We looked around, found nothing, and shortly went back to sleep.

In the morning, my wife was opening our interior shutters, which are used to keep out sunlight, when she discovered… a bat.

What happened next seemed perfectly sensible at the time. I went to the garage, got a heavy leather glove, returned, and grabbed the bat while my wife opened the front door. We stepped outside, let it go, and it flew away. We were glad to have it out of the house and proceeded to fix breakfast.

I had just made two mistakes but did not realize it.

It was early August, and we had been staying at our vacation home in Kent County, Maryland, on the Eastern Shore. In a few days, we were back home in our retirement community just outside Baltimore. We have a lady who watches out for our vacation place when we are away. I asked her to arrange a pest control person to check out the house to see if there were other bats, perhaps in the attic. As it turned out, he arrived when we were back just before Labor Day to celebrate our 63rd anniversary.

We described what happened. He looked at me and said, “You really should go to the emergency room or see a doctor.”

My wife smiled and said, “He’s a doctor.”

“Well,” he replied, “I just want you to be safe.”

He looked around the entire house and found multiple places where a bat could slip in. He found a few bat droppings in the attic. Still, he thought this was probably a “one off.” Maybe the bat got in when the garage door was open or something like that. He said he would send us a proposal for caulking up the various holes he found. We were back home in Baltimore when we got a message from our property manager that he had sent his proposal, but he also said he really thought I should go to the emergency room. Up to now I had not paid much attention but having heard it multiple times, I decided to do some research.

What I learned

I turned to Open Evidence, an AI system that looks only at quality medical and scientific information. The answer was unambiguous. I should go to the emergency room, now.

Because the bat had actually been crawling on my head while I was asleep, and because it was no longer available for testing, I should receive rabies post-exposure prophylaxis (PEP.)

Bat bites can be so small that a person may never see or feel them. And rabies presents an unusual medical calculation: The probability that this particular bat was rabid and infected me was exceedingly small, but the consequence of being wrong was enormous. Once clinical rabies develops, it is fatal; there is no treatment. But PEP given before symptoms begin, is nearly 100% effective.

That was a clear wake up call.

The current guidance supports the central lesson. CDC says potential direct physical contact with a bat warrants assessment, and Maryland specifically advises considering treatment when bat exposure cannot reasonably be ruled out. CDC also advises not releasing a bat found in the home until public-health experts have been consulted, because testing the bat may determine whether PEP is necessary. Guidelines favor treatment whenever exposure cannot be excluded.

The last sentence is the key one.

Just to be clear, it is very uncommon for a person to develop rabies from a bat. In our area, less than 1% of bats are infected. I had no clear bite or scratch. The risk in my case was extremely small. The problem is if I do win the Lottery, that’s bad.

Bats are the source of most rabies cases, but these are rare. There were two deaths from rabies (neither person received PEP) in America last year but over 30,000 people were potentially exposed and received PEP.

The rabies virus travels from the bite site through peripheral nerves toward the spinal cord and brain. Once symptoms appear, the disease progresses to severe neurologic illness ending in coma and death. There is no reliably effective treatment once clinical rabies has developed. The opportunity to prevent the disease is therefore before symptoms begin.

What to do if you encounter a bat

I had not thought about rabies since I took the board certification exam in infectious diseases some 40 years ago. I worked with cancer patients, not the general population, so I had no experience other than book learning long ago.

It did not occur to me that the bat could have been rabid or that it might have bitten me, since I did not find evidence of a bite or scratch, nor was the bat aggressive. Not being worried about rabies, I did not think to kill the bat so it could be tested. Absent that testing, as I learned, I needed rabies post exposure prophylaxis or PEP.

I was talking with a speech therapist whose family had a cabin with “lots of bats flying around all the time.” She remembered as a kid being told that if you got bitten by a rabid bat or other animal, they would “inject you with 9-inch needles into your abdomen many, many times with lots of side effects.“ She wasn’t entirely wrong. The nine-inch needles were folklore, but the old rabies treatment really did involve numerous injections into the abdominal wall. The earliest vaccines descended from Pasteur’s 1885 work and were prepared from rabies-infected nervous tissue. They were far more cumbersome and produced substantially more adverse effects than today’s purified cell-culture vaccines.

Fortunately, that era of painful shots is long gone, but it was only in 1980 that the modern anti-rabies vaccine was licensed, so it is no surprise that the myth still abounds.

None of this means that bats are bad animals. Quite the contrary. Bats have been saddled with centuries of bad publicity, from witches to Dracula, when in reality they are among our most useful neighbors, gobbling huge quantities of insects like mosquitoes every night.

That said, the CDC reports that rabies exposures have recently increased. We just read that a rabid bat was found in a school about 20 miles from our home, and rabid bats have been reported in Los Angeles recently.

Post-exposure prophylaxis

My primary care physician called the local emergency room to determine if they had the PEP available, and learning that they did, and that they were “not too busy,” we headed off.

After signing in (“oh you’re here because of rabies”) we were ushered into the triage room where a doctor and nurse took a history. The doctor, obviously very experienced, said that there was no question that I needed PEP. He then looked at my wife and said, “You were asleep in the bed next to him, so the bat may have crawled on your head also.” “I have hair on my head,” she responded. “Yes, but he could have walked across your forehead, and you might not have been aware. You need PEP also.”

PEP for someone who has never previously been vaccinated against rabies consists of human rabies hyperimmune globulin, which supplies immediate antibodies, followed by four doses of rabies vaccine given on days 0, 3, 7, and 14 to give long lasting protection.

We went back to the waiting room and after a while we were ushered into the main area of the ER. They had to order PEP from the pharmacy, which took a while until it arrived. The hyper immune globulin dose is based on weight. For me it was 2.6ml and for my wife it was 1.7. If there had been evidence of a bite, some of the globulin would have been injected there. But for us it was divided into two shots, one into each thigh. And then the vaccine, 1ml, goes into the shoulder.

We now are back three days later for the second vaccine dose. We will still have day seven and fourteen to go.

I told this story to retired senior engineer who said she had grown up on a farm and would have done exactly the same thing with the bat. We had lunch with a family medicine physician; he also was not surprised that we just got rid of the bat. That made me feel better because, as is always easy in retrospect, it was not smart to try and catch the bat myself. But given that I did, I should have killed it so it could be checked for rabies. Chances are it would have been negative, and we would have escaped getting PEP.

But even more importantly, it never occurred to me that the bat might have bitten or scratched me on the head since I did not see any obvious evidence. I really should have been curious and looked up the proper course of action right away. Fortunately, the pest-control man knew enough to keep pestering us. Eventually, I listened.

So here is the lesson I would pass along. If you have direct contact with a bat (or other wild animal), don’t handle it yourself. Contact animal control or your health department so that it can be safely captured and, when appropriate, tested. If the animal is gone and can’t be tested promptly, seek medical advice about whether rabies prophylaxis is needed. Rabies is exceedingly uncommon. But this is one of those unusual situations in medicine where a very small probability is paired with an almost unimaginable consequence.

And should you need the shots, don’t worry about those childhood stories of enormous needles in the belly. Modern rabies prophylaxis is nothing like that. It is still a pain in the butt — although, in our case, mostly a pain in the thigh.

The post I Woke Up with a Bat on My Head. appeared first on Medika Life.