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Utah man dies from rabies, the first in the state since 1944 (deseretnews.com)
176 points by wglb 5 days ago | hide | past | web | favorite | 214 comments





There's actually an experimental treatment for rabies that can be administered if post-exposure prophylaxis fails (called the "Milwaukee Protocol"). It involves a drug-induced coma followed by a cocktail of antivirals, and the success rate is around 20% in the best case (n.b. the sample size for the study that figure was 10).

Not that it would have helped here, when the diagnosis came at such a late stage.

The case report for the patient treatment that pioneered the Milwaukee Protocol—the first-ever successful treatment of a rabies patient—is worth a skim, if you're into this sort of thing.

[0]: https://www.nejm.org/doi/pdf/10.1056/NEJMoa050382


https://www.wnycstudios.org/story/312245-rodney-versus-death

There is a radio lab episode on how this protocol was established.


The Wikipedia page seems to indicate that the success rate is closer to 8%.

* https://en.wikipedia.org/wiki/Rabies#Milwaukee_protocol


To be clear, only one person has survived after receiving the Milwaukee protocol - the first person it was tried on. No one else has survived. It was tried on 25 other people, and it failed every time. It's very possible the initial patient was a fluke and the protocol isn't effective at all.

https://pandorareport.org/2014/05/01/no-rabies-treatment-aft...


That would be one hell of a fluke. Rabies kills about 17,000 people a year, and excluding the Milwaukee protocol survivor, only 13 untreated survivors are known to have ever existed. It is basically completely and utterly fatal if left untreated.

Depends how many people get experimental treatments. If say ~10+% of people got experimental treatments, and you have ~10% of the survivors that revived experimental treatments, then the odds are very good it's a fluke.

http://www.ajtmh.org/content/journals/10.4269/ajtmh.2012.11-...

11% RVNA positive, evidence of abortive rabies infection.


I should specify, it’s basically 100% fatal once you’re symptomatic.

That's a fascinating report, thank you for sharing. Especially the detailed data visualizations of the patient course, I don't normally see those on case reports.

I believe it’s also associated with severe health consequences and the only survivor has stated regretting the protocol...

EDIT: Seems I'm misinformed. Thanks for clarifying, commenters below.



> I had less than 4 hours left to live. Dr. ... was not ready to let me die. He researched the internet and found a few key phrases that helped him devise a treatment

Well I guess in desperate times all treatments started somewhere, a quick goog is probably as good as any.


Interesting how one doctor casually dismissed a bite from a bat. Bats are pretty well known for carrying all kinds of interesting diseases.

>> Being the animal lover that I was,

I was bit in my finger by a puppy that I was trying to feed when I was up in the desert doing mountain biking. A few days later, I had to get vaccinated because we could not bring the dog for observation. The vaccination itself can be risky. But it is preferable than risking rabies. I was told it is a horrible way of dying.

Lesson learned.


From what I can find, the original survivor had a child and seems to have a functional adult life. Not to say there weren't side effects (and it seems like she was in therapy for several months), but she seems to have a normal enough life.

There has been more than one survivor (wikipedia is outdated) and I don't think they really regret it

> There has been more than one survivor

That seems to be a matter of debate.

The other reported Milwaukee protocol survivors apparently include:

(1) people who died of the rabies infection, but were characterized as “survivors” in some reports because they survived past the initial acute phase,

(2) People who received both post-exposure vaccination and the Milwaukee protocol,

(3) One survivor who, based on antibody tests, probably was never infected with rabies in the first place.

https://www.cambridge.org/core/journals/canadian-journal-of-...


More severe than death?

There are lots of things more severe than death. Imagine the treatment gave you an aggressive form of Alzheimers, for instance - would you really rather have that?

Agreed, yet most countries have laws that assume we would all offer to live, no matter what. “Sanctity of life” somehow means maximum suffering is best.

Some metrics use quality of life instead of survival at 5 years.

It has seen success with children, small children. Their brains are plastic. I'm not sure the protocol would work for a symptomatic adult.

> It has seen success with children

AFAICT, the use of the plural is unwarranted; there seems to be one uncontroversial case of someone infected with rabies treated with the Milwaukee protocol and not podt-infection vaccination, who survived the rabies infection.


I've had bats slip into my house late at night several times. They're cute little fuzzballs when I see them outside flapping around far away from me, but hearing a "pittpittpittpattpatt" whirling above your head at night is terrifying. My first assumption was always rabies, because why else would a tiny animal get so close to a huge and dangerous animal like me?

A large number of stories I've heard involving people playing with small wild mammals end with rabies. When it comes to bats, raccoons, and possums, I was always taught to treat them as rabid because healthy ones won't ever get close to random humans if they can help it. That this guy was letting them lick his fingers is unimaginable to me.


Opossums are nearly immune to rabies. Their body temperature is lower than most other mammals', which makes them immune to many diseases that affect mammals like raccoons.

I was also taught to treat animals like this as rabid. When a bat came in my house a few weeks ago, I trapped it in a plastic tub, and took it outside. Here's a video of the release: https://www.youtube.com/watch?v=1zwt71GMe5M

I also live in Utah and it's strange to think that this man was likely already infected, but didn't know it, at the time I dealt with my bat.


Luckily, it's extremely rare for opossums to contract rabies, so keep snuggling those scary beasts to your heart's content.

what's the rate for opossums who get close to humans though?

This!

It's related to the assertion that fewer than 1 in 100 programmers is unable to write "FizzBuz" in the programming language of their choice.

The rate may be statistically insignificant amongst all programmers, but what is the rate amongst programmers looking for a job?

Different question :-)


I really struggle with the concept that some programmers cannot write FizzBuzz. I'd expect it from someone who has finished their first programming unit.

I've known some programmers that I expect might not be able to write FizzBuzz in the time allotted within an interview, based on how long it has taken them to produce code 5-6 times as verbose as needed given the simplicity of the task at hand.

As I recall, their defense mechanism is to play dead, and they look cute, so I am going with not unusual.

I think we have very different definitions of cute... However, I have had many more run ins with opossums than bats.

Bats are tricky because you can often not see the bite marks and it can be hard to tell if you were bitten or not. It is sometime recommended to get the rabies vaccine if you find a bat in your house in the morning after sleeping all night. Same applies if you are camping and a bat gets in your tent.

This also depends where you live and what types of bats live around you. I have little brown bats around my home all the time. They get in my ceiling and sometimes get confused and end up in the house. They will not bite a human unless picked up by one. They eat moths and mosquitoes, which is why I try to avoid hurting them when I release them outside. I just wear gloves and wash everything afterwards.

>They will not bite a human unless picked up by one

The scary thing is that's pretty much how you know that an animal is rabid: animals that would avoid people completely will now bite them.


In the case of my little brown bats, they detest being picked up. The screech and scream like it's the end of the world. I usually have to follow them around the house until they get themselves into a corner.

The exception to this in my case was a little pup that was scared and confused due to a forest fire outside. The smoke drove it into the house and it only screeched a little bit when I picked it up. It's doing fine now.


> They never hurt us

I guess as I understand it, it doesn’t matter if animals are normally friendly because rabies causes them to act aggressively.

Radiolab did an episode on rabies that is absolutely fascinating. They talk about the “Milwaukee Protocol” for treating it, which I’d never heard of before that. It’s no longer a recommended treatment, if it ever was, but the story really stuck with me.

https://www.wnycstudios.org/story/312245-rodney-versus-death


>I guess as I understand it, it doesn’t matter if animals are normally friendly because rabies causes them to act aggressively.

I wrote a whole comment about bats being asymptomatic carriers, but Googling around the information is not clear. According to [1], bats have been shown to be symptomatic (and they die from rabies), but other bats of the same species remained asymptomatic (but still spread the disease).

At least it seems it's possible there were asymptomatic bats in their house.

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3168224/


Infection is possible before being symptomatic.

Symptomatic rabies is one of those nightmare scenarios that docs read about in history books. A few cases have involved older relatives recognizing symptoms in kids, symptoms that modern docs would never suspect to be rabies.

Why is it no longer recommended? Is it not the only viable way to save someone infected to life, when the disease has progressed far enough?

According to a study [1] it has never been a viable treatment. The treatment has been repeated on at least 12 patients since the original case (Jeanna Giese) and has been a failure every time.

