PHE 500 Module 8 Milestone Three Example

From the Base Up: Choosing Rabies Interventions for a Pennsylvania County With the Health Impact Pyramid

[Student Name]

Southern New Hampshire University

PHE 500: Principles of Public Health

Final Project Milestone Three

[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.

From the Base Up: Choosing Rabies Interventions for a Pennsylvania County With the Health Impact Pyramid

The first two milestones showed that the county's rabies response prevents deaths but is under strain: exposures and vaccine courses are rising, costs fall on the uninsured and key partners have no seat at the table. This milestone asks which interventions would do the most good. It uses the health impact pyramid of Frieden (2010) to sort options by how many people they reach and how much individual effort they require, then compares them on evidence, cost, equity and feasibility.

The Health Impact Pyramid

Frieden (2010) arranged public health interventions in five tiers. At the base are changes in socioeconomic factors, which have the greatest potential impact. Next come changes to surroundings that make protection automatic; above those sit one-time or rare protective measures; then continuing clinical care; and, at the peak, advice and teaching. The lower an intervention sits, the more people it reaches and the less it asks of each one; measures near the peak rely on individuals acting. Frieden argued that programs work best when they combine tiers, but that public health often over-relies on the top.

Options by Tier

At the base, broader insurance coverage and paid sick leave for farm workers would reduce the cost and lost wages that keep people from completing vaccine. These are largely beyond county control but can be supported through advocacy.

In the context tier, three options stand out. Free pet vaccine clinics, held in every township rather than only in the county seat, would make vaccinating barn cats and dogs the easy choice. Small grants to seal bat entry points in camps and older homes would remove exposures at the source. And the county could ask state and federal partners to extend oral rabies vaccine baiting into its area; Slate et al. (2009) described how baiting has held raccoon rabies back along a long barrier, though at substantial cost and with uneven success.

In the long-lasting protection tier, pre-exposure vaccine for farm workers, veterinary staff, animal control officers and rehabilitators would simplify their care after any exposure. The 2022 federal schedule reduced it to two doses for most people at risk (Rao et al., 2022).

In the clinical tier, a fund or payment agreement with the hospitals would ensure that no exposed resident is billed before treatment, and stocking immune globulin at one northern urgent care clinic would cut travel. At the top, education would include bat exposure guidance for camps and families in English and Spanish.

Comparing the Options

Table 1 compares the main options. Ratings are high, moderate or low.

Table 1. Intervention comparison

Note. Ratings reflect the reviewed evidence and county conditions.

Weighing the Evidence

Pet vaccination has the strongest case. Pieracci et al. (2019) placed keeping pets vaccinated near the top of their list of protective steps, and its low cost and high reach make it efficient. The post-exposure fund rests on clear evidence that prophylaxis prevents rabies when given promptly; its value lies in removing a barrier, not in a new treatment. Pre-exposure vaccine is well supported but reaches few people. Wildlife baiting is promising but expensive and outside county control, so it is a request to partners rather than a county program. Education is cheap and reaches many but changes behavior least on its own.

Recommended Package

The milestone recommends a package that combines tiers, as Frieden advised. The county should hold free pet vaccine clinics in every township, create a post-exposure fund with the hospitals, offer pre-exposure vaccine through the regional farm worker clinic and fund bat-proofing at camps first. Bilingual guidance should accompany each. The county should also formally ask state partners to assess extending wildlife baiting. Together these steps act on exposure at its source, protect those most at risk and remove the cost barrier.

Links to the Essential Services

The package strengthens the services that Milestone One's mapping found weakest. The fund addresses equitable access to care. Township clinics and bilingual guidance improve communication and community partnerships. Tracking clinics, fund use and doses completed would strengthen evaluation. Castrucci (2021) argued that the essential services give public health a shared language; framing the package in those terms can help the county explain it to its board and partners.

Measuring the Package

Each piece needs a measure. For clinics, the number of animals vaccinated by township and the share that are barn cats. For the fund, the number of residents helped and the days between exposure and first dose for uninsured residents compared with insured ones. For pre-exposure vaccine, workers who complete both doses. For bat-proofing, the number of camp and home bat exposures reported each summer. For guidance, calls to the rabies line from Spanish-speaking residents. These measures would let the county report progress to its board and adjust the package after the first season, as the essential services framework expects.

Feasibility and Risks

The main risks are funding and staff. Township clinics need veterinarians willing to donate time, the fund needs hospital agreement and the nurses are already stretched. Starting with the two lowest-cost steps, clinics and bilingual guidance, would build momentum while the fund and pre-exposure program are negotiated.

A second risk is that the fund could be seen as rewarding people for not having insurance. Framing it as a public health measure that protects everyone, since a single human case would cost the county far more, should help.

Conclusion

The health impact pyramid shows that the county relies heavily on the clinical and education tiers. Moving resources toward pet vaccination, removing cost barriers and protecting high-risk workers would reach more residents, especially those the current system serves least. The final analysis will bring these recommendations together with the issue's history, stakeholders and system response.

References

Castrucci, B. C. (2021). The "10 Essential Public Health Services" is the common framework needed to communicate about public health. American Journal of Public Health, 111(4), 598-599. https://doi.org/10.2105/AJPH.2021.306189

Frieden, T. R. (2010). A framework for public health action: The health impact pyramid. American Journal of Public Health, 100(4), 590-595. https://doi.org/10.2105/AJPH.2009.185652

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

Rao, A. K., Briggs, D., Moore, S. M., Whitehill, F., Campos-Outcalt, D., Morgan, R. L., Wallace, R. M., Romero, J. R., Bahta, L., Frey, S. E., & Blanton, J. D. (2022). Use of a modified preexposure prophylaxis vaccination schedule to prevent human rabies: Recommendations of the Advisory Committee on Immunization Practices, United States, 2022. MMWR Morbidity and Mortality Weekly Report, 71(18), 619-627. https://doi.org/10.15585/mmwr.mm7118a2

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