FOLEY - Elizabeth Richardson thought she may have contracted rabies when a stray kitten bit her right hand between her thumb and index finger, and she soon discovered that local health departments either do not stock the rabies vaccine or have a very limited supply.  

A self-described animal lover, Richardson, 50, said in a recent interview that she often feeds stray cats that meander their way to her Summerdale home.

“I had tamed one of the cats, the momma, and the baby kitten would also come up to me,” Richardson said in the lobby of the Baldwin Clinic in Foley.  “I’m a wild animal lover, I try to tame everything.”

But, one of the kittens in that litter, approached Richardson about three weeks ago, and sunk its teeth into her hand, leaving three tiny punctures.

She did the right thing by immediately washing her hands with soap and warm water, and decided to take precautionary action by calling her family doctor with the thought in her mind that the kitten may have exposed her to the rabies virus.

Rabies is passed from animals to humans usually by way of a bite from an infected animal from its saliva, said county health department officials in phone interviews.  The virus can also be passed if the infected saliva gets into the eyes, nose and mouth.  

Once a person is infected, the virus travels along the nervous system into the spinal cord, and eventually into the brain, causing acute encephalitis – inflammation of the brain.

After the infection, symptoms begin two to twelve weeks later and can include hydrophobia, a fear of swallowing water, anxiety, insomnia, agitation, cerebral dysfunction, paranoia, hallucinations and delirium.  Death almost always follows the appearance of symptoms within 10 days.  

Melissa Tucker, Director of Epidemiology at the Mobile County Health Department, said that once her department determines that a person may be infected with rabies they begin preventative treatment which includes one shot of rabies immunoglobulin, a dose of antibodies to fight the virus, followed up by five shots of rabies vaccine, spread over a one-month period.

“We like to (provide the shots) within 48 to 72 hours; we want to start as quickly as possible,” Tucker said.

But whether the treatment is given depends on weighing the factors – how the person was infected - on a case-by-case basis, such as whether the animal was domestic or wild, and whether it can be trapped and quarantined.  

“When somebody gets bit, and we can’t find the animal, we immediately begin the shot cycle,” Tucker said.

If the department’s animal control staff can locate the stray or wild animal, it is euthanized and sent to Auburn University where lab technicians determine if the animal was rabid or not by decapitating it and testing its brain - the area of viral infection, Tucker said.  

Human-infection can only be determined by testing or observing the animal.  

A domesticated animal, a neighbor’s pooch or cat for example, must be quarantined for 10 days at a shelter, Tucker said, if the owner cannot provide an updated rabies shot record, according to Alabama law.    

“We look for neurological signs, like the classic foaming at the mouth,” Tucker said.  

The quarantine period allows county health departments to determine whether a shot cycle should begin in order to prevent human rabies infection.  

Other considerations do come into play.  Raccoons, squirrels, bats and foxes are considered high-risk rabies carriers and treatment promptly begins following a bite while stray dogs and cats are considered low-risk so quarantine is used to determine whether the vaccine needs to be given.   

The Baldwin County Health Department also follows these general procedures to determine if a person should or should not be treated.  

Teresa Porter, surveillance nurse coordinator for the Baldwin County Health Department, said that in the county 95 percent of the animals are found by animal control and quarantined, making treatment almost always unnecessary since rabid animals are very rare.  

“If there is an animal exposure (bite), these exposures should be reported to the Animal Control Center,” Porter said.  

Richardson, the bite victim, reported the incident to the county’s animal control department, but they were not able to find or trap the suspect kitten, she said.   

Richardson said they trapped the mother and the other kitten, but did not call her back to let her know of the results.

She visited her physician and he referred her to the South Baldwin Regional Medical Center, where they gave her the first dose, the rabies immunoglobulin.  

Richardson said she then went to the Baldwin Clinic, a community health facility in Foley.

Dr. Barbara Corcoran, a clinic staff physician, treated Richardson as a potential rabies case, and began making phone calls to county health departments to locate the five-dose vaccine since her office did not have it on hand.  

Corcoran called the Baldwin County Health Department and the Escambia County Health Department, Florida, but both departments did not have the vaccine in stock, she said.  

The Escambia County Health Department was not available for comment by press time.

Corcoran then called the Mobile County Health Department, and discovered that they had just two-doses of the five that they could give her.  

“We learned that there were very few institutions that keep rabies vaccine on hand,” Michael Trainor, Baldwin Clinic CEO, said in an interview.  “It may well have been the need wasn’t there.”

Corcoran drove to Mobile’s office, picked up the vaccine, and the next day gave Richardson her first shot, which was followed up with the second shot three days later, as prescribed, but that left Corcoran three short of the required five.  

