The targeted rabid bat education and outreach plan is a new practice which includes some aspects of the Protocol for Assessing Community Excellence in Environmental Health (PACE EH) protocols, utilizing the core public health principals of assessment, policy development and assurance. VPH found that community awareness about the local risk of bat rabies was low, both among the public and veterinary staff. As a result, there were instances where people handled ill bats, released bats after they had access to bedrooms or didn't submit them for testing, resulting in possibly unneeded rabies PEP. Continued lack of awareness of rabies risk may ultimately result in a person contracting rabies after a bat exposure if they did not seek medical help after the contact. Also, many owners of indoor cats were not aware that rabid bats have been found indoors in LAC, did not believe their cats were at risk of exposure to rabies and so did not get their pets immunized against rabies, putting their pets at risk of contracting rabies or having to be euthanized after an exposure to a rabid or untested bat.
Although all LAC residents are potentially at risk of contact with bats, as specimens were submitted throughout the area over the years, bat submissions are concentrated in certain areas of LAC. For instance, since 2010 about 40% of rabid bats have been found in the Santa Clarita Valley each year. The location of bat roosts in the area is unknown, however, since rabies does spread from animal to animal, exposure risk is expected to be elevated in areas where a rabid bat is found. Thus, targeting education efforts to higher risk areas would reduce cost and effort, while still reaching those at greatest risk.
Local rabies surveillance is performed by VPH in collaboration with 28 animal control agencies, over 500 veterinary clinics, wildlife facilities and the public. Prior to this program, VPH worked to educate veterinarians and the public about bat rabies risk by providing information about local cases in presentations to the local veterinarians, the veterinary clinic reporting manual, at health fairs, on the program website, in sporadic press release and via targeted outreach when there may have been unknown public exposures. Despite these efforts staff found awareness about bat rabies continued to be low when discussing the issue with people at health fairs and in a survey of local veterinary clinics. Awareness may have been low, in part, since bats are very small animals and the clinical signs of rabies in bats is not as dramatic as the infection in pets or larger wildlife. In LAC rabid bats are generally found on the ground or inside a building, are unable to fly, or remain attached to a wall outside a home for an extended period without leaving to forage during the night. In contrast, rabid dogs, cats, raccoons, foxes, and other carnivores often become aggressive when rabid, attacking people and other animals, and generally drawing a lot of attention. In areas where there are no terrestrial reservoirs of rabies, people may believe that rabies is not an issue as rabies in bats is easily missed and doesn't create a dramatic attack that may be broadcast on the news or be shared on social media. Sadly, the lack of awareness that bat contact may result in a rabies exposure, even if a bite wound isn't seen, has led to bats being the primary cause of human deaths from rabies in the United States (US) in recent years. It is also possible that awareness is low because of the large number of new residents moving into the area each year, who may be unaccustomed to concerns about rabid bats where they lived previously.
The goal of the new practice was to educate residents in areas where rabid bats were found so that they know what to do if they saw a sick or dead bat, and what steps they should take to reduce rabies risk to themselves, their family, and pets.
The focus was to notify all residents within 10 homes from where a rabid bat was found, or all nearby businesses within the block. Residents and business staff who received the related handouts would be expected to be more aware that they should not handle bats found on the ground or in their home and to contact their animal control agency so that the bat could be collected and tested. Outreach materials distributed to veterinary clinics within 5 miles of each case would also help educate their clients, help spread information beyond the target area and raise general community awareness in higher risk areas.
This multipronged outreach effort ensured that residents who don't have pets or are unable to afford veterinary care in the high-risk areas still received the information. The messages were further distributed to the rest of the nearby community through the postings at veterinary practices and sharing of information on social media by both impacted residents and the clinics. The Rabid Bat Notices were provided in English and Spanish; however, additional translations would be used if the outreach was to an area where many residents communicated in a different language (e.g., Armenian).
Rabies education and outreach methods have not been included in the main tools or lists of best practices in public health even though rabies remains a public health concern throughout the US. Rabies is found in animals across the continental United States each year, and while terrestrial strains vary state to state, bat rabies is found throughout the nation. Rabies control and surveillance efforts may be led by a variety of agencies, including animal control, police, humane societies, community services and public health. However, public health agencies become involved when someone develops rabies, or when they may have been exposed to a rabid animal and need evaluation regarding rabies PEP. A One Health Approach is needed when developing rabies outreach plans, since rabies not only impacts human health, but also animal and environmental health.
VPH utilized parts of the PACE EH when developing the framework for this project. The first step was assessment and identifying the issue. When staff talked to residents at health fairs, during rabies case investigations and at other venues, it was clear that many people were not aware that rabies was circulating in the local bat population and that the virus could spread to people or pets. A survey of local veterinary practices in 2017 showed that most veterinarians were not aware that there were rabid bats detected near their practices, even though the information waws distributed to each practice every few years in a VPH Manual for Veterinary Clinics and was posted on our program's website. This lack of awareness led to most veterinarians considering indoor pets at very low risk of rabies exposure and 29% not recommending rabies vaccination for indoor cats.