No-one know why Ms Giese survived, but the Milwaukee protocol does not seem to have been the reason. Or if it was, it is not repeatable on other patients.

[1] https://www.cambridge.org/core/journals/canadian-journal-of-...


According to a source I've found, it seems there are at least 5 known survivors thanks to the Milwaukee protocol: http://outbreaknewstoday.com/rabies-survivor-milwaukee-proto...

An NCBI article claims 13: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947331/


That NCBI article claims there are 13 known survivors of rabies. In total. Nothing to do with whether they got the Milwaukee protocol treatment

It also notes the deaths of at least two of the "known survivors", that others received the PEP vaccine either completely or partially, and that one survivor likely didn't have rabies at all due to no anti-bodies being found.

That leaves just the original case in 2004 where someone survived without vaccine and received the MP.


Sure, but I don't understand what the harm would be in trying the treatment for a patient who will otherwise have a 100% chance of dying in a very short timeframe. I mean, if the Milwaukee protocol did help the one patient, then the treatment has a 5% success rate, which is better than 0, no?

The harm is that these patients and their families lose the tiny amount of time together they'd otherwise have left, because the patient is put in a coma.

It's a difficult trade-off for a lot of high risk medical interventions to judge the relative worth of the potential chance of survival vs. that last remaining time, and it's certainly not a choice we can objectively make on behalf of other people.

In this case it's not certain the protocol have helped any patients. If it did help, then the success rate is so low that there are ethical issues with overselling the potential vs. giving people that extra time together.

If a patient wants to try, I'd be all for giving them that choice. But there's a big gap from letting a patient ask for something and promoting it as the recommended course of action without evidence of any efficacy.


Well, are you aware of how death by rabies happens? Way better for you and your family if you die in a coma, then to have to watch you going through it consciously. If I had rabies in a stage where death is certain, the options I would be looking at would be either the Milwaukee protocol or euthanasia. The other option (doing nothing) doesn't just means death, it means painfully, awful death.

If people want to take that option, then I'd be fine with that. But it's not for anyone to decide on behalf of others. If MP has no effect - and it's very possible it's effectiveness is actually zero, as we don't know if it was what saved Giese, - then it is wildly unethical to give unjustified hope to people, especially when this will prevent doctors from trying to find other options that might at least give them a chance.

The outcome of an aggressive medical treatment can be much worse than death, not even taking economic or opportunity costs into account.

The opportunity cost of spending a lot of money on an intervention not likely to work. (I have no object-level opinion on the efficacy of the Milwaukee protocol.)

That's really up to each individual to decide for themselves. There's not an objective answer to the question.

Because it has saved just one life. It's since been claimed that person may have had natural immunity or been unrepresentative in some other way.

https://www.sciencedirect.com/science/article/pii/S016635421...


You mean 13 lives. It has a 8% success rate.

Of the 29 cases from 2005 to December 2014, "Therapy failed in all; the only survivor (Case No. 14) did not have neutralizing anti-rabies virus antibodies and likely did not have rabies"

https://www.cambridge.org/core/journals/canadian-journal-of-...

So where does 13 come from?



13 survivors total, not 13 saved by the Milwaukee protocol.

Notably:

> Prior to 2004, there were only five documented human survivors, all of whom had received the PEP, albeit incomplete or late [5] > In 2004, the first survivor without PEP was reported after this individual had undergone the MP. However, the use of the MP did not increase survival in subsequent cases [6]. Our patient was managed with aggressive supportive care without the MP or steroids. Our patient survived the acute phase of rabies encephalitis and was discharged after five months of intensive nursing care in the hospital.

And:

> Out of the seven reported rabies survivors until 2008, only the index case that used the MP did not receive PEP. Rabies virus was detected in only one case in all of the others that were diagnosed using only the rabies antibody [9]. Our case was diagnosed using both the rabies antibody and highly specific rabies antigen detection tests.

The article points out a number of confounding factors that makes it hard to determine what saved the patient, including potential effects of use of PEP even if unsuccessful in stopping the disease completely (e.g. note that the virus itself was only found in one of the cases of survivors discussed by this article), the high level of other interventions to manage the disease, as well as the potential for genetic variations and the possibility that some of them didn't have Rabies in the first case


Not sure about 13, but the "only one success" is old news https://www.dailymail.co.uk/health/article-5258433/Brazilian...

It's not clear even all of those were successes at all, though - at least a couple of the claimed successfully treated patients subsequently died.

Several others had completed most or all of the PEP treatments, and it's not clear if the MP had anything to do with their survival, given other patients have survived without MP in similar circumstances.


Regardless... it is no where even close to statistically significant.

But we might get the data to make statistically significant claims if we keep applying the protocol. By abandoning it, it seems we won't.

If I were there patient and my options were medicated coma that possibly has an 8% chance of healing me and possibly has no benefit, I'd prefer that to the excruciating death by rabies I'd be facing otherwise.


One success on top of a solid 100% fatality rate is extremely significant

You need to read the comments. The whole point is that it was not necessarily a success because subsequent tests showed it didn't work, there are several reasons why Ms Giese might have survived including the reasons why previous survivors who didn't get the protocol also survived.

You are right, its probably no longer recommended because they use a "modified Milwaukee protocol" now. That being said the MP is a last ditch effort and often fails. Its just the best option we have if someone is outside of the window for post-exposure prophylaxis (PEP).

Treatment success rates: Vaccination: ~100% PEP: ~100% MP: ~8%

So MP provides a slightly less than 1/10 chance for life when the patient would face otherwise certain death.

You might find this interesting: http://www.mjdrdypu.org/article.asp?issn=0975-2870;year=2017...


I heard that about it not being recommended too but find it to be one of the stupidest things in medicine ever. Because while it's no longer recommended, the only other "treatment" is painkillers and wait until the patient is dead which has throughout history had a fatality rate of >99.99%

So yeah I really don't understand why any doctor wouldn't want to try the Milwaukee protocol. Even if it had 99% fatality rate it would still be a huge improvement and afaik it's more like 80-90% i.e. from 10 tries it worked twice or so. Also there are plenty of small changes to it that might make a difference. We just don't know, we do know however that untreated rabies is fatal in the closest to 100% fatality of any disease ever known.

Hell, rabies (post the 24h post exposure vaccination period) has a higher fatality rate than lethal injection and the electric chair!


There are lot of confounding factors. It is not certain it has worked even once. All we know is a few patients that have been on MP has survived. But so hav a few patients that have not been on MP, and most patients on MP have died, as have several of the "successful" MP patients subsequent to overcoming the initial stage of the disease.

A further problem is that many of the patients have had the PEP treatment partially or wholly first. In those cases we don't know if the outcome was due to MP or PEP. Several other (single digit numbers) patients have survived without MP. It is not clear why. It's not clear that their treatments had any effect. Or it might have saved them. It may be genetics. It may be difference in virulence. It may be specific aspect of the treatments. It may be aspects of how the patients are treated that are not part of the protocol itself. It may be dumb luck.

The problem is that this is not a matter of MP or nothing. It's a matter of MP or trying to find other alternatives. If MP serves no purpose in saving these patients - and it may very well not - then focusing on MP may hinder exploration of other options.


There are massive consequences to survivors of the protocol who arguably may have been better off succumbing to the disease, iirc. There’s no point in using a protocol that keeps people alive with no quality of life. (This kind of handoff is discussed in ethics classes in healthcare, the cost/benefit analysis of a treatment on a patient.)

Sources? Anything I've found seems to indicate survivors have gone to have kids and reasonably functional lives - not side effect free, but not by any means worse than death.

Minor nit: it's important to take the vaccine even if 24 hours has passed, and you're most likely going to be fine. The vaccine takes 10 to 22 days to produce antibodies, but the disease gives you more time than that (weeks to months).

So to summarize, the protocol is to vaccinate even if late.


Several in my family were exposed to rabies via trying to save a rabid calf (before we knew it was rabies). We started the vaccination protocol ~3 days later. That was more than 2 years ago, and we are all fine. Definitely not only a 24hr window, thankfully. Was still pretty scary...

This explanation of how it is to die from rabies is horrific, if anyone fancies a story that stops you from sleeping at night :P

https://www.reddit.com/r/news/comments/9vdumn/utah_man_dies_...


