Citation
U.S. Army Medical Department journal

Material Information

Title:
U.S. Army Medical Department journal
Alternate title:
United States Army Medical Department journal
Alternate Title:
AMEDD journal
Running title:
Army Medical Department journal
Abbreviated Title:
U.S. Army Med. Dep. j.
Creator:
United States -- Army Medical Department (1968- )
Place of Publication:
Fort Sam Houston, TX
Publisher:
U.S. Army Medical Department
Publication Date:
Frequency:
Quarterly[<Oct.-Dec. 2001->]
Bimonthly[ FORMER Sept.-Oct. 1994-]
quarterly
regular
Language:
English
Physical Description:
volumes : illustrations ; 28 cm

Subjects

Subjects / Keywords:
Medicine, Military -- Periodicals -- United States ( lcsh )
Military Medicine ( mesh )
Medicine ( mesh )
Medicine, Military ( fast )
United States ( mesh )
United States ( fast )
United States
Genre:
Electronic journals.
Periodicals.
Periodicals. ( fast )
Fulltext.
Government Publications, Federal.
Internet Resources.
serial ( sobekcm )
federal government publication ( marcgt )
periodical ( marcgt )
Electronic journals ( lcsh )
Periodicals ( mesh )
Periodicals ( fast )
Fulltext
Government Publications, Federal
Periodicals
Internet Resources

Notes

Dates or Sequential Designation:
Sept.-Oct. 1994-
General Note:
Title from cover.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
This item is a work of the U.S. federal government and not subject to copyright pursuant to 17 U.S.C. §105.
Resource Identifier:
32785416 ( OCLC )
98642403 ( LCCN )
1524-0436 ( ISSN )
ocm32785416
Classification:
RC970 .U53 ( lcc )
616.9/8023/05 ( ddc )
W1 JO96 ( nlm )

Related Items

Preceded by:
Journal of the US Army Medical Department.

UFDC Membership

Aggregations:
Digital Military Collection

Downloads

This item is only available as the following downloads:


Full Text

PAGE 1

en-USJanuaryJune 2017en-USThe Role of Birds in Arboviral Disease Surveillanceen-US en-US in Harris County and the City of Houston, Texas . ...................................... en-US1en-USLauren Wilkerson, MS; Martin Reyna Nava, MS; Cheryl Battle-Freeman; et alen-USen-US en-US en-US Aedes aegyptien-US en-US . ........................ en-US13en-USMAJ Lee P. McPhatter, USA; Paula D. Mischler, PhD; Meiling Z. Webb, PhD; et alen-USen-US en-US . .............................................. en-US23en-USR. Christopher Rustin, DrPH, MT, REHS; Deonte Martin; Varadan Sevilimedu, MPH; et alen-USen-US en-US . ................... en-US34en-USDesmond H. Foley, PhD; David B. Pecoren-USen-US en-US en-US Anopheles en-US(en-USAnophelesen-US)en-US . .......... en-US47en-USLeopoldo M. Rueda, PhD; Heung-Chul Kim, PhD; Sung-Tae Chong, MS; et alen-US . ............. en-US55en-USMaj Bryant J. Webber, USAF; Lt Col Edward J. Wozniak, TXSG; CPT David Chang, USA; et alen-US . .................................. en-US60en-USJohn N. Waitumbi, PhD; MAJ Joshua Bast, USA; Nancy Nyakoe, MS; et alen-USen-US en-US . ................... en-US65en-USLeopoldo M. Rueda, PhD; James E. Pecor; Matthew Wolkoff; et alen-USen-US en-US . ......................................................... en-US86en-USWill K. Reeves, PhD; Myrna M. Miller, DVM, PhD; Orhan Bayik, PHS; Maj Leah Chapman, USAFen-USen-US en-US . ......................................... en-US90en-USMelissa N. Garcia, PhD, MPH; Thomas L. Cropper, DVM, MPVM, ACVPM; et alen-USen-US en-US . ......................... en-US102en-USJamal Hasoon, MDen-US . ................ en-US106en-USColeen Baird, MD, MPH; Jessica Sharkey, MPH; Joel Gaydos, MD, MPHen-US . ....... en-US112en-USLTC(P) Paul O. Kwon, USAen-USen-USen-US en-US . ................................................ en-US115en-USBenjamin Cameron Schaffer en-USJ OURNAL THE UNITED STATES ARMY en-USMEDICAL DEPARTMENT VECTOR-BORNE DISEASES ANdD CCHALLENGES TO PUbBLIC HHEALTH

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en-USJ OURNAL en-USA Profen-US essional Publicationen-US of the en-USAMEDD Communityen-USTHE UNITED STATES ARMYen-US MEDICAL DEPARTMENTen-USOnline issues of the en-USAMEDD Journal en-US are available at http://www.cs.amedd.army.mil/amedd_journal.aspx JanuaryJune 2017 US Army Medical Department Center & School P B 8-17-1/2/3/4/5/6 en-USThe Army Medical Department Journalen-US [ISSN en-US1524en-US-en-US0436en-US] is published quarterly en-US en-US en-US3630en-US Stanley RD STE Ben-US0204en-USen-US78234en-US-en-US6100en-US.en-US en-US Theen-US en-US Army Medical Department Journalen-US are listed and en-US en-US en-US Journalen-USs en-US en-US en-USCORRESPONDENCE:en-US en-USen-US en-US en-US en-US(210) 221-6301, DSN 471-6301en-USDISCLAIMER:en-US The en-US AMEDD Journal en-USen-US en-US en-US en-US en-US en-US en-US en-US in the en-USAMEDD Journal en-US en-US en-US en-US en-US en-US en-US AMEDD Journal en-USen-US en-USCONTENT: en-USen-US en-US AMEDD Journalen-US .en-USOFFICIAL DISTRIBUTION: en-USen-US en-US en-USBy Order of the Secretary of the Army:en-US en-USGERALD B. OKEEFEen-US en-US Secretary of the Army en-USMark A. Milleyen-US en-US en-US en-US 1626611en-USLTG Nadja Y. Westen-USen-US en-US en-USMG Brian C. Leinen-USen-US en-US

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en-USJanuary June 2017 en-US1en-USThe Avian Section of Harris County Public Health en-US (HCPH) Mosquito and Vector Control Division (MVCD) en-US is responsible for monitoring avian populations in Haren-US -en-US ris County and the City of Houston, Texas, for West Nile en-US virus (WNV), St. Louis encephalitis (SLE), and other en-US mosquito-borne diseases. Since birds are the main hosts en-US for many of these viruses, they are included in mosquito en-US surveillance activities to provide a complete picture of en-US the enzootic cycle rather than simply monitoring mosen-US -en-US quitoes alone. While infected birds are only viremic for en-US a few days,en-US1en-US surviving birds produce detectible levels of en-US en-US several years.en-US2,3en-US This persistence allows for a more long-en-US term big picture surveillance effort that can identify en-US the presence of a virus in a new area even if no virus is en-US currently circulating.en-US en-US States was due to large numbers of dead birds, primaren-US -en-US ily crows, in New York City.en-US4en-US Subsequently, wildlife en-US and disease ecologists noted continued large die-offs en-US of crows and Blue Jays as the virus spread across the en-US continent.en-US5en-US Harris County Public Health MVCDen-US en-US created en-US a Dead Bird Hotline for residents to report dead birds. en-US en-US from a dead Blue Jay in 2002.en-US Since WNV has been established in Harris County, en-US avian monitoring helps explain the complex ecological en-US interactions responsible for outbreaks. For humans to be en-US en-US avian transmission cycle. Avian antibodies, like human en-US ones, are important to immune responses and make suren-US -en-US viving, seropositive birds essentially resistant to reinfecen-US -en-US tion.en-US6en-US In standard epidemiological susceptible-infected-en-US removeden-US en-US (SIR) models, large numbers of immune indien-US -en-US viduals reduce the viral transmission rate below a susen-US -en-US tainable level, bringing outbreaks to an end.en-US7en-US Although en-US more research is needed, there is evidence that some en-US arboviruses, such as WNV and SLE, follow multiyear en-US SIR cycles. A 40-year history of SLE seroprevelances en-US in Harris County demonstrated a consistent cyclical en-US en-US that the best predictor of WNV activity in a given year en-US was the proportion of seropositive birds at the end of the en-US previous year.en-US2en-US Similarly, in Los Angeles, a preseason en-US seropositive rate of less than 10% was associated with en-US WNV outbreaks.en-US8en-US This study provides the results from en-US the 2015 MVCD avian surveillance activities. COLLEc C TION METHODS Live bird trapping was conducted daily throughout the en-USyear, except when prevented by inclement weather. Trapen-US -en-US ping locations were located in Houston or Harris County en-US parks and varied on a rotational basis. Sites that were en-US chosen for live bird trapping provided the most uniform en-US coverage available, ie, included historic and current en-US WNV and SLE hot spots and provided a high degree en-US of trapping success. In 2015, 27 sites were trapped, with en-US 20 monitored biweekly from June to December when en-USThe Role of Birds in Arboviral Diseaseen-US en-US Surveillance in Harris County and theen-US en-US City of Houston, Texas Lauren Wilkerson, MS H ilda Guzman Martin Reyna Nava, MS R obert Tesh, MD, PhD Cheryl Battle-Freeman M ustapha Debboun, PhD, BCE Amelia Travassos da Rosa ABSTRac AC T Avian arboviral surveillance is an integral part of any disease-based integrated mosquito control program. The en-USHarris County Public Health Mosquito and Vector Control Division has performed arboviral surveillance in en-US the wild birds of Harris County and the City of Houston since 1965. Blood samples from live trapped birds were en-US tested for arboviral antibodies to West Nile virus (WNV), St. Louis encephalitis, Eastern equine encephalitis, en-US and Western equine encephalitis. A dead bird surveillance program was created in 2002 with the arrival of en-US WNV in Harris County. Since implementation, the program has detected considerable variability in viral activen-US -en-US ity with annual WNV seroprevelance rates ranging from 2.9% to 17.7%, while the percentage of positive dead en-US birds has ranged from 0.3% to 57.2%. In 2015, 1,345 live birds were sampled and 253 dead birds were tested, en-US with WNV incidence rates of 16.5% and 5.9%, respectively.

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2 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USseasonal help was available, and on a monthly rotation en-US during the rest of the year (Figure 1).en-US During bird trapping, an average of 3 to 5 Japanese mist en-US nets were set up before sunrise and maintained until en-US 9:30 am. The nets were 2.6 m in height and 6 or 12 m in en-US length, and attached to poles that were hammered into en-US the ground with mallets. Nets were positioned in areas en-US en-US and baited with commercial bird seed at least one day en-US en-US-en-US vorable areas included open spaces interspersed with en-US layered vegetation, backyard bird feeders, open trash en-US cans, and picnic tables. Nets were checked at least even-US -en-US ery 15 minutes with optimum trapping occurring when en-US all nets were observed from one central location. Afen-US -en-US ter trapped birds were removed from the mist nets, they en-US were placed in a holding bag, transported to a mobile en-US laboratory station and processed on-site.en-US During processing, we recorded the birds species, sex en-US (if possible), age, and whether or not it was previously en-US banded, as required by the Bird Banding Laboratory. en-US We used theen-US en-US National Geographic Societyen-US Field Guide en-US to Birds of North Americaen-US9en-US along with en-US The Sibley Field en-US Guide to Birds of Eastern North Americaen-US10en-US for species en-US en-USen-US American Birdsen-US11en-US for ageing, sexing, and determining en-US the correct band size. The age of a bird is of particular en-US interest for WNV and SLE surveillance because posien-US -en-US tive hatch year birds indicate exposures that occurred en-US within the current season. After we collected all pertien-US -en-US nent information, we drew blood from the birds jugular en-US vein or brachial vein if it was a dove, because the jugular en-US vein is frequently obscured by engorged skin in doves. en-US We collected either 0.1 cc of blood for smaller (sparrow-en-US sized) birds or 0.2 cc for larger birds (ie, Blue Jays) and en-US added it to a corresponding amount of 0.4 cc or 0.8 cc en-US diluent of 0.9% normal buffered saline in a 13 mm by en-US THE ROLE OF BIRDS IN ARBOVIRAL DISEASE SURVEILLANCEen-US en-US IN HARRIS COUNTY AND THE CITY OF HOUSTON, TEXASen-USFigure en-US1en-US. Map of Harris County and the City of Houston, Texas, showing bird trap sites in en-US2015en-US.

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en-USJanuary June 2017 en-US3 en-US100 mm glass culture tube. Once blood collection was en-US complete, the bird was banded and released.en-US e culture tubes were labeled with a unique identifyen-US -en-US ing number and kept in a refrigerated cooler while in en-US the eld. Once the diluted blood samples arrived at the en-US MVCD Avian Laboratory, they were placed in a refrigeren-US -en-US ated (4en-US en-US C) centrifuge which ran for 15 minutes at 2,500 en-US rpm. e sera were extracted with disposable transfer en-US pipettes into similarly labeled 2 ml cryovials, which were en-US kept frozen until they were transferred to the University en-US of Texas Medical Branch at Galveston (UTMB-G) or the en-US MVCD Virology Laboratory for testing.en-US Most dead birds were reported to the Dead Bird Hoten-US -en-US line, while a smaller number was reported to the HCPH en-US website (https://secure.hcphes.org/MC/DeadBirdReen-US -en-US port.html). Residents may also bring dead birds to the en-US MVCD Avian Laboratory. Information collected on all en-US birds included the contact information (name, address, en-US and phone number) of the caller, location, condition of en-US the bird, and time and date the bird was found. If the en-US bird was found within 24 hours of the call and appeared en-US reasonably fresh, the caller was instructed to double bag en-US the bird and place it in the freezer or a bag of ice to preen-US -en-US serve it until retrieved by a MVCD technician. In years en-US with large numbers of dead bird calls, 18 additional drop en-US off centers located throughout Harris County were actien-US -en-US en-US its condition evaluated. If the carcass was fresh and conen-US -en-US tained no maggots or ants, it was submitted for WNV/en-US SLE testing and assigned a unique identifying number. TTESTING PROc C EDURES en-US-en-US en-US -en-US ing of dead birds. Sera samples were screened with the en-US hemagluttination inhibition (HI) test, which detected en-US the presence of viral antibodies, but could not differenen-US-en-US tiate between antibody subtypes. Since some subtypes, en-US such as IgG, can persist for long periods of time, this test en-US cannot be used to distinguish currently infected birds en-US from those that were infected in previous years. West en-US Nile virus and SLE are also structurally similar, causing en-US HI antigens to cross-react. If the titer levels for one virus en-US were 4 times or more titers higher than the other, the en-US virus with the higher titer was considered the causative en-US agent.en-US12en-USen-US was considered positive solely for the causative virus. en-US Samples in which the causative virus could not be deteren-US -en-US mined were listed as WNV/SLE and analyzed separatelyen-US .en-US To determine if the birds were recently infected, the en-US MVCD Virology Laboratory preformed a second test, en-US ie, the IgM antibody capture method, on all HI positive en-US samples. This test does not cross-react and detects only en-US IgM antibodies which are only produced during the inien-US -en-US tial stages of infection, and persist for about a month. A en-US limitation of the IgM test is its potential for reacting to en-US a naturally occurring antigen in the blood of some indien-US -en-US vidual birds, resulting in a false positive rate of approxien-US -en-US en-US results were from combining these tests. For example, a en-US en-US exposed and, most likely, that exposure was within the en-US last month, indicating recent viral activity.en-US Dead birds were initially screened at the MVCD Avian en-US Laboratory with vector and rapid analyte measurement en-US platform (RAMP) test kits, both of which can also be en-US used for mosquitoes. The vector test is a quick dipstick en-US test that detects SLE and Eastern equine encephalitis en-US (EEE) in addition to WNV. While the RAMP test takes en-US longer, it is more accurate and provides quantitative reen-US -en-US sults. For both tests, the birds throat was swabbed with en-US a cotton-tipped applicator. For vector tests, the applicaen-US-en-US tor was swirled in a 0.6 ml vial containing 600 l of en-US grinding solution for 10 seconds. A test strip was placed en-US in the vial and left to mature for 15 minutes. Each virus en-US en-US RAMP testing, a separate applicator was swirled in a en-US 1.5 ml vial containing 1 ml of RAMP buffer solution for en-US 10 seconds. Then, 120 l of the supernatant was transen-US -en-US ferred to a smaller 0.6 ml vial where it was mixed with en-US en-US sample well of the test cartridge and dried for 90 minen-US -en-US utes. The dry cartridge was placed into a RAMP reader en-US which provided a quantitative ratio in a range of less en-US than 10 to more than 640. Results of 50 or greater were en-US considered positive.en-US After testing, dead birds were labeled with weatherproof en-US tags, double-bagged and placed in an ultra-low (-62C) en-US en-US -en-US formation on the tags included date, location, species, en-US and MVCD Avian Laboratory number. If more than 25 en-US birds were collected during the week, only those that en-US tested positive or species with historically high rates en-US en-US -en-US en-US small portion of brain was removed from each dead en-US bird and was homogenized in approximately 2.0 ml of en-US phosphate-buffered saline, pH 7.4, containing 10% feen-US -en-US tal bovine serum. After centrifugation at 10,000 rpm for en-US en-US en-US Vero cultures were maintained at 37C for 14 days and en-US observed daily for viral cytopathic effect (CPE). If CPE

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4 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USen-US en-US test antigen assay done on the culture medium. Due to en-US en-US consisting of a RAMP result of 100 or greater, correen-US -en-US en-US implemented by MVCD Avian Laboratory from Octoen-US -en-US ber 14, 2015 to December 31, 2015.en-US The capture and handling of wild birds was done in acen-US -en-US en-US Acten-US13en-US and required both federal and state permits. This en-US en-US en-US Federal Bird Banding Permit 09415 en-US en-US en-US 0816-179 from the Texas Parks and en-US Wildlife Department. RRESULTS The MVCD Avian technicians col en-US-en-US lected a total of 1,345 sera samples en-US and received 358 dead bird calls en-US from 40 species of live bird species en-US and 39 species of dead birds in 2015 en-US (Tables 1 and 2). Sera collections inen-US -en-US creased over 2014, improving upon en-US the 50% increase over the number of en-US samples collected in 2013 and suren-US -en-US passing all previous years since 2009. en-US Of the dead birds called in, en-US 319 (89%) were collected and en-US en-US Fifteen dead birds (5.9% of en-US en-US positive for WNV, while 222 en-US (16.5%) sera samples were HI en-US positive for WNV, 2 (0.15%) en-US were HI positive for SLE en-US and 10 (0.7%) were HI posien-US -en-US tive for either WNV or SLE. en-US Additionally, 2 samples each en-US were HI positive for EEE and en-US Western equine encephalitis en-US (WEE). Of the samples that en-US were HI positive, 25 (10.6%) en-US were IgM positive for WNV en-US and 4 (1.6%) IgM positive for en-US SLE. This represented about en-US 1.8% and 0.3% of all samples. en-US The percentage of HI positive en-US samples for WNV increased en-US slightly over 2014, maintainen-US -en-US ing the generally elevated numbers recorded since 2012 en-US (Figure 2), while the percentage of IgM positives deen-US -en-US creased by half or more (Figure 3). The percentage of en-US positive dead birds also decreased from 2014 (Figure 4).en-US en-US the year (Figure 5). The period of greatest activity was en-US from July to September, 2015. There were no IgM posien-US -en-US tive samples in January. Between 5% and 9% of samples en-US were IgM positive from February to June, 2015. This en-US increased to 11% in July before peaking in August at en-US en-US 2015. More followed, with all other positive dead birds, en-US with one exception, occurring in July and August. The en-US percentage of HI WNV positives en-US peaked in September at 25%. The en-US IgM WNV positives also remained en-US high in September at above 20% been-US -en-US fore falling below 10% in October. en-US There were no IgM positives in Noen-US -en-US vember and December. The last posien-US -en-US tive dead bird was found on Novemen-US -en-US ber 6, 2015. The percentage of HI en-US WNV positive samples was the only en-US metric to remain elevated during the en-US winter months, remaining at around en-US 15% for January, November, and Deen-US -en-US cember 2015. This is not surprising en-US given the persistence of WNV antien-US -en-US bodies and the high levels of WNV en-US activity in 2012 and 2014.en-US THE ROLE OF BIRDS IN ARBOVIRAL DISEASE SURVEILLANCEen-US en-US IN HARRIS COUNTY AND THE CITY OF HOUSTON, TEXAS en-USYear en-USPercentage Positiveen-US20%en-US 0%en-US 5%en-US 10%en-US 15%en-USFigure en-US2en-US. Percentage of live bird sera samples collected from Harris County and the City of en-US Houston that tested HI positive for WNV, SLE, and WNV/SLE since en-US2002. en-US2002en-US 2003en-US 2004en-US 2005en-US 2006en-US 2007en-US 2008en-US 2009en-US 2010en-US 2011en-US 2012en-US 2013en-US 2014en-US 2015 en-USWNV/SLE en-USSLE en-USWNVen-USFigure en-US3en-US. en-US Percentages of live bird seroposen-US -en-US itive samples collected from Harris County en-US and the City of Houston, Texas that tested en-US IgM positive for WNV and SLE in en-US2014en-US and en-US2015en-US. en-USPercentage Positive en-USYearen-US20%en-US 30%en-US 0%en-US 10% en-US25%en-US 12.5%en-US 2%en-US 11% en-USSLE en-USWNVen-US 2014en-US 2015

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January June 2017 5 en-USTable en-US1en-US. Number of live bird sera samples collected from Harris County and the City of Houston, Texas, that tested HI and IgM en-US positive at the University of Texas Medical Branch, Galveston and the Mosquito and Vector Control Division in en-US2015en-US.en-USCommon Nameen-US en-US Seraen-US HI WNVen-US HI SLEen-US HIen-US en-US WNV/SLEen-US HI EEEen-US HI WEEen-US IgM en-US WNVen-US IgMen-US en-US SLEen-US House Sparrowen-US Passer domesticusen-US628en-US 86en-US 1en-US 6en-US 1en-US 0en-US 11en-US 2en-USBlue Jayen-US Cyanocitta cristataen-US158en-US 46en-US 0en-US 1en-US 0en-US 0en-US 10en-US 2en-USNorthern Cardinalen-US Cardinalis cardinalisen-US117en-US 54en-US 0en-US 1en-US 0en-US 0en-US 2en-US 0en-USNorthern Mockingbirden-US Mimus polyglottosen-US66en-US 11en-US 0en-US 0en-US 0en-US 2en-US 2en-US 0en-USMourning Doveen-US Zenaida macrouraen-US63en-US 9en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USMyrtle Warbleren-US Dendroica coronataen-US48en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USWhite-winged Doveen-US Zenaida asiaticaen-US37en-US 3en-US 0en-US 1en-US 0en-US 0en-US 0en-US 0en-USRed-winged Blackbirden-US Agelaius phoeniceusen-US34en-US 0en-US 1en-US 0en-US 0en-US 0en-US 0en-US 0en-USEuropean Starlingen-US Sturnus vulgarisen-US20en-US 4en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USCommon Grackleen-US Quiscalus quisculaen-US18en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USGreat-tailed Grackleen-US Quiscalus mexicanusen-US18en-US 2en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USSavannah Sparrowen-US Passerculus sandwichensisen-US17 en-US0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USBrown-headed Cowbirden-US Molothrus ateren-US15en-US 1en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USRed-bellied Woodpeckeren-US Melanerpes carolinusen-US13en-US 1en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USChipping Sparrowen-US Spizella passerinaen-US12en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USAmerican Robinen-US Turdus migratoriusen-US11en-US 2en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USNutmeg Manakinen-US Lonchura punctulataen-US8en-US 1en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USCarolina Wrenen-US Thryothorus ludovicianusen-US8en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USTufted Titmouseen-US Baeolophus bicoloren-US7en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USHouse Finchen-US Carpodacus mexicanusen-US5en-US 1en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USWhite-throated Sparrowen-US Zonotrichia albicollisen-US5en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USHermit Thrushen-US Catharus guttatusen-US4en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USInca Doveen-US Scardafella incaen-US4en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USYellow-bellied Sapsuckeren-US Sphyrapicus variusen-US4en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USDowny Woodpeckeren-US Picoides pubescensen-US3en-US 0en-US 0en-US 0en-US 0 en-US0en-US 0en-US 0en-USRed-headed Woodpeckeren-US Melanerpes erythrocephalusen-US3en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USBronzed Cowbirden-US Molothrus aeneusen-US2en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USBrown Thrasheren-US Toxostoma rufumen-US2en-US 1en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USEurasian Collared Doveen-US Streptopelia decaoctoen-US2en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USLoggerhead Shrikeen-US Lanius ludovicianusen-US2en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USRock Doveen-US Columba liviaen-US2en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USCarolina Chickadeeen-US Parus carolinensisen-US1en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USEastern Bluebirden-US Sialia sialisen-US1en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USEastern Phoebeen-US Sayornis phoebeen-US1en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USGray Catbirden-US Dumetella carolinensisen-US1en-US 0en-US 0en-US 1en-US 0en-US 0en-US 0en-US 0en-USLincoln's Sparrowen-US Melospiza lincolniien-US1en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USOrange-crowned Warbleren-US Vermivora celataen-US1en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USPurple Martinen-US Progne subisen-US1en-US 0en-US 0en-US 0en-US 1en-US 0en-US 0en-US 0en-USRose-breasted Grosbeak en-USPheucticus ludovicianusen-US1en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-USWhite-eyed Vireoen-US Vireo griseusen-US1en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US 0en-US (40 en-USBird Speciesen-US)en-US Totals en-US1,345en-US 222en-US 2en-US 10en-US 2en-US 2en-US 25en-US 4 HI indicates hemagluttination inhibition. SLE indicat es St Louis encephalitis. WEE indicat es Western equine encephalitis. WNV indicates West Nile virus. EEE indicat es Eastern equine encephalitis. IgM indicat es immunoglobulin M en-USBoth HI and IgM results for WNV differed by age. Afen-US -en-US ter-hatch year birds had a HI seropositive rate more than en-US double that of hatch year birds, while hatch year birds en-US that were HI positive for WNV were twice as likely to be en-US IgM positive (Table 3). This is consistent with after-hatch en-US year birds maintaining protective immunity after being en-US exposed to WNV within the previous 2 to 3 years. When en-US disease prevalence in hatch year and after-hatch year en-US birds was plotted by month, the differences were more en-US pronounced (Figure 6). After-hatch year birds accounted en-US for the majority of all positives until July, when hatch en-US year IgM prevalence increased dramatically. After-hatch

