Rabies Awareness with a Camp Perspective

Linda Ebner Erceg, RN, MS, PHN
March 2020
Bat hanging on curtain

Many camp professionals consider the bat a benign, friendly critter. Readers may have grown up with an occasional bat flying through the house and the dear things are often seen around camp. Despite the good done by bats in the natural world, the bat’s “benign” days are over. The bat has become persona non grata in camp sleeping quarters, and showing a captive bat to interested campers — if done — should be done by appropriately trained staff wearing leather gloves and reminding campers not to touch. Something has changed.

That change has to do with exposure to rabies. Departments of Health typically consider a person presumptively exposed when that person wakes up in a room in which a bat is flying. The concern with rabies is genuine, because without appropriate medication attention, it is a disease “ultimately resulting in death” (CDC, 2019). If the bat is captured and submitted for rabies testing, the concern about human rabies exposure waits for the results of that testing. But when the bat cannot be tested, presumptive exposure is assumed. That triggers the need for rabies immunizations. 

To date, US deaths from rabies have been associated with bats (CDC, 2019), but other animals can also harbor the virus, most notably raccoons, skunks, and foxes. Worldwide, however, dog bites are most commonly associated with rabies. This may explain why international staff and campers are wary of the camp canine. Interestingly, people generally know when they’ve been bitten by animals like raccoons, skunks, and foxes — but that’s not necessarily the case with bats. Their bites are tough to identify. Indeed, seeing or not seeing a suspected bat bite is not diagnostically significant (Heyman, 2015; CDC, 2019).

As expected, concern about bats and their potential to transmit rabies has kicked up mitigation practices within camps. “Bat proofing” camp sleeping areas tops the list. While some businesses provide bat-proofing services, many camp professionals do their own work using guidelines provided by entities such as the Department of Natural Resources, the Centers for Disease Control (CDC) (CDC.gov), and Bat Conservation International (batcon.org). The CDC has a PDF available specifically for camps; it includes bat proofing and commentary about using mosquito netting over beds (CDC, 2011).

Bats, however, are part of the natural setting at most camps, so totally eradicating them is problematic. One can work to limit the potential for exposure to rabies through bats, but the risk cannot be eliminated. In other words, the risk is inherent to many camp experiences. Consequently, there is increased reason for camp professionals to update their knowledge about bats, update risk-reduction practices used at camp, and become familiar with managing post-exposure rabies prophylaxis for campers and/or staff should the need arise. These are the topics of this article.

Understand the Scope of the Rabies Exposure Challenge

To more fully understand how a determination is made about rabies exposure in humans, talk with the appropriate person from the Department of Health of the state in which your camp is located. This is important because recommendations from the CDC are national in scope, but interpreted and implemented at the state level. Specifically talk about your concern with bats; learn what constitutes “presumptive exposure” insofar as bats are concerned. This baseline information helps a camp shape an effective response. If campers are sleeping in a cabin and a counselor walks in to find a bat flying around, have all those sleeping people been “presumptively exposed” to rabies? What if, during the day, a camper spots a bat hanging from the peak of the roof inside the cabin; is that a presumptive exposure? What if a counselor picks up a bat bare-handed and shows it to campers; is that an exposure? The goal is to understand how the determination about exposure is made and the facts that color that determination process. Many state health departments word their exposure statements along the lines of “presumptive exposure to rabies is assumed when a person/people wake up in a room in which a bat is flying and the bat cannot be captured for testing.”

If the bat can be captured for testing, Departments of Health are generally tolerant of waiting for the results of that test before initiating post-exposure prophylaxis. Ask how long it takes to get results from the testing process; potentially exposed people will want to know. If the bat cannot be caught — or simply gets away — then a decision of presumptive exposure will most likely be made. 

Also find out where to take an animal for rabies testing. A local veterinarian can probably answer this question. The vet may also provide a service for packaging and submitting a captured animal to the appropriate testing location. This is especially helpful when testing is done at only one state lab and camp is geographically some distance from that site. The use of courier services and electronically delivered test results help keep wait times to a minimum. These services often have a price, so ask about that too.

