Spatio-temporal patterns of tick-borne disease diagnoses in Indiana, USA (2009-2018).

AIMS: Although tick-borne disease (TBD) incidence has increased in the United States (U.S.) in the past decade, new evidence suggests that notifiable diseases surveillance records may not accurately reflect the true magnitude of TBD diagnoses. Furthermore, while regional electronic health records (EHR) are readily accessible their potential use as a more stable and consistent source of TBD diagnoses data has remained largely unexplored. METHODS AND RESULTS: In this study, we used EHR from a database of more than 100 hospitals, healthcare networks, and insurance providers in Indiana, U.S., to better understand incidence, spatio-temporal and demographic distribution of TBD Diagnoses from 2009-2018. Our results revealed that in Indiana, from 2009 to 2018, there were 5173 unique TBD Diagnoses across three diagnoses categories: Lyme disease (72.5%, n = 3751), Rickettsioses (12.0%, n = 623) and Other TBD Diagnoses (15.4%, n = 799). Using EHR, the average yearly Lyme disease diagnoses was more than double the cases obtained using notifiable disease surveillance data for the same period. Patients with a TBD Diagnoses were generally older (ages 45-59) and less racially diverse (96.3% white). Rickettsiosis diagnoses were reported more among male patients (55.2%), while Lyme disease diagnoses were higher among female patients (57.1%). Temporal data illustrated higher frequencies of diagnoses from May to July. Hot spot analysis identified a Lyme disease hot spot in northwest Indiana, while hotspots of Rickettsiosis and Other TBD Diagnoses category were identified in southwest Indiana. Extrapolated to the Indiana population, chi-squared (χ2) tests of independence revealed that the observed distribution of TBD diagnoses in our data was significantly different from the expected distribution in the Indiana population-based race, gender and age groups. CONCLUSIONS: Our study findings demonstrate that in Indiana, EHR provide a stable data source for elucidating TBD disease burden and for monitoring spatio-temporal trends in TBD diagnoses.

An application of the reasoned action approach to clinical students' intention toward a career in geriatrics.

Guided by the reasoned action approach, this study examined select individual, information, and social factors that influence intention toward pursuing a career in geriatrics among 314 clinical medical and nursing students in Ghana. A Poisson regression showed attitude toward older persons was a significant influencing factor of intention to choose a career in geriatrics for medical students (B = 0.015, SE = 0.0048, p = 0.002) but not nursing students (B = 0.009, SE = 0.0145, p = 0.512). Personal interest was, however, a significant influencing factor for both medical and nursing students (B = 0.462, SE = 0.0592, p = 0.000) and (B = 0.015, SE = 0.0048, p = 0.002), respectively. Nursing students with moderate to strong interest were 1.6 times more likely to express an intention to specialize in geriatrics, and medical students were 1.5 times more likely to express an intention to specialize in geriatrics. The results show that the most important factor influencing geriatric career intention is students' personal interest in the field. Evidence-based interventions such as early educational and practice exposure to the field and interactions with older adults are recommended.

Socio-ecological determinants of rickettsial seroprevalence in a rural community of Yucatán, Mexico.

