Engaging the Wisdom of Older Veterans to Enhance VA Healthcare, Research, and Services.

BACKGROUND: Stakeholder engagement helps ensure that research is relevant, clinical innovations are responsive, and healthcare services are patient-centered. OBJECTIVE: Establish and sustain a Veteran engagement board involving older Veterans and caregivers to provide input on aging-related research and clinical demonstration projects. DESIGN AND PARTICIPANTS: The Older Veteran Engagement Team (OVET)-a group of eight Veterans and one caregiver who range in age from 62 to 92-was formed in November 2017 and has met monthly since January 2018. The OVET provides feedback on topics that reflect the foci of the VA Eastern Colorado Geriatric Research Education and Clinical Center (GRECC) (e.g., physical functioning, hearing health, and emotional wellness/mental health). Ongoing evaluation documents the return on investment of Veteran engagement. MAIN MEASURES: The OVET member and provider/investigator meeting evaluations with longitudinal follow-up at 6 and 12 months. RESULTS: Return on investment of Veteran engagement is multi-faceted. For OVET, ROI ranges from grant support to improved healthcare quality/efficiency to social-emotional benefits. To date, funding awards total over $2.3 M for NIH and VA-funded projects to which OVET provided substantive feedback. Documented impacts on healthcare services include reductions in patient wait times, more appropriate utilization of services and increased patient satisfaction. Social-emotional benefits include generativity, as OVET members contribute to improving clinical and community-based supports for other Veterans. The OVET provides an opportunity for older Veterans to share their lived experience with trainees and early career investigators who are preparing for careers serving Veterans. CONCLUSION: The OVET is similar to other established stakeholder engagement groups; team members offer their individual viewpoints at any stage of research, clinical demonstration, or quality improvement projects. The OVET provides a mechanism for the voice of older Veterans and caregivers to shape aspects of individual projects. Importantly, these projects support patient-centered care and promote the characteristics of an age-friendly healthcare system.

Glaciation effects on the phylogeographic structure of Oligoryzomys longicaudatus (Rodentia: Sigmodontinae) in the southern Andes.

The long-tailed pygmy rice rat Oligoryzomys longicaudatus (Sigmodontinae), the major reservoir of Hantavirus in Chile and Patagonian Argentina, is widely distributed in the Mediterranean, Temperate and Patagonian Forests of Chile, as well as in adjacent areas in southern Argentina. We used molecular data to evaluate the effects of the last glacial event on the phylogeographic structure of this species. We examined if historical Pleistocene events had affected genetic variation and spatial distribution of this species along its distributional range. We sampled 223 individuals representing 47 localities along the species range, and sequenced the hypervariable domain I of the mtDNA control region. Aligned sequences were analyzed using haplotype network, bayesian population structure and demographic analyses. Analysis of population structure and the haplotype network inferred three genetic clusters along the distribution of O. longicaudatus that mostly agreed with the three major ecogeographic regions in Chile: Mediterranean, Temperate Forests and Patagonian Forests. Bayesian Skyline Plots showed constant population sizes through time in all three clusters followed by an increase after and during the Last Glacial Maximum (LGM; between 26,000-13,000 years ago). Neutrality tests and the "g" parameter also suggest that populations of O. longicaudatus experienced demographic expansion across the species entire range. Past climate shifts have influenced population structure and lineage variation of O. longicaudatus. This species remained in refugia areas during Pleistocene times in southern Temperate Forests (and adjacent areas in Patagonia). From these refugia, O. longicaudatus experienced demographic expansions into Patagonian Forests and central Mediterranean Chile using glacial retreats.

Using satellite images of environmental changes to predict infectious disease outbreaks.

Recent events clearly illustrate a continued vulnerability of large populations to infectious diseases, which is related to our changing human-constructed and natural environments. A single person with multidrug-resistant tuberculosis in 2007 provided a wake-up call to the United States and global public health infrastructure, as the health professionals and the public realized that today's ease of airline travel can potentially expose hundreds of persons to an untreatable disease associated with an infectious agent. Ease of travel, population increase, population displacement, pollution, agricultural activity, changing socioeconomic structures, and international conflicts worldwide have each contributed to infectious disease events. Today, however, nothing is larger in scale, has more potential for long-term effects, and is more uncertain than the effects of climate change on infectious disease outbreaks, epidemics, and pandemics. We discuss advances in our ability to predict these events and, in particular, the critical role that satellite imaging could play in mounting an effective response.

