Rabies Knowledge In Harnett County

A Study on Rabies Knowledge, Perceptions, and Barriers in Rural Harnett County, NC

Michelle Hanna

MSPH Capstone Project

Campbell University

Abstract

Rabies is an incidental infectious zoonoses with an almost 100 percent mortality rate among humans and animals alike. Although this disease is not nearly as prevalent in the United States as it is in developing countries, it is still a real threat to public health. This study aims to determine the disease knowledge level, disease perceptions, and barriers to pet vaccination in rural Harnett county, North Carolina’s community members. A self-administered survey was distributed at fall festivals and fairs throughout Harnett County, NC between September and November 2015. Persons were recruited for the survey while approaching the Harnett County Animal Services tent. 110 people were surveyed throughout the study. Those surveyed were predominantly female (75%) and Caucasian (82.6%) and owned a “pet” dog or cat (79.8%) with varying ages, educational, income, and household backgrounds. Almost 40 percent (39.3) of pet owners said they wouldn’t report being bitten by their own animal or didn’t know if they would report it. A Pearson Chi-Square analysis also showed a significant difference between the survey takers that listed death as the outcome of rabies exposure in animals and humans. Of the total people surveyed, 28.4 percent of people selected death as the outcome for animal rabies exposure but not death for human exposure. Minority races/ethnicities were found to be 87% less likely to select death as an outcome for animals exposed to rabies when accounting for confounding factors (OR=0.134, p=0.010). Increased education and animal vaccinations could help to decrease rabies and increase the community’s knowledge on the disease and its outcomes.

Introduction

Overview of Rabies:

Zoonotic diseases, or diseases that can be transmitted between animals and humans, have plagued human populations since their first interactions. One of the oldest, deadliest, and most widespread zoonoses is rabies (Rupprecht, Hanlon & Hemachudha, 2002). Caused by Rhabdoviridae Lyssavirus (family and genus), rabies can be transmitted to all mammals and has an almost 100 percent mortality rate if not treated with post-exposure prophylaxis or PEP (Dyer et al. 2013; CDC, 2016). The virus is transmitted from saliva and mucosal tissue of a host rabid animal to broken skin of another (i.e. bites, scratches), but can also manifest from exposure to brain matter or nervous tissue, or organ transplants (WHO, 2016; CDC, 2016; Dyer et al., 2013). Once infected and symptomatic there is no effective treatment or cure.

The incubation period of this virus is extremely variable, depending on the location and severity of the bite/exposure and the amount of nervation at the site (WHO, 2016). Human symptoms may start appearing as early as a few days to as long as a few years, with the average incubation period being 1-3 months (Rupprecht, Hanlon & Hemachudha, 2002). The most common and easiest way to diagnose a human with rabies is to test and diagnose the animal they had contact with. This requires euthanasia of the animal for a direct fluorescent antibody test of a cross section of the brainstem and cerebellum (Dyer et al., 2013). If it was unlikely that there was direct contact or the animal is asymptomatic, the animal will be kept under quarantine for 10 days or until it becomes symptomatic (CDC, 2016). Directly testing a human (ante-mortem) for rabies is much more difficult, timely, and resource intensive (CDC, 2016). Because of the extensive nature of these ante-mortem tests and the extremely high mortality rate, it is common practice to start post-exposure prophylaxis on anyone who had direct contact or was bitten by the infected animal immediately.

If exposed to a rabid animal, a person will need post exposure prophylaxis, including flushing the wound with human rabies immune globulin and a series of four injections over two weeks (Dyer et al., 2013). Immediate wound washing is also an extremely important part of treatment, as it can greatly decrease a person’s risk of developing the disease (CDC, 2016). Once symptomatic, the only treatment is for symptoms and to make the person more comfortable until they eventually succumb to the disease, usually within 10 days to two weeks (CDC, 2016; WHO, 2016). Symptoms start out flu-like and progress to neurological symptoms such as confusion, agitation, hypersalivation, hydrophobia, and/or flaccid muscle weakness, all leading to an eventual coma as the virus attacks the Central Nervous System (CDC, 2016; WHO, 2016). Human survival from rabies is extremely rare, but has occurred in less than 10 cases globally (CDC, 2016; WHO, 2016).

