An Encounter with Rabies in New York City

To the Editor—Rabies exposure in the urban setting is rare in the United States. We report the case of a family exposed to rabies, including a lactating woman who was bit by a rabid raccoon, in the Bronx, New York, where 43% of tested raccoons are positive for rabies virus.

The bitten patient was a 34-year-old breast-feeding mother with no significant past medical history other than an uneventful, normal, spontaneous vaginal delivery of a baby girl 2 weeks earlier. In the backyard of her home in April 2005, in an unprovoked daytime attack, a raccoon bit her right 5th digit and scratched her right arm multiple times. Her husband ran outdoors to encounter her struggling with the animal, which he choked and fatally stabbed. Although he was not bitten, he sustained superficial scratches on his legs and arms and was covered in the animal's blood. Two children who were present had no direct contact with the animal but were embraced by their parents immediately after the incident (the baby was sleeping inside the house). Both parents washed their wounds with soap and water, called emergency services, and were brought to a local emergency department. The New York City Police Department transferred the dead raccoon to the New York City Department of Health and Mental Hygiene for testing.

The mother exhibited multiple scratch marks on her arms and a 0.7-mm–deep puncture and traction wound of the right 5th digit. The husband revealed no bite marks but had superficial scratch wounds on all extremities. Both initiated rabies postexposure prophylaxis (PEP) with Chiron rabies vaccine and Imogam human rabies specific immunoglobulin (hRIG). The following day, direct fluorescence antibody test results of the raccoon's brain were positive for rabies. Although the 2 children exhibited no injuries, the pediatric infectious disease team felt that their risk of acquiring rabies outweighed the risk exhibited by receipt of the vaccine, and they were administered the same vaccine series as their parents. Further investigation revealed another raccoon attack in the same neighborhood 2 h prior, perhaps by the same animal. This other bite victim received the full rabies PEP hRIG and a complete vaccine series.

Concern was raised about the potential transmission of rabies virus to the baby via the mother's breast milk. The Centers for Disease Control and Prevention's 1999 Human Rabies Prevention Advisory Committee on Immunization Practices recommendations do not specifically comment on whether breast-feeding is contraindicated after rabies exposure and/or PEP. Despite reports of human cases of rabies transmission via breast milk and of experimental transmission in animals [1–3], the possibility of salivary transmission was not excluded in these studies. We did not recommend cessation of breast-feeding, but the patient herself chose to discontinue it.

In 2001, 92% of the 7437 rabid animals reported to the Centers for Disease Control and Prevention were wildlife species (e.g., raccoon, skunk, and fox) [4]. During 2005, the Department of Health and Mental Hygiene detected rabies in a total of 28 of 528 animals tested. Raccoons accounted for 23 (82.1%) of these, and 22 of the raccoons were from the Bronx (table 1). Since 1992, there have only been 7 reported bites from rabid animals in New York City. Three of these (the present case included) were caused raccoons; the others were caused by 2 bats and 2 cats.

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Table 1

Results of rabies tests, by animal species, in 2005 in New York City.

The Department of Health and Mental Hygiene provides follow-up of all patients bitten by known rabid animals or by known rabies vectors, and reporting of animal bites is mandatory. Of course, there is no way to know how many are unreported. A recent survey of patients in the Bronx revealed that only 44% of patients who began PEP completed treatment, and only 50% of these patients observed the animal that bit them well enough to make an informed decision about its identity [5].

We report the first attack in 5 years by a known rabid raccoon in New York City. Our case underscores the complex issues surrounding PEP in lactating women and the growing need for raccoon control in the urban setting.

• © 2006 by the Infectious Diseases Society of America