Imported Human Rabies - Kentucky and Ohio, 2024

Human rabies cases are rare in the United States; most result from domestic wildlife exposure. U.S. residents can acquire rabies abroad, typically through contact with dogs in areas where dog-maintained rabies is endemic. In November 2024, a man from Haiti was admitted to a Kentucky hospital with an 8-day history of progressive lower extremity pain and weakness. Soon after admission, he experienced hypersalivation, dysphagia, agitation, and eventually, respiratory failure requiring invasive mechanical ventilation. Ten days after admission, he was transferred to a referral hospital in Ohio, where his condition further deteriorated. Despite early consideration of rabies in the differential diagnosis, testing was delayed until late in the clinical course while other diagnostic possibilities were pursued. Rabies testing was initiated on the 29th hospital day and was confirmed 5 days later; the patient died that day. Phylogenetic analysis of the nucleoprotein gene supported acquisition of a dog-maintained rabies virus variant in Haiti. In total, 709 possible contacts during the patient's infectious period underwent risk assessment; 60 (8%) were recommended to receive rabies postexposure prophylaxis (PEP) because of exposure to saliva. Before the patient's rabies diagnosis, standard precautions were used inconsistently during his care; among 60 persons recommended to receive PEP, 52 (88%) were health care workers. Earlier rabies diagnosis and regular adherence to standard infection control precautions, recommended for all patient care, might have reduced health care-associated exposures. This case underscores the importance of early public health consultation upon clinical suspicion of rabies and universal adherence to standard precautions.