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6 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USTHE ROLE OF BIRDS IN ARBOVIRAL DISEASE SURVEILLANCEen-US en-US IN HARRIS COUNTY AND THE CITY OF HOUSTON, TEXAS en-USTable en-US2en-US. Number of dead birds collected from Harris County and the City of Houston, Texas, that were tested en-US en-US Control Division in en-US2015en-US.en-USCommon Nameen-US en-US Testeden-US Vector Testen-US en-US Positiveen-US RAMPen-US en-US Positiveen-US en-US en-US Positiveen-US Percentageen-US en-US en-US White-winged Doveen-US Zenaida asiaticaen-US61en-US 0en-US 0en-US 0en-US 0.0%en-USBlue Jayen-US Cyanocitta cristataen-US30en-US 9en-US 9en-US 11en-US 36.7%en-USEuropean Starlingen-US Sturnus vulgarisen-US22en-US 0en-US 1en-US 0en-US 0.0%en-USBlue-winged Tealen-US Anas discorsen-US19en-US 0en-US 0en-US 0en-US 0.0%en-USHouse Sparrowen-US Passer domesticusen-US18en-US 0en-US 0en-US 0en-US 0.0%en-USGreat-tailed Grackleen-US Quiscalus mexicanusen-US17en-US 1en-US 1en-US 1*en-US 5.9%en-USMourning Doveen-US Zenaida macrouraen-US14en-US 0en-US 0en-US 0en-US 0.0%en-USNorthern Mockingbirden-US Mimus polyglottosen-US8en-US 0en-US 1en-US 1en-US 12.5%en-USAmerican Robinen-US Turdus migratoriusen-US7en-US 1en-US 0en-US 0en-US 0.0%en-USCedar Waxwingen-US Bombycilla cedrorumen-US6en-US 0en-US 0en-US 0en-US 0.0%en-USCommon Grackleen-US Quiscalus quisculaen-US6en-US 0en-US 0en-US 0en-US 0.0%en-USRock Doveen-US Columba liviaen-US4en-US 0en-US 0en-US 0en-US 0.0%en-USYellow-crowned Night-heronen-US Nycticorax violaceaen-US4en-US 0en-US 1en-US 0en-US 0.0%en-USCooper's Hawken-US Accipter cooperiien-US3en-US 0en-US 0en-US 1en-US 33.3%en-USEastern Screech-owlen-US Otus asioen-US3en-US 0en-US 0en-US 0en-US 0.0%en-USNorthern Cardinalen-US Cardinalis cardinalisen-US3en-US 0en-US 1en-US 1en-US 33.3% en-USBrown-headed Cowbirden-US Molothrus ateren-US2en-US 0en-US 1en-US 0en-US 0.0%en-USCarolina Wrenen-US Thryothorus ludovicianusen-US2en-US 0en-US 0en-US 0en-US 0.0%en-USEurasian Collared Doveen-US Streptopelia decaoctoen-US2en-US 0en-US 0en-US 0en-US 0.0%en-USHermit Thrushen-US Catharus guttatusen-US2en-US 0en-US 0en-US 0en-US 0.0%en-USPurple Martinen-US Progne subisen-US2en-US 0en-US 0en-US 0en-US 0.0%en-USAmerican Cooten-US Fulica americanaen-US1en-US 0en-US 0en-US 0en-US 0.0%en-USAmerican Crowen-US Corvus brachyrhynchosen-US1en-US 0en-US 0en-US 0en-US 0.0%en-USBaltimore Orioleen-US Icterus galbula galbulaen-US1en-US 0en-US 0en-US 0en-US 0.0%en-USBrown Pelicanen-US Pelecanus occidentalisen-US1en-US 0en-US 0en-US 0en-US 0.0%en-USChipping Sparrowen-US Spizella passerinaen-US1en-US 0en-US 0en-US 0en-US 0.0%en-USLaughing Gullen-US Larus atricillaen-US1en-US 0en-US 0en-US 0en-US 0.0%en-USLesser Snow Gooseen-US Chen caerulescens en-US1en-US 0en-US 0en-US 0en-US 0.0%en-USMallarden-US Anus platyrynchosen-US1en-US 0en-US 0en-US 0en-US 0.0%en-USMyrtle Warbleren-US Dendroica coronataen-US1en-US 0en-US 0en-US 0en-US 0.0%en-USOrange-crowned Warbleren-US Vermivora celataen-US1en-US 0en-US 0en-US 0en-US 0.0%en-USOvenbirden-US Seiurus aurocapillusen-US1en-US 0en-US 0en-US 0en-US 0.0%en-USRed-eyed Vireoen-US Vireo olivaceusen-US1en-US 0en-US 0en-US 0en-US 0.0%en-USRed-winged Blackbirden-US Agelaius phoeniceusen-US1en-US 0en-US 0en-US 0en-US 0.0%en-USSoraen-US Porzana carolinaen-US1en-US 0en-US 0en-US 0en-US 0.0%en-USTennessee Warbler en-USVermivora peregrinaen-US1en-US 0en-US 0en-US 0en-US 0.0%en-USVeeryen-US Catharus fuscescensen-US1en-US 0en-US 0en-US 0en-US 0.0%en-USWhite-faced Ibisen-US Plegadis chihien-US1en-US 0en-US 0en-US 0en-US 0.0%en-USYellow-breasted Chaten-US Icteria virensen-US1en-US 0en-US 0en-US 0en-US 0.0%en-US (39 en-USBird Speciesen-US)en-US Totalsen-US253en-US 11en-US 14en-US 15en-US 5.9%en-US*en-US en-USRAMP indicates rapid analyte measurement platform. en-USyear IgM rates did not undergo a similar increase until en-US August. Hatch year HI rates were generally low, peaking en-US at 21.5% in September, about 15% less than after-hatch en-US year HI rates for the same month. There were no hatch en-US year birds in January and February, and low sample sizes en-US prevented the analysis of hatch year seropositive rates in en-US March and April, which had one HI positive each.en-US Each species had a seropositive rate markedly differen-US -en-US ent from the average. Northern Cardinals had the highen-US -en-US est HI incidence rate of 46.1%, followed by Blue Jays en-US at 29.1% (Figure 7). Of the HI positive samples, the en-US majority were from House Sparrows (39%), Northern en-US Cardinals (24%), and Blue Jays (21%) (Figure 8). The en-US highest IgM incidence rates were in Blue Jays (21.3%), en-US Mockingbirds (18.2%), and House Sparrows (11.8%), en-US while Blue Jays and House Sparrows comprised the en-US bulk of the IgM positive samples (84.0%). No HI or IgM en-US positives were found in Myrtle Warblers, Red-Winged en-US Blackbirds, Common Grackles, and Savanah Sparrows. en-US Myrtle Warblers and Savanah Sparrows are migraen-US -en-US tory birds that only reside in the Houston area during

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January June 2017 7 en-USthe winter months. House Sparrows were by far the en-US most frequently tested species, caught 4 times as much en-US as Blue Jays, the next most commonly caught species, en-US and comprised 46.7% of all samples tested. The next 4 en-US most commonly tested species were Blue Jays, Northen-US -en-US ern Cardinals, Northern Mockingbirds, and Mourning en-US Doves, comprising 30.0% of all samples tested. en-US Dead Blue Jays were also positive frequently, en-US accounting for 73.3% of positive dead birds. en-US All other dead positive bird species (Coopers en-US Hawk, Northern Cardinal, Northern Mockingen-US -en-US bird, and Great-tailed Grackle) had one posien-US -en-US tive sample each (Figure 9).en-US Positives were not uniformly distributed en-US across Harris County. Parts of the Harris en-US County that had high prevalence rates were en-US the Spring-Cypress area in the northwest, en-US Kingwood in the north, and western Houston. en-US Figure 10 shows the distribution of HI positive en-US results within Harris County for all viruses in en-USFigure en-US5en-US. en-US Monthly WNV activity in live and dead birds collected from Harris en-US County and the City of Houston, Texas, in en-US2015en-US. en-USMonth en-USPercentage Positiveen-US0%en-US 5%en-US 30%en-US 25%en-US 20%en-US 15%en-US 10%en-USJanen-US Feben-US Maren-US Apren-US Mayen-US Junen-US Julen-US Augen-US Sepen-US Octen-US Noven-US Dec en-USHI WNV en-USDead Birds en-USIgM WNV en-USTable en-US3en-US. Number and percentage of live birds collected in Harris County and the City of Houston, Texas, that tested HI en-US and IgM positive in en-US2015en-US.en-US2015en-USTotal Seraen-US en-US Nen-US HI WNVen-US en-US (%N)en-US HI SLEen-US en-US (%N)en-US HI WNV/SLEen-US en-US (%N)en-US HI EEEen-US en-US (%N)en-US HI WEEen-US en-US (%N)en-US IgM WNV+en-US en-US (%N)en-USIgM SLE+en-US en-US(%N)en-US All Birdsen-US1,345en-US 222 (16.5%)en-US 2 (0.1%)en-US 10 (0.9%)en-US 2 (0.1%)en-US 2 (0.1%)en-US 25 (10.7%)en-US 4 (1.7%)en-USAgeen-US After Hatch Yearen-US777en-US 177 (22.8%)en-US 1 (0.1%)en-US 7 (0.9%)en-US 1 (0.1%)en-US 0 (0.0%)en-US 16 (8.7%)en-US 3 (1.6%)en-USHatch Yearen-US568en-US 45 (7.9%)en-US 1 (0.2%)en-US 3 (0.5%)en-US 1 (0.2%)en-US 2 (0.3%)en-US 9 (18.3%)en-US 1 (2.0%)en-USSexen-US Maleen-US395en-US 91 (23.0%)en-US 1 (0.2%)en-US 3 (0.7%)en-US 0 (0.0%)en-US 0 (0.0%)en-US 7 (7.3%)en-US 0 (0%)en-USFemaleen-US234en-US 42 (17.8%)en-US 1 (0.4%)en-US 2 (0.8%)en-US 1 (0.4%)en-US 0 (0.0%)en-US 0 (0.0%)en-US 1 (2.2%)en-USUnknownen-US716en-US 89 (12.4%)en-US 0 (0.0%)en-US 5 (0.7%)en-US 1 (0.1%)en-US 2 (0.2%)en-US 18 (19.3%)en-US 3 (3.2%) HI indicates hemagluttination inhibition. SLE indicat es St Louis encephalitis. WEE indicat es Western equine encephalitis. WNV indicates West Nile virus. EEE indicat es Eastern equine encephalitis. IgM indicat es immunoglobulin M. en-USFigure en-US4en-US. en-US Number and percentage of dead birds collected from Harris County and the City of Houston, Texas, that were tested and en-US en-US2002en-US. en-USPercentage WNV Positiveen-US70%en-US 60%en-US 50%en-US 40%en-US 0%en-US 10%en-US 20%en-US 30% en-USNumber of Dead Birdsen-US2500en-US 2000en-US 1500en-US 1000en-US 500en-US 0en-US 2002en-US 2003en-US 2004en-US 2005en-US 2006en-US 2007en-US 2008en-US 2009en-US 2010en-US 2011en-US 2012en-US 2013en-US 2014en-US 2015en-US57.2%en-US 18.6%en-US 24.5% en-US12.7%en-US 14.1%en-US 9.2% en-US0.3% en-US3.0%en-US 1.9%en-US 5.3%en-US 32.5%en-US 1.6% en-US23.5%en-US 5.9% en-USYear en-US% WNV Positiveen-US Lab Tested en-USWNV

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8 http://www.cs.amedd.army.mil/amedd_journal.aspxen-US2015. The prevalence rate for WNV ranged en-US from 0.0% to 28.6%, and areas with the highen-US -en-US est percentages were in the center and southen-US -en-US ern part of Harris County. Only 6 samples en-US tested positive for SLE, EEE, and WEE. Aren-US -en-US eas 411 and 425 tested positive for SLE, while en-US EEE was detected in areas 820 and 904, and en-US WEE was detected in 710 and 923, which was en-US en-US Figure 11 shows the distribution of IgM results en-US for WNV in Harris County. The percentage en-US of IgM positive samples is the percentage of en-US HI samples testing IgM positive and indicates en-US the proportion of HI positives in each area that en-US is due to a recent infection. The en-US percentage of IgM positives in en-US each area ranged from 0.0% to en-US 36.4%. The areas with the highen-US -en-US est percentage of IgM positives en-US were 820, 225, and 606. Area 606 en-US was the only one that had a high en-US percentage of both IgM and HI en-US positives.en-US Most dead birds were reported en-US from the western loop and northen-US -en-US western Harris County, near the en-US towns of Spring and Cypress en-US (Figure 12). Positive birds were en-US clustered in Baytown and near en-US the intersection of highways 610 en-US and 290. Five more birds were en-US en-US northwest of the Sam Houston en-US Beltway and one from the town en-US of Humble. COmpa MPA RISONS TO PREVIOUS YEa A RS en-USwas low, while the percentage of HI WNV positive live en-US birds was high, relative to their historical occurrences en-US (Figure 13). This could be explained by the high prevaen-US -en-US lence of antibodies in the avian population providing en-US protective immunity against WNV resulting in the avien-US -en-US an low death rate, which is reasonably well supported by en-US the historical data. However, high antibody levels did en-US not prevent a high death rate in 2014.en-US en-US birds were particularly susceptible as none had been en-US previously exposed. Although SLE antibodies provide en-US some protection against WNV,en-US6en-US they were at a historien-US -en-US cally low rate of 1.9%. Mortality was high, particularly en-US for American Crows (68.4%) and Blue Jays (66.9%). It en-US took 4 years for antibody levels to peak in 2006 at 17.7%, en-US double the highest annual SLE rate from 1975 to 2001 of en-US 8.4%. From 2006 to 2011, the mortality and seroprevaen-US -en-US lence rates decreased, until antibody levels reached 6% en-US to 5% (Figure 13). In 2012, there was a sudden resuren-US -en-US gence in WNV activity, with mortality rates reaching en-US 2003-2004 levels. Antibody levels jumped to 14.7% and en-US remained high throughout 2015. Recent mortality rates en-US were inconsistent; 1.6% in 2013 and 23.5% in 2014. PROGRam AM E EXpa PA NSION The objectives were to expand and improve the MVCD en-USAvian Surveillance Program in 2016. Trapping sites were en-US continually evaluated and subjected to change if catch en-US rates decreased. Scouting for new trapping locations, en-US THE ROLE OF BIRDS IN ARBOVIRAL DISEASE SURVEILLANCEen-US en-US IN HARRIS COUNTY AND THE CITY OF HOUSTON, TEXAS en-USNorthern Cardinal en-USAmerican Robin en-USNorthern Mockingbird en-USMourning Dove en-USHouse Sparrow en-USGreat-tailed Grackle en-USWhite-winged Dove en-USRed-bellied Woodpecker en-USBrown-headed Cowbird en-USOther en-USMyrtle Warbler en-USRed-winged Blackbird en-USCommon Grackle en-USSavannah Sparrow en-USChipping Sparrow en-USBlue Jay en-USEuropean Starlingen-US 0%en-US 5%en-US 30%en-US 50%en-US 25%en-US 45%en-US 20%en-US 40%en-US 15%en-US 35%en-US 10%en-USFigure en-US7en-US. Percentages of live bird sera samples collected from Harris County and the City en-US of Houston that tested HI positive for WNV in en-US2015. en-USFigure en-US6en-US. en-US Monthly WNV activity in live hatch year and after-hatch year birds en-US collected from Harris County and the City of Houston, Texas, in en-US2015en-US. en-USMonth en-USPercentage Positiveen-US10%en-US 5%en-US 0%en-US -5%en-US 20%en-US 40%en-US 35%en-US 30%en-US 25%en-US 15% en-USHatch Year HI en-USHatch Year IgM en-USAfter-hatch Year HI en-USAfter-hatch Year IgMen-USJanen-US Feben-US Maren-US Apren-US Mayen-US Junen-US Julen-US Augen-US Sepen-US Octen-US Noven-US Dec

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January June 2017 9 en-USFigure en-US8en-US. en-US Species distribution of HI positive live bird samples en-US collected from Harris County and the City of Houston, Texas, in en-US2015. en-USNorthernen-US en-US Cardinalen-US en-US 24.3% en-USHouseen-US en-US Sparrowen-US en-US 38.7% en-USOtheren-US en-US 7.2% en-USBlue Jayen-US en-US 20.7%en-US Northernen-US en-US Mockingbirden-US en-US 5% Mourning Dove en-US en-US 4.1% en-USNorthernen-US en-US Cardinalen-US en-US 6.6% en-USGreat-taileden-US en-US Grackle 39% en-USCoopers Hawk 6.6% en-USBlue Jayen-US en-US 73.3%en-US Northern Mockingbirden-US en-US 6.6% Figure en-US9en-US. en-US Species distribution of WNV dead birds collected from en-US Harris County and the City of Houston, Texas, in en-US2015. en-USFigure en-US10en-US. en-USMap of Harris County and the City of Houston, Texas, showing en-US the geographicalen-US en-US distribution of HI test results for WNV, SLE, EEE, and WEE en-US in en-US 2015en-US.

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10 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USparticularly in areas of high virus activity or low curen-US -en-US rent coverage, were conducted as time permitted. Testen-US -en-US ing was expanded to include Highlands J virus (HJV), en-US an alphavirus in the WEE complex. Although HJV is en-US not thought to cause illness in humans, it can react with en-US antigens for WEE similarly to WNV and SLE. Testing en-US en-US Five sera samples have already tested HI positive for en-US HJV in 2016.en-US Testing for non-arboviral viruses, such as Newcastle en-US en-US-en-US en-US en-US en-US and doves collected in Harris County and the City of en-US Houston.en-US14en-US Although HPAI is not a vector-borne disease, en-US en-US -en-US tially life-threatening disease that uses avian species as en-US the main host. In 2015, an HPAI outbreak occurred in at en-US least 15 states (3 declaring states of emergency) resulten-US -en-US ing in the destruction of 49.5 million birds and at least en-US $500 million spent in emergency funds.en-US15-17en-US The HPAI en-US was also found in wild birds in Kansas and Missouri,en-US18en-US en-US en-US includes important wintering grounds in the Houston en-US area. The HPAI may persist in wild birds and resurface en-US en-US Indeed, the 2015 outbreak was linked to incidences in en-US en-US19en-US en-US en-US in Indiana where 43,000 birds were destroyed as part of en-US the containment effort.en-US20en-USWe plan to test for Avian Flu in 2017. Test kits are availen-US -en-US able from several commercial manufactures for use by en-US veterinarians. Further testing by UTMB-G will be needen-US -en-US ed to conrm any positive samples as highly pathogenic.en-US THE ROLE OF BIRDS IN ARBOVIRAL DISEASE SURVEILLANCEen-US en-US IN HARRIS COUNTY AND THE CITY OF HOUSTON, TEXASen-USFigure en-US11en-US. en-USMap of Harris County and the City of Houston, Texas, showing en-USthe geographical distribution of IgM test results for WNV en-US in en-US 2015en-US.

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January June 2017 11 CONc C LUSION Avian surveillance is an integral part of disease-based en-USintegrated mosquito and vector management programs. en-US Overall, an average level of Avian WNV activity was inen-US -en-US dicated in 2015, and low levels of EEE and SLE in Harris en-US County and the City of Houston. However, WEE was en-US last detected in 2011. Most infections were in residential en-US birds. If viral activity conforms to SIR models, Harris en-US County should be entering a low point in the WNV cyen-US -en-US cle. Initial results showed WNV activity was low in 2016, en-US en-US activity will eventually diminish avian arboviral protecen-US -en-US tion, inviting another outbreak. Continued surveillance en-US is needed to determine when this will likely occur. RREFERENc C ES 1. en-USRappole JH, Hubalek Z. Migratory birds and West en-US Nile virus. en-USJ Appl Microbiolen-US 2003;94(suppl):47s-58s. 2. en-USMcKee EM. en-USen-US -en-US ence of Herd Immunity on Disease Risk in a Long-en-US Term Study of Free-Ranging Birdsen-US [masters thesis]. en-US en-US 2012. Available at: http://opus.govst.edu/theses/9/. en-US Accessed December 14, 2016. 3. en-USNemeth NM, Oesterlem PT, Bowen RA. Humoral en-US immunity to West Nile virus is long-lasting and en-US protective in the House Sparrow (en-US Passer domestien-US -en-US cusen-US ). en-USAm J Trop Med Hygen-US 2009;80(5):864-869. 4. en-USNash D, Mostashari F, Fine A, et al. The outbreak en-US of West Nile virus infection in the New York City en-US area in 1999. en-USN Engl J Meden-US 2001;344:1807-1814. 5. en-USKoenig WD, Hochachka WM, Zuckerberg en-US B, Dickinson JL. Ecological determinants of en-US American crow mortality due to West Nile virus en-US during its North American sweep. en-USOecologiaen-US en-US 2010;163:903-909.en-USFigure en-US12en-US. en-USMap of Harris County and the City of Houston, Texas, showing en-US the geographical distribution of en-USdead birds reported, tested, and en-US en-US en-US in en-US 2015en-US.

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12 http://www.cs.amedd.army.mil/amedd_journal.aspx 6. en-USFang Y, Reisen WK. Previous infection with West en-US Nile or St. Louis encephalitis viruses provides en-US en-US -en-US es. en-USAm J Trop Med Hygen-US 2006;75(3):480-485. 7. en-USAnderson RM, May RM. en-US Infectious diseases of en-US Humans: Dynamics and Controlen-US New York, NY: en-US 8. en-USKwan JL, Kluh S, Reisen WK. Antecedent avian en-US immunity lifts tangential transmission of West en-US Nile virus to humans. en-USPLoS Oneen-US 2012;7:e34127. 9. en-USDunn JL. en-US National Geographic Field Guide to the en-US Birds of North Americaen-US 4th ed. Washington, DC: en-US National Geographic Society. 2002. 10. en-USSibley DA. en-USThe Sibley Field Guide to Birds of en-US Eastern North Americaen-US New York, NY: Alfred A. en-US Knopf, Inc; 2003. 11. en-USPyle P. en-US en-US Birds, Part 1en-US Bolinas, CA: Slate Creek Press; 1997. 12. en-USCasals J. The arthropod-borne group of animal vien-US -en-US ruses. en-USTrans N Y Acad Scien-US 1957;19(3):219-235. 13. en-USen-US 703-712; Ch 128; 40 Stat. 755 (July 13, 1918). en-US Available at: http://law2.house.gov/view.xhtml?en-US en-US en-US bchapter2&saved=%7CMTYgdXNj%7CdHJlZXNen-US vcnQ=%7CdHJ1ZQ==%7C5302%7Ctrue%7Cprelen-US im&edition=prelim. Accessed December 14, 2016. 14. en-USKim LM, Guzman H, Tesh RB, Bueno R, Dennett en-US JA, Alonso CL. Biological and phylogenetic charen-US -en-US acterization of pigeon paramyxovirus serotype-1 en-US circulating in North American pigeons and doves. en-US J Clin Microbiolen-US 2008;46:3303-3310. 15. en-USen-US -en-US pact, uncertain future [The National Geographic en-US Society Web site]. May 7, 2015. Available at: http://en-US phenomena.nationalgeographic.com/2015/05/07/en-US 16. en-USen-US worse could be coming [The National Geographic en-US Society Web site]. June 15, 2015. Available at: http://en-US phenomena.nationalgeographic.com/2015/07/15/en-US en-US en-USAccessed December 14, 2016. 17. en-USen-US producers into uncharted territory [NPR Web site]. en-US May 21, 2015. Available at: http://www.npr.org/en-US sections/thesalt/2015/05/21/408306843/avian-flu-en-US outbreak-takes-poultry-producers-into-uncharted-en-US territory. Accessed September 19, 2016. 18. en-USen-US -en-US en-US en-US en-US h5/. 19. en-USen-US No: IM OA 2014-05. Detection of Highly Pathoen-US -en-US en-US 20. en-USen-US en-US www.aphis.usda.gov/aphis/ourfocus/animalhealth/en-US animal-disease-information/avian-influenza-disen-US -en-US ease/sa_detections_by_states/ai-2016-mapen-US Acces-en-US sed September 19, 2016. AUTHORS Ms Wilkerson is the Avian Biologist at the Mosquito and en-USVector Control Division, Harris County Public Health, en-US Houston, Texas.en-US Mr Reyna Nava is a Medical Entomologist and the Techen-US -en-US nical Operations Manager of the Mosquito and Vector en-US Control Division, Harris County Public Health, Houston, en-US Texas.en-US Ms Freeman is the Virologist at the Mosquito and Vector en-US Control Division, Harris County Public Health, Houston, en-US Texas.en-US Ms Travassos da Rosa is a Virologist at the Departen-US -en-US en-US Galveston, Texas.en-US Ms Guzman is a Virologist at the Department of Patholen-US -en-US en-US Texas.en-US Dr Tesh is a Professor at the Department of Pathology, en-US en-US Dr Debboun is the Director of the Mosquito and Vector en-US Control Division, Harris County Public Health, Houston, en-US Texas.en-USTHE ROLE OF BIRDS IN ARBOVIRAL DISEASE SURVEILLANCEen-US en-US IN HARRIS COUNTY AND THE CITY OF HOUSTON, TEXASen-USFigure en-US13en-US. en-US Percentage of en-US en-US -en-US tive and live birds that testen-US -en-US ed HI positive for WNV from en-US Harris County and the City of en-US Houston, Texas, since en-US2002. en-USPercentage Positive en-US0%en-US 20%en-US 60%en-US 50%en-US 40%en-US 30%en-US 10%en-US 2002en-US 2003en-US 2004en-US 2005en-US 2006en-US 2007en-US 2008en-US 2009en-US 2010en-US 2011en-US 2012en-US 2013en-US 2014en-US 2015 en-USDead Birds en-USLive Birds

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en-USJanuary June 2017 en-US13en-USAedes aegyptien-US (L.), also known as the yellow fever mosen-US -en-US quito, is an important vector of viral diseases such as en-US yellow fever, dengue, Chikungunya, and, most recently, en-US Zika virus.en-US1,2en-US Despite current vector control efforts, the en-US incidence and geographical expansion of these pathoen-US -en-US gens continue to increase at an alarming rate. For exen-US -en-US ample, the incidence of dengue has increased 30 fold en-US over the last 50 years.en-US3en-US The World Health Organization en-US (WHO) estimates 50-100 million cases occur annually en-US in over 100 endemic countries, putting almost half of en-US the worlds population at risk. More than 70% of the en-US population at risk for dengue worldwide live in member en-US en-US region.en-US3en-US As a result, the Department of Defense (DoD) en-US personnel and family members stationed in these reen-US -en-US gions are at risk.en-US Vector control remains the primary defense against en-US vector-borne diseases. Standard preventive deterrence en-US against vector-borne diseases incorporates integrated en-US pest management (IPM) with personal protective meaen-US -en-US sures (PPMs). The IPM approach to pest control inteen-US -en-US grates cultural, biological, physical, and chemical methen-US -en-US ods which minimize health and environmental risk. Ofen-US -en-US ten in situations when the threat of vector-borne disease en-US transmission is high, direct suppression of vectors using en-US pesticides is favored over nonchemical control methods. en-US However, the repeated failure of conventional insectien-US -en-US cides to control vector species in some areas continues en-US to put Soldiers at risk. Furthermore, the failure to conen-US-en-US trol vector populations may result in additional chemical en-US applications that potentially contribute to other vector en-US control problems such as pesticide resistance, unintenden-US -en-US ed exposure to nontarget organisms, and environmental en-US pollution.en-US The PPM standards mandated by the military include en-US use of a topical repellent, N, N-diethyl-3-methylen-US -en-US benzamide (DEET) or 1-piperidinecarboxylic acid 2-en-US en-US (2-hydroxyethyl)-1-methylpro-pylester) (Picaridin), propen-US en-US er wear of a permethrin-treated uniform, and the use en-US of a bed net.en-US4en-US Additionally, malaria prophylaxis is preen-US -en-US scribed when service members are deployed in endemic en-US areas. However, compliance with PPM standards reen-US -en-US mains a problem among service members.en-US5-7en-US Sanders et en-US alen-US8en-US reported that responders in a 2004 study of personen-US -en-US nel returning from Iraq and Afghanistan indicated that en-US a majority (51%) did not use DEET, even though most en-US knew that it was readily available. A report on the use of en-US en-US that compliance with 4 preventive measures (use of en-US DEET, proper uniform wear, adherence to prophylaxis, en-USLaboratory and Semi-field Evaluationsen-US en-US of Two (Transfluthrin) Spatial Repellenten-US en-US Devices Against en-USAedes aegypti en-US(L.)en-US en-US (Diptera: Culicidae) P aula D. Mischler, PhD A lec G. Richardson, PhD M eiling Z. Webb, PhD M ustapha Debboun, PhD, BCE K amal Chauhan, PhD ABSTRac AC T en-USRaid Shield (currently not commercially available), SC Johnson, Racine WI) were evaluated for spatial repellent en-US effects against female en-US Aedes aegyptien-USen-US en-US behaviors. The mean baseline (control) landing counts for the Raid Dual Action and Raid Shield were reduced en-US by 95% and 74% respectively. Mean probing counts for the Raid Dual Action were reduced by 95%, while the en-US en-US en-US -en-US ducted in outdoor enclosures at the Navy Entomology Center of Excellence, Jacksonville, Florida. A moderate en-US reduction in mosquito entry into military style tents resulted when either product was placed near the tent openen-US -en-US ing. The Raid Shield reduced mosquito entry into tents by 88%, while the Dual Action decreased entry by 66%.

