Global Doc: Once Bitten

Author: Dr. Vincent DeGennaro Jr. ’02

The path down by the river was well-worn from foot traffic, a clear area of volcanic dirt parting the wild grasses on either side. Just past the grass on the right, the land fell away to the river below. In the rainy season, the river climbed up the banks of the small ravine, but in late October, the cloudy water was no more than three feet deep. A friend and I had just arrived in the Central Plateau of Haiti, and I wanted to show her the rural beauty. After being cooped up in Port-au-Prince traveling from one walled compound to another, I needed to stretch my legs and breathe the fresh air of the countryside. Following a stroll through the town of Thomonde, a peace settled in my chest, untying the knot that had constricted each breath.

The peace was shattered when an angry dog approached rapidly and quietly from behind, and bit my exposed heel. I turned towards the little dog, who was barking and bearing his sharp teeth, pausing only to let out a guttural growl. A tall man with broad shoulders called to the dog as he walked down the narrow path towards us, his two young children kicking at the tall grass as they ambled at his side. The dog, a typical Haitian mutt, was trying to secure the path for its master when it had bit me.

“Tsst. Tssst. Vini,” he called to the dog, but the animal ignored its master and continued to bark at me. The man assured me that the dog was harmless and continued down the path. The dog finally veered off into the tall grass to play, forgetting about the menace that had threatened his owner.

I examined the heel where the cur had nipped but saw no break in the skin. We finished our two-hour walk through the countryside and ended back at the Project Medishare guest house. I forgot to wash my heel and didn’t shower until the next morning after I went for a run through the green hills of the Central Plateau. Two days later I returned to Port-au-Prince. Amid the chaos of the hospital, I realized that I should investigate the possibility of rabies in a dog in Haiti.

Over 55,000 people die of rabies every year, the majority from dog bites in Africa and Asia. Haiti allegedly has one of the highest rates of prevalence in the Western Hemisphere. However, much like all health issues in Haiti, the dearth of available data makes it impossible to know the true pervasiveness of the disease. A veterinarian colleague from the Center for Disease Control (CDC), eager to defend the reputation of the dogs of Haiti, claimed that there is little if any rabies in Haiti, in contradiction to the data presented by the World Health Organization (WHO).

Google reinforced the numbers from the WHO, including a story of a Dutch traveler who had contracted rabies in Haiti in June and died 30 days later in his home country. He was initially bitten on his hand in Haiti, choosing only to clean the wound and not seek medical care. If he had sought medical care, a doctor would have recommended that he get the rabies vaccine. Rabies has been fatal in every recorded case in human history except one, a miracle that medicine has been unable to replicate since a 12-year-old girl in Milwaukee survived 20 years ago. Because of the near universal mortality rate, the CDC and WHO both recommend giving the vaccine to people who have come in contact with any number of wild animals and for exposures as minor as being licked by an unknown cat.

Rabies infects the peripheral nerves at the site of the primary bite, and then travels slowly up the nerves to the brain. The farther the bite lies from the brain, the longer the infection can take to enter the central nervous system. The incubation period can last from two days to two years, but once a patient has symptoms from rabies, it is too late. The most common symptoms are headache, the inability to swallow which produces the characteristic foaming at the mouth, and personality changes leading to severe irritability.

I had been bitten by a dog, and even though the teeth hadn’t broken the skin in any visible way, prevention in the form of the vaccine is paramount with rabies. The CDC and WHO both recommend initiating vaccination on the day of infection whenever possible. In addition, washing the wound can decrease the chances of infection by as much as 90 percent, but I had neglected to do that. The Dutch traveler had in fact washed out his wound, but still contracted the virus.

Nearly three days after the bite, I woke up irritable and with a sore throat; the mild pain with swallowing caused some pooling of saliva in my mouth. My mind swirled with the possibilities and I dove into patient care duties at the hospital to distract myself while I tried to locate the vaccine in the city. I had arrived back to Port-au-Prince on a Thursday, the day before a three-day weekend for the Day of the Dead. When I finally tracked down the vaccine at the only pharmacy in town that carries it, it was late in the afternoon. We drove around searching for the pharmacy, asking for directions several times as the day grew later and later. By the time that I knocked on the metal gates of the pharmacy, the guard informed me that they had closed for the long weekend at 4 o’clock. My heart sank, wondering if I would survive the Day of the Dead, feeling pain with swallowing a bolus of saliva. I told the guard that I was a doctor desperately searching for the rabies vaccine, that the situation couldn’t wait until Monday.

“Rabies?” he asked in Creole. On my phone, I quickly looked up the word for rabies in French – rage. Perfect synonym.

“Rage! Mwen bezwen vaksen an pou rage.”

He instructed me to wait outside while he asked the boss if we could enter. A well-dressed man appeared and asked in French if I had a prescription.

“No, but I’m a doctor. I can write the prescription now.” I answered. I paid the $125 for the series of four vaccines in cash, the most-well spent healthcare dollars of my life.

We thanked him and headed home, realizing that we didn’t have any needles or syringes to inject the first dose. I called a friend who was still at the hospital to bring the supplies when he met us for dinner. My roommate drew up the vaccine into the syringe at the dinner table while the salsa music of the Cuban restaurant blared in the background. A wave of relief passed gently through my body, emanating from the shoulder that had received the injection. We went to the Oloffson Hotel and grooved with the band until late, surrounded by people dressed as ghouls in celebration of the majesty of the underworld. From the late night and stress, the sore throat developed into a full-fledged cold, a more welcome virus than I had anticipated only the morning before.

Vincent DeGennaro is an internal medicine doctor and a global public health specialist at the University of Florida’s Division of Infectious Diseases and Global Medicine and works half time in Haiti with the nonprofit Project Medishare. See his An American Doctor in Haiti blogs.