Targeted Rabies Outreach at Veterinary Clinics & Online to Increase Awareness & Reduce Risk

The Los Angeles County (LAC) Department of Public Health (DPH) has over 5,000 employees, making it one of the largest accredited health departments in the nation.  DPH's mission is to protect health, prevent disease, and promote health and well-being for everyone in LAC. Department activities and services range from data collection and analysis, health education, communicable disease control and health inspections to provision of preventive health services, emergency preparedness, policy development and veterinary public health.  LAC is unique in that DPH has authority over rabies control and animal disease surveillance activities, whereas the 28 local animal control agencies provide shelter, licensing, and stray animal control services. However, rabies control can only be achieved by collaboration with local animal control agencies, veterinary clinics, health care providers, and the public.  

LAC is home to a large diverse population of about 10 million residents, which represent many of the cultures around the world.  Over a third of residents are foreign born, 55% of residents speak languages other than English, and about 3.5 million speak Spanish. There are 1.4 million residents who speak English less than very well.  In LAC, 49% of residents are Latinos, 25% non-Hispanic Whites, 15.6% Asian, 9% Black or African American, 1.5% American Indian or Alaskan Natives, 0.4% native Hawaiian or Pacific Islanders, and 3% multiracial.  The environment of LAC spans urban, suburban, and rural settings, covering land from the ocean to mountains and high desert. Both domestic and wild animals are found in all areas of LAC.

The Veterinary Public Health program (VPH) is responsible for rabies surveillance and control in LAC.  Since the 1970's, rabies has only been found to be circulating in bats, with one spillover to a skunk in 2014. Local veterinarians haven't treated rabid animals for decades, except two ill imported pets that were diagnosed with rabies shortly after arriving in the US (1987 cat from Mexico, 2004 dog from Thailand).  Through the years, the program noted many LAC residents and veterinarians were not aware that bats could carry rabies locally and handled bats inappropriately. Examples include multiple children handled a bat at camp, a bat was taken into a classroom for examination, and multiple people tried to help bats by moving or feeding them.  Residents have released bats from homes after they may have had access to the bedrooms. When public health became aware of the potential exposures, the individuals received rabies post-exposure prophylaxis (PEP), preventing the spread of the virus. However, many of these exposures could have been prevented if the person had knowledge of bat and rabies risk. In 2017, VPH conducted a survey of local veterinarians on their knowledge about local rabid bat cases and their rabies immunization practices.  The survey showed that although a rabid bat had been detected within 5 miles of 85% of the veterinary hospitals in the preceding decade, only 36% of the clinics reported being aware of this.

The general lack of awareness about bat rabies is a local public health issue which resulted in preventable potential rabies exposures, increased medical costs, and the lack of preventive measures such as pet immunization and bat exclusion from homes. To address this problem, in 2018 VPH developed a targeted outreach and education campaign to increase awareness of bat rabies and steps people could take to reduce risk.  The goals were to:

1)      educate residents in neighborhoods where a rabid bat was found and

2)      contact veterinary practices within five miles to request assistance with public education about the rabid bats and encourage clients to keep their pet's rabies immunizations up to date.

An educational flyer, standard rabid bat notice, and standardized messaging were developed.  A listing of veterinary clinics, with contact phone/fax numbers and email addresses was created, and nearby clinics were identified using Google maps each time a rabid bat was identified. Since learning that some people had found information on-line encouraging them to release bats that are found in homes, VPH updated its website to include information about what to do if a bat is found in the home, including a flow chart about what to do and a video about never touching bats. Starting in 2019, each time a rabid bat was identified, residents in the neighborhoods were provided the handout and flyer by door-to-door outreach, emails by their homeowner's association, and/or through social media platforms such as Nextdoor. The flyer was shared with veterinary clinics, and they were encouraged to post them in their lobbies and share them on their social media platforms, websites, and other venues.

The project objectives were met. Between 2018 and 2021, awareness of bat rabies improved in areas where infected animals were found. The number of animals tested for rabies in LAC increased annually from 592 in 2018 to 709 in 2021, as did the number of bats tested (241 in 2018 to 322 in 2021). 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. The number of homes visited also increased from 189 in 2018 to over 740 in 2021.  More rabid bats were found in neighborhoods where outreach had occurred previously, but fewer people had direct contact with the animals and most immediately contacted animal control for assistance. A preliminary analysis revealed less people touched bats with their bare hands over time as well (3.3% in 2018 to 1.6% in 2021). The level of veterinarian contact and collaboration increased. Veterinary clinics were contacted about bat rabies 52 times in 2018 and 654 times in 2021.  When staff distributed reporting manuals to clinics in 2020, VPH rabid bat posters were seen next to the entrance of most clinics in the Santa Clarita Valley, an area where about 40% of rabid bats are found each year.

