PHE 500 Module 3 Milestone One Example

Rare Deaths, Common Fears: Rabies as a Public Health Issue in a Central Pennsylvania County

[Student Name]

Southern New Hampshire University

PHE 500: Principles of Public Health

Final Project Milestone One

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Rare Deaths, Common Fears: Rabies as a Public Health Issue in a Central Pennsylvania County

Rabies kills few Americans, yet it occupies a large share of a county health department's summer. That gap between deaths and effort is what makes it a useful issue for a public health analysis. This milestone describes the disease, traces its history, measures its size nationally and in one composite ridge-and-valley county of roughly 90,000 residents, and states the problem the rest of the analysis will address.

The Disease

Rabies is caused by a virus that infects the nervous system of mammals. It usually spreads through the bite of an infected animal, whose saliva carries the virus into the wound. From there it travels along nerves to the brain, a journey that can take weeks or months. Once symptoms begin, such as fever, agitation, difficulty swallowing and paralysis, the disease is almost always fatal. Before symptoms, however, a course of rabies immune globulin and vaccine, known as post-exposure prophylaxis, is highly effective. Rabies is therefore a disease that public health can nearly always prevent but medicine can almost never cure.

History

Tarantola (2017) traced descriptions of rabies across four thousand years, from ancient legal codes that fined owners of mad dogs to remedies of every kind. The turning point came in 1885, when Louis Pasteur gave an experimental vaccine to a boy bitten by a rabid dog, who survived. Vaccines improved steadily through the twentieth century, and modern cell-culture vaccines are safe and require only a few doses.

In the United States, the decisive change came through animal control. As dog vaccination and leash laws spread after the 1940s, dog rabies declined until the canine variant was declared eliminated in 2007. Pieracci et al. (2019) showed that before 1960 most human cases followed dog bites, while today wildlife, especially bats, raccoons, skunks and foxes, carries the virus. Since the 1990s, oral vaccine baits dropped from aircraft and vehicles have been used to stop raccoon rabies from spreading west along the Appalachian ridge (Slate et al., 2009).

National Magnitude

From 1960 to 2018, 125 human rabies cases were reported in the United States. Thirty-six followed dog bites abroad, and of the 89 acquired at home, 62, or 70%, were linked to bats (Pieracci et al., 2019). Deaths are rare, about two a year, but exposures are common. Pieracci and colleagues estimated that about 55,000 people sought post-exposure prophylaxis in 2018. An earlier survey of state health departments put average annual use at about 23,000 courses and found that no national system tracked it (Christian et al., 2009). The burden of rabies in this country is therefore measured less in deaths than in exposures, vaccine and the work of preventing them.

How the Numbers Are Known

Rabies figures come from several surveillance streams, each with limits. Human cases are reportable nationally and almost certainly complete, because the disease is so severe. Animal rabies is counted through laboratory testing, but only animals that bite or contact people or pets are usually tested, so the numbers reflect human contact as much as the true spread of the virus in wildlife. Post-exposure prophylaxis is the weakest stream. There is no national reporting system for it, which is why estimates range from about 23,000 to 55,000 courses a year depending on method. In the county, vaccine courses are known only because the health department authorizes immune globulin through the hospital pharmacy.

County Magnitude

County records for the past three years show a rising trend, summarized in Table 1.

Table 1. County rabies indicators, last three years

Note. County figures are composite but realistic for the region.

Year three's jump in vaccine courses followed a wet spring, more raccoon positives near the county seat and two bat exposures at a children's camp. The absence of human cases is a success, but each of those 214 courses represents a person who needed fast access to costly care.

Why the Trend Is Rising

Three explanations are plausible, and they are not exclusive. Raccoon rabies may be increasing locally after several mild winters. More animals may be tested because public awareness rose after the camp exposures made the news. And clinicians may be recommending vaccine more readily. Separating these will matter for the analysis, because a true rise in wildlife rabies calls for different action than a rise in testing or caution.

Costs and Access

Post-exposure prophylaxis is expensive. A complete course, by the estimate of Pieracci et al. (2019), runs to several thousand dollars, much of it for immune globulin given on the first day. Insured patients may face large deductibles, and uninsured residents can receive bills that discourage them from seeking care after an exposure. Because the vaccine must start promptly, any delay caused by cost or confusion raises the risk of the one outcome that cannot be treated.

Who Is Most at Risk

Exposure risk is highest for people who handle animals, such as farmers, veterinarians and animal control officers, for children at camps and in older homes where bats roost, and for families with unvaccinated barn cats. Access risk is highest for residents without insurance or a regular source of care, including many farm workers.

Pets matter too. A dog or cat without current vaccination that tangles with a rabid raccoon may need months of strict quarantine or euthanasia, and the family that handled it may need vaccine themselves, so gaps in pet vaccination spread risk to people.

Problem Statement

Rabies deaths are rare in the county because a system of testing, investigation and vaccine works most of the time. But rising wildlife rabies, a near doubling of vaccine courses and costs that fall hardest on the uninsured mean the system is under strain. This analysis will examine how the public health system responds to rabies in the county, who carries that response and which interventions would protect residents most fairly.

References

Christian, K. A., Blanton, J. D., Auslander, M., & Rupprecht, C. E. (2009). Epidemiology of rabies post-exposure prophylaxis, United States of America, 2006-2008. Vaccine, 27(51), 7156-7161. https://doi.org/10.1016/j.vaccine.2009.09.028

Pieracci, E. G., Pearson, C. M., Wallace, R. M., Blanton, J. D., Whitehouse, E. R., Ma, X., Stauffer, K., Chipman, R. B., & Olson, V. (2019). Vital signs: Trends in human rabies deaths and exposures, United States, 1938-2018. MMWR Morbidity and Mortality Weekly Report, 68(23), 524-528. https://doi.org/10.15585/mmwr.mm6823e1

Slate, D., Algeo, T. P., Nelson, K. M., Chipman, R. B., Donovan, D., Blanton, J. D., Niezgoda, M., & Rupprecht, C. E. (2009). Oral rabies vaccination in North America: Opportunities, complexities, and challenges. PLoS Neglected Tropical Diseases, 3(12), Article e549. https://doi.org/10.1371/journal.pntd.0000549

Tarantola, A. (2017). Four thousand years of concepts relating to rabies in animals and humans, its prevention and its cure. Tropical Medicine and Infectious Disease, 2(2), Article 5. https://doi.org/10.3390/tropicalmed2020005