Hydrophobia

I think it is time we all learned a little more about rabies. When I was little my family had a goat that provided us with milk and cheese, seriously. Goats don't really get bigger than 4 feet at the shoulder (and that is massive for a goat), but my rememberance of our goat was that is was very large. But after 23 years of looking for a species of horse-sized goats, I have conceeded that the goat was probably normal sized and I was just very small. I also remember that the goat died of rabies and have fabricated some childhood memories of the goat foaming at the mouth and an old yeller style ending. Actually, the goat died of tetnus, a less exciting disease that doesn't involve any foaming.

But rabies came up again in my life the other day on a field trip to the Lewis County Health Department, in Lewis County ( 45 minutes S of Olympia). We were there to examine the strategic planning process, or lack thereof, of a rural health department, but the story they first reeled us in with was one of infectious disease. Apparently, a few months ago a kid found a wee little bat under a rock in the national forest that is in Lewis county. This forest is known for its rabid bats. He picked up the bat (Don't ever pick up the bat) and handed it around to all 40 people at the picnis he was attending. Unfortunately, the kid apparently then released the bat back into the wild. Unfortunate, because, had he taken the bat home to be his merry animate souvenier it could have been tested for rabies. As it was, the bat rejoined its thousand of identical bat brethren. Following the CDC's guidelines, anyone exposed to a bat is not available to be tested for rabies should be assumed to be exposed to rabies and in need of postexposure prophylaxis.

First a word on exposure and then a word on prophylaxis.

The best way to get rabies is to be bitten by an infected animal. However, a bite does not need to occur for exposure to happen. Saliva from the animal can infect someone if it gets into one of many eligible orifices (eyes, nose, mouth) or an open wound. Saliva is the key here; blood, urine, feces -- these bodily fluids are safe rabies-wise. Which means that if you get bat blood in your eye or manage to snort guano, don't worry about it. But if the li'l guy licks you, go to the emergency room. The CDC facts page on rabies suggests precaution above all. It warns that bat bite marks can be tiny enough to not be easily visible, thus you should take precautions after any bat handling, especially if you are "drunk or mentally incompetent." The only way to know for certain if you have been exposed to rabies or not after wild mammal handling is to test the handled animal for rabies. In our case, since there was no bat to test, precaution says you must treat everyone with contact as if they had been exposed, which leads us to prophylaxis.

Prophylaxis for rabies consists of five injections over the course of 28 days. The recommended course of injections has never been known to fail, which means that no one who got them properly had ever contracted rabies. Here's the catch, the sooner you start prophylaxis the better because once symptoms of rabies appear (fever, mood swings, paralysis) the disease is irreversably fatal no matter how many injections you get. The complete course of shots is about 1000 bucks a person.

Now we have the problem of the Lewis County Health Department. These 40 picnicers are considered exposed to rabies and need immediate prophylaxis. It can't really be up to the people themselves to pay because some of them might see the risk as too low to be worth shelling out thousands for their family. But if someone in that family then dies it will be the health department's fault for not communicating the risk well enough, plus it will be horrible. So maybe the National Forest should help pay, after all, it was their bat. But, though the forest owns that land and all the revenue is federal, it is in Lewis County and thus subject to the purview of the Lewis County Health Department for public health issues. So the health department does not have much choice but to order and administer $40,000 of shots, burning a hole in their tiny, rural health department budget. So much for strategic planning. I hope that kid grows up to be a public health worker in a rural area.

But there's more to rabies than bats. I bet everyone is wondering right now: Is it true that rabid people will bite other people and inffect them? Well, maybe, but it hasn't yet been documented. So far, the only hunan-to-human transmission cases occured from organ transplants. There have been about 11 cases, 8 from corneas and 3 from organs. I read up on the organs.

An otherwise healthy man came into the hospital with fever and mood changes and died shortly after admission of a brain hemmorage. It was all sudden, so who knows how much time the ER had to take a history, and the hemmorage was attributed to no specific cause (or at least not one I understood from the article). The family of the patient agreed to organ donation and his organs were cleared to be safe for transplant. You see where this is going.

The person who got his lungs died during surgery, no rabies. The guy who got his liver had a smooth procedure and recovered very quickly, The two people who got kidneys did ok. Within 24-27 days after each surgery, all three transplant paitnets returned to their respective hospitals with non-specific encephilitis (brain swelling, a result of an infection of the central nervous system, like rabies. They all died pretty quickly. You can read the case here http://www.cdc.gov/mmwr/preview/mmwrhtml/mm53d701a1.htm.

Well, that's just really terrible, You get your organ (maybe you're a recovering alcholic with a decimated liver who got the medical cue to turn your life around, or maybe you're the woman who has not had the means to treat her diabetes and has wrecked kidneys as a result which has made it even harder to get by) and it turns out that the fine print on your new lease on life says 'oh, by the way, along with this life-saving organ you are also getting a painful illness that you will have no way to even suspect until it makes you go crazy and start to die.' Really, really terrible, Was it preventable?

I don't know enough about rabies to say. This particular case has driven more rigorous testing of donated organs. But how sensitive are tests for rabies? For those who don't do the science thing, no diagnostic test is absolute. The really great ones are right about 90% of the time, the good ones about 75-80% and the others . . . well, that's why doctors do a clinical examination as well. My guess is that because human rabies cases are so infrequent, there is no great demand for a really good test and it has not been worthwhile for our Mercks or GSKs to develop one (is that a pharmacynical public health student I hear?).

Where I really got to thinking about prevention in this case was in communication between the hospitals with the transplant patients. The first patient showed symptoms 24 days after transplant, the last 27. Since organs are best served fresh, their transplant dates were probably the same or very close. So there was at least a 3 day gap between the first rabid person and the last. Did part of the first patient's investigation include tracking back to the donor and alerting the hospitals who received that donor's other organs? I don't know. It may not even have made a difference since I am not sure the prophylaxis would be effective that close to the onset of symptoms (if the other patient's hospital had the heads up and decided rabies was a possibility).

In my dream medical world. The first hospital immediately tracks back to the donor and demands that the other organ recipients be examined. truth is, the code of communication between hospitals can sometimes be more of a don't ask/don't tell type of thing. This is rooted in the fact that no one wants anyone else to know if they mess up. Medicine, while pretty damn good most of the time, is not an exact science. Health professionals makes thousands or decisions about every disease and every patient. Some decisions are perfect and some of them are not, but are the best possible decision at the time. The grey space is, when is a less-than-perfect decision simply the inevitable result of combining the best-possible decision-making process with the best available information, and when is it a mistake? And now you understand malpractice insurance.

I read about a case a few years ago where a girl in Canada had some kind of surgery as a result of a condition she had. During the surgery, her doctor decided to administer the regular meds for the condition side-by-side with the anasthesia because that seemed simpler than poking more holes in the girl. She died during the operation because of a reaction to the medication. The doctor was flabbergasted -- it's not all that uncommon of a condition or a surgery - how come she had never heard of anything like this happening before? So she did some investigating and found 3 other kids who had all died in Canada in the last couple of years because of the exact same reaction. The respective hospitals had not covered the events up per se, but hadn't put them out there in any way either. What if someone thought it was a error? Well, no, it turns out the true error was not putting the information from the fatal cases out there so that doctors down the line could make decisions based on a more complete body of information.

A pause in writing now, because I get a little overworked when people die from something that the common sense and practice of publc health could have prevented. Deeeeeeep breeeeeeeeeath.

Rabies, batboy, a quick-acting and uber-responsible poorly resourced health department, liver disease, and hospital culture around adverse events. It's been a journey. Don't handle bats, especially when you are drunk.