Eh, I've heard worse. Fatal Familial Insomnia[0], for instance. At least rabies is relatively quick once it becomes symptomatic. I'm sure anyone with a half decent imagination can easily think of even worse fates. I guess what I'm saying is that just having read about this sort of thing shouldn't keep you up at night and if it does then it might be healthy for you to spend some more time contemplating your mortality.

[0]https://en.wikipedia.org/wiki/Fatal_insomnia



There's no rabies in the UK, right?

No, apparently it has been fully eradicated in 1922, and only deaths due to rabies were due to bites while abroad.

Last death: Scotland 2002. A chiropterologist studying native bats. He had not travelled out of UK

Now chiropterologists all get vaccinated as a matter of course (source - my wife is one).

I initially read that as chiropractor and was very confused... I obviously need beer!

My father had to catch and release a bat which flew into our house a few years ago. Even though he wasn't knowingly bitten or scratched, our GP still recommended he have the vaccine just in case.

That's it - I'm done with nature ...

It’s fun to ask an anti vaxxer what they would do if they were bitten by a rabid animal. You can watch cognative dissonance kick in.

They'd die. But there would be no dissonance, since they would just say "no-one gets rabies anymore", so, in their eyes, the argument is a non-sequitur.

"It’s fun to ask an anti vaxxer what they would do if they were bitten by a rabid animal. You can watch (cognitive) dissonance kick in."

Of course I "get" your joke - and sympathize with the sentiment. I am on your team wrt vaccination policies.

However, I also cringe at the notion that critical thought about vaccinations has been completely reduced to extreme, fundamental positions.

I consider a specific, personal experience of this debate: I am a typical, unremarkable advocate of and participant in vaccination protocols in the United States. And yet, I think there should be critical thought and robust debate about the influenza vaccine(s)[1] and the emerging consensus that we should all consume this product, annually, forever.

In my experience it is impossible to have this discussion because it immediately (and incorrectly) becomes a "vaxxer" debate. This should not be the case. Our critical thought about these increasingly complex medical, scientific, social and economic[2] issues should be encouraged - not swept up in a proxy fight between two "tribes".

[1] A vaccine that I consume annually as part of local protocols for first responders / EMRs / Paramedics.

[2] https://www.cnbc.com/2015/10/19/the-16-billion-business-of-f...


I'll bite. What would you like to see changed?

"I'll bite. What would you like to see changed?"

I am uneasy about the very rapid (<10 year) shift from the influenza vaccine as a tool for immune-compromised individuals or emergency/health workers to a universal good that everyone consumes.

I think there's a qualitative difference between a standard vaccine for a deadly or crippling disease like Rubella and a non-standard, reformulated every season, coin-flip efficacy vaccine for an illness that healthy adults and children in first world settings can withstand just fine.

This is an application of a conservative heuristic: "if it isn't broken, don't fix it".


As I understand it the reformulation is necessary to adapt to mutations. Behind it is likely a fear of a repeat of 1918, which is going to come one of these days.

A key point is I don't get the vibe that the vaccine push is a money grab, but is a sincere effort to manage communicable disease in a modern society.


I get a flu vaccine, in part for a couple of specific reasons. I haven't made a study of it though so I don't really have an opinion.

One can at least raise an eyebrow though in noting how major pharmacy chains have taken to so promoting vaccinations. It started with flu. The latest is shingles. Again, I have no opinion on whether these are good ideas in general or not. But there are certainly commercial interests aligned with giving them to people.


I still don’t quite understand your argument. Is it that the vaccine’s side effects will be more harmful that its benefits when applied broadly to a population?

Not against vaccines, but I think understanding the views of things you disagree with is important. And even more so on this issue because people believe things that even more absurd, but more socially acceptable - and so these ideas persist. The issue some have with vaccines is not generally an outright denial whether or not vaccines work. It's people weight the risk:reward of vaccines differently than others largely supplemented by a large number of correlations to all sorts of nasty things with vaccines.

The reason the opposition to vaccines is not a reasonable view is because these are correlations and correlation is not the same as causation. At the same time consider the innumerable number of social views that people hold, and that continue to be published about, that are based absolutely and completely on correlations relying on the absence of evidence against causality, as evidence of causality. But of course proving a negative is impossible -- the burden of proving causality is on the one suggesting such exists. Failing to recognize this is the exact logical fallacy that drives the opposition to vaccines.

If all correlations were held to the same standard as those that reflect negatively of vaccines, the world (and science itself) would be in much better shape.


> It's people weight the risk:reward of vaccines differently than others

And they are wildly misinformed about the risks.

And they neglect to consider that the reward of them vaccinating their kid is that MY KID is less likely to get those diseases. That's how herd immunity works.

If they were only risking their own kid's life, then it'd be a very different conversation.

> largely supplemented by a large number of correlations to all sorts of nasty things with vaccines.

Except those are almost all exaggerated or outright lies.

To be clear: if I were a selfish individual, I might not get vaccinated. Vaccines have actual risks. But the actual risks are minimal and rare.

But I recognize that herd immunity works, and that the risks are minimal and rare.


There's a funny thing about society. Do you know how you create wildly misinformed idiots? By assuming people who disagree with you on topics are wildly misinformed idiots. The National Academies put up a release in 2011 surveying all available information on the correlations between vaccines and a wide array of nasty stuff. It's available here [1]. It gives an extremely in depth overview of the evidence of the time, which has not radically changed since then. It's a 900 page report, but it's well organized. And you'll find that indeed there are quite a huge number of very real and very nasty correlations between vaccines and all sorts of things. By making the false statement (presumably based on the view that everybody who abides anti-vaccine views must be a wildly misinformed idiot) that 'almost all studies show correlations between nasty things and vaccines are exaggerated or outright lies', you do something really bad. You implicitly suggest that if the correlations were not 'exagerrated or outright lies', they would be meaningful. They are not.

Correlation does not equal causation.

There's an extremely strong correlation between US spending on science, space, and technology and suicides by hanging, strangulation, and suffocation. The correlation is a 99.8% fit. But this means absolutely nothing whatsoever. There are some 30,000 various correlations available here [2]. You'll find many, such as the one I mentioned, are incredibly strong fits. But that's really the danger of data. Just because something fits, doesn't mean anything. The entire process of science is about discovering causation. Correlations mean nothing without clear causation. Even correlations that make sense mean nothing without causation. For instance, I'm sure you'd agree that US spending on science has pretty much nothing to do with suicides by hanging. So it's easy to see it's spurious. What if instead that correlation was e.g. an increase in enrollment in STEM degrees being pursued? Again, you should assume this correlation is spurious until you have a very compelling reason, certainly beyond bias confirmation, to do otherwise.

[1] - http://www.nationalacademies.org/hmd/Reports/2011/Adverse-Ef...

[2] - http://www.tylervigen.com/spurious-correlations


You're absolutely right. Thank you.

Herd immunity is a desirable outcome, but not a right. IF you want someone else to get a vaccine for your sake, you should compensate them for their risk and inconvenience.

That'd work, if not for selfish bargaining.

As soon as people realize they can blackmail me for my daughter's health, what wouldn't I pay?

I propose we as a society set a fair price, instead:

I vaccinate myself and my kids, and you vaccinate yourself and your kids.

If you want a vaccine with lower risk and inconvenience, you are entitled to ask the government to spend more on research, or you can donate your time and money to that research.


> As soon as people realize they can blackmail me for my daughter's health, what wouldn't I pay?

Because you don't need everyone vaccinated, you need most. Most already do it for their own interest. Bear in mind that this is what the state usually does by giving out free vaccines: they are effectively paying people that wouldnt pay for them. But some feel strongly against it.

> I propose we as a society set a fair price, instead.

There is no fair, certainly not in economics. There is only consented prices. You can propose whatever you want, but in the end you need to persuade those that have different ideas than you, or force them to do it. Forcefully vaccinating people is against the practice and principles of medicine, and against common decency, if not morality.


> Because you don't need everyone vaccinated, you need most

Have you researched different vaccines to find out how their effectiveness falls with the percent of the population that is not vaccinated?

Genuinely curious if you have.

I suspect you have not.

> Forcefully vaccinating people is against the practice and principles of medicine, and against common decency, if not morality.

