Research ArticleQualitative Case Study of Public HealthPreparedness and Response to the Rabid RaccoonDiscovered in Wise County, Virginia
Brian Martin,1 BenjaminWilliamson,1 Vinayak K. Nahar ,1,2 Karen Gruszynski,1
Manoj Sharma ,3 and JasonW. Johnson1
1Center for Animal and Human Health in Appalachia, College of Veterinary Medicine,DeBusk College of Osteopathic Medicine and School of Mathematics and Sciences, Lincoln Memorial University, Harrogate, TN, USA2Department of Dermatology, School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA3Behavioral & Environmental Health, School of Public Health, Jackson State University, Jackson, MS, USA
Correspondence should be addressed to Vinayak K. Nahar; [email protected]
Received 1 November 2018; Revised 21 January 2019; Accepted 18 February 2019; Published 1 April 2019
Rabies is a zoonotic lyssavirus of mammals that is a major public health threat due to the high mortality rate in humans whodevelop clinical symptoms. In the United States and other developed countries, the main reservoirs are wildlife species. In April2017, a raccoon tested positive for rabies in Wise County, Virginia, with a second raccoon testing positive in May. Wise County,Virginia, is one of the few counties in western Virginia that is not endemic for raccoon rabies variant virus. Due to this fact, local,state, and federal agencies worked together to prevent and control the outbreak to stop the public health theat. The purpose of thisstudy was to understand how professionals from these various agencies viewed the response efforts to the two rabid raccoons in2017 and to determine what could be done to improve future responses. A list of responders from the different agencies involved inthe outbreak in 2017 was created. Participants were recruited via email and those who agreed to be interviewed were contacted viatelephone. Participants were asked a series of 13 questions pertaining to the 2017 outbreak to understand more about the strengthsand weaknesses perceived during the outbreak. Of the 11 individuals contacted, six agreed to an interview. Data were analyzedutilizing a three-step qualitative analysis process which included the steps of open coding, audit trail, and axial coding. Staff andpartnerships were identified as strengths of the responsewhile funding, community, and region were identified as weaknesses of theresponse. It is hoped that by identifying different strengths and weaknesses through qualitative analysis this will aid in improvingfuture responses.
1. Introduction
Rabies is a zoonotic lyssavirus that is endemic in mostof the world and the United States (US). It is capable ofinfecting and being transmitted by all mammals. In theUS, the main reservoirs are wildlife species such as bats(Order Chiroptera), raccoons (Procyon lotor), foxes (FamilyCanidae), and skunks (Mephitis mephitis). However, in thedeveloping world, the primary source of infection is fromdogs, due to a lower rate of canine vaccination [1]. Rabiesis a major health concern for both humans and animals.In humans, rabies can cause symptoms such hydrophobia,
incoordination, aggression, uncontrolled excitement, andconfusion. Similar symptoms present in animals. After theappearance of symptoms, rabies is not curable, eventuallyresulting in death of the infected human or animal [2].Rabies is most commonly transmitted through the bite of aninfectious animal but can also be spread via brain or centralnervous system tissue from an infected animal. It can beprevented in humans by the administration of postexposureprophylaxis after an exposure occurs, but before symptomsappear. Cost of the postexposure prophylaxis (PEP) is amajor concern as it often exceeds $3,000 in the US [3]. Inthe US, rabies usually falls under the jurisdiction of public
HindawiJournal of Veterinary MedicineVolume 2019, Article ID 5734590, 5 pageshttps://doi.org/10.1155/2019/5734590
health officials and affiliated agencies as these agencies areoften responsible for overseeing testing of animals, providingguidance on the administration of rabies PEP, and otheractivities related to rabies prevention and control.
In Virginia, the first case of raccoon rabies variant wasidentified in 1978. The virus gradually spread throughout theMid-Atlantic area creating a public health burden in the area[4]. According to the Rabies Surveillance in the United States2017 [5], Virginia had 355 animals that tested positive forrabies between January 1 and December 31, 2017 includingraccoons (157), skunks (100), foxes (40), bats (20), ground-hogs (2), cats (25), cattle (4), dogs (2), sheep and goats (2),and swine (1).