The main reservoir and vector of rabies throughout the world is dogs, causing over 90 percent of human exposure and 99 percent of rabies deaths in humans (CDC, 2016). According to the World Health Organization each year more than 55,000 people die from rabies throughout the world, or one every ten minutes (2016). Most of these deaths occur in Africa and Asia, particularly in rural communities, and about 40 percent of rabies deaths are children under the age of 15. (WHO, 2016). Rural areas have less access to healthcare, PEP, and are in closer contact with wildlife and feral dogs. More than 15 million people across the globe receive rabies PEP each year but there are thousands more that do not receive the injections because they cannot afford it or do not have access to it (WHO, 2016). Although in Africa and Asia the PEP is only about $40-50 (US dollars), for people living on $2 a day or less, this is an unimaginable price to pay (WHO, 2016).

Rabies in the US and North Carolina:

Although the main rabies reservoir in the United States is wildlife, dogs as well as cats and domesticated ferrets, can all host the virus (CDC, 2016). Cats are the domestic animal vector most commonly infected with rabies (Dyer et al., 2013) while raccoons are the most commonly infected wildlife species (CDC, 2016; NCDHHS, 2016). Human exposure is much more likely with “pets” and domesticated animals than with wildlife due to the close proximity humans have with their animal counterparts. Fortunately there is a pre-exposure vaccination available for domestic pets. This vaccine is readily obtainable in the U.S. and North Carolina state laws mandate that all cats, dogs, and ferrets over the age of 4 months must be vaccinated (NCDHHS, 2016). Vaccinations last one or three years and can be relatively inexpensive or free depending on the clinic. If a non-vaccinated animal is exposed to rabies, the animal will either have to be euthanized or quarantined for up to 6 months at the owner’s expense, as opposed to only 45 days for vaccinated animals (CDC, 2016). Currently, the U.S. spends upwards of $300 million a year on rabies prevention, most of which is animal vaccinations (CDC, 2016).

Due to its communicability and deadly effects, rabies is a nationally notifiable disease. Any animal bites treated by a physician or emergency department must be reported to the local health department and animal control within 24 hours (NCDHHS, 2016; CDC, 2016). Dogs are the most common species to bite humans in the United States, but they are typically underreported (Bingham, Budke, & Slater, 2010). Many people will not seek medical treatment unless the wound becomes infected (Bingham, Budke, & Slater, 2010). There are an average of 1-3 positive human rabies cases per year in the U.S., with 12 cases having occurred from 2010-2013 (CDC, 2016; Dyer et al., 2013). Of these cases, five were exposed in other countries, one was exposed via an organ transplant, and one case survived (Dyer et al., 2013). Each year between 30,000 and 50,000 people receive PEP in the United States (CDC, 2016). This series of injections can cost upwards of $6,000, creating quite a financial burden, not to mention the psychological burdens.

Health Belief Model:

One of the most commonly used theories worldwide in public health education is the Health Belief Model or HBM (Hayden, 2014). The theory states “that health behavior is determined by personal beliefs or perceptions about a disease and the strategies available to decrease its occurrence” (Hayden, 2014). These personal perceptions include perceived benefits, barriers, susceptibility, and severity, as well as cues to action and self-efficacy (Hayden, 2014). The greater the perceived susceptibility and severity, the more likely a person is to engage in healthy behavior (Hayden, 2014). The same can be said for perceived benefits; the more benefit a person perceives in engaging in a health behavior, the more likely they are to actual act in that way (Hayden, 2014). Perceived barriers are the obstacles, physical or psychological, that a person has to overcome to engage in the healthy behavior (Hayden, 2014). The greater the the perceived barriers, the less likely a person is to engage in that healthy behavior; the benefits must outweigh the barriers (Hayden, 2014). By measuring the community’s perceptions, interventions can be designed to target specific perceptions, for example increasing rabies knowledge to change perceptions of severity, susceptibility, barriers, and benefits of the disease, PEP, and animal vaccination.