You're right. People who refuse to get vaccinated should have to get insurance to pay for the damages of the illness and death they cause, right? Or place the money in escrow?

And if that insurance is prohibitively expensive, and someone won't pay it, then we can just send them to prison, right?

If you cause me harm through your behavior, that's against common decency, too, right? If not morality?

And if it's hard to determine who caused me harm directly, then the "pollution" is an externality, right? Tragedy of the commons?

You're literally polluting the environment with a virus.

Of all of the topics Libertarians have an interesting position on, I am by far least impressed with their efforts to describe how they think we should protect the environment. Shedding viruses everywhere you go falls pretty well into that discussion, don't you think?

Also I'm quite sure that medicine allows for quarantine, against your will.


> Have you researched different vaccines to find out how their effectiveness falls with the percent of the population that is not vaccinated?

I am very well aware of the basic concepts of epidemiology, why launch this gratuitous disqualification attack?

> You're right. People who refuse to get vaccinated should have to get insurance to pay for the damages of the illness and death they cause, right? > And if that insurance is prohibitively expensive, and someone won't pay it, then we can just send them to prison, right?

You make the ultimate escrow with your own body, since you risk infection as well. But now you mention again the application of force. I ask you, are you willing to go into peoples homes and forcefully inject them with vaccines? Because then I can use your same argument to you: you propose using force but you are demanding others to apply it. How about each time you propose to impose your view on other people you are also responsible to physically do it. You know, put your skin in the game.

Regarding your environment argument, I reiterate that herd immunity is a benefit, not having it is not a cost. Its too onerous a requirement to demand of people to do things to help someone else at their own expense. There would be no limit. You could ask for anything and always find a way to justify taking it.


You asserted, "you need most".

That says you know what percentage of the people I am in contact with need to be vaccinated for some level of what you think I would consider to be "acceptable risk."

So, do you know what that percentage would be, for various vaccines?

And how did you define what my acceptable risk would be?

Because I think you must have an opinion on both of those things, if you're willing to advise me that "I need most."

Since you're favoring an economic slant to this discussion, how, exactly, did you decide what I need?

> You make the ultimate escrow with your own body, since you risk infection as well.

People can be carriers of diseases, and not become ill from them. This nullifies your argument.

Also, that line of argument can be used as a defense of drunk driving.

Drunk driving is not victim-less, even if your own body is risked, as well.

That's insufficient escrow even for automobile insurance.

> But now you mention again the application of force.

Yes, I think people can enact a government. A government has an enforced monopoly on force, and hopefully has established a system of laws that give the people the opportunity to change those laws over time.

And frankly, we voted. We use force against ourselves. We're okay with that.

Feel free to vote that we shouldn't be okay with that. Also, feel free to move and renounce your citizenship.

Those legal options are available to you.

You can also attempt to resist the laws of your country, peacefully or otherwise. I wouldn't recommend it.

> I ask you, are you willing to go into peoples homes and forcefully inject them with vaccines?

If you want to discuss actual policy, I agree it's complicated.

1) Medical wavers. Some people cannot get vaccinated, for many different reasons.

2) If you want to live in a bubble with no human contact, and you can demonstrate that, then maybe that's fine.

3) If you want to form a colony of leapers, who have no contact with the rest of us, then maybe that's fine, too.

> How about each time you propose to impose your view on other people you are also responsible to physically do it. You know, put your skin in the game.

Fine by me.

Counter-proposal, each time you increase the statistical chances of someone else suffering through an externality such as a pollutant, or increasing the risk of disease, how about you put your skin in the game:

Watch them die.

Here, this child recovered. It shouldn't be too emotionally difficult for you to imagine my daughter dying like this.

https://www.youtube.com/watch?v=S3oZrMGDMMw

(The beeping sound is her oxygen level falling to dangerous levels, on the verge of causing brain damage.)

Watch her mother sit there, completely helpless. Imagine that's me and my wife, watching our daughter die.

> Regarding your environment argument, I reiterate that herd immunity is a benefit, not having it is not a cost.

Oxygen is a benefit. Not having it is not a cost.

Have I somehow used a slippery slope argument? Or is your line of argument fundamentally flawed? Genuinely curious what you think.

> Its too onerous a requirement to demand of people to do things to help someone else at their own expense. There is no limit.

Ah, there, you ARE engaging in a slippery slope argument!

It's NOT too onerous, actually. We have government to debate issues exactly like this. We compromise. There are limits, they're enforced by making changes to the law slowly, and by people voting.

> You can ask for anything and always find a way to justify it.

You can deny anything, and always find a way to justify it.

Together we vote. Hopefully we find a compromise.

In this case, our current compromise is that you're not forced to vaccinate yourself or your children. But your children may lose access to public schools. And you may be forced to continue paying taxes in to public schools. And there may be jobs you are disqualified from holding.

Feel free to advocate for changes to that.

Personally, I'm realizing I should be trying to get my employer to demand all of the employees be reasonably vaccinated, via their employment contracts. Flu, MMR, etc.


> That says you know what percentage of the people I am in contact with need to be vaccinated for some level of what you think I would consider to be "acceptable risk." So, do you know what that percentage would be, for various vaccines? And how did you define what my acceptable risk would be? Because I think you must have an opinion on both of those things, if you're willing to advise me that "I need most." Since you're favoring an economic slant to this discussion, how, exactly, did you decide what I need?

You need most to get herd immunity. It varies on the disease, but you dont need unanimity to get it. Herd immunity was the prize you mentioned that justified using forceful mechanisms, where I answered you dont need it. What you individually want most is your judgement, I'm just telling you that you dont need everyone to agree with you to get herd immunity effects.

> People can be carriers of diseases, and not become ill from them. This nullifies your argument. Also, that line of argument can be used as a defense of drunk driving. Drunk driving is not victim-less, even if your own body is risked, as well. That's insufficient escrow even for automobile insurance.

In drunk driving, you are harming someone. In not vaccinating, you are not protecting someone. The comparable analogy would be that as long as you have space in your house, you should be forced to home the homeless. Since you, by taking space, are directly harming them with your negligence and self-interest, which then also have cumulative effects on society.

> Yes, I think people can enact a government. A government has an enforced monopoly on force, and hopefully has established a system of laws that give the people the opportunity to change those laws over time. And frankly, we voted. We use force against ourselves. We're okay with that. Feel free to vote that we shouldn't be okay with that. Also, feel free to move and renounce your citizenship. Those legal options are available to you. You can also attempt to resist the laws of your country, peacefully or otherwise. I wouldn't recommend it.

It is illegal to force vaccinations in the U.S. If you live in the use, you should move to a country that enforces your vaccination ideals.

> (of physically forcing people) Fine by me.

When you do it successfully, please send me proof and Ill gladly share your story with the world. I'd like to see you try doing this. Until then, talk is talk.

> Oxygen is a benefit. Not having it is not a cost.

Oxygen is nature, herd immunity is a societal benefit. Humans dont own oxygen, but they do, in a way, own the capacity to build herd immunity. This kind of logic is trying to reverse the burden of proof: that whatever you dont have is yours because it could be. Herd immunity is not a right, its not a natural right, not a legal right, etc. It's merely an effect of vaccines.

> We have government to debate issues exactly like this.

Governments have decided against forceful vaccination. Albeit some arguments about kids, babies and dogs, but to adults its generally in most cases, illegal to force it.

Also, I find the line of argumentation about government kind of off-the-mark. Government is not supposed to be the way you force other people to do your will. That is a tyranny. If 51% vote to enslave the other 49%, a disservice to mankind was made. Thats why the modern governments are democracies with severe limitations on individual rights.

> Personally, I'm realizing I should be trying to get my employer to demand all of the employees be reasonably vaccinated, via their employment contracts

I hope your employer has the right to do that. He might not have it, due to some other person believing the opposite to your point, and willing to break into the employers home and physicially forcing them to do it.


> I'm just telling you that you dont need everyone to agree with you to get herd immunity effects.

Agreed.

And you've suggested I track down and pay some of the people I come in contact with, who have not vaccinated, to convince them to vaccinate, if I think the percentage of them is too high?

> In drunk driving, you are harming someone. In not vaccinating, you are not protecting someone.

Walking around, spreading a disease, is analogous to getting in a car's driver seat when you're drunk. If you want to avoid driving drunk, don't get drunk, or don't drive.