To control the spread of raccoon rabies variant, theUnitedStates Department of Agriculture Wildlife Service (USDAWS) has maintained the Appalachian Ridge Oral RabiesVaccination (ORV) Zone for over 15 years [6]. The goal ofthe zone is to prevent the spread of rabies westward intonew ecosystems. LenowiscoHealthDistrict, which consists ofWise, Lee, and Scott counties along with the city of Norton,is the major health district impacted by the vaccination zonein Virginia.
In April 2017, a raccoon tested positive for rabies in WiseCounty, Virginia, with a second raccoon testing positive inMay [7, 8]. From the implementation of the AppalachianRidge ORV Zone in 2002 to the racoon outbreak in 2017,there have only been a total of four bats (2002, 2008, 2013),three skunks (2002, 2009, 2011), and one dog (2003) that havetested positive for rabies in the LenowiscoHealth District [9].In response to this outbreak, public health officials advisedresidents to take preventative measures such as avoidingwild and stray animals and ensuring that their animal’svaccinations were up to date [8]. Additionally, the USDAWS distributed the ORV, Raboral V-RG, September throughOctober in Tennessee, Virginia, and North Carolina as partof their Abingdon, VA project [10].
The finding of two rabid raccoons west of the zonepresented a public health risk to the people in the WiseCounty and other communities west of the oral vaccine zoneas it was an unexpected threat to the community.The purposeof this study was to evaluate the perception of professionalsfrom various public health agencies involved in the responseto the rabid raccoons in the LenowiscoHealthDistrict in 2017.
2. Methods
Participants were identified as having a public health relatedrole in the prevention and control of rabies in Wise County,Virginia during the time of the discovery of the rabidraccoons. Participants were recruited via email and thosewho agreed were interviewed via telephone. Oral consentwas received at the onset of the telephone interview andconfidentiality of participants was maintained by collectingno identifiable information.
2.1. Interview Instrument. Participants were interviewed uti-lizing a standardized open-ended interview consisting of13 questions. The first three questions established the par-ticipants’ role in rabies control in Wise County, Virginia.
Questions 4–6 addressed the participants’ connection to therabid raccoons. Question 7 asked the participant to ratepublic health preparedness in Wise County regarding rabiescontrol while questions 8 and 9 probedwhat current strengthsand weaknesses existed in Wise County. Questions 10 and 11solicited opinions from the participant about what potentialopportunities and barriers exist regarding rabies controlin Wise County. Question 12 asked the participant if theyhad heard of the Center for Animal and Human Health inAppalachia (CAHA) and what role they felt it played in rabiescontrol. The final question allowed the participants to addany additional on the topic. The questionnaire is attached assupplemental information (available here).
2.2. Data Analyses. Data were analyzed utilizing a three-step process [11]. The first step, open coding, established athematic conceptualization around codes. The second step,audit trail, linked the data with themes. Finally, axial codingwas used to put together the conceptual model. Initially,interviews were transcribed and responses were organized byquestion in an Excel spreadsheet. Responses were analyzed byeach researcher individually for codes which were extractedto form a preliminary list of codes. A codebook was thendeveloped by comparing individual code lists as a group soas to create a parsimonious list. This codebook was then usedto code the remaining interview transcripts. Similar codeswere combined into categories based onhow related the codeswere to each other as well as how distinct they were fromother proposed categories. This process of simplification andgrouping was repeated at the category stage, grouping cate-gories into themes based on their similarities. Actual quoteswere linked to each theme. Finally, the entire conceptualmodel was developed.
3. Results
Eleven participants from local, state, and federal agencieswere contacted for this study. Of the 11 individuals contacted,six agreed to an interview (54.5% response rate). Intervieweeshad an average of 15.25 (SD: 10.69) years of experience inthe area of public health or One Health and worked withthe community of Wise County for an average of 10.25(SD: 10.83) years. Participants reported working as epidemi-ologists, medical professionals, and health administrators.Seven categories were identified from interview results: staff,partnerships, funding, community, region, communication,and education. These categories were further placed into oneof three themes: current strengths, which included staff andpartnerships, current barriers, which included funding, com-munity, and region, and finally opportunities for improvement,which included communication and education.