Rabies Knowledge:

Rabies knowledge tends to vary among race/ethnicity, gender, age, education level, household income, and pet owners. In previous studies, American women tend to have a higher knowledge level of rabies than males (Bingham, Budke, & Slater, 2010; Palamar, Peterson, Deperno, & Correa, 2013), whereas in developing countries such as Tanzania, men have higher knowledge on the subject (Sambo et al., 2014). Studies found that higher education levels were correlated to higher rabies knowledge (Bingham, Budke, & Slater, 2010; Palamar, Peterson, Deperno, & Correa, 2013; Sambo et al., 2014). Pet ownership is also a predictor of increased rabies knowledge, in the U.S. and globally (Bingham, Budke, & Slater, 2010; Sambo et al., 2014; McCollum et al., 2012). Palamar, Peterson, Deperno, & Correa’s study in North Carolina assessed racial/ethnic minorities’ knowledge of rabies (2013). They found that being a minority (Latino or African American) was a predictor of low rabies knowledge. Minorities, Hispanics in particular, may also have a different view on animal ownership and attachment to their animals according to Ramon, Slater, & Ward (2010).

From these studies, in the United States, it can be hypothesized that people with low educational attainment, low socioeconomic status, and racial minorities have less knowledge of rabies than those highly educated, with higher incomes, and are white.

Research Question:

This study focuses on investigating what Harnett County citizens know about rabies. The purpose of this study is to gauge the knowledge and perceptions the community has on the rabies virus and identify barriers to animal rabies vaccinations in the community. Do they perceive rabies as a threat to themselves and their animals? How severe do they think rabies is?

Materials and Methods

Survey Development and Design:

The surveys used in this study were a combination of questions adapted from a study done by Bingham, Budke, and Slater (2010) and original questions developed by the PI and Harnett County Animal Services Department. There were a total of four different surveys distributed, categorized and color-coded: Non-animal owners, animal owners who had not had their animal vaccinated with Harnett County Animal Services and those that had, and lastly, those that chose to get their animal vaccinated with Harnett County Animal Services at the festival then and there. The first 18 questions on each survey were the same and were followed by specialized questions for pet owners, clinic visitors, and festival clinic visitors. An application, including the surveys and informed consent, was sent to the Campbell University Institutional Review Board and was approved.

Study Site and Population:

Harnett County, North Carolina is a predominantly rural county in central North Carolina with a population of about 128,140 persons (CB, 2015). The population is primarily White (72.1%) with the largest minority population being African American (21.5%) and Hispanic/Latino population of 11.9 percent (CB, 2015). Median household income and per capita personal income for Harnett County are $44,417 and $20,274 respectively; both well under the North Carolina average (CB, 2015). About 85 percent of the county’s population has a high school degree or higher (CB, 2015).

Harnett County Animal Services (HCAS) is the county’s animal control and assistance agency. They respond to any rabid or stray animal calls, domestic or wild. During 2014 they had nine raccoons and one fox test positive for rabies (Berube, 2015). In 2015 there was a decrease in rabid animals found in the county, with only three raccoons testing positive (Berube, 2015). HCAS staff are rabies vaccination certified (CRV) and offer one-year rabies vaccinations four days a week as well as at fall festivals/fairs and their clinic in May, always for $6 (at cost) (Berube, 2015). By North Carolina law, all governmental animal agencies must provide their community with at least one rabies clinic per year; HCAS holds an annual “drive thru” clinic in May (Berube, 2015). In 2014 the aforementioned clinic vaccinated 780 pets in the county (Berube, 2015). The same clinic in 2015 provided only 348 vaccinations (Berube, 2015). This study was prompted by the noticeable and drastic decrease in rabies vaccinations from 2014-2015.

Data Collection:

The persons surveyed were a convenience sample from the Harnett County, North Carolina area. First-year Public Health students assisted in the survey administration. The survey was distributed at approximately four fall festivals and fairs throughout Harnett County, NC between September and November 2015. Persons were recruited for the survey while approaching the Harnett County Animal Services tent. Upon agreeing to participate the subjects were given an informed consent and asked one or two questions to determine which survey they would take. The first question: “Do you have a pet (cat or dog)?” and if they answered yes, the follow up question: “Have you ever had your animal vaccinated with Harnett County Animal Services before?” was asked. Once the appropriate survey was given to the participant, the survey was self-administered and took no more than 5 minutes. Students and HCAS staff were present to collect surveys and answer any questions the participants had.