If you want to avoid spreading a disease, get a vaccine.

Also, drunk driving is NOT harming someone. It has increased the risk you will harm someone, to a level our government has deemed unacceptable.

The analogy seems very appropriate.

Do you want me to go around finding people with a certain blood alcohol level, and pay them to not drive?

Our laws bar drunks from driving. That can actually be a life-or-death situation for them, or cause severe financial harm. "I need to get where I'm going for my job, and I don't have any money, but I'm inebriated."

We use force against people who are drunk, because they increase the risk of harm. We detain them in jails, we put them in prisons, we rescind their privilege to drive.

That's a lot of force being used against someone who didn't even cause any harm!

> When you do it successfully, please send me proof and Ill gladly share your story with the world. I'd like to see you try doing this. Until then, talk is talk.

If it's the law, and they need people to help enforce it, I may do my service. As my father was a veteran, my uncle is a veteran, my grandfather was a veteran, etc, serving your country and doing things that are not universally beloved is something my family has done.

> It's merely an effect of vaccines.

...and arguably the most important thing humanity has done. It's a shame to watch people abandon it pointlessly, endangering those around them.

> Albeit some arguments about kids, babies and dogs, but to adults its generally in most cases, illegal to force it.

We're not debating whether is IS legal, we're discussing whether it should be. It's not like I'm unaware of the law.

You seem to question the basis of a government using force. Governments do use force, that's all I'm saying.

> Government is not supposed to be the way you force other people to do your will.

It's how we compromise to live together. Intelligent creatures change their environment to suit them. We will all attempt to force other people to do our will.

I think governments should enforce Intellectual Property rights. That means the government will use force to take property away from you, if it is found to be infringing someone else's government-granted monopoly.

That is me using the government to force other people to do my will.

> That is a tyranny.

Tyranny is when you don't have a vote, don't have representation, can't speak your view, and can't move.

It's entirely possible for you to lose faith in the government. Any government. And then you could reasonably see the laws of that government as tyranny. There's nothing illogical about that. But literally anyone can declare that at any time.

> If 51% vote to enslave the other 49%, a disservice to mankind was made.

Which is why it's great that our government protects us from exactly that kind of vote. We can debate whether it protects us well enough.

NB: Our Constitution permitted slavery. It took a bloody Civil War to change that. People fought the righteous fight to end slavery. To a degree, we have to count on our government and our fellow man to protect us from being enslaved.

> Thats why the modern governments are democracies with severe limitations on individual rights.

I'm not sure where you're going with this. I presume you think that's a bad thing.

> willing to break into the employers home

Why would you go there?

Don't you believe in Free Association?

If my employer wants to limit employment only to people who have been vaccinated, are you going to argue they don't have that freedom?

Regardless, I'm betting you use vaccines, and you just enjoy moral / legal debates. That's fine.

Or are you really personally against using vaccines?


> You seem to question the basis of a government using force. Governments do use force, that's all I'm saying.

Im questioning the value of a solution with the application of force. A dangerous tool, that requires all sorts of limitations to make sure it is not used abusively. And injecting things into people against their will is pretty high up there.

It is not the intention of the act alone that decides if its moral or not: the act itself is. I think we have had enough experiences to know that if the government decided what to do with your own body, great tragedies follow. If you can force people onto their bodies, can you forbid them to each unhealthy foods? can you ban drugs and alcohol? Can you decide on forcefully aborting, or forbidding abortion? How people are dressed? Its not the act of using a hammer on a nail that is in question: its the hammer itself, and the act of nails voting who gets hit next.

Why would government enacted violence be any more dignified than individual violence? What change does it make to the morality of a violent act if it was voted on?


> Im questioning the value of a solution with the application of force.

Governments use force. By definition. That means you question the value of governments.

I don't. The alternative is warlords, who also use force.

The benefit of a Government, specifically of a mostly democratic one, is I have some say in when and how that force gets used, without myself having to be a warlord.

> A dangerous tool, that requires all sorts of limitations to make sure it is not used abusively.

Absolutely. A Constitution enacting checks and balances, and guaranteeing free speech and a free press, are the best ways I know to limit that power.

> And injecting things into people against their will is pretty high up there.

Sure?

Allowing nuclear testing where it can impact people is also bad. (We did that.)

Allowing the for-profit sale of known carcinogens is also bad. (We do that. See: asbestos, tobacco.)

We've also committed absolute atrocities. [1]

Clearly we need more checks and balances, and a more powerful press.

> It is not the intention of the act alone that decides if its moral or not: the act itself is.

Is the act of murder moral?

I'm pretty sure you would say, "no."

What about when the US sees Germany invading neighboring countries, and killing Jews and gypsies? Is it moral for the US to start murdering German soldiers, in open war?

I'm pretty sure you have to concede, "yes."

Therefore, it is not the act alone. The intention also plays a part.

> I think we have had enough experiences to know that if the government decided what to do with your own body, great tragedies follow.

I'm pretty sure great tragedies will happen regardless, and unfortunately, governments have to make decisions. King Solomon's wisdom over deciding to cut a baby in half comes to mind.

> can you ban drugs and alcohol

I think a far better parallel track of conversation is antibiotics.

If you don't follow the prescribed course of antibiotics, you can breed drug-resistant bacteria. That's a very good argument in favor of limiting access to antibiotics, to people who have consulted with a doctor.

There are countries (India) where antibiotics are much more freely available, and people don't use them properly. They take them for a few days, until they feel better. Breeding dangerous strains.

The argument can be made that governments should stop you from improperly using antibiotics, because it increases the risk to all of us.

> Can you decide on forcefully aborting, or forbidding abortion?

We do decide that. We have to make decisions about how our laws work.

> How people are dressed?

We decide that, too, yes.

> Its not the act of using a hammer on a nail that is in question: its the hammer itself, and the act of nails voting who gets hit next.

Hitler 2.0 comes up. Should we murder his soldiers?

I vote yes. How vote you?

> Why would government enacted violence be any more dignified than individual violence?

"Dignified" is an interesting word choice.

"having or showing a composed or serious manner that is worthy of respect."

The simple answer is that the government composed a law in a respectful manner, and hopefully the officers of the government carried out the law in a respectful manner.

When they don't, we're supposed to hold them to account.

> What change does it make to the morality of a violent act if it was voted on?

Catholics say a phrase, "in what I have done, and in what I have failed to do."

It can be immoral to NOT act.

It would be immoral to not intervene in WW3 with Hitler 2.0.

The way we decide if it's time to intervene is that we vote on how our representative government is run.

[1] : http://www.slate.com/articles/health_and_science/cover_story...


Anti-vaxxers usually say the benefits outweigh the risks and don't consider herd immunity. When you've just been bitten by a rabid animal the risk-benefit calculation is different, no cognitive dissonance there. You'd also predict that an antivaccionationist hunter has at least his dog vaccinated against rabies, you see rabid foxes and raccoons out there with your own eyes.

What you'd really like to do is ask an anti-vaxxer woman who is pregnant or trying to conceive what she thinks about measles, mumps and rubella vaccine, especially rubella.


Plenty of women in the UK turned it down due to unconfirmed (and now debunked) links to autism. It's just what you choose to believe and whether you think the risk of autism and its outcome is worse than the risk of Rubella and its outcome.

How would a vaccine help someone who already has rabies?

It takes a while for rabies to travel from the muscle or skin cells of the original bite up into the central nervous system. The virus initially replicates inside muscle cells to avoid detection by the immune system, and only starts traveling up peripheral nerves once a sufficient viral load has been generated.

PEP works by massively boosting the patient's immune system (via immunoglobulin) and sensitizing it to the rabies virus (via the vaccine) before the virus can get to the points (the brain) that it's impossible to remove it from. Think of an army retreating in wartime: if you know that the enemy has successfully established a beachhead within your country, the logical next step is to start fortifying cities & chokepoints so that as the enemy advances, they meet unbeatable resistance. That's also why it's critical to get treated ASAP after being bitten: once you show symptoms, it's too late.


The vaccine is extremely effective if taken between the bite and when symptoms occur. If treated properly and promptly, you have basically a 100% chance of living. As symptoms begin to show up, the chance of survival drops rapidly to 0%.

> As symptoms begin to show up, the chance of survival drops rapidly to 0%.