3.1. Current Strengths. One of the identified strength was staffquality and their ability to work with other agencies. Everyparticipant praised the current staff and most described thecurrent preparedness as “good” or better. In particular, all butone participant mentioned the ability of the staff to utilizepartnerships with other agencies as a primary strength.
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Staff described the quality of the individual staff mem-bers as well as staff numbers. Staff in Wise County weredescribed as knowledgeable, proactive, experienced, and hada good physical presence within the community. Interviewee3 stated, “I was really impressed by them, they were willingto initiate a lot of contact with the public and worked heavilywith USDA Wildlife Services. They were more than willingto go above and beyond whatever was asked of them.”Interviewee 1 said “I think that the local health staff are wellintegrated into those communities. . . being present in themoment and the location where they need to be.” Regardingthe staff response to the rabid raccoon, Interviewee 2 stated“They are very proactive andwhen an event happens it is dealtwith immediately,” And “. . .the response, the understandingof rabies is very good, the understanding of the effects of arabid racoon is really important and they’re very respons[iv]eand they take everything very seriously.”
Partnerships described interactions between organiza-tions including the Virginia Department of Health, com-munity hospitals, universities, and even the army. Currentpartnerships were described as strengths but participantsalso mentioned the need to improve. Interviewee 4 stated,“. . .I think that the collaboration with veterinarians and thecollaboration with animal control is good. . . Animal controland the health department work very closely with statelabs, the Division of Consolidated Laboratory Services, thathave human or other animal exposures and you know, theturnaround time and the turnaround on reporting is quitegood.” Interviewee 2 likewise mentioned, “. . .they are one ofthe areas that is very inclusive with all of their partners andthey have more partners than almost anyone else,” And that“. . .they immediately reach out and pull in people directlyrelated and people, such as myself, who can offer assistancein either large and small ways.”
3.2. Current Barriers. Participants primarily described thecurrent barriers to effective rabies control as funding, com-munity (e.g., compliance with government regulations), andthe rural region of southwest Virginia. Low community com-pliance and cooperation which ranged from not vaccinatingpets to actively transporting animal populations across thestate was also mentioned. Half of the participants mentionedthe geographic and demographic barriers within the regionas a weakness in terms of communicating and providingsurveillance for new rabies cases.
Funding was primarily mentioned in terms of insufficientstaff levels, as both a current weakness, and as a potentialbarrier to improving rabies response in the area. Low fundingwas implicated as the reason for decreased support of rescu-ing animals in neighboring counties, specifically an inabilityto collect and house stray cats. Interviewee 6 stated “. . .moneyis always a barrier no matter what you are talking about. . .they do plenty but I’m sure they could do more if they hadadditional staff.” It was also mentioned as a potential causeof decreased community compliance in terms of vaccinatingpets. As Interviewee 4 stated, “. . .the cost of going to aveterinarian’s office and getting a vaccine when you aren’tgetting it from a low-cost annual rabies clinic can cost quite abit of money. . .” In terms of staff numbers, Interviewee 6 said,
“The biggest weakness inmy opinion is, I guess there is a lot ofturnover in the emergency room staff and occasionally we getnotifications of the bite sometimes 8-10 days late. And that’sthe exception, it’s certainly not the rule. They are not alwaysaware of the protocols and that has to do with other issues.”
Community described the actions of the general publicacting on their own and includes topics such as compliancewith vaccination and leash laws, reporting suspicious ani-mals, and translocating animals (e.g., formaintaining popula-tion levels for hunting). Community was typically mentionedas a barrier to rabies control in terms of funding (e.g., a visitto the veterinarian’s office), lack of education, or a lapse inpersonal accountability. Interviewee 1 claimed “. . .[T]here isan element of irresponsibility among pet owners. . . and I’mspeaking of things like leaving food out, leaving water out,allowing animals to run loose, failing to vaccinate animals forrabies, all of these things are challenges that we deal with. . .”A culture of self-reliance was mentioned by Interviewee 3 asan impediment to compliance, saying “. . .they are more thanwilling to just take care of the problem and not call up andreport that problem to the local health department and to thegame department, so that testing of the carcass can occur.”
