Oops... Fixing an Immunization Decision and Some Other Valuable Lessons!
Ugh, this is a long one…
To begin, so no one gets confused, as a household we are massively disciplined around immunizations. We love vaccines and have the vaccine history cards for each one of us in hand to prove it!
The past week identified a hole in our vaccine arsenal, Rabies. The power of vaccines is obviously physical, but we also learnt this week just how psychological the protection is too.
Before we left in June we had a travel medicine appointment at the Polyclinic in Seattle (awesome!). We (i.e. Whitney, with me chiming in every few minutes to make sure I knew what they were talking about) and the infectious disease doctor had a very lively debate about each destination on our itinerary, what the possible exposures may be and which vaccines were available to reduce the risk of those exposures. With me and our 3 daughters in the room, it was both an awe inspiring discussion between Whitney and the Doctor and somewhat of a nightmare inducing event that made me feel like we were certainly going to die of some infectious disease at some point over the next year - it was a pretty intense and scary appointment!
We discussed rabies deeply. The key focus was our time in Asia and Africa where there is a small risk of exposure mostly due to the large number of stray dogs. We have 3 kids (6 yo, 3 yo & 6 months) and the oldest 2 absolutely love to connect with any animals, so it was definitely on our minds. However, the rabies vaccine is expensive and long (about $350 per shot, 3 shots per person. So $5,000 for our family of 5, not covered by insurance, spread over 21 days of shots) and the higher risk countries weren’t on the itinerary until 2020, so we passed figuring we could change our minds later if needed. We left that day with about 10 shots between us all and a handful of typhoid pills.
This is where the psychological value of immunizations comes in. Whitney, a pediatrician, and me a cautious finance person, are not known for risk-taking and that is putting it mildly. We arrive in Costa Rica and after the eventful first night in San Jose (see post on Children’s Hospital visit in San Jose!) drive to our home for a month in a nature reserve (i.e. jungle) near San Juanillo, north of Nosara in the Guanacaste province. Well, what we quickly learned is that there is a large colony of ‘fruit’ bats living under the overhang outside the house, and pretty much everywhere else in the region. (Interesting, or terrifying, fact: Over half the species of bats 🦇 in the world are known to exist in Costa Rica). Also, there are stray dogs literally everywhere. We are acutely aware of this every time the big girls jump with excitement as a pack of skin and bones dogs come running down the street. All we can think about is that we are all going to get rabies and die, probably a bit overdramatic, but a huge worry nonetheless.
This all came to a head on Wednesday (6 days ago) morning when Whitney woke up with two small marks on her arm that we couldn’t explain. We were like, wholly (insert set of expletives) this is real, she was bitten by a bat. We circulated a photo of the mark and hoped that the couple of infectious disease doctors we started with would laugh at us and send us back to the pool/beach/child-tantrum matters at hand. Not so much. Both the infectious disease doctor in Seattle and an infectious disease specialist here in Costa Rica felt the marks could be consistent with a bat bite and that she should get treated. There is a post-exposure (i.e. after you have been or think you have been bitten) rabies vaccine regimen that came into focus. If you have never had the vaccine (i.e. us) this involves an injection of rabies antibodies (immunoglobulin) followed by 4 vaccines over the next 2 weeks. We also consulted with local doctors and specialists who felt there was absolutely no way this could be a bat bite, and even if it was there was no way the guanacaste bats had rabies. While the local knowledge was definitely reassuring, it did not erase the opinions of the specialists who thought Whitney should seek treatment.
We kept the days going pretty normally with the visits to the beach, horseback riding activity for the girls and a marine experience to see the sea turtles. But this rabies concern was on our minds and clearly not concealed from our kids with Scarlett leading with “why are you both (Mom & Dad) so grumpy all the time?" and several other quotes. Plus I think our increase in approval of and even (shocking!) requests that they watch TV and/or eat ice cream to give us some much needed time to sort this all out added to the sense that something was going on. We were trying to decide if we should be ultra conservative and all get the post-exposure treatment, just get the regular vaccine series or some combination thereof.
In the end, after consulting (and re-consulting) with many doctors and doctor friends we decided the best/safest approach was for Whitney to get the post-exposure treatment and for the rest of us to start the regular vaccine series. The one we passed on two months ago in Seattle. By the way, Kudos to the US Consulate who has a 30+ page list of medical facilities and doctors sorted by discipline, it was a huge and valuable starting point. Similarly our high deductible insurance carrier was timely in providing their suggested points of contact.
Once we made our decision we were able to move into our more comfortable ‘action’ mode. How do we get this vaccine for everyone? This frankly is for me where I enjoy the world of business and it felt very similar now. Whitney needed the post-exposure course of injections (immunoglobulin + injections on day 0, 3, 7 & 14) while the other 4 of us would have the pre-exposure schedule of injections (day 0, 7 & 21). We were ~4 1/4 hours driving distance from San Jose and then a 3 hour flight to the nearest US city, Miami, or a connection away from Seattle if needed.