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en-US14 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USand postdeployment antirelapse therapy) was 0%.en-US9en-US Even en-US when compliance with PPM is high, service members en-US are still exposed to vectors during physical training or en-US while off duty. Additional control methods are needed to en-US augment the DoDs current vector control strategy. SSpaPA TIa A L R REp P ELLENTS Recently, area (spatial) repellents have received inter en-US-en-US est as a novel system for vector control. Spatial repelen-US -en-US lents work by releasing chemicals into the air to reduce en-US mosquito entry into treated spaces and to inhibit blood-en-US en-US en-US -en-US velopment in the emergence of insecticide resistance.en-US10en-US en-US Several types of commercial spatial repellent products en-US have been reported in the literature: impregnated plastic en-US or paper strips,en-US11en-US coils,en-US12-14en-US candles,en-US15-17en-US fan emanators,en-US18-21en-US en-US heat-generating devices,en-US20-22en-US and microdispensers.en-US23en-USImpregnated Plasticen-USen-US en-US -en-US sively deliver spatial repellents without external energy en-US input. Yayo et alen-US11en-US investigated the effect of Rambo Inen-US -en-US en-US densities and biting rates of 2 important malaria vecen-US -en-US tors (en-US Anopheles funestus en-USGiles and en-USAn. gambiae s.l.en-US ) at a en-US en-US both indoor resting density (91%) and biting rate (86%) en-US was reported. Passive emanators may be preferred by en-US the DoD, as these devices would be most likely to meet en-US logistical and safety requirements.en-USMosquito Coilsen-USMosquito coils are the most commonly used household en-US insecticidal product in the world.en-US12en-US Avicor et alen-US13en-US conen-US -en-US ducted a laboratory evaluation of 3 commercial coil en-US en-US An. gambiae en-US Giles in southern Ghana. All 3 coils (FISH M (0.005% en-US en-US 74%, and Tesco Value (0.3% allethrin) 72% showed high en-US en-US12en-US demonstrated the effecen-US -en-US en-US SC Johnson, Racine, WI) in households to reduce maen-US -en-US en-US -en-US vided 77% protection against en-US Plasmodium falciparum en-US Welch. Msangi et alen-US14en-US assessed feeding inhibition and en-US repellency of 3 pyrethroid brands (Kiboko, Total, and en-US Risasi) of mosquito coils in experimental huts in northen-US -en-US ern Tanzania. Induced exophily was high for en-US Culex en-US quinquefasciatusen-US Say (95%), but was low in en-US An. gambien-US -en-US aeen-US (61%) for all products tested. Feeding inhibition was en-US en-US Cx. quinquefasen-US-en-US ciatusen-US (97%) and en-USAn. gambiaeen-US (88%).en-USFan Emanatorsen-USen-US as promising tools with long-lasting spatial protection en-US against mosquitoes. Various studies have evaluated the en-US en-US et alen-US18en-USen-US Florida, which proved to be 70% and 79% effective at en-US repelling en-US Aedes albopictus en-US Skuse and en-US Ae.en-US en-US taeniorhynen-US -en-US chus en-US (Wiedemann) from human test subjects. In a semi-en-US en-US arms of volunteers against en-US Ae. albopictusen-US by 96% and en-US Cx. pipiensen-US L. by 95%.en-US19en-US Lloyd et alen-US20en-US reported a 64% en-US reduction in en-US Ae. albopictusen-US collected from Biogents en-US Sentinel (BGS) traps located near the repellent device. en-US en-US en-US study conducted by Dame et al,en-US21en-US the device failed to en-US reduce the populations of en-US An. quadrimaculatusen-US Say and en-USPsorophora columbiaeen-US (Dyar and Knab) collected in en-US surrogate traps. Reduction rates for this study ranged en-US from 8% to 16%.en-USHeat Generating Devicesen-USThe ThermaCell (Thermacell Repellents, Bedford, MA) en-US spatial repellent device (active ingredient allethrin), is en-US one of the most popular heat generating devices on en-US the market. Collier et alen-US22en-US conducted a study in Louien-US -en-US siana using several spatial repellent devices (Dragon en-US en-US Mosquito Lantern) and systems to determine their efen-US -en-US fect on backyard mosquito population levels, in which en-US the ThermaCell device was the most effective device in en-US reducing mosquito populations (en-US Cx. salinariusen-US Coquilen-US -en-US lett, en-US Cx. quinquefasciatusen-US and en-USAe. vexansen-US (Meigen)). In en-US en-US20en-US the en-US number of en-USAe. albopictusen-US repelled by the ThermaCell en-US en-US evaluated (Lentek Bite Shield and Bug Button Mosquito en-US Eliminator).en-US en-US -en-US en-US repellents for inhibiting en-USAe. aegypti en-US(L.) host-seeking en-US behaviors (anemotaxis, landing, and blood feeding) en-US under laboratory conditions, and (2) determine if these en-US products were effective in reducing the number of host-en-US seeking en-US Ae. aegyptien-US from entering a baited military-en-US MaA TERIa A LS aA ND METHODS Mosquitoes en-USAedes aegyptien-US eggs (Liverpool and Orlando strain) en-US en-US en-US LABORATORY AND SEMI-FIELD EVALUATIONS OF TWO (TRANSFLUTHRIN) SPATIAL REPELLENT DEVICESen-US en-US AGAINST en-US AEDES AEGYPTI en-US(L.) (DIPTERA: CULICIDAE)

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en-USJanuary June 2017 en-US15 en-USfor Medical, Agricultural, and Veterinary Entomology, en-US Gainesville, Florida. They were reared in an insectary en-US using a 12:12 hour (light/dark) photoperiod at 26C and en-US 35% to 50% relative humidity (RH). Larvae were fed en-US en-US -en-US ny). Adults were held in screened, 3.79 liter plastic bucken-US -en-US ets, and fed with a cotton pad moistened with 10% aqueen-US -en-US ous sucrose solution. Adult female mosquitoes were 5 to en-US 10 days old and incubated in plastic buckets along with a en-US water-moistened pad without sugar for 24 hours before en-US they were used in bioassays.en-USSpatial Repellent Devices Evaluateden-USen-US Company) products: Raid Dual Action Insect Repellent en-US and Home Freshener, and Raid Shield were evaluated in en-US this study (Figure 1).en-US en-US Sustainable Global Enterprise, and the Bill and Melinda en-US Gates Foundation created the WOW, which is a busien-US -en-US ness concept that creates access to pest control products en-US that can help prevent malaria in at-risk populations at en-US the base of the pyramid, as well as home-cleaning and en-US personal care products valued by rural consumers. The en-US Raid Dual Action Insect Repellent and Home Freshener en-US is one of 6 products developed from the en-US WOW program in Ghana. The product conen-US-en-US en-US and a colorful plastic poster decorated with en-US a well-known Ghanaian adinkra symbol.en-US Raid Shield is a product developed for reen-US -en-US search purposes (not commercially availen-US -en-US able) by the SC Johnson Company. It is a en-US clear plastic strip that is impregnated with en-US en-US en-US -en-US leased into the immediate area.en-USLaboratory Evaluations (Wind Tunnel)en-USLaboratory evaluations were conducted in a 3.0 m x 61 en-US en-US Invasive Insect Biocontrol and Behavior Laboratory en-US in Beltsville, Maryland. With a few minor deviations, en-US the wind tunnel was set up in accordance with Klun et en-US al.en-US24en-US Air temperature in the chamber was controlled by en-US a window air conditioner and baseboard electric heaten-US -en-US ers and maintained at 25C4C in the tunnel. The RH en-US inside the chamber was maintained at 25% to 35% using en-US en-US connected to the air conditioning chamber by a cowling en-US that housed a 61 cm diameter fan driven by a rheostat-en-US controlled Dayton Electric Model 2Z846A motor that en-US en-US -en-US en-US en-US was recorded using a HOBO data logger (Onset Comen-US -en-US puter Corp, Bourne, MA).en-US en-US -en-US ing reservoir (Figure 2B) that was positioned at the upen-US -en-US en-US reservoir was placed on a stand made of 0.5 cm thick en-US Plexiglas with a 33.8 cm x 15.4 cm base and a 29.8 cm x en-US 7.0 cm (length x width) upper shelf with 1.2 cm high edgen-US -en-US es at each end of the shelf to secure the reservoir on the A B Figure en-US1en-US. The SC Johnson spatial repellents tested in this study: (A) Raid Dual en-US Action Insect Repellent and Home Freshener; (B) Raid Shield. en-USFigure en-US2en-US. en-US (A) Wind tunnel at the Invasive Insect Biocontrol & Behavior Laboratory, USDA-ARS, Beltsville, MD. (B) Mosquito feeding en-US reservoir. A B

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16 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USshelf. Positioned on the shelf, the top surface of the reseren-US -en-US en-US tunnel, and 47 cm away from the upwind tunnel screen. en-US In order to maintain a constant temperature (38C) for en-US en-US connected to a water bath circulator (Lauda E100, Woben-US -en-US ser GMBH and Co, Konigshofell, Germany). A breath-en-US delivery tube (2.5 m x 22 mm inner diameter; Tri-Anim, en-US Sylmar, CA) ran from outside of the upwind end of the en-US tunnel to breath exhaust position inside the tunnel 20 cm en-US en-US from the upwind end of the tunnel.en-US Prior to each test, the upper surface of the feeding resen-US -en-US ervoir was coated with a thin layer of high-vacuum silien-US -en-US cone grease (Dow Corning Corp, Midland, MI), and the en-US en-US-en-US man blood from the Walter Reed Army Institute of Reen-US -en-US search (WRAIR), Silver Spring, MD, to which Adenosen-US -en-US ine triphosphate (ATP) was added on the day of testing en-US to obtain a concentration of 10en-USen-USen-US cells were covered with an Edicol collagen membrane en-US (G Street Fabrics, Rockville, MD). During treatment en-US evaluations, the treatment device was suspended from en-US the wind tunnel ceiling facing downwind and positioned en-US 38 cm in front of the feeding reservoir.en-US Trials for each spatial repellent device were replicated 5 en-US times. Each trial consisted of one control test followed en-US by 5 consecutive treatment tests. The purpose of the en-US control evaluation was to establish a baseline for mosen-US -en-US quito activity under normal conditions (untreated) and en-US en-US wind tunnel. A test began by placing a mosquito release en-US canister containing 20 female en-US Ae. aegyptien-US (Liverpool-en-US strain) inside the wind tunnel. Subsequently, human en-US breath was expired from the breath-delivery tube for 5 en-US seconds and the mosquitoes were released and allowed en-US en-US -en-US ing this time period an observer recorded the frequency en-US of probing and landing occurring on the mosquito feeden-US -en-US en-US the mosquitos were visually examined for evidence of en-US knockdown from chemical exposure and feeding status en-US (blood-fed or unfed). Mosquitoes were removed from en-US the chamber using a vacuum aspirator.en-USSemi-field Evaluations (Enclosures)en-USen-US enclosures (Figure 3A), located at the Navy Entomology en-US Center of Excellence in Jacksonville, Florida. Each enen-US -en-US closure consisted of a metal frame that measured 6.1 m en-US wide x 10.7 m long x 3.4 m high. The enclosure was comen-US -en-US pletely covered with mosquito screen and had a concrete en-US base. Several potted plants were placed in the interior of en-US each enclosure to mimic the natural outdoor habitat. A en-US single military style tent (3-person) was placed at the far en-US end of the enclosure, opposite the entrance. Each tent en-US housed a BGS 2.0 trap baited with dry ice and BGS proen-US -en-US prietary lure. Temperature, relative humidity, and wind en-US speed were measured throughout the evaluation using a en-US HOBO data logger.en-US Enclosure experiments were conducted simultaneously en-US in the 2 enclosures. Prior to each trial, one of the enen-US -en-US closures was randomly selected as the treatment and en-US the other as the control. Inside the treatment enclosure, en-US the spatial repellent device was placed on the outside of en-US the tent near the upper door opening (Figure 3B). Trials en-US were conducted in the morning (8 AM to 11 AM ) which en-UScorresponded with the peak host-seeking period of en-US Ae. en-US aegyptien-US Two hundred female en-US Ae. aegyptien-US (Orlando-en-US strain) were simultaneously released into each enclosure en-US and allowed to move freely for one hour. At the end of en-US the trial, the mosquitoes inside the tents were collected en-US from the BGS traps and vacuumed out using an aspirator.en-US LABORATORY AND SEMI-FIELD EVALUATIONS OF TWO (TRANSFLUTHRIN) SPATIAL REPELLENT DEVICESen-US en-US AGAINST en-US AEDES AEGYPTI en-US(L.) (DIPTERA: CULICIDAE) A B Figure en-US3en-US. en-US en-US -en-US mercial tent used in this study.

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January June 2017 17 en-USStatistical Analysisen-USLaboratory (Wind Tunnel) Studyen-USStatistical 2-way hypothesis tests were conducted at the en-US en-US in landing, probe, blood-fed, and knock down counts en-US among the 2 products (Raid Dual Action and Raid en-US Shield) and treatments (Control and treatment).en-USSemi-field Studyen-USStatistical 3-way and 2-way hypothesis tests were conen-US -en-US en-US differences in mosquito counts (inside tent and BGS en-US traps) between the 2 products (Raid Dual Action and en-US Raid Shield), between the treatment and control, and en-US en-US testing using the Kolmogorov-Smirnov test for normalen-US -en-US ityen-US25en-US and the Bartlett test for homoscedacity (homogeneen-US -en-US ity of variances)en-US26,27en-US indicated that the data were non-en-US normal and non-homoscedastic. Thus, the nonparameten-US -en-US ric Kruskal-Wallis testen-US28en-US was used instead of the paraen-US -en-US metric ANOVA test for the statistical analysis. Post hoc en-US Tukey multiple-comparison,en-US29en-US Newman-Keuls, Duncan en-US multiple-range,en-US30,31en-US and Scheffe multiple-contrasten-US32en-US tests en-US were evaluated based on an optimization analysis, and en-US en-US en-US each other and contribute to the overall variance source. en-US Interaction effects of air temperature and humidity on en-US mosquito counts were evaluated by regression analysis. en-US All statistical analysis was performed using Intel Visual en-US Fortran Compiler XE 2013 (Intel Corporation, Santa en-US Clara, CA). RRESULTS Laboratory (Wind Tunnel) en-USBoth products were effective in reducing host-seeking en-US activity of en-USAe.en-US en-US aegypti en-US in the wind tunnel. Figure 4A en-US shows the treatment effect of both products on the mean en-US landing counts of the mosquitoes. The mean baseline en-US (control) landing counts for the Raid Dual Action and en-US Raid Shield were reduced by 95% (en-US Pen-US <.006) and 74% en-US (en-US Pen-US <.006) respectively. Mean probing counts for the Raid en-US Dual Action were reduced by 95% (en-US Pen-US <.02), while the en-US probing counts for the Raid Shield were decreased by en-US 69% (en-US Pen-US <.02) (Figure 4B). Baseline blood-feeding sucen-US -en-US en-US Pen-US <.002) for both treaten-US -en-US ments: Raid Dual Action (100%) and Raid Shield (96%) en-US (Figure 4C). Figures 5 and 6 show the time analysis (50 en-US minutes) for the mean counts of landing, probing, and en-US blood feeding for each treatment. Maximum reduction en-US en-US -en-US utes, reduction rates dropped below 50%. Blood-feeding en-US reduction rates remained above 85% for the duration of en-USaen-US aen-US ben-US ben-US0en-US 3en-US 5en-US 7 en-US1 en-US2 en-US4 en-US6 en-USRaid Dual Action en-USRaid Shield en-USControl en-USTreatment en-USMean Number of Blood-Fed Mosquitoes C en-US10en-US 0en-US 20en-US 30en-US 40en-US 50en-US 60en-US 70en-USaen-US aen-US ben-US b en-USRaid Dual Action en-USRaid Shield en-USControl en-USTreatment en-USMean Number of Mosquito Probe Counts B 20 en-US0en-US 40en-US 60en-US 80en-US 100en-US 120en-US 140en-US 160 en-USMean Number of Mosquito Landings en-USRaid Dual Action en-USRaid Shielden-USaen-US aen-US ben-US b A en-USControl en-USTreatment en-USFigure en-US4en-US. Treatment effects of both products on host-seeking acen-US -en-US tivity: (A) Mean (SE) mosquito landing counts; (B) Mean (SE) en-US number of mosquito probes; (C) Mean (SE) number of blood-en-US fed mosquitoes. Note: Bars tagged with the same letter are not en-US

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18 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USLABORATORY AND SEMI-FIELD EVALUATIONS OF TWO (TRANSFLUTHRIN) SPATIAL REPELLENT DEVICESen-US en-US AGAINST en-US AEDES AEGYPTI en-US(L.) (DIPTERA: CULICIDAE) en-USTime (minutes) en-USControl en-USTreatment en-USMean Number of Blood-Fed Mosquitoes en-USRaid Dual Action on Blood Feedingen-US3en-US 5 en-US1 en-US0 en-US2 en-US4 en-US6en-US 20en-US 10en-US 40en-US 50en-US 30 C en-USRaid Dual Action Effect on Probing Rate en-US20en-US 10en-US 40en-US 50en-US 30en-US 10en-US 0en-US 20en-US 30en-US 40en-US 50en-USTime (minutes) en-USMean Probing Count B en-USControl en-USTreatment en-USTime (minutes)en-US20en-US 0en-US 40en-US 60en-US 80en-US 100en-US 120 en-USMean Landing Count en-US20en-US 10en-US 40en-US 50en-US 30 en-USControl en-USTreatment A en-USRaid Dual Action Effect on Landing Rate en-USFigure en-US5en-US. Time-series analysis of the Raid Dual Action effects en-US on en-US Ae. aegyptien-US host-seeking activity: (A) Mean mosquito landing en-US counts; (B) Mean number of mosquito probes; (C) Mean number en-US of blood-fed mosquitoes. en-USTime (minutes) en-USControl en-USTreatment C en-USMean Number of Blood-Fed Mosquitoes en-USRaid Shield Effect on Blood Feedingen-US3en-US 5 en-US1 en-US0 en-US2 en-US4 en-US6en-US 20en-US 10en-US 40en-US 50en-US 30 en-US5en-US 0en-US 10en-US 15en-US 20en-US 25en-US 30en-US 35en-US 40en-USTime (minutes) en-USControl en-USTreatment B en-USMean Probe Counts en-USRaid Shield Effect on Probing Rateen-US20en-US 10en-US 40en-US 50en-US 30en-USFigure en-US6en-US. Time-series analysis of the Raid Shield effects on en-US Ae. aegyptien-US host-seeking activity: (A) Mean mosquito landing en-US counts; (B) Mean number of mosquito probes; (C) Mean number en-US of blood-fed mosquitoes. en-US20en-US 0en-US 40en-US 60en-US 80en-USTime (minutes) en-USControl en-USTreatment A en-USMean Landing Count en-USRaid Shield Effect on Landing Rateen-US20en-US 10en-US 40en-US 50en-US 30

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January June 2017 19 en-USthe 50 minute test. Overall, knock-down effects for both en-US products were minimal. Average knock-down was 1.08 en-US mosquitoes, with a maximum count of 4 (20%).en-USSemi-field (Enclosure)en-USWeather conditions at NECE, Naval Air Station, Jacken-US -en-US sonville, Florida were hot and humid. Temperature and en-US en-US-en-US closures averaged 25.5C (max=29C and min=21C) en-US and 86.8% (max=97% and min=66%). The prevailen-US -en-US ing wind direction was from the northeast with averen-US -en-US age daily wind speeds less than one kph. Regression en-US analysis showed negative correlation of rep-averaged en-US mosquito counts with temperature (C) and humidity en-US (%) ( r=-0.4637, df=16, en-USPen-US =.3406). Collections of mosen-US -en-US quitoes from treatment (with a spatial repellent device) en-US en-US spatial repellent device) tents (en-US Pen-US <.0001; Figure 7). The en-US Raid Shield reduced mosquito entry into tents by 88%, en-US while the Dual Action only decreased entry by 66%. COmm MM ENT en-US-en-US pellents have been reported in the literature. Dethieren-US33en-US en-US en-US a vapor physical state which elicits an avoidance reacen-US -en-US tion. Gouck et alen-US34en-USen-US any compound or agent that can produce repellency at a en-US distance. Nolen et alen-US35en-USen-US inhibiting compound, dispensed into the atmosphere en-US of three dimensional space which inhibits the ability of en-US mosquitoes to locate and track a target such as a human en-US or livestock. Results from our investigation indicated en-US that both of the SC Johnson spatial repellent products en-US functioned as spatial repellents. The active ingredien-US -en-US ent used in both products was the synthetic pyrethroid en-US en-US -en-US en-US -en-US sure which enables the chemical to passively vaporize en-US at ambient temperature. Other pyrethroids such as peren-US -en-US methrin require an external energy source for volatilizaen-US -en-US tion. In order to be a practical tool for Soldiers, a spatial en-US repellent device must be effective, nontoxic, simple to en-US construct and operate, and it should not require frequent en-US maintenance. The 2 products used in this study are en-US lightweight, inexpensive, contained low amounts of pesen-US -en-US ticide, and are easy to set up. From a logistics standpoint, en-US these devices are available in high quantity and can be en-US easily integrated into military logistic transportation en-US platforms. For example, more than a hundred of these en-US devices could be carried in a Soldiers rucksack and the en-US load effect would be minimal. The operation of these en-US devices only consisted of placing it at the desired locaen-US -en-US tion and exposing the treated surface to the air (spray the en-US product on the poster (Dual Action) or open the folded en-US plastic (Raid Shield)). Compliance with mandated topien-US -en-US en-US topical repellents, these devices do not require reapplien-US -en-US cation by the user. Furthermore, the protection from the en-US en-US Our laboratory (wind tunnel) evaluations of the SC Johnen-US-en-US en-US -en-US tions in host-seeking behaviors (landing, probing and en-US blood-feeding) of en-US Ae.en-US en-US aegyptien-US However, reduction rates en-US en-US -en-US en-US periods of effectiveness. Ogoma et alen-US36en-US evaluated transen-US -en-US en-US reared en-US An.en-US en-US arabiensisen-US Patton. A single hessian strip (4.0 en-US en-US the mosquito attack rate on human volunteers by 99% en-US and consistently conferred greater than 90% protective en-US en-US37en-US evaluen-US -en-US en-US landing boxes against en-US An. arabiensisen-US en-US -en-US en-US protection to human volunteers, and continued to show en-US knockdown effects up to 3 weeks in postlaboratory testen-US -en-US ing. Govella et alen-US38en-USen-US en-US An. gambiaeen-US The strips conferred 99% en-US protection and remained effective for over 3 months. One en-US major limitation of our study was control of the amount en-US of active ingredient used. Material Safety Data Sheets en-US en-US -en-US rin was less than 60 mg (less than 2% concentration). In en-US comparison with previous studies, these amounts were en-US relatively low. Additionally, it is important to note that en-US the 2 products are marketed for indoor use.en-USFigure en-US7en-US. Mean (SE) mosquito capture rate per tent for control en-US and treatments. Note: Bars tagged with the same letter are not en-US en-US20en-US 0en-US 40en-US 60en-US 80en-US 100en-US 120 en-USMean Number of Mosquitoes Collected en-USRaid Dual Action en-USRaid Shielden-USaen-US aen-US ben-US b en-USControl en-USTreatment

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20 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USKnockdown is the incapacitation of arthropods as a en-US result of contact with a sublethal dose of pesticide. In en-US en-US -en-US sure were low for both products. However, the relative en-US knockdown of mosquitoes was consistently higher for en-US the Dual Action device. This is particularly interesting en-US due to the fact that the Dual Action device contained en-US en-US made direct contact with the Dual Action device. This en-US was not observed with the Raid Shield device. The Dual en-US Action product was designed with a multipurpose funcen-US -en-US tion of repelling insects and serving as a home freshener.en-US en-US -en-US ity for spatial repellents. The BGS traps are commonly en-US used by mosquito vector control districts to conduct en-US surveillance and have been proven to be highly effecen-US -en-US tive for collecting en-US Ae. aegyptien-US and en-USAe. albopictusen-US In en-US this study, BGS traps baited with COen-US2en-US were placed in en-US military style tents and served as surrogates for human-en-US bait collectors. Mosquito entry into military style tents en-US was moderately reduced when using the spatial repelen-US -en-US lent devices. As expected due to environmental condien-US -en-US en-US of reduction. However, mosquito levels in treated tents en-US remained well below that of control tents. This result en-US en-US this study may have functioned as attraction inhibitors. en-US A more likely explanation is that this behavior involved en-US excito-repellency. For example, the mosquitoes could en-US have detected and followed the COen-US2en-US source inside the en-US en-US of them quickly egressed from the tent to seek fresh air. en-US Other studies suggest that placement of the device inen-US -en-US side certain structures enhances the spatial repellent efen-US -en-US fect. Kawada et alen-US39en-USen-US plastic strips against en-USAe. aegyptien-US in houses located in en-US My Tho City, Vietnam. Multiple regression analysis of en-US environmental factors indicated that both an increase en-US in average room temperature and a decrease in area of en-US en-US impregnated strips positively affected its spatial repelen-US -en-US en-US affected other key mosquito behaviors such as blood-en-US en-US -en-US en-US evaluations of these behaviors. Therefore, the effect of en-US en-US -en-US perimental tents remains unknown.en-US This study suggests that spatial repellents have great poen-US -en-US tential for enhancing existing vector control and PPM en-USefforts. However, sole reliance on this technology is en-US not practical. Although spatial repellents have shown en-US en-US protection, changing environmental conditions (wind, en-US precipitation, temperature, and humidity) may presen-US -en-US en-US Traditional military approaches to mosquito control are en-US based on the use of insecticides for area-wide abatement en-US and PPM (topical repellents, treated uniforms, and bed en-US nets). However, there is much concern among entomoloen-US -en-US gists that these approaches may be severely restricted en-US in the future due to insecticide resistance. Over the past en-US few decades, there has been an overreliance on the use en-US of pyrethroid insecticides for mosquito control. Global en-US malaria eradication programs depend almost exclusively en-US on pyrethroid-based indoor residual spraying and long-en-US lasting insecticidal nets (LLINs). Although this strategy en-US has been viewed as having an important role in the reen-US -en-US cent reductions in global malaria mortality, major maen-US -en-US laria vectors have developed resistance to this class of en-US insecticides and the resistance alleles are very common en-US in mosquito populations throughout the world. One way en-US to overcome resistance is to rotate different classes of en-US en-US acquisition of other classes of insecticides is often difen-US -en-US en-US -en-US en-US -en-US ily available and are relatively inexpensive. A potential en-US means of slowing the evolution of pyrethroid resistance en-US may be the integration of spatial repellents into the proen-US -en-US gram strategy.en-US40en-US For example, the incorporation of a spaen-US -en-US tial repellent with LLINs would result in a 3-tier line of en-US defense: (1) the spatial repellent, (2) contact pyrethroid, en-US and (3) physical barrier (net). The spatial repellent would en-US provide protection outside of the LLIN and contribute to en-US reducing selection for resistance. Additional studies that en-US explore the effects of integrating spatial repellents into en-US AcC KNOWLEDGEm M ENTS We thank SC Johnson and Company for their coopera en-US-en-US tion and assistance in providing the 2 products, Raid en-US Dual Action Insect Repellent and Home Freshener and en-US Raid Shield, used in the study.en-US We thank Anna Katrina Briley and Jason Fajardo for proen-US -en-US viding mosquitoes as well as for their assistance with the en-US en-US Farooq for collecting the weather data at the Navy Entoen-US -en-US mology Center of Excellence.en-US Financial support for this project was provided by the en-US Defense Health Program 6.7.en-USLABORATORY AND SEMI-FIELD EVALUATIONS OF TWO (TRANSFLUTHRIN) SPATIAL REPELLENT DEVICESen-US en-US AGAINST en-US AEDES AEGYPTI en-US(L.) (DIPTERA: CULICIDAE)

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January June 2017 21 RREFERENc C ES 1. en-USWebb CE, Doggett SL. Exotic mosquito threats reen-US -en-US quire strategic surveillance and response planning. en-US Public Health Res Practen-US 2016;26(5). doi: 10.17061/en-US phrp2651656. 2. en-USCastellanos J. Zika, evidencia de la derrota en-US en la batalla contra en-USAedes aegyptien-US en-US Biomdicaen-US en-US 2016;36(1):5-9. 3. en-USWorld Health Organization. Dengue and severe en-US dengue fact sheet [internet]. July 2016. Available at: en-US http://www.who.int/mediacentre/factsheets/fs117/en-US en/. Accessed March 8, 2017. 4. en-USTechnical Guide 36, en-US Personalen-US Protective Techen-US -en-US niques Against Insects and Other Arthropods of en-US Military Importanceen-US en-US Forces Pest Management Board. 2015. Available en-US at: http://www.acq.osd.mil/eie/afpmb/docs/techen-US en-US guides/tg36.pdf. Accessed March 8, 2017. 5. en-USDunn L, Mcguire J, Rockswold P. 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Field evaluation of commercial off-the-shelf en-US spatial repellents against the Asian tiger mosquito, en-US Aedesen-US en-US Albopictusen-US (Skuse), and the potential for use en-US during deployment. en-USUS Army Med Dep Jen-US April-en-US June 2013:80-86. 21. en-USDame D, Meisch M, Lewis C, Kline D, Clark G. en-US Field evaluation of four spatial repellents devices en-US against Arkansas rice-land mosquitoes. en-US J Am Mosq en-US Control Assocen-US 2014;30(1):31-36. 22. en-USCollier B, Perich M, Boquin G, Harrington S, Franen-US -en-US cis M. 2006. Field evaluation of mosquito control en-US devices in southern Louisiana. en-US J Am Mosq Control en-US Assocen-US 2006;22(3):444-450. 23. en-USen-US of microdispensers with spatial repellents for peren-US -en-US sonal protection against mosquito biting. en-US J Med Enen-US -en-US tomolen-US 2015;53(2):470-472.