Hantavirus infection and habitat associations among rodent populations in agroecosystems of Panama: implications for human disease risk.

Hantavirus cardiopulmonary syndrome (HCPS), which is caused by infection with Choclo virus, is uncommon in Panama, yet seropositivity among rural residents is as high as 60%. To clarify the environmental risk factors favoring rodent-to-human transmission, we tested serum from 3,067 rodents captured over a five-year period for antibodies against recombinant N protein of hantavirus by enzyme immunoassay and strip immunoblot. Among 220 seropositive rodents, Oligoryzomys fulvescens, the reservoir of Choclo virus, had the highest overall seroprevalence (23.5%); more abundant rodents (Zygodontomys brevicauda and Sigmodon hirsutus) had lower seroprevalences. In the mixed (combined modern and traditional) productive agroecosystem, the highest seroprevalence was among O. fulvescens captured in residences and in crops grown within 40 meters of a residence, with significantly lower seroprevalence in adjacent pasture and non-productive vegetation. Thus, crop habitats may serve as refugia for invasion into adjacent human residences and suggests several interventions to reduce human infection.

Experimental evidence for reduced rodent diversity causing increased hantavirus prevalence.

Emerging and re-emerging infectious diseases have become a major global environmental problem with important public health, economic, and political consequences. The etiologic agents of most emerging infectious diseases are zoonotic, and anthropogenic environmental changes that affect wildlife communities are increasingly implicated in disease emergence and spread. Although increased disease incidence has been correlated with biodiversity loss for several zoonoses, experimental tests in these systems are lacking. We manipulated small-mammal biodiversity by removing non-reservoir species in replicated field plots in Panama, where zoonotic hantaviruses are endemic. Both infection prevalence of hantaviruses in wild reservoir (rodent) populations and reservoir population density increased where small-mammal species diversity was reduced. Regardless of other variables that affect the prevalence of directly transmitted infections in natural communities, high biodiversity is important in reducing transmission of zoonotic pathogens among wildlife hosts. Our results have wide applications in both conservation biology and infectious disease management.

Phylogenetically distinct hantaviruses in the masked shrew (Sorex cinereus) and dusky shrew (Sorex monticolus) in the United States.

A limited search for hantaviruses in lung and liver tissues of Sorex shrews (family Soricidae, subfamily Soricinae) revealed phylogenetically distinct hantaviruses in the masked shrew (Sorex cinereus) from Minnesota and in the dusky shrew (Sorex monticolus) from New Mexico and Colorado. The discovery of these shrew-borne hantaviruses, named Ash River virus and Jemez Springs virus, respectively, challenges the long-held dogma that rodents are the sole reservoir hosts and forces a re-examination of their co-evolutionary history. Also, studies now underway are aimed at clarifying the epizootiology and pathogenicity of these new members of the genus Hantavirus.

The effect of habitat fragmentation and species diversity loss on hantavirus prevalence in Panama.

Habitat fragmentation and diversity loss due to increased conversion of natural habitats to agricultural uses influence the distribution and abundance of wildlife species and thus may change the ecology of pathogen transmission. We used hantaviruses in Panama as a research model to determine whether anthropogenic environmental change is associated with changes in the dynamics of viral transmission. Specifically, we wanted to determine whether hantavirus infection was correlated with spatial attributes of the landscape at both large and small scales or whether these changes are mediated by changes in community composition. When analyzed at coarse spatial scales, hantavirus reservoirs were more commonly found in disturbed habitats and edge habitats than in forested areas. At local scales, reservoir species dominance was significantly correlated with the slope of the terrain. To evaluate the effect of small-mammal diversity loss on infection dynamics, we implemented an experiment with selective species removal at experimental sites. Seroprevalence of hantavirus was higher in the community of small mammals and increased through time in the experimental sites. The higher seroprevalence in experimental plots suggests that greater diversity likely reduces encounter rates between infected and susceptible hosts. Our studies suggest that habitat loss and fragmentation and species diversity loss are altering hantavirus infection dynamics in Panama. Our work represents a multidisciplinary approach toward disease research that includes biodiversity concerns such as environmental change and degradation, human settlement patterns, and the ecology of host and nonhost species, work that may be especially important in tropical countries.

