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One day last fall, a man in his 80s living in Lake County, Ill., woke up to find a bat on his neck. He caught the bat and turned it in to the health department for testing, which revealed the bat had rabies. The man was offered rabies treatment — but refused.

“There were multiple hours of consultation over several weeks between the health department and this individual about the seriousness of his exposure, that the bat had tested positive and that vaccines were the only thing that would be guaranteed to save his life,” said Ryan Wallace, a veterinary medical officer and the lead of the Center for Disease Control and Prevention’s rabies epidemiology team. “He declined.”

The man later died, one of three people to die from rabies contracted from bats during a six-week period last fall. All three deaths could have been prevented had the people sought or accepted post-exposure rabies care, the CDC said Thursday in a report on the unusual cases.

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The rare confluence of fatal rabies cases — in a typical year, one to three individuals in the United States dies from rabies — suggests the public may not fully understand the rabies risk that is associated with bats, CDC scientists said in an interview. Rabies is virtually always a fatal infection if not treated, but treatment is highly effective if given early enough.

“Human deaths due to rabies from bats are preventable,” Amber Kunkel, an Epidemic Intelligence Service officer with the CDC’s poxvirus and rabies branch told STAT. “If you do have contact with a bat, contact your local health department for guidance on receiving post-exposure prophylaxis and whether the bat can be tested for rabies.”

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There were 89 rabies deaths in the country from 1960 to 2018. Most were due to exposure to bats, though raccoons, skunks, and other small wild mammals can also be infected with rabies. In a number of countries, canine rabies is also a risk.

In 2021, five people in the United States died from rabies. Four of the cases involved exposure to bats, with the fifth stemming from a bite from a rabid dog. In that case, a person from the U.S. was bitten in the Philippines and did not seek rabies treatment.

In a short article published in this week’s issue of Morbidity and Mortality Weekly Report, scientists from the CDC and the state health departments of Illinois, Idaho, and Texas reported on three of the 2021 cases. In all three, the individuals had bats exposures in August. All three knew they had had direct contact with bats.

The Illinois man had a longstanding fear of vaccines and medical care in general, stemming from an event much earlier in his life, Kunkel said. Details of that event were not revealed.

In the other two cases, a man and a child knew they had had physical contact with a bat but didn’t think they were at risk.

The man, from Boise County, Idaho, was struck by a bat that flew at him and got caught in his clothing. He didn’t think he’d been bitten or scratched so didn’t seek care.

The boy, from Texas, picked up a bat.

“He thought he had been bitten. But there was no visible mark on his hand when others around looked, and so they didn’t think that constituted an exposure,” Wallace said. He noted that the lack of visible wounds isn’t uncommon — but also shouldn’t be taken as an all clear. Bat teeth are tiny and the wounds they make aren’t always visible, he said.

“So a pretty important message to get out there is at any direct contact with a bat needs to be assessed by your health department and likely a medical professional,” Wallace said.

These exposures only came to the attention of public health after the individuals were too sick to be saved.

Wallace said piecing together the details of a rabies exposure and the decisions an individual makes after it can be difficult because by the time cases come to light, the patient is generally unable to speak.

“With almost all rabies cases, we don’t get much of an ability to talk to the individuals themselves. By the time they’re diagnosed and the cases are notified to CDC, these people are usually quite ill, if not comatose,” he said.

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