Program website: http://publichealth.lacounty.gov/vet/

Rabid bats in LAC website: http://publichealth.lacounty.gov/vet/bats.htm

Rabid bat in home website: http://publichealth.lacounty.gov/vet/batinhouse.htm

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:

1. 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. 
2.  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.  
3. 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.
4. 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.  
5. 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.

The goal of targeted rabid bat education and outreach was to increase local awareness that bats may carry rabies, educate individuals about what to do if they find a bat in or around their home or business, and identify more instances where people or pets may have had contact with a rabid bat so that steps can be taken to reduce the risk of transmission.

The objectives included notifying all residents in the neighborhood where each rabid bat was found so that they would know what to do if they saw a sick or dead bat in the area, plus notifying veterinary practices within 5 miles of where each rabid bat was found so that they could assist with the education effort. The resident that found the bat was encouraged to share the information via local social media platforms, such as Nextdoor. If the home was in an area with a homeowner's association, the association was contacted so that they could also assist with the outreach effort and reach more residents than could be notified either door-to-door or on neighborhood sharing apps.

VPH outlined what tools were needed to initiate the targeted education and outreach campaign: 1) an educational handout on Bats and Rabies, 2) a rabid bat notification flyer, 3) website information about bat rabies, $) an infographic in English and Spanish titled, What to Do if you Find a Bat”, and 5) a list of veterinary clinic contact information for engaging local veterinarians in the effort. 

The Department's Health Education Administration and Communication experts were utilized to ensure that the handout met standards of plain language, structure, and clarity, and also to develop a short video about not handling bats. Once the tools were developed, outreach to neighborhoods where each rabid bat was found was implemented starting in April 2019, before the usual summer seasonal increase in rabid bats.  By June 2019, an increase in rabid bats was already noted, and local veterinary clinics were sent an Animal Health Alert email to educate them about bat rabies, the increase in cases and how they could help educate pet owners.  Outreach efforts have continued throughout 2022 and are planned to remain as an on-going practice. 

As each rabid bat was identified, new stakeholders and collaborators were identified. In areas with homeowner's associations, they were contacted and assisted with distributing the handouts to all residents in their area. Some printed the flyers and distributed them door to door in their area, while others had email lists or social media platforms where they shared important information with residents. In each case, homeowners who reported bats were asked to participate in the education effort by sharing the flyers with neighbors or posting them on neighborhood social media platforms. When rabid bats were found at businesses, the managers were contacted and requested to post the flyers where customers could see them and distribute them to their staff. The flyers were also shared with regional public health staff so that they could share the information with city officials, at health fairs and other venues.

VPH staff led the planning and implementation of this project using existing staff and resources. They leveraged existing relationships with local veterinarians, animal shelters and other public health staff to extend the reach of the outreach effort. Efforts were made to educate homeowners and business staff that found the bats about bat rabies and steps that could be taken to reduce risk and explain how they could help with educating their neighbors and the community. Notifications were sent to public health management, area health officers and key area staff when each rabid bat was detected to ensure department staff were aware of the circumstances and supported outreach efforts.

During the first year, veterinary clinics were individually called and verbally informed of each rabid bat within five miles of their practice, followed by an email with the related flyer and handouts. As the number of rabid bats detected in certain areas increased, notably during the summer months, some veterinary clinics were being notified multiple times per week or month. Many of these clinics became accustomed to our notifications and outreach was completed simply by email as clinic staff were already educated about the issue and were both familiar and willing to share the information with their clients. The process of notifications became more efficient as bat rabies awareness increased among staff at veterinary practices and homeowner's associations, and less staff time was needed to engage these groups in the outreach effort.

The goal was to increase awareness about local bat rabies cases, both among the public and veterinary community and to improve the identification and reporting of bats and potential human or pet exposures. Prior to the implementation of the new procedures, a survey of local veterinarians found that the majority were unaware that rabid bats had been detected within five miles of their practice, even though this information was included in a VPH Manual for Veterinary Clinics that was hand delivered to their practice every few years. The survey showed that although a rabid bat had been detected within 5 miles of 85% of the veterinary hospitals in the preceding decade, only 36% of the clinics reported being aware of this. 29% of veterinarians did not recommend that indoor cats be vaccinated against rabies because they believed they were at very low risk of rabies exposure. Many of the veterinarians were not aware that rabid bats had been detected inside homes near their clinics in the past decade.

