While rabies kills approximately 50,000 people a year globally, there’s no reason anyone should die from rabies in places where people have access to a well developed public health system. Rabies is almost invariably fatal, but is also almost entirely preventable with appropriate and timely response to an exposure. The weak link is getting people to recognize that there’s a risk that needs to be addressed.

Once someone reports a potential rabies exposure (and it is assessed as a significant risk), the response should be fairly straightforward, resulting in the person receiving highly effective post-exposure prophylaxis (PEP). But if the exposed person doesn’t realize the risk, they won’t take the basic steps needed to save their life.

That’s what happened with a woman from California who recently died of rabies. She was a teacher who found a bat in her classroom which she handled while trying to carefully remove it, and she was bitten in the process. It was a minor bite, which makes it easy to dismiss because of the limited amount of trauma. You wouldn’t need to go to a doctor to address the physical damage from a bat bite, but that tiny bite can transfer enough rabies virus to a person to cause infection. Any bite from a bat is a potential rabies exposure.

What should have happened?

• If she’d realized the risk, she would have gone to a healthcare provider or called public health, and a rabies risk assessment would have been done (and concluded that this was a high risk exposure).
• If the bat was still available, it would have been humanely euthanized and tested for rabies, and if positive (as it no doubt would have been in this case) she would have started PEP right away.
• If the bat was not available (e.g. flew away), it would be assumed that the bat could have been rabid (erring on the side of caution) and she would have started PEP right away.
• The PEP (which typically includes an injection of antibodies then a series of 4 rabies vaccines over 2 weeks) almost certainly would have prevented rabies, and this tragedy would have been averted.

What actually happened?

Presumably the teacher did not know about the risk from bats and did not recognize the tiny bite as a major risk, so she did not seek a risk assessment and did not get PEP. That allowed the rabies virus to work its way through her body to her brain. By the time disease developed (typically several weeks to months later) it was too late to save her, as rabies it almost 100% fatal, even with aggressive medical care.

This shows that we need to continue to educate the public about the risk of rabies. It’s rare, but these deaths are entirely preventable.

The second case of a rabies death I want to mention is one that is a lot less clear-cut. A 53-year-old woman from Vietnam died of rabies after an encounter with a feral cat. Cats are not a rabies reservoir species (i.e. there’s no cat-variant strains of rabies like there are in dogs and certain wildlife species) but they are an important source of rabies exposure for humans because cats can get rabies from other animals and they also have close contact with people.

The woman in this case was “scratched” by a cat in May, and the developed signs of rabies and died at the end of November. The time frame fits, but the history of a scratch (versus a bite) is unusual. Rabies virus is shed in saliva, so when it comes to exposure we focus on bites and other ways that saliva can be inoculated into the body (e.g. a cat spitting in someone’s eye, or licking an wound). Scratches alone are low risk since because animals do not carry rabies virus on their nails. However, if there’s saliva flying around at the same time, such as a fractious cat spitting and scratching simultaneously, the scratch could drive saliva that was deposited on the skin into the body. The cat in this case was killed by the family after it scratched the woman and bit her sister, and it wasn’t tested.

So, how did she get infected? Should this change our approach of not typically giving PEP after a scratch?

• She might have been infected via the scratch if saliva had been deposited on her skin at the same time. A more detailed history of the encounter would be needed.
• She might have received a small bite at the time and didn’t notice or pay attention to it. As with bat bites, a really minor bite is all that’s needed.
• The victim (or the report) could have mistaken a “scratch” from a tooth (which would certainly be a risk for rabies exposure) for a scratch from a claw (which would not be a risk by itself).
• She might have had another exposure to a different animal that wasn’t reported.

We’ll likely never know unless more details about the encounter (and possibly the rabies strain) are reported.

This shouldn’t change our approach to scratches, which are incredibly common, but shows the importance of a good history and a proper risk assessment, especially when the scratch is from an animal that has a greater chance of being infected (e.g. an unvaccinated feral cat that roams outside, versus a well vaccinated indoor cat).

Overall, these cases are reminders that rabies is still here, and will likely always still be here. While we have tools to effectively prevent infections, the human factor is the weak link. We need to be able to get these tools to those who need them for them to be effective, and the entry point for that is better public understanding of rabies risk.

Always remember that the best prevention for rabies it to avoid exposure in the first place, which means avoiding direct contact with wildlife and unfamiliar animals whenever possible.