“I was looking out the window, and I saw a cloud of bats swooping and twirling through the air in the dusk over my neighbor’s trees,” Cathleen recalls. “I said, ‘Wow, that’s a lot of bats. Go bats. Eat those mosquitoes.’
“I like having bats around,” says Cathleen, who doesn’t want her last name used. “I didn’t imagine that one would get into my house and be rabid.”
But a few days later, the fifty-eight-year-old Ann Arbor resident found a bat on her living room mantel. It was Memorial Day weekend, the beginning of “bat season,” the summer and fall months when Michigan’s bats are most active. Local residents encounter them most often in August and September, according to Washtenaw County Public Health. The agency tracks them closely, because bats are the most common reservoir of rabies in Michigan.
“We get a couple calls a day about encounters during peak time,” says Judy Gwozdek, the health department’s communicable disease program coordinator. “A lady went out without her glasses into her garage, and it was dark, and she thought ‘Oh, who left this banana skin on top of the trash can?’ It was a bat. So she picks it up. Or how about the person who reached into their shower to warm it up and on the handle was the bat?”
Encounters spur many questions. Was the bat rabid? Did it come in contact with anyone? Should someone who might have been bitten or scratched seek medical treatment?
None of those questions is easily answered. “More people run into rabid bats in Michigan compared with thirty years ago because there are more people,” says Allen Kurta, a bat expert at Eastern Michigan University. But last year, only one of the sixty-five bats tested in the county was rabid. Typically, among bats who get tested, “the positive rate is near 5 percent, but in the wild bat population it is less than 1 percent,” says Kurta.
While the chance of encountering a rabid bat is low, the risks are great. Rabies is one of the most lethal diseases, killing tens of thousands of people worldwide every year.
Globally, most people are infected after being bitten by rabid dogs. In the U.S., where pets are routinely vaccinated, deaths are extremely rare, and infection almost always comes from a wild animal. A Wyoming woman died of rabies last October, apparently after being exposed to a rabid bat. Bat bites are so small they can pass unnoticed, and symptoms typically don’t show up until one to three months after a bite–and by that time, the disease is fatal.
As a medical professional, Cathleen knew she needed to find out if the bat on her mantel was rabid. She closed all the doors to give her time to make phone calls and prepare. She poked holes in the lid of a widemouthed plastic container, quietly approached the bat, covered it, and quickly slid the lid on. “I was very careful about not exposing myself to the bat or letting him go,” she says.
She realized that no one would be available to test the bat until after the holiday weekend. So when it died the next day she put it in her freezer. On Tuesday, she called Washtenaw County Public Health (the number is 734-544-6700) and was told to bring the bat in. It was tested and found to have rabies.
“I couldn’t believe it,” says Cathleen. Though she had no visible bites, Gwozdek “recommended that I get the rabies prophylaxis,” she says. “Since rabies is essentially 100 percent fatal, I decided not to take any chances. I went to the U-M emergency room and spent an intense four hours waiting, worrying about the shots.” Emergency rooms are the only places that offer the post-exposure shots in Washtenaw County.
She has a fear of shots. In the past rabies was treated with many painful injections in the stomach. Today, they’re fewer and less painful, given in the arms, legs, and butt.
Cathleen asked the nurses what the shots would cost. “No one knew,” she says.
Gwozdek says that rabies vaccination and antibodies to boost the immune system until the vaccine kicks in cost “between $15,000 to $20,000 per person for the whole series. But sometimes when we recommend post-exposure prophylaxis it’s not just for one person. It could be for a family of five.”
“Insurance typically covers it,” Gwozdek says. “But you compound their ER visits, their deductibles, and their co-pays.” She says one five-person family paid $10,000 out of pocket, including the shots and the ER visits. Fortunately, Cathleen’s husband works for U-M, and they have excellent health insurance.
“On my initial visit to the ER, I occupied a room for four hours and had multiple nurses and a doctor taking my history, questioning me about my health, double-checking info, and taking my vitals before and after the injections,” Cathleen says. “Two nurses made the injections at multiple sites simultaneously. They observed me for thirty minutes afterwards to see if I had a reaction. It was comforting to have nearby the equipment and skilled personnel of the ER.”
