Peg Kerr&#39;s Journal

I missed this part the first time around. How did you get bit?

B

From:

The problem is, I don't know whether I got bit or not. I woke up two nights in a row with bats flying around the bedroom. Bat bites are very tiny, and often not detected. Minnesota State Department of Health protocol is that this is counted as a positive exposure if rabies cannot be ruled out by autopsy on the bat. One bat got away, and the other was too deteriorated to determine whether it was positive or not, so it is assumed to be positive.

The risk is small. But fatal if I lose.

From:

Wow. We woke up with a bat in the bedroom about a week before you did, and it never occured to either of us to get rabies shots.

What is the risk, actually? Chance a bat in the area has rabies times chance bite was undetected, assuming 100% fatality rate given zero symptoms to date. If we can get something resembling data for those two variables, we can compare that with the risk of dying in a car accident on the way to and from the hospital -- don't you need something like four shots over four weeks -- and determine which is the safer course of action.

Let's see...

"Bat rabies accounts for approximately one human death per year in the United States."
http://www.batcon.org/discover/rabies.html

Okay. That means the odds are approximately zero that you have rabies.

Same website: "Symptoms most often develop about 10 days to seven months after infection, and death follows 2-12 days after symptoms appear."

Okay, so not having symptoms yet is significant, but we don't know how much. I'd like to see the distribution of symptoms over time.

Again the website: "Bat bites are typically felt and detected at the time." But you were sleeping. I don't know how light a sleeper you are.

The CDC website has similar information:
"People usually know when they have been bitten by a bat. However, because bats have small teeth which may leave marks that are not easily seen, there are situations in which you should seek medical advice even in the absence of an obvious bite wound. For example, if you awaken and find a bat in your room, see a bat in the room of an unattended child, or see a bat near a mentally impaired or intoxicated person, seek medical advice and have the bat tested."
http://www.cdc.gov/ncidod/dvrd/rabies/bats_&_rabies/bats&.htm

I wish I knew how many bat bites there are per year, so I can divide that into the one case of fatal rabies per year. Let's assume a hundred thousand bites per year. And let's assume there's a 1 in 100 chance you were bitten undetected. (I'm making these numbers up; my guess is that there are more bites per year, and a much smaller chance you were bitten.)

So you have a 1 in a 10 million chance of having rabies.

In the U.S., there is one automobile death per 50 million vehicle-miles driven. (40,000 deaths per year. Two trillion vehicle miles driven. Don't ask; I just know this kind of thing.) I'm going to assume you have to drive ten miles to get your shots. That means you have a one in 5 million chance of being killed driving to and from the hospital.

My analysis is that you should stay home and not risk driving. And I think I was unreasonably generous estimating your chance of having rabies.

And I have no idea what the risk of the shots are.

But I know this is not a rational decision, and that's okay. It's not for most everyone. Bats are rare and scary; cars are common and benign. There's not much of a risk either way. Good luck.

B

From:

callunav.livejournal.com

Um. This has been extensively discussed in previous posts. It is not an irrational decision. It was based on some seriously thorough research by people who are knowledgeable on the subject.

If you want to look at some of Peg's previous posts on the subject, there were a number of knowledgeable responses. I think

heavenscalyx was one of the people who provided good figures and citations, if you'd like them for comparison with the findings you came up with.

I'm sorry if I sound shirty. It's just, I know this wasn't a decision that was made lightly or out of fear - if anything, fear would be more likely to persuade one to do nothing, because getting the shots is not only unpleasant in and of itself, it's also an acknowledgement that there *could* be something to be afraid of. It would be very normal to veer towards denial under these circumstances.

I myself know nothing about it. That's why I read what's been written by the people who do. And...I don't expect you meant anything slighting in what you said, so probably I'm reading it all wrong, but it just seems a little hard when a decision has been debated and debated and viewed from all different angles, to have it put down to being an emotional, illogical need for security.

