Materials and Methods

At the time of the study, Eddy County was 90% rangeland and had a population of 54,419 (5.0 persons/km²). However, most residents (26,296 persons; 356.2 persons/km²) lived in the city of Carlsbad.

The study used a community-based participatory research protocol, which requires community partnership from study design through interpretation of results.⁷ Community stakeholders identified the need for this project, assisted in designing survey questions, and provided guidance in survey administration. Stakeholders included staff from the city of Carlsbad, Eddy County Animal Control, the local agricultural extension office, the local animal shelter, the Carlsbad office of the New Mexico Department of Health, and the 3 local veterinary practices.

With the aid of statistical analysis software,^a 366 residential properties were randomly selected from the 11,976 residential addresses within the Carlsbad Soil and Water Conservation District, the area in Eddy County where the 2011–2012 rabies outbreak had occurred (Figure 1). Sample size was determined on the basis of the likelihood of detecting a 7% difference in proportions between dichotomous categories with 95% confidence and a design effect of 1, assuming, on the basis of local stakeholder estimates, that 80% of residents owned pets and that 70% would respond to the survey. To increase response rate, a presurvey outreach campaign was conducted from December 2012 through January 2013. This campaign consisted of strategically posting flyers, mailing notices with the city water bill, and messaging through local media and stakeholder social media. The survey was pilot tested in conversational Spanish and English before administration.

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Map of the Carlsbad Soil and Water Conservation District, which experienced a skunk rabies outbreak during 2011–2012, showing location of rabid animals identified during the outbreak.

Citation: Journal of the American Veterinary Medical Association 246, 11; 10.2460/javma.246.11.1242

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From January 23 through February 2, 2013, after completion of standardized training, staff from the New Mexico Department of Health and the CDC conducted a read-aloud, door-to-door, 31-question survey. After learning from stakeholders that a substantial number of persons in the community worked alternate shifts in oil fields, mines, and ranches, a goal was made to visit each residence up to 6 times at different times of the day and different days of the week. The Carlsbad Police Department provided insight with regard to homes unsafe to visit. Bilingual notices about the survey were left when no one was home. Household members aged < 18 years and persons who were not full-time residents were excluded from participating. An information card, including rabies facts and contact information for animal control personnel, veterinarians, and the local animal shelter, was provided to respondents after survey completion. For survey questions asking about pets’ rabies vaccination status, up-to-date rabies vaccination status was defined as having received a rabies vaccine within the previous 3 years, regardless of the pet's age or history of receiving an initial booster vaccination at 1 year of age.

Prevalence ratios were calculated to measure the strength of associations. Qualitative data were collected in writing by interviewers in response to an open-ended question asking respondents to share additional comments about rabies in the community, and were evaluated by categorizing comments according to topics. Consistent with community-based participatory research protocols, results were presented to stakeholders for interpretation and development of locally appropriate, community-based recommendations. Because human subjects were involved, the study protocol was reviewed by the CDC but was considered to be public health practice rather than human subjects research.

Results

Individuals were contacted at 277 of the 366 (76%) residential properties selected for inclusion in the study. Of the 277 individuals who were contacted, 247 (89%) completed the survey, 2 (1%) were disqualified because they were nonresidents, and 28 (10%) declined to participate.

Fifty-six percent (138/246) of respondents were women. Median age of the respondents was 50 years (interquartile [25th to 75th percentile] range, 17 years; range, 18 to 97 years), and 74% (184/247) lived in Carlsbad. Sixty-eight percent (167/247) of respondents did not have a college degree, 31% (77/247) were Hispanic, 58% (144/247) were non-Hispanic white, and 73% (180/247) were pet owners. Of the 89 residential properties for which contact was not made, 68 (76%) were households at which no one answered the door, 17 (19%) were unoccupied houses, and 4 (4%) were houses that were not contacted because of police-identified safety risks.

Vaccination prevalence and barriers to vaccination—Among the 180 pet-owning households responding to the survey, 52 (29%) reported that not all pets had an up-to-date rabies vaccination status. Pet-owning respondents without a college degree (119/180 [66%]) were significantly more likely (PR, 2.0; 95% CI, 1.1 to 3.6) to have pets without an up-to-date vaccination status, compared with pet-owning respondents with a college degree or higher (61/180 [34%]). A higher percentage of households with dogs for pets (133/160 [83%]) had an up-to-date rabies vaccination status, compared with households with cats for pets (28/62 [45%]) and households with dogs and cats for pets (20/42 [48%]). Only 43% (18/42) of households leaving food outside overnight for their own pets and 36% (12/33) leaving food out for strays or wildlife reported that all of their pets had an up-to-date rabies vaccination status.