Richardson said she was disappointed and somewhat shocked that the county health departments did not have the vaccine or had a very limited supply, in the case of Mobile.

She also noted that she was concerned for the next person to be bitten by a potentially rabid animal - especially a child that would need immediate care.  

“It’s 100 percent fatal if you don’t get (the vaccine)” Richardson said.  “It was a circus because (the vaccine) doesn’t exist in Baldwin County.”

The clinic was able to obtain the vaccine from a national supplier which shipped it overnight to their office.  

“It’s a just in time situation, if the chain of supply is good, it can be air shipped,” Trainor said.  

Corcoran said: “It’s a learning experience to find out (the vaccine is) not carried at the clinics and the health departments.

“It didn’t get located on the first call.”

Prior to calling the supplier, the clinic contacted the sole manufacturer of the rabies vaccine: Sanofi Pasteur, a French company, with a U.S. office in Swiftwater, PA.  

Corcoran said that Sanofi Pasteur said they were on “backorder,” which caused the clinic to order from a supplier.  

Donna Cary, a spokesperson with Sanofi Pasteur, said that the rabies immunoglobulin “is in short supply” but not the vaccine, in an email interview.  

“We limit orders (of the immunoglobulin) so people don’t stock up on it…(with) 20-30 vials sitting in their fridge.”

There are “no supply limitations for…rabies vaccine for the U.S.  This does not imply there are problems outside the US, just that I can only speak for the US market,” Cary said.  

“The main reason that there is a limited supply of it is that you need (infected) donors to isolate the immunoglobulin,” Cary noted.

Rare Rabies

According to the Center for Disease Control (CDC), the number of human rabies deaths dropped from nearly 100 or more a year around the turn of the century to an average of two to three a year.  

In 2006, 49 states and Puerto Rico reported 6,940 cases of animal rabies, but only three human cases were reported to the CDC. One human rabies case was reported in 2005.  

Wild animals are the primary cause for human-infection with bats leading the pack for causing deaths nationally.

Dogs and cats transmitting the disease to humans is rare since states began enacting laws that require domestic animals to get annual rabies vaccinations, which is the case in Alabama.  

During 2006, only 82 animals in the state were reported as infected with rabies, 80 wild and two cats, according to the Journal of the American Veterinary Medical Association. 56 raccoons, 17 bats and seven foxes were rabid, but no humans.  

And according to the state Public Health Department, there were no instances of rabid animals in Baldwin and Mobile counties, and all of southern and western Alabama in 2006.  Houston County, home of the city of Dothan in the southeastern corner of the state, had the most cases with 22 rabid animals, 18 being raccoons.  

The last person to die in Florida of rabies was in 1948, and he rejected treatment, according to reports from the Florida Department of Health.  

Charlotte Plumb, environmental supervisor with Baldwin County animal control, said, “We didn’t have any (rabid animal cases)…I can’t really remember any cases this year.”

“The last one I remember was at the shelter about three years ago,” Plumb said.  “We’ve had bats and raccoons in years past.”

Tucker, with the Mobile County Health Department, said, “I usually only order enough (vaccinations) for 10 people,” and added that, “I can’t soak up my budget” with rabies vaccinations.  

Her department charges $145 a shot, a total cost of $725 for the entire treatment.  

Cory, with Sanofi Pasteur, said that the current market-price is $161 a shot.  

“We’re losing money on it right now,” Tucker said, in part because they had to give two shots to the Baldwin Clinic.  

She also noted that the rabies vaccine has a short-shelf life, lasting only about one year, and that cases are so rare that keeping a supply is not feasible.  

“It would be a total loss if I had to throw it away,” Tucker said.  And “we haven’t had any human-infection cases since I’ve been director and that’s been five years.”

Last year, her department treated four people for possible rabies infection.  

The situation is similar at the Baldwin County Health Department, Porter said.  

Porter said that the department does not have the vaccine in stock since they do not have any physicians in the department which can administer it immediately, and if they had to do a vaccination, they need to call the state Department of Public Health for permission.  

(The Mobile County Health Department has staff physicians and is able to administer vaccines immediately.)

Porter said that possible human-infections must be determined by a private physician or hospital physicians before the department can take any action.  

She said that if the evidence leads to the possibility of an infection, then she requests permission, receives the vaccine from either the state, another county health department or supplier, then administers the vaccination.  

In her five years with the department, she said, however, “I never have investigated a case of” actual human rabies.  

“It’s very rare we are going to see someone that is going to meet (our) criteria that is going to need it,” Porter said.  

Last year, similar to Mobile, the Baldwin County Health Department treated less than five people with the vaccination, she recalled.  

Treatment, however, is prevention and not infection.  

Richardson is now on her third shot in the cycle and doing well.  The kitten has yet to be found.