The new targeted rabid bat education and outreach began in 2019. Multiple data elements were tracked, including the number of animals tested for rabies, an account of human exposures to the animal, the method of capture of the animal, the number of rabid bats detected, the geographic areas where the rabid bats were found, notifications to veterinary clinics, neighborhoods receiving door to door handouts and the utilization of homeowner's associations to distribute the materials.  Between 2018 and 2021, awareness of bat rabies improved in areas where infected animals were found. The number of animals tested for rabies increased annually from 592 in 2018 to 709 in 2021, as did the number of bats (241 in 2018 to 322 in 2021). 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.  More rabid bats were found in neighborhoods where outreach had occurred previously, but few people had direct contact with the animals and most immediately contacted animal control for assistance. In an effort to evaluate if public knowledge about the risk of bat rabies was increasing over time, VPH identified the number of humans who purposefully touched a bat with their bare hands in each of the rabies datasets from 2018 to 2021. VPH found less humans were touching a bat with their bare hands over time, despite more bats being reported (from 3.3% in 2018 to 1.6% in 2021).

The level of veterinarian contact, and collaboration also increased, as veterinary clinics were contacted about bat rabies 52 times in 2018 but 654 times in 2021.  In areas where there were higher numbers of rabid bats, veterinary staff were contacted multiple times per month during the summer, which increased their knowledge that bat rabies was a major risk in their area. When staff distributed reporting manuals to clinics in 2020, VPH rabid bat posters were seen next to the entrance of most clinics in the Santa Clarita Valley, an area where about 40% of rabid bats are found each year. The signs were posted near the entrance and were clearly visible even when clinics implemented curbside service during the COVID-19 pandemic. When individuals were provided information about the bat found at their home being rabid, many reported that they had learned about bat rabies through handouts distributed in their neighborhood or by their homeowner association, or they had seen information at a veterinary hospital or on social media.  A few reported having found other rabid bats on their property before. For those that had contact with a bat or a bat had access to their bedroom, they reported that they understood they may have been exposed to rabies and so had sought the animal to be tested.  In one case, a resident stepped on a bat with their barefoot when they walked into their backyard barefoot at night. They reported they only became aware that bats carry rabies because of the handout that has been left on their doorstep the week prior for a separate rabid bat that had been detected on a neighboring street.

The annual increases in bats being tested and being found to be positive, as well as the annual decreases in the number of people touching bats with their bare hands, demonstrate that awareness that bats may carry rabies is increasing, as do statements by residents that have submitted bats for testing and local veterinarians who are now posting the notification flyers in their offices.

This practice was developed without any additional funding or staff and utilized existing relationships with local veterinarians, animal shelters and public health staff. Educational materials and a bat rabies webpage were created at the beginning of the project and are regularly maintained. Standardized templates were created for specific rabid bat flyers, and spreadsheets that included contact information for each local animal control agency were created so that flyers could be created for each rabid bat quickly and would include the appropriate agency for residents to call if they saw a sick or dead bat or if one was found in their home.  Contact lists were created for local veterinary clinics and were updated with new email addresses and phone numbers as needed.  Template emails were created to notify veterinary practices or homeowner associations, speeding up the notification process to these locations. LAC is very large, with over 500 veterinary clinics. At times 15 or more clinics need to be contacted related to a single rabid bat, and during the summer, several rabid bats may be detected in a single week. In 2022, VPH staff wrote code in R to automate the veterinary clinic email notification of a rabid bat in their area, which decreases the amount of time staff had to devote to outreach. Notifications of the homeowner and homeowner associations can be completed by one person. If door to door outreach is necessary, this can be completed by either one of the program staff in the normal course of their field work, or as staff are commuting towards their homes. Because of the successful increase in awareness, bat testing and rabies case identification, the program intends to make targeted rabid bat education and outreach a regular component of our program.

This project highlighted the value of One Health partnership, and the important role veterinary practices may play with educating the public about rabies and zoonotic infections.  When environmental risks are in an area that is overseen by a homeowner association, those associations may be good public health partners, especially if they understand the vital role they play in protecting the health of local residents. It also became clear that utilizing the identification of a rabid bat in an area can increase public interest, leading them to read risk reduction messages, since the nearness of the incident increases their sense of potential risk.  Previous efforts to educate the public through health fairs, social media messages and a website were a good start, but we were able to increase bat specimen submissions and detect more rabid bats after we started the targeted education. This practice is simple to execute and could easily be replicated in other cities and counties. The leveraging of veterinary clinics to help with public health messaging can also strengthen collaboration with the animal health community, making the public health department better able to address emerging zoonotic infections in the future.