Persistently highest risk areas for hantavirus pulmonary syndrome: potential sites for refugia.

Interannual variation in the number of cases of human disease caused by hantaviruses in North America has been hypothesized to reflect environmental changes that influence rodent reservoir populations. This hypothesis postulates that when cases are rare reservoir populations are geographically restricted in patches of suitable habitat. Identifying these sites, which is needed to test the hypothesis, has proven to be a challenge. Satellite imagery of the U.S. Southwest has shown associations among the likelihood of human hantaviral disease and increases in the rodent populations, as well as increased prevalence of Sin Nombre virus (SNV) in rodent populations. In this study we characterize local areas that had environmental signatures that persisted as predicted highest risk sites for human disease through much of the 1990s. These areas represent a small percentage (0.3%) of the region. Exploratory analyses indicate that these areas were not randomly distributed, but were associated with certain landscape characteristics. Characteristics of elevation, slope, aspect, and land cover were associated with persistent high risk. Using multivariate Poisson regression to control for confounding effects, sites with deciduous- or mixed-forest land cover on moderate to steep slopes (>5 degrees) above 2130 m elevation were associated with increasing numbers of years at highest risk. These are candidate locations for refugia. Sites associated with cleared ground or shrubland were less often associated with high risk compared to reference conditions. The seasonal patterns of vegetation growth in persistently high-risk areas were compared to matched locations using MODIS (moderate resolution imaging spectroradiometer) NDVI (normalized difference vegetation index) during a time of a severe drought in the region from 2002 to 2004. Despite the drought and regardless of land cover, the NDVI in persistently highest risk areas had an early onset, with significantly higher levels of green vegetation that lasted longer than at comparable sites. These observations identify locations that can be monitored for the abundance of P. maniculatus and presence of SNV. If these sites are refugia, we predict they will be occupied by infected deer mice when other monitored sites are unoccupied.

Demographic factors associated with prevalence of antibody to Sin Nombre virus in deer mice in the western United States.

We used long-term data collected for up to 10 yr (1994-2004) at 23 trapping arrays (i.e., webs and grids) in Arizona, Colorado, Montana, and New Mexico to examine demographic factors known or suspected to be associated with risk of infection with Sin Nombre virus (SNV) in its natural host, the deer mouse (Peromyscus maniculatus). Gender, age (mass), wounds or scars, season, and local relative population densities were statistically associated with the period prevalence of antibody (used as a marker of infection) to SNV in host populations. Nevertheless, antibody prevalence and some of the risk factors associated with antibody prevalence, such as relative population density, gender bias, and prevalence of wounding, varied significantly among sites and even between nearby trapping arrays at a single site. This suggests that local microsite-specific differences play an important role in determining relative risk of infection by SNV in rodents and, consequently, in humans. Deer mouse relative population density varied among sites and was positively and statistically associated with infection prevalence, an association that researchers conducting shorter-term studies failed to demonstrate. Both wounding and antibody prevalence increased with mass class in both males and females; this increase was much more pronounced in males than in females and wounding was more frequent in adult males than in adult females. Prevalence of wounding was greatest among seropositive deer mice, regardless of mass class, but many deer mice without detectable wounds or scars eventually became infected. Many of these patterns, which will be useful in the development of predictive models of disease risk to humans, were only detected through the application of data collected over a long (10-yr) period and with abundant replication.

Hantavirus in northern short-tailed shrew, United States.

