Rabies case raises public notification questions

By Jennifer Fernandez

A rabid raccoon attacked Durham resident Christine Houghton in broad daylight in May when she was running on a trail at Eno River State Park. 

Houghton escaped by drowning the animal in nearby water, even as its teeth were still sunk into her calf. She left its carcass behind as she sought help. And while she was sure the raccoon was rabid, she received confirmation only because park rangers sent the animal for testing.

Houghton said the Durham County Department of Public Health declined to send the raccoon for rabies testing because it had been left unsupervised after she killed it. Besides, those tests are typically done at the State Laboratory of Public Health in Raleigh.

“People go down there every day,” she said. “Like, I run on this trail five times a week.”

Joy Nolan, Durham County Public Health’s communicable disease nurse supervisor, said park rangers didn’t recover the dead raccoon until the next day and couldn’t guarantee that it was the animal involved in the attack. But a state parks spokesperson said the animal was recovered the day of the attack and preserved according to the requirements for rabies testing.

Nonetheless, the rangers decided to send the raccoon to be tested at the Rollins Animal Disease Diagnostic Laboratory, one of several labs that are part of the North Carolina Veterinary Diagnostic Laboratory System.

The attack on Houghton was thankfully rare, but a potent reminder that in North Carolina, warm weather brings more people outdoors and potentially brings them into contact with more wildlife. 

And sometimes, those critters have rabies. 

Getting the word out

“Our staff wanted to do their due diligence because the visitor had expressed a desire to conduct the testing,” Kris Anne Bonifacio, public information officer for the state’s Division of Parks and Recreation, said in an email to NC Health News.

Houghton said she never saw a notification from the Durham County Department of Public Health that a rabid raccoon was found on the trail. She said the only warning she saw was signs posted at the park a couple of days after she was bitten warning visitors about a confirmed rabies case and advising them what to do if they see a potentially rabid animal or are bitten or scratched.

The parks system also posted a public service announcement ahead of Memorial Day weekend on its Facebook page that included reminders to stay away from wildlife and not to disturb or feed wildlife, as well as what to do if an animal is acting strangely.

Not every rabies case gets reported publicly, state and county health officials told NC Health News. However, all positive tests get added to a publicly available state database showing the type of infected animal and the county where it was found. 

From the first of the year through the end of July, the database lists 128 instances of rabid animals from all over the state, with the distribution of cases pretty evenly spread across both warm and cold weather months.

Use this interactive state database to check for rabies cases reported in your county. 

Some counties issue public notices for every case. Others share based on the circumstances of the exposure, such as when a rabid animal is found near a school or several cases are reported in one area, Nolan said.  

In the case of the Eno River State Park raccoon attack, Nolan said the decision on notifying the public was up to park officials since the attack happened in their jurisdiction.

“We try to respect each other’s areas,” she said.

Bonifacio said the parks system followed the protocol of the state Wildlife Resources Commission and the Durham County Health Department, which requires two positive cases before issuing a public notification.

No public reporting requirement

North Carolina law puts local health directors in charge of handling rabies cases in their jurisdiction. However, many delegate the work of tracking potentially rabid animals to local law enforcement or animal services divisions, State Public Health Veterinarian Carl Williams told NC Health News.

The state does not require that cases of rabid animals be publicly announced, although many counties share that information, he said.

On July 19, Wake County’s Public Health and Animal Control departments issued a news release confirming that a fox tested positive for rabies after biting a woman the day before in a Knightdale neighborhood. She was trying to break up a fight between the fox and a cat that belonged to a feral cat colony.

Officials asked anyone who may have seen the fox or the feral cat to call the health department’s communicable disease line, and encouraged anyone who had been bitten or scratched to seek medical attention immediately.

Likewise, Davidson County Health Department reported April 23 that it had received reports confirming the county’s fourth positive rabies case after a fox attacked a Thomasville resident the week before. And Alamance County Health Department announced May 10 its second rabies case after someone was exposed to a fox that later tested positive. 

“There’s not a specific requirement saying they must, but they do it anyway because they recognize it’s good public health practice to get the word out,” Williams said. 

“Now, that’s not to say that they do an alert for every rabid animal because we have a lot of them every year,” he continued. “They take that opportunity when they think it’s appropriate to promote that information and try and get the attention of the public.”

‘Survival mode’

Houghton had been running five days a week on that trail at Eno River State Park a mile from her home.

The run in May started out like any other, although the creek by the trail was unusually high and Houghton had to cross it to stay on the trail. She was stepping from rock to rock when she saw a raccoon approaching with a determined glint in its eyes. It stayed focused on her, not even changing course when she splashed it with water.

The next thing she knew, the raccoon had latched onto her calf, biting down so hard she couldn’t pry its jaws open. She grabbed its head to hold it in place as she pushed her leg under the water, drowning the raccoon.

“There was really, honestly, no decision-making,” Houghton said. “It was completely my mammalian brain. I wasn’t like ‘Oh, what should I do?’ I just … went into survival mode.”