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22 http://www.cs.amedd.army.mil/amedd_journal.aspx 24. en-USKlun J, Kramer M, Debboun M. Four simple stimuli en-US that induce host-seeking and blood-feeding behaven-US -en-US iors in two mosquito species, with a clue to DEETs en-US mode of action. en-USJ Vector Ecolen-US 2013;38(1):143-153. 25. en-USSmirnov N. On the estimation of discrepancy been-US -en-US tween empirical curves of distribution for two inen-US -en-US dependent samples. en-US Bull Moscow Univ Intern Ser en-US (Math)en-US 1939;2:3-16. 26. en-USBartlett M. Some examples of statistical methods en-US of research in agriculture and applied biology. en-US J R en-US Stat Socen-US 1937;4(suppl 2):137-170. 27. en-USen-US tests. en-USProc R Stat Soc Aen-US 1937;160(901):268-282. 28. en-USen-US -en-US terion analysis of variance. en-US J Am Statist Assocen-US en-US 1952;47:583-621. 29. en-USTukey J. One degree of freedom for non-additivity. en-US Biometricsen-US 1949;5:232-242. 30. en-USNewman D. The distribution of range in samples en-US from a normal population, expressed in terms of en-US an independent estimate of standard deviation. en-US Biometrikaen-US 1939;31:20-30. 31. en-USDuncan D. Multiple range and multiple F tests. en-US Bioen-US -en-US metricsen-US 1955;11:1-42. 32. en-USScheffe H. A method of judging all contrast in the en-US analysis of variance. en-USBiometrikaen-US 1953;40:87-104. 33. en-USDethier V, Brown L, Smith C. The designation of en-US chemicals in terms of the responses they elicit from en-US insects. en-USJ Econ Entomol.en-US 1960;53:134-136. 34. en-USGouck H, McGovern TP, Beroza M. Chemien-US -en-US cals tested as space repellents against yellow-en-US fever mosquitoes. I. Esters. en-USJ Econ Entomolen-US en-US 1967;60(6):1587-1590. 35. en-USNolen JA, Bedoukian RH, Maloney RE, Kline DL, en-US inventors; Biosensory Inc, Bedoukian Research en-US Inc, assignees. Method, apparatus and composien-US -en-US tions for inhibiting the human scent tracking abilen-US -en-US en-US en-US 26, 2002. 36. en-USOgoma SB, Ngonyani H, Simfukwe ET, Mseka A, en-US Moore J, Killeen GF. Spatial repellency of transen-US -en-US en-US reared en-US Anopheles arabiensisen-US mosquitoes in a semi-en-US en-USParasit Vectorsen-US 2012;5:54. 37. en-USAndres M, Lorenz L, Mbeleya E, Moore S. Modien-US -en-US en-US -en-US thrin provide effective protection against en-US Anophen-US -en-US eles arabiensisen-US mosquitoes under simulated outen-US -en-US en-US Malar Jen-US en-US 2015;14:255. 38. en-USGovella N, Ogoma S, Paliga J, Chaki P, Killeen G. en-US 2015. Impregnating hessian strips with the volatile en-US en-US en-US -en-US ban Dar es Salaam, Tanzania. en-USParasit Vectorsen-US 8:322. 39. en-USKawada H, Iwasaki T, Tien T, Mai N, Shono Y, en-US Katayama Y, Takagi M. 2006 Field evaluation of en-US en-US -en-US ticework plastic strips against en-USAedes aegyptien-US (L.) en-US and analysis of environmental factors affecting its en-US en-US Am en-US J Trop Med Hygen-US 75:1153en-US en-US 1157. 40. en-USOgoma S, Lorenz L, Ngonyani H, et al. An experien-US -en-US mental hut study to quantify the effect of DDT and en-US airborne pyrethroids on entomological parameters en-US of malaria transmission. en-USMalar Jen-US 2014;13:131. AUTHORS MAJ McPhatter is with the Entomology Branch, Wal en-US-en-US ter Reed Army Institute of Research, Silver Spring, en-US Maryland.en-US Dr Mischler is with the Entomology Branch, Walter Reed en-US Army Institute of Research, Silver Spring, Maryland.en-US Dr Webb is with the Invasive Insect Biocontrol & Behaven-US -en-US en-US -en-US tural Research Service, Beltsville, Maryland.en-US Dr Chauhan is with the Invasive Insect Biocontrol & Been-US -en-US en-US -en-US cultural Research Service, Beltsville, Maryland.en-US CPT Lindroth is with the Navy Entomology Center of en-US Excellence, Jacksonville, Florida.en-US Dr Richardson is with the Navy Entomology Center of en-US Excellence, Jacksonville, Florida.en-US Dr Debboun is the Director of the Mosquito & Vector en-US Control Division, Harris County Public Health, Houston, en-US Texas.en-USLABORATORY AND SEMI-FIELD EVALUATIONS OF TWO (TRANSFLUTHRIN) SPATIAL REPELLENT DEVICESen-US en-US AGAINST en-US AEDES AEGYPTI en-US(L.) (DIPTERA: CULICIDAE)

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en-USJanuary June 2017 en-US23en-USZika virus (ZIKV), a mosquito-borne disease, was deen-US -en-US clared an international public health emergency by the en-US World Health Organization (WHO) on February 1, 2016 en-US en-US -en-US fects from multiple countries.en-US1en-US The state of Georgia en-US en-US monitoring and surveillance capacity to properly assess en-US the risk of ZIKV transmission, as well as trained staff to en-US respond to potential local outbreaks of the disease. This en-US limited capacity was a result of federal budget reductions en-US that affected funding earmarked for mosquito monitoren-US -en-US ing and surveillance programs. Once a strong program en-US that had a large number of county health departments en-US conducting mosquito surveillance and several trained en-US staff, the program had been reduced to one state level en-US position and a few counties conducting surveillance. en-US This case study describes and evaluates Georgias rapid en-US response from the perspective of those challenges. OOVERVIEW Zika virus is a mosquito-borne en-USFlavivirusen-US (family Flaen-US -en-US en-US en-US surveillance and later isolated in humans in 1952.en-US2en-USen-US -en-US like West Nile virus (WNV) that circulates between en-US birds and mosquitoes with humans serving as dead-end en-US hosts,en-US3en-US ZIKV can be transmitted from human-to-human en-US via the bite of an infected en-US Aedes en-US sppen-US en-US mosquito.en-US1en-US From the en-US 1960s through the 1980s, the disease was found in mosen-US -en-US quitoes from several Asian countries with few human en-US cases. It eventually traveled east, resulting in a large outen-US -en-US break on Yap Island in 2007 and additional outbreaks en-USGeorgias Collaborative Approach toen-US en-US Expanding Mosquito Surveillance inen-US en-US Response to Zika Virus: A Case Study R. Christopher Rustin, DrPH, MT, REHS S arbesh Pandeya, MPH Deonte Martin, BS H aresh Rochani, DrPH, MPH, MBBS Varadan Sevilimedu, MPH R osmarie Kelly, PhD, MPH ABSTRac AC T Zika virus (ZIKV) was declared an international public health emergency by the World Health Organization on en-USen-US states faced increased risk of ZIKV transmission. With the state of Georgia hosting the worlds busiest international en-US airport, a climate that supports the ZIKV vectors, and limited surveillance (13 counties) and response capacity, the en-US Department of Public Health (DPH) was challenged to respond and prevent ZIKV transmission. This case study en-US describes and evaluates the states surveillance capacity before and after the declaration of ZIKV as a public health en-US emergency.en-US Method:en-US We analyzed surveillance data from the DPH to compare the geographical distribution of counties conen-US -en-US ducting surveillance, total number, and overall percentage of mosquito species trapped in 2015 to 2016. Counties en-US en-US en-US t en-US test to test for en-US en-US2en-US analysis to test for differences between numbers of species across en-US the 13 counties. In addition, weighted frequency counts of mosquitoes were used to test (en-US en-US2en-US) an association between en-US major mosquito vector species and 7 urban counties. Lastly, using data from 2012-2016, a time-trend analysis was en-US conducted to evaluate temporal trends in species prevalence.en-US Results:en-US From 2015 to 2016, surveillance increased from 13 to 57 (338% increase) counties geographically dispersed en-US en-US -en-US en-US Pen-US en-US Pen-US <.0001) between 7 en-US en-US several species and year highlighting species-year temporal trends.en-US Conclusions:en-US The DPH collaborative response to ZIKV allowed a rapid increase in its surveillance footprint. Existen-US -en-US ing and new partnerships were developed with the military and local health departments to expand and share data. en-US This additional surveillance data allowed DPH to make sound public health decisions regarding mosquito-borne en-US disease risks and close gaps in data related to vector distribution.

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en-US24 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USin French Polynesia in 2013.en-US2en-US In 2015, Brazil reported en-US unusual cases of rash and ultimately associated a high en-US number of babies born with microcephaly and cases of en-US en-US -en-US national public health emergency order.en-US2en-USResearch and analysis of previous outbreaks indicated en-US that the primary vector responsible for transmitting en-US ZIKV is the en-US Aedes en-US spp mosquito with the urban dwellen-US -en-US ing en-US Ae. aegyptien-US (L.) the likely vector in the Americas.en-US4en-US A en-US daytime biter of humans, this mosquito prefers tropical en-US to somewhat temperate climates and lays eggs in conen-US -en-US tainers around urban areas.en-US4en-US A secondary ZIKV vecen-US -en-US tor is en-USAe. albopictusen-US (Skuse)en-US en-US theen-US en-US Asian tiger mosquito. en-US This mosquito also lay eggs in containers, but feeds on en-US humans and other animals, thus lowering the risk of en-US transmission.en-US4en-US However, en-US Ae. albopictusen-US can survive in en-US cooler areas, increasing its potential distribution across en-US en-US Prevention (CDC), using several limited data sources, en-US developed 2 maps (Figure 1) that estimate the potential en-US geographic range of en-USAe. aegyptien-US and en-USAe. albopictus.en-US4en-USThe potential distribution of these 2 vectors placed seven-US -en-US en-US States on alert for potential transmission of ZIKV and en-US en-US en-US -en-US veillance across the country, as it only en-US estimatesen-US the en-US potential range of the 2 ZIKV vectors. This data gap is en-US a result of public health budget cuts and lack of priority en-US placed on mosquito surveillance in the last decade. Conen-US-en-US sequently, this negatively affected the states ability to en-US critically assess the actual risks of ZIKV transmission en-US for its citizens.en-USNational Funding Trendsen-USen-US en-US States. The primary mission of public health and mosen-US -en-US quito control programs is to inform, prevent, and proen-US -en-US tect the public from injury and disease. This mission is en-US achieved through disease and vector surveillance proen-US -en-US grams that provide critical data used to quickly respond en-US and control threats. Mosquito surveillance, coupled en-US with clinical (human and animal) surveillance proen-US -en-US grams, are critically important because they can detect en-US the abundance and distribution of vectors, monitor for en-US viral diseases, aid in quantifying human risks, and preen-US -en-US dict changes in the dynamics of disease transmission.en-US6-8en-US en-US en-US -en-US grams have decreased over time, leaving a patchwork en-US of jurisdictions conducting surveillance and resulting in en-US en-US9en-USWest Nile virus (WNV), the last major new and exotic aren-US -en-US en-US -en-US cant media attention and heightened the publics fear.en-US10-12en-US en-US This outbreak highlighted a general lack of capacity for en-US public health and mosquito control agencies to conduct en-US human and vector surveillance and rapidly respond to en-US disease events.en-US13en-US To improve detection, monitoring, and en-US control capacity for WNV (which eventually spread to en-US en-US 50 states and 6 major cities through its Epidemiology en-US and Laboratory Capacity (ELC) grant.en-US13en-US This funding en-US was eventually expanded to cover over 20 mosquito-en-US borne and tick-borne diseases and allowed states and en-US jurisdictions to increase human and vector surveillance, en-US en-US surveillance systems; and develop response plans.en-US14en-USIn 2002, approximately $34.7 million was provided to en-US states to fund these important programs, but by 2014, en-US this had been reduced by approximately 75% to $9.2 en-US GEORGIAS COLLABORATIVE APPROACH TO EXPANDING MOSQUITO SURVEILLANCEen-US en-US IN RESPONSE TO ZIKA VIRUS: A CASE STUDYen-USFigure en-US1en-US. Estimated range of en-US Aedes albopictusen-US and en-US Aedes aeen-US -en-US gypti en-US in the United States, en-US2016en-US. The maps represent the best en-US estimate by CDC of the potential range of the named mosquien-US -en-US toes. Maps courtesy of the Centers for Disease Control and en-US Prevention.en-US4

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en-USJanuary June 2017 en-US25 en-USmillion.en-US14en-US A CDC report based on a follow-up survey en-US conducted by the Council of State and Territorial Epien-US -en-US demiologists indicated that since 2005, 22% of funded en-US jurisdictions eliminated active human surveillance, 13% en-US eliminated mosquito surveillance, 70% eliminated mosen-US -en-US quito trapping, and 64% stopped avian surveillance.en-US13en-US en-US Since 2005, the number of counties conducting routine en-US mosquito surveillance in Georgia was reduced by 78%, en-US from 60 to 13 counties, and all public health funding for en-US arboviral testing and avian surveillance was eliminated en-US (R. Kelly, unpublished data*). This report concluded en-US that the states ability to rapidly detect and respond to en-US emerging disease threats is compromised,en-US13en-US thus placen-US -en-US ing states, including Georgia, at a disadvantage in reen-US -en-US sponding to vector-borne diseases.en-USGeorgia Preparednessen-USGeorgia, like many states, faces several challenges to en-US monitoring and responding to emerging arboviral disen-US -en-US eases, with ZIKV highlighting this issue. In addition en-US to the CDC estimating that the range of ZIKV vectors en-US spans the entire state, several additional issues raise en-US the risk of ZIKV transmission. First, Georgia is home en-US to the worlds busiest international airport, thus hosting en-US visitors and tourists from ZIKV endemic countries. Aden-US-en-US ditionally, many Georgia citizens travel to tourist destien-US -en-US nations that have active ZIKV circulating. This raised en-US the risk that a traveler could become infected and return en-US to Georgia, thus spreading ZIKV to local mosquitoes. en-US Second, Georgia lacks statewide suren-US -en-US veillance and vector control which are en-US limited to just 13 counties conducting en-US surveillance and 6 counties providing en-US comprehensive mosquito control seren-US -en-US vices. Third, previous surveillance has en-US determined that en-USAe. albopictusen-US is presen-US -en-US ent in every county,*en-US15en-US en-USbut with limited en-US surveillance, the true distribution of en-USAe. en-US aegypti en-US isen-US en-US unknown having only been en-US recently found in 2 counties. en-US Ae. aeen-US -en-US gyptien-US had been a common species in en-US Georgia until the introduction of en-US Ae. alen-US -en-US bopictusen-US in the 1990s. This lack of suren-US -en-US veillance data prevents accurate quanen-US -en-US en-US the federal funding cuts, the DPH has en-US limited capacity to conduct comprehenen-US -en-US sive surveillance and mapping of vector en-US abundance and evaluate insecticide reen-US -en-US sistance, and limited ability to provide en-US emergency vector control.en-US These challenges are compounded by the fact that Georen-US -en-US gias population is over 10 million people and growing en-US (Figure 2), and has the largest number of counties (159), en-US second only to the state of Texas.en-US16en-US These counties range en-US from urban to suburban, with approximately 108 (68%) en-US en-US -en-US lation).en-US17en-US With the population of the state steadily increasen-US -en-US ing, and a public health program with limited resources, en-US more people are potentially at risk of exposure to emergen-US -en-US ing vector-borne diseases. However, faced with these en-US challenges, the DPH used the expertise of its State Entoen-US -en-US mologist and the environmental health program to evaluen-US -en-US ate its weaknesses and implement a rapid, collaborative en-US response to the threat of ZIKV. PURp P OSE The purpose of this case study was to describe and com en-US-en-US pare the DPHs mosquito surveillance capacity in 2015 en-US before ZIKV was declared a public health emergency to en-US the 2016 surveillance capacity following that declaration. en-US Statistical comparisons were made between years on the en-US number of counties conducting surveillance and differen-US -en-US ences in prevalence and species, in addition to a time en-US trend analysis of mosquito species distribution. These en-US data were used to evaluate the states rapid response to en-US the threat of ZIKV and the risk of autochthonous vector en-US transmission based on the presence of the ZIKV vectors. METHODS Mosquito surveillance trapping data provided by the en-USDPH and surveillance data collected in collaboration en-USFigure en-US2en-US. Population of the state of Georgia by year, en-US2005-2015en-US. en-USGeorgia Population (millions) 2005 en-US2006en-US 2007en-US 2008en-US 2009en-US 2010en-US 2011en-US 2012en-US 2013en-US 2014en-US 2015en-US 10.0en-US 10.5en-US 9.5en-US 9.0en-US 8.5en-US 8.0en-USProjected: en-US10.2en-US Million en-US*en-USUnpublished arboviral summary statistics report prepared quaren-US -en-US terly and annually by author R. Kelly and distributed internally en-US within DPH, public health departments, MC agencies, and acaen-US -en-US demic partners.

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26 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USwith DPH were analyzed. The geographical distribution en-US of counties conducting surveillance, total number, and en-US overall percentage of mosquito species collected in 2015 en-US were compared to 2016 data. The distribution of counen-US-en-US ties conducting surveillance was mapped using ArcMap en-US 10.4.1 (Esri, Inc, Redlands, CA).en-US Statistical comparisons were made for the 13 counties en-US conducting mosquito surveillance between 2015 and en-US 2016 to test for differences in response before and afen-US -en-US ter the ZIKV emergency declaration. To test differences en-US in prevalence (number of mosquitoes trapped/100,000 en-US population) in both years, the overall number of mosen-US -en-US quitoes was compared using the independent 2 sample en-US ten-US test. A en-US en-US2en-US analysis was performed to test for statistical en-US differences between numbers of species trapped across en-US all 13 counties. In addition, weighted frequency counts en-US of mosquitoes were used to conduct a test of association en-US (en-US en-US2en-US) between the major vector species of mosquitoes and en-US the geographic county in 7 urban counties. The counen-US-en-US ties included in this en-US en-US2 en-USanalysis were Chatham, Fulton, en-US Glynn, Liberty, Lowndes, Muscogee, and Richmond. en-US Lastly, a time-trend analysis was conducted using suren-US -en-US veillance data from 2012-2016 to test differences in speen-US -en-US en-US RRESULTS In 2015, prior to the declaration that ZIKV represented a en-USpublic health emergency, Georgia had 13 counties conen-US -en-US ducting surveillance, with the DPH medical entomologist en-US (one full time equivalent/statewide) providing routine en-US surveillance in 4 of those counties. In 2016 (March-Deen-US -en-US cember), the DPH expanded surveillance to 57 counties en-US (338% increase) geographically dispersed in urban and en-US rural areas (Figure 3).en-US This rapid expansion of surveillance was a result of hiren-US -en-US ing new staff and collaborating with the local health deen-US -en-US partments (LHDs) and the military. Table 1 shows that en-US en-US compared to 144,731 mosquitoes trapped in 2016, repen-US -en-US resenting a 90% increase. Forty-four mosquito species en-US en-US Culex quinquefasciaen-US -en-US tusen-US (Say), Georgias primary WNV vector, representing en-US the highest percentage of mosquitoes trapped in both en-US years (79.45% and 62.53% respectively). In reference to en-US ZIKV vectors, en-USAe. aegyptien-US represented only 0.108% and en-US 0.018% respectively of the total mosquitoes trapped each en-US year, and were found in Muscogee County only, home to en-US Fort Benning. en-USAedes albopictusen-US represented only 1.50% en-US and 3.703% of the total mosquitoes trapped respectively en-US each year, reported from 11/13 (84%) counties in 2015 en-US and 42/57 (74%) counties in 2016.en-USOverall Mosquito Prevalenceen-USTo test differences in overall prevalence (number of en-US mosquitoes/100,000 population) of mosquitoes trapped en-US in both years from the 13 counties that have historically en-US conducted surveillance, the number of mosquitoes was en-US compared using the independent 2 sample en-USten-US test. The en-US value of the number of mosquitoes was normalized en-US GEORGIAS COLLABORATIVE APPROACH TO EXPANDING MOSQUITO SURVEILLANCEen-US en-US IN RESPONSE TO ZIKA VIRUS: A CASE STUDYen-USFigure en-US3en-US. Georgia counties conducting mosquito surveillance in collaboration with the Georgia Department of Public Health in en-US2015en-US (en-US13en-US counties) and en-US2016en-US (en-US57en-US counties). en-US 2015 Surveillance en-US No Surveillance en-US No Surveillance en-US 2016 Surveillance en-USNo Surveillance en-US2015en-US 2016

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January June 2017 27 en-USusing the log transformation and the normality en-US en-US While the total number of mosquitoes trapped inen-US -en-US creased from 2015 to 2016 for the 13 counties, this en-US en-US differences (en-US Pen-US =.7901) in the overall prevalence of en-US mosquitoes trapped before and after ZIKV was en-US declared an international public health emergency en-US (Table 2A).en-US en-US ten-US test assumen-US -en-US ing equal and unequal variances. Table 2C shows en-US the results for the test of equality of variances been-US -en-US tween the 2 samplesen-USSpecies Analysisen-USTo test for differences in the prevalence of individen-US-en-US ual mosquito species trapped in 2015 versus 2016 en-US for the 13 counties, a en-US en-US2en-US analysis was performed. en-US en-US P<.en-US 001) in en-US the distribution of all mosquito species trapped in en-US those years (Table 1). However, while there were en-US en-US tell us the behaviors associated with individual en-US species.en-US By combining both years (2015, 2016) of mosquito en-US data, a secondary en-US en-US2en-US analysis was conducted to en-US test for an association between Georgias primary en-US arboviral vector species and urban counties with en-US a large population of people at risk. Adjusting for en-US inconsistent or missing data, weighted frequency en-US counts of mosquitoes were used in the analysis. en-US While the previous en-USten-US test results (Table 2) indicate en-US that overall difference in prevalence of mosquitoes en-US en-USTable en-US2Aen-US. The en-US2en-US-sample en-US ten-US test for difference in en-US mosquito prevalence between en-US2015en-US and en-US2016en-US.en-USYearen-US Methoden-US Mean en-US95en-US% CIen-US2015en-US 6en-US.en-US34en-US 4en-US.en-US79en-US, en-US7en-US.en-US88en-US 2016en-US 6en-US.en-US63en-US 4en-US.en-US86en-US, en-US8en-US.en-US39en-USDiff (en-US1en-US-en-US2en-US)en-US Pooleden-US -en-US0en-US.en-US29en-US-en-US2en-US.en-US51en-US, en-US1en-US.en-US93en-USDiff (en-US1en-US-en-US2en-US)en-US Satterthwaiteen-US -en-US0en-US.en-US29en-US-en-US2en-US.en-US51en-US, en-US1en-US.en-US94 en-USTable en-US2Ben-USen-US ten-US test assuming en-US equal and unequal variances.en-USMethod en-US Variances en-US dfen-US ten-US valueen-US Pen-US valueen-US Pooleden-US Equal en-US24en-US -0.27en-US .7901en-USSatterthwaiteen-US Unequalen-US23.589en-US -0.27en-US .7902 en-USTable en-US2Cen-US. Results for the test of equality of varien-US -en-US ances between the en-US2en-US samples.en-USMethoden-US Num en-US dfen-US Den en-US dfen-US F-valueen-US Pen-US valueen-US Folded Fen-US12en-US 12en-US 1.30en-US .65 en-USTable en-US1en-US. Mosquito Species Collected, en-US2015-2016en-US.en-USSpecies*en-US 2015en-US en-US Totalsen-US 13 Countiesen-US en-US Percentagesen-US 2016en-US en-US Totalsen-US 57 Countiesen-US en-US Percentagesen-US Ae. aegyptien-US82en-US 0.108%en-US 26en-US 0.018%en-USAe. albopictusen-US1,141en-US 1.500%en-US 5,360en-US 3.703%en-USAe. cinereusen-US0en-US 0.000%en-US 4en-US 0.003%en-USAe. japonicusen-US0en-US 0.000%en-US 1en-US 0.001%en-USAe. vexansen-US162en-US 0.213%en-US 6,536en-US 4.516%en-USAedes/Ochlerotatus spp.en-US6en-US 0.008%en-US 120en-US 0.083%en-USAn. barberi en-US0en-US 0.000%en-US 1en-US 0.001%en-USAn. cruciansen-US25en-US 0.033%en-US 1,873en-US 1.294%en-USAn. punctipennisen-US26en-US 0.034%en-US 486en-US 0.336%en-USAn. quadrimaculatusen-US61en-US 0.080%en-US 265en-US 0.183%en-USAnopheles spp.en-US5en-US 0.007%en-US 134en-US 0.093%en-USCq. perturbansen-US1,265en-US 1.663%en-US 5,969en-US 4.124%en-USCs. inornataen-US130en-US 0.171%en-US 14en-US 0.010%en-USCs. melanuraen-US906en-US 1.191%en-US 996en-US 0.688%en-USCulex spp.en-US4,996en-US 6.569%en-US 10,830en-US 7.483%en-USCx. coronatoren-US262en-US 0.345%en-US 604en-US 0.417%en-USCx. erraticusen-US300en-US 0.394%en-US 2425en-US 1.676%en-USCx. nigripalpusen-US5,657en-US 7.438%en-US 11,071en-US 7.649%en-USCx. peccatoren-US0en-US 0.000%en-US 12en-US 0.008%en-USCx. quinquefasciatusen-US60,423en-US 79.450%en-US 90,505en-US 62.533%en-USCx. restuansen-US100en-US 0.131%en-US 389en-US 0.269%en-USCx. salinariusen-US350en-US 0.460%en-US 2,746en-US 1.897%en-USCx. territansen-US1en-US 0.001%en-US 33en-US 0.023%en-USMa. titillans en-US0en-US 0.000%en-US 98en-US 0.068%en-USOc. japonicusen-US8en-US 0.011%en-US 52en-US 0.036%en-USOc. atlanticusen-US1en-US 0.001%en-US 757en-US 0.523%en-USOc. canadensisen-US0en-US 0.000%en-US 117en-US 0.081%en-USOc. fulvus pallensen-US0en-US 0.000%en-US 1en-US 0.001%en-USOc. infirmatusen-US2en-US 0.003%en-US 45en-US 0.031%en-USOc. mitchellaeen-US0en-US 0.000%en-US 9en-US 0.006%en-USOc. sticticusen-US0en-US 0.000%en-US 31en-US 0.021%en-USOc.taeniorhynchusen-US0en-US 0.000%en-US 5en-US 0.003%en-USOc. triseriatusen-US25en-US 0.033%en-US 78en-US 0.054%en-USOr. signifera en-US3en-US 0.004%en-US 23en-US 0.016%en-USPs. ciliata en-US0en-US 0.000%en-US 25en-US 0.017%en-USPs. cyanscensen-US2en-US 0.003%en-US 30en-US 0.021%en-USPs. columbiaeen-US88en-US 0.116%en-US 332en-US 0.229%en-USPs. feroxen-US10en-US 0.013%en-US 106en-US 0.073%en-USPs. howardiien-US3en-US 0.004%en-US 34en-US 0.023%en-USPsorophora spp.en-US6en-US 0.008%en-US 0en-US 0.000%en-USTx. rutilusen-US1en-US 0.001%en-US 52en-US 0.036%en-USUr. iowiien-US0en-US 0.000%en-US 13en-US 0.009%en-USUr.sapphrinaen-US2en-US 0.003%en-US 115en-US 0.079%en-USUnknownen-US3en-US 0.004%en-US 2,408en-US 1.664%en-USTotalen-US76,052en-US 144,731en-US*en-USData for distribution of all species statistically significant (en-US Pen-USen-US).