Phylogenetic analyses, based on partial medium- and large-segment sequences, support an ancient evolutionary origin of a genetically distinct hantavirus detected by reverse transcription-PCR in tissues of northern short-tailed shrews (Blarina brevicauda) captured in Minnesota in August 1998. To our knowledge, this is the first evidence of hantaviruses harbored by shrews in the Americas.

Phylogeography of the deer mouse (Peromyscus maniculatus) provides a predictive framework for research on hantaviruses.

Phylogeographical partitioning of Sin Nombre and Monongahela viruses (hantaviruses) may reflect that of their primary rodent host, the deer mouse (Peromyscus maniculatus). Lack of a comprehensive assessment of phylogeographical variation of the host has precluded the possibility of predicting spatial limits of existing strains of these viruses or geographical regions where novel viral strains might emerge. The complete cytochrome b gene was sequenced for 206 deer mice collected from sites throughout North America to provide a foundation for future studies of spatial structure and evolution of this ubiquitous host. Bayesian analyses of these sequences partitioned deer mice into six largely allopatric lineages, some of which may represent unrecognized species. The geographical distributions of these lineages were probably shaped by Quaternary climatic events. Populations of mice were apparently restricted to refugia during glacial advances, where they experienced genetic divergence. Expansion of these populations, following climatic amelioration, brought genetically distinctive forms into contact. Occurrence of parallel changes in virus strains can now be explored in appropriate regions. In New Mexico, for example, near the location where Sin Nombre virus was first discovered, there are three genetically distinctive lineages of deer mice whose geographical ranges need to be delineated precisely. The phylogeography of P. maniculatus provides a framework for interpreting geographical variability, not only in hosts, but also in associated viral variants and disease transmission, and an opportunity to predict the potential geographical distribution of newly emerging viral strains.

Modeling hantavirus reservoir species dominance in high seroprevalence areas on the Azuero Peninsula of Panama.

Habitat fragmentation commonly influences distribution of zoonotic disease reservoirs. In Panama, populations of rodent hosts of hantaviruses are favored by small habitat fragments isolated by agricultural lands. We expected a similar relationship between landscape characteristics and host distribution at fine geographical scales in southern Panama. The relative abundance of Zygodontomys brevicauda, the primary host for "Calabazo" virus, and other rodents was assessed at 24 sites within the Azuero Peninsula. We used satellite imagery to produce several spatial variables that described landscape; however, only slope was consistently related to abundances of the two most dominant rodent species. Using regression, we constructed a spatial model of areas of Z. brevicauda dominance, which in turn relates to higher infection rates. The model predicts highest abundances of Z. brevicauda in flat areas, where humans also dominate. These predictions have important ecological and conservation implications that associate diversity loss, topography, and human land use.

Community ecology of small mammal populations in Panamá following an outbreak of Hantavirus pulmonary syndrome.

In late 1999 and early 2000, an outbreak of hantavirus pulmonary syndrome (HPS) occurred in and around Los Santos, on the Azuero Peninsula of southwestern Panamá. This HPS episode, resulting in 22% case fatality, was linked to the Costa Rican pigmy rice rat, Oligoryzomys fulvescens costaricensis, which harbored a then undescribed hantavirus, Choclo virus. In addition, Cherrie's cane rat, Zygodontomys brevicauda cherriei, was identified as carrying a distinct hantavirus, Calabazo virus with no known pathogenicity to humans. Herein we present the ecological results of the outbreak investigations in the Azuero region. A total of 164 animals were captured, of which 126 were potential small, non-volant mammal hosts of a hantavirus: rodents in the family Muridae. There were significant differences in small mammal community structure between case sites and a negative control site. Differences were manifest in ecological measures of species diversity and in species evenness and heterogeneity measures, as indicated by Pairwise Euclidian distances and Morisita indices of community similarity. Our analyses suggest that human activities (i.e., deforestation for cattle ranching) coupled with environmental factors (i.e., increased precipitation) may have synergistically coalesced for an increased risk of HPS to area residents.

Serosurvey of wild rodents for hantaviruses in Panama, 2000-2002.

