Bats in the Belfry: Camp Doctor vs Rabies

[[{"type":"media","view_mode":"media_crop","fid":"40251","attributes":{"alt":"©JHindman/Shutterstock.com","class":"media-image media-image-right","height":"219","id":"media_crop_4123120583322","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4097","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"©JHindman/Shutterstock.com","typeof":"foaf:Image","width":"304"}}]]I went a little crazy while serving as camp physician a few summers ago. I overheard 2 ten-year olds talking about how scary it was when a bunch of bats were flying around inside their cabin after the critters had been disturbed by some smoke from a grill. Upon further investigation by local pest experts, it was determined that a group of bats had indeed been nesting inside a cupola (kind of like a belfry…) at the top of the cabin. Ten boys and 2 counselors had been sleeping in this cabin for 4 nights.

What would you have done at this point?

A. Order rabies immune globulin and vaccine for everyone in the cabin.

B. Inspect the 12 persons sleeping in that cabin for signs of bite marks and treat anyone with anything remotely suspicious.

C. Nothing needs to be done since no one had been bothered by these bats until they were smoked out

D. Have the pest experts trap all the bats and have their brains examined for rabies by the closest veterinarian school and treat only if a positive result for rabies virus.

E. Draw antirabies serum titers on the 12 persons and repeat in 10 days; treat anyone with a 2-fold rise in titers.

For the answer, discussion, and outcome, please click here.

Answer: A. Order rabies immune globulin and vaccine for everyone in the cabin.

The correct answer is Option A, unless the camp is in Hawaii which is the only state that is “rabies free.” Most experts would recommend post exposure prophylaxis (PEP) for children sleeping in a room where a bat has been found. One should always consult the local or state health department for questionable exposures. Close to 90% of the confirmed cases of human rabies over the last several decades in the US have been of bat origin.

Option B might be a reasonable answer if no one had slept in the cabin and the only exposure was the bats flying around.  

Option C is wrong. Of the 34 cases of bat rabies (as determined by genetic sequencing) confirmed in the US between 1990 to 2007, only 8 individuals had reported a bite or probable bite; 15 reported having touched or been in a room with a bat; and 11 reported no bat contact at all. Bite marks from bats can easily be overlooked.

Option D might be reasonable if one could be sure that all the bats were captured which is not the case in this scenario.

Option E is not a recommended approach.

Outcomes

So, the 12 children and counselors got their immune globulin and 5 vaccine shots (the new recommendation, however, is that only 4 vaccine doses instead of 5 are needed) over a 2-week period and everyone did fine. The rabies vaccine is very well tolerated with minimal side effects. When I told the kids that “in the old days” people got 20+ shots in the abdomen, they then decided that 6 shots in the arm wasn’t so bad after all, particularly since their cabin got a special pizza party on the days they got their shots.

One of the great things about being a camp doc is being able to treat the children without having to deal with the parents. Obviously, that did not apply to this situation and I had to call 12 sets of parents to explain what happened. As you might expect, I got some interesting feed-back:  “I’ll have to run this by my chiropractor to see what he thinks.”  “Can’t we wait to see if any symptoms develop and then just treat it with antibiotics?” Thus, by the end of the calls, I was going a little “batty.”

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References:

Human Rabies Prevention--United States, 2008. MMWR. 2008;57(RR03);1-26,28.

American Academy of Pediatrics. Report of the Committee on Infectious Diseases. Red Book. Rabies. RED BOOK Online. 2015;658-666.