Dr. Kube: Summer campers waking up to bats inside their tents leads to ED visit for rabies

It had been a busy July day in the Emergency Department (ED) with several patients coming in for being heat-related illnesses as well as several trauma patients injured in car accidents. The triage nurse called me to let me know that several young adults had checked in to the triage to receive prophylactic rabies vaccines as they were all exposed to rabies while at a summer camp. I briefly recalled seeing an email from the health department about this and I went to talk to the patients to get more history about what had happened.

In speaking with these young adults, they were attending a summer camp and woke up with numerous bats in their tents one morning. Several campers reported being bitten by the bats and several others said the bats were touching their arms and legs. There were over 200 campers exposed in this scenario. The Ohio Department of Health recommended that all the potentially exposed campers be offered rabies prophylaxis.

Rabies is a virus that is transmitted from animals to humans that infects the central nervous system. Symptoms, which include confusion, hallucinations, abnormal behavior, fear of water, insomnia, coma and death, can occur from days to years after exposure. It is a serious public health problem in many countries, most prevalent in Asia and Africa. Rabies is estimated to cause 70,000 deaths annually, 40% of deaths being children under age 15.

Dog bites and scratches are the most common cause of human rabies cases worldwide, which can be prevented through dog vaccination and preventing dog bites. In the U.S., rabies in dogs was considered eliminated as of 2007, with current estimates of dogs making up only 1% of rabies cases annually nationwide. This was accomplished by states requiring rabies vaccines in dogs, cats, and other animals like ferrets once they reach 3-6 months of age. Human deaths after exposure to skunks, raccoons, foxes and other wild mammals are rare and there are no rodents known to transmit rabies.

In the U.S., where rabies from dogs is exceedingly rare, blood-feeding bats are the main source of rabies in humans. Most deaths from rabies in the U.S. — 70% — is from bat exposure. Rabies is present in the saliva of infected bats and can be spread by the bite of a bat, but also can be spread if the saliva from an infected bat gets into open wounds or mucous membranes such as the mouth, lips and nostrils. According to the Ohio Department of Health, criteria for bat exposure include being bitten by a bat, having direct, bare-skinned contact with a bat and being uncertain that a bite has not occurred, and being in a room with a bat when unable to say if an exposure had occurred. For example, a person sleeping in a room wakes up with a bat in the same room.

For patients that have had a bat exposure, the treatment is washing the area of direct contact thoroughly with soap and water and receiving post exposure prophylaxis (PPE). PPE is a series of shots given to an exposed patient to prevent contracting rabies, which is almost always fatal once symptoms appear. However, vaccination and early treatment can be lifesaving.

Depending on the scenario of the individual patient, they may receive an immunoglobulin or antibodies at the site of the exposure, which give passive protection. In addition, the patient receives a series of vaccines over two weeks to elicit the individuals’ immune system to prevent infection with the rabies virus.

The health department had to notify all the campers — who live all over Ohio — of their possible exposure and need to seek medical care to receive rabies prophylaxis. On this day, I saw five patients that needed rabies prophylaxis. One of my patients woke up with a bat on her arm and thought she maybe had felt a slight pinch on her arm, which is what she thinks woke her up from sleep. She had never seen any bleeding and there was no visible bite on her skin. The others were unaware of any specific contact with the bats, but were considered exposed because they woke up with the bats in their tent where they had been sleeping.

The five patients received their immunoglobin injections followed by the first rabies vaccine. They were instructed to return to the ED on days three, seven and 14 post exposure to complete their vaccine series. For people who have not been vaccinated for rabies in the past, they require four total doses of rabies vaccine. For people who have previously received rabies vaccine, they only need two doses after a rabies exposure.

Annually, about 60,000 Americans receive rabies post exposure prophylaxis, and thankfully only one to three deaths are reported. While the risk of contracting rabies is generally small, the risk of death is so high once an individual contracts the disease, it is beneficial to be overly cautious about prophylaxis. My patients all did well with their vaccinations in the ED and planned to return three days later for their next vaccine.

Dr. Erika Kube is an emergency physician who works for Mid-Ohio Emergency Services and OhioHealth.

drerikakubemd@gmail.com

This article originally appeared on The Columbus Dispatch: Dr. Kube: Summer campers waking up to bats inside their tents leads to ED visit for rabies