Statistical Analysis:

Survey data was entered into Excel and coded. All data was analyzed using SPSS (IBM). The questions “What are the consequences of animal (dog or cat) and human exposure to rabies” were dichotomized to death and all other outcomes. Race was dichotomized to racial/ethnic minorities and white, as well as any question with answers yes, no and don’t know dichotomized with no and don’t know grouped together. Descriptive statistics, Pearson Chi-Squared, and multiple logistic regression analyses were run on selected variables to determine significant differences and other data associations.

Results

A total of 110 persons were surveyed, and were predominantly female (75%), pet owners (79.8%), and were White (82.6%). Table 1 displays frequencies of demographic questions as well as rabies knowledge questions of all persons (pet owners and non-pet owners) from the survey. Age, education level, household income, and persons and children in household were relatively evenly distributed in the surveys. The majority of people surveyed knew humans could get rabies, knew rabies was present in North Carolina, and knew there was rabies in Harnett County (95.4%, 97.2%, 88.1% respectively, shown in Table 1). Ninety-six (96.3) percent of people knew that it was possible to get rabies from a raccoon or dog, however only eighty-three (83.5) percent of people knew that it was possible to get rabies from a cat (Table 1). When asked about the consequences of animal exposure to rabies, about seventy percent of people selected death as the outcome, while when asked about human exposure only forty-five (45.9) percent of people selected death (Table 1). The majority of people said they would report being bitten by a dog or cat they don’t own to someone of authority (90.7%) and even more so if they were bitten by a wild animal (98.1).

Table 1: Descriptive statistics of survey

Variable

Frequency (%)

Gender

Male

Female

27 (25)

81 (75)

Pet owner

Yes

88 (79.8)

22 (20.2)

Age

18-24

25-34

35-44

45-54

55-64

65+

20 (18.2)

25 (22.7)

18 (16.4)

16 (14.5)

6 (5.5)

Race/Ethnicity

African American

Hispanic

White

Other

Prefer not to respond

3 (2.8)

11 (10.1)

90 (82.6)

1 (0.9)

4 (3.7)

Highest Education Level

High school

Some college

Completed college/Advanced degree

20 (22.7)

31 (35.2)

37 (42.0)

Household Income

Less than $25,000

$25,000-$49,999

$50,000-$74,999

$75,000-$99,999

$100,000 or more

18 (18.9)

26 (27.4)

25 (26.3)

14 (14.7)

12 (12.6)

Persons in household

Prefer not to respond

12 (10.9)

32 (29.1)

19 (17.3)

28 (25.5)

15 (13.6)

4 (3.6)

----

Children in household

Prefer not to respond

54 (50)

11 (10.2)

29 (26.9)

10 (9.3)

3 (2.8)

1 (0.9)

Can people get rabies

Yes

No/Don’t know

103 (95.4)

5 (4.6)

Rabies in North Carolina

Yes

No/Don’t know

106 (97.2)

3 (2.8)

Rabies in Harnett County

Yes

No/Don’t know

96 (88.1)

13 (11.9)

Rabies from a raccoon

Yes

No/Don’t know

105 (96.3)

4 (3.7)

Rabies from a dog

Yes

No/Don’t know

104 (96.3)

2 (3.7)

Rabies from a cat

Yes

No/Don’t know

91 (83.5)

18 (16.5)

Animal exposure outcome

Death

All other outcomes

77 (70.6)

32 (29.4)

Human exposure outcome

Death

All other outcomes

50 (45.9)

59 (54.1)

Reporting bite from animal they don’t own (dog or cat)

Yes

No/Don’t know

98 (90.7)

10 (9.3)

Reporting wild animal bite

Yes

No/Don’t know

104 (98.1)

2 (1.9)

Table 2 includes pet owner specific question frequencies. Of the pet owners surveyed, about 40 percent said that they would not report being bitten by their own dog or cat to someone of authority (60.7 % said they would). Most had visited the veterinarians within the last year (84.7 %) and their animal had been vaccinated against rabies (96.5%). When asked about how much money they had spent in the last year at veterinarians and how much they would be willing to spend on a rabies vaccination, the amounts were somewhat evenly distributed (Table 2). Sixty percent of people stated their animal(s) had been vaccinated against rabies within the last year and about ninety percent had been vaccinated within the last three years.

Table 2: Animal Owner Frequencies

Variable

Frequency (%)

Reporting bite from own animal (dog or cat)

Yes

No/Don’t know

51 (60.7)

33 (39.3)

Most recent vet visit

Less than a year ago

1-2 years ago

3 or more years ago

Don’t know

72 (84.7)

10 (11.8)

2 (2.3)

1 (1.2)

How much money spent in last year at vets

Less than $100

$101-$200

$201-$300

$300+

Don’t know

13 (15.3)

19 (22.4)

21 (24.7)

24 (28.2)

8 (9.4)

Animal ever been vaccinated for rabies

Yes

No/Don’t know

82 (96.5)

3 (3.5)

Most recent rabies vaccination

Less than a year ago

1-3 years ago

4-6 years ago

Don’t know

51 (60)

26 (30.6)

1 (1.2)

7 (8.2)

Max willing to spend on rabies vaccination

$0-$5

$6-$10

$11-$15

$16 or more

Don’t know

2 (2.4)

14 (16.5)

17 (20.0)

37 (43.5)

15 (17.6)

Table 3 shows the significant difference found in the Pearson Chi-Square analyses between race and both animal (p=0.001) and human exposure outcomes (p=0.038). A Pearson Chi-Square analysis also showed a significant difference between the survey takers that listed death as the outcome of rabies exposure in animals and humans, shown in Table 4 (p=0.000). Of the total people surveyed, twenty-eight (28.4) percent of people selected death as the outcome for animal rabies exposure but not death for human exposure.

Table 3: Crosstabulation of race and rabies exposure outcomes

Race

Variable

Minorities (%)

White (%)

P-Value

Animal Exposure

All other outcomes

Death as outcome

12 (60)

8 (40)

20 (22.5)

69 (63.3)

0.001*

Human Exposure

All other outcomes

Death as outcome

15 (75)

5 (25)

44 (54.1)

45 (50.6)

0.038*

*Significant p<0.05

Table 4: Crosstabulation of human and animals rabies exposure outcomes

Human Exposure

Variable

All Other Outcomes (%^)

Death as Outcome (%)

P-Value

Animal Exposure

Other Outcomes

Death

28 (25.7)

31 (28.4)

4 (3.7)

46 (42.2)

0.000*

^% of total *Significant p<0.05

A multivariable logistic regression on pet owners (N=88) showed a strong association (OR=0.134, p=0.010) between race and how the survey taker answered the animal rabies exposure question when adjusting for household income, education level, age, and gender, as shown in Table 5. Minority races/ethnicities are eighty-seven percent less likely to select death as an outcome for animals exposed to rabies when accounting for confounding factors.

Table 5: Multivariate Adjusted Odds Ratio of Death as Perceived Animal Exposure Outcome

Variable	OR	95% CI	P-Value
Race White Minorities	Ref. 0.134	--- (0.029-0.620)	--- 0.010*
Household Income	0.652	(0.411-1.034)	0.069
Education Completed College/Advanced Degree Some College High School	Ref. 0.638 0.425	--- (0.157-2.595) (0.100-1.797)	--- 0.530 0.245
Age	0.891	(0.562-1.413)	0.624
Gender Female Male	Ref. 1.365	--- (0.333-5.587)	--- 0.666

*Significant p<0.05

Discussion

The study yielded some positive results from the community members. Over ninety percent of people surveyed knew basic rabies information, with the exception of rabies presence in Harnett County (88.1%) and getting rabies from cats (83.5%). Although these numbers are not terribly low, they show the knowledge gap and the lack of perceived susceptibility within the community. This is consistent with the current trends of increased rabies incidence in cats however (CDC, 2016). With less people being aware of cats transmitting rabies, more educational material should be provided specifically noting cats as rabies vectors, as well as making sure all cats are vaccinated. This should be the case regardless of if the cat is an “inside cat only” or an “indoor/outdoor cat” and needs to include “barn cats.” Feral or stray felines and canines can be problematic when dealing with rabies vaccinations. The only real way to combat rabies transmission between them and wild and pet animals is to decrease their population through sterilization (WHO, 2016).

Nearly all surveyed would report being bitten by an animal, wild or domesticated, to someone of authority. This is a favorable result, especially since those surveyed are aware of raccoons transmitting rabies. For the pet owners surveyed, however this was not the case. Many of them answered that they would not report their own pets if they were bitten by them. Due to this finding, pet owners need to be educated on the importance of rabies vaccinations and bite reporting. Unfortunately there is a negative stigma associated with animal services/controls and rabies investigations, so the only way to increase bite reporting is through education to increase people’s perceived susceptibility and severity. Healthcare providers and veterinarians involvement is crucial as well for education and bite reporting. It is important that veterinarians council pet owners about the benefits of rabies vaccinations while also warning them about the potential harm rabies can bring to animals and humans alike. This is especially vital since the large majority of pet owners surveyed had visited their veterinarian within the last year.

One of the most prevalent findings in the data showed that race/ethnicity is attributable to rabies outcome knowledge, even after accounting for gender, income, education, and age. This is supported by a previous study in Greensboro, North Carolina (Palamar, Peterson, Deperno, & Correa, 2013), who, as previously mentioned, found racial and ethnic minorities to have less knowledge of rabies. There was a significant difference between race and outcome knowledge for both animals and humans when using a Pearson Chi-Squared analysis.

The aforementioned study took place in an urban environment and had similar results to this study which took place in a rural environment. Regardless of location, minorities still had less knowledge of rabies. Targeting minorities with rabies information and providing that information simply, and in both English and Spanish, could increase the rabies knowledge of these populations (Palamar, Peterson, Deperno, & Correa, 2013). Enlightening veterinarians to this factor, they could amend their practices, and animal services can educate and advertise their clinic to these targeted audiences.

Another significant finding that should be noted was the difference in answers people gave between animal outcomes and human outcomes. From this result, almost 30 percent Harnett County community members surveyed find rabies more of a threat to animals than humans. In HBM terms, their perceived susceptibility and severity is lower for human exposure than for animal exposure. The recurring theme of education will play a large role in helping citizens to realize how dangerous the disease actually is for humans. Child susceptibility should also be focused on, since they are more likely to come in contact with and be bitten by domestic and wild animals.

Although in various other studies women were shown to have more knowledge than men with regards to rabies, this study yielded no significant difference in genders (Bingham, Budke, & Slater, 2010; Palamar, Peterson, Deperno, & Correa, 2013). This could be due to the disproportionate amount of women that participated in the survey, nonetheless both genders should be equally targeted with interventions.

Limitations:

This study was designed specifically for Harnett County and it’s community. Not only was the study limited by area but also by time and people. It was a small sample size and was limited to the persons attending fall festivals and fairs in the county. Because the surveys were distributed from the HCAS tent, the survey takers were those that actually came up to the tent, presenting a bias towards those who have positive or neutral attitudes towards HCAS. Passersby were recruited as well, however most did not want to participate. The HCAS tent attracted those who already have animals much more frequently than those that did not, so including more non-pet owners could potentially change the results. Weather also played a factor in recruitment. Rain during one festival limited the amount of people present and decreased the potential numbers. In addition, the surveys were limited by the lack of resources. With the factors of time and money, paper surveys were the only feasible option.

Future Research and Suggestions:

In the future to expand on this research, electronic or mailed surveys could be used to increase participation and sample size. More in depth surveys of rabies outcomes, knowledge, and barriers is needed to increase vaccination, education, and awareness. Another research direction would be to investigate the knowledge levels of children. Additional research into animal bite reporting, bite treatment, and animal vaccination and quarantine would be beneficial to not only animal services/controls but also emergency departments, physicians, and health departments.

Conclusion

This study suggests that although residents in Harnett County may have a general knowledge base of rabies, they are not completely aware of the severity of the disease or that it is still an actual threat to themselves and their animals. Education for the entire population, with special attention to pet owners and racial minorities, should be used to increased animal vaccinations. Increasing both awareness and vaccination levels can lead to decreased rabies incidence levels. With further research, increased education, and targeted interventions, the community’s rabies and rabies outcome knowledge can be increased, providing a safer environment for both humans and animals.

References

Baron Palamar, M., Peterson, M. N., Deperno, C. S., & Correa, M. T. (2013). Assessing Rabies Knowledge and Perceptions Among Ethnic Minorities in Greensboro, North Carolina. The Journal of Wildlife Management, 77(7), 1321–1326. doi:10.1002/jwmg.593

Berube, S. (2015). Personal Communication. Harnett County Animal Services Director.

Bingham, G. M., Budke, C. M., & Slater, M. R. (2009). Knowledge and Perceptions of Dog-Associated Zoonoses: Brazos County, Texas, USA. Preventive Veterinary Medicine, 93, 211–221. doi:10.1016/j.prevetmed.2009.09.019

Dyer, J. L., Yager, P., Orciari, L., Greenberg, L., Wallace, R., Hanlon, C. A., & Blanton, J. D. (2014). Rabies Surveillance in the United States during 2013. Journal of American Veterinary Medicine Association, 245(10), 1111–1123. doi:10.2460/javma.245.10.1111

Hayden, J. (2014). Chapter 4: Health Belief Model. In Introduction to Health Behavior Theory, Second Edition (pp. 63–95). Burlington, MA: Jones & Bartlett Learning.

Lankau, E. W., Cox, S. W., Ferguson, S. C., Blanton, J. D., Tack, D. M., Petersen, B. W., & Rupprecht, C. E. (2015). Community Survey of Rabies Knowledge and Exposure to Bats in Homes-Sumter County, South Carolina, USA. Zoonoses and Public Health, 62, 190–198. doi:10.1111/zph.12135

McCollum, A. M., Blanton, J. D., Holman, R. C., Callinan, L. S., Baty, S., Phillips, R., Callahan, M., Levy, C., Komatsu, K., Sunenshine, R., Bergman, D.L., & Rupprecht, C. E. (2012). Community Survey after Rabies Outbreaks, Flagstaff, Arizona, USA. Emerging Infectious Diseases, 18(6), 932–938. doi:10.3201/eid1806.111172

North Carolina Department of Health and Human Services (NCDHHS). (2016, February). Rabies. Retrieved from http://epi.publichealth.nc.gov/cd/rabies/control.html

Ramon, M. E., Slater, M. R., & Ward, M. P. (2010). Companion Animal Knowledge, Attachment and Pet Cat Care and Their Associations with Household Demographics for Residents for a Rural Texas Town. Preventive Veterinary Medicine, 94, 251–263. doi:10.1016/j.prevetmed.2010.01.008

Rupprecht, C.E., Hanlon, C.A., & Hemachudha, T. (2002). Rabies re-examined. The Lancet: Infectious Diseases, 2, 327-343.

Sambo, M., Lembo, T., Cleaveland, S., Ferguson, H. M., Sikana, L., Simon, C., Urassa, H., & Hampson, K. (2014). Knowledge, Attitudes and Practices (KAP) About Rabies Prevention and Control: A Community Survey in Tanzania. POLS Neglected Tropical Diseases, 8(12), 1–10. doi:10.1371/journal.pntd.0003310

United States Census Bureau (CB). (2015, July). North Carolina, Harnett County Quick Facts. Retrieved from http://www.census.gov/quickfacts/table/PST045215/37,37085

United States Centers for Disease Control and Prevention (CDC). (2016, January). Rabies. Retrieved from http://www.cdc.gov/rabies/index.html

World Health Organization (WHO). (2016, January). Rabies. Retrieved from http://www.who.int/rabies/about/en/ http://www.who.int/mediacentre/factsheets/fs099/en/