I'm sorry. I have a feeling I've said all this very badly. My apologies both to you and Peg if I'm coming off offensively; it certainly wasn't my intent.

From:

Okay. I read her post. The only data point she has different is the number of fatal bat rabies cases in the U.S. I found one per year, and she has found 2.5 cases per year.

I was woken up by a bat in the exact same circumstances as Peg within a few miles and a few days, and I'm still not getting the shots.

But I know I'm weird. I do this for a living, and I know that math almost never trumps fear.

B

From:

And I am 100% certain that K, who was asleep with me when the bat made itself known, will have the exact same reaction after reading this exchange.

B

From:

callunav.livejournal.com

Okay. I believe that you are writing these responses in order to present information as you understand it, to be helpful. However, it is my perception that your identification of the choice to get the shots as an irrational response to fear is rude.

It is also my perception that by continuing this conversation, I'm making things worse, myself, so I'm going to stop. I'm glad to know that we are both trying to be supportive, albeit in very different ways.

From:

I never meant to say that a decision to get the shots, whether made by Peg or myself or K, is irrational. "But I know this is not a rational decision, and that's okay" was meant to apply to the process, not any particular result.

In general, if you think someone is behaving irrationally it's because you don't understand their rationality.

Security is both a reality and a feeling. It's easy to focus on the reality, but the feeling is just as important. Take an easy example. Someone might buy a home alarm system because it makes them feel safer. I could produce all the crime statistics in the world, but none of that takes the feeling into account. And if that feeling makes them happier in the world, then it's a good thing. And there's rational analysis that says even though a burglar alarm system isn't "worth it" based on the crime statistics, it is very much worth it based on the crime statistics and the good feelings.

People are not irrational about security. They base their decisions on the perceptions of risk and the perceptions of cost. On the one hand, this results in inefficient security allocation, but on the other hand this results in a maximation of happiness in the world.

There's a balance here, and it's not an obvious one -- especially on the national scale.

B

From:

I have the distinct impression that both you, B. and K. look at me at times with . . . well, I guess I would describe it as bemused disbelief about some of the decisions I make, especially ones involving personal risk, about both myself and my girls. And sometimes a tinge of, well, something more, rather beyond bemused disbelief.

In this case, I was following the recommendations of the Minnesota Dept. of Health, and my own doctor's clinic.

Look, I'm crabby today, I freely admit it. I made a difficult decision, followed some advice of people I respect, went and sat three and a half hours in an ER because of that decision, and then come back to find my decision being second-guessed in my LJ.

After much trial and error, Kij and I have come up with a code phrase for situations like this, and I'm pulling it out now.

You can make different decisions than I do.

And that's all I am going to say on the subject.

From:

He's right.

K.

From:

jbru.livejournal.com

I think one part of the calculations you are missing is how many cases of rabies are treated successfully each year. That is, the number of deaths by rabies doesn't seem to take into account how many would die without treatment.

Also, I'm unclear as to whether or not getting the treatment would inoculate against future bites. When I travelled to India, I had the option of getting vaccinated for rabies; if I had that vaccination, it would be a no-brainer to skip treatment for an unproved bat bite.

From:

I believe rabies is 100% fatal if untreated, and 100% curable if treated in time. So the math is right, assuming that now is "in time."

There is a rabies innoculation. I've considered getting it myself, considering all the Third-World travel I do. But so far I haven't. I do not know if the post-rabies shots count towards innoculation.

B

From:

redbird

If I read your analysis right, you calculated the risk of rabies based on number of bites (guessed) and number of fatalities. That doesn't actually give us an infection rate; the number of treated bites is also relevant. (Otherwise, we're in a position similar to calculating the risk of driving a car based on the number of crashes, without looking up the number of actual deaths and injuries.)

From:

Yes, the number of successfull treated cases is required to correctly crunch the numbers. My guess is that it won't change my analysis much.