Rickettsial diseases have seen a re-emergence in the Americas in the last few decades, with concerning morbidity, mortality and economic implications that result from loss of productivity, income, curbs in liberal trade agreements, and reduction in agricultural practices. The aim of this study is to determine the socioecological determinants and seroprevalence for Rickettsia typhi and Rickettsia rickettsii among residents of Teabo, a rural community of Yucatán, Mexico. Sociodemographic data and serum samples were obtained from 180 consenting participants. Antibody titers for R. typhi and R. rickettsii were determined by indirect immunofluorescence assay (IFA). Participants also submitted tick samples collected from their residential area. We conducted logistic regression models to evaluate the association between exposure variables and seroprevalence. Rhipicephalus sanguineus s.l. (37%; n = 65), and Amblyomma cajennense Fabricius (17%; n = 29) were the predominant tick species in peri-domestic areas. Out of the 180 participants, there was significantly higher seroprevalence of R. typhi (n = 77; 46%) compared to R. rickettsii [n = 27, 15%, (p < 0.05)]. Pearson's chi-square test of independence revealed significant differences in R. rickettsii seroprevalence by gender (X2 [n = 175, df = 4, (p < 0.001)] = 180.26), level of education, (X2 [n = 180, df = 4, (p < 0.001)] = 44.0), and by tick species found in residential area, (X2 [n = 180, df = 4, (p = 0.050)] = 9.48). After adjusting for other variables in a logistic regression model, for each unit increase in the number of dogs present in the residential area, there was a 27% increase in the odds of human seroprevalence for R. typhi IgG (AOR = 1.27, 95% CI: 1.01-1.63). Compared to study participants living in residential areas with a 'low' height of vegetation, those living in residential areas with a 'medium' height of vegetation had 2.5 times greater odds of human seroprevalence for R. typhi IgG (AOR = 2.51, 95% CI: 1.19-5.40). Potentially modifiable existing factors in the peri-domestic area may constitute a high-risk source of seroprevalence for rickettsial antibodies among residents of the rural community of Teabo, Yucatán, Mexico.

Using convolutional neural networks for tick image recognition - a preliminary exploration.

Smartphone cameras and digital devices are increasingly used in the capture of tick images by the public as citizen scientists, and rapid advances in deep learning and computer vision has enabled brand new image recognition models to be trained. However, there is currently no web-based or mobile application that supports automated classification of tick images. The purpose of this study was to compare the accuracy of a deep learning model pre-trained with millions of annotated images in Imagenet, against a shallow custom-build convolutional neural network (CNN) model for the classification of common hard ticks present in anthropic areas from northeastern USA. We created a dataset of approximately 2000 images of four tick species (Ixodes scapularis, Dermacentor variabilis, Amblyomma americanum and Haemaphysalis sp.), two sexes (male, female) and two life stages (adult, nymph). We used these tick images to train two separate CNN models - ResNet-50 and a simple shallow custom-built. We evaluated our models' performance on an independent subset of tick images not seen during training. Compared to the ResNet-50 model, the small shallow custom-built model had higher training (99.7%) and validation (99.1%) accuracies. When tested with new tick image data, the shallow custom-built model yielded higher mean prediction accuracy (80%), greater confidence of true detection (88.7%) and lower mean response time (3.64 s). These results demonstrate that, with limited data size for model training, a simple shallow custom-built CNN model has great prospects for use in the classification of common hard ticks present in anthropic areas from northeastern USA.

Tick trails: the role of online recreational trail reviews in identifying risk factors and behavioral recommendations associated with tick encounters in Indiana.

BACKGROUND: Recreational trails abound across the United States and represent high risk areas for tick exposure. Although online reviews represent a rich source of user information, they have rarely been used in determining the risk of tick exposure during recreational trail use. Based on online user reviews and comments, the purpose of this study was to determine risk factors and behavioral recommendations associated with tick encounters (Tick Presence) on recreational trails in the state of Indiana, U.S. METHODS: We reviewed 26,016 user comments left on AllTrails.com for 697 Indiana trails. Reviews were evaluated to determine Tick Presence/Absence, the total number of Tick Presence Reviews per trail, and multiple trail and user behavioral characteristics. We used hot spot (Getis-Ord Gi*) analysis to test the hypothesis of whether there are clusters in the number of Tick Presence Reviews. Pearson chi-square tests of independence evaluated whether tick presence was associated with several trail characteristics. Finally, negative binomial regression evaluated the strength of the association between the number of Tick Presence Reviews and several trail characteristics. RESULTS: Tick Presence was recorded at 10% (n = 65) of trails and occurred most frequently in May. Hot spot analysis revealed statistically significant clusters of Tick Presence Reviews on trails in the Southern Indiana State Region. Results of χ2 tests indicated significant associations between Tick Presence Reviews and (a) State Region and (b) Land Management Type; Mann-Whitney U tests detected significant differences in Tick Presence Reviews based on Trail Length and Elevation Gain. Subsequent results of a negative binomial regression model indicated that Southern Indiana State Region, Federal and Private Land Management Type, and Elevation Gain were factors significantly associated with Tick Presence Reviews. Content of user reviews indicated several behaviors employed to prevent tick encounters, particularly Repellent Application and Recreational Deterrence; 25% included a behavior Recommendation to others. CONCLUSIONS: Online, user-generated trail reviews have the potential to serve as rich data sources for identifying recreational trails, where 1) the risk of tick exposure is great, 2) more robust active tick and tick-borne pathogen surveillance may be warranted, and 3) tailored prevention interventions are needed.