Overall, 292 dogs and 163 cats were owned by the 180 pet-owning households that responded to the survey. Of the 455 dogs and cats, 116 (25%) were reported to not have an up-to-date vaccination status. Cats (74/163 [45%]) were significantly more likely than dogs (42/292 [14%]) to not have an up-to-date vaccination status (PR, 3.2; 95% CI, 2.3 to 4.4; Table 1). Vaccination prevalence was not significantly different between urban (ie, within the city of Carlsbad) and rural (ie, within unincorporated portions of the county) pets (PR, 1.0; 95% CI, 0.7 to 1.4).

Pets allowed to roam freely were more likely (PR, 2.7; 95% CI, 2.0 to 3.7; Table 1) to not have an up-to-date vaccination status than were pets that were not allowed to roam, and pets housed primarily outside were more likely (PR, 1.4; 95% CI, 1.1 to 2.1) to not have an up-to-date vaccination status than were pets housed primarily inside. Sexually intact pets were more likely (PR, 4.5; 95% CI, 3.0 to 6.7) to not have an up-to-date vaccination status than were neutered pets.

Respondents most frequently identified cost (81/245 [33%]) and time or scheduling (52/246 [21%]) as barriers that prevented themselves or their neighbors from vaccinating pets against rabies; 14% (35/245) did not believe any barriers to obtaining rabies vaccinations were encountered. Analysis of qualitative data suggested that time and scheduling posed unique challenges for rural residents, who often had to drive as much as an hour each way to a veterinary clinic. Even though rural residents may have made routine trips to the city, those trips may not have coincided with clinic hours.

Knowledge of and attitudes about rabies, rabies vaccination, and wild animal exposure—Of the 247 respondents, 222 (90%) correctly identified raccoons, skunks, cats, dogs, coyotes, and foxes as species capable of transmitting rabies. However, 161 (65%) did not know horses and cattle can also transmit rabies. A total of 226 of 245 (92%) respondents knew that unvaccinated pets can contract rabies. However, 79 of 246 (32%) respondents did not know that rabies vaccination was required by law, 89 (36%) did not know a bat scratching a person can be an exposure, 45 (18%) did not know a dog playing with a bat can be an exposure, and 106 (43%) did not correctly identify both of these as exposures. Overall, 78 of 245 (32%) respondents did not know rabies is fatal.

Of the 247 respondents, 169 (68%) had heard about the rabies outbreak through 1 or more sources (multiple answers allowed). Respondents cited newspapers (100/169 [59%]), television (38/169 [22%]), and family or friends (31/169 [18%]) as the most common sources. Among the 9 of 169 (5%) respondents who had learned about rabies through the radio, almost all lived in unincorporated rural areas. When asked which sources were the most trusted to learn about rabies (multiple answers allowed), respondents identified veterinarians (210/246 [85%]) as the most trusted, followed by animal control officials (140/246 [57%]), public health officials (124/246 [50%]), television (120/246 [49%]), newspaper (119/246 [48%]), radio (91/246 [37%]), and the Internet (90/246 [37%]). Pet owners (94/180 [52%]) were significantly less likely than those not owning pets (46/67 [69%]) to list animal control officials as a most trusted source.

Fewer than half of pet owners (79/180 [44%]) but most non–pet owners (47/67 [70%]) stated the top reason for vaccinating pets was because people might get rabies. A significantly higher percentage of pet owners (70/180 [39%]) than non–pet owners (10/67 [15%]) answered that the top reason was concern that a dog might get rabies. The primary reason given by other respondents for vaccinating included legal requirements (18/180 [10%] pet owners and 9/67 [13%] non–pet owners) and veterinarian recommendation (5/180 [3%] pet owners).

Respondents were asked to indicate what actions they would take if bitten by a wild animal or a dog they did not own (multiple answers were allowed). Most indicated that they would seek medical treatment and contact animal control officials (Figure 2). Some respondents stated they would kill the animal as a write-in response. Qualitative data revealed a substantial number of respondents who answered that they would seek medical treatment knew that doctors were required to report animal bites to animal control.

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Actions respondents (n = 245) to a survey about rabies knowledge would take in response to a bite by a wild animal (gray bars) or a dog they did not own (black bars; multiple answers were allowed); the survey was administered to residents of Eddy County, NM, which had experienced a skunk rabies outbreak during the preceding 2 years.

Citation: Journal of the American Veterinary Medical Association 246, 11; 10.2460/javma.246.11.1242

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Respondents were allowed only 1 answer when asked how they might respond to finding a sick bat or a sick skunk. The most common answers were to contact animal control (187/246 [76%] for a sick skunk and 170/246 [69%] for a sick bat) and to kill it (46/246 [19%] for a sick skunk and 46/246 [19%] for a sick bat). Limited qualitative responses suggested that respondents who would kill a sick skunk or bat would usually not contact animal control.

