Thomas A. Bell The author is expressing his personal, not departmental, view.

In March 1995, rabies killed a 4-year-old girl from Centralia, Lewis County, a rural area equidistant from Seattle and Portland. This was the first human death from rabies in Washington since a 1939 infection by a dog bite. The 1995 case changed the recommendations of the Centers for Disease Control and Prevention (CDC) for dealing with bat exposures. The following account summarizes the official report of the case (MMWR 1995-44:265) and adds some unpublished details. This case affected local, state, and national policies about rabies prevention, policies that will greatly increase the use of rabies vaccine in the United States. It also showed the power of the media to affect public perceptions and raised questions about the political philosophy of public health.

On March 6, the child developed abdominal pain. On March 9, she developed seizures, suffered a cardiorespiratory arrest, and was transferred to Children's Hospital and Medical Center, Seattle, where she was sustained in a coma. Had she not been resuscitated, the diagnosis of rabies might not have been considered. It was, though, and a biopsy taken March 13 was examined by the Rabies Laboratory at the CDC and interpreted as "not inconsistent with rabies" on March 14. When the Lewis County Health Department (LCHD) received this report, sanitarian Ron Renbarger and I exhumed the bat and shipped it to the CDC.

The child died on March 15. The Washington State Public Health Laboratory examined her brain on March 16 and confirmed the diagnosis. Subsequent analysis revealed that the viruses from the girl and the bat were genetically identical.

Media coverage of the case began March 15 when The Chronicle, a local newspaper, published a story on our suspicion of the diagnosis. Media coverage intensified after the diagnosis was confirmed. The day care center was awash in reporters from newspapers and television stations while we were immunizing children on March l6. These events were the feature story that day on the early evening news television programs in Seattle.

This case troubled public health officials because it revealed a deficiency in the policy for rabies postexposure treatment. After this incident, the state health department's and CDC's recommendations about vaccination against bat rabies expanded from one of vaccination only after definite physical contact with an untestable or proven rabid bat to include vaccination after exposure of a sleeping person to a bat in the same room. The health departments in Lewis and Cowlitz counties immediately implemented this new policy.

In subsequent months, public fear of rabies was rampant in Lewis County, and many implausible species were viewed as potential vectors. LCHD was consulted about incidents involving goats, raccoons, beavers, coyotes, rabbits, rats, hamsters, domestic fowl, and dogs and cats, in addition to bats. Some incidents involved persons bitten by wild animals that they had captured. Others involved the capture of bats by cats, usually unvaccinated. Many families found bats in their homes. Some captured the bats so they could be tested for rabies. Others discarded or released the bats and thus became candidates for postexposure vaccination, which costs about $800 to $1,500 per person. The local media publicized some of the stories, which reinforced our public health messages, and a few stories were carried by Seattle and Portland television stations in June.

The bizarre nature of many of the stories, our perception that the new policy was not being followed in other parts of the State, our concern for the welfare of humans and animals, and the increased workload imposed on the health department by several of our constituents encounters with animals led us to enlist media relations help from the Washington State Department of Health (DOH). On August 1, DOH issued a news release that stimulated stories in The Chronicle on August 2, the Tacoma News-Tribune on August 3, and The Seattle Times on August 4.

Figure 1: Number of bats submitted for testing by various counties, by month,1994-95. Medical coverage of the March 1995 death and subsequent articles about bat rabies increased submission of bats for testing.

On August 3, a couple in Longview, Cowlitz County, found a bat in their bed. The story ran in that days edition of The Daily News, which is distributed there and in adjacent Wahkiakum County. Even though its jurisdiction shares a long border with LCHD, the Cowlitz County Health Department (CCHD) had submitted only one bat for testing in 1995 before this story appeared. Wahkiakum had submitted none. The story had an immediate effect on the awareness of the hazard of bat encounters that had not been created by local coverage of the child's death in March (Figure 1). On September 2, a family in Cowlitz County found a bat in their house for the third time that summer. They had discarded the first two, but, having read stories in The Daily News in August, they knew to capture the third bat, which the state laboratory found to be rabid. The family's child was vaccinated, and the story was reported on Seattle television. Thus, we saw the need for repetition of the public health message in the media and for an emphasis on local relevance.