Update your knowledge about post-exposure prophylaxis for rabies. Should an exposure occur, campers, staff, and parents will have questions. Information should be from a reputable source such as your Department of Health, the camp’s physician, and/or the Centers for Disease Control. Know about the post-exposure rabies prophylaxis process. While rabies immunization used to be a series of five injections given over four weeks, it is now a series of four injections done over two weeks. The day of the first immunization is followed by additional rabies injections on days 3, 7, and 14. In addition, a dose of immune globulin is given with the first injection (CDC, 2011). 

Determine where one goes to get rabies immunizations. These are typically done through emergency rooms, not clinics. While the hospital’s pharmacy may have enough rabies vaccine for one or two people, find out what happens should an entire cabin group need the injections. This may be the point when the Department of Health can be a great ally, as was the case for a camp with more than 30 exposed people. In that case, their Department of Health assisted with getting enough rabies vaccine and gamma globulin to the immunization site.

Camp administrators are urged to talk with their liability and worker compensation insurance carrier(s) before experiencing an incident to determine what support will be available. Specifically ask how to file a claim; rabies shots and gamma globulin are expensive.

Update Staff Training

Along with bat proofing designated sleeping areas, update the education provided to staff about interaction with wild animals, especially those posing threats like rabies. Develop a “bat-catching protocol” that’s used to capture bats inside of buildings. Information about capturing is available online; the CDC has a particularly good printed piece (2011). It includes using supplies like leather gloves, a long-handled insect (not fish) net, and a container with a tight-fitting lid (see Figure 1, Sample Bat-Catching Procedure). Such “bat kits” can be prepared ahead of time so they’re easy to grab when needed.

Make sure all camp staff get trained regarding bats; don’t forget maintenance and food service staff. Talk through the process that will unfold should a bat be captured, as well as what will happen if a bat “gets away.” This conversation will be especially helpful should a bat escape capture efforts, something that happened at two camps. The staff who valiantly tried to capture the bat were unable to do so. It was tough knowing that people needed to get rabies immunizations because of the failed effort. However, because of the way camp leadership handled the situation, the staff understood the distinction between their valiant effort and an escaped, artful-dodger bat.

Communicate with Stakeholders

Communication with impacted people will be a crucial component of a camp’s response to a rabies exposure incident. This task is often led by a camp administrator (director). The camp nurse may provide support, but key messages must come through the camp administrator because a potential rabies exposure also has the potential to be a significant public relations issue. Stakeholders heading the list include impacted campers and their parents, camp staff, and the camp’s liability insurance carrier. Consequently, key messages and scripted conversations may be utilized. 

If the offending bat has been caught and sent for testing, camps should call parents of impacted campers to tell them of the exposure and that the offending bat has been sent for rabies testing. Communicated information includes comment about when test results are expected, how those results will be communicated to the parent, and provides the name of a camp professional and their phone number should questions arise in the interim. This notification is eased if the camp’s pre-camp parent information includes information about inherent risks associated with camp life.

If the offending bat was not caught, communication with parents focuses on informing them of the exposure incident, the child’s need for post-exposure rabies prophylaxis, and obtaining the parent’s permission to start that process. While a parent’s verbal permission may be heard via phone, direct them to email their written permission. Consult your legal counsel regarding this. Also note the difference between initial notification and follow-up calls. The initial call to parents of exposed campers typically focuses on the fact that the exposure incident occurred and the need to start the child on the rabies post-exposure immunization series. Follow-up communication can provide additional information. Indeed, one may not have complete information when initially telling parents about the incident.

Communication tips from camps that have been through a rabies exposure incident include the following:

  • Verify baseline information before initiating parent contact. This might include a call to the Department of Health to verify that an exposure incident has, indeed, occurred. Recognize that one may not know all follow-up information when placing early calls, especially to impacted parents. Be prepared to acknowledge this.
  • Ask your Department of Health representative to prepare a letter — perhaps an electronic version so it’s quicker to disseminate — that outlines the rationale for the rabies immunization series. Getting the immunizations is a personal choice, but Departments of Health are sensitive about making sure everyone is appropriately informed.
  • Inform the parents of impacted campers. There will be a series of communications with these parents, so think through this process. This is also one of the times when the integrity and quality of a camp’s relationship with parents makes a difference. 
    • The initial contact informs parents that their child has been presumptively exposed to rabies and, as a result, the Department of Health wants the child started on rabies injections. Obviously, this is a heavy message to deliver, let alone for a parent to hear. A scripted message may help the person(s) making these calls provide a consistent and effective message (see Figure 2, Sample Script for Notifying Parents of Exposed Campers). Be prepared to leave an appropriate voice message should the parent not answer their phone. Also be prepared for a parent “to think about it” or want to consult the other parent. Provide all parents with the name and phone number of the camp professional who will handle their call-backs; these will come.
    • Stay in touch with impacted parents; they need fairly consistent updates from the camp spokesperson. Depending on your relationship with the group, updates might be provided by email supported by individual one-on-one calls as needed.
    • Resident camps should note that parents often need to talk with their child, especially if the rabies injections are given/started while the child is at camp. Be ready to organize this in a way that complements the camp’s capacities.
    • Day camps have the advantage of children being in their home communities. Parents can often both inform their child about the need for rabies shots and be with their child for the injections. Talk about this to make sure what the camp assumes is happening concurs with the parents’ understanding.
  • Inform camp staff. Get them ready to support impacted people as well as the process. Remind them of your camp’s media policy and the need to protect the privacy of impacted parties.
  • Talk with impacted campers. 
    • In resident camps, this conversation is often led by the camp director and supported by the camp nurse and the cabin counselors of the impacted youth. Telling campers that their parents have already been informed (assuming this is true) often helps. Straightforwardly respond to their questions.
    • Day camps may not need to talk with impacted campers; parents often want this task.
  • Talk with the other campers who were not impacted. These campers need to know the basics of what’s going on delivered in a manner that complements their developmental capacity. Undoubtedly, they will be friends with some of the impacted campers. 
  • Inform the camp’s liability and/or worker compensation carrier(s). These companies often open a case file for anticipated claims and may provide a phone number for parents should the need arise.
  • Inform parents of non-exposed campers. Campers may write home or call using their hidden cell phones. As a courtesy, consider emailing these parents. Let them know that they may hear about a recent rabies exposure incident, something parents of impacted campers have already been informed about. You’d like them to be aware so they aren’t caught off guard should their child pose questions. Stress the camp’s continued efforts with bat proofing and ongoing concern with safeguarding the health of campers. “We’d like you to know” goes a long way.

When Rabies Shots Are Given to Campers While at Camp

The decision about starting rabies immunizations while campers are still at camp is generally made with an eye on the date the campers leave camp. Obviously, if the exposed campers will be at camp for at least the next two weeks, the Department of Health (DOH) will want the immunizations started (and perhaps completed) before campers head home. Consult the DOH about this. If campers will go home fairly soon, the DOH may recommend that the child start the injections at home. Then there’s the middle ground, in which some shots are given while the child is at camp and the remaining are completed at home. Each scenario has follow-up points.

If the four rabies inoculations can be completed at camp before the camper goes home, then the designated camp professional — most commonly the camp nurse — should contact the place where the immunizations are given and a) make sure they know the number of people to be injected, b) the approximate weight of each person (the gamma globulin dose is based on client weight), and c) when the individuals will arrive for the first immunizations. Some providers are willing to set up a special location and bring in additional staff when groups must be immunized, so talk about this if several campers and/or staff are involved. It may also be necessary to enlist the DOH’s help to secure enough rabies serum and/or gamma globulin if multiple people have been exposed. 

The first time campers and staff go in for the immunizations will take a bit of time. A record will be set up for each person, and each individual will receive two serums: rabies and gamma globulin. While the rabies injection goes into the person’s arm, the gamma globulin will go into their gluteus maximus (their butt). The quantity of gamma globulin needed is based on weight, so most people will have at least two of these injections. Clients do much better if they know about this ahead of time, so while the camp director may be focused on getting people registered, the camp nurse has a significant role in adequately preparing campers and staff. A word to the wise: if someone is extremely afraid of injections, have a skilled staff member work one-on-one with this individual, consider keeping this individual separated from others, and have them go through the injection process first. There’s nothing worse than waiting for a perceived “bad” thing to happen. 

If individuals will only partially complete the rabies series before going home, then it becomes necessary to coordinate with parents for the series to be completed at home. Parents will want to know when remaining injections should be given and how to arrange for them. Most often this is a matter of talking with the camper’s physician who, in turn, orders the remaining injections. The DOH might help coordinate this process should many campers and staff be involved and/or if campers/staff live out of state or out of country. The medical staff who will oversee completion of the rabies series need to be informed ahead of time so enough rabies serum is available and appointments can be scheduled on required days. Again, communication between camp and parents is crucial for a smooth transition. 