Discussion

In the present study, only 75% (339/455) of pet dogs and cats had a current rabies vaccination status (ie, had received a rabies vaccine within the past 3 years), and all pets had a current rabies vaccination status in only 71% (128/180) of pet-owning households. This was despite the fact that the study was conducted in an area that had just experienced a 2-year outbreak of skunk rabies during which dozens of unvaccinated pets were euthanized after potential exposures. This was well below the postoutbreak rabies vaccination prevalence of 90% in a Flagstaff, Ariz, study⁴ and indicated a need for increased education about the benefits of rabies vaccination of pet dogs and cats. Several factors (ie, pet species [cat vs dog], allowing pets to roam freely, housing pets outdoors, and not having pets spayed or neutered) were associated with a lower rabies vaccination prevalence, and households that left food outside overnight for pets, strays, or wildlife were more likely to have 1 or more pets that were not up-to-date on their rabies vaccinations.

Similar to findings of a previous study,⁴ only 68% (167/245) of respondents in the present study knew that rabies is fatal. Individuals who are not aware of the serious consequences of rabies might not call about possible exposures or seek medical care. Although the community generally was knowledgeable about species of animals that can transmit rabies, a substantial percentage of respondents were unaware that livestock can transmit rabies. Increasing awareness regarding rabies transmission among livestock owners is important, not only for herd protection but also to protect persons working with livestock.

In New Mexico, potential rabies exposures are addressed when animal control is contacted by an exposed person, a medical provider caring for an exposed person, or a veterinarian caring for an exposed pet. We found certain exposures can go unreported, including bat scratches to persons, dogs playing with bats, dog bites, wild animal bites, and sightings of sick skunks and sick bats. More respondents reported that they would seek medical care rather than contact animal control after a dog bite exposure; therefore, reporting by medical providers is critical for exposure identification.

The study had several findings unique to a rural community. Certain residents were accustomed to depredation practices and shared that they would kill suspect animals without calling animal control. Because of the distances across the county, waiting multiple hours for animal control to kill a sick skunk or bat that is interacting with pets or livestock is often not a viable option. We identified a need for public education to ensure persons contact animal control, even if they kill the suspected rabid animal, to allow animal control personnel to determine whether an exposure occurred and whether the animal needs to be tested for rabies.

Limitations of the study included that vaccine rates and pet details were based on owner recall and might have been subject to social desirability bias. Additionally, 24% (59/247) of respondents did not provide income data, and consequently, education level was the only socioeconomic status variable included in analyses. Selection bias was possible owing to the presurvey outreach that was done; however, it was difficult to discern the impact of any bias, given that presurvey outreach was bilingual and through general public information sources. During the random selection of residential parcels, no multiunit properties were selected; therefore, our findings reflect rabies knowledge and vaccination practices of single-family households and not of apartments or mobile home park households. The percentage of respondents who did not know rabies is fatal might be inaccurate because the question did not specify that we were asking about rabies without postexposure prophylaxis treatment. While many stakeholders were pet owners, the solutions developed by the stakeholder team may have been limited by not including additional pet owner representation.

The community-based participatory research approach we used provided a unique opportunity for stakeholders to work together to interpret the findings and identify an action plan to strategically approach gaps that were identified. To increase rabies vaccination prevalence, community stakeholder partners subsequently implemented measures to improve rabies vaccination rates in the community. For example, small animal practices required that dogs and cats have an up-to-date rabies vaccination status before any procedures were performed; the local animal shelter provided free rabies vaccination vouchers for adopted dogs and cats that could be redeemed at local veterinary clinics after adoption; stakeholders agreed to develop an annual multiagency outreach campaign highlighting the importance of vaccinating both dogs and cats against rabies at 12 weeks of age, 1 year, and then every 3 years; and the 3 veterinary clinics agreed to collaborate on an annual vaccination clinic for the community.

To address knowledge gaps associated with rabies in the community, stakeholders began conducting outreach through their own agencies and education programs in local schools in April 2013. To ensure correct responses to potential rabies exposure and accurate dissemination of public rabies information, stakeholders recommended ensuring animal control and wildlife field personnel receive appropriate training on these topics. In addition, the stakeholders designated an annual rabies awareness month, with plans to distribute educational messages through billboards, stickers on pet food bags in stores, and social media messaging during the month and to promote increased media attention to the importance of dog and cat rabies vaccination. Consensus messaging was developed by the group to ensure that key knowledge gaps were addressed across all constituent groups.

We believe that the community-based participatory research approach used in the present study helped us identify how the community can best reduce future exposure risk through increased vaccination prevalence, can expand awareness of what constitutes an exposure and how to best address exposures, and can enhance knowledge about the risks of rabies. We recommend future evaluation of rabies knowledge and vaccination practices to understand how effective the action steps and outreach campaign planned by the community stakeholder group have been.