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28 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USen-US Pen-US <.0001) between urban en-US counties and major vector species as shown in Table 3. en-US However, while en-US en-US2en-US tests can provide information on disen-US -en-US tribution of species between years, it does not provide en-US detailed information on behavior of individual species, en-US trends, and patterns over time.en-USTime Trend Species Analysisen-USA time-trend species analysis using generalized linen-US-en-US ear models (Proc GLM in SAS 9.2) was conducted on en-US mosquito data from 2012 to 2016 to evaluate temporal en-US en-US -en-US cant differences were observed over the 5-year period en-US in species prevalence (en-US Pen-US <.0001). While time (in years) en-US en-US prevalence, (en-US Pen-US <.1219) its differential effect on species en-US en-US -en-US en-USPen-US <.0001) (Table 4).en-US en-US en-US -en-US ly different prevalence compared to the reference group, en-US ie, en-US Oc. sticticusen-US (Meigen), throughout the 5-year period. en-US This reference group was chosen due to low numbers en-US of species trapped. These species were en-US Ae. albopictusen-US en-US (S.) (en-US Pen-US <.0001), en-US Ae. vexansen-US (Meigen) (en-US Pen-US =.0240), en-US Cq. peren-US -en-US turbansen-US (Walker) (en-US P<.en-US 0001), en-US Cs. melanuraen-US (Coquillett) en-US (en-US P<.en-US 0001), en-US Culex en-US spp. (en-US P<.en-US 0001), en-US Cx. coronatoren-US (Dyer en-US and Knab) (en-US Pen-US =.0463), en-US Cx. erraticusen-US (Dyer and Knab) en-US (en-US P<.en-US 0001), en-US Cx. nigripalpusen-US (Theobald) (en-US P<.en-US 0001), en-US Cx. en-US quinquefasciatusen-US (Say) (en-US P<.en-US 0001), en-US Cx. restuansen-US (Theoen-US -en-US bald) (en-US Pen-US =.0004), en-US Cx. salinariusen-US (Coquillett) (en-US P<.en-US 0001) en-US and en-USOc. triseriatusen-US (Say) (en-US P<.en-US 0001).en-US For associated species-year trends in Table 5, en-US Cs. melen-US -en-US anuraen-US (en-US Pen-US <.0042), en-US Culexen-US spp. (en-US P<.en-US 0013), en-US Cx. erraticusen-US en-US (en-US Pen-US <.0271), en-US Cx. nigripalpusen-US (en-US P<.en-US 0074en-US ), Cx. restuansen-US en-US (en-US P<.en-US 0433) and en-US Cx. salinariusen-US (en-US P<.en-US 0266) were found to en-US en-US each year compared to the reference species en-US Oc. sticticusen-US COmm MM ENT The public health entomology program, which includes en-USmosquito surveillance, falls under the DPH Environen-US -en-US mental Health (EH) Section. This program is managed en-US by a medical entomologist who holds graduate degrees en-US in public health and entomology and who was originalen-US -en-US ly hired under Epidemiology and Laboratory Capacity en-US funding in 2002 to manage the WNV outbreak. The en-US state medical entomologist provides technical assistance en-US and consultation to LHDs, mosquito control agencies en-US and the general public and was largely responsible for en-US overseeing Georgias rapid response to ZIKV. In 2015, en-US en-US -en-US ited to just 13 counties in Georgia. With this limited en-US data, DPH provided quarterly surveillance reports en-US to partner agencies for planning and risk assessment en-US purposes.en-US GEORGIAS COLLABORATIVE APPROACH TO EXPANDING MOSQUITO SURVEILLANCEen-US en-US IN RESPONSE TO ZIKA VIRUS: A CASE STUDY en-USTable en-US3Aen-US. Weighted frequency counts and corresponding weighted row percentages of important mosquito species stratien-US -en-US en-USChathamen-US Fultonen-US Glynnen-US Libertyen-US Lowndesen-US Muscogeeen-US Richmonden-US Totalen-US Ae. aegyptien-US 2en-US en-US 1.67%en-US 2en-US en-US 1.67%en-US 2en-US en-US 1.67%en-US 2en-US en-US 1.67%en-US 2en-US en-US 1.67%en-US 108en-US en-US 90.00%en-US 2en-US en-US 1.67%en-US 120en-US Ae. albopictusen-US 26en-US en-US 0.70%en-US 871en-US en-US 23.46%en-US 72en-US en-US 1.94%en-US 53en-US en-US 1.43%en-US 177en-US en-US 4.77%en-US 653en-US en-US 17.59%en-US 1,861en-US en-US 50.12%en-US 3,713en-US Ae. vexansen-US 2en-US en-US 0.07%en-US 94en-US en-US 3.23%en-US 2en-US en-US 0.07%en-US 2en-US en-US 0.07%en-US 2en-US en-US 0.07%en-US 101en-US en-US 3.47%en-US 2,704en-US en-US 93.02%en-US 2,907en-US Cs. melanuraen-US 196en-US en-US 10.36%en-US 2en-US en-US 0.11%en-US 2en-US en-US 0.11%en-US 2en-US en-US 0.11%en-US 1,686en-US en-US 89.11%en-US 2en-US en-US 0.11%en-US 2en-US en-US 0.11%en-US 1,892en-US Culex spp.en-US 13,985en-US en-US 99.30%en-US 28en-US en-US 0.20%en-US 2en-US en-US 0.01%en-US 2en-US en-US 0.01%en-US 2en-US en-US 0.01%en-US 17en-US en-US 0.12%en-US 48en-US en-US 0.34%en-US 14,084en-US Cx. nigripalpusen-US 1,417en-US en-US 8.56%en-US 2en-US en-US0.01%en-US 529en-US en-US 3.20%en-US 2en-US en-US 0.01%en-US 13,556en-US en-US 81.90%en-US 2en-US en-US 0.01%en-US 1,044en-US en-US 6.31%en-US 16,552en-US Cx. quinquefasciatusen-US 58,184en-US en-US 42.09%en-US 8,472en-US en-US 6.13%en-US 41,910en-US en-US 30.32%en-US 85en-US en-US 0.06%en-US 23,776en-US en-US 17.20%en-US 778en-US en-US 0.56%en-US 5,031en-US en-US 3.64%en-US 138,236en-US Totalen-US 73,812en-US 9,471en-US 42,519en-US 148en-US 39,201en-US 1,661en-US 10,692en-US 177,504 en-USTable en-US3Ben-US. Chi-square value with corresponding en-US Pen-US value (en-US en-US.en-USStatisticen-US dfen-US Valueen-US Pen-US valueen-USen-US2en-US36en-US 143,393en-US <.0001 en-USTable en-US4en-US. Time trend analysis showing the type III sums of squares en-US and corresponding en-US Pen-USen-US0.05en-US) for the variables species, en-US year, and the interaction term.en-USdfen-US Type III SSen-US Mean Squareen-US F-valueen-US P en-US valueen-US Speciesen-US41en-US 1589.943667en-US 38.779114en-US 14.25en-US <.0001en-USYearen-US1en-US 6.521391en-US 6.521391en-US 2.40en-US .1219en-USYear speciesen-US41en-US 318.828534en-US 7.776306en-US 2.86en-US <.0001

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January June 2017 29 en-USWhen ZIKV was declared an international public en-US health emergency,en-US1en-US the DPH recognized its weaken-US -en-US nesses and formed a core team of professionals to en-US develop and lead a response. This diverse team was en-US comprised of EH, medical entomology, medical epien-US -en-US demiology, communications, emergency prepareden-US -en-US ness, and leadership. An assessment was conducted to en-US ascertain agency strengths, weaknesses, and overall en-US needs to develop a response. This evaluation assessed en-US geographical gaps in mosquito data and surveillance en-US staff needs, opportunities for new or expanded parten-US -en-US nerships that could enhance a response and facilitate en-US data sharing, training of existing staff, and funding en-US needs. Leadership made the ZIKV response a priority en-US en-US -en-US cantly contributed to a rapid response. The assessment en-US guided DPH in utilizing those funds to hire additional en-US surveillance staff and assign them regionally across en-US the state, updated existing surveillance and response en-US plans originally written for WNV, provided rapid en-US training to new and existing staff across the state in en-US surveillance and response, purchased equipment, and en-US expanded collaborations with the military to share en-US data and respond to this threat.en-US As the results in Table 1 indicate, DPH successfully en-US and rapidly expanded its surveillance footprint by en-US 338%, from 13 counties in 2015 to 57 counties in 2016, en-US representing 36% of the state. While the overall number en-US of counties conducting surveillance seems low, given en-US there are 159 counties, it should be noted that this rapid en-US expansion occurred in just 8 months (May-December) en-US and all major urban population centers have active suren-US -en-US veillance. In addition, the distribution of surveillance en-US covered all regions of the state. This expansion led to en-US the overall number of mosquitoes trapped increasing en-US by 90.3%, from 2015 to 2016, allowing better decision en-US making. Rapid expansion was achieved because the en-US DPH leadership made the ZIKV response a top prioren-US -en-US ity and streamlined the hiring and purchasing processes. en-US Prior to hiring new staff (March-April), the environen-US -en-US mental health program updated its WNV surveillance en-US and response plan by tailoring it for ZIKV. In addition, en-US a training curriculum, standard operating procedures, en-US job description for surveillance staff, and regions were en-US established. The DPH collaborated with regional public en-US en-US for the new surveillance staff, a critical component for a en-US successful program.en-US In April and May, 5 new surveillance staff members en-US were hired and provided 2 weeks of just-in-time trainen-US -en-US ing on mosquito surveillance techniques and identien-US -en-US en-US communication, data management, and vector control. en-US Each new staff member was assigned a region to cover en-US and provided with surveillance and response equipment en-US (traps, larvicides, backpack sprayers, microscope, educaen-US -en-US tional material). In addition, the state entomologist proen-US -en-US vided ongoing training and consultation throughout the en-US year, and assisted new staff with establishing surveillance en-US sites throughout their region. To assist the new regional en-US staff, the DPH provided training, surveillance equipment, en-US and funding to existing LHD environmental health staff en-US across the state, efforts which were invaluable in expanden-US -en-US ing the surveillance footprint across Georgia.en-US Historically, Georgias mosquito surveillance objectives en-US were driven by the threat of WNV, and mosquito trapen-US -en-US ping was prioritized to capture the primary WNV vecen-US -en-US tor, en-USCx. quinquefasciatus. en-USThis is highlighted in Table 1, en-US with en-US Cx. quinquefasciatusen-US as the highest percentage of en-US mosquitoes trapped overall in 2015 and 2016 at 79.4% en-US (60,423) and 62.5% (90,505) respectively. However, en-US the threat of ZIKV required surveillance staff to shift en-US some focus away from the WNV vector and prioritize en-US trapping in urban/suburban areas to target container-en-US breeding en-US Ae. aegpytien-US and en-US Ae. albopictus. en-US While overall en-US counts and percentages of both ZIKV vectors were low en-US in 2015 and 2016, it is important to note that this shift en-US in surveillance focus is demonstrated in Table 1 by an en-USTable en-US5en-US. The results of the PROC GLM (SAS en-US9.2en-US) procedure showing en-US changes in the log of mosquito prevalence by year and the en-US differential trends in log of mosquito prevalence by year.en-US*en-USParameteren-US Estimateen-US Standard en-US Erroren-US ten-US valueen-US P en-US valueen-US Intercepten-US0.18en-US 0.61en-US 0.29en-US .76en-USAe. albopictusen-US5.34en-US 1.20en-US 4.44en-US <.0001en-USAe. vexansen-US1.84en-US 0.81en-US 2.26en-US .02en-USCq. perturbansen-US2.84en-US 0.71en-US 4.00en-US <.0001en-USCs. melanuraen-US3.03en-US 0.72en-US 4.21en-US <.0001en-USCulex spp.en-US4.02en-US 0.75en-US 5.33en-US <.0001en-USCx. coronatoren-US1.50en-US 0.75en-US 1.99en-US .0463en-USCx. erraticusen-US4.00en-US 0.79en-US 5.01en-US <.0001en-USCx. nigripalpusen-US4.07en-US 0.68en-US 5.91en-US <.0001en-USCx. quinquefasciatusen-US6.79en-US 0.66en-US 10.16en-US <.0001en-USCx. restuansen-US2.48en-US 0.69en-US 3.55en-US .0004en-USCx. salinariusen-US2.97en-US 0.69en-US 4.30en-US <.0001en-USOc. triseriatusen-US1.62en-US 0.70en-US 2.29en-US .02en-USOc. sticticusen-US Refen-US year species en-USCs. melanuraen-US-1.29en-US 0.45en-US -2.87en-US .004en-USyear species en-USCulexen-US spp.en-US-1.51en-US 0.46en-US -3.23en-US .001en-USyear species en-USCx. erraticusen-US-1.10en-US 0.50en-US -2.21en-US .02en-USyear species en-USCx. nigripalpusen-US-1.15en-US 0.43en-US -2.68en-US .007en-USyear species en-USCx. restuansen-US-0.88en-US 0.43en-US -2.02en-US .04en-USyear species en-USCx. salinariusen-US-0.95en-US 0.43en-US -2.22en-US .02en-USyear species en-USOc. sticticusen-US Refen-US *en-USen-US0.05en-US en-USare shown.

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30 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USincrease in en-US Ae. albopictusen-US trapped (1.5% to 3.7%) and en-US a decrease in WNV vectors trapped (79.4% to 62.5%). en-US Aedes aegyptien-US the primary ZIKV vector, was trapped in en-US one county (Muscogee) for both years and overall numen-US -en-US bers decreased from 82 mosquitoes in 2015 to 26 in 2016, en-US representing an 83% decrease. While surveillance has en-US been limited, en-USAe. aegpytien-US was only found in Muscogee en-US County and Chatham County in the last decade, sugen-US -en-US gesting that en-US Ae. albopictusen-US has outcompeted this species en-US given its propensity for surviving in surburban/urban en-US areas.en-US18en-USThe next 4 highest percentages of mosquitoes trapped in en-US 2016 were en-USCx. nigripalpus, Culex en-USsppen-US Ae. vexans, en-USand en-US Cq. perturbans.en-US The number of en-USAe. vexansen-US exploded in en-US 2016 to 6,583 mosquitoes compared to 2015 at 162. This en-US increase came in the aftermath of Hurricane Matthew, en-US which left behind ideal breeding conditions for this inen-US -en-US en-US low-land and grassy areas of southeast Georgia. Its imen-US -en-US portant to point out that the top 5 mosquitoes captured en-US are major vectors of Eastern Equine Encephalitis (EEE), en-US St. Louis Encephalitis (SLE), and WNV, either serving en-US to amplifying the virus enzootically, or as a primary or en-US bridge vector to humans.en-US19-21en-USStatistical Analysisen-USTo determine if there were any statistical differences or en-US associations in the DPH surveillance program before en-US and after the ZIKV emergency declaration, a series of en-US statistical tests were run comparing data between the en-US same 13 counties historically conducting surveillance. en-US The en-US ten-US test examined the overall prevalence of mosquien-US -en-US toes per 100,000 population. While this test did not en-US en-US it should be noted that the overall number of mosquitoes en-US trapped increased by 66%, from 76,052 to 126,584 mosen-US -en-US quitoes in these 13 counties. This increase demonstrated en-US the rapid expansion of surveillance in response to ZIKV.en-US A series of en-US en-US2en-US analyses were conducted to test for any en-US differences between both years for the same counties at en-US en-US -en-US ences found in several of the mosquito species trapped en-US between years. Of importance to ZIKV, there was a en-US en-US Ae. albopictus en-USfrom en-US en-US Ae. aegyptien-US between those years. In addition, there was en-US en-US Cx. en-US quinquefasciatusen-US This was likely due to a shift in foen-US -en-US cus on targeting the ZIKV vectors which have different en-US breeding habitats. However, Georgia experienced a dry en-US late spring and summer with abnormally cooler nights, en-US which could have affected both vector species.en-US When Georgias primary disease vector species was staen-US -en-US en-US association between species and county was found. This en-US is critically important because the majority of the states en-US population is found in these large urban counties, puten-US -en-US ting more people at risk for arboviral diseases and demen-US-en-US onstrating the ongoing need for surveillance.en-US To determine if there were any temporal trends in the en-US distribution of species over time, a time-trend analysis en-US was conducted on mosquito data from 2012 through en-US 2016. This analysis demonstrated that over a 5-year peen-US -en-US en-US several important disease vector species in Georgia that en-US transmit WNV (en-US Cx. quinquefasciatusen-US ) EEE (en-US Cs. melen-US -en-US anura, Ae. vexans, Culex en-US spp), SLE (en-US Cx. nigripalpus)en-US en-US and LaCrosse encephalitis (en-US Oc. triseriatusen-US ), in addition en-US en-US of en-US Oc. triseriatus en-US over the 5-year period. This mosquien-US -en-US to represents Georgias primary vector for LaCrosse en-US encephalitis and demonstrates potential risk, as it has en-US been trapped consistently over the 5-year period. It can en-US adapt to its surroundings and lay eggs in forest or urban en-US container environments,en-US22en-US highlighting the critical imen-US-en-US portance of continued surveillance for this species and en-US other major disease vectors. Knowing these temporal en-US trends allows public health and mosquito control profesen-US -en-US sionals to predict risks and better prepare.en-USMilitary Collaboration en-USWhile Georgia was able to expand its surveillance caen-US -en-US pacity rapidly with internal resources, it is important en-US to point out the vital collaborations and contributions en-US made by the military. These collaborations were essenen-US-en-US tial because military personnel travel to ZIKV endemic en-US countries and many of them live off base, necessitating en-US a need to partner and share data. In past years when en-US WNV was the focus of concern, the DPH Vector-borne en-US and Zoonotic Section formed a cooperative agreement en-US en-US en-US surveillance and testing data collected within the State. en-US en-US headquarters from Georgia to Fort Sam Houston, Texas, en-US that collaboration was largely lost.en-US In 2016, as mosquito surveillance was being increased en-US in Georgia, a connection with the military was sought en-US again. Not having one central agency made this process en-US en-US individually, but ultimately several connections were en-US made. As one example, Dobbins Air Reserve Base en-US Bioenvironmental Engineers (BEE) partnered with the en-US DPH as part of the Department of Defense initiative to en-US GEORGIAS COLLABORATIVE APPROACH TO EXPANDING MOSQUITO SURVEILLANCEen-US en-US IN RESPONSE TO ZIKA VIRUS: A CASE STUDY

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January June 2017 31 en-UScombat ZIKV and other mosquito-borne diseases. One en-US of DPHs new vector surveillance coordinators, along en-US en-US range, an area of frequent mosquito complaints. Mosen-US -en-US en-US reduction, and chemical control were used to reduce en-US mosquito numbers in the area and reduce risk to milien-US -en-US tary personnel. Follow up surveillance was done, and en-US plans were made to continue this partnership in 2017. en-US en-US Force News Service as shown in Figure 4.en-US23en-USIn addition, Fort Benning, Fort Stewart, Hunter Army en-US en-US -en-US quito surveillance and testing data with the DPH. This en-US not only provides additional information to the DPH conen-US -en-US cerning disease risks, but also provides mosquito conen-US-en-US trol both on and off the bases with the information they en-US need to reduce mosquito populations and disease risk. It en-US should be noted that Fort Gordon has had a long-standing en-US collaboration with the Richmond County Mosquito Conen-US -en-US trol Program, a division of the local health department. CONc C LUSION The collaborative response to ZIKV allowed DPH to rap en-US-en-US idly increase its surveillance footprint across the state en-US and train new and existing staff on outbreak response. en-US With these new monitoring and response capabilities, en-US the DPH can make sound public health decisions regarden-US -en-US ing disease risks and quickly respond to local outbreaks en-US of ZIKV or other vector borne diseases.en-USEnhanced Capabilitiesen-USThe Georgia DPH was able to rapidly expand its surveilen-US -en-US lance capacity statewide because its leadership recogen-US -en-US nized the seriousness and potential impact of ZIKV on en-US the state and prioritized vector-borne diseases and suren-US -en-US veillance. This allowed the agency to maximize existing en-US resources to expand surveillance capacity and reignite en-US historic and develop new collaborations with en-US various entities, most importantly the LHDs en-US and the military. This expanded surveillance en-US network provided a clearer picture of the types en-US of mosquitoes potentially exposing the public en-US to mosquito-borne diseases and allowed DPH en-US to better quantify risks and provide public eduen-US-en-US cation. Statistical analysis of the data validates en-US the need for ongoing expanded surveillance.en-US In evaluating the risk of ZIKV transmission, en-US recent historic data for the primary vector of en-US ZIKV, en-US Ae. aegypti, en-USwas isolated to just 2 counen-US -en-US ties in Georgia. Expanded surveillance in 2016 en-US en-US Ae. aegyptien-US having en-US been found in just one county, suggesting the en-US primary vector for Zika has been displaced by en-US Ae. albopictusen-US This also suggests a reduced risk en-US of autochthonous transmission of Zika virus in en-US en-US Ae. Albopictusen-US for en-US feeding on both humans and animals. However, en-US this should be interpreted with caution due to en-US unstandardized reporting techniques for each en-US county, lack of systematic surveillance in even-US -en-US ery county, and a dry spring and summer that en-US reduced overall number of mosquitoes trapped. en-US The DPH is working with all counties to imen-US -en-US prove the quality of data reported, and will continue to en-US assess the abundance and distribution of en-US Ae. aegyptien-US en-US each year to evaluate risks. In addition, while DPH exen-US -en-US panded surveillance to 57 counties which comprise apen-US -en-US proximately 36% of the states 159 counties, the agency en-US continues to work with the LHDs to establish additional en-US surveillance sites with the goal of 100% of counties conen-US -en-US ducting mosquito surveillance. This will allow better en-US interpretation of overall mosquito abundance and distrien-US -en-US bution across the state.en-USPublic Health Implicationsen-USBy increasing the number of counties involved in suren-US -en-US en-US -en-US toes throughout the state, the DPH can better predict en-US en-USFigure en-US4en-US. Georgia Department of Public Health vector surveillance coordien-US -en-US nator installing mosquito traps at the Dobbins Air Reserve Base.en-US23

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32 http://www.cs.amedd.army.mil/amedd_journal.aspx en-USregions of Georgia. However, increasing and maintainen-US-en-US ing surveillance comes with its own challenges, with en-US stable funding being the largest obstacle to a robust en-US surveillance system. The DPH was able to prioritize en-US existing funding to kick start a rapid response and was en-US en-US for ZIKV, but these funding streams are temporary and en-US en-US that funding for monitoring, surveillance, and response en-US becomes a permanent federal funding source, and that it en-US does not follow the same path as WNV funding reducen-US -en-US en-US -en-US pared to respond to the next emerging arboviral disease, en-US and the results could be disastrous for a population that en-US has no natural immunity. RREFERENc C ES 1. en-USWorld Health Organization. Zika virus and comen-US -en-US en-US Available at: http://www.who.int/emergencies/zika-en-US virus/en/. Accessed February 2, 2017. 2. en-USWorld Health Organization. Zika virus [internet]. en-US en-US www.who.int/mediacentre/factsheets/zika/en/. Acen-US -en-US cessed February 2, 2017. 3. en-USRandle YH, Freeman CB, Jackson M, Reyna M, en-US Debboun M. 2014: A record-breaking year for West en-US Nile virus positive mosquito pools in Harris Counen-US -en-US ty and the City of Houston, Texas. en-US USen-US en-US Armyen-US en-US Meden-US en-US Depen-US en-US Jen-US October-December 2016;1-8. Available at: en-US http://www.cs.amedd.army.mil/FileDownloadpuben-US -en-US lic.aspx?docid=ede3a0ed-f2ff-4ed1-9414-7e04den-US en-US b25e724en-US Accessed March 16, 2017. 4. en-USCenters for Disease Control and Prevention. Zika en-US en-US -en-US en-US www.cdc.gov/zika/vector/range.html. Accessed en-US February 2, 2017. 5. en-USMoore CG, Mitchell CJ. en-USAedesen-US en-US albopictusen-US in the en-US en-US implications. en-USEmergen-US en-USInfen-US en-USDisen-US 1997;3(3):329-334. 6. en-USVasquez-Prokopec GM, Chaves LF, Ritchie en-US en-US -en-US ting surveillance budgets. en-USPLoSen-US en-US Neglen-US en-US Tropen-US en-US Disen-US en-US 2010;4(10):e858. doi: 10.1371/journal.pntd.0000858. 7. en-USFlores C. Mosquito surveillance for effective mosen-US -en-US quito population control [internet]. Vector Disease en-US Control International. Available at: http://www.en-US vdci.net/blog/mosquito-surveillance-for-effective-en-US mosquito-population-control. August 19, 2015. Acen-US -en-US cessed February 2, 2017. 8. en-USMoore CG, McLean RG, Mitchell CJ, et al. Guideen-US -en-US lines for arbovirus surveillance programs in the en-US en-US -en-US trol and Prevention. April 1993. Available at: https://en-US www.cdc.gov/ncezid/dvbd/pdf/arboguid_508.pdf. en-US Accessed February 2, 2017. 9. en-USCouncil of State and Territorial Epidemiologists. en-US Assessment of capacity in 2012 for the surveillance, en-US prevention, and control of West Nile virus and en-US other mosquito-borne virus infections in state and en-US large city/ county health departments and how it en-US compares to 2004 [internet]. February 2014. Availen-US -en-US able at: http://www.cste2.org/docs/VBR.pdf. Acen-US -en-US cessed February 2, 2017. 10. en-USAsnis DS, Conetta R., Teixeira AA, Waldman G, en-US Sampson BA, The West Nile virus outbreak of en-US 1999 in New York: the Flushing hospital experien-US -en-US ence. en-USClinen-US en-USInfecten-US en-USDisen-US 2000;30:413-418. 11. en-USAsnis DS, Conetta R, Waldman G, Teixeira AA. en-US The West Nile virus encephalitis outbreak in the en-US en-US York, to beyond its borders. en-US Annen-US en-US NYen-US en-US Acaden-US en-US Scien-US en-US 2001;951:161-171. 12. en-USMurray KO, Mertens E, Despres P. West Nile virus en-US en-US Veten-US en-USResen-US 2010;41(6):67. 13. en-USHadler JL, Patel D, Bradley K, et al. National capacen-US -en-US ity for surveillance, prevention, and control of West en-US en-US States, 2004 and 2012. en-USMMWRen-US 2014;63(13):281-en-US 284. Available at: https://www.cdc.gov/mmwr/preen-US en-US view/mmwrhtml/mm6313a2.htmen-US Accessed March en-US 17, 2017. 14. en-USAmerican Mosquito Control Association. Policy en-US Statement: Epidemiology and laboratory capacen-US -en-US ity grants for mosquito-borne disease surveillance en-US [internet]. 2015. Available at: http://www.mosquito.en-US org/assets/WashingtonConf/2015/federal%20funden-US en-US ing%20issue%20paper%202015.pdf. Accessed en-US February 2, 2017. 15. en-USWomack ML, Thuma TS, Evans BR. Distribution en-US of en-US Aedes albopictusen-US en-US Jen-US en-US Amen-US en-US Mosqen-US en-US Controlen-US en-USAssocen-US 1995;11:237. 16. en-USen-US -en-US lation Search [internet]. Available at: https://www.en-US en-US Accessed January 29, 2017. 17. en-USGeorgia Department of Community Health. Georen-US -en-US gia rural county map [internet]. August 2008. en-US Available at: https://dch.georgia.gov/documents/en-US georgia-rural-county-map. Accessed February 3, en-US 2017.en-USGEORGIAS COLLABORATIVE APPROACH TO EXPANDING MOSQUITO SURVEILLANCEen-US en-US IN RESPONSE TO ZIKA VIRUS: A CASE STUDY

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January June 2017 33 18. en-USJuliano SA. Coexistence, exclusion, or neutralen-US -en-US ity? A meta-analysis of competition between en-US Aeen-US -en-US des albopictusen-US and resident mosquitoes. en-USIsr J Ecolen-US en-US 2010;56:325-351. 19. en-USen-US Culex nigripalpusen-US [internet]. en-US en-US en-US dept.ufl.edu/creatures/aquatic/fl_sle_mosquito.en-US htm. Accessed February 6, 2017. 20. en-USGoddard LB, Roth AE, Reisen WK, Scott TW. Vecen-US -en-US tor competencies of California mosquitoes for West en-US Nile virus. en-USEmergen-US en-USInfen-US en-USDisen-US 2002;8(12),1385-1391. 21. en-USVirginia Mosquito Control Association. en-US Coquilen-US -en-US lettidia perturbansen-US [internet]. Available at: http://en-US mosquito-va.org/?page_id=437. Accessed Februen-US -en-US ary 6, 2017. 22. en-USen-US relative abundance, body size, and susceptibility of en-US Ochlerotatus triseriatusen-US (Diptera: Culicidae) to La en-US Crosse virus. en-USJen-US en-USMeden-US en-USEntomolen-US 2015;52(3):452-460. 23. en-USen-US with Georgia department of Public Health [interen-US -en-US net]. Available at: http://www.af.mil/News/Articleen-US en-US Display/tabid/223/Article/925942/dobbins%ADcen-US ombats%ADzika%ADwith%ADgeorgia%ADdepen-US artment%ADof%ADpublic%ADhealth.aspx. Acen-US -en-US cessed February 6, 2017. AUTHORS Dr Rustin is an Assistant Professor, Department of Epi en-US-en-US demiology and Environmental Health Science, Jiann-en-US Ping Hsu College of Public Health, Georgia Southern en-US en-US Mr Martin is a MPH graduate student, Department of en-US Epidemiology and Environmental Health Science, Jiann-en-US Ping Hsu College of Public Health, Georgia Southern en-US en-US Mr Sevilimedu is a DrPH (Biostatistics) student at the en-US Jiann-Ping Hsu College of Public Health, Georgia Southen-US -en-US en-US Mr Pandeya is a DrPH (Biostatistics) student, Departen-US -en-US ment of Biostatistics, Jiann-Ping Hsu College of Puben-US -en-US en-US Georgia.en-US Dr Rochani is an Assistant Professor, Department of en-US Biostatistics, Jiann-Ping Hsu College of Public Health, en-US en-US Dr Kelly is a Public Health Entomologist with the Vector-en-US Borne & Zoonotic Diseases Team Environmental Health en-US Section, Georgia Department of Public Health, Atlanta, en-US Georgia.