That time, Cathleen got one poke of rabies vaccine and four prods of rabies antibodies–the “immune globulin.” Over the next two weeks, she returned three times for vaccine boosters.
Despite her initial fears, “the shots were as easy as a flu shot. They didn’t hurt,” she says.
During the process, the bills gradually arrived. The four vaccine shots cost $4,000; the four immune globulin shots cost $7,000 total. Why so much? “The lead time and sourcing of the immune globulin is a whole different profile than traditional pharmaceuticals,” says Chris Healey, vice president of public affairs at Grifols, one of two companies that make the antibodies. Instead of mass production with laboratory cultures or recipes, Grifols has to purify antibodies obtained after vaccinating real people.
Cathleen’s ER visit and services cost around $900. With the shots, the bills totaled around $12,000. Even though she was unsure the bat had touched her, her insurance paid for everything after her $100 co-pay, because the bat was rabid.
“I feel really lucky,” she says. “I think I have good insurance.”
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Valerie Mates, fifty, was awake late at night with her sixteen-year-old son when a bat flew through their Ann Arbor home a year ago. Her fourteen-year-old daughter and eight-year-old son were asleep.
“I tried to trap it with a kitchen strainer, but it flew through the house and vanished, probably going out through a gap in the screen on our screened-in porch,” says the freelance web programmer and Observer webmaster.
Mates studied whether to get her family the rabies shots, posting on Facebook and calling the health department. If her insurance didn’t cover it, “It was alarming that I would possibly have had to pay up to $80,000 out of pocket if I wanted to get my family the rabies shots,” she says. She does have insurance, purchased through the Affordable Care Act marketplace, but even if it were to cover the treatment Mates would have had to pay a deductible and co-pay amounting to around $12,000.
“Last time I checked, there was no other deductible available in the marketplace for a family of four people,” says Mates–except one that cost $6,000 more in premiums and had a $6,000 deductible–“which is basically the same thing.”
Looking at the cost and likely low risk, Mates and her family did not get the rabies prophylaxis. She didn’t even call her insurance company. They remain rabies free.
Marlene Cooper didn’t get the shots, either–even though she was told to do so after a bat was in her house at least one night.
“I had a red irritation spot on the back of my neck or upper shoulder area, which really made me nervous,” she says. She went to a doctor in her general practitioner’s office. “He was very adamant I go to the ER and get rabies shots.”
Cooper works at Costco and has medical insurance with Aetna through her employer. She went to St. Joe’s emergency room and from there called to see if Aetna would pay for the shots.
“They told me no,” she says. That left her with a life-and-death choice: “If I don’t get the shots and begin to exhibit symptoms, there’s no going back. So I’m weighing all of this and wondering if my life is worth $19,000, which I can’t afford.”
Aetna spokesperson Rohan Hutchings says it’s hard to know for sure whether Cooper would have been covered, because she never filed a claim. “If the animal is rabid and the member is attacked, we would cover the post-exposure treatment,” Hutchings says. But because Cooper hadn’t caught the bat there was no way to tell whether it was rabid. Trying to capture it would have greatly increased her risk of being scratched or bitten–and rabies spreads through saliva.
Even though she didn’t get the shots, between Cooper’s deductible and co-pay, the ER visit cost her about $600. A few days later, she checked the red spot again at her doctor’s office. “It turned out to be a case of shingles,” she says.
Another Aetna rep later told her that “they probably would have paid for the rabies shot but needed to know” more about the treatment, she says. “But of course we never got that far because I opted not to get the shot, so it was never billed.”
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An ER can’t deny treatment based on ability to pay. If someone is underinsured or uninsured for rabies shots, there are patient assistance programs that the ER and the county public health agency can suggest. Some drugmakers’ programs are listed on the CDC website about rabies. But if they don’t come through or don’t cover the full cost, the patient will still be financially liable.