Probably even before symptoms show up, right?


It would be also fun to give you a rabies vaccine, and a rabid bat, and see what would you say to not let the bat bite you.

There was also a fatal case in Virginia this year, a woman who contracted the disease while traveling in India. It took several trips to the hospital before they diagnosed it correctly, since it’s not something docs are expecting to see. They tried the Milwaukee protocol unsuccessfully. https://www.cdc.gov/worldrabiesday/stories/rabies-virginia.h...

"I had no clue," Giles said. "We would wake up in the night and they would be walking on our bed"

I'm sorry for the family but I can't exactly say I'm not surprised. Generally having any wild mammal hanging out where you sleep is a very bad idea.

Edit: Reworded to be less arse


And it's a very good idea to get a rabies vaccine shot if you find an unknown dog in your bed at night. Like a very very good idea

> "I had no clue," Giles said. "We would wake up in the night and they would be walking on our bed."

Not to judge, but isn't this getting a little too close with nature?


The practical takeaway here underscores the advice in Auerbach's authoritative text Wilderness Medicine. If a person interacts with potentially rabid animals and that interaction results in even the smallest scratch or contact with saliva the victim should undergo rabies treatment and if possible have the animal undergo necroscopy.

The odds of surviving rabies once it becomes symptomatic are negligible. They can throw the hail Mary from the 5 yard line in a snowstorm but the chances of winning the game with it are slim.


Rabies enters a nerve cell at the bite site. It then travels along the nerve axon to the next cell. It does not proliferate at this time. Cell by cell, via the axon railway to the brain. It then proliferates in the brain and kills large numbers of brain cells and causes death. If you have antibodies, they can somehow block the axon travel. The Milwaukee treatment was a success - the only one? Perhaps that girl had some immunity? In any event, once it hits the brain the body starts to mount it's own immune response, and apparently the anitivirals she was given, along with the induced coma, allowed her immune system to overcome the rabies.

Rabies is one of the scariest diseases to me, because most aren't vaccinated, it's virtually 100% lethal, and most of the time, doctors will tell you that you don't need to be vaccinated "just in case", because the incidence is so rare.

If you can, bring in the animal that bit you; you don't want to go through the shots unless they are necessary, but you also don't want to die.


Also, by the time you show any symptoms, you’re as good as dead. So you have to anticipate whether the animal that bit you might have had rabies or not. Many people are reluctant to seek treatment when they feel fine, especially given the cost of healthcare in the U.S.

Yeah, its pretty weird. I had never really ran into bats until late this summer when I was sitting on the couch around 10:30PM and one flew through our living room. I caught it in a plastic container and let it go.

Looking down the rabbit hole on the internet was absolutely terrifying. I talked to my doctor and our daughters pediatrician but there is really no standard on what you should do because it varies so much by location. We went to the ER and chose not to get the PEP since we were about 99% certain I caught it right after it entered our house and my wife and daughter were in other rooms with doors closed.

It still makes me feel uneasy when thinking about it or reading stories like this.


I was dumbfounded by the attitude of some of the medical personnel I had to deal with when I was once randomly bitten by a stray dog. After I demanded to be vaccinated at the emergency room they finally gave in but their attitude was "the dog lives in the city, it doesn't interact with wildlife so you're most likely fine". I told them 'most likely' doesn't make the cut for me when we're talking about a disease with a mortality rate at 100%.

It's amazing how, to doctors, what were once once meaningful life and death scenarios just become more work or less work scenarios over time. They are desensitized.

It might help to demand in writing that there is no risk. Of course, they would never do that, so likely would just give the shots. Ensure they know that all your friends, lawyers and insurance company will be advised of the doctors decision to not inoculate.

Did they go to medical school? That's medical malpractice if I ever saw any.

That's honestly quite terrifying. In Germany there was a supply chain problem for rabies vaccine a while back and even though they seem to have managed it kinda scared me.

> If you can, bring in the animal that bit you

Don’t they still need to kill the animal and send it’s head to the lab? At least when I was a kid you still needed the shots because it took a week to get the animal’s results back.


I was told you could avoid shots by bringing the animal in, but I am not in the field, so I don't know if that's generally true.

Yes, and if is alive is easier to look for symptoms. People bitten by any species of microbat receive three shots.

There is a lot of difference between risk depending on the bat species, so it helps a lot if can be classified by a specialist.


> if is alive is easier to look for symptoms

As I understand it, removing and examining the brain can yield a definitive diagnosis in cases where time is of the essence. In cases where it's not immediately obvious that the animal is rabid, it can take a week or two of observation to look for more overt symptoms.

That's how my parents ended up adopting a stray dog, who later became just about their favorite pet ever. By the time they'd watched him for a couple weeks, he wasn't going anywhere. :)


Yeah pre-Milwaukee protocol it was an undeniably legitimate case for euthanasia in confirmed cases being irreversible and painful. I believe that Gandhi of all people noted the situationality of ethics - normally killing a child is a horrifying crime but if they are suffering from rabies and it is too late horrifically killing them was long the best option.

Even with advances it is a bit of a longshot but it is still better than the alternatives. There is an irony in medicine that it becomes ethical to be more reckless when odds are longer. It makes sense of course but there is some dark comedy that trying something drastic and seeing if it sticks being the moral thing.


And that's one of the main benefits of the Milwaukee protocol, even if it likely doesn't work, induced coma is still the best place to be once you show rabies symptoms.

Rabies also returned to Europe in the big scam's period. With several recent cases in Greece since 2012. The country was clean of rabies in the previous 20 years.

The expansion of the golden jackal as new centroeuropean animal promoted for the deliberate extinction of the gray wolf by man, could also increase this probability. Jackals are much more prone to bite and interact with dogs and cats without killing it.


big scam period?

> Rabies also returned to Europe in the big scam's period.

Can you be more specific? Are you talking about the early 2010s?


Rabies never went out of Europe. In C&E Europe it exists since I remember, and you get shots every time anything bites you.

You are right, I should have say European Union, not Europe.

The areas of Spain in the European continent are declared free from the presence of rabies virus, but rare cases can occur. We had a case in 2013 from a female dog that got the virus after a travel to Morocco.


Poland is in EU since 2004, you would still be wrong :)

Also AFAIK Germany isn't free of rabies, either.


Sounds like Germany is free of it, officially, except for bats. Caution is advised...

http://www.faz.net/aktuell/wissen/medizin-ernaehrung/tollwut...


Interesting. Is rabies endemic in Poland?

Yes, wild red foxes and bats are the main infected populations. It's not very common, and the last human victim was in 2002 apparently, but it's there and you have to follow the rules if something bites you.

Hum, I see: a young man dead in 2002 in Podkarpackie (unknown origin) and also a woman dead in 2000 in Warmian-Masurian after being bitten by her cat.

>you don't want to go through the shots unless they are necessary

The shots aren't that bad these days. It's just a series of relatively large intramuscular injections.


As someone with a severe fear of needles, that is pretty much my personal nightmare. It is my personal nightmare because I assume they also do blood test.

I may still choose to go through with it, but I am not entirely sure.


No blood test.

getting a course of rabies vaccines cured me of my dislike of needles, YMMV

No, the vaccination shots are relatively small. Very small painless shots, not as bad as a flu vaccine at Walmart/Walgreens. HOWEVER, the first shot of the PEP series, the immunoglobulin shot, is a large painful shot... But the subsequent vaccination is a piece of cake. Source: received PEP a few years ago.

Since the vaccine is pretty harmless and saves you from certain death if you got infected. It's a very very good idea to get a rabies shot after any close contact with any mammal with unknown vaccination status.

Our son was on a school trip in some fairly remote parts of Tanzania and as they were cycling and running they recommended fairly strongly to get a rabies vaccination - glad we did!

they allowed bats to walk on their beds at night? WTF

To be fair bats are pretty harmless when they aren’t infected with rabies.

To be fair, in quite a few places bats are the main rabies infection vector.

USA is one of those locations, but bats have approximately 0.5% infected rate estimated. 6% measured, but when you take into account that most of the tested bats were sickly, injured, easily captured, etc. Overall, it is very hard to measure, so it is pretty safe to assume around 0.5%[0]

[0]: https://batworld.org/rabies-info/


The places where bats are the main rabies infection vector are generally places where rabies is extremely rare[1], such as the US with 1-2 cases per year. ~99% of human rabies cases globally are from dogs[2], unsurprisingly these are mostly in places where dogs are not usually vaccinated.

