackson, 2009).

Rabies can also be diagnosed through bodily fluids such as saliva and urine, however, similar to CSF samples and skin biopsies, these may not always show up positive on initial testing. This is because the virus is not continuously shed by those infected with it, meaning it’d be a hit or miss whether a sample was collected while the infected person was shedding the virus (Nigg & Walker, 2009). The method for these kinds of bodily fluid tests are known as Direct Fluorescent Antibody Technique (DFA) and they’re applicable for almost all tissue sources in living patients (Yousaf et al., 2012).

Another method that could work for diagnosing rabies is Magnetic Resonance Imaging (MRI) of the brainstem, hippocampus, and/or hypothalamus regions. Abnormal scans can appear in these three regions when a person is infected, but the degree may vary on a wide scale depending on the stage of rabies the infected person currently has. It’s also very important to note that the reason laboratory testing is so necessary for diagnosing rabies is because there are many other medical conditions that have similar symptoms of paralytic rabies. These conditions include “Guillain Barre syndrome, Japanese encephalitis, cerebral malaria, and the West Nile Virus” (Nigg & Walker, 2009). This is important to know because a disease as fatal as rabies should be diagnosed and treated as soon as possible, which could be delayed if a misdiagnosis were to occur. To summarize diagnosing rabies, no one test is sufficient. Multiple tests should be run in congruency in order to accurately diagnose rabies (CDC, 2011).

Anytime a human is bit by any sort of animal, to include: dogs, cats, ferrets, raccoons, or bats, the animal is supposed to be captured and observed for a minimum of ten days. If any signs of rabies are shown while the animal is confined, they are supposed to be killed and beheaded, so the head could be refrigerated and transported for laboratory research examination. Then, the same methods for diagnosing rabies in humans are used to try and diagnose it in the deceased animal’s head. This is to better locate and prevent the spread of any further rabies from a certain area through more of those specific animals (Jackson, 2009).

When it comes to treating humans with rabies, the main focus is the rabies vaccine. Prior to administering the vaccine though, the wound (if found) should be thoroughly cleaned with soap and water (Yousaf et al., 2012). As for how the vaccine is used, it depends if the infected person has had their vaccine in the past two years or not. If the person infected has had their vaccine with in the past two years, they will be treated with 1 ml of the rabies vaccine on days zero and three since being diagnosed. For those infected who have not had a rabies vaccine with in the last two years, it’s recommended that they receive the same 1 ml dose of the rabies vaccine on days zero, three, seven, and fourteen. In addition to the vaccine, these people should also receive doses of human rabies immune globulin (HRIG) on days zero through seven at the dose of 20 IU/kg. The rabies vaccine is considered active immunization and should be injected into the deltoid muscle on the infected individual. The vaccine comes from a rabies strain grown on a human diploid cell culture (Nigg & Walker, 2009).

HRIG is considered passive immunization since it works by passively providing immunization by making viral antibodies neutral. HRIG is administered by injecting it into the muscle nearest the rabies bite on an infected person. The products that make HRIG come from human donors, making them effective but expensive. These should only be used on an infected person who has not had their rabies vaccine within the last two years (Nigg & Walker, 2009).

In conclusion, there are two types of rabies: encephalitic rabies, characterized my rage/madness and paralytic rabies, characterized by paralysis. These types of rabies could be initially diagnosed through their symptoms. However, to fully diagnose an infected person with rabies, multiple laboratory tests must be run congruently. Tests can be run using CSF samples, bodily fluids like saliva or urine, skin biopsies from the nape of the neck, or brain biopsies from specific locations. Since sometimes a rabies infected person’s tests will appear negative, multiple tests must be used and tested multiple times. Once diagnosed, the infected person should thoroughly clean their wound with soap and water. Once that’s been done, there are two different methods of treatment dependent upon how recently the infected person has had their rabies vaccine. If the person has had their vaccine within the last two years, they will be treated with just the active immunization of the rabies vaccine over multiple days. However, if the infected person has not had their rabies vaccine within the last two years, they will be treated with both the active immunization of the vaccine as well as the passive immunization of human rabies immune globulin (HRIG) for multiple days straight. Properly diagnosing and treating rabies is important due to how fatal the infectious disease could be. Aside from just the fatality of it, the symptoms of the infection are extreme and can be detrimental even if the infected person survives. By educating people on proper diagnosis and treatment of it, rabies can be more quickly diagnosed as well as better prevented due to education regarding keeping up to date with vaccines.

References

Evans, K. (2017, April 12). A brief history of rabies. Retrieved April 29, 2019, from https://www.labroots.com/trending/microbiology/5761/brief-history-rabies

Jackson, A.C. (2009). Update on rabies diagnosis and treatment. Current Infectious Disease Reports, 11(4), 296-301.

Nigg, A.J. & Walker, P.L. (2009). Overview, prevention, and treatment of rabies. Pharmacotherapy, 29(10), 1182-1195.

Rabies. (2011, September 20). Retrieved from https://www.cdc.gov/rabies/diagnosis/animals-humans.html

Yousaf, M.Z., Qasim, M., Zia, S., Khan, M.U., Ashfaq, U.A., & Khan, S. (2012). Rabies molecular virology, diagnosis, prevention and treatment. Virology Journal, 9(1), 1-5.