Region referred to the unique challenges that come withworking within a rural area. Wise County’s low populationdensity was cited as a barrier to surveillance as well ascommunication with the public. As Interviewee 5 put it, “Icertainly think that we are working together to do the bestthat we can, but due to the nature of the low populationdensity and the rural nature of that area sometimes it’s a littledifficult to get the word out to people.” The poor socioeco-nomic status and sparse telecommunication infrastructure inthe region also present a barrier to effective rabies control.Interviewee 3 claimed “. . .internet is really, really sparse downthere and the economic status of many of the citizens downthere doesn’t allow them access to the internet. . .”
3.3. Opportunities for Improvement. Possibilities for improve-ment in regard to rabies control in Wise County wasdescribed primarily in terms of improving communicationwith the public, increasing efforts to educate the public aboutrabies spread and the proper methods of reporting possiblerabies cases. Most participants described improvements incommunication as increasing the number of outlets forreleasing information about new rabies cases in order toincrease the number of people receiving the news. Increasingeducation was mentioned by most participants in terms ofincreasing community compliance, especially in regard toproper vaccination of pets.
Communication between the health department and itspartners was described as a strength in terms of beingconsistently prompt and inclusive. Communication with thepublic; however, was cited as a potential barrier due to thereasons mentioned under region. Diversification of informa-tion dissemination could improve rabies control Interviewee2 suggested “[b]etter posting of information on social mediaand the routes that people use to get information other thantelevision and newspapers.” Interviewee 3 emphasized non-internet sources, stating “Whether its leaning more heavilyon public meetings or trying to get more information on to
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the local news as opposed to website updates and relying onthe internet, which is our go to so frequently. The first thingsomething happens, you throw something up on your websiteand for this particular part of the state it’s not going to work.”
Education refers to teaching the public about rabiesprevention and surveillance. Community education was con-sistently seen as an opportunity to improve rabies preventionand a lack of education was mentioned as a possible causefor low community compliance. For example, Interviewee4 stated some members of the public vaccinate animalsthemselves using vaccines they found at a bait store whichis considered noncompliance in the state of Virginia thusillustrating a lack of knowledge about rabies laws. Interviewee6 suggested “. . .coordination with the schools, educatingthe schools about rabies more. . .” as a possible avenue ofimprovement. In regard to improving community education,Interviewee 3 stated “I think that theremay be an opportunityfor that center [Center for Animal and Human Health inAppalachia] to assist with that or get the right people tothe table to be able to talk about changing attitudes. Talkingabout the human dimension side of things, increasing com-munication, just increasing awareness out there.” Similarly,Interviewee 5 commented “. . .any group like that, especiallygiven the locality, can help create or come up with ideas foroutreach and education. . .”
4. Discussion
In this study, six of the eleven public health officials whoworked on the 2017 rabid raccoon outbreak were interviewedregarding rabies prevention and control. Most intervie-wees believed that agencies responded to this situation inan effective and timely manner. Local health departmentemployees, veterinarians and animal control were consis-tently mentioned as a strength in rabies control due totheir knowledge and skill. The ability and frequency withwhich employees partnered with other organizations wasalso mentioned as a strength, but also as a potential area ofimprovement, particularly in areas of public outreach andeducation. However, while the employees were described asskilled, it wasmentioned that they are short-staffed and couldbemore effective if they received additional funding. Fundingcould be used to increase staff numbers, but also to increaseprograms which improve public education regarding rabies,such as transmission, the importance of vaccinating pets,and the importance of working with government agencies indealing with potentially rabid animals.