[1] https://www.cdc.gov/rabies/bats/education/index.html

[2] http://www.who.int/news-room/fact-sheets/detail/rabies


Yes and when a bat has a 10% chance of carrying rabies you get a rabies shot it you come into contact with one.

Yes, the odds of you getting it are small, but the downside is that if you do get it you’re almost guaranteed to die.


The number is probably way below 10%, but yes obviously getting the shot is still a very good idea.

Though the other nasty thing is that getting rabies shots cost thousands or in some cases tens of thousands of dollars in the US, which leaves a lot of people with the choice between bankruptcy or some unknown probability of getting rabies and the subsequent guaranteed death.


WA state for example: between 3-10% of bats submitted for testing are found to be rabid (this is from the DOH website). Yes, 10% is the high number in some years.

Bats that have been submitted for testing are not likely representative of the overall bat population.

Bats that have been submitted for testing are likely fairly representative of the bat population that is likely to bite you.

The issue with getting a rabies shot if you come into contact with them is that in the USA, it can cost $3,000 easily ($1634 to $8415)[0]. Which when you assume most people live in a household, can be quite expensive. And if you look at the exposure to bats vs. human infected rate of rabies, it is so exceedingly rare.[1]

[0]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5525325/ [1]: https://academic.oup.com/cid/article/48/11/1493/347031


The article seems to suggest that the victim wasn't suspicious because he wasn't knowingly bitten or scratched and could have either simply not noticed or caught it via a saliva path.

Very good point :)

Two points - to be precise ...

Points taken :P

We have enough bat rabies in our community that our recommendation would be vaccination even with just trivial contact. It's our #1 reservoir.

Note to self: don't let bats lick my hands.

When I got my rabies shots to do bat work years ago i remember the nurse that gave the shots told me the story of one of her first patients out of med school who died of rabies. Apparently, he was actually bit a bat that flew into his tent when he was camping and he didn't end up going to a doctor about it until it was too late and he slowly died. This was in canada. We've had deaths more recently than the USA from rabies.

It sounds like a horrible way to die. She gave me shit for going to work with bats...even after getting the shots...

Rabies is pretty intense. Even after being vaccinated you still need to get a titer shot every few years to keep your level of antibodies high enough to fight off the virus if you're exposed to it.


Why is rabies vaccine so expensive as to be rationed?

I had to get the post-exposure series of shots after getting bit by an unvaccinated dog earlier this year. The rabies vaccine shots themselves are not too expensive. I want to say Kaiser charged on the order of $500-1000 for the series of vaccine shots.

The real cost came with the Human Rabies Immune Globulin shots I had to get after being potentially exposed to the virus. These are shots of the rabies antibody that they administered in the area where the dog bit me. Kaiser charged $15,000 for this stuff (insurance brought it down to $1,250 to me). It is costly because they make it by vaccinating humans and then collecting antibodies from their blood/plasma.

I would add that the rabies vaccine shots themselves were not painful and are like flu shots. However, I ended up being allergic to the shots and would break out in hives and get flu-like symptoms for days after each one. I actually stopped the vaccine series early because the symptoms kept getting worse after each shot and by the time the last shot was due animal control told me the dog that bit me made it out of quarantine without showing rabies symptoms.

The Immune Globulin shots were the most painful because it was a thick gauge needle and a super viscous material. I could see a big, swollen lump under my skin after getting the series of Immune Globulin shots. There was pain and bruising for a few days, but it eventually went away.


Rabies is far less common than other diseases that you are vaccinated for. The market is small enough (~50K vaccines per year) that it is unlikely that multiple players will be able to enter the marketplace and survive. Vaccines also expire regularly and are typically money losers for most clinics. Add to that the crazy sticker price scheme that most hospitals have in place in order to negotiate with insurance companies and you wind up with insane bills.

If you vaccinated everyone for rabies, the cost per vaccine would come down but you would likely do more harm than good. Vaccines (like all medicines) come with risks. I've printed the specific risks for the Rabies vaccine taken from the CDC so you can get an example.

Mild problems • soreness, redness, swelling, or itching where the shot was given (30%–74%) • headache, nausea, abdominal pain, muscle aches, dizziness (5%– 40%) Moderate problems • hives, pain in the joints, fever (about 6% of booster doses)


The risk of suffering collateral damage increases each time you are vaccinated again, and there are several strains.

I can't see a good reason, aside from US labor being more expensive, but even that doesn't bring the cost up THAT much. We have to be one of the only countries where this is so expensive.

My friend's dog nibbled my ankle in Vietnam and I picked up a few precautionary shots. Perhaps 3 of them and it wasn't a financial crisis. I thought about it just as much as I think about buying lunch.

I don't even recall the number. Probably like $20-40 out the door after all 3, with walk-in service. Being able to monitor the animal to see that it is fine saved me a few bucks. You have to get more if the animal dies or is in the wild.

I had no idea this was something you would want to insure against in the US. Totally absurd.


It's not expensive outside the USA. Personal experience as travel was involved; for the full round of shots:

  - 1 USD in Nepal
  - 5 USD in India
  - free in UAE
  - ~350 USD in Texas
This was without insurance.

I got vaccinated against rabies in 2010. It was 3 shots at $300 each if I remember right. It was hard to find a clinic that stocked it. I live in Colorado, I think only two clinics in the state had it. Note that is for pre-exposure shots, not post-exposure.

It's not a common vaccine, typically it is only given to vets and vet techs. I think that is a public health decision - rabies exposure is very rare in the United States.

I was getting it because I was going to Peru for a caving expedition. It probably wasn't necessary for me, but the travel pharmacist said it could get it due to possible stray dog exposure in remote Peru and possible bat exposure in caves. I never saw a single bat in the caves there. But since the travel pharmacist recommended it, my insurance paid, which was nice.


How painful of a series was it? What was the time between injections?

Not painful at all. Just like a flu shot. The painful shots are the post-exposure ones that go in the gut.

I received Imovax. It was a brilliant purple color - it was the prettiest vaccine I have ever seen. Shot #2 is 1 week after the first, shot #3 is 3-4 weeks after the first.

https://www.vaccineshoppe.com/image.cfm?doc_id=5983&image_ty...


I got post-exposure shots and they were in the arm. 5 shots: 2 shots day 1, then 1 shot day 3, 7, 14.

This is essentially asking, if rabies is so terrible, why isn't everyone vaccinated? Yes, it's terrible, but in the USA and most developed countries it's so rare (as in just 23 cases nationwide from 2008-2017) that the trivial risks of the vaccine and the small number of people who will have an adverse reaction are generally greater than the benefit in the general population, which is almost nil. This isn't true for people who work with animals, but even with them it's quite rare to have an exposure.

Rabies vaccine and BCG are two of my rebuttals when I hear the allegation public health doesn't consider risks and benefits when selecting vaccines. You can add OPV to that list, too.


Yes. There are a large number of diseases for which vaccines exist but for which people aren't routinely vaccinated in the US if they aren't traveling somewhere for which a particular vaccine is recommended. For traveling, I've had all sort of vaccines (yellow fever, typhoid, encephalitis, etc.) that I wouldn't get if I just stayed in the US.

That's not the case in Europe.

Free in Turkey, even if you have no insurance. You just need to go to an ER that has shots.

They give you a schedule for up to 5 shots. If you decide to skip one, they send police to your house, who will take you to ER.


It was still 210€ for 3 shots when I took it. (Germany)

Yet it is fully covered by public health insurance in Germany (got my rabies shots refunded by the TK).

Not fully and not by all public insurers AFAIK. But the price of the vaccination itself is still high anyway.

And why is it more expansive than for dogs.

It's pretty well known that you can user veterinary antibiotics to treat humans for a fraction of the price, I wonder if rabies vaccine doesn't make the cut too...


Sounds reasonable to me. The legal risks associated for the company selling it are much higher.

Go to the vet. Ask vet for the correct dose of the vaccine for you, including the tooling to administer it. Administer the vaccine yourself in the vet office. Pay the vet. Come back at the right time for the booster dose.