HIV Pandemic in China

            Some societal factors that have contributed to the pandemic of HIV in China are attitudes towards specific groups, fear, stigma, and shame. This is because the most prominent groups who have HIV in China are gay men and people who inject drugs. Since being gay is not widely accepted in China, men who are gay feel the need to live in secrecy and therefore have minimal understanding regarding the infectious nature of the disease since they cannot openly seek information on it. The risk is so high because these men unfortunately remain ignorant of what is considered risky behavior because everything already seems to be risk behavior for them, having secret relations. About a quarter of HIV cases in China come from homosexual men, with about a 9.9% prevalence rate among these men. As for people who inject drugs, they too hold a negative stigma against them in China. Since drug use is already illegal, just like the homosexual men, these drug users are ignorant to risky behaviors that can transmit HIV. In addition to that, even if they are aware, they are addicts and will use any materials for drug use they can get their hands on regardless of if it were previously used or not. Luckily, China has recognized this and began extensive treatment/prevention programs that include harm reduction interventions, methadone maintenance treatment clinics, and clean needle exchange projects. These programs have shown to be marginally helpful so far reducing the rate of people seeking the methadone treatment from 0.13% to 0.12% over the span of a year.

Some factors that have helped limit the ability of the HIV organism to spread further in China are the previously mentioned prevention programs, medically preventing mother-to-child transmission, and prevention of infected blood donations & transfusions. By preventing the spread of HIV from mother-to-child, a significant amount of cases are prevented since many people who have HIV choose to still have children. In addition to this, there are a number of pregnant women who don’t even realize that antenatal health services are an option and therefore either choose to have the child regardless or avoid pregnancy altogether. As of 2009, there have been no reported cases of children getting HIV even when born to HIV infected mothers. To prevent the transmission of HIV through infected blood transfusions, more funding has gone into screening for HIV for blood donations. Funding has increased all the way to one billion dollars towards blood donations in China.

One overall effect that the HIV pandemic has had on China’s society is infringing upon human rights of Chinese citizens. Since HIV activism is not as widely shown in China as it is in other countries around the world, the government has been accused of harassing, detaining, and censoring activist groups. Also, many federal laws protecting the rights of those with HIV are commonly undermined by lower authorities such as state police. Unfortunately, this further leads to more negative stigmas and discrimination against those with HIV in the Chinese society.

References (Help Received)

https://www.avert.org/professionals/hiv-around-world/asia-pacific/china

Deadly Cholera: Contaminated Water That Results in Rice Water

            There have already been seven pandemics of cholera that we know of. Dating to before the first pandemic, an endemic of the disease is known to have been associated in India and traced to crowds in the river Ganges. The disease spread from India to other countries when British war ships entering and leaving India spread it elsewhere in 1816. This spread of cholera lead to the first pandemic of it. In addition to British troop spreading cholera elsewhere, trade routes allowed cholera to be transmitted to China, Japan, the Philippines, Persian Gulf, Africa, and Central Asia. Along with trading resources and goods, slave trade made it easy to transmit cholera efficiently. Furthermore, cholera was further spread by Chinese soft-shell turtles which allow the disease to hang on it and develop.

Another pandemic began in 1829, where it started in Russia and quickly made its way across Europe. Furthermore, the disease spread to Canada and New York when Irish immigrants immigrated there. From there the disease spread to the U.S. west coast as well as Mexico and Latin America. Port cities, such as New York, New Orleans, and Philadelphia, tended to get hit hard due to constant trade and immigration flowing through them. Since urbanization and immigration had become common, diseases like cholera flourished. This is because urbanization caused tight spaces with crowds and lower sanitation due to high populations and poverty. If water or food became infected with cholera it was easy to spread if people continuously kept taking from that same location.

A third pandemic occurred between 1852 and 1863 and is thought to have been the deadliest of the cholera pandemics. This pandemic was associated with Africa, the U.S. the Middle East, Europe, and India. During this outbreak, John Snow, with the help of Henry Whitehead, published groundbreaking studies on Cholera. Snow observed that in the Epidemic Soho area of London, water was being taken from polluted areas. This led Snow to believe contaminated water was causing cholera. Once he had knowledge to believe this to be true, the handle on the water pump on Broad Street was removed and deaths from cholera began to decrease. Although Snow hypothesized water causing cholera, he never truly determined the bacterial root cause of it. Around the same time as Snow’s research, a researcher named Filippo Pacini identified the cholera bacterium. Unfortunately, he did not get recognized for this discovery until after his death when Dr. Robert Koch identified the same bacteria in 1883. Once the bacteria was identified, it could be properly prevented and treated in the area’s where it was found such as Calcutta.

As for cholera outbreaks in the 21^stcentury, Africa still has many cases of it. This is mainly due to poor water quality as well as poor sanitation. In these impoverished areas, water is rare to come by so people drink whatever they can find. Since poverty in Africa is so prevalent, many health sanitation systems and hospitals had closed down due to a lack in economics. In 2010, an outbreak began in Haiti following the enormous earthquake they experienced. The earthquake caused fecal matter to contaminate the Artibonite River, one of Haiti’s prime sources for drinking water. As of January 2017, Haiti has been receiving assistance from the U.S. National Institutes of Health in order to provide vaccines. Unfortunately, in October 2016 Hurricane Matthew had hit Haiti, which caused even more people in Haiti in need of homes and health assistance, as well as a further spread of cholera that came with a decrease in available drinking water. As of now, Haiti needs approximately $66 million for water sanitation and hygiene interventions to eliminate the transmission of cholera. However, in the meantime, oral vaccines have been brought in affordable, large amounts to Haiti to fight cholera and public health research remains to occur.

References (Help Received)

Sherman, I.W. (2017). The Power of Plagues (2^nded.). Washington, D.C.: ASM Press.

“Eliminating Cholera Transmission in Haiti” article (New England Journal of Medicine)

Cholera PowerPoint