Five hundred fifty-six samples representing 24 species of small mammals (two species of marsupials and 22 rodents) were collected in Panama between February 2000 and July 2002. The samples were examined for antibodies to hantaviruses by means of enzyme-linked immunosorbent assay or immunoblot assays. The serologic results indicated that several rodent species might act as hantaviral reservoirs in Panama: Costa Rican pygmy rice rat (Oligoryzomys fulvescens costaricensis), four positive of 72 tested (5.6%); Cherrie's cane rat (Zygodontomys brevicauda cherriei), five of 108 (4.6%); Mexican deer mouse (Peromyscus mexicanus), one of 22 (5%); Mexican harvest mouse (Reithrodontomys mexicanus), one of seven (14%); Chiriquí harvest mouse (Reithrodontomys creper), one of two (50%); and Sumichrast's harvest mouse (Reithrodontomys sumichrasti), three of four (75%). Hantavirus infection in Peromyscus mexicanus and the three species of Reithrodontomys was caused by Rio Segundo hantavirus, a species of virus not previously reported from Panama. At least three hantaviruses, therefore, are known to infect populations of wild rodents in the country. However, given the total number of animals tested, the role of these rodent species in the epidemiology and epizootiology of hantavirus infections remains unclear.

Peridomestic small mammals associated with confirmed cases of human hantavirus disease in southcentral Chile.

Cases of human hantavirus disease have been reported in Chile since 1995, most of them in people living in rural and periurban areas. We conducted a peridomestic study of small mammals to evaluate the relationships between the presence of rodents with antibodies to Andes virus confirmed human cases of hantavirus pulmonary syndrome in southcentral Chile. The results of 20 sampled sites, which involved the capture of 272 mice over an 18-month period, showed the occurrence of 10 small mammal species, of which Oligoryzomys longicaudatus was the only seropositive species for hantavirus, with an intra-specific serologic rate of 10.4%.

Satellite imagery characterizes local animal reservoir populations of Sin Nombre virus in the southwestern United States.

The relationship between the risk of hantaviral pulmonary syndrome (HPS), as estimated from satellite imagery, and local rodent populations was examined. HPS risk, predicted before rodent sampling, was highly associated with the abundance of Peromyscus maniculatus, the reservoir of Sin Nombre virus (SNV). P. maniculatus were common in high-risk sites, and populations in high-risk areas were skewed toward adult males, the subclass most frequently infected with SNV. In the year after an El Niño Southern Oscillation (ENSO), captures of P. maniculatus increased only in high-risk areas. During 1998, few sites had infected mice, but by 1999, 1820 of the high-risk sites contained infected mice and the crude prevalence was 30.8%. Only 118 of the low-risk sites contained infected rodents, and the prevalence of infection was lower (8.3%). Satellite imagery identified environmental features associated with SNV transmission within its reservoir population, but at least 2 years of high-risk conditions were needed for SNV to reach high prevalence. Areas with persistently high-risk environmental conditions may serve as refugia for the survival of SNV in local mouse populations.

Phylogenetic and biogeographic relationships of the mouse opossum Thylamys (Didelphimorphia, Didelphidae) in southern South America.

Nucleotide sequence data from the mitochondrial cytochrome b gene were used to evaluate the phylogenetic relationships among mouse opossum species of the genus Thylamys. Based on approximately 1000 bp in five of the six species of the genus and including different localities for some of the species, we concluded that T. macrura from the subtropical forests of eastern Paraguay is the most primitive taxon. Subsequent radiation of the genus is explained mainly via founder effect speciation. This evolutionary scenario would account for the speciation of T. pusilla, T. venusta, T. pallidior, and T. elegans in the Chaco, southern Bolivia and northern Argentina, the Andean Altiplano, the Coastal Desert of Chile, and coastal Perú, respectively. Calibration of a molecular clock set the Pleistocene as the period for the differentiation of Thylamys species. The molecular results confirm the strong genetic connection between populations that inhabit the "pre-cordillera" of northern Chile (T. pallidior) and the canyons that run through the Atacama Desert to the lowlands in northern Chile. Our results confirm the occurrence of two Thylamys species in Chile, T. pallidior and T. elegans, within and south to the Atacama Desert, respectively.