There should not be any difference in suitability between the vaccines, but you might want to check if the same style of vaccination (i.e., kind of disease and procedure of deriving the vaccine) is used for both humans and some animal the vet would use the vaccine for if you hadn't come. You might do that with a different vaccine, but there isn't much difference between mammalian vaccinations.


It’s interesting to me that my town, Mountain View refuses to require rabies vaccinations or licensing for cats.

I think that's pretty typical throughout the US.

So why doesn't everyone simply get vaccinated?

Rabies vaccine is crazy expensive and takes multiple shots. Even then you still need immediate post-exposure treatment.

patient 0

It's a real human, not a Hollywood film for your entertainment

This is a badly written article, journalists should have a little science background.

"... the bats .... were carriers of a rabid and highly contagious virus."

Yes, it is a rabid virus...

"A person usually has some time before it is necessary to get the post-exposure prophylaxis vaccination."

A friend had to handle a bat in her cabin, and she was not told she had "some time" before the shots. If you've been exposed get your butt to the ER.

"An estimated 40,000

people in the US who might not be up-to-date on vaccinations

get preventive treatment for rabies after a bite or scratch from a dog or cat."

Statistically 100% of peeps aren't up to date on rabies vaccines. Vets, bat researchers, and bat house zookeepers may be up-to-date, but no one else is.

Rabies shots costs thousands of dollars, btw. Tricare, for military dependents, doesn't charge a copay for rabies post-exposure injections. My friend's insurance had something like $4000 copayment.


"Rabies shots costs thousands of dollars"

I assume you mean in the US. Really? I had no clue. They are like $5 in Eastern Europe.

Edit: I am referring to the post-exposure shots.

Edit 2: All of this reads like a bad joke - if our numbers are representative, rabies treatment is 20-2000x the cost of other countries in the US. Would be interesting to see someone play devil's advocate on this.


Oh! I got rabies shots in 2014 after being bitten by a dog.

The course of treatment is injections 0day, 3day, 7day, and 14day. I went to the emergency room to get these injections, at the recommendation of my primary doctor.

Unfortunately I don't have the bills anymore, but the total cost was a bit over $20,000, which insurance adjusted down to about $500/visit.

Basically, it would have bankrupted me if I didn't have insurance. Yes, the US healthcare system is really this broken.


Yep, my family had to do the same ER visit for our treatments. Immune globulin is a blood product and I was told it is atypical for any medical center outside of a hospital to have it available. Having to go the ER added a not insignificant amount to our total bill, but we did only have to pay for a single visit to the ER - our followups, we just walked in and a nurse would give us the shot.

On the somewhat funny side, it's weird walking into an ER and being greeted by first name and a wave . . .


Hah yeah, it was kind of funny that by the 4th shot, the ER docs and police there knew me as "the rabies guy".

I also was told that the immune globulin is a bit complicated because it needs to be prepared specifically for the person's weight. So unlike off the shelf vaccines, it requires an on duty pharmacist to actually do something before they can give it to you, which I'm sure adds to the cost.


I can also confirm this. Similar situation and similar pre-insurance costs.

I got the post-exposure series with rabies vaccine and immune globulin shots earlier this year. The total insurance charge was around $20,000 for me as well. $15,000 for the immune globulin and $5,000 for ER/Vaccine/etc. My out of pocket cost was below a few thousand after insurance, but it was expensive nonetheless.

With those kind of costs, you're probably going to hit the out-of-pocket maximum even if your insurance covers 80% or whatever which is going to be a few thousand dollars for most people. (But might be more with a cheaper high deductible plan.)

Yes, post-exposure costs in the US for human rabies immune globulin (antibodies isolated from the blood of a vaccinated person) in the United States is roughly a $10,000 to $15,000 expense per person (dosage is based on body weight). The vaccine cost is much less, well under $1,000 total per person.

I know these costs from direct experience. I also know that insurance coverage for this cost varies widely as well.

My entire family had a nighttime (meaning the family members were in bed asleep) exposure to an untested bat. Following the U.S. Center for Disease Control and local health department guidelines, plus the advice of infectious disease MD specialists, we had to receive both the immune globulin and rabies vaccine. These costs were not covered expenses under my (otherwise pretty solid) medical insurance plan - we wound up having to pay approximately 30% of the total cost.

In the end, I felt fortunate that at least our insurance kicked in to cover 70% of the costs and that we were in a financial position that allowed us to pay the low five-figure out-of-pocket expense for our treatment without undue hardship.

I'm actually debating keeping our vaccinations up-to-date going forward - I think the booster vaccine, while still uncovered by my medical insurance plan, is relatively low cost and incidences of rabid animal encounters seems to be steadily rising in my home state.


> I'm actually debating keeping our vaccinations up-to-date going forward - I think the booster vaccine, while still uncovered by my medical insurance plan, is relatively low cost and incidences of rabid animal encounters seems to be steadily rising in my home state.

You can get a rabies titer to see if you need the vaccine booster.

https://www.cdc.gov/rabies/specific_groups/doctors/serology....


I got them in the us about 10 years ago (international travel with likely animal exposure). About $600.

Parent is talking about post-exposure rabies shots, not the rabies vaccine. If you read https://www.vox.com/policy-and-politics/2018/2/7/16851134/ra... it's actually still very expensive in the UK as well.

In India they are free in State owned hospitals.

Free in Spain, if I'm not wrong

Completely free and everybody is vaccinated because they vaccinate kids in schools, I assume it's the same in every country of the first world.

Hum, not. Is obligatory for dogs (it was like 50€ or so), but children aren't vaccinated from rabies normally in Spain at the school.

Rabies is endemic in Ceuta and Melilla in any case. I don't know if people in those places are systematically vaccinated but would be a surprise to me.


Wow, I stand corrected! I thought rabies was in the programme. My mistake.

About Ceuta and Melilla, there have been efforts to have pets vaccinated for free: https://elfarodeceuta.es/sanidad-vacunacion-gratuita-rabia/


I took my wife/daughter/myself to the ER to figure out if we should get it since it is the only place that carries the vaccine near us. We ended up not getting it and still walked out with a $3000 bill.

Free in Canada, as well.

Pre-exposure rabies vaccination is generally not included with statuatory health insurance in Germany. Still, the insurance carrier often covers it if the vaccination is indicated for a country you travel to. The three shots cost about 200-300 Euros combined, IIRC.

Or in Vietnam it was about 10 euro a shot and probably would have been free if I had been a local.

> A friend had to handle a bat in her cabin, and she was not told she had "some time" before the shots. If you've been exposed get your butt to the ER.

The article doesn't claim otherwise. Rabies can usually be treated successfully days or weeks after the initial bite. Obviously you should get the shots ASAP regardless; it's more likely to take hold with every day that passes.

> Statistically 100% of peeps aren't up to date on rabies vaccines. Vets, bat researchers, and bat house zookeepers may be up-to-date, but no one else is.

Again, the article doesn't say otherwise. It doesn't say "40,000 people aren't vaccinated," it says "40,000 people (who aren't vaccinated) get rabies shots after a dog/cat bite."


The article does specifically say "a person usually has some time," which is why I put it in quotes. There's no value to the article downgrading an urgent medical situation, and the author lists herself only as a journalist. The standard of care is urgent, ERs are equipped to give the shots. This is USA.

"An estimated 40,000 people in the United States who might not be up-to-date on vaccinations," again, I used quotes specifically because that is how it is worded, "people who might not be up-to-date on vaccinations," as it is less usual for someone to be up to date on rabies vaccinations.

The science was badly worded, as if it was copied without understanding the context, and this is a legitimate concern when the press misstates medical advice. The number is probably from the CDC information page,

"Every year, about 40,000 people receive a rabies prevention treatment called post-exposure prophylaxis (PEP) because they had contact with potentially rabid animal."

CDC also doesn't say dog/cat bite or scratch, just potentially rabid animal, mostly dogs or cats.

I read the article, notices her carelessness, checked sources. There are more errors. It's badly done.


Another sad case of lack of scientific formation. Could be easily solved spending 20 minutes at the schools to study basic ecology of parasites, vectors and diseases.

Microbats shouldn't be, never, ever, manipulated with bare hands. Specially if they seem to be sluggist or ill. Full stop. You need strong gloves, or much better, let it to a trained zoologist or veterinary.




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