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en-US34 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USIn 2016, Zika virus and congenital infections became en-US en-US1en-US en-US en-US virus (ZIKAV) with illness onset were reported to Aren-US -en-US en-US managed by the Centers for Disease Control and Preen-US -en-US vention and state health departments, from January 1 to en-US July 31, 2016.en-US2en-USen-US en-US the state of Florida.en-US3en-US en-US Aedes en-US mosquitoes transmit ZIKAV, en-US chikungunya virus (CHIKV), dengue virus (DENV), en-US and yellow fever virus, among others. Although en-US Aeen-US -en-US des albopictusen-US Skuse is thought to be a competent vecen-US -en-US tor of ZIKAV,en-US4en-US en-US Ae. aegyptien-US (L.) has been implicated as en-US the primary transmitter of the virus in human populaen-US -en-US tions in the ongoing outbreak in the Americas.en-US5,6en-US This is en-US likely the result of en-US Ae. aegyptien-US preferring to feed more en-US frequently on humans,en-US7,8en-US and being highly peridomestic en-US compared to en-USAe. albopictusen-US which can inhabit more en-US rural environments.en-US9,10en-US The role of other mosquito speen-US -en-US cies in ZIKAV transmission is either unknown, refers to en-US en-US -en-US sial,en-US11en-US therefore only en-USAe. aegyptien-US and en-USAe. albopictusen-US are en-US considered here.en-US en-US -en-US fense (DoD) facilities, but the approach could be used for en-US any area of interest. Some military facilities have long-en-US standing mosquito surveillance programs,en-US12en-US and Zika en-US en-US as a result of the recent threat. For example, surveilen-US -en-US lance efforts are supported by funding from the Global en-US Emerging Infections Surveillance and Response section en-US of the Armed Forces Health Surveillance Branch in the en-US Defense Health Agencys Public Health Division.en-US13en-US Acen-US -en-US cording to a March 2016 DoD memo, 190 DoD installaen-US -en-US tions are located in areas where mosquitoes capable of en-US carrying ZIKAV occur, and increased vector monitoren-US -en-US ing will be conducted in installations in 27 states, the en-US District of Columbia, Guam, and Puerto Rico.en-US14en-US Four en-US en-US Command, all of which have entomological sciences dien-US -en-US visions that conduct mosquito surveillance. Additionalen-US -en-US en-US en-US regional Navy Environmental and Preventive Medicine en-US en-US assist those undertaking vector surveillance or arbovien-US -en-US rus testing.en-US For a military entomologist tasked with establishing and en-US maintaining an en-US Aedesen-US spp./ZIKAV surveillance proen-US -en-US gram in temperate areas that experience high mosquito en-US seasonality, two important questions arise: (1) is ZIKAV en-US transmission possible here?; (2) when should vector suren-US -en-US veillance be conducted? In temperate zones like the conen-US-en-US en-US may vary depending on the time of year. In this article, en-US we describe an Excel-based tool that is designed to asen-US -en-US sist entomologists and other health professionals address en-US these 2 questions throughout the year.en-US Habitat suitability models displaying potential distribuen-US -en-US tion have been published for both en-US Ae. aegyptien-US and en-US Ae. en-USA Location-specific Spreadsheet foren-US en-US Estimating Zika Risk and Timing foren-US en-US Zika Vector Surveillance, Using USen-US en-US Military Facilities as an Example De smond H. Foley, PhD D avid B. Pecor, BS ABSTRac AC T en-USAedes en-US aegyptien-US and en-US Ae. albopictus,en-US is of major concern. To assist efforts to anticipate the risks of transmission, we en-US developed an Excel spreadsheet tool that uses vector and virus temperature thresholds, remotely sensed maxien-US -en-US mum temperature, and habitat suitability models to answer the questions: is Zika transmission likely here? en-US and when should we conduct vector surveillance? An example spreadsheet, updated regularly and freely en-US available, uses near real-time and forecast temperature data to generate guidance, based on a novel four level en-US en-US Guam and Puerto Rico.

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en-USJanuary June 2017 en-US35en-USalbopictusen-US ,en-US15-19en-US as well as for ZIKAV.en-US20-23en-US While these en-US models often display average yearly suitability, they do en-US not necessarily provide information that could be used en-US for decisions about the timing of surveillance activities, en-US and are global in extent rather than focused on particuen-US -en-US lar areas where a surveillance program might be estaben-US -en-US lished. Questions about timing of mosquito monitoring en-US and allocation of resources requires a consideration of en-US what conditions limit adult mosquito activity and ZIen-US -en-US en-US Relative humidity, rainfall, drought, and wind velocity en-US affect survival and behavior of mosquitoes, and thereen-US -en-US fore transmission.en-US24en-US However, temperature is the most en-US important ecological determinant of the development en-US rate of en-USAe. aegyptien-US ,en-US25en-US and one of the principal determien-US -en-US nants of en-USAedesen-US survival.en-US26en-US Temperature also directly afen-US -en-US fects the replication rate of arboviruses, thus affecting en-US the extrinsic incubation period.en-US27en-US What then do we know en-US about how temperature limits en-US Aedesen-US and arboviruses en-US such as ZIKAV?en-US In their review of reports published in the early 20th cenen-US -en-US tury, Bonne-Wepster and Brugen-US28en-US presented data about en-US the effects of temperature on the activity and survival of en-US Ae. aegyptien-US mosquitoes, summarized below: Š enen-US Female mosquitoes were observed to feed most en-US readily between 26C and 35C, between 19C and en-US 25C they are slow to blood feed, and below 15C en-US to 19C they do not feed (Marchoux et al,en-US29en-US Howard en-US et al,en-US30en-US Connoren-US31en-US). Š enen-US Female mosquitoes in Montevideo can continue to en-US bite at 14C to 15C (Cossioen-US32en-US). Š enen-US Adults were observed to die when exposed to temen-US -en-US peratures above 38C, but Davisen-US33en-US reported some en-US adults surviving exposure to 40C during 7 hours, en-US and amongst another group exposed to 45C for 2 en-US hours. Š enen-US At 7C to 9C, adult females may live up to 80 en-US days, and the male up to 14 days (Guiteras; Otto; en-US Newmanen-US34en-US). Š enen-US The female dies within 24 hours, if exposed to a en-US temperature of 6C (Fluen-US35en-US). Š enen-US Dinger et alen-US36en-US reported survival of adult female en-US mosquitoes kept for 6 days at 5C.en-US More recently, in Saudi Arabia, Khormi et alen-US37en-US found that en-US the minimum temperature range of 18C to 25C is suiten-US -en-US able for en-US Ae. aegyptien-US survival, and the survival rate increasen-US -en-US es up to 38C. Conneren-US38en-US and Wayne and Grahamen-US39en-US found en-US that en-US Ae.en-US en-US aegyptien-US is most active at temperatures between en-US en-US -en-US tions found survival rates from about 18C to 38C or en-US less, based on daily or monthly minimum and maximum en-US temperatures.en-US40-42en-US In a study of en-USAe. aegyptien-US distribution en-US using the program CLIMEX, Khormi and Kumaren-US18en-US set en-US the limiting low temperature at 18C, the lower optimal en-US temperature at 25C, the upper optimal temperature at en-US 32C, and the limiting high temperature at 38C. Brady en-US et alen-US16en-US limited their predictions of temperature suitability en-US to areas with a maximum monthly temperature exceeden-US -en-US ing 13C for en-USAe. albopictusen-US and 14C for en-USAe. aegyptien-US en-US These threshold temperatures were based on previous en-US studies of the observed temperatures below which biting en-US and movement behaviors were impaired.en-US42-45en-USStudies suggest that an increase between 14C to 18C en-US and 35C to 40C can lead to higher transmission of denen-US -en-US gue.en-US46en-US Xiao et alen-US47en-US found that oral infections of DENV2 en-US did not produce antigens in the salivary glands of en-US Ae. alen-US -en-US bopictusen-US kept at 18C for up to 25 days but did produce en-US antigens at 21C. It is not known if en-USAe. albopictusen-US held en-US longer at the lower temperature would have disseminated en-US infections, but Dohm et alen-US48en-US found that en-US Culex pipiensen-US reen-US -en-US quired 25 days at 18C to disseminate infections of West en-US Nile virus (WNV). For comparison, WNV is capable of en-US replication from 14C to 45C.en-US49,50en-US Tilston et alen-US51en-US analyzed en-US monthly average temperature of cities that experience en-US en-US occurred when average monthly temperatures were 20C en-US or higher. At the upper temperature limit, Kostyuchenko en-US et alen-US52en-US found that ZIKAV is more thermally stable than en-US DENV, and is also structurally stable even when incuen-US -en-US bated at 40C, mimicking the body temperature of exen-US -en-US tremely feverish patients after virus infection. However, en-US a study by Goo et alen-US53en-US indicates that the thermal stability en-US of some ZIKAV strains, including those involved in reen-US -en-US cent outbreaks, falls between those of DENV and WNV.en-US Remotely sensed temperature data is freely available en-US from multiple sources as both near-real time recordings en-US and forecast predictions. Combining remotely-sensed en-US temperature data with predicted distributions of the vecen-US -en-US tors and virus could provide insight into when areas of en-US interest are suitable for transmission and should be acen-US -en-US tively monitored. Our aim was to produce a knowledge en-US product and surveillance decision tool that uses publicly en-US available information about potential distribution and en-US en-US military facilities. MaA TERIa A LS aA ND METHODS Areas of Interest en-USen-US en-US THE ARMY MEDICAL DEPARTMENT JOURNAL

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en-US36 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USen-US54en-USen-US en-US Ricoen-US ,en-US and Guam. As some facility names comprised en-US multipart polygons, these were reduced from 804 to 733 en-US to match the number of unique facility names, using the en-US Dissolve tool in ArcMap 10.4 (ESRI, Redmond, CA). en-US The centroid of each facility was selected to produce a en-US en-US polygon option checked) of ArcMap. The georeference en-US of each centroid was obtained by the Add XY Coordien-US -en-US en-US en-US by the Extract Values to Points toolen-US ,en-US then for polygons en-US using the Zonal Statistics as Table tool, and the results en-US merged. This approach was required because smaller en-US polygons would not produce results using the Zonal Staen-US -en-US tistics as Table tool, which necessitated use of the raster en-US data associated with the points for these facilities.en-USTemperature Dataen-USTo monitor temperature in near real-time, daily time aven-US -en-US eraged maps of air temperature at the surface (daytime/en-US ascending) were downloaded from the Giovanni 4.19 en-US (Released Date: 2016-04-12. Data provided by the Naen-US-en-US tional Air and Space Administration (NASA) Goddard en-US Earth Sciences Data and Information Services Center) en-US data portal at 1 spatial resolutionen-US .en-US55en-US Daily gridded temen-US -en-US perature analyses were also collected from the National en-US en-US National Weather Service Climate Prediction Center en-US (CPC)en-US en-US56en-US Forecast temperature data was also provided en-US by the CPC and the NOAA National Digital Forecast en-US Database at 5 km spatial resolutionen-US .en-US57en-US For predictions en-US based on monthly averages, monthly gridded climate en-US data with a spatial resolution of 1 km were downloaded en-US from WorldClim.en-US58en-USHabitat Suitability Modelsen-USWe chose the models of en-US Ae. aegyptien-US and en-USAe. albopictus en-US by Kraemer et al,en-US59en-US which were based on an extensively en-US documented set of presence observations for each vecen-US -en-US tor. We also used the habitat suitability model for ZIen-US -en-US KAV transmission by Messina et al.en-US21en-US This model used en-US Zika case reports and data on temperature, precipitation, en-US humidity, enhanced vegetation index, and urban versus en-US rural. Both vector and virus maps are at a 5 km x 5 km en-US spatial resolution. The 0.5 model suitability score was en-US arbitrarily used as a presence/absence threshold.en-USThresholdsen-USThe temperature suitable for activity of en-US Ae. aegyptien-US en-US and en-US Ae. albopictusen-US combined was estimated as 13Cen-US en-US to en-US 38C, and 18Cen-US to en-US 42C for ZIKAV. We chose to be en-US conservative, using temperatures at the extremes of the en-US reported suitable temperature range, and maximum en-US rather than mean air temperatures.en-USHuman Population Dataen-USIn order to more fully understand the potential impact of en-US ZIKAV risk to military and nonmilitary personnel and en-US their families in and around each facility, we explored en-US risk in terms of human population data, with the folen-US -en-US en-US Ae. aegyptien-US en-US and en-US Ae. albopictusen-US is in the order of hundreds of meters en-US onlyen-US ,en-US60,61en-US and each facility would differ in the average en-US distance that human carriers of ZIKAV would routinely en-US travel to and from each facility. Additionally, some faen-US -en-US cilities were remote, while others were adjacent to or en-US enclosed within urban and suburban areas. To address en-US these complications, we created a buffer of 5 km around en-US all facility polygons to capture the human population en-US density according to LandScan 2011.en-US62en-US This was accomen-US -en-US plished using the LandScan raster and the Buffer and en-US Sum output in the Zonal Statistics as Table tools in Arcen-US -en-US Map. A buffer of 5 km is a conservative estimate and is en-US meant to give a uniform measure for each facility of the en-US potential host density affected in an outbreak or vector en-US control situation.en-USExcel-based Zika Risk Toolen-USA goal of this project was to display disparate data en-US sources visually and in a simple and intuitive way in en-US order to more effectively communicate the level of risk en-US at each military facility. The risk estimation and alert en-US system had to be in a format that was readily underen-US -en-US standable and easily accessible by military users, who en-USoften have information system security restrictions or en-US bandwidth caps. We chose MS Excel (Microsoft Corp, en-US Seattle, WA), as a universal platform for performing en-US calculations and reporting results. This software had en-US the added advantage that the scatterplot function can be en-US used to map each military facilityen-US ,en-US63en-US with icons displayen-US -en-US ing various categories of risk, and using a geocorrected en-US map backgrounden-US64en-US for each state. Other notable features en-US that were used in the Excel risk estimation tool were en-US the formula functions, conditional formatting to repreen-US -en-US sent categories of numbers as different types of symbols, en-US dependent dropdown lists and hyperlinks to allow usen-US -en-US ers to navigate more quickly to the results of individual en-US facilities, and textualized results that users can read as en-US statements describing the situation and as guidance for en-US vector surveillance.en-USCalculations Within the Excel Risk Estimation Toolen-USGiven that the maximum temperature is available en-US for a site (ie, Temp), the following lists an example en-US A LOCATION-SPECIFIC SPREADSHEET FOR ESTIMATING ZIKA RISK AND TIMING FORen-US en-US ZIKA VECTOR SURVEILLANCE, USING US MILITARY FACILITIES AS AN EXAMPLE

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en-USJanuary June 2017 en-US37 en-USsequence of tasks and their calculations, with explanations and the Excel formula (in square brackets), culminating en-US in a risk rating: 1. en-USColumn A. Was temperature suitable during period for the vector?, ie, if the maximum was 13C to 38C, en-US it is 1, otherwise 0 [=IF((Temp>=13)-(Temp>38),1,0)], 2. en-USColumn B. Was temperature suitable during period for virus replication in mosquito?, ie, if the maximum en-US was 18C to 42C, it is 1, otherwise 0 [=IF((Temp>=18)-(Temp>42),1,0)] 3. en-USColumn C. What is the sum of the thermal suitability values for vector (Column A) and virus (Column en-US B)?, ie, possible choices are: 0, 1, or 2. 4. en-USColumn D. If temperature for the vectors (Column A) was within the required range, what is the model en-US suitability for vector?en-US ,en-US ie, this was the maximum modeled suitability (0-1.00) for either en-US Ae. aegyptien-US or en-USAe. en-US albopictusen-US 5. en-USen-US D>=0.5,3))]. The 0.5 model suitability score was arbitrarily used as the cutoff for presence/absence. 6. en-USColumn F. If temperature for the virus (Column B) was within the required range, what is the model suiten-US -en-US ability for the virus? (0-1.00) 7. en-USen-US F>=0.5,7))]. The 0.5 model suitability score was arbitrarily used as the cut-off for presence/absence. 8. en-USColumn H. What is the Combined Score for the interaction of temperature suitability of vector and virus, en-US vector model suitability, and virus model suitability score (ie,=Cen-US en-US Een-US en-US G)? The use of 0, 1en-US ,en-US and prime numen-US -en-US bers for the component scores produces a unique semien-US -en-US prime number for the product, ie, 0, 10 (=1en-US en-US 2en-US en-US 5), 14 en-US (=1en-US en-US 2en-US en-US 7), 15 (=1en-US en-US 3en-US en-US 5), 21 (=1en-US en-US 3en-US en-US 7), 20 (=2en-US en-US 2en-US en-US 5), 28 (=2en-US en-US 2en-US en-US 7), 30 (=2en-US en-US 3en-US en-US 5), or 42 (=2en-US en-US 3en-US en-US 7). A zero indien-US -en-US cated that the temperature at the site was unsuitable for both vector and pathogen, so suitability scores were en-US irrelevant, and combination scores were all scored zero. 9. en-USThe 9 possible Combined Scores were divided into 6 categories based on whether preconditions do not exist en-US for transmission, are unsuitable for transmission, are somewhat suitable for transmission, or are suitable en-US for transmission (Figure 1). 10. en-USColumn I. An Overall Zika Risk Code was established based on the Combined Score (Figure 1), and rates en-US conditions as low (Blue: Code 1) to high risk (Red: Code 4). The 9 possible Combined Scores are initially en-US divided according to whether temperature conditions are not suitable (Code 1) or suitable for the vectors en-US and virus (Codes 2en-US -en-US 4). Codes 2en-US -en-US 4 are then characterized according to increasing habitat suitability, with en-US Code 4 being where models predict suitable habitat for vectors and virus. 11. en-USAction statements were constructed based on the temperature and habitat model suitability scores (Figure en-US 2). For example, if conditions are too cold for the development of the vectors and models predict that the en-US location is unsuitable for the vectorsen-US ,en-USen-US -en-US lance unnecessary. When Temp suitable, model suggests vectors unlikely or low numbers. Alternatively, en-US if conditions are warm enough for the development of the vectors and models predict that the location is en-US highly suitable for the vectorsen-US ,en-USen-US en-US minimizing exposure. RRESULTS en-US-en-US erage monthly maximum temperatures (suitable for en-US longer term planning), and near real-time and forecast en-US en-US the VectorMap websiteen-US .en-US65en-US The tool provides risk maps en-US of facilities as a continental overview (Figure 3), and en-US on a state by state basis (Figure 4). Results for indien-US -en-US vidual facilities are navigable via dropdown menus and en-US hyperlinks (Figure 5). Statewide summary data of risk en-US en-US -en-US ure 6. The temporal changes in average risk based on en-US en-US number of facilities affected (of 733) and the number of en-US people within 5 km of the facilities. April to October en-US was the period of greatest risk with suitable conditions en-US for Zika transmission (ie, code 4) potentially affecting en-US a maximum of 114 facilities in 12 states and territories,

PAGE 40

38 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USand 4,546,505 people within the vicinity of these facilien-US -en-US ties, of a total of 32,811,618 within the vicinity of all 733 en-US facilities. The maximum number of facilities recording en-US code 4 in any one month (eg, August) were: Florida (36), en-US Hawaii (16), Louisiana (12), Texas (11), and Virginia (11). en-US Of these, the number of people within 5 km of these en-US facilities were: Texas (1,215,230), Florida (1,125,032), en-US Louisiana (462,586), Virginia (409,066), and Hawaii en-US (247,918).en-US These data may assist public health planning, and can en-US be seen as an indicator of potential disease burden, or en-US en-US vector surveillance and control program conducted on en-US military facilities. Results are provided in a variety of en-US symbologies and as textualized statements of how the en-US factors examined may affect ZIKAV transmission, and en-US recommended actions for entomologists conducting en-US routine vector surveillance. The action statement textuen-US -en-US alizes the data and is designed to assist a preparedness en-US postureen-US ,en-US particularly around vector surveillance and en-US control. Changes in the action statement over the year, en-US for example as a result of rising temperature, can be en-US used as a guide to affect changes in vector surveillance en-US and control activities at particular facilities. COmm MM ENT The Excel tool is designed to provide insights into ZI en-US-en-US en-US but could be applied to other arboviruses and situations, en-US such as citiesen-US ,en-US66en-US tire dumpsen-US ,en-US or parks. The spreadsheet is en-US en-US temperature limits, and the wording of action stateen-US -en-US ments can be replaced depending on the context, and as en-US new information is compileden-US .en-US en-US conjunction with the Electronic Surveillance System for en-US en-US67en-US en-US or Medical Situational Awareness in Theater,en-US68en-US which Figure en-US2en-US. en-US Action statements constructed on the basis of the temperature and habitat model suitability scores. Figure en-US1en-US. en-US An overall Zika Risk Code based on the combined score, which rates conditions from low risk (Blue: Code en-US1en-US) to high risk en-US (Red: Code en-US4en-US). en-USA LOCATION-SPECIFIC SPREADSHEET FOR ESTIMATING ZIKA RISK AND TIMING FORen-US en-US ZIKA VECTOR SURVEILLANCE, USING US MILITARY FACILITIES AS AN EXAMPLE

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January June 2017 39 en-USreports on febrile illnesses and rash in the military en-US population. Coordination of result reporting through the en-US Armed Forces Pest Management Boarden-US69en-US and VectorMap en-US may also be desirable. The Navy and Marine Corps Puben-US -en-US lic Health Center (NMCPHC) guide, en-US Aedes Surveillance en-US and Control Plan for U.S. Navy and Marine Corps Inen-US -en-US stallationsen-US ,en-US70en-US states that each installations medical peren-US -en-US sonnel should conduct ongoing en-US Aedesen-US surveillance duren-US -en-US ing the mosquito season appropriate to their region and en-US take preventive and responsive action to reduce disease en-US risk to active duty, government employees, and family en-US member populations.en-US70(p4)en-US In addition, it points out that en-US OPNAVINST 6250.4Crequires all Navy and Marine en-US Corps installations to have an Emergency Vector Conen-US -en-US trol Plan (EVCP) for disease vector surveillance and en-US control during disease outbreaks.en-US70(p4)en-US The spreadsheet en-US described in this study should provide an additional reen-US -en-US source for installations as they use the NMCPHC guide en-US to complement installation pest management plans, en-US including the EVCP, as a way to assess the risk of vector en-US borne diseases, and implement strategies to reduce the en-US risk to personnel assigned to installations.en-US70(p4)en-USKnowing when conditions are suitable for vectors is en-US crucial for monitoring the success or failure of any conen-US -en-US trol program. Appendix C of the NMCPHC guideen-US70en-US is en-US a chart to determine the risk of infection on an instalen-US -en-US lation and when to apply vector control measures. This en-US 4-level vector threat response plan relies on information en-US about vector abundance and reports of disease transmisen-US -en-US sion. We believe the Excel spreadsheet risk tool to be en-US a valuable adjunct to the NMCPHC plan, as it would en-US en-US and the judicious deployment and timing of entomologien-US -en-US cal resources. Each military facility is unique and varies en-US in size, function, human density, and suitable mosquito en-US habitat, so not all of the 733 facilities addressed in this en-US study will be at risk of mosquito-borne disease and suiten-US -en-US able candidates for mosquito surveillance. However, in en-US any case, all locations should be useful as points of refen-US -en-US erence for other nearby locations where mosquito suren-US -en-US veillance is conducted.en-US Development of the Zika Risk Code in Figure 1 derived en-US some inspiration from Figure 3 of Fischer et al,en-US71en-US who en-US combined models of vector habitat suitability with temen-US -en-US perature categories for CHIKV replication to produce a en-US matrix of climate related risk classes.en-US It is important to note that each data source used in this en-US analysis has the potential for errors which should be conen-US -en-US sidered when determining risk. For example, habitat suiten-US -en-US ability models for each vector may not be accurate for en-US all areas, and may only predict average yearly suitability. en-US Traits like temperature vary continuously over the suren-US -en-US face of the earth but are effected by elevation and use of California military facilities Outside temp.range for ZIKV Within temp. range for ZIKV Outside temp. range for Zika vectors Within temp. range for Zika vectors California military facilities Outside temp.range for ZIKV Within temp. range for ZIKV Outside temp. range for Zika vectors Within temp. range for Zika vectors Figure en-US3en-US. en-US Average maximum temperature conditions for January for vectors and ZIKAV at military facilities within the contiguous en-US 48 states.