The World Health Organization offers post-exposure injections for $40 to $50 in Asia and Africa due to negotiated bulk purchases and tiered pricing with their manufacturers. Why do they cost so much more here? “In setting our prices in the U.S., we strive to balance the interests of multiple stakeholders while reflecting the relative benefits of our medicines or vaccines compared to available alternatives, appropriately rewarding the inherent risk, time, and cost of drug development, and generating broad affordable access for patients,” says Robin Gaitens, director of U.S. external communications for vaccines at GlaxoSmithKline, one of the two manufacturers of the rabies vaccine.
In the developed world, post-exposure vaccine is a comparatively rare item, and the supply is low. The shots also provide immense value. They could save a person’s life.
What about getting vaccinated against rabies as a precaution, without waiting to be exposed? Cathleen paid less than $100 for her cat’s rabies vaccination, and common human vaccines offered at Walgreens and other drugstores range from $100 to $300.
“The pre-exposure [rabies vaccine] series is less expensive than post-exposure treatment,” says Kimberly Signs, a vet and epidemiologist specialist at Michigan’s Department of Health and Human Services. This is especially true because a vaccinated person doesn’t need immune globulin if they’re exposed to rabies, just two booster shots. However, the Centers for Disease Control recommend precautionary vaccination only for people who work with certain animals and travelers going to areas where rabies is endemic. Since it’s rarely needed, for most people it would be an unnecessary expense. Negative side effects also are more common than for other vaccines, according to information on the CDC and University of Pennsylvania websites.
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Residents in rural areas, older homes, or homes with outer damage see bats more often. They may also be less able to afford the costs of rabies treatment.
“If you have a hole a dime size or larger, a bat can get in. It’s also important to get your pets current with their rabies vaccinations,” says Gwozdek.
Cathleen even had her home “bat proofed” nine years ago. It’s possible her bat may have come through an open back door or flue.
For Cooper, the moral of the story is “not to let the bat leave,” she says. “Call professionals to capture it and have it tested for rabies.”
Cathleen caught her bat, but Mates and Cooper did not. Cooper didn’t get rabies, and neither has anyone else in Washtenaw County since pet vaccination became widespread. And because Cooper didn’t get the shots after her own bat encounter, “the system saved big money,” she says.
Does that mean the policies and system are working? “I’m not sure,” Cooper says. “It seems like a matter of time before somebody gets rabies and dies.”
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Call & letters, October 2016: Bats, Rabies, and Insurance
“I don’t want people so horrified they don’t get treatment,” Mary Roth said after reading our September feature on the high cost of treating potential bat bites. “You don’t have to get it at the ER.”
When an infected cat bite landed Roth in University Hospital in February, she was vaccinated against rabies as a precaution. As an inpatient, “the pharmacy total for four days was $1,122,” Roth said in a phone call, “and that included IV antibiotics and morphine as well as the rabies vaccine and immune globulin.” She got her three follow-up vaccine boosters at University Health Service (UHS), the U-M’s on-campus clinic. They cost $326 apiece, compared to the $1,000 that a patient we interviewed was billed at the U-M ER.
We contacted UHS, which confirms that it can provide the full rabies prophylaxis to university affiliates. The pharmacy cost is about $4,000, plus doctors’ fees, compared to estimates of $11,000 to $18,000 at local ERs. UHS is open to U-M students, faculty, and staff, and alumni, and qualifying dependents age ten and older, who have an established UHS primary care provider (PCP).
Judith Becker emailed to recommend “the simplest way to get a bat out of your house. One only needs to fully open a window or a door, and then turn out all the lights in the house. The bat will sense the air current and get himself out the door or window within a minute.”
Washtenaw Public Health doesn’t recommend that, since then there’s no way to be sure the bat isn’t rabid. “If residents aren’t comfortable or aren’t able to [capture it], there are private companies that offer services [such as] Critter Control,” says WPH public information officer Susan Cerniglia. “The Humane Society of Huron Valley also offers some wildlife rescue services.”