We were getting mixed information on the availability of the rabies vaccine in Costa Rica. Again, this is a good thing as it means no one is really needing it! But in our case, not exactly supporting our goal of achieving rabies immunization. Messages were mixed as to whether the vaccine was available at hospitals in San Jose. Everyone was certain there was no immunoglobulin in the country.
We landed on our ground game. We would drive to San Jose, walk into Hospital CIMA (and another couple of hospitals if needed) and see if we could get the rabies vaccination. If that was unsuccessful for any reason, we would stay the night in San Jose, book flights to Miami for the next morning (we were monitoring the tickets all the time and it was holding at about US$420 per person return with American Airlines) and spend a week on the ground in Miami getting everyone vaccinated. Then we would return to our house in the jungle or something nearby to resume our trip.
This decision, although it hurt local pride as they feel there is zero risk (and they are probably almost totally right) made us feel good. For me it came down to the following key points:
1) There were Costa Rica and USA infectious disease doctors who assessed Whitney’s bite marks as possibly from a bat.
2) The vaccine works vs. Rabies kills you. The post-exposure cost for Whitney became like a life insurance policy premium.
3) 3 Young Kids. We knew Hazel (6 months) couldn’t tell us if a bite happened and I wasn’t close to certain that Scarlett or Nora would tell us if they got a “small” bite from an animal like a bat or a dog.
So, with so much of our trip ahead of us this became a relatively easy decision to make. The biggest challenge was, and continues to be, the logistics of getting the vaccine and moving around Costa Rica to do so.
Yesterday late afternoon we got to Hospital CIMA in a suburb of San Jose and after some initial confusion we were told they do in fact carry the vaccine! So, we were successful in getting the first injection of three for Rabies - the cost was ~US50 per person, yes about 14% of the cost for a USA domestic consumer. Whitney and Hazel (who is still breastfeeding) got on a flight to Miami at 6:30am and she got the post-exposure immunoglobulin shot plus the first vaccine there and is returning to Costa Rica tomorrow morning. We will all do our remaining vaccine shots at the major hospitals in Costa Rica.
The confusion at Hospital CIMA was a good reminder of needing to ask for help (checking your ego at the door) and being fortunate to find great people to help you. When we first asked for the rabies vaccination a couple of staff members said they did not have it in stock so we should try the other hospitals. We then mentioned that one of their doctors had let us know yesterday that it was available here, but if it wasn’t was there someone at another hospital they could call for us and ask. This was said as we were tired from the 5+ hours of traveling, kids were hungry and whining, we were the tourists who were hard to understand because our Spanish is poor (Whitney is solid, me non-existent beyond basic pleasantries) and it was 5pm Monday afternoon. Anyway, it seemed like a senior member of the staff checked in with the staff members and instead of calling a neighboring hospital they dug deep and got us the vaccine. We were so happy and grateful for their effort. We were not the “easy” or “uncomplicated” customer and we had an unusual ask so just fortunate that they took pity on us.
Later that night I had to go back to pick up some nappies, which we forgot to bring, and Nora and Scarlett came with me. We accidentally left Nora’s sacred blanket there and only realized it when we got back to the hotel room. So, Nora and I made the trek back for a third time to see if it was still there. It was and we thanked the staff once again for saving the day. I think that last visit gave them more amusement than anything, we were just a walking tired mess at that point.
So, knowing the first round of vaccines have gone well, and given how fortunate we are to have Whitney’s knowledge and the professionalism of doctors, pharmacists and other specialists and friends around the world willing to consult with us on options we are reuniting tomorrow morning. We will spend a couple of days in San Jose to get Whitney’s day 3 shot and then workout where we can get the remaining shots on the dates needed.
So from a mental energy, anxiety and family time perspective we wish very much we had done the rabies vaccine in Seattle in June. But, for the way we gathered information, called complete strangers at hospitals all over San Jose, and had incredible help from people in our local community here it opened us up to an even deeper experience. Most importantly, this issue was one of the good ones in that it had a definable solution and one that could be achieved, many others will not unfortunately have these attributes!
I had a good day with Scarlett and Nora exploring a couple of attractions in San Jose while Whitney was in Miami. We are not sure what the final cost of the Miami part will be but the “savings” for the vaccine shots in Costa Rica will total about US$3,600 which helps a lot.
Looking forward to resuming our experience together tomorrow, knowing more of these challenges await us in the future, but feeling like we learned, mostly thrived, and grew as a family through this experience. Perhaps we will view those insect eating bats a little more favorably or be a little less brittle when the next group of neighborhood dogs approach. Baby steps, we will see.
A fun trip to the Costa Rica National Art Museum after our immunization shots and while we were hanging out in San Jose (while Whitney and Hazel flew to Miami).