Once she was sure the raccoon was no longer a threat, she pulled off her shirt to wrap around the wound. 

“That was really when I started freaking out,” she said.

The fear set in, Houghton said, that she had been exposed to rabies, a viral disease that attacks the central nervous system. 

“I had no doubt in my mind that it was rabid,” she said.

Rabies in NC

Left untreated in humans, rabies is fatal. However, rabies in humans in the United States is rare. Williams said there are just a handful of deaths each year. Five people in the U.S. died from rabies in 2021 — the highest number of deaths in the country in a decade.

The last recorded death in North Carolina was a Jones County hunter in 2011 who had been bitten by a raccoon. 

Exposure is much more common, Williams, the state public health veterinarian, said. About 60,000 people get treated for exposure or potential exposure to rabies across the nation annually, according to the Centers for Disease Control and Prevention.

That exposure comes from being bitten or scratched by wildlife carrying rabies or from domestic animals who contract the illness from sick wildlife. It is transmitted through direct contact with infectious nervous system tissue or saliva.

North Carolina is one of several states with a lot of rabies activity, according to a report that Williams gave on Jan. 20 to the N.C. Division of Public Health Wildlife Medicine Symposium.

In 2020, almost three-fifths of all animal rabies cases occurred in eight states, most of them on the East Coast — California, Texas, New York, New Jersey, Maryland, Pennsylvania, Virginia and North Carolina.

“Rabies is one of those things that once it moves into a wild animal population, it’s extremely difficult to get rid of,” Williams said.

Raccoons and bats are top carriers for wildlife, followed by foxes and skunks. Cats are the top domestic animal that gets infected with rabies, although dogs and ferrets also show up in state and national reports of animal rabies cases.

From Jan. 1 to July 31 this year, the State Laboratory of Public Health found 46 positive cases of rabies in raccoons followed by 22 cases in foxes, 21 in bats and 17 in skunks. During that same period, 13 cats tested positive.

Other wildlife and domestic animals can also get infected. Through July 31 this year, three cows, two equines and one bobcat, goat, groundhog and coyote each have tested positive.  

In North Carolina, the State Laboratory of Public Health tests animals for rabies, but testing is limited, Williams said. For wildlife, typically only animals at high risk of carrying rabies that have exposed a person or domestic animal get tested.

The lab tested 3,206 animals in 2022. Of those, 258 tested positive for rabies.

Costly treatment

After Houghton got off the trail she was given a ride home, where she told her husband, a nurse, what happened.

She then sought treatment at Duke Regional Hospital, where she took the required series of rabies shots to prevent contracting the deadly viral disease. 

Houghton paid the $250 emergency room co-pay required by her insurance company, Aetna. What the hospital charged before insurance, however, was much higher — $16,834.98, according to a copy of the bill Houghton shared with NC Health News. 

The vast majority of that covered the cost of the human rabies immune globulin ($12,312.30) and the rabies vaccine ($1,885.39) that make up the first phase of what is called postexposure prophylaxis. 

Houghton had to return for three more rabies vaccine shots to finish the series over a two-week period. She was able to get those at urgent care, including an out-of-state urgent care when she was on a previously planned family vacation. Insurance greatly reduced the cost for those shots as well, she said. Copays ranged from $50 to $250.

“It’s expensive. There’s no doubt about that,” Williams said.

The cost to the hospitals is less than what they charge patients, he said. They mark up the cost of the medication, and they usually charge physician and emergency department fees, he added.

Houghton’s more than $16,800 initial bill before insurance included $1,999 for the emergency department visit.

For people who are uninsured or underinsured, Williams suggested checking with the hospital for its policy on charity care. The companies that make the rabies vaccine also offer help to people who cannot afford the medicine. And the state has an indigent care program, although that is only if other avenues to access the medicine fail, Williams said. The state has a limited supply of the human rabies immune globulin and vaccine, he said.

While health officials consider rabies exposure an urgency, not an emergency, victims don’t want to wait too long to get treated, Williams said. Once a person exhibits symptoms of rabies, it is too late. 

“We tend to try and worry about the cost and managing the cost on the back end,” he said. “We don’t want anybody to not get postexposure prophylaxis that really needs it.”

Nolan said the recommendation is to take the postexposure prophylaxis within 72 hours. However, most people need to be treated before then to make sure the bite wound is cleaned and any other medications, such as a tetanus shot and antibiotics, are administered.

‘Profound trauma’

Houghton said the cost goes beyond the medical bills for the rabies vaccine.

She also hurt her back, probably from reaching down and twisting while fending off the raccoon. She ended up going to a chiropractor and acupuncturist and getting physical therapy.

The attack also left her traumatized, so she underwent a psychotherapy treatment called eye movement desensitization and reprocessing that is designed to help people recover from the distress of traumatic memories.

That added several hundred dollars to her medical bills.

There were other costs, too.

Getting attacked by the raccoon was an “incredibly profound trauma,” she said. 

She switched to using the more public Al Buehler Trail, a 2.9-mile loop around Duke University Golf Course. 

“It just feels safer,” she said.