The next step was bringing together a team within our program to discuss the survey results, what were the issues, potential solutions and capacity to implement the project. Local rabies surveillance was also reviewed. The lack of public and veterinary awareness that rabies was circulating in bats was a concern. The surveillance data demonstrated that rabies was detected in some areas more frequently than others, so a targeted education campaign was a better use of the program's limited resources and staffing. There were no additional funds for this project, and so it would need to be completed with existing funds and staffing.
Previous outreach efforts were considered (clinic reporting manuals, website, health fairs, occasional targeted outreach, and media releases) and ideas of where they could be improved were generated and evaluated given the limited resources. Potential ideas of how bat rabies awareness could be increased were discussed and the group decided that door-to-door outreach in neighborhoods where rabid bats were found had the greatest likelihood of reaching most residents in the high-risk areas. Also, that veterinarians/veterinary clinics and homeowners associations could be leveraged to expand our reach to the various communities via their social media platforms, email lists and postings at the clinics themselves.
Once the general plan was decided upon, priorities for action were set to implement the project. Specific educational materials were developed, utilizing plain language and department guidelines, and approval was obtained from Health Education Administration and the Office of Communications. The program website was updated with information about bat rabies and what people should do if they find a bat in or around their homes, including a flow chart to help individuals know when a potential rabies exposure had occurred. The veterinary practice contact list was updated and protocols on how to notify veterinary practice about rabid bats in their areas were developed. An Animal Health Alert was sent to local veterinary practice via email about bat rabies, the need to report bat encounters and a request that they help educate pet owners about the need for rabies vaccination, how to keep bats outside of homes and what people should do if a bat gets into a home or has contact with people or pets.
The next step was to implement the planned education and outreach effort. Starting in April 2019, outreach was conducted for every bat found to be rabid. As the number of rabid bats increased each year, the number of people contacted also increased. The number of rabid bats detected also increased from 27 in 2018 to 68 in 2021. Collaborating with homeowner's associations and posting of information on neighborhood social media platforms reduced staff time required for door-to-door outreach with many of the cases, but still the number of homes visited also increased from 189 in 2018 to over 740 in 2021. The level of veterinarian contact, and collaboration also increased, as veterinary practices were contacted about bat rabies 52 times in 2018 but 654 times in 2021.
The increase in bat rabies submissions and detections demonstrated that the targeted outreach was increasing public awareness about bat rabies, with many individuals reporting that they had heard about bat rabies or had received our outreach materials when being interviewed about their potential bat exposures. In one instance a resident submitted a bat for testing after stepping on it with a barefoot. They reported that they knew it needed to be tested for rabies after reading a handout left on their door step the previous week when a rabid bat had been detected on the neighboring block. They stated they hadn't realized bats carried rabies prior to reading the material. The bat was submitted, tested, and found to be positive for rabies and the resident received appropriate PEP.
This outreach effort is a new practice so there are no existing guidelines for how to increase awareness about bat rabies. However, it has been shown that bat rabies poses a risk to humans in the United States. Avoiding contact with wildlife and bats, vaccinating pets, obtaining medical care after potential exposures, and receiving post-exposure prophylaxis after exposures are critical to reduce rabies risk and prevent deaths.
References:
- Pieracci EG, Pearson CM, Wallace RM, et al. Vital signs: trends in human rabies deaths and exposures—United States, 1938–2018. MMWR Morb Mortal Wkly Rep 2019;68:524–8.
- Brown CM, Slavinski S, Ettestad P, Sidwa TJ, Sorhage FE; National Association of State Public Health Veterinarians; Compendium of Animal Rabies Prevention and Control Committee. Compendium of animal rabies prevention and control, 2016. J Am Vet Med Assoc 2016;248:505-17.
- Dato VM, Campagnolo ER, Long J, Rupprecht CE. A Systematic Review of Human Bat Rabies Virus Variant Cases: Evaluating Unprotected Physical Contact with Claws and Teeth in Support of Accurate Risk Assessments. PLoS One. 2016 Jul 26;11(7):e0159443. doi: 10.1371/journal.pone.0159443.
- Ma, X., Monroe, B. P., Wallace, R. M., et. al. Rabies surveillance in the United States during 2019. J Am Vet Med Assoc. 2021 258(11), 1205-1220.
- Wright, E., Anuradha, S., Richards, R., & Reid, S. A review of the circumstances and health-seeking behaviours associated with bat exposures in high-income countries. Zoonoses Public Health.2022 69:593–605.