Using i-tree canopy vegetation cover subtype classification to predict peri-domestic tick presence.

While extant literature has generally indicated significant associations between vegetation cover and tick activity, no study has demonstrated the relative association between peri-domestic area vegetation cover subtypes and tick presence. In this study, we seek to determine whether neighborhood wood index and residential tick control practices confound or modify the effect of peri-domestic vegetation cover subtypes on tick presence. We conducted an ecological inventory of vegetation cover distribution using i-Tree Canopy on 210 private residential/peri-domestic properties in Indiana, USA. Results were paired with field obtained tick presence/absence data for each property together with online survey data provided by primary occupant of the property. Amblyomma americanum was the predominant tick species in peri-domestic areas. Higher proportion of vegetation cover in the peri-domestic area was significantly associated with tick presence. Of the four vegetation cover subtypes, (grass, shrubs, understory, and canopy), canopy was the most prevalent vegetation in peri-domestic areas of Indiana, USA. It was also the most significant predictor of tick presence. Among residential tick control processes, frequent leaf litter removal was significantly associated with reduced likelihood of peri-domestic tick presence. Neighborhood Wood Index (NWI) confounded the relationship between canopy and peri-domestic tick presence, while leaf-litter removal confounded the effect of understory vegetation subtype on peri-domestic tick presence. Compared to peri-domestic areas in neighborhoods with sparse NWI, those in neighborhoods with heavy/dense NWI had a 3.5x odd of peri-domestic tick presence (AOR = 3.46; 95 % CI: 1.23-9.65). Compared to peri-domestic areas in the central region, those in the southern region of Indiana were 8.7x more likely to have peri-domestic tick presence. Canopy as a vegetation cover subtype and frequent leaf litter removal represent particularly key peri-domestic variables that have significant implications for peri-domestic tick presence. Beyond parcel-scale landscape features, neighborhood wood index also plays an important role in peri-domestic tick presence. Additionally, i-Tree Canopy represents a promising methodological tool for identifying landscape features that predict tick presence.

Preventing tick-bites among children in Indiana, USA: An analysis of factors associated with parental protective behaviors.

Despite evidence to the effect that there is low parental adoption of tick-bite personal protective behavior (PPB) for their children - a population at high risk for tick exposure, very limited information is available on factors associated with parental adoption of PPB. The objective of this study was to identify the most significant factors associated with parental adoption of tick-bite PPB on behalf of a child or children at risk of tick encounters. A cross-section of parents in Indiana, USA whose child had spent time outdoors in tick habitat during the summer were recruited from representative online panels maintained by Qualtrics. Binary logistic regression was used to model determinants of five tick-bite PPBs. Our results revealed that the application of tick repellent (89 %, n = 718) followed by conducting a tick check of the child's body soon after returning from the outdoors (84 %, n = 676) were the PPBs most frequently adopted by parents. Conversely, tucking one's shirt into pants and pants into socks was the least frequently adopted PPB (48 %, n = 386). Compared to other factors evaluated in logistic regression models, parents who reported implementing one or more residential tick control practices were significantly more likely to adopt nearly all five tick-bite PPBs for their children. Additionally, parents who were more worried about their health due to ticks and reported being more likely to avoid the outdoors because of ticks were more likely to adopt at least three PPBs on behalf of their children. To ensure children can most safely engage in outdoor activity, identifying the factors associated with parental adoption of tick-bite preventive behaviors represents an important mechanism in the prevention of tick-borne diseases.