Policy Questions

1. Who should pay for testing for bats that invade homes?
Common law doctrine holds that homeowners are responsible for events on their properties, especially inside houses. Under current practice, bats found in houses are tested at public expense at the state laboratory, which cannot charge for such tests. Many such exposures are preventable by "batproofing" attics. One Cowlitz County resident had so many bats in her house, sited in prime hunting ground for bats, that she frequently vacuumed them from her floors. How many bats should be tested from one house? Should that family receive preexposure prophylaxis against rabies and periodic booster doses? Should the house be condemned as a health hazard?

2. What is a reasonable quarantine policy for a dog or cat that bites a human?
Local health departments and animal control agencies in Washington have diverse policies about quarantining cats and dogs. In theory, local health officers can do whatever they think is appropriate to quarantine potentially rabid animals. In practice, a cat or dog that has had two doses of rabies vaccine has an infinitesimal risk of contracting rabies. Quarantine of such an animal is mainly for the peace of mind of the victim. Should the animal continue to run loose and disappear, or be killed, before the 10-day observation period has ended, the victim may be terrified of the possibility of contracting rabies, regardless of the actual risk. According to Covello's model of risk calculation,* in such cases the victims perception of risk is many thousand-fold the actual risk. Even though the human case of rabies was acquired from the state's only natural reservoir, the public extrapalated the hazard from bats to a host of improbable vector-species. The LCHD responded by making quarantines for dogs and cats more stringent after an incident in which a bite victim demanded the offending unvaccinated dogs be euthanized even though they survived the quarantine period.

*Covello V: Presentation at Public Health Leadership Institute, Santa Cruz, California, March 18, 1993.

3. Who should pay for postexposure vaccination for persons who cannot or will not pay, especially if the medical need is dubious?
LCHD received a bill for $43,700 by the state health department for doses of rabies vaccine and rabies immune globulin. The local hospital paid for vaccine allocated of its employees, but the day care center did not assume responsibility for the possible exposure of 52 children and eight adults. LCHD billed them enough to pay for the biologicals but not the staff time for assessing the need and giving the vaccine. In at least one other western state, public funds are not available to pay for postexposure prophylaxis for indigent persons.

Was such expense justified? The CDC Epidemic Intelligence Service officer who assisted with the case did not address this question directly, but stated the CDC position: human-to-human transmission of rabies has never been documented, except by corneal transplant. Parents probably perceived the risk as being many thousand-fold the most pessimistic risk that an epidemiologist would estimate, and their expectations and actions were based on their perceptions, not a statement by government employee. The case also provoked internal debate about appropriate use of the media, worker safety, management of pets and stock animals exposed to bats, and the relationship of the health department to animal control agencies. Without the experience of this single case of a rare disease, the LCHD probably would not have grappled with this host of difficult issues that portend to affect our operations for the foreseeable future.

Recommended Reading

Brass DA: Rabies in Bats: National History and Public Health Implications. Ridgefield, CT: Livia Press, 1994.

Center for Disease Control and Prevention: Rabies Prevention, United States, 1991. MMWR 1991;40(RR-3):l 19.

Helmick CE, Tauxe RV, Vernon AA: Is there a risk to contacts of patients with rabies? Rev Infect Dis 1987:9:511-518.

Munoz JL, Wolff R, Jain R, et al: Human Rabies-Connecticut, 1995. MMWR 1996;45:207-9.

National Association of Public Health Veterinarians; Compendium of Animal Rabies Control, 1995. MMWR 1995,44(RR-2):l-9.

Paves A, Gill P, McKenzie J, Renharger R, Bell T, et al. Human rabies. Washington State, 1995, MMWR 1995;44:25-627627.

Rupprecht CE, Smith JS, Fekadu M, Childs JE: The ascension of wildlife rabies: A cause for public health concern or intervention? Emerging Infectious Diseases 1995;1:107-114.

Acknowledgments

Thanks to Richard Ellis, M.S., R.S., J.D., program specialist, vector control and housing of the Washington State Department of Health, for helpful comments and advice about public health law; Steven LaCroix and Beth Weiman, Washington State Public Health Laboratory, and Paul Swenson, Ph.D., Seattle-King County Public Health Laboratory, for data about testing of bats.

Author

Thomas A. Bell, M.D., M.PH., is health officer for the Cowlitz County and Lewis County health departments and clinical assistant professor of epidemiology at the University of Washington.

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