When people receive rabies immunizations while at camp — whether or not the series is completed — camp nurses are reminded to get copies of all pertinent paperwork and pass this information along to parents.

When the DOH gives permission for people to wait and start the rabies series when they get home, ask the DOH to provide a letter that explains as much to parents. Some parents go to Google and see statements such as “immediately start rabies prophylaxis.” Having a DOH letter that explains why it’s OK to wait until getting home really helps. In addition to that letter, parents appreciate coaching for their at-home follow-up. Tell them to contact their child’s physician to initiate the process. Sometimes the MD’s office staff will facilitate the process; at other times, the MD may refer the parent to the local emergency room. The key is to let the appropriate medical staff know ahead of time so adequate serum is available and appointment times can be arranged.

When Staff Need Post-Exposure Rabies Prophylaxis

Assuming the staff member’s exposure incident occurred while doing their job, the camp’s worker compensation insurance would apply. Staff need the same coaching and attention regarding rabies immunizations that campers receive, but their billing should be directed per instructions from the camp’s worker compensation carrier. This is particularly important if staff receive rabies injections after leaving camp (e.g., following the end of their work agreement). One camp gave affected staff members a letter to show their at-home provider; it provided information about the exposure incident, the address for submitting the bill and, if needed, the name/phone number of a person who could respond to provider questions.

Maintain Records of Your Actions

Risk management practice includes developing and maintaining adequate records. Consult your camp’s liability insurance carrier for coaching on this process. The insurance company may already have forms to facilitate the record process. Start keeping written records at the point a bat is found in a sleeping area. Even if the bat is a nuisance bat (no one was presumptively exposed), record where it was found, who handled it and how, the rationale behind the decision about submitting the animal for rabies testing or not, and efforts taken to block places where the bat may have entered. 

When an exposure incident takes place, gather the same information, but also develop a record specific to each exposed person. This individual record focuses on that person’s experience; it should summarize conversations, phone calls (including attempts to call), and the individual’s reaction to the rabies prophylaxis process. Various people may make entries to the individual record (each dated and signed), but the record is specific to a given person. Individual records are complemented by the file (record) of the incident itself. The incident file includes a broader synopsis of actions, date and time of those actions, and who did them. Add copies of emails and other materials provided to people involved with the incident. Individual records become part of the overarching incident file. 

Potential Exposure to Rabies: An Inherent Risk of the Camp Experience?

The concept of “inherent risk” refer to those risks that arise from the environment and during human activities that occur in that environment. Inherent risks are impossible to eliminate. Indeed, doing so would change the experience. When we consider the camp experience, there are some inherent risks — like the presence of bats — that arise from the camp environment. Yes, there are things one can do to reduce the likelihood that an exposure to bats will be impactful. From a legal perspective, one probably has a duty to do those things, but it is not possible to totally eliminate the risk. It’s inherent. 

Our camp world is hesitant about communicating inherent risks such as the potential for rabies exposure through bats. We articulate risks associated with specific activities but have largely been silent about those associated with the camp’s environment. It’s time to do otherwise. Talk with your camp’s leadership team and legal counsel. Determine the inherent risks of your camp program that are associated with location (think flora and fauna), then review the strategies you utilize to minimize, if not eliminate, those risks. Finally, consider how to inform potential clients and staff so they more fully understand the impact of a decision to be at camp. Doing so can make a big difference when working through incidents like rabies exposure.

Is this challenging? Yes. Is there risk in doing it? Yes. How one communicates the message(s) makes a difference. We want people to understand the impact of their decision to have a camp experience. While this article focuses on bats and responding to post-exposure rabies prophylaxis, the silver lining is that many good reasons for camp exist. In the resulting cost-benefit analysis, a camp experience still comes out on top. 

Many thanks to the camp professionals who shared their bat and rabies shot stories. Their shared perspectives contributed to fleshing out our knowledge and provided tips for effectively managing an exposure incident. Camp professionals with additional information and/or comments can email Linda Erceg at erceg@campnurse.org.