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en-US40 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USmultiple scale data, including weekly and monthly, and en-US 1 km and 1 spatial resolution data used here will result en-US in important spatial and temporal variations in accuracy. en-US Temperature data refers to the maximum daytime air en-US temperature near the surface (averaged over various spaen-US -en-US tial resolutions) from daily data for a recent date range, en-US which NASA acknowledges has limitations. Vectors can en-US also seek microclimates (eg, indoors, subterranean habien-US -en-US tats) that may be warmer or cooler than the outside temen-US -en-US perature that is estimated by remote sensing data.en-US Temperatures within the suitable range may not affect en-US organisms uniformly. According to Westbrook et al,en-US72en-US en-US adult female mosquitoes reared from immature stages en-US at 18C, were 6 times more likely to be infected with en-US CHIKV than those reared at 32C. Westbrook et alen-US72en-US en-US noted that climate factors, such as temperatureen-US ,en-US experien-US -en-US enced at the larval stage (which would not be detected en-US en-US -en-US tence of adult female mosquitoes to vector arboviruses. en-US en-US -en-US cording to Lambrechts et al,en-US73en-US mosquitoes lived longer en-USFigure en-US4en-US. en-US Thermal conditions for January and August for vectors and ZIKAV at military facilities in California. Note: unsuitable en-US conditions in August in the south are due to temperatures too high for the vectors. California military facilities Outside temp.range for ZIKV Within temp. range for ZIKV Outside temp. range for Zika vectors Within temp. range for Zika vectors California military facilities Outside temp.range for ZIKV Within temp. range for ZIKV Outside temp. range for Zika vectors Within temp. range for Zika vectors January en-USAugust en-USA LOCATION-SPECIFIC SPREADSHEET FOR ESTIMATING ZIKA RISK AND TIMING FORen-US en-US ZIKA VECTOR SURVEILLANCE, USING US MILITARY FACILITIES AS AN EXAMPLEen-USFigure en-US5en-US. en-US An overall Zika virus risk code for near real-time and forecast periods (A) is assigned based on a combination of: en-US temperature suitability for adult activity of the vectors (en-USAe. aegyptien-US and en-USAe. albopictusen-US ) (B), modeled habitat suitability of the en-US vectors (C), temperature suitability for Zika virus replication within the vectors (D), and modeled habitat suitability of Zika virus en-US transmission (E). If suitable conditions exist (Zika Risk Code en-US4en-US), the number of people within en-US5en-US km is shown (F) as one indication en-US en-US-en-US lance and control programs. en-USA en-USB en-USC en-USD en-USE en-USF Overall Zika en-US Risk Code en 1 (Blue)=low risk en-US 4 (Red)=high risk Number of en-US people within en-US 5 km with en Code 4 Zika level Is it usually warm enough during Jan for Aedes aegypti / albopictus ? (Red=Yes; Green= No) If above threshold temperature, what is annual % suitability for Aedes aegypti or albopictus ? (Red=Yes; Green=No) Is it usually warm enough during January for Zika replication en-US in mosquito? (Red=Yes; Green=No) If above threshold temperature, what is annual % suitability en-US for Zika? (More red=more suitable)

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January June 2017 41 en-USand were more likely to become infected with DENV en-US en-US -en-US en-US74en-US en-US and Ferreira-de-Brito et alen-US6en-US found that ZIKAV can be en-US vertically transmitted in en-US Ae. aegyptien-US but not en-USAe. albopen-US -en-US ictusen-US This capability suggests mechanisms for the virus en-US to survive in eggs that can survive for months in a dried en-US dormant state during adverse conditions, for example, a en-US harsh winter that would normally kill adult mosquitoesen-US .en-US The approach to estimating risk levels in this project deen-US -en-US en-US and mosquito physiology and relies on published models en-US to consider other drivers, which could include: precipitaen-US -en-US en-US -en-US tors such as imported cases, built-up areas, vegetation en-US indices, human behavioren-US ,en-US and economic indices that can en-US modify risk in complex and less understood ways. Other en-US models could be used in place of the ones included in en-US this study. For example, Samy et alen-US23en-US used proxies for en-US poverty and accessibility that may further increase the en-US biological reality of estimates of transmission risk. As en-US a risk factor for ZIKAV infections is congenital brain en-US abnormalities including microcephaly,en-US75en-US risk estimates en-US would be greatly enhanced by quantifying the proximity en-US of pregnancies to areas of interesten-US76en-US ,en-US 77en-US (ie, military facilien-US -en-US en-US age represent the majority,en-US78en-US and from 2001 to 2010, an en-US average of 15,600 children were born to active compoen-US -en-US nent women each yearen-US .en-US79en-US Data from the Defense Medical en-US Surveillance System do not include records of nonreimen-US-en-US bursed care received at medical facilities outside of the en-US en-US -en-US mating numbers of potentially at-risk mothers, or those en-US en-US programs conducted within military facilities.en-US The Zika virus can be imported and spread by nonvecen-US -en-US tor transmission routes (egen-US ,en-US sexual transmissionen-US80en-US), so it en-US is recommended that a level of caution be taken when en-US interpreting the data provided by this system. It is wise en-US to monitor activity in surrounding facilities and any en-US reputable information from other sources before acting en-US on any recommendations given here. It is further recen-US -en-US ommended that the near-real time and forecast analyen-US -en-US sis should be viewed in conjunction with the monthly en-US en-US monthly maximum temperature, to gain further longer-en-US term insights into where thermal conditions will support en-US vector activity.en-US While this tool could be improved with higher resoluen-US -en-US tion data and more nuanced models, our aim was to creen-US -en-US ate an accessible and adaptable, yet useful platform for en-US entomological decisionen-US -en-US making that uses readily availen-US -en-US able data and models. New models and higher resolution en-US climate data can be easily incorporated into this tool as en-US they become available. Validation of the output from this en-US tool using mosquito surveillance results, and obtaining en-US user feedback, would be useful goals for future research. State # Military facilities1 Zika Risk Code2-5 (average) # facilities where preconditions suitable for transmission (Zika Risk Code 4)5 # facilities with above threshold temperature for the vectors6 # facilities with above threshold temperature for the pathogen7 Total population within 5 km of facilities8 Total population within 5 km with suitable conditions for transmission Alaska 20 1 0 0 0 357,044 0 Alabama 14 1 0 10 0 553,648 0 Arkansas 4 1 0 0 0 187,622 0 Arizona 112.19 0 10 0 556,120 0 California 1001.71 0 79 0 6,655,724 0 Colorado 9 1 0 0 0 386,446 0 Connecticut 10 1 0 0 0 212,038 0 District of Columbia 8 1 0 0 0 842,772 0 Delaware 2 1 0 0 0 52,946 0 Florida 482.44 17 48 1 1,373,859653,556 Georgia 16 1 0 9 0 1,021,113 0 Hawaii 363.2 16 36 1 980,370247,918 Iowa 2 1 0 0 0 266,567 0 Summary of Vector hazard during January for U.S. Military facilities by State for Zika virus en-USFigure en-US6en-US. en-US Summary risk data for each US state (top of list shown) to assist with public health and resource allocation planningen-US

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42 http://www.cs.amedd.army.mil/amedd_journal.aspx AcC KNOWLEDGm M ENTS We thank Jean-Paul Chrietien (Armed Forces Health en-USSurveillance Branch (AFHSB)) for constructive feedback en-US during the development of the Excel Risk Tool, as well as en-US Jim Writer and Penny Masuoka for providing references en-US and feedback useful in the development of the ZIKAV en-US threshold information. We thank LTC Jeff Clark and en-US MAJ Wes McCardle (former and current Walter Reed en-US en-US -en-US port during the development of this tool. We also thank en-US LTC (Ret) Jason Richardson, MAJ Karl Korpal, CDR en-US Fred Stellen-US ,en-US and Dr Terry Carpenter of the Armed Forces en-US Pest Management Board for their feedback. This study en-US was made possible by FY2016 grant P2007_16_WR from en-US the AFHSB and its Global Emerging Infections Surveilen-US -en-US lance and Response Section.en-US This research was performed under a memorandum of en-US understanding between the Walter Reed Army Institute en-US of Research and the Smithsonian Institutions National en-US Museum of Natural History, with institutional support en-US provided by both organizations. The opinions contained en-US en-US views of the supporting agencies. RREFERENc C ES 1. en-USCouncil of State and Territorial Epidemiologists en-US Zika virus disease and congenital Zika virus infecen-US -en-US en-US -en-US en-US Available at: https://www.cste2.org/docs/Zika_Vien-US en-US rus_Disease_and_Congenital_Zika_Virus_Infecen-US en-US tion_Interim.pdf. Accessed February 27, 2017. 2. en-USWalker WL, Lindsey NP, Lehman JA, et al. Zika en-US virus disease cases 50 states and the District of en-US Columbia, January 1-July 31, 2016. en-US MMWR Morb en-US Mortal Wkly Repen-US 2016;65(36);983-986. 3. en-USen-US mosquito-borne transmission of Zika virus Mien-US -en-US ami-Dade and Broward counties, Florida, June-en-US August 2016. en-USMMWR Morb Mortal Wkly Repen-US en-US 2016;65(38):1032-1038. 4. en-USGrard G, Caron M, Mombo IM, et al. Zika vien-US -en-US rus in Gabon (Central Africa)-2007: a new threat en-US from en-US Aedes albopictusen-US ?. en-US PLoS Negl Trop Disen-US en-US 2014;8(2):e2681. en-USNumber of military facilities en-USNumber of facilities with above threshold temperature for the vectors en-USNumber of facilities with above threshold temperature for the pathogen en-USTotal population within en-US5en-US km of facilities en-USTotal population within en-US5en-US km of facilities with suitable conditions for transmission en-USNumber of facilities where preconditions are suitable for transmission (Zika Risk Code 4) en-USJan en-USFeb en-USMar en-USApr en-USMay en-USJun en-USJul en-USAug en-USSep en-USOct en-USNov en-USDec en-USMonthen-US 100000000en-US 10000000en-US 1000000en-US 100000en-US 10000en-US 1000en-US 100en-US 10en-US 1 en-USTotal Population (Logen-US10en-US)en-US800en-US 700en-US 600en-US 500en-US 400en-US 300en-US 200en-US 100en-US 0 en-USNumber of Facilities en-USFigure en-US7en-US. en-US Summary risk data for en-US733en-US US military facilities over en-US12en-US months. en-USA LOCATION-SPECIFIC SPREADSHEET FOR ESTIMATING ZIKA RISK AND TIMING FORen-US en-US ZIKA VECTOR SURVEILLANCE, USING US MILITARY FACILITIES AS AN EXAMPLE

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January June 2017 43 5. en-USGuerbois M, Fernandez-Salas I, Azar SR, et al. en-US Outbreak of Zika virus infection, Chiapas State, en-US en-US Aedes aegyptien-US mosquitoes in the Americas. en-US J Infect en-US Disen-US 2016;214(9):1349-1356. DOI: 10.1093/infdis/en-US jiw302. 6. en-USFerreira-de-Brito A, Ribeiro IP, Miranda RM, et al. en-US First detection of natural infection of en-US Aedes aegypen-US -en-US tien-US with Zika virus in Brazil and throughout South en-US America. en-US Mem Inst Oswaldo Cruzen-US 2016;111(10):655-en-US 658. DOI: 10.1590/0074-02760160332. 7. en-USScott TW, Amerasinghe PH, Morrison AC, et al. en-US Longitudinal studies of en-US Aedes aegypti en-US (Diptera: en-US Culicidae) in Thailand and Puerto Rico: blood feeden-US -en-US ing frequency. en-USJ Med Entomolen-US 2000;37(1):89-101. 8. en-USScott TW, Clark GG, Amerasinghe PH, Lorenz LH, en-US Reiter P, Edman JD. 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Zika mosquito vectors: the jury is still en-US out [version 2; referees: 5 approved]. en-US F1000Resen-US en-US 2016;5:2546. DOI: 10.12688/f1000research.9839.2. 12. en-USFoley DH, Maloney FA Jr, Harrison FJ, Wilkeren-US -en-US son RC, Rueda LM. Online spatial database of en-US en-US 1947-2009. en-US US Army Med Dep Jen-US July-September en-US 2011:29-36. 13. en-USPellerin C. DoD adds funding to enhance Zika en-US surveillance by military labs. en-US DoD News, Defense en-US Media Activityen-US May 16, 2016. Available at: http://en-US www.defense.gov/News/Article/Article/760169/en-US dod-adds-funding-to-enhance-Zika-surveillance-en-US by-military-labs. Accessed February 27, 2017. 14. en-USen-US hubs are most at risken-US ? Military Timesen-US April 10, en-US 2016. Available at: http://www.militarytimes.com/en-US story/military/2016/04/10/Zika-threat-hits-home-en-US which-us-military-hubs-most-risk/82664202/. Acen-US -en-US cessed February 27, 2017. 15. en-USAttaway DF, Waters NM, Geraghty EM, Jacoben-US -en-US sen KH. Zika virus: endemic and epidemic ranges en-US of en-US Aedesen-US mosquito transmission. en-USJ Infect Puben-US -en-US lic Healthen-US 2016;10(1):120-123. DOI: 10.1016/j.en-US jiph.2016.09.008. 16. en-USBrady OJ, Golding N, Pigott DM, et al. Global en-US temperature constraints on en-USAedes aegyptien-US and en-US Ae. en-US albopictusen-US persistence and competence for dengue en-US virus transmission. en-US Parasit Vectorsen-US 2014;7:338. en-US Available at: http://parasitesandvectors.biomeden-US en-US central.com/articles/10.1186/1756-3305-7-338. Acen-US -en-US cessed March 29, 2017. 17. en-USCampbell LP, Luther C, Moo-Llanes D, Ramsey en-US JM, Danis-Lozano R, Peterson AT. Climate change en-US en-US -en-US gue and chikungunya viruses. en-USPhilos Trans R Soc en-US Lond B Biol Scien-US 2015;370(1665). DOI: 10.1098/en-US rstb.2014.0135. 18. en-USKhormi HM, Kumar L. Climate change and the poen-US -en-US tential global distribution of en-US Aedes aegyptien-US : spatial en-US modelling using geographical information system en-US and CLIMEX. en-USGeospat Healthen-US 2014;8(2):405-415. 19. en-USMedley KA. Niche shifts during the global invaen-US -en-US sion of the Asian tiger mosquito, en-US Aedes albopictusen-US en-US Skuse (Culicidae), revealed by reciprocal distribuen-US -en-US tion models. en-USGlob Ecol Biogeogren-US 2010;19:122-133. 20. en-USCarlson CJ, Dougherty ER, Getz W. An ecologien-US -en-US cal assessment of the pandemic threat of Zika virus. en-US PLoS Negl Trop Den-US is. 2016;10(8):e0004968. DOI: en-US 10.1371/journal.pntd.0004968. 21. en-USen-US -en-US ping global environmental suitability for Zika virus. en-US Elifeen-US 2016;5. pii: e15272. DOI: 10.7554/eLife.15272. 22. en-USPerkins TA, Siraj AS, Ruktanonchai CW, Kraeen-US -en-US en-US Zika virus infections in childbearing women in en-US the Americas. en-US Nat Microbiolen-US 2016;1(9):16126. DOI: en-US 10.1038/nmicrobiol.2016.126. 23. en-USSamy AM, Thomas SM, Wahed AA, Cohoon en-US KP, Peterson AT. Mapping the global geoen-US -en-US graphic potential of Zika virus spread. en-US Mem en-US Inst Oswaldo Cruzen-US 2016;111(9):559-560. DOI: en-US 10.1590/0074-02760160149. 24. en-USen-US -en-US tion in mosquitoes. en-US Adv Virus Resen-US 2003;60:187-232. 25. en-USCouret J, Benedict MQ. A meta-analysis of the en-US en-US in en-US Aedes aegyptien-US (Diptera: Culicidae). en-US BMC Ecolen-US en-US 2014;14:3. DOI: 10.1186/1472-6785-14-3. 26. en-USBrady OJ, Johansson MA, Guerra CA, et al. Modelen-US -en-US ling adult en-USAedes aegypti en-USanden-US Aedes albopictusen-US suren-US -en-US vival at different temperatures in laboratory and en-US en-USParasit Vectorsen-US 2013;6:351. 27. en-USGubler DJ, Kuno G, Markoff L. Flaviviruses. In: en-US en-US Fields Virologyen-US Vol. 1, 5th Ed. Philadelphia, PA: en-US Lippincott Williams & Wilkins; 2007;1153-1252. 28. en-USBonne-Wepster J, Brug SL. The Subgenus en-US Stegoen-US -en-US myiaen-US in Netherland India. en-US Geneeskundig Tijdschrift en-US voor Nederlandsch-Indien-US 1932;72:39-119.

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44 http://www.cs.amedd.army.mil/amedd_journal.aspx 29. en-USMarchoux, Salimbeni, Simond. La Fivre Jaune. en-US en-US Annals de linstitut en-US Pasteuren-US 1903;XVII:665-734. Cited by: Bonne-en-US Wepster J, Brug SL. The Subgenus en-US Stegomyiaen-US in en-US Netherland India. en-USGeneeskundig Tijdschrift voor en-US Nederlandsch-Indien-US 1932;72:39-119. 30. en-USHoward LO, Dyar HG, Knab F. en-US The Mosquitoes of en-US North and Central America and the West-Indiesen-US en-US Vol I. Washington DC: The Carnegie Institution en-US of Washington; 1912. Cited by: Bonne-Wepster J, en-US Brug SL. The Subgenus en-US Stegomyiaen-US in Netherland en-US India. en-US Geneeskundig Tijdschrift voor Nederlanden-US -en-US sch-Indien-US 1932;72:39-119. 31. en-USConnor ME. Renseignements sur lAedes calopus en-US (en-US Stegomyiaen-US ). Mexico [abstract]. en-US Bull Off Int Hyg en-US Publen-US 1922;XV:506. Cited by: Bonne-Wepster J, en-US Brug SL. The Subgenus en-US Stegomyiaen-US in Netherland en-US India. en-US Geneeskundig Tijdschrift voor Nederlanden-US -en-US sch-Indien-US 1932;72:39-119. 32. en-USen-US -en-US stract] en-US Bull Off Int Hyg Publen-US 1931;XXIII:1664; and en-US Bull Inst Pasten-US 1931;XXIX:895. Cited by: Bonne-en-US Wepster J, Brug SL. The Subgenus en-US Stegomyiaen-US in en-US Netherland India. en-USGeneeskundig Tijdschrift voor en-US Nederlandsch-Indien-US 1932;72:39-119. 33. en-USDavis NC. Brazil Medico. en-US Trop Dis Bullen-US en-US 1931;XLV:77; [abstract] 1931;XXVIII:726.Cited by: en-US Bonne-Wepster J, Brug SL. The Subgenus en-US Stegoen-US -en-US myiaen-US in Netherland India. en-US Geneeskundig Tijdschrift en-US voor Nederlandsch-Indien-US 1932;72:39-119. 34. en-USGuiteras, Otto, Neumann [detailed citation inforen-US -en-US mation not available] In: Howard LO, Dyar HG, en-US Knab F. en-US The Mosquitoes of North and Central en-US America and the West-Indiesen-US Vol I. Washington en-US DC: The Carnegie Institution of Washington; 1912. en-US Cited by: Bonne-Wepster J, Brug SL. The Subgenus en-US Stegomyiaen-US in Netherland India. en-US Geneeskundig Tijden-US -en-US schrift voor Nederlandsch-Indien-US 1932;72:39-119. 35. en-USFlu PC. Tests re the period in which Stegomia fasen-US -en-US ciata can live at low temperatures. Mededeel. v. d. en-US burgerl. geneesk. dienst. In: en-USNederlIndien-US Batavia, en-US Deel vii:95-105. Cited by: Bonne-Wepster J, Brug en-US SL. The Subgenus en-USStegomyiaen-US in Netherland India. en-US Geneeskundig Tijdschrift voor Nederlandsch-Indien-US en-US 1932;72:39-119. 36. en-USDinger JE, Schffner WAP, Snijders EP, Swellenen-US -en-US grebel NH. en-US Ned Tijdschr v Genen-US 1929;LXXV(I):2964 en-US Cited by: Bonne-Wepster J, Brug SL. The Subgenus en-US Stegomyiaen-US in Netherland India. en-US Geneeskundig Tijden-US -en-US schrift voor Nederlandsch-Indien-US 1932;72:39-119. 37. en-USKhormi HM, Kumar L, Elzahrany R. Describing en-US and analyzing the association between meteorologen-US -en-US ical variables and adult en-US Aedes aegyptien-US mosquitoes. en-US J Food Agr Environen-US 2011;9:954-959. 38. en-USConnor ME. Suggestions for developing a camen-US -en-US paign to control yellow fever. en-US Am J Trop Meden-US en-US 1924;4:277-307. 39. en-USWayne AR, Graham CL. The effect of temperaen-US -en-US en-US -en-US mance of female en-US Aedes aegyptien-US en-US J Insect Physiolen-US en-US 1968;14:1251-1257. 40. en-USen-US Stegomyiaen-US en-US fasciataen-US short en-US exposures to raised temperatures. en-USAnn Trop Med en-US Parasitolen-US 1920;14:73-82. 41. en-USBliss AR, Gill JM. The effects of freezing on en-US the larvae of en-USAedes aegyptien-US Aen-US m J Trop Med Hygen-US en-US 1933;13:583-588. 42. en-USChristophers SR. en-US Aedes aegypti (L.) the Yellow en-US Fever Mosquito. Its Life History, Bionomics and en-US Structureen-US en-US Press; 1960. 43. en-USEstrada-Franco JG, Craig GB. en-US Biology, Disease en-US Relationships, and Control of Aedes albopictusen-US en-US Washington DC: Pan American Health Organizaen-US -en-US tion; 1995. 44. en-USCarrington LB, Armijos MV, Lambrechts L, Barker en-US en-US -en-US atures at critical thermal extremes on en-US Aedes aegypen-US -en-US tien-US life-history traits. en-USPLoS Oneen-US 2013;8(3):e58824. 45. en-USCarrington LB, Seifert SN, Willits NH, Lamen-US -en-US brechts L, Scott TW. Large diurnal temperature en-US en-US Aedes aegyptien-US en-US (Diptera: Culicidae) life-history traits. en-US J Med Entoen-US -en-US molen-US 2013;50(1):43-51. 46. en-USWallis RC. en-USA GIS Model for Predicting Potential en-US High Risk Areas of West Nile Virus by Identifying en-US Ideal Mosquito Breeding Habitatsen-US [masters thesis]. en-US 47. en-USXiao FZ, Zhang Y, Deng YQ, He S, Xie HG. en-US The effect of temperature on the extrinsic incuen-US -en-US bation period and infection rate of dengue vien-US -en-US rus serotype 2 infection in en-US Aedes albopictusen-US en-US Arch Virolen-US 2014;159:3053-3057. DOI: 10.1007/en-US s00705-014-2051-1. 48. en-USDohm DJ, OGuinn ML, Turell MJ. Effect of enen-US -en-US vironmental temperature on the ability of en-USCulex en-US pipiensen-US (Diptera: Culicidae) to transmit West Nile en-US virus. en-USJ Med Entomolen-US 2002;39:221-225. 49. en-USCornel AJ, Jupp PG, Blackburn NK. Environmenen-US -en-US tal temperature on the vector competence of en-US Culex en-US univittatusen-US (Diptera: Culicidae) for West Nile Vien-US -en-US rus. en-USJ Med Entomolen-US 1993;30:449-456. 50. en-USKinney RM, Huang CY, Whiteman MC, et al. Avien-US -en-US an virulence and thermostable replication of the en-US North American strain of West Nile Virus. en-US J Gen en-US Virolen-US 2006;87:3611-3622.en-USA LOCATION-SPECIFIC SPREADSHEET FOR ESTIMATING ZIKA RISK AND TIMING FORen-US en-US ZIKA VECTOR SURVEILLANCE, USING US MILITARY FACILITIES AS AN EXAMPLE

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January June 2017 45 51. en-USTilston N, Skelly C, Weinstein P. Pan-European en-US en-US surveillance zones. en-USInt J Health Geogren-US 2009;8:61. en-US DOI: 10.1186/1476-072X-8-61. 52. en-USKostyuchenko VA, Lim Elisa XY, Zhang S, et en-US al. Structure of the thermally stable Zika virus. en-US Natureen-US 2016;533(7603):425-428. DOI: 10.1038/en-US nature17994. 53. en-USGoo L, Dowd KA, Smith AR, Pelc RS, DeMaso en-US CR, Pierson TC. Zika virus is not uniquely stable en-US at physiological temperatures compared to other en-US en-US MBioen-US 2016;7(5). Available at: https://en-US www.ncbi.nlm.nih.gov/pubmed/27601578. Acen-US -en-US cessed March 30, 2017. 54. en-USen-US at: http://www.census.gov/geo/maps-data/data/tien-US -en-US ger.html. Accessed February 28, 2017. 55. en-USNASA/GSFC (Air temperature at surface Daytime/en-US Ascending AIRX3STD v006). Available at: http://en-US giovanni.gsfc.nasa.gov/giovanni/. Accessed Februen-US -en-US ary 28, 2017. 56. en-USen-US Weather Service. Available at: http://www.cpc.en-US ncep.noaa.gov/products/GIS/GIS_DATA/. Acen-US -en-US cessed February 28, 2017. 57. en-USNational Digital Forecast Database. Available at: en-US http://www.nws.noaa.gov/ndfd/index.htm. Acen-US -en-US cessed February 28, 2017. 58. en-USWorldClim-Global Climate Data center. Available en-US at: http://www.worldclim.org/. Accessed March 30, en-US 2017. 59. en-USen-US Shearer FM, Barker CM, et al. The global distrien-US -en-US bution of the arbovirus vectors en-USAedes aegyptien-US and en-US Ae. albopictusen-US en-US ELifeen-US 2015;4:e08347. DOI: 10.7554/en-US eLife.08347. 60. en-USHonrio N, Alves S, Wellington da Costa L, et al. en-US Dispersal of en-USAedes aegyptien-US and en-USAedes albopictusen-US en-US (Diptera: Culicidae) in an urban endemic dengue en-US area in the State of Rio de Janeiro, Brazil. en-US Mem Inst en-US Oswaldo Cruzen-US 2003;98(2):191-198. 61. en-USHarrington LC, Scott TW, Lerdthusnee K, et al. en-US Dispersal of the dengue vector en-USAedes aegyptien-US withen-US -en-US in and between rural communities. en-US Am J Trop Med en-US Hygen-US 2005;72:209-220. 62. en-USOak Ridge National Laboratory. LandScan [inen-US -en-US ternet]. 2011. Available at: http://web.ornl.gov/sci/en-US landscan/landscan_data_avail.shtml. Accessed en-US February 28, 2017. 63. en-USFoley DH. A spreadsheet mapping approach for eren-US -en-US ror checking and sharing collection point data. en-US Bioen-US -en-US diversity Informaticsen-US 2011;7(3):137-142. 64. en-USArcGIS. World Terrain Base. Redlands, CA: Esri; en-US Available at: http://www.arcgis.com/home/item.hten-US en-US ml?id=c61ad8ab017d49e1a82f580ee1298931. Acen-US -en-US cessed Feb 28, 2017. 65. en-USVectorMap; 2016. Available at: http://vectormap.en-US si.edu/Project_ESWG_ExcelZika.htm. Accessed en-US February 28, 2017. 66. en-USMonaghan AJ, Morin CW, Steinhoff DF, et al. On en-US the seasonal occurrence and abundance of the Zika en-US virus vector mosquito en-US Aedes aegyptien-US in the conen-US -en-US en-US PLoS Curren-US [serial online]. en-US March 16, 2016. Available at: http://currents.plos.en-US org/outbreaks/article/on-the-seasonal-occurrence-en-US and-abundance-of-the-Zika-virus-vector-mosquien-US en-US to-aedes-aegypti-in-the-contiguous-united-states/. en-US Accessed March 30, 2017. 67. en-USDefense Health Agency. Electronic Surveillance en-US en-US based Epidemics [internet]. 2017. Available at: en-US http://www.health.mil/Military-Health-Topics/en-US Technology/Clinical-Support/Centralized-Credenen-US en-US tials-Quality-Assurance-System/Decision-Supen-US en-US port/Electronic-Surveillance-System-for-the-Earen-US en-US ly-Notification-of-Community-based-Epidemics. en-US Accessed Feb 28, 2017. 68. en-USen-US -en-US ater [internet]; 2017. Available at: http://www.mc4.en-US army.mil/apps/MSAT. Accessed February 28, 2017. 69. en-USArmed Forces Pest Management Board. Available en-US at: http://www.acq.osd.mil/eie/afpmb/. Accessed en-US June 13, 2016. 70. en-USNavy and Marine Corps Public Health Center. en-US Aeen-US -en-US des Surveillance and Control Plan for U.S. Navy en-US and Marine Corps Installationsen-US February 2016. en-US Available at: http://www.med.navy.mil/sites/en-US nmcphc/Documents/program-and-policy-support/en-US NMCPHC-Aedes-Surveillance-Contro-for-NMC-en-US Installations.pdf. Accessed February 27, 2017. 71. en-USFischer D, Thomas SM, Suk JE, et al. Climate change en-US effects on chikungunya transmission in Europe: en-US geospatial analysis of vectors climatic suitability en-US and virus temperature requirements. en-US Int J Health en-US Geogren-US 2013;12:51. DOI: 10.1186/1476-072X-12-51. 72. en-USWestbrook CJ, Reiskind MH, Pesko KN, Greene en-US KE, Lounibos PL. Larval environmental temperen-US -en-US ature and the susceptibility of en-US Aedes albopictusen-US en-US Skuse (Diptera: Culicidae) to Chikungunya virus. en-US Vector Borne Zoonotic Disen-US 2010;10(3):241-247. 73. en-USLambrechts L, Paaijmans KP, Fansiri T, et al. Imen-US -en-US en-US virus transmission by en-USAedes aegyptien-US en-US Proc Natl en-US Acad Sci USAen-US 2011;108(18):7460-7465.