B

From:

em-h.livejournal.com

Symptomatic rabies is untreatable and fatal. Exceptions to this are so rare as to be statistically meaningless.

In the research that I have done (after my own low-risk exposure) I have found mention of one person who survived symptomatic rabies, however this was a case where prophylaxis had been applied, but inadequately, not a case where there had been no prophylaxis.

In the very recent past, ONE person has been treated with a new, highly experimental protocol which enabled her to survive symptomatic rabies -- she was, essentially, frozen alive. It is a very risky and certainly not fully tested procedure. But it does mean that there is a single known case of successfully treated symptomatic rabies. ONE, using a very radical procedure.

Odds like that, I think the shots make sense for even a very low risk.

From:

Oh, I know. Seems like lots of poeple think it makes sense. I just know that I was in the exact same situation -- asleep in the same room with a bat that I had no reason to believe bit me -- and it never occured to me to get the shots. Not that I thougth about it and decided not to, that the thought of having rabies never entered my mind until I read Peg's journal a week later.

As Peg said, different people are allowed to make different decisions.

B

From:

I believe that rabies prophylaxis functions, at least for some period of time, as vaccination. (One would have to examine the documentation about the prophylaxis to determine that length of time.) If one has had the vaccination, one should not require prophylaxis if one's rabies titer is sufficient for adequate defense.

If I ever go to India, I'd get the vaccination. There's something like 10,000 cases of human rabies in India every year, and the main vector is the dog (as it is in pretty much all countries except North America and some European countries). Too easy to pet a puppy, get a scratch, and die (like someone did in England, after visiting India, last month).

From:

kijjohnson.livejournal.com

B, you are such a research slut! Me too; though on different topics.

Chris's statistical likelihood of being bitten by a brown recluse was fairly low but it happened. He didn't know about it, just thought it was a fly bite. If he hadn't had a medical professional in his tech writing class who identified the bite early, the necrosis would have been well underway before he noticed. In my house, at least, we're generally more safe than sorry.

From:

tinymich.livejournal.com

Did you manage to talk insurance into covering it?

From:

Yeah, but I have to pay the deductible. And it's the more expensive emergency room deductible, because my clinic doesn't have the vaccine. And the goddamn emergency room wait.

Shit.

From:

matociquala.livejournal.com

Think how handy it will come in when you write the vampire novel.

*hug*

From:

I hadn't thought of the cost in money and time. That also affects the trade-off.

B

From:

tinymich.livejournal.com

Eugh. And there was no other accepted clinic which had the shots where you could go? (On my particular plan, I know I can go to any of the clinics on the list - there are about 70, and I have to call them myself to find if any of them have what I want/need, but I am allowed to visit any of them at the same deductible.)

Honestly, the geek side of me is attracted to and somewhat agrees with minnehahaB's crunching of the numbers. But I have also been known to take unwise risks, so do what feels right for you.

From:

Agreed. Even after all the math is done, you have to do what feels right to you. Security is both a reality and a feeling, and often the feeling matters more than the reality.

B

From:

jonquil.livejournal.com

I'm sorry. You certainly didn't need this on top of everything else.

From:

No kidding.

From:

callunav.livejournal.com

Since I don't do virtual hugs much, this is a virtual basket filled with buttercups, individually wrapped gourmet chocolates, and tiny white paper cranes.

This sucks. (I think you're right, it just still sucks.) I hope things get better for you soon.

From:

Buttercups, gourmet chocolates and paper cranes are most welcome, thank you!

From:

wild-irises.livejournal.com

Good luck to you!

From:

pameladean

Ewwww. I hope at least the effect of the vaccine lasts a good long time, so you can simply not worry about bats for ten years.

P.

From:

There's at least one case of a (IIRC) 40- or 50-something in Germany last year who received a liver transplant from someone with rabies not developing rabies (when all the other recipients of internal organs died within days) due to, doctors think, this individual receiving rabies prophylaxis as a child.

