Unified Command in Local Public Health: Case Studies of Rabies and Tuberculosis Responses in Douglas County, Nebraska

As public health emergencies become more frequent and complex, local health departments must increasingly rely on public-private partnerships and whole-community approaches to respond effectively. The Douglas County Health Department (DCHD), serving Nebraska's most populous county, demonstrates how a local agency can coordinate large-scale responses by implementing a unified command structure with diverse partners. This case study presents 2 concurrent public health emergencies that occurred in late 2023: (1) the detection of raccoon rabies virus variant (RRVV) in a domestic kitten, a pathogen not previously identified in Nebraska, and (2) the largest pediatric tuberculosis (TB) exposure investigated in the county's history. Both incidents required rapid coordination across local, state, and federal agencies, as well as engagement with healthcare systems and community organizations. In each response, DCHD activated a unified command structure to facilitate operational objectives, allocate resources, and coordinate risk communication. The rabies response included enhanced animal surveillance, a trap-vaccinate-release campaign, and the manual distribution of 18,000 oral rabies vaccine baits. No additional human or animal cases of RRVV were identified. The TB response involved identifying 643 exposed individuals, conducting mass testing clinics with local healthcare partners, and rapidly initiating prophylaxis for vulnerable populations. No cases of secondary transmission were identified. These case studies demonstrate how local health departments can lead complex responses by leveraging established partnerships, aligning with National Incident Management System principles, and coordinating unified command operations. Lessons learned from Douglas County's experience offer practical guidance for other jurisdictions preparing for zoonotic and airborne infectious disease threats, especially when internal resources are limited.