from the LA Times: http://www.latimes.com/features/health/la-he-bat27oct27223420,1,2446606.story?coll=la-headlines-health-manual
Too close an encounter with a bat
What happens when you accidentally step on one? A lot of scary things if you don't get help quickly. One woman learns firsthand what it's like to face the risk of rabies.
By Irene Wielawski, Special to The Times
I didn't set out to squish a bat with my bare foot. My mission was to turn out the kitchen light, which I noticed only after climbing into bed. My husband, Tom, was already asleep, so I figured I'd tiptoe out to the kitchen without turning on other lights.
In retrospect, Tom surely would have preferred lights blazing to the bloodcurdling scream that ended his slumber a few seconds later. This was my answer to the bat's tiny squeak as I crushed its furry, winged body in the pitch-black hallway. "B-B-B-B-AT!" I shrieked, hopping up and down on one foot.
Tom raced to my rescue, brandishing his favorite heavy object — the 3-inch-thick Baseball Encyclopedia. One blow finished off the bat. For the rest of the night, I cowered under blankets pulled over my head. By morning, I'd decided I was being silly, and resolved to put the unnerving episode out of my mind. It never occurred to me to call my doctor or health authorities.
That sort of ignorance — from which I was saved by knowledgeable friends and alert health workers — is why people still die of rabies in the United States.
We don't hear much about rabies. The headliner viruses today are SARS, HIV and West Nile, even though rabies is the deadliest of them all. There is no treatment once symptoms set in — typically one to three months after exposure — and death is inevitable. But because human rabies deaths are rare — only one or two a year in the United States — public awareness remains spotty, and misunderstanding abounds.
"Some people have extremely high levels of paranoia," says Linda J. Demma, virologist and rabies expert for the national Centers for Disease Control and Prevention. Health authorities, according to Demma and others, field many calls from people propelled by unreasonable fear to demand rabies treatment. But others genuinely at risk sometimes fail to call because they don't realize the danger.
I was a perfect example of the latter group. Though diligent about vaccinating our pets, I had the idea that human rabies was largely eradicated, like smallpox. My casual attitude was encouraged by rabies' low incidence; I'd never known of anyone dying of rabies.
But there had been a rabies death in the close-knit northern suburb of New York City, to which our family moved from Los Angeles. A small child was the tragic victim, after a bat bite. It happened before we arrived, but residents still recall the extensive media coverage and the barrage of educational literature issued by health authorities and local doctors. This is why my somewhat jocular account of squishing the bat went over so badly on an outing three nights later with friends. Moira, a health lawyer, and Vicki, the town librarian, could not have been less amused.
Moira fired questions: Had I notified the county health department? What happened to the bat? Could I retrieve it for laboratory analysis? Then both women proceeded to rattle off rabies facts that put me in a cold sweat.
Health experts bluntly confirmed what my friends told me that night. Bats are the major source of human infection in the United States, and the risk is widespread: Rabies-infected bats have been found in every state except Hawaii. Though most bats are rabies-free and perform such important functions as insect control, they still are the wild card in rabies prevention, implicated in more than 90% of human rabies cases.
The reason is that bats have tiny teeth, making bites extremely hard to detect. People may not even realize they've been bitten, which would never be the case with, say, a raccoon bite, explains Dr. Richard W. Gerhold of the Southeastern Cooperative Wildlife Disease Study at the University of Georgia. Moreover, bites from larger animals usually require professional treatment, which triggers public health oversight and, when indicated, rabies inoculation. Medical experts say post-exposure rabies shots are 100% effective if promptly administered.
Although these shots are an important factor, the stunning decline in human rabies cases in the United States (from about 100 deaths annually pre-World War II to one or two today) is largely the result of aggressive vaccination of such domestic animals as dogs and cats. The nation spends about $300 million annually on these prevention measures, the CDC says.
In poorer countries, death rates are much higher because pets and livestock still transmit rabies to humans following encounters with infected wildlife (remember "Old Yeller"?).
Newly educated by Moira and Vicki, I wasted no time calling the health department. But I still harbored hopes of skating through this — that is, avoiding shots. Early in our conversation I assured the public health nurse manning the rabies hotline that my foot looked "fine." This amateurish risk assessment failed to convince her, especially after the nurse learned how thoroughly the bat and I had connected. Did we have the bat, she asked urgently.
Sure enough, there it was in the underbrush where Tom had tossed it. Within an hour, a county animal officer was knocking on my door to collect the carcass for autopsy. If rabies could be ruled out, then I wouldn't need shots.
But my delay in reporting eliminated that chance. The bat was too decomposed for a definitive ruling. Moreover, the health department had labeled my case a high-risk exposure. Even without laboratory proof, the circumstantial evidence was damning. A healthy bat shouldn't have been in the house, nor should it have been sitting on the floor after dark, when instinct compels bats to fly.
Because there is no blood test for asymptomatic infection — and it's too late once symptoms appear — public health authorities aggressively advocate shots at the merest possibility of contact with a sick bat.
My case was way over that threshold. Whether I needed shots was no longer a matter of debate. The issue was how soon. Because seven days had passed since exposure, the health department's ruling was unequivocal: "Immediately," the public health nurse told me, segueing neatly into a discussion of the new and improved rabies shots. Perhaps I'd heard that the old ones involved gigantic needles in the stomach? As a matter of fact, I had.
You've figured out by now how I spent the rest of the summer. The rabies vaccination series takes about a month to complete. The shots are adminis- tered on a strict schedule, more frequently at first, then tapering off. There are six appointments. All but the first involve a single shot of rabies vaccine in the arm.
The first session, though, is humdinger. In addition to the shot in the arm, you get several in the rear. These are one-time immune system booster shots. The number you need is determined by weight — I needed three — and those needles are long! I loudly estimated 5 inches as the first one came at me.
"Oh, come on, they're only 2 1/2 inches," cooed our medical group's nurse practitioner. But, I protested, the cylinder is gigantic! "Well," she admitted, "This is the biggest hypodermic we ever use."
She turned out to be an expert shot-giver, as skilled and knowledgeable about rabies prevention as the local health officials who'd guided me to appropriate action. I shudder to think what might have happened if I hadn't lucked into well-informed friends.
Indeed, the most recent U.S. rabies death occurred last month in Northern California. A man awoke to find a bat darting about his bedroom. After chasing it outside, he noticed a pin dot of blood on a finger of his right hand. He thought it might be a bat bite, so washed his hands. But he never called his doctor or health authorities, believing he'd taken sufficient precautions.
Several weeks later, the man was hospitalized with pain in his right arm and chest, which grew steadily worse, according to the Shasta County Department of Public Health, which investigated the case and reported it to state and federal authorities.
Catastrophic symptoms developed rapidly; rabies attacks the nervous system, inducing mental delirium, insomnia, extreme anxiety, paralysis and organ failure. Within a week, the man was dead.
"It was so tragic, just heartbreaking," says Dr. Andrew Deckert, the Shasta County public health officer who investigated the case and interviewed the man as he lay dying.
