The Emergency Department (ED) was bustling with activity on a hot July day. Patients were streaming in with heat-related illnesses, and a few were trauma patients from car accidents. Just then, the triage nurse informed me about a group of young adults seeking prophylactic rabies vaccines. It turned out that they had been exposed to rabies during a summer camp. I vaguely remembered reading an email from the health department about this. I immediately went to talk to the patients, gathering more information about the incident.
During a summer camp, a group of young adults encountered a startling situation when they woke up to find their tents filled with multiple bats. The campers reported being bitten by these bats and feeling them touch their arms and legs. The incident resulted in over 200 campers being exposed to the bats. In response, the Ohio Department of Health advised that all potentially exposed individuals receive rabies prophylaxis to ensure their safety.
Rabies is a highly contagious virus that can be transmitted from animals to humans, causing a severe infection of the central nervous system. The symptoms of this virus are quite alarming and can range from confusion and hallucinations to abnormal behavior, insomnia, fear of water, coma, and even death. It is a significant public health concern in numerous countries, particularly prevalent in Asia and Africa. Shockingly, rabies accounts for an estimated 70,000 deaths each year, with children under the age of 15 comprising 40% of these fatalities.
Preventing dog bites and vaccinating dogs are effective ways to avoid human rabies cases, which are primarily caused by dog bites and scratches worldwide. In 2007, the U.S. was successful in eliminating rabies in dogs, and the annual percentage of rabies cases in dogs is estimated to be only 1% nationwide. This achievement was made possible by states implementing mandatory rabies vaccines for cats, dogs, and even ferrets once they reach 3-6 months old. It is rare for people to die from exposure to wild mammals such as skunks, raccoons, and foxes, and there are no known rodents that transmit rabies.
In the U.S., rabies from dogs is extremely rare. However, blood-feeding bats are the primary source of rabies in humans, accounting for 70% of deaths from rabies in the country. The virus is present in the saliva of infected bats and can be transmitted through their bites. Additionally, it can be spread if the saliva from an infected bat comes into contact with open wounds or mucous membranes such as the mouth, lips, and nostrils. The Ohio Department of Health has specific criteria for bat exposure, including being bitten by a bat, having direct, bare-skinned contact with a bat and being unsure if a bite has occurred, and being in a room with a bat when unable to determine if an exposure has occurred. For instance, if a person is sleeping in a room and wakes up to find a bat in the same room.
If a patient has been exposed to a bat, the recommended treatment is to thoroughly wash the area of direct contact with soap and water, followed by receiving post-exposure prophylaxis (PPE). PPE involves a series of shots given to prevent the contraction of rabies, a disease that is typically fatal once symptoms manifest. However, timely vaccination and treatment can be life-saving.
The immunoglobulin or antibodies are administered to the site of exposure, providing passive protection, based on the patient’s specific case. Along with that, a series of vaccines are given to the patient over a period of two weeks. This helps to trigger their immune system and prevent infection with the rabies virus.
The health department had to inform all the campers, scattered throughout Ohio, about the possibility of exposure to rabies and the need to seek medical care to receive rabies prophylaxis. During my shift, I attended to five patients who required rabies prophylaxis. One of my patients woke up with a bat perched on her arm and felt a slight pinch, which she assumed had woken her up from her sleep. She observed no bleeding and no visible bite mark on her skin. The rest of the patients were not aware of any direct contact with the bats, but were considered exposed because they were sharing a tent with the bats while they were sleeping.
After receiving their immunoglobin injections, the patients were given the first dose of the rabies vaccine. To complete the vaccine series, they were advised to return to the ED on the third, seventh, and fourteenth day post-exposure. Those who haven’t been vaccinated for rabies before require four doses of the vaccine. However, individuals who have received the vaccine in the past only need two doses after exposure to rabies.
Every year, approximately 60,000 Americans undergo rabies post-exposure prophylaxis, with only one to three reported deaths, thankfully. Although the likelihood of contracting rabies is usually low, the risk of death is significantly high once the disease sets in. Hence, it is always wise to be extra careful about prophylaxis. During my tenure, all my patients responded positively to their vaccinations in the emergency department and scheduled their next vaccine three days later.
An emergency physician, Dr. Erika Kube, is currently employed by Mid-Ohio Emergency Services and OhioHealth.
