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The first person to die of rabies in Utah since 1944 contracted the illness in 2018 and exposed nearly 300 people to the virus before doctors made a correct diagnosis.
The U.S. Centers for Disease Control studied the incident in-depth to see where officials could bolster the public health system and diagnose rabies patients on their first visit with a doctor. The incident also illustrates a failure to educate the public about the dangers of rabies vectors like bats, the culprits in the Utah case, the CDC report said.
“Educating the general public about the risk for rabies through bat exposure and advising health care providers to consider rabies in the differential diagnosis of unexplained neurologic symptoms could reduce exposures,” states the report, released this month.
The Utah case resulted in potential exposure of 279 health care workers and others in the state. Of those, 74 healthcare workers and 30 family and community members who had contact with the patient’s body fluids received a battery of shots including a rabies vaccine, the standard treatment to stave off infection.
The 55-year-old man who died in 2018 first sought treatment Oct. 17 for neck and arm pain he ascribed to a workplace injury. On Oct. 19, emergency department physicians evaluated him for muscle spasms, numbness and burning in his right arm. Doctors treated the muscle pain and discharged the man.
The report did not identify the man, the region of the state, or any of the hospitals in question.
On Oct. 20, the man called an ambulance, reporting that he couldn’t breathe and hadn’t slept in four days. His arm continued to give him severe pain and he couldn’t eat or drink because of esophageal spasms.
Still, doctors failed to diagnose the man, shuffling him among hospitals and treating symptoms, exposing him to even more healthcare workers.
It wasn’t until Nov. 3 at the patient’s fourth hospital that a consulting physician thought to test him for rabies, and by then, it was too late. Doctors did not even learn of the man’s bat exposure – an infestation in his family home’s attic – until that day. The man died Nov. 4, 19 days after the first symptoms and too late for the standard battery of rabies vaccine shots (called “post-exposure prophalaxis” or “PEP” by health experts).
The positive rabies test did not return from the lab until three days after the Utah man’s death, and neither the patient nor any of his family members were previously aware that handling bats could give you rabies. The deceased, in fact, removed multiple dead bats from his home using bare hands, and even reported waking up once with a bat on his pillow next to him, the CDC report states. Neither the patient nor his family members remembered any bites from the bats, so the man may have contracted rabies simply through exposure to infected body fluids from the animals.
According to the CDC investigation, healthcare workers exposed to the Utah man, and his family, who also were exposed to the bat infestation, received PEP without developing symptoms. A professional pest control company removed the bats from the home.
How Can I Prevent Rabies Exposure for Me and My Family?
Rabies prevention is mostly about good pet care and outdoor behavior. Vaccinate pets and keep them away from outdoor and wild animals. Don’t approach wild animals. Keep bats out of the home, and stay away from areas with bats (caves), writes Jerry R. Balentine, DO, FACEP, a MedicineNet author. About 5,000 cases of animal rabies are reported annually to the CDC, with most of these cases occurring in wildlife, Dr. Balentine said. He also offered some other prevention tips:
- When traveling, be aware of stray animals.
- If spending significant time in a country where rabies is common, one should consider rabies vaccination.
- Any activity that brings someone in contact with possible rabid animals, such as traveling in an area where rabies is more common (Africa and Southeast Asia) as well as outdoor activities near bats and other possible rabid animals, increases one’s risk of getting infected with rabies.
What to Do if You Think You’ve Been Exposed to Rabies
Medical care is recommended if a health care professional thinks that someone was exposed to a potentially rabid animal, Dr. Balentine said.
If the animal is a pet or farm animal with no symptoms, the animal can be isolated and observed for 10 days. Wild animals that can be captured can be killed and tested for the virus. If the animal can’t be found, it is best to consult with the health department, he said.
The U.S. Centers for Disease Control and Prevention (CDC) recommends prophylaxis (protective treatment) after a wildlife bite from an animal suspected to have rabies, Dr. Balentine said.
The general pathway to determine post-exposure prophylaxis for rabies requires the following information, according to Dr. Balentine:
- Bite: Did a bite occur, and where is the location of the bite? (Any penetration of the skin is considered a bite; although bites to the face and hands carry the highest risk, all bites need to be considered for prophylaxis.)
- Non-bite incident: Did the saliva touch an open wound or a mucous membrane?
- Animal risk factors: No cases of rabies infection have been reported in the U.S. from fully vaccinated domestic animals (dogs or cats). If bitten, it is important to determine if the bite was provoked or unprovoked. A provoked bite includes any circumstances during which the person touched, threatened, scared, fed, or otherwise interacted with the animal prior to the bite. If no such interaction occurred, the bite is considered unprovoked, and it increases the likelihood that the animal may have rabies.
- Bats: A health care professional should evaluate any contact with a bat that leads to a potential scratch, bite, or mucous membrane exposure to saliva. If prolonged exposure to a bat is discovered (sleeping in a room where a bat is found), postexposure prophylaxis needs to be considered.
As rabies is a fatal disease, if it is suspected, it is often best to start treatment until further information is available, Dr. Balentine said.
A health care professional administers a series of injections. The first is a rabies immune globulin (human rabies immune globulin [HRIG]), which health care professionals only give to previously unvaccinated individuals, as well as the rabies vaccine. Those who have been previously vaccinated or are already receiving pre-exposure vaccination should only receive the vaccine. Over the next two weeks, health care professionals administer three additional rabies vaccine injections during follow-up visits on days 3, 7, and 14. Health care professionals give the first of these vaccines as soon as possible after exposure. Doctors give these rabies vaccinations as intramuscular injections, and the vaccines help the body fight the virus, Dr. Balentine said.
The treatment regimen for previously vaccinated individuals is different, with no HRIG given and only two doses of the rabies vaccine, he said.