Confusion, anger surround report of soldier's rabies death
January 27, 2012
HEIDELBERG, Germany — A soldier who died in August from rabies received none of the treatment that would have saved him, an Army investigation has found, because he did not seek medical care after a dog bit him in Afghanistan last January or report it to his company command.
Spc. Kevin Shumaker did mention the dog bite to a veterinarian he met in March and on a post-deployment health form in April, according to the Army investigation.
Neither the vet nor medical officers who reviewed Shumaker’s form took any action, the investigation found, to ensure that Shumaker was treated for the virus. Rabies is completely curable if treated before symptoms occur, but invariably fatal once symptoms emerge.
But the report, by a Marine colonel, with a staff of three officers whose names are redacted, placed most of the blame on Shumaker and his command in the 615th Military Police Company, based in Grafenwöhr, Germany, for ignoring the longstanding Central Command general order against pets or mascots, known as General Order-1B.
“The principal contributing factors to SPC Shumaker contracting rabies are the Command’s lack of enforcement of GO-1B, SPC Shumaker’s non-adherence to GO-1B and Shumaker’s failure to seek prompt medical treatment, and no treatment was given,” the report said.
The investigation report angered Shumaker’s family because it says the dead soldier is responsible.
“I got madder by the minute at the total failure of everyone,” said his mother, Elaine Taylor, a manager at Genentech, a California biotechnology company, in a telephone interview. She provided a copy of the report to Stars and Stripes.
“They can try to put the blame on Kevin, but he was a Spec 4; he was a nobody, just a cook, who did what he was told to do,” she said. “Blame lies with his chain of command. We want people punished.”
In addition to ignoring the order against pets, the report cited a number of other shortcomings: inconsistent or incorrect protocols on how and when to treat possible rabies exposure, and faulty medical reporting and record-keeping. It found that other troops had not reported animal bites.
One part of the report said that rabies education presented to deploying troops was sufficient. “SPC Shumaker and the members of his command were fully aware of the potential for rabies to be transmitted by a feral dog bite and the consequences of contracting rabies…,” it said.
But another part of the report seemed to contradict that, saying even medical personnel were badly informed.
“The investigation team found a concerning lack of knowledge about rabies among some U.S. military medical providers in the theater,” the report said.
Pushing the message
Shumaker’s death — the first confirmed rabies death of a soldier since the Vietnam War, according to the military — alarmed Defense Department and Army public health officials, who worried there might be more infected troops.
The U.S. Army Public Health Command, consulting with the Centers for Disease Control and Prevention in Atlanta, set up a task force to identify troops potentially at risk in the past 18 months and to get them screened for treatment. They combed through medical databases and post-deployment forms for reports of animal bites and informed troops who’d never reported a bite through their commands, Veterans Affairs and the media.
“We pushed the message as far and wide as we could,” said Lt. Col. Steven Cersovsky, senior epidemiologist for the Army Public Health Command.
Of more than 8,600 people the command followed up on from the database search, about 140 received post-exposure rabies treatment. The treatment for those who haven’t previously been vaccinated against rabies is a dose of human rabies immune globulin followed by several injections of vaccine spaced over about two weeks.
Of about 300 more people who had not reported bites until the outreach effort, about 50 also received the immunizations, Cersovsky said.
“We know it still works,” Cersovsky said of the immunizations administered long after exposure. “There’s no outside window,” he said, as long as a patient has no symptoms.
Headache, pain or tingling at the site of the bite and malaise are frequently the first signs of infection, and these symptoms usually appear about two weeks after exposure to within three months.
Experts say the timing depends on the location of the bite, the severity of the wound and the amount of infected saliva from the rabid animal that gets into the wound. And there are additional “poorly understood” factors, Cersovsky said, in cases where the incubation period is far longer than usual.
“There’s a lot of uncertainty why it would sit in the muscle tissue and then decide to get into the nerves,” he said.
But once symptoms appear, the bullet-shaped virus has moved into the nervous system and become all but unstoppable on its way to attack the brain, experts said. From there, rabies progresses within days to paralysis, throat spasms, convulsions and death.
A love of dogs
Shumaker, a 24-year-old cook who’d struggled in school but could easily fix computers, loved dogs. As a lonely only child, he said he wanted to be part of a wolf pack, his mother remembered.
He was bitten on Combat Outpost Base Chamkani on Jan. 11, 2011, as he tried to break up a fight between two dogs, the investigation found. Another soldier witnessed the attack, but also did not report it, according to the investigation. Shumaker told his mother he was protecting a base dog from a wild one.
Shumaker had been attacked by a dog previously, the investigation found. In a record of a July medical visit, he was treated with topical antibiotics for an abrasion on his hand. Shumaker wasn’t sure whether the dog or his falling to the ground had caused the wounds, the report said.
The base, in Paktiya Province in eastern Afghanistan, had a lot of dogs, the report said, and inconsistent ways of dealing with them.
GO-1B forbids troops from keeping pets and mascots, but the order was disregarded on the base, the report said.
The order has been widely ignored in recent years on many bases in Afghanistan. Pets are good for morale and provide added security, troops say.
Afghanistan, lacking animal vaccination programs, has a high rate of rabies in dogs, and scratches and bites from an infected dog, or even licks to mucous membranes, pose a risk. But troops who kept a pet that remained healthy throughout their deployments are not at risk from them, Cersovsky said.
“A healthy puppy — I’m not concerned,” Cersovsky said. Rabies is also fatal to dogs, and kills them within 10 days, he said.
Shumaker told his mother that he had shot the dog that bit him with an AK-47 he grabbed from an Afghan police officer. But the report said there were no witnesses to any such shooting or other evidence it had occurred.