From:

rachelmanija.livejournal.com

Out of curiousity, do you know why the shots used to be given into the stomach (or the abdominal area?) and were excruciatingly painful, and now they're not?

From:

I have absolutely no idea.

Was not v. impressed by the hospital, btw. The nurse thought the shot was still supposed to be in the abdomen, until I told her I was pretty sure that was wrong. She went away and apparently looked it up, and said, yep, you're right--in the arm.

And the doctor seemed flummoxed when I said I thought I was supposed to get the immune globulin shot as well as the vaccine. After all that was the entire reason I was coming to the ER rather than the clinic--my clinic had the vaccine, but not the immune globulin. I got the distinct impression he had to go look up the procedure.

From:

*facepalm*

I'm glad they were willing to go look it up.

From:

dd-b.livejournal.com

Doesn't bother me the nurse definitely and the doctor apparently needed to go look up the procedure. Bothers me a lot that you had to point this out to them, though!

On the stomach to arm change -- a while ago somebody came up with a much better version of the stuff, so the procedure changed. It's fewer injections now, as well as much less painful. Yay progress!

I'd have thought your situation would be the simplest case for rabies vaccine -- early enough to not worry much, no clear indication of rabies in the animal that bit you (or clear evidence it even did). So why does your clinic have the rabies vaccine, indicating they're prepared to handle some case, but not the other stuff you needed for what I would have thought was the common simple case? That's bizarre! What is just the vaccine good for? Sorry, I know it's not your field and you don't know this answer, I'm just ranting.

From:

Basically, they developed a better shot. I'm sure it was a major effort to a) make people more willing to get the prophylaxis and b) make the prophylaxis more easily available in third-world countries. The original was, I believe, intraperitoneal (into the abdominal cavity). Unfortunately, the intraperitoneal series is still the standard of treatment in some areas of some countries (because that's what they have on hand, or that's what they can afford), and it doesn't work as well.

Now the response is a double-whammy of the vaccine and immunoglobulin (and, I note, when the post-exposure prophylaxis is being administered, the thing fails if both the vaccine and immunoglobulin are not administered). Some authorities are concerned because the post-exposure prophylaxis in this form is only being manufactured by a single company in the US.

From:

em-h.livejournal.com

It was my understanding that the immunoglobulin is not generally given to someone who is more than a certain period of time post-exposure, but you may well know more about this than I do. I had both, but I was treated very shortly after exposure. (Not at home so can't look up the research material I was reading at the time myself).

Peg, I'm really very sorry about the ER wait; it sucks that the health department can't send the vaccine to your doctor, which is what they did in my case. But I still think it's the right decision, no matter how much of a drag it is.

From:

amandageist.livejournal.com

Oh, I'm so sorry. I know your fear: I almost had to get the shots about 30 years ago, when a kitten bit me, foamed at the mouth, and died. The word came in--negative--the day before my first shot appointment.

Living in the country, it's good to be married to someone who's had rabies vaccine. It's very expensive, and so rare to be inoculated, but the government does it for lab workers who interact with animals a lot, so there you go. That means he gets to deal with all the wildlife.

Factoid: possums cannot carry rabies.

~Amanda

From:

rachelmanija.livejournal.com

I'm so sorry you have to go through this. I hope at least they weren't too painful, and you had a good book with you.

From:

kijjohnson.livejournal.com

Oh, honey. Rabies shots suck, even now.

From:

genealogygirl.livejournal.com

Ouch ----- good luck!

Hey --- is there any chance that one could be bitten by a bat and not know it? This whole phenomenon of bats flying around in the house is a new one to me. Is there much likelihood that a bat would end up in your house and go out the same way it came in, having bitten you or someone else in the interim? Or, are you always going to see the bat? How does one catch a bat anyway?

You don't have to reply to these questions if they seem silly. I'm just curious since I know we have quite a large bat population in Central Texas for sure and probably over the whole state for all I know, but I've never heard of them getting in houses really.

From: