Surveillance data for Coconino County of the numbers of rabid animals identified during 2000–2009, were obtained from the Arizona Department of Health Services. Emergency department admission data, in which the chief complaint included animal bites during 2005–2009, were obtained from the infection control office for the Flagstaff Medical Center.

Addresses of all households in the quarantine area of Flagstaff were provided by the Coconino County Public Health Services District. Occupancy status of the households was not available, and names associated with each address were permanently removed and not shared for the mailings. In October 2009, surveys were mailed to all households, and 1 adult from each household was asked to complete the survey. Respondents could complete the survey online or by an included paper-based form and returned in a prepaid envelope by mail. The surveys were anonymous and were not linked to a name or address. Educational material on rabies was not included, but for more information, respondents could request printed materials on a separate request form and were directed to the rabies website of the Centers for Disease Control and Prevention (CDC) (Atlanta, GA, USA) (7). The community survey was determined to be public health nonresearch by CDC. The survey elicited information from respondents on knowledge of rabies, the Flagstaff rabies outbreak, practices regarding domestic and wild animals, and adherance to quarantine restrictions. Survey questions are included in Table A1.

A general definition of “knowledge of rabies” was defined as the answer of “yes” when the respondent correctly identified that bites, scratches, and saliva were modes of rabies virus transmission and also identified 1 other incorrect mode of transmissions as a mode of transmission or did not identify any incorrect mode of transmission. A more specific definition of “knowledge of rabies in Flagstaff” was defined as “yes” if the respondent knew about the outbreak in Flagstaff and knew the 3 main animals which had rabies in Flagstaff (bat, skunk, and fox).

Univariate and multivariate analyses were conducted for 4 separate resident subpopulations to further characterize the groups. The outcomes of interest were 1) knowledge of rabies in Flagstaff, 2) pet owners, 3) dog owners, and 4) translocators (persons who trapped and moved wild animals on their property). Odds ratios with 95% CIs for individual characteristics were calculated by using logistic regression. Characteristics that were considered associated (p<0.1) with each outcome in the univariate analysis were further assessed through multivariate logistic regression models (8).

After a period of quiescence from 2005, another rabies epizootic occurred in Flagstaff during 2008 (Figure 1, panel A). Seven rabid animals were reported in Coconino County, including 2 foxes and 2 skunks (Table 1). No human exposures to rabid animals were reported in 2008, but several companion animal exposures occurred, including 6 cats exposed to rabid bats, 2 dogs exposed to rabid skunks, and 1 dog exposed to a rabid fox. In 2009, Coconino County reported 35 rabid animals. All rabies viruses typed from the immediate Flagstaff area (from 14 foxes and 1 ringtail cat) were identified as a bat rabies virus variant. Two human exposures to rabid animals were identified in 2009: one person had been bitten by a rabid fox and the other person had been bitten by a rabid skunk. Also, 3 companion dog exposures to rabid foxes were reported. A review of Emergency Department discharge data at Flagstaff Medical Center specified a total of 88 animal bite–related admissions during 2005–2009. In 2009, 25 animal bite–related admissions were recorded, and 12 (48%) persons received PEP.

The number of rabid animals and control measures that were initiated in Coconino County in 2009 are shown in Figure 1, panel B. During July 21–24, the US Department of Agriculture, Animal and Plant Health Inspection Service, Wildlife Services, distributed 140,000 oral rabies vaccination (ORV) baits containing a vaccinia–rabies glycoprotein vaccine (Merial, Duluth, GA, USA) by air and ground over a 191-km² area in Coconino County, targeting gray foxes (Figure 2). The vaccinia–rabies glycoprotein vaccine is not effective for vaccinating skunks against rabies (9). A 6-week trap, vaccinate, release campaign targeting skunks was initiated in the eastern portion of Flagstaff at the end of July. Additional control initiatives included prohibiting relocation of nuisance wildlife, comprehensive public education on rabies, rabies vaccine clinics for pets, a leash policy for pets on trails, and quarantine. The quarantine was established from April 7 through September 13, 2009, for a 15-mile-radius area centered on Flagstaff and later expanded to the entire ORV zone. The following measures were mandatory: do not disrupt ORV baits, do not feed wild animals, enclose compost bins and piles, do not leave pet food outside after sundown, confine cats and dogs to an enclosure on the owner’s property, keep pets on a leash when off of the owner’s property, and maintain current rabies vaccination for cats and dogs.

A total of 3,141 surveys were mailed, but 172 were returned because of an incorrect address or no occupancy of household, and 1,058 were completed and returned (35.6%); 1,039 written and 19 website-based. Most respondents had lived in Flagstaff for ≥10 years (74%), lived in Flagstaff year round (98%), were ≥51 years of age (68%), female (59%), and had at least a college degree (75%). A summary of responses is shown in Table A1.

Most respondents recognized that rabies virus can be transmitted to humans from infected animals through a bite (97%), scratch (73%), or contact with saliva (74%). More than half of respondents thought rabies virus can be transmitted by contact with blood, almost a quarter by contact with an infected animal’s urine or feces, and 13% identified skunk spray as infectious. Most residents were aware that skunks and foxes in Flagstaff may have rabies (89% and 73%, respectively), but only 52% were aware that bats in Flagstaff had rabies. Information about the current outbreak was ascertained by many methods, with newspapers or magazines being the most frequently cited source (78%).

Most (70%) respondents reported that if they were bitten or scratched by a domestic animal they would wash the wound with soap and water and likely seek medical care. More persons indicated they would seek medical care if they had an encounter with a wild (90%) animal than with a domestic (72%) animal. Most respondents indicated they would call one of 3 public agencies (city animal control, county health department, fish and game department) if they saw a sick animal than if they were bitten or scratched by an animal. Sixty residents (6%) reported seeing a sick wild animal on their property in the last 6 months. Of those that specified the type of animal, 21 persons (38%) reported a sick skunk, 20 (36%) a sick fox, and 1 (2%) a sick bat; 38% of responses were listed as “other.” Thirty-six percent of the residents reported doing nothing after seeing the ill animal, while 36% called animal control, and 17% called the county health department.

Seventy-three respondents (7%) reported that they would trap and translocate a nuisance animal themselves. Ninety-five persons (9%) have personally relocated a wild nuisance animal that was on their property. Furthermore, 57% translocated the animals >5 miles from their property. Skunks were the most frequent animal to be translocated (56%).

Eighty-four percent of respondents were aware of the rabies quarantine, and 82% of those stated that they complied with quarantine restrictions. Twelve percent of respondents did not believe the requirement to keep pets on a leash at all times would help prevent rabies exposures.

One half of all households owned dogs, and 29% of all households owned cats (Table 2). The overall proportion of dogs vaccinated was 96%. A higher proportion of outdoor cats (90%) was vaccinated than were indoor (76%) or indoor/outdoor (84%), and the overall reported proportion of cats vaccinated was 81%.

Persons who had knowledge of rabies in Flagstaff were more likely to have knowledge of other aspects regarding rabies (Table A2), including the quarantine and concern about rabies in Flagstaff; these characteristics were independently associated with knowledge of rabies in Flagstaff (Table 3). Male respondents were more likely to have knowledge of rabies in Flagstaff than female respondents. Multivariate analysis did not identify an independent association between those who have knowledge of rabies in Flagstaff and contact with a nuisance wild animal.

Pet and dog owners were more likely to have had contact with a sick domestic animal and to be aware of the rabies quarantine than those who did not own pets (Table A2). Pet ownership in general was associated with knowledge of rabies. In multivariate analyses, pet owners were less likely to believe that the leash policy prevents exposures to rabid animals than non–pet owners. Dog owners were more likely to be aware of the 2009 quarantine (Table 3). There was significant interaction between age group and potential for contact with sick domestic animals, and for respondents <60 years of age, those that indicated potential for contact with a sick domestic animal were more likely to be general pet owners or dog owners. Among women, general pet owners were more likely to be aware of the quarantine than non–pet owners; this association was not seen for men. Men and women were similarly aware of the quarantine (83% and 84%, respectively).

Persons who had translocated nuisance animals were more likely to be male and to not own a pet (Table A2), although these associations did not remain independently significant in the multivariate analysis (Table 3). In the multivariate analyses, those who moved animals from their property were more likely to have a potential for contact with a wild animal and to have lived in Flagstaff for at least 10 years.