‘The worst pain’
Shumaker’s symptoms appeared Aug. 14 on the airplane from Germany to New York, where he was reassigned to Fort Drum. That was seven months after being bitten, more than twice the usual rabies incubation period.
“His first words were, ‘Thank God I’m in the U.S. I’ve got the worst pain in my arm,’  ” his mother said of his call to her from the airport.
Shumaker had told his mother in a January phone call from Afghanistan about the bite on his right hand.
He’d told her he’d gotten partial treatment in a series of shots, but that one of the doses had been past its expiration date. He also told her that the dog’s brain had tested negative for rabies.
But none of that appeared to be true, according to the report.
Shumaker’s paper deployment health records were never located, the report said. But all the base medics, as well as Shumaker’s platoon leader, sergeant and captain told investigators that he’d not reported any bite and therefore had received no treatment.
There was no documentation that a dog’s brain from Shumaker’s base had ever been received for testing, which would have been done by the Army in Europe.
There was no shortage of fresh HRIG and vaccines in theater, the investigation found.
None was stored at COP Chamkani; troops there would have received it from FOB Gardez or Salerno. There were no records of any request from there for rabies prophylaxis from Chamkani from January through May.
The vet, who was visiting the base in March when Shumaker told her he’d been bitten, told investigators she’d suggested Shumaker report the bite. But she did not inform the medical command or Shumaker’s chain of command, the report said. Then in April, Shumaker wrote that he’d gotten a “dog bite” on his Post Deployment Health Assessment, the report said. But “he did not orally communicate to medical personnel that he was concerned about the bite.”
A captain at FOB Gardez who reviewed the assessment and interviewed Shumaker before he left Afghanistan told investigators that Shumaker did not “specifically inform (the captain) that any animal bite occurred or that he was given any rabies vaccination.” The captain “did not review every line … and did not ask SPC Shumaker about an animal bite,” the report said.
In May, a major who is a doctor at Grafenwöhr’s medical clinic for troops, also reviewed the assessment, the investigation found, but did not flag Shumaker’s assessment for follow-up.
The investigative officer recommended that the 615th MP Company’s higher command, the 709th Military Police Battalion, and the U.S. Army Medical Command should determine if any members of their commands should be disciplined for “actions or omissions.”
Maj. Gen. William Rapp, U.S. Forces–Afghanistan Deputy Commander-Support, approved the investigating officer’s findings and recommendations in October. Rapp additionally requested in his memo that the Army Medical Command ensure that Army veterinarians know that “part of their responsibilities concerning animal bites/potential rabies exposure is to inform the Service members’ chain of command…”
Rapp’s memo also asked that health care providers “read the entire PDHA (post-deployment health assessment)” and he requested a policy that all medical providers “specifically discuss feral animal bites” during the PDHA review.
He directed his medical command in theater to devise a Fragmentary Order to reduce and monitor rabies exposure risk, identify potential exposures and “improve delivery of appropriate care…”
What disciplinary actions have been taken, if any, is unknown.
‘No longer here’
Shumaker’s symptoms escalated rapidly. He went to a hospital Aug. 15 in Carthage, N.Y., near Fort Drum. Doctors there didn’t know what was wrong with him, his mother said. They diagnosed him with tendonitis and gave him a pain reliever.
On Aug. 18, he started vomiting, returned to the hospital and was given anti-nausea medication, hydrated and released, according to the report, and then signed in to Fort Drum.
The next day, he collapsed, his mother said. This time at the Carthage hospital, a retired Army doctor asked him if he’d been bitten “by a bat or a skunk or a dog,” Taylor said.
“Yeah, a dog,” Shumaker said.
Shumaker was taken to the State University of New York Upstate Medical University Hospital in Syracuse, where tests confirmed he had rabies. He called his mother.
“I’m scared,” Shumaker said. She could hear he was having trouble breathing.
Taylor was stunned. “You told me the dog tested negative,” she said.
A nurse got on the phone, Taylor said, and told her to come, quickly.
By the time she arrived from California, her son was in a coma. Taylor had to wear goggles, gloves and a gown to go in and see him.
“He was in that coma from Aug. 19th to the 31st,” she said. “I really thought Kevin was going to make it.
“My only child,” she said. “He never got to do anything.”
Doctors attempting to save Shumaker had chemically induced the coma, treating him with an experimental protocol credited with saving a handful of rabies patients in the past few years, and which in any case spares the patient suffering.
“They went all-out,” Cervosky said. “But unfortunately it didn’t work.”
On Aug. 31, after Shumaker suffered a massive brain hemorrhage, a neurologist told Taylor the son she’d known was “no longer here.”
“They took him off the ventilator,” she said. “He didn’t even make it two minutes, and he was dead.”
His mother doesn’t know why he told her that he’d gotten treatment, why he’d told her the story about the dog’s head and the expired vaccine. She said she has little confidence that the AR15-6 report is entirely accurate, and said she’s convinced that her son and other soldiers were not adequately warned about rabies’ lethality.
“Kev didn’t want to die,” she said.
If rabies had really been such a concern, she said, why did no one take action after Shumaker told the vet about the bite or note it in his health assessment?
Why had other soldiers who came forward to report bites after Shumaker’s death, not reported them at the time?
And why, she asked, would the report recommend that soldiers reporting bites “not be punished”?
The report does not discuss whether troops downrange who reported animal bites were subject to disciplinary measures for violating the order against having pets — or whether troops did not report bites because they believed they would face discipline.
“If a mortar had hit, I would have missed him like crazy, but I wouldn’t feel like I do,” Taylor said. “It’s between anger and missing him so much. How do you replace a son?”