Nearly half the people who got shots to prevent rabies between 2011 and 2013 didn’t meet criteria to receive them, according to a King County review of treatment with post-exposure prophylaxis, or PEP. Anxiety often plays a role in unnecessary use, experts said.
When a dozen bats flew from a crack near the door of Aaron Holmes’ Guemes Island vacation home last fall, the 39-year-old retired Microsoft developer said he was startled, but not scared.
But when he felt a sharp prick on his finger and saw one of the critters clinging to his pants, Holmes immediately knew he’d need quick treatment for possible rabies exposure.
“When I talked to the nurse on the phone, I figured I was in need when her reaction was, ‘You’d better get your butt in here,’ ” said Holmes, who jumped into a car and drove more than two hours to a Group Health urgent-care center near his Sammamish home.
The nurse was right. Bites or scratches from a bat, the only known reservoir for rabies in Washington state, call for a series of at least five shots delivered over two weeks to prevent the almost-always fatal infection.
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But a new review by King County health officials shows that, while Holmes’ treatment was appropriate, many people who have run-ins with dogs, cats, ferrets and other animals are getting rabies shots when they don’t need them.
In fact, nearly half of those treated in King County between 2011 and 2013 didn’t meet criteria for receiving rabies post-exposure prophylaxis, or PEP.
“Some of them were getting PEP for dog bites, some of them for stray cat bites, some for raccoon scratches and bites,” said Meagan Kay, a veterinarian and medical epidemiologist for Public Health — Seattle & King County.
“The concern is giving people rabies PEP when it’s not really a high-risk exposure.”
Of course, Kay and other experts acknowledge that, with rabies — a viral infection spread through saliva that targets the central nervous system — the stakes are high if treatment is missed.
“The hard part with rabies is, it’s always a fatal disease,” Kay said.
But medical officials say health workers should be conducting better background checks for every patient with possible rabies exposure, and should follow guidelines to the letter to avoid unnecessary use of the costly and often-scarce vaccines.
“Oftentimes, insurance will not cover the administration of PEP when it’s not recommended, and it can be thousands of dollars,” Kay noted. “Sometimes that will get people to reconsider whether they want it.”
But, she added: “When there’s fear in the picture, no amount of money will discourage it.”
King County officials looked at hospital prescriptions for rabies immune globulin between 2007 and 2013. They closely examined records from 2011 to 2013, after a change in Washington law that limited reports of animal bites to those that included possible rabies exposure.
In recent years, King County health officials have received as many as 350 reports of animal bites each year, with about 80 people receiving rabies PEP. Statewide, nearly 240 people received rabies PEP in 2014, records show.
PEP includes doses of rabies immune globulin based on the weight of the patient and four rabies vaccine shots delivered at days 3, 7 and 14 after the first vaccination. The series can cost between $4,000 and $10,000 — or more, depending on where and how it’s delivered, experts estimated. In addition, the products can be difficult to get because of supply problems or outright shortages.
As summer begins — the peak season for contact between people and wildlife — health officials are urging medical professionals and the public to understand when treatment for rabies is indicated, and when it isn’t.
Across the U.S., human deaths from rabies are at a historic low, with only one or two fatal cases per year, according to the Centers for Disease Control and Prevention, both because of required vaccinations for animals and the wider use of human vaccines. The last fatal case in Washington state was in 1997 in a Mason County man, health officials said.
Because rabies is so serious, more than 40,000 people receive PEP treatment each year after contact with potentially rabid animals, the CDC says. There’s no national reporting system for PEP, so it’s unclear how many of those treatments may be inappropriate, said Jesse Blanton, the CDC’s lead epidemiologist for rabies.
But one national study published in 2000 suggested that 40 percent of patients were given PEP when they didn’t need it — and 6 percent didn’t get it when they should have.
“We should spend more time talking with people about whether prophylaxis should occur,” Blanton said.
Rabies is a more serious concern on the East Coast, where rabid raccoons are common, and in the Southwest, where it often affects skunks.
“Washington is one of the few states with a limited reservoir,” Blanton said. Bats are it, with no known terrestrial source of the disease.
Still, residents of Washington worry about rabies exposure from other sources, including dogs, cats, ferrets and raccoons — as well as bats, said Lori Roehl, lead nurse in the travel and infectious disease clinic at Group Health. Some report possible contact with rabid monkeys or dogs during trips abroad.
“We get all kinds of calls,” she said. “People call about feral cats. They might call about a dog that bit them when they were jogging in their own neighborhood. They might call because a squirrel bit them when they were trying to feed it, or if they were breaking up a fight between their dog and a raccoon.”
In nearly all of those cases, the risk of developing rabies is very low, said Dr. Paul Thottingal, Group Health’s program chief for infectious diseases. In most situations, direct bat exposures are the cases that truly warrant PEP.
“It is definitely a case-by-case situation,” Thottingal said. “If there was absolutely no contact with a bat, that’s a zero situation.”
But that often isn’t enough reassurance for someone who may have had, say, a run-in with an aggressive raccoon.
“People do become very anxious,” Roehl said. “We like to say, we don’t treat anxiety with PEP, but we also factor that in sometimes.”
King County officials understand that anxiety may play a role in some decisions to administer rabies PEP, Kay said. But they’re also urging health officials to review carefully the histories of people with suspected rabies exposures.
In many cases, PEP for rabies can be avoided. If an animal has been vaccinated against rabies — required for all dogs and cats in Washington state — there’s no concern. Ditto if the animal can be quarantined and observed for 10 days, with no signs of disease. If the animal shows symptoms or is otherwise suspicious for rabies, it can be killed and tested for a definitive answer.
In Washington state last year, 276 bats were tested for rabies, with 15, or 5 percent, identified as positive for the disease, health records show. In addition, 75 cats, 53 dogs, 12 raccoons and 19 other animals were tested — all with negative results.
In Aaron Holmes’ case, he caught the bat that bit or scratched him with a butterfly net as it flew around his kitchen. But the animal later escaped, which meant Holmes had to be treated.
The shots themselves weren’t so bad, he said. The once-feared rabies vaccine injections into the stomach were discontinued in the 1980s; now the rabies immune globulin is given at the site of the wound, but the vaccines are delivered in leg or arm muscles.
Holmes’ concern was mostly about keeping the bat away from his 9-year-old daughter, who was in the house during the incident. But, only later, after his wife reviewed rabies on the Internet, did Holmes realize how serious his bat encounter could have been.
“She said, ‘Did you know you could die?’ ” he recalled. “She was the one who got me a little worried.”