Unprecedented Outbreak of West Nile Virus - Maricopa County, Arizona, 2021.

West Nile virus (WNV) is a mosquitoborne disease primarily transmitted through bites of infected Culex species mosquitos (1). In the United States, WNV is the leading domestically acquired arboviral disease; it can cause severe illness affecting the brain and spinal cord with an associated case fatality rate of 10% (2,3). On September 2, 2021, Maricopa County Environmental Services Department, Vector Control Division (MCESD-VCD) notified the Maricopa County Department of Public Health (MCDPH) and the Arizona Department of Health Services (ADHS) that the WNV vector index (VI), a measure of infected Culex mosquitoes, was substantially elevated. By that date, at least 100 WNV cases had already been reported among Maricopa County residents to MCDPH by health care providers and laboratories. Within 2 weeks, the VI reached its highest ever recorded level (53.61), with an associated tenfold increase in the number of human disease cases. During 2021, a total of 1,487 human WNV cases were identified; 956 (64.3%) patients had neuroinvasive disease, and 101 (6.8%) died. MCESD-VCD conducted daily remediation efforts to mitigate elevated VI and address mosquito-related complaints from residents (i.e., large numbers of outdoor mosquitoes from an unknown source and unmaintained swimming pools potentially breeding mosquitoes). MCDPH increased outreach to the community and providers through messaging, education events, and media. This was the largest documented focal WNV outbreak in a single county in the United States (4). Despite outreach efforts to communities and health care partners, clinicians and patients reported a lack of awareness of the WNV outbreak, highlighting the need for public health agencies to increase prevention messaging to broaden public awareness and to ensure that health care providers are aware of recommended testing methods for clinically compatible illnesses.

Contraceptive Technologies: Looking Ahead to New Approaches to Increase Options for Family Planning.

With persistently high global rates of unintended pregnancy and contraceptive nonuse, nonadherence and discontinuation, new contraceptive methods must address the needs of women and men who seek alternatives to their current options. Methods under development aim to reduce potential side effects, improve access and ease of use, ensure safety, increase secondary benefits associated with method use and expand options for both women and men. Developmental approaches employed to enhance current methods utilize new delivery systems and novel active pharmaceutical ingredients. This will improve overall user satisfaction with the methods used while expanding the number of options available to provide choice and value user autonomy in the highly diverse contraceptive markets around the world.

Associations Between Motives for Casual Sex, Depression, Self-Esteem, and Sexual Victimization.

People's motives for casual sex moderate associations between their sexual behavior and the outcomes they experience. Derived from self-determination theory, autonomous motives for casual sex (e.g., I wanted the fun and enjoyment) and non-autonomous motives (e.g., I wanted to please someone else) correlated in previous research differentially with measures of well-being and incidence of casual sex. In a sample of American college students (N = 284), we replicated these prior findings and extended them as follows: autonomous and non-autonomous motives for sex were correlated with two measures of casual sex (i.e., the three behavior questions from the Sociosexual Orientation Inventory; the number of partners with whom participants had penetrative sex but did not wish to become emotionally involved); two measures of well-being (i.e., self-esteem, depression), and a measure of overall sexual victimization (i.e., a combined score from the Sexual Experiences Survey). We found that autonomous motives were more strongly associated with casual sexual behavior than were non-autonomous motives in both sexes. Autonomous motives were positively associated with sexual victimization in women but not in men. Compared to autonomous motives, sex for non-autonomous motives was linked to less self-esteem in both sexes, and with more depression and sexual victimization in women. Sex differences in associations between motives and victimization persisted even when the general effects of participant's sex and casual sex were controlled in hierarchical regressions. Our findings further revealed the importance of agency (or lack thereof) in predicting sexual behavior and psychological health.

Use of temperature to improve West Nile virus forecasts.

Ecological and laboratory studies have demonstrated that temperature modulates West Nile virus (WNV) transmission dynamics and spillover infection to humans. Here we explore whether inclusion of temperature forcing in a model depicting WNV transmission improves WNV forecast accuracy relative to a baseline model depicting WNV transmission without temperature forcing. Both models are optimized using a data assimilation method and two observed data streams: mosquito infection rates and reported human WNV cases. Each coupled model-inference framework is then used to generate retrospective ensemble forecasts of WNV for 110 outbreak years from among 12 geographically diverse United States counties. The temperature-forced model improves forecast accuracy for much of the outbreak season. From the end of July until the beginning of October, a timespan during which 70% of human cases are reported, the temperature-forced model generated forecasts of the total number of human cases over the next 3 weeks, total number of human cases over the season, the week with the highest percentage of infectious mosquitoes, and the peak percentage of infectious mosquitoes that on average increased absolute forecast accuracy 5%, 10%, 12%, and 6%, respectively, over the non-temperature forced baseline model. These results indicate that use of temperature forcing improves WNV forecast accuracy and provide further evidence that temperature influences rates of WNV transmission. The findings provide a foundation for implementation of a statistically rigorous system for real-time forecast of seasonal WNV outbreaks and their use as a quantitative decision support tool for public health officials and mosquito control programs.

A conceptual framework for measuring community health workforce performance within primary health care systems.

BACKGROUND: With the 40th anniversary of the Declaration of Alma-Ata, a global effort is underway to re-focus on strengthening primary health care systems, with emphasis on leveraging community health workers (CHWs) towards the goal of achieving universal health coverage for all. Institutionalizing effective, sustainable community health systems is currently limited by a lack of standard metrics for measuring CHW performance and the systems they work within. Developed through iterative consultations, supported by the Bill & Melinda Gates Foundation and in partnership with USAID and UNICEF, this paper details a framework, list of indicators, and measurement considerations for monitoring CHW performance in low- and middle-income countries. METHODS: A review of peer-reviewed articles, reports, and global data collection tools was conducted to identify key measurement domains in monitoring CHW performance. Three consultations were successively convened with global stakeholders, community health implementers, advocates, measurement experts, and Ministry of Health representatives using a modified Delphi approach to build consensus on priority indicators. During this process, a structured, web-based survey was administered to identify the importance and value of specific measurement domains, sub-domains, and indicators determined through the literature reviews and initial stakeholder consultations. Indicators with more than 75% support from participants were further refined with expert qualitative input. RESULTS: Twenty-one sub-domains for measurement were identified including measurement of incentives for CHWs, supervision and performance appraisal, data use, data reporting, service delivery, quality of services, CHW absenteeism and attrition, community use of services, experience of services, referral/counter-referral, credibility/trust, and programmatic costs. Forty-six indicators were agreed upon to measure the sub-domains. In the absence of complete population enumeration and digitized health information systems, the quality of metrics to monitor CHW programs is limited. CONCLUSIONS: Better data collection approaches at the community level are needed to strengthen management of CHW programs and community health systems. The proposed list of metrics balances exhaustive and pragmatic measurement of CHW performance within primary healthcare systems. Adoption of the proposed framework and associated indicators by CHW program implementors may improve programmatic effectiveness, strengthen their accountability to national community health systems, drive programmatic quality improvement, and plausibly improve the impact of these programs.

Do Women Find the Progesterone Vaginal Ring Acceptable? Findings from Kenya, Nigeria, and Senegal.

The progesterone vaginal ring (PVR) is a contraceptive designed for use by breastfeeding women in the first year postpartum. This Report presents results of an acceptability study of the PVR in Kenya, Nigeria, and Senegal. Women seeking postpartum family planning services were offered various contraceptive options including the PVR. Of the 174 participating women, 110 (63 percent) used one ring and 94 (54 percent) completed the study by using two rings over a six-month period. Women were interviewed up to three times: at the time they entered the study, at 3 months (the end of the first ring cycle), and at 6 months (the end of the second ring cycle or when they exited if they had discontinued earlier). Many participants found the ring to be acceptable, with over three-quarters reporting that it was easy to insert, remove, and reinsert. While a small proportion of women experienced ring expulsion, the majority did not. These findings suggest that even in countries with little or no use of vaginal health products, contraceptive vaginal rings offer women a new option that they are able and willing to use.

St. Louis encephalitis virus possibly transmitted through blood transfusion-Arizona, 2015.

BACKGROUND: St. Louis encephalitis virus is a mosquito-borne flavivirus that infrequently causes epidemic central nervous system infections. In the United States, blood donors are not screened for St. Louis encephalitis virus infection, and transmission through blood transfusion has not been reported. During September 2015, St. Louis encephalitis virus infection was confirmed in an Arizona kidney transplant recipient. An investigation was initiated to determine the infection source. STUDY DESIGN AND METHODS: The patient was interviewed, and medical records were reviewed. To determine the likelihood of mosquito-borne infection, mosquito surveillance data collected at patient and blood donor residences in timeframes consistent with their possible exposure periods were reviewed. To investigate other routes of exposure, organ and blood donor and recipient specimens were obtained and tested for evidence of St. Louis encephalitis virus infection. RESULTS: The patient presented with symptoms of central nervous system infection. Recent St. Louis encephalitis virus infection was serologically confirmed. The organ donor and three other organ recipients showed no laboratory or clinical evidence of St. Louis encephalitis virus infection. Among four donors of blood products received by the patient via transfusion, one donor had a serologically confirmed, recent St. Louis encephalitis virus infection. Exposure to an infected mosquito was unlikely based on the patient's minimal outdoor exposure. In addition, no St. Louis encephalitis virus-infected mosquito pools were identified around the patient's residence. CONCLUSION: This investigation provides evidence of the first reported possible case of St. Louis encephalitis virus transmission through blood product transfusion. Health care providers and public health professionals should maintain heightened awareness for St. Louis encephalitis virus transmission through blood transfusion in settings where outbreaks are identified.

Strategic partnering to improve community health worker programming and performance: features of a community-health system integrated approach.

BACKGROUND: There is robust evidence that community health workers (CHWs) in low- and middle-income (LMIC) countries can improve their clients' health and well-being. The evidence on proven strategies to enhance and sustain CHW performance at scale, however, is limited. Nevertheless, CHW stakeholders need guidance and new ideas, which can emerge from the recognition that CHWs function at the intersection of two dynamic, overlapping systems - the formal health system and the community. Although each typically supports CHWs, their support is not necessarily strategic, collaborative or coordinated. METHODS: We explore a strategic community health system partnership as one approach to improving CHW programming and performance in countries with or intending to mount large-scale CHW programmes. To identify the components of the approach, we drew on a year-long evidence synthesis exercise on CHW performance, synthesis records, author consultations, documentation on large-scale CHW programmes published after the synthesis and other relevant literature. We also established inclusion and exclusion criteria for the components we considered. We examined as well the challenges and opportunities associated with implementing each component. RESULTS: We identified a minimum package of four strategies that provide opportunities for increased cooperation between communities and health systems and address traditional weaknesses in large-scale CHW programmes, and for which implementation is feasible at sub-national levels over large geographic areas and among vulnerable populations in the greatest need of care. We postulate that the CHW performance benefits resulting from the simultaneous implementation of all four strategies could outweigh those that either the health system or community could produce independently. The strategies are (1) joint ownership and design of CHW programmes, (2) collaborative supervision and constructive feedback, (3) a balanced package of incentives, and (4) a practical monitoring system incorporating data from communities and the health system. CONCLUSIONS: We believe that strategic partnership between communities and health systems on a minimum package of simultaneously implemented strategies offers the potential for accelerating progress in improving CHW performance at scale. Comparative, retrospective and prospective research can confirm the potential of these strategies. More experience and evidence on strategic partnership can contribute to our understanding of how to achieve sustainable progress in health with equity.

Defining the roles of local precipitation and anthropogenic water sources in driving the abundance of Aedes aegypti, an emerging disease vector in urban, arid landscapes.

Understanding drivers of disease vectors' population dynamics is a pressing challenge. For short-lived organisms like mosquitoes, landscape-scale models must account for their highly local and rapid life cycles. Aedes aegypti, a vector of multiple emerging diseases, has become abundant in desert population centers where water from precipitation could be a limiting factor. To explain this apparent paradox, we examined Ae. aegypti abundances at > 660 trapping locations per year for 3 years in the urbanized Maricopa County (metropolitan Phoenix), Arizona, USA. We created daily precipitation layers from weather station data using a kriging algorithm, and connected localized daily precipitation to numbers of mosquitoes trapped at each location on subsequent days. Precipitation events occurring in either of two critical developmental periods for mosquitoes were correlated to suppressed subsequent adult female presence and abundance. LASSO models supported these analyses for female presence but not abundance. Precipitation may explain 72% of Ae. aegypti presence and 90% of abundance, with anthropogenic water sources supporting mosquitoes during long, precipitation-free periods. The method of using kriging and weather station data may be generally applicable to the study of various ecological processes and patterns, and lead to insights into microclimates associated with a variety of organisms' life cycles.

The Mosquito Fauna of Arizona: Species Composition and Public Health Implications.

Arizona is home to many mosquito species, some of which are known vectors of infectious diseases that harm both humans and animals. Here, we provide an overview of the 56 mosquito species that have been identified in the State to date, but also discuss their known feeding preference and the diseases they can (potentially) transmit to humans and animals. This list is unlikely to be complete for several reasons: (i) Arizona's mosquitoes are not systematically surveyed in many areas, (ii) surveillance efforts often target specific species of interest, and (iii) doubts have been raised by one or more scientists about the accuracy of some collection records, which has been noted in this article. There needs to be an integrated and multifaceted surveillance approach that involves entomologists and epidemiologists, but also social scientists, wildlife ecologists, ornithologists, representatives from the agricultural department, and irrigation and drainage districts. This will allow public health officials to (i) monitor changes in current mosquito species diversity and abundance, (ii) monitor the introduction of new or invasive species, (iii) identify locations or specific populations that are more at risk for mosquito-borne diseases, and (iv) effectively guide vector control.

A taxonomy and results from a comprehensive review of 28 maternal health voucher programmes.

It is increasingly clear that Millennium Development Goal 4 and 5 will not be achieved in many low- and middle-income countries with the weakest gains among the poor. Recognizing that there are large inequalities in reproductive health outcomes, the post-2015 agenda on universal health coverage will likely generate strategies that target resources where maternal and newborn deaths are the highest. In 2012, the United States Agency for International Development convened an Evidence Summit to review the knowledge and gaps on the utilization of financial incentives to enhance the quality and uptake of maternal healthcare. The goal was to provide donors and governments of the low- and middle-income countries with evidence-informed recommendations on practice, policy, and strategies regarding the use of financial incentives, including vouchers, to enhance the demand and supply of maternal health services. The findings in this paper are intended to guide governments interested in maternal health voucher programmes with recommendations for sustainable implementation and impact. The Evidence Summit undertook a systematic review of five financing strategies. This paper presents the methods and findings for vouchers, building on a taxonomy to catalogue knowledge about voucher programme design and functionality. More than 120 characteristics under five major categories were identified: programme principles (objectives and financing); governance and management; benefits package and beneficiary targeting; providers (contracting and service pricing); and implementation arrangements (marketing, claims processing, and monitoring and evaluation). Among the 28 identified maternal health voucher programmes, common characteristics included: a stated objective to increase the use of services among the means-tested poor; contracted-out programme management; contracting either exclusively private facilities or a mix of public and private providers; prioritizing community-based distribution of vouchers; and tracking individual claims for performance purposes. Maternal voucher programmes differed on whether contracted providers were given training on clinical or administrative issues; whether some form of service verification was undertaken at facility or community-level; and the relative size of programme management costs in the overall programme budget. Evidence suggests voucher programmes can serve populations with national-level impact. Reaching scale depends on whether the voucher programme can: (i) keep management costs low, (ii) induce a large demand-side response among the bottom two quintiles, and (iii) achieve a quality of care that translates a greater number of facility-based deliveries into a reduction in maternal morbidity and mortality.

West Nile virus outbreak in Phoenix, Arizona--2010: entomological observations and epidemiological correlations.

In 2010, Arizona experienced an unusually early and severe outbreak of West Nile virus (WNV) centered in the southeast section of Maricopa County. Entomological data were collected before and during the outbreak, from May 25 through July 31, 2010, using the CO2-baited light trap monitoring system maintained by Maricopa County Vector Control. In the outbreak area, the most abundant species in the Town of Gilbert and in the area covered by the Roosevelt Water Conservation District was Culex quinquefasciatus, constituting 75.1% and 71.8% of the total number of mosquitoes collected, respectively. Vector index (VI) profiles showed that the abundance of infected Cx. quinquefasciatus peaked prior to human cases, suggesting that this species was involved in the initiation of the outbreak. In contrast, the VI profiles for Cx. tarsalis were consistently low, suggesting limited involvement in initiating and sustaining transmission. Taken together, the higher abundance and the VI profiles strongly suggest that Cx. quinquefasciatus was the primary vector for this outbreak. The VI profiles consistently showed that the abundance of infected mosquitoes peaked 1 to 2 wk before the peaks of human cases, suggesting that VI could have successfully been utilized to predict the WNV outbreak in Maricopa County, AZ, in 2010.

COMPARING THE EFFICIENCY OF DIFFERENT CARBON DIOXIDE SOURCES IN COLLECTING MOSQUITO VECTOR SPECIES ON THE TEMPE CAMPUS OF ARIZONA STATE UNIVERSITY.

We compared the effectiveness of 4 different carbon dioxide (CO2) sources (sugar-fermented BG-CO2, sugar-fermented Fleischmann yeast, dry ice, and compressed gas cylinders) in attracting different mosquito species in 2 separate 4 × 4 Latin square trials. The CO2 generated by dry ice and the gas cylinders collected more Culex quinquefasciatus than the sugar-fermented BG-CO2 and Fleischmann yeasts during the 1st trial (16-h surveillance periods), but there was no significant difference in Aedes aegypti numbers. There were no significant differences between the different CO2 sources in collecting Cx. quinquefasciatus and Ae. aegypti mosquitoes in the 2nd trial (24-h surveillance periods). Catches for Culiseta inornata and Cx. tarsalis were too low in both experiments for formal statistical analysis. Data can be used to inform local mosquito surveillance programs, but the selection of a CO2 source will also depend on financial and logistical constraints.

Unintended effects of urban policies on the risk of arbovirus transmission.

Cities across the USA are implementing urban policies to mitigate unwanted effects of urbanization. These policies may inadvertently promote the proliferation of mosquito vectors. Limited evidence exists regarding how urban policies impact arbovirus transmission risk. Models can evaluate public health interventions aimed at reducing arbovirus-related risks caused by urban policies.

Spatiotemporal distribution of vector mosquito species and areas at risk for arbovirus transmission in Maricopa County, Arizona.

Mosquito-borne diseases are a major global public health concern and mosquito surveillance systems are essential for the implementation of effective mosquito control strategies. The objective of our study is to determine the spatiotemporal distribution of vector mosquito species in Maricopa County, AZ from 2011 to 2021, and to identify the hotspot areas for West Nile virus (WNV) and St. Louis Encephalitis virus (SLEV) transmission in 2021. The Maricopa County Mosquito Control surveillance system utilizes BG-Sentinel and EVS-CDC traps throughout the entire urban and suburban areas of the county. We estimated specific mosquito species relative abundance per unit area using the Kernel density estimator in ArcGIS 10.2. We calculated the distance between all traps in the surveillance system and created a 4 km buffer radius around each trap to calculate the extent to which each trap deviated from the mean number of Culex quinquefasciatus and Culex tarsalis collected in 2021. Our results show that vector mosquito species are widely distributed and abundant in the urban areas of Maricopa County. A total of 691,170Cx. quinquefasciatus, 542,733 Cx. tarsalis, and 292,305 Aedes aegypti were collected from 2011 to 2022. The relative abundance of Ae. aegypti was highly seasonal peaking in the third and fourth quarters of the year. Culex quinquefasciatus, on the other hand, was abundant throughout the year with several regions consistently yielding high numbers of mosquitoes. Culex tarsalis was abundant but it only reached high numbers in well-defined areas near irrigated landscapes. We also detected high levels of heterogeneity in the risk of WNV and SLEV transmission to humans disregarding traps geographical proximity. The well-defined species-specific spatiotemporal and geographical patterns found in this study can be used to inform vector control operations.

Aedes aegypti abundance in urban neighborhoods of Maricopa County, Arizona, is linked to increasing socioeconomic status and tree cover.

BACKGROUND: Understanding coupled human-environment factors which promote Aedes aegypti abundance is critical to preventing the spread of Zika, chikungunya, yellow fever and dengue viruses. High temperatures and aridity theoretically make arid lands inhospitable for Ae. aegypti mosquitoes, yet their populations are well established in many desert cities. METHODS: We investigated associations between socioeconomic and built environment factors and Ae. aegypti abundance in Maricopa County, Arizona, home to Phoenix metropolitan area. Maricopa County Environmental Services conducts weekly mosquito surveillance with CO2-baited Encephalitis Vector Survey or BG-Sentinel traps at > 850 locations throughout the county. Counts of adult female Ae. aegypti from 2014 to 2017 were joined with US Census data, precipitation and temperature data, and 2015 land cover from high-resolution (1 m) aerial images from the National Agricultural Imagery Program. RESULTS: From 139,729 trap-nights, 107,116 Ae. aegypti females were captured. Counts were significantly positively associated with higher socioeconomic status. This association was partially explained by higher densities of non-native landscaping in wealthier neighborhoods; a 1% increase in the density of tree cover around the trap was associated with a ~ 7% higher count of Ae. aegypti (95% CI: 6-9%). CONCLUSIONS: Many models predict that climate change will drive aridification in some heavily populated regions, including those where Ae. aegypti are widespread. City climate change adaptation plans often include green spaces and vegetation cover to increase resilience to extreme heat, but these may unintentionally create hospitable microclimates for Ae. aegypti. This possible outcome should be addressed to reduce the potential for outbreaks of Aedes-borne diseases in desert cities.

In-person follow-up visit attendance after telemedicine visits.

BACKGROUND: Although Coronavirus disease 2019 rapidly increased the use of telemedicine for pediatric primary care, vaccinations, screening tests, lab draws, and other procedures still require follow-up in-person visits. We investigated in-person follow-up rates after telemedicine visits at our primary care clinic, and what patient or visit characteristics were associated with non-completion of in-person follow-up. METHODS: A retrospective cohort study was conducted of telemedicine visits completed between April and May 2020. A manual chart review was performed to determine which encounters required a follow-up in-person visit; and was tracked through August 2020. Bivariate comparisons were performed according to completion of in-person follow-up and multivariable analysis of follow-up visit attendance was performed using Cox proportional hazards regression. RESULTS: Of 500 eligible encounters, 16% did not attend at least one in-person follow-up. The median time for follow-up was 2 days (IQR: 1, 6). Patients older than 1 year of age (32%, p= <0.001) and with Medicaid insurance (83%, p=0.019) were more likely to not complete a follow-up visit. The likelihood of completion was higher for Hispanic as compared to non-Hispanic Black patients (HR: 1.65; 95% CI: 1.28, 2.12; p<0.001) and patients requiring routine screening (HR: 1.40; 95% CI: 1.04, 1.89; p=0.028). CONCLUSIONS: Not all required in-person follow-ups were completed after telemedicine visits, which could have negative impacts on children's health. Improving the transition between telemedicine and inperson follow-up of primary care can help ensure the quality of care provided in a telemedicine-first model.

Sexual hookups among college students: sex differences in emotional reactions.

The purpose of the study was to test four predictions derived from evolutionary (sexual strategies) theory. The central hypothesis was that men and women possess different emotional mechanisms that motivate and evaluate sexual activities. Consequently, even when women express indifference to emotional involvement and commitment and voluntarily engage in casual sexual relations, their goals, their feelings about the experience, and the associations between their sexual behavior and prospects for long-term investment differ significantly from those of men. Women's sexual behavior is associated with their perception of investment potential: long-term, short-term, and partners' ability and willingness to invest. For men,these associations are weaker or inversed. Regression analyses of survey data from 333 male and 363 female college students revealed the following: Greater permissiveness of sexual attitudes was positively associated with number of sex partners; this association was not moderated by sex of subject (Prediction 1); even when women deliberately engaged in casual sexual relations, thoughts that expressed worry and vulnerability crossed their minds; for females, greater number of partners was associated with increased worry-vulnerability whereas for males the trend was the opposite (Prediction 2); with increasing numbers of sex partners, marital thoughts decreased; this finding was not moderated by sex of subject; this finding did not support Prediction 3; for both males and females, greater number of partners was related to larger numbers of one-night stands, partners foreseen in the next 5 years, and deliberately casual sexual relations. This trend was significantly stronger for males than for females (Prediction 4).