A major weakness mentioned by most interviewees wasa lack of public compliance in regard to rabies control.Wise County residents were described as having an indepen-dent mentality, avoiding government involvement when theydeemed it unnecessary (e.g., disposing of a rabid animal).Residents were noted to sometimes leave food and waterout for wild animals, increasing the chances of contractingrabies by either themselves or their pets. There is also thelikelihood of residents transporting raccoons across the statein an effort to maintain/increase population levels. Thesefindings suggest there is a general lack of education regardingrabies among the residents of Wise County and underline
the importance of increasing efforts to educate the publicabout the dangers of rabies and handling wild animals andthe importance of vaccinating pets.
Public compliance is of utmost importance when at-tempting to control rabies for many reasons. Rabies is aresilient virus which has successfully established itself inmany mammalian species. In 2018, Ma et al. [6] found that2/3 of reported rabies cases in the US were not variant typed,increasing the risk of a rabies case going unidentified, andpossibly missing the spread of a known variant into a newenvironment. Unreported cases (e.g., when individuals donot report animals behaving strangely) naturally increase therisk of allowing a rabies case to go unidentified.
Communication with the public was mentioned as anarea of difficulty, primarily due to the rural nature of WiseCounty. Internet access was described as being sparse andnot wholly reliable as a means of disseminating knowledgeto the average citizen. Barring improvements to telecommu-nications infrastructure, more traditional means of reachingand educating the public may be necessary and could bea task undertaken by Lincoln Memorial University’s Centerfor Animal and Human Health in Appalachia (CAHA). Halfof the participants indicated a potential role for CAHAin increasing the presence of veterinarians and medicalprofessionals familiar with rabies virus and other zoonoses.CAHA was viewed as a way to increase public knowledgethrough either educational campaigns or outreach such astown meetings regarding vaccinations and animal health.
From a government standpoint, continued use of ORVremains an effective method of controlling rabies. However, itis an object of concern that the two raccoons were found westof the Appalachian ORV, which brings up questions on howthe raccoons arrived there. In neighboring West Virginia,Plants et al. [12] found significant decreases in the numberof rabies-infected racoons from 2000-2015 due to heavy ORVutilization. However, they found that ORV was less effectiveagainst nonraccoon hosts, suggesting possible viral spread toother animals such as pets and livestock and emphasizingthe need for regular vaccinations of animals in contactwith humans. In a Canadian study on rabies containmentin raccoon populations, Stevenson et al. [13] found thatrabies could be eliminated from raccoon populations throughoral vaccine baiting tailored to raccoon environments andfollowing up on public reports. However, they found that inthe provinces of Quebec, New Brunswick, and Ontario thatrabies returned to the raccoon population after a period aslittle as four years, underscoring the importance of continuedvigilance in surveillance and baiting. Freuling et al. [14]described the necessity of increased funding needs for totalrabies elimination in their study of the eradication of rabiesfrom fox populations in western and central Europe. Theynoted diminishing returns to oral vaccination efforts whichnecessitated a determined effort to reach total elimination,rather than simply diminishing rates of occurrence.
5. Conclusion
Overall, the public health officials in Wise County, Virginiathought that the response to the 2017 rabies outbreak in
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raccoons was effective. Strengths included experienced staffand partnerships with local and national agencies. Funding,compliance, and communication were identified as areas thatcould be improved upon in the future. These findings are notonly of importance to Wise County, Virginia, but could beof value to other rural, raccoon variant endemic areas in theEastern US.
Data Availability
The data used to support the findings of this study areavailable from the corresponding author upon request.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Authors’ Contributions
Vinayak K. Nahar and Manoj Sharma contributed to con-ception and design; Manoj Sharma and Vinayak K. Naharcontributed to instrument development; Brian Martin andBenjamin Williamson contributed to analysis of data; allauthors are responsible for interpretation of data; all authorsdrafted the article or revised it critically for importantintellectual content; all authors gave final approval of theversion of the article to be published; and all authors agreeto be accountable for all aspects of the work in ensuring thatquestions related to the accuracy or integrity of any part ofthe work are appropriately investigated and resolved.
Supplementary Materials
Interview instrument measuring public health preparednessand response to the rabid raccoon. (Supplementary Materi-als)
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