Active surveillance of ticks in peri-domestic areas of Indiana, Midwest United States.

BACKGROUND & OBJECTIVES: The incidence of Borreliosis, Anaplasmosis, Babesiosis and other tick-borne diseases acquired from private residential/peri-domestic areas has increased over the decades. However, tick activity and proportion of private residential properties with established tick populations remain unknown. The purpose of the current study was to determine the predictors of tick activity in peri-domestic areas. METHODS: In a cross-sectional study design, we used snowball-sampling with cold-calling techniques to collect free-living ticks, sociodemographic, and microclimatic data from June to November 2018 from a total of 96 private residential areas in south-central Indiana, USA. RESULTS: Thirty-eight percent of peri-domestic areas sampled had tick activity, and of these, 50% had established tick populations. Nymphal ticks were the most abundant life stage. Self-reported TBD diagnosis was 16%. Amblyomma americanum [Linnaeus (lone star tick)] was the most abundant tick species collected. Other tick species identified include: Ixodes scapularis [Say (black-legged/deer tick)] and Dermacentor variabilis [Say (American dog tick)]. Increasing temperature was positively associated with tick activity, while elevation was negatively associated with tick abundance. INTERPRETATION & CONCLUSION: Our study results reveal that the proportion of peri-domestic areas in Indiana with established tick populations is high. Amblyomma americanum tick is the most predominant tick species in peri-domestic areas of south-central Indiana. Active surveillance of ticks in peri-domestic areas is necessary for informing decisions by households and communities about where to target tick exposure and tick-borne disease prevention efforts.

Prevalence of Risk and Protective Factors for Tick Exposure and Tick-Borne Disease Among Residents of Indiana.

OBJECTIVE: To determine the prevalence of risk and protective factors for tick exposure and tick-borne disease (TBD) based on gender and living in urban or rural areas (urbanicity) among a cross section of Indiana adults. METHODS: Data were collected from 3003 adults (81% response rate) spread across all 92 Indiana counties. Study participants were recruited from existing online panels maintained by Qualtrics. We calculated prevalence ratio (PR) and 95% confidence interval (CI) of 8 primary outcomes for 2 different exposures: (1) gender (male/female) and (2) urbanicity. RESULTS: Female participants were 10% less likely to find a tick on themselves than male participants (PR = 0.90; 95% CI, 0.74-0.99) and significantly more likely to worry about their health and safety because of ticks, whereas males avoided the outdoors less because of worry about ticks. Female participants were significantly more likely to adopt various personal protective measures, specifically because of concern for ticks. Female participants were also less likely to have been told by a health care provider that they have a TBD (PR = 0.53; 95% CI, 0.38-0.75). Rural participants were significantly more likely to report seeing a tick at their residential property (PR = 2.40; 95% CI, 2.11-2.76), report finding ticks on themselves (PR = 1.90; 95% CI, 1.68-2.23), and report finding a tick on a child at their residential property within the past 6 months than urban dwellers (PR = 1.37; 95% CI, 1.06-1.77). In addition, we found that 62% of participants have very high trust in government sources of information on TBD and tick prevention. CONCLUSIONS: In Indiana, the area around people's residences may constitute an important source of tick exposure for humans. Being exposed to ticks is most prevalent in those living in rural areas of Indiana. Finally, risk factors for TBD are higher among males than among females.

Relationship Between Tick Activity, Tick-Borne Diseases, Cognitive and Affective Risk Assessment in Peri-domestic Areas.

Peri-domestic areas constitute an important source of tick exposure and tick-borne diseases (TBD). Nonetheless, the association between distal TBD risk factors (i.e. cognitive-/affective-risk perceptions, knowledge of the effectiveness of personal protective behaviors) and proximal TBD risk (i.e. tick activity and TBD diagnosis), among adult residents of private residential properties (PRP) is unknown. Data was collected from 299 PRP in south and central Indiana. We used Mann-Whitney U and Kruskal-Wallis non-parametric tests to identify differences in proximal and distal outcome measures. We found evidence of 'tick activity' at thirty-nine percent of PRP (n = 116). Thirteen-percent of respondents (n = 40) self-reported a TBD diagnosis within their household. We found no significant association between 'self-reported TBD diagnosis within a household' and 'tick activity in the peri-domestic area.' Mean scores on 'affective tick & TBD risk assessment' were significantly higher among respondents when 'tick activity' was present in the peri-domestic area (median = 2, M = 2.54, p < 0.001). Similarly, respondents who 'self-reported TBD diagnosis within their household' had significantly higher mean scores on 'affective tick & TBD risk assessment' (median = 3, M = 3.30) than those who did not (median = 1, M = 1.93), (U = 2750, p < 0.001). The proportion of peri-domestic areas with 'tick activity' was significantly higher if the primary respondent was male or an older adult respectively, compared to females and younger adults. Occupational/recreation-based settings may be more important pathways of tick exposure than peri-domestic settings in Indiana. Beyond education, it is important to consider the feelings and emotions that are elicited when at-risk populations consider their peri-domestic tick exposure and TBD risk, and where necessary design interventions to address those affective assessments.

A Space-Time Permutation Scan Statistic for Evaluating County-Level Tickborne Disease Clusters in Indiana, 2009-2016.

The purpose of this study was to identify age group, gender, rural-urban differences, and spatiotemporal clusters of tickborne disease diagnoses in Indiana. We analyzed retrospective surveillance data for Lyme disease, ehrlichiosis, Rocky Mountain spotted fever, typhus/rickettsial diseases, and tularemia diagnosed in Indiana from 2009 to 2016. We used chi-square cross tabulation to test gender, age group, and county classification (rural, rural-mixed, urban) differences in tickborne disease. We used the Kruskal-Wallis test with a post hoc Conover test to identify differences in summated tickborne disease by county classification. Finally, we used retrospective space-time permutation models in SaTScan to test the hypothesis of complete spatiotemporal randomness of tickborne disease. We found more Lyme disease diagnoses among Indiana residents 44 years of age or younger compared with those over 44 years. Conversely, more ehrlichiosis, Rocky Mountain spotted fever, and tularemia were reported in Indiana residents aged over 44 years of age. An analysis of summated tickborne disease by county showed significantly higher diagnosis reported in urban counties, compared with rural and rural-mixed counties. Finally, 2 significant clusters of summated tickborne disease were observed in south-central Indiana in 2014 and in western Indiana from 2010 to 2011. The detection of tickborne disease clusters, coupled with the finding that significant differences exist in the diagnosis of tickborne diseases between urban, rural, and rural-mixed counties in Indiana, suggests a need for continued surveillance of the counties observed within these clusters.

Etiologic Agents of Fever of Unknown Origin Among Patients Attending Mnazi Mmoja Hospital, Zanzibar.

BACKGROUND: Fever of unknown origin (FUO) remains an important public health problem. With malaria transmission declining in some parts of Africa, the evidence suggests other infectious agents now account for most FUO. The purpose of this study was to identify the etiologic agents of FUO in a cross-section of patients at the Mnazi Mmoja hospital in Zanzibar, Tanzania. METHODOLOGY: A multiplex TaqMan gene expression Array Card (TAC) and plates were used for detection and classification of different pathogens in blood samples obtained from patients with FUO. Logistic regression analyses was performed using pathogens detected and sociodemographic characteristics as outcome and exposure variables respectively. Odd ratios and 95% confidence interval were calculated and statistical significance was set at P < .05. RESULT: Thirty-three different pathogens were detected in 27 patient blood samples. The following pathogens were detected in decreasing order of prevalence; Dengue virus, Plasmodium species, Rickettsia, Brucella species, Salmonella typhi, and less than 1% for each of Bartonella, Coxiella burnetii, Salmonella species, and Leptospira. Co-infections of Plasmodium with Dengue and S. typhi were also detected, including one case with three different pathogens-Plasmodium, Rickettsia and Brucella. There was no association between the etiologic agents of FUO and demographic or clinical characteristics. CONCLUSIONS: Zoonotic and arboviral etiological agents of fever of unknown origin are present among patients at the Mnazi Mmoja hospital in Zanzibar, Tanzania. There is a need to develop a baseline of standardized diagnostic approaches particularly within the hospital setting. In areas with low malaria prevalence like Zanzibar, Dengue, Rickettsia, Coxiella burnetii, Brucellosis should be considered by clinicians in the differential diagnoses of FUO.

Predictors of Tick Exposure Risk-Reduction Behavior in Indiana.

To identify significant predictors of the adoption of more than one tick-exposure and tick-borne disease risk reduction behavior among a cross-section of Indiana residents. Study participants were recruited through quota sampling, before completing an online self-administered questionnaire in Qualtrics. The most adopted tick exposure risk reduction behavior (TERRB) (was 'Walking on established trails and avoiding contact with adjacent vegetation' (83%, n = 2418). This was followed by 'Conducting a thorough check of clothing and the body soon after returning from the outdoors' (81%, n = 2373). The two least adopted TERRBs were,' Treating outdoor clothing with special insect repellent (e.g. Permethrin)' (48%, n = 1409) and 'Wearing appropriate clothing' ('Tucking shirt into pants, and the pants into socks when outdoors') respectively (52%, n = 1524). Study participants who engaged in residential tick control practices (i.e. 'three-foot wide barrier of wood chips/gravel between lawn and woodland', 'yard pesticide application', 'shrub & tree-branch trimming', 'yard fencing', 'fixed time lawn mowing', and 'leaf litter removal') were significantly more likely to adopt nearly all the assessed TERRBs. Higher scores on TERRB efficacy index were associated with engaging in multiple TERRBs. Higher degree of worry about safety/health because of ticks was also associated with adoption of multiple TERRBs. In conclusion, increased risk perceptions, among Indiana residents is significantly associated with adoption of multiple TERRBs. Identifying the predictors of the adoption of more than one TERRB is vital for the prevention of tick-borne diseases.

Predicting Chikungunya disease personal protective behaviors: Results of a cross-sectional survey of US-Caribbean travelers.

Background: Incidents of vector-borne disease have recently tripled in the United States. Chikungunya disease is a particularly common disease in the Caribbean, posing a threat to international tourists. However, the relationship between psychological variables derived from the protection motivation theory (PMT), and adoption of protective behaviors against the disease, is uncertain. This study sought to identify the psychological predictors of travelers' protective health behaviors, specifically (1) appropriate clothing use, and (2) indoor spatial repellent use. Methods: An online, retrospective survey of U.S. international travelers to Caribbean destinations measured the five constructs of the PMT in the context of Chikungunya disease: Perceived severity, perceived vulnerability, perceived response efficacy, perceived self-efficacy, and knowledge. Hierarchical logistic regression analyzed whether these five theoretical constructs predicted the two protective behaviors in respondents who met study criteria (n = 184). Results: Results suggest that the interaction between chikungunya knowledge and perceived chikungunya severity predicts both appropriate clothing use (odds ratio [OR]: 1.95, CI: 1.18-3.25, P =0.010) and indoor spatial repellent use (OR: 1.55, CI: 1.05-2.29, P =0.029). In the cases of appropriate clothing use, the interaction between perceived chikungunya severity and perceived vulnerability was also a significant predictor (OR: 9.67, CI:1.23-75.80, P =0.031). Additionally, indoor spatial repellent use was also predicted by the interaction of chikungunya knowledge and perceived vulnerability (OR: 1.88, CI:1.18-3.02, P =0.009). Conclusion : Two-pronged educational approaches may be most efficacious in increasing protective health behaviors. Such efforts could reduce incidents of chikungunya disease and other vectorborne diseases in travel destinations featuring high exposure risks.

Associations Between Personal Protective Measures and Self-Reported Tick-Borne Disease Diagnosis in Indiana Residents.

Several personal protective measures (PPMs) are recommended to prevent tick-borne diseases (TBD). We aimed to quantify the strength of seven PPMs and self-reported TBD diagnosis associations and to understand what variables modify these associations. In June-July 2018, with a cross-sectional study design, we surveyed a sample of adult Indiana state residents. Overall, 2927 participants were eligible for this analysis. All data were self-reported. We used the double robust approach of stabilized inverse probability weighting and propensity score adjustment to obtain ORs. Approximately 5% of participants (n = 142) self-reported TBD diagnosis. Practicing different PPMs ranged from 48% for treating outdoor clothing with special bug-spray to 83% for walking on established trails. Using insect repellent on exposed skin was protective against TBD diagnosis [OR (95% CI): 0.55 (0.35, 0.88)]. A thorough body/clothes check after being outdoors was also protective against TBD diagnosis [OR (95% CI): 0.40 (0.25, 0.67)]. In stratified analyses, TBD knowledge, safety worry because of ticks, avoiding outdoors because of ticks, and pet TBD risk modified the associations between different PPMs and self-reported TBD diagnosis. In the state of Indiana, thorough body/clothes check after being outdoors and use of insect repellent on exposed skin might be strongly effective in preventing TBD. The protective effect of different PPMs might be stronger among people with high TBD knowledge, high safety worry because of ticks, high avoidance of being outdoors because of ticks, and low pet TBD risk. These results might be useful in the design of intervention programs.

Social Determinants of Health-Related Quality of Life: A Recreation Setting Analysis.

Objective. To determine if significant differences between park users and non-park users are associated with scores on a composite health-related quality of life (HRQoL) index. Methods. Data for this study were collected based on random intercept of a cross section of eligible Monroe County, Indiana, residents at four selected public recreational parks, as well as nonpark locations from July to December 2017. Based on data collected using validated survey items, we created a composite HRQoL index. Statistical analysis included independent-samples t test, chi-square cross-tabulation, bivariate regression, and multivariate regression. Results. Frequent park users were significantly different from nonfrequent park users in various respects. The most leisure-time physical activity (LTPA) experiences of frequent park users occurred at a park location. Body mass index and park-based LTPA were significantly positively associated with HRQoL scores in a linear regression model. Conclusion. Frequent park use was shown to be positively associated with increased park-based LTPA and HRQoL. It is therefore possible that increasing park visitation will result in more members of a community who report experiencing their LTPA at a park location. Study outcomes lend support to the validity of a composite HRQoL index for population health assessments.

Zika knowledge and prevention practices among U.S. travelers: a large cross-sectional survey study.

BACKGROUND: The aim of this study was to investigate what factors predict knowledge about Zika transmission, symptomology, and treatment among U.S. travelers and, additionally, to evaluate how Zika knowledge influences the adoption of personal protective behaviors. METHODS: Data were collected as part of a cross-sectional survey study using a probability-based internet panel of U.S. travelers in June 2017. We ran logistic regression models of factors predicting Zika knowledge (high vs. low) and of knowledge predicting adoption of personal protective measures. RESULTS: We found that traveling to a Zika endemic country and travelers' gender were both significantly predictive of higher Zika knowledge (odds ratio (OR): 1.48, 95% confidence interval (CI): 1.14-1.93 and OR: 1.44, 95% CI: 1.08-1.92), adjusting for age, race, education, income, and trip purpose. Additionally, among travelers to Zika endemic countries, individuals with higher Zika knowledge had significantly higher odds of engaging in preventive behaviors compared to those with lower knowledge. However, few travelers knew about the sexual transmission of Zika and adopted sexual prevention measures. CONCLUSIONS: Our findings suggest that there are gaps in knowledge about the risks and transmission of Zika and travelers with low knowledge are less likely to engage in the appropriate prevention methods. Significantly, few U.S. travelers have knowledge of the sexual transmission of Zika and, accordingly, there is less overall engagement with prevention measures for this transmission mechanism than for vector-borne transmission.

Spatial Clusters and Non-spatial Predictors of Tick-Borne Disease Diagnosis in Indiana.

The purpose of this study was two-fold. First, we sought to identify spatial clusters of self-reported tick-borne disease (TBD) diagnosis in Indiana. Secondly, we determined the significant predictors of self-reported TBD diagnosis in a sample of Indiana residents. Study participants were selected from existing online panels maintained by Qualtrics and completed a cross-sectional survey (n = 3003). Our primary outcome of interest was self-reported TBD diagnosis (Yes/No). Cases and background population were aggregated to the county level. We used a purely spatial discrete Poisson model in SatScan® to determine significant clusters of high-risk TBD diagnosis counties. We also used X2 tests in bivariate analyses, to identify potential predictor variables for inclusion in an initial model, and backward elimination selection method to identify the final model. Two clusters of counties with significant high relative risk of self-reported TBD diagnosis in the southeast and southwest of Indiana were detected. Males in Indiana were more likely to self-report TBD diagnosis compared to females. Study participants who conducted a thorough tick check after being outdoors were significantly less likely to report TBD diagnosis compared to those who did not. Increased positive perceptions of TBD personal protective measures were associated with reduced self-reported TBD diagnosis. Older study participants were less likely to self-report TBD diagnosis compared to younger participants. The identification of two clusters of TBD diagnosis in southern Indiana is consistent with a northern spread of TBDs and suggests a need for continued surveillance of the counties in the vicinity of the observed clusters. Future studies should be designed to identify risk factors for TBD diagnosis in the affected counties of Indiana.

Knowledge of the Sexual Transmission of Zika Virus and Preventive Practices Against Zika Virus Among U.S. Travelers.

Individuals are often at increased risk of acquiring infectious disease while traveling. We sought to understand knowledge, attitudes and practices (KAP) regarding Zika virus among travelers from the United States. A total of 1043 study participants were recruited from a probability-based internet panel. Participants self-reported their knowledge of Zika infection and modes of transmission, and identified actions they had taken to prevent Zika infection and transmission including actions to prevent unintentional pregnancy since becoming aware of the Zika virus. Logistic regression was used to model the odds of taking preventive actions against Zika infection with adjustment for potential confounding factors. Knowledge of the sexual transmissibility of Zika virus significantly increased the odds of taking a preventive action against Zika infection, especially condom use or sexual abstention. Participants reported preferences for receiving information about Zika from private doctors and from the Internet. Discrepancies between where travelers seek information about Zika and how they would like to receive information regarding Zika were also found. These findings suggest that improving targeted messaging through online media may increase awareness of the sexual transmissibility of Zika as well as improve health communications with U.S. travelers. Travelers who are unaware of potential disease risks are less likely to adopt personal protective measures to protect themselves and reduce disease spread. Thus, future work should focus on improving communication and providing education to adopt effective prevention strategies while traveling.

Mosquito-borne infectious disease, risk-perceptions, and personal protective behavior among U.S. international travelers.

Vector-borne diseases account for a significant amount of the global infectious disease burden, including morbidity and mortality. In particular, mosquito-borne infectious diseases (MBIDs) have the greatest burden in number of cases, mortality, and disability-adjusted life years and their prevention and control is critical. However, prevention efforts are hindered by the absence of vaccines and failure of long-term mosquito vector control for these MBIDs. Thus, personal protective behaviors (PPBs) may offer the most promising and effective mode of prevention. This study examines the impact of awareness, perceived susceptibility, and perceived severity for five MBIDs (e.g., Malaria, Dengue, Zika, Chikungunya and West Nile) on the adoption of PPBs. Study participants (n = 1043) were recruited from a probability-based internet panel of adult United States residents with a history of traveling outside of the country in the past year. Data were collected in the U.S. between June 7, 2017 and June 12, 2017. Our findings show that awareness of Zika disease among respondents was consistently associated with adoption of all three PPBs. Respondents that reported high-perceived severity for all five MBIDs were also more likely to report adopting the PPBs of wearing covering clothing and use of mosquito repellent spray. Our findings indicate that U.S. travelers are largely more concerned about Zika, Chikungunya, and Dengue than Malaria and West Nile and that these concerns drive their adoption of the three recommended PPBs. This information should inform the development and design of future public health campaigns for behavior modification to prevent MBIDs.