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46 http://www.cs.amedd.army.mil/amedd_journal.aspx 74. en-USThangamani S, Huang J, Hart CE, Guzman H, en-US Tesh RB. Vertical transmission of Zika virus in en-US Aedes aegyptien-US mosquitoes. en-USAm J Trop Med Hygen-US en-US 2016;95(5):1168-1173. 75. en-USKrauer F, Riesen M, Reveiz L, et al. Zika virus inen-US -en-US fection as a cause of congenital brain abnormalities en-US en-US PLoS Meden-US 2017;14(1):e1002203. DOI: 10.1371/jouren-US -en-US nal.pmed.1002203. 76. en-USTatem AJ, Campbell J, Guerra-Arias M, de Beren-US -en-US nis L, Moran A, Matthews Z. Mapping for maen-US -en-US ternal and newborn health: the distributions en-US of women of childbearing age, pregnancies en-US and births. en-US Int J Health Geogren-US 2014;13:2. DOI: en-US 10.1186/1476-072X-13-2. 77. en-USAlex Perkins T, Siraj AS, Ruktanonchai CW, Kraeen-US -en-US en-US Zika virus infections in childbearing women in en-US the Americas. en-US Nat Microbiolen-US 2016;1(9):16126. DOI: en-US 10.1038/nmicrobiol.2016.126. 78. en-USBraun L, Kennedy H, Womack J, Wilson C. Inen-US -en-US en-US genitourinary and reproductive health. en-US Mil Meden-US en-US 2016;181(1):35-49. 79. en-USArmed Forces Health Surveillance Center. Births, en-US en-US MSMRen-US 2011;18(12):16-17. 80. en-USFoy BD, Kobylinski KC, Chilson Foy JL, et al. Proben-US -en-US able non-vector-borne transmission of Zika virus, en-US en-US Emerg Infect Disen-US 2011;17:880-882. AUTHORS Dr Foley is a Research Entomologist at the Walter Reed en-USen-US Army Institute of Research, and a Research Associate en-US of the Entomology Department within the National Muen-US -en-US seum of Natural History, located at the Smithsonian Inen-US -en-US stitution, Museum Support Center, Suitland, Maryland.en-US Mr Pecor is the VectorMap technical assistant at the en-US en-US Walter Reed Army Institute of Research, located at the en-US Smithsonian Institution, Museum Support Center, Suiten-US -en-US land, Maryland.en-USA LOCATION-SPECIFIC SPREADSHEET FOR ESTIMATING ZIKA RISK AND TIMING FORen-US en-US ZIKA VECTOR SURVEILLANCE, USING US MILITARY FACILITIES AS AN EXAMPLE en-USAedes aegyptien-US en-US(courtesy of the CDC) en-USAedes albopictusen-US en-US(courtesy of the CDC)

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en-USJanuary June 2017 en-US47en-USMalaria is a major health threat to military and civilian en-US personnel as well as family members deployed or residen-US -en-US ing in the Republic of Korea (ROK). Members of the en-US Anophelesen-US (en-US Anophelesen-US ) are placed in 3 groups, namely en-US the Hyrcanus Group (en-US An.en-US en-US belenraeen-US Rueda, en-USAn.en-US en-US kleinien-US en-US Rueda, en-US An.en-US en-US sinensisen-US Wiedemann, en-US An.en-US en-US pullusen-US Yamada, en-US An.en-US en-US lesterien-US Baisas and Hu, en-US An.en-US en-US sineroidesen-US Yamada), the en-US Barbirostris Group (en-US An.en-US en-US koreicusen-US Yamada and Wataen-US -en-US nabe), and the Lindesayi Group (en-US An.en-US en-US lindesayien-US en-US japonien-US -en-US cusen-US Yamada).en-US1-3en-US en-US Anophelesen-US en-US kleinien-US and en-USAn.en-US en-US lesterien-US are the en-US primary vectors of en-US Plasmodiumen-US en-US vivaxen-US malaria near the en-US demilitarized zone (DMZ), while en-US An.en-US en-US sinensisen-US is a very en-US poor vector and the status of the remaining species is en-US undetermined.en-US4,5en-US Laboratory studies have shown the poen-US -en-US tential for en-USAn.en-US en-US lesterien-US en-US6,7en-US and is conen-US -en-US sidered a primary vector (as en-USAn.en-US en-US anthropophagusen-US Xu and en-US Feng) in parts of China.en-US8en-US In the ROK, the populations of en-US An.en-US en-US lesterien-US are very low,en-US9en-US except on the northwest coastal en-US islands.en-US10en-US Females of en-US An.en-US en-US belenraeen-US and en-US An.en-US en-US sineroidesen-US en-US have been found positive for en-US P.en-US en-US vivaxen-US by enzyme-linked en-US immunosorbent assay and polymerase chain reaction en-US (PCR).en-US9,11en-US Species in Barbirostris and Lindesayi Groups en-US have not been implicated as malaria vectors in the ROK.en-US9en-USKnowledge of the species composition of common en-US Anophelesen-US (en-US Anophelesen-US ) in various habitats in different en-US en-US-en-US tions, biosurveillance and vector control. Data are limiten-US -en-US ed on the collections and habitats for the occurrence and en-US relative abundance of indigenous en-US Anophelesen-US mosquitoes en-US in the ROK.en-US With several human malaria cases reported annually en-USfrom the ROK,en-US10,12,13en-US there is an urgent need to accurately en-US identify the potential en-US Anophelesen-US mosquito vectors. Misen-US -en-US en-US -en-US veillance, misunderstanding of the epidemiology of en-US disease transmission, and the development and impleen-US -en-US mentation of ineffective strategies for control measures.en-US1en-US en-US Both morphological and molecular analyses are essenen-US -en-US en-US the en-US Anophelesen-US Hyrcanus Group species, particularly en-US those where their geographic distribution and vector poen-US -en-US tential are better understood. During the mosquito suren-US -en-US en-US may also be convenient and necessary, when possible.en-US Waxy body ornamentations have been previously reen-US -en-US ported on various insects, particularly scale insects,en-US14en-US en-US aphids,en-US15en-US and heliconian caterpillar,en-US16en-US and they have en-US en-US -en-US en-US in the body ornamentations for different stages of deen-US -en-US velopment, eg, leg paddles observed in the sabethine en-US mosquitoes, en-US Sabethesen-US en-US cyaneusen-US (Fabricius)en-US17en-US are imporen-US -en-US tant. Knowledge on mosquito body ornamentation is en-US very limited, and little is known about the waxy body en-US covering of larvae and pupae of en-US Anophelesen-US species or its en-US en-US Immature stages (both larvae and pupae) and adults of en-US members of the en-US An.en-US (en-US Ano.en-US ) Hyrcanus Group in the ROK en-US en-US techniques. Although there are some slight differences en-US in the branching patterns of the setae in the larval head en-US (setae 3, 7, 9-C), thorax (14-M) and abdomen (5, 9-II; 4, en-US 9-III; 4, 6-IV; 6-V),en-US3en-US they are still not very useful in peren-US -en-US en-USBiosurveillance and Morphological Variationsen-US en-US of Larvae and Pupae of Common Malariaen-US en-US Vectors, en-USAnophelesen-US (en-US Anophelesen-US ) Hyrcanusen-US en-US Group Species in the Republic of Korea L eopoldo M. Rueda, PhD T erry A. Klein, PhD H eung-Chul Kim, PhD M ustapha Debboun, PhD, BCE S ung-Tae Chong, MS ABSTRac AC T A total of 4,576 en-USAnophelesen-US (en-US Anophelesen-US ) Hyrcanus Group larvae belonging to 6 species (en-US An.en-US en-US belenraeen-US en-US An.en-US en-US kleinien-US en-US An.en-US en-US sinensisen-US en-US An.en-US en-US pullusen-US en-US An.en-US en-US lesterien-US and en-USAn.en-US en-US sineroidesen-US ) were collected from 7 different habitat types in 3 proven-US -en-US inces of the Republic of Korea. The occurrence and relative abundance of 6 en-US Anophelesen-US species were noted. The en-US descriptions in the article of the waxy body ornamentations or patterns of en-US An.en-US (en-US Ano.en-US ) Hyrcanus Group larvae en-US

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en-US48 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USrequiring the need for the PCR techniques. Furthermore, en-US specimens must be mounted on glass slides for microen-US -en-US scopic morphological examinations of the branching en-US patterns of setae of the head and other body parts, reen-US -en-US en-US Some waxy ornamentations or patterns on the dorsal en-US parts of the larval bodies were observed during the conen-US -en-US en-US Anophelesen-US mosquitoes from various parts of the ROK.en-US The main objectives of our study were: (1) to conduct en-US a comparative survey of mosquito larvae from selected en-US habitats using standardized sampling methods to obtain en-US pertinent data on the occurrence and relative abundance en-US of indigenous en-USAnophelesen-US species, and (2) to identify the en-US waxy body ornamentations or patterns of en-USAnophelesen-US en-US (en-US Anophelesen-US ) Hyrcanus Group larvae and pupae which en-US en-US -en-US quito vector surveillance and control. MaA TERIa A LS aA ND METHODS Immature mosquito collections that included both en-USanophelines and culicines were conducted from 3 proven-US -en-US inces (Gyeonggi, Gyeongsangbuk, and Chungcheongen-US -en-US buk) of the ROK (Figure 1). Selected habitats were samen-US-en-US pled including the following: rice paddies (uncultivated en-US and cultivated), irrigation ditches (concrete and nonen-US -en-US concrete ditches), drainage ditches (concrete and nonen-US -en-US concrete ditches, culvert and dammed ditches), ponds en-US (including pond reservoir), stream margins (including en-US stream ponds, inlets, algal mats), and other habitats (inen-US -en-US en-US en-US As part of the mosquito biosurveillance, data were colen-US -en-US lected monthly from May 2007 to October 2007 and en-US were combined over the sampling periods for each of en-US the selected habitats in 3 provinces (Gyeonggi, Gyeongen-US -en-US sangbuk, and Chungcheongbuk). The relative abundance en-US of each en-USAnopheleen-US s species in each habitat was calculated en-US as the percentage of the total number of larvae recoven-US -en-US ered either per month or over the entire 6-month period.en-US As part of the morphological study of waxy body ornaen-US -en-US mentations, en-US Anophelesen-US larvae were collected from 9 loen-US -en-US cations in Gyeongsangbuk Province, including Hayang-en-US eup, Gyeongsansi (Collection nos. KSK-509, 511, 513, en-US 514, 520, 522, 523) and Cheongsong-eup, Jinbo-myeon en-US (Collection nos. KSK-529, 533, 543, 545).en-US Depending on the habitats, larvae and pupae were colen-US -en-US lected using a standard larval dipper (350 ml, 13 cm dien-US -en-US ameter) or a white plastic larval tray (25 cm x 20 cm x 4 en-US cm) (BioQuip, Rancho Dominguez, CA). Collected live en-US larvae and pupae, with intact waxy ornamentations or en-US body patterns were placed in plastic Whirl-Pak bags (118 en-US ml, 8 cm x 18 cm) (BioQuip, Rancho Dominguez, CA) en-US en-US -en-US tion site. The Whirl-Pak was tightly closed en-US to retain air, placed in a cooler, and brought en-US to the laboratory where selected specimens en-US were photographed on the same day, and en-US 3rd and 4th instar larvae then placed and en-US directly preserved in 100% ethanol (EtOH) en-US en-US -en-US ing larvae were individually link-reared to en-US adult stage as morphological voucher specen-US -en-US imens for this work. Emergent mosquito en-US adults were pinned on paper points, each en-US given a unique collection number, and en-US en-US en-US -en-US cations, DNA was isolated from individual en-US larval mosquitoes and adults (1 or 2 legs en-US per adult) by extraction procedure and dien-US -en-US rect sequencing as described in Wilkerson en-US et al.en-US12en-US Sequencing of en-US An.en-US en-US sinensisen-US en-US An.en-US en-US pulen-US -en-US lusen-US en-US An.en-US en-US lesterien-US en-US An.en-US en-US belenraeen-US and en-US An.en-US en-US kleinien-US en-US are those of Wilkerson et alen-US12en-US and Li et alen-US18en-US en-US using the primers therein. GenBank acen-US -en-US cession numbers for the above species are en-US in Wilkerson et alen-US12en-US and Li et al.en-US18en-US Voucher en-US specimens and collection records were en-US BIOSURVEILLANCE AND MORPHOLOGICAL VARIATIONS OF LARVAE AND PUPAE OF COMMON MALARIAen-US en-US VECTORS, en-US ANOPHELESen-US (en-US ANOPHELESen-US ) HYRCANUS GROUP SPECIES IN THE REPUBLIC OF KOREAen-USFigure en-US1en-US. Geographic locations of the 3 provinces in the Republic of Korea en-US within which mosquitoe collections were conducted. en-USLatitude (degrees)en-US38en-US 37en-US 36en-US 39en-US 35en-US 34en-US 33en-USLongitude (degrees)en-US130en-US 129en-US 128en-US 127en-US 125en-US 126 en-US45,000 en-US0 en-US90,000 en-US 180,000 Meters

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en-USJanuary June 2017 en-US49 en-USen-US -en-US tory, Smithsonian Institution, Suitland, Maryland. RRESULTS Occurrence and Relative Abundance of Mosquito en-USLarvae from Selected Habitatsen-USA total of 4,576 specimens belonging to 6 species of en-US An.en-US en-US (en-US Ano.en-US ) Hyrcanus Group species (en-US An.en-US en-US belenraeen-US en-US An.en-US en-US kleinien-US en-US An.en-US en-US sinensisen-US en-US An.en-US en-US pullusen-US en-US An.en-US en-US lesterien-US and en-USAn.en-US en-US sineroien-US -en-US desen-US ) were collected monthly from May 2007 to October en-US 2007 from 7 general habitats by standard larval samen-US-en-US pling method. As shown in the Table, all 6 species were en-US collected from irrigation ditches, while only 5 species en-US were collected from rice paddies, ponds, swamps, and en-US other habitats, and only 4 species were collected from en-US drainage ditches, and stream margins. In the irrigation en-US ditches, en-US An.en-US en-US sinensisen-US (71.82%) was the most abundant en-US species, followed by en-US An.en-US en-US kleinien-US (12.84%) and en-US An.en-US en-US sineren-US -en-US oidesen-US (9.68%). en-US Anophelesen-US larval population increased en-US from 19.92% in June to 24.50% in August. In the rice en-US paddies, en-US An.en-US en-US sinensisen-US (82.09%) had the greatest relative en-US abundance followed by en-US An.en-US en-US pullusen-US (10.38%) and en-US An.en-US en-US kleen-US -en-US inien-US (5.04%). Larval population increased from 16.03% in en-US May to 23.81% in June. Except for en-US An.en-US en-US lesterien-US all speen-US -en-US cies were collected from the rice paddies. In the pond en-US reservoir, en-US An.en-US en-US sinensisen-US (54.63%) was the dominant speen-US -en-US cies, followed by en-US An.en-US en-US kleinien-US (22.82%) and en-USAn.sineroidesen-US en-US (12.55%). Larval population increased from 15.75% in en-US July to a peak of 24.28% in August. In the stream maren-US -en-US gins and swamps, respectively, en-US An.en-US en-US sinensisen-US (80.07%, en-US en-US An.en-US en-US kleen-US -en-US inien-US (13.07%, 27.78%) and en-USAn.en-US en-US pullusen-US (5.85%, 30.38%). en-US Larval population increased from 23.04% and 12.08% en-US in July to 26.37% and 29.31% in August. In the drainage en-US ditches, en-US An.en-US en-US sinensisen-US (51.98%) was the dominant species, en-US followed by en-USAn.en-US en-US pullusen-US (20.63%) and en-USAn.en-US en-US kleinien-US (9.33%). en-US Larval population increased from 15.38% in June to a en-US peak of 35.90% in August. In all sampled habitats, en-US An.en-US en-USsinensisen-US had the highest relative abundance in all habien-US -en-US tats, and its larvae were found in all 7 habitats similar en-US to en-US An.en-US en-US kleinien-US en-US An.en-US en-US pullusen-US and en-USAn.en-US en-US sineroidesen-US en-US Anophelesen-US en-US lesterien-US larvae were only collected from the irrigation en-US ditches and swamps, while en-USAn.en-US en-US belenraeen-US larvae were en-US only found in rice paddies, irrigation ditches, and ponds. en-US Rueda et alen-US2en-US reported the associations of en-USAn.en-US (en-US Ano.en-US ) with en-US other species of en-US Aedesen-US and en-USCulexen-US from different habitats en-US in the ROK.en-USMorphological Descriptions of 5 Common en-USAnophelesen-US en-US (en-US Anophelesen-US ) Speciesen-US ,en-US with Emphasis on Waxy en-US Ornamentations or Body Patterns, Based on en-US en-US Korean Specimens 1. en-USAn.en-US en-US belenraeen-US Larva:en-US Body coloration is usually en-US green or light reddish brown. Thorax has dorsal parts en-US almost covered with white waxy materials, primarily en-US along the anterior and lateral edges. It usually has en-US a slightly pointed waxy ornamentation extending up en-US to the anterior tip of the dorsum of abdominal segen-US -en-US ment I (Figure 2; collection nos. KSK-545-1001L, en-US KSK-545-1008L, KSK-545-1011L). Abdomen has 2 en-US distinct white waxy ornamentations on the dorsal en-US parts of segments III and V. Abdominal segment III en-US has a dorsal part with white waxy ornamentations en-US of various shapes, including barrel shape (Figure en-US 2A), diamond shape (Figure 2B), and chalice-shape en-US (Figure 2C). Abdominal segment V has a dorsal part en-US with a white waxy ornamentation that is almost simien-US -en-US lar to that one on abdominal segment I (Figure 2).en-US en-US Pupa:en-US No live specimen was available to examine. 2. en-USAn.en-US en-US kleini,en-US Larva:en-US Body coloration is usually reden-US -en-US dish brown to dark brown. Thoraxen-US en-US has dorsal parts en-US almost covered with white waxy materials, primaren-US -en-US ily along the anterior half and narrowly extending en-US towards the anterior edge of abdominal segment I. en-US The tip of this extension is usually blunt (Figure 3B, en-US 3C) or rarely pointed (Figure 3A). Abdomen has one en-US distinct white waxy ornamentation, barrel-shaped, en-US on the dorsal part of segment III (Figure 3; collecen-US -en-US tion nos. KSK-511-1004L, KSK-523-1004L, KSK-en-US 545-1005L), and nothing on abdominal segment V.en-US en-US Pupa:en-US Abdominal segments III and IV have doren-US -en-US sal parts with white waxy ornamentations of varien-US -en-US ous shapes, including Aladdin lamp shape (Figure en-US 4A, collection no. KSK-511-1006P), blown tubular en-US glass shape (Figure 4B, collection no. KSK-513-en-US 1004P) and cork crown shape (Figure 4C, collecen-US -en-US tion no. KSK-514-1008P; Figure 5A, collection no. en-US KSK-522-1004P). en-USFigure en-US2en-US. Mosquito larvae of en-US Anopheles belenraeen-US dorsal view, en-USshowing en-US waxy ornamentations of the thorax and abdomen (arrows).en-USBE(KSK-545-1001L) A en-USBE(KSK-545-1008L) B en-USBE(KSK-545-1011L) C

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50 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USBIOSURVEILLANCE AND MORPHOLOGICAL VARIATIONS OF LARVAE AND PUPAE OF COMMON MALARIAen-US en-US VECTORS, en-US ANOPHELESen-US (en-US ANOPHELESen-US ) HYRCANUS GROUP SPECIES IN THE REPUBLIC OF KOREA en-USRelative abundance of en-USAnophelesen-US (en-US Anophelesen-US ) larvae on various habitats in en-US3en-US provinces (Geonggi, Gyeongsangbuk, en-US Chungcheongbuk) of the Republic of Korea (May en-US2007en-US October en-US2007en-US ) [part en-US1en-US of en-US2en-US].en-USRelative Abundance (%)en-USaen-USHabitat and Speciesen-US Mayen-US Juneen-US Julyen-US Augusten-US Sepemberen-US Octoberen-US6en-US-month en-US Meanen-US Totalen-US en-US Collected (n)en-US en-USben-USAn. belenraeen-US1.34en-US 0.00en-US 0.00en-US 0.57en-US 0.00en-US 0.62en-US 0.42en-US 0.38 (7)en-USAn. kleinien-US3.01en-US 12.61en-US 10.00en-US 1.98en-US 2.62en-US 0.00en-US 5.04en-US 6.06 (113)en-USAn. lesterien-US0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00 (0)en-USAn. pullusen-US54.18en-US 4.50en-US 0.88en-US 1.98en-US 0.75en-US 0.00en-US 10.38en-US 10.4 (194)en-USAn. sinensisen-US33.44en-US 82.88en-US 88.82en-US 95.47en-US 96.25en-US 95.68en-US 82.09en-US 81.45 (1519)en-USAn. sineroidesen-US8.03en-US 0.00en-US 0.29en-US 0.00en-US 0.37en-US 3.70en-US 2.07en-US 1.72 (32)en-USTotal collected (n)en-US299en-US 444en-US 340en-US 353en-US 267en-US 162en-US (1865)en-USen-UScen-USAn. belenraeen-US11.11en-US 0.00en-US 0.55en-US 0.78en-US 1.27en-US 0.00en-US 2.29en-US 1.24 (13)en-USAn. kleinien-US29.17en-US 2.87en-US 18.78en-US 13.62en-US 11.46en-US 1.16en-US 12.84en-US 11.06 (116)en-USAn. lesterien-US0.00en-US 0.96en-US 0.00en-US 0.00en-US 0.00en-US 0.58en-US 0.26en-US 0.29 (3)en-USAn. pullusen-US4.17en-US 6.70en-US 2.21en-US 1.95en-US 2.55en-US 1.16en-US 3.12en-US 3.05 (32)en-USAn. sinensis en-US51.39en-US 61.72en-US 78.45en-US 81.71en-US 60.51en-US 97.11en-US 71.82en-US 74.45 (781)en-USAn. sineroidesen-US4.17en-US 27.75en-US 0.00en-US 1.95en-US 24.20en-US 0.00en-US 9.68en-US 9.91 (104)en-USTotal collected (n)en-US72en-US 209en-US 181en-US 257en-US 157en-US 173en-US (1049)en-USen-USden-USAn. belenraeen-US0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00 (0)en-USAn. kleinien-US0.00en-US 0.00en-US 14.29en-US 25.00en-US 16.67en-US 0.00en-US 9.33en-US 12.82 (5)en-USAn. lesterien-US0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00 (0)en-USAn. pullusen-US0.00en-US 16.67en-US 7.14en-US 0.00en-US 0.00en-US 100.00en-US 20.63en-US 12.82 (5)en-USAn. sinensisen-US0.00en-US 83.33en-US 78.57en-US 75.00en-US 75.00en-US 0.00en-US 51.98en-US 71.79 (28)en-USAn. sineroidesen-US0.00en-US 0.00en-US 0.00en-US 0.00en-US 8.33en-US 0.00en-US 1.39en-US 2.56 (1)en-USTotal collected (n)en-US0en-US 6en-US 14en-US 4en-US 12en-US 3en-US (39)en-USen-USeen-USAn. belenraeen-US0.16en-US 0.00en-US 0.00en-US 0.99en-US 1.10en-US 0.00en-US 3.86en-US 1.44 (12)en-USAn. kleinien-US50.00en-US 16.16en-US 41.22en-US 16.83en-US 12.15en-US 0.55en-US 22.82en-US 17.55 (146)en-USAn. lesterien-US0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00 (0)en-USAn. pullusen-US13.16en-US 8.08en-US 1.53en-US 6.93en-US 3.31en-US 3.87en-US 6.15en-US 5.05 (42)en-USAn. sinensisen-US13.16en-US 8.08en-US 57.25en-US 75.25en-US 78.45en-US 95.58 en-US54.63en-US 66.71 (555)en-USAn. sineroidesen-US2.63en-US 67.68en-US 0.00en-US 0.00en-US 4.97en-US 0.00en-US 12.55en-US 9.25 (77)en-USTotal collected (n)en-US38en-US 99en-US 131en-US 202en-US 181en-US 181en-US (832)en-USen-USfen-USAn. belenraeen-US0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00 (0)en-USAn. kleinien-US66.67en-US 4.76en-US 2.06en-US 0.90en-US 4.05en-US 0.00en-US 13.07en-US 2.14 (9)en-USAn. lesterien-US0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00 (0)en-USAn. pullusen-US33.33en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 1.74en-US 5.85en-US 0.71 (3)en-USAn. sinensisen-US0.00en-US 95.24en-US 97.94en-US 99.10en-US 95.95en-US 92.17en-US 80.07en-US 95.49 (402)en-USAn. sineroidesen-US0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 6.09en-US 1.01en-US 1.66 (7)en-USTotal collected (n)en-US3en-US 21en-US 97en-US 111en-US 74en-US 115en-US (421)en-US Notes:en-US en-US Anophelesen-US larvae collected during the period.en-US b. Rice paddies, vacant or with rice plantsen-US c. Irrigation ditches include concrete and nonconcrete ditchesen-US d. Drainage ditches include concrete and nonconcrete ditches, culverts, dammed ditchesen-US e. Ponds include pond reservoirsen-US f. Stream margins include stream ponds, stream inlets, algal mats

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January June 2017 51 3. en-USAn.en-US en-US pullus,en-US Larva:en-US Body coloration is usually green en-US or brown. Thorax has dorsal parts almost covered en-US with white waxy materials, primarily along the miden-US -en-US dle part, and narrowly extending towards the anterior en-US edge of abdominal segment I. The tips of this waxy en-US extension are usually blunt (Figure 6A, 6C; collection en-US nos. KSK-543-1005L, KSK-543-1013L) or seldom en-US pointed (Figure 6B, collection no. KSK-543-1006L). en-US Abdomen has one distinct white waxy ornamentaen-US -en-US tion, barrel-shaped, on dorsal part of segment III en-US (Figure 6), and nothing on the abdominal segment V.en-US en-US Pupa:en-US Abdominal segments III and IV have doren-US -en-US sal parts with white waxy ornamentations of varien-US -en-US ous shapes, including Aladdin lamp shape (Figure en-US 7A, 7B; collection nos. KSK-514-1001P, KSK-523-en-US 1003P), and pear shape (Figure 7C, collection no. en-US KSK-520-1001P). 4. en-USAn.en-US en-US sinensis,en-US Larva:en-US en-US Body coloration is usually en-US green, reddish brown, or dark brown. Thoraxen-US en-US has en-US dorsal parts almost completely covered with white en-US or creamish colored waxy materials, primarily along en-US the anterior half, and narrowly extending towards the en-US anterior edge of abdominal segment I. The tip of this en-US extension is usually blunt (Figure 8A, 8B; collection en-US nos. KSK-543-1003L, KSK-545-1007L). Abdomen en-US has one distinct white or creamish waxy ornamenen-US -en-US tation, barrel-shaped or pear-shaped, on dorsal part en-US of segment III (Figure 8A, 8B), and usually lacking en-US ornamentation on abdominal segment V. It is very en-US rare that dorsal parts of the abdomen have 2 white en-US waxy ornamentations. Greenish larvae usually have en-US no or very light waxy ornamentations on the body.en-US en-US Pupa:en-US Cephalothorax has a cup-shaped white waxy en-US ornamentation on dorsal part. Abdominal segments en-US I-V have median longitudinal white waxy ornamenen-US -en-US tations on dorsal parts (Figure 5B, 5C; collection nos. en-US KSK-522-1001P, KSK-523-1002P). 5. en-USAn.en-US en-US lesteri,en-US Larva:en-US Body coloration is usually green en-US or dark brown. Thorax has dorsal parts almost coven-US -en-US ered with white waxy materials, and approximately en-USRelative abundance of en-USAnophelesen-US (en-US Anophelesen-US ) larvae on various habitats in en-US3en-US provinces (Geonggi, Gyeongsangbuk, en-US Chungcheongbuk) of the Republic of Korea (May en-US2007en-US October en-US2007en-US ) [part en-US2en-US of en-US2en-US].en-USRelative Abundance (%)en-USaen-USHabitat and speciesen-US Mayen-US Juneen-US Julyen-US Augusten-US Sepemberen-US Octoberen-US6en-US-month en-US Meanen-US Totalen-US en-US Collected (n)en-US en-US An. belenraeen-US0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00 (0)en-USAn. kleinien-US83.33en-US 4.65en-US 35.00en-US 41.24en-US 2.44en-US 0.00en-US 27.78en-US 20.24 (67)en-USAn. lesterien-US0.00en-US 0.00en-US 5.00en-US 1.03en-US 7.32en-US 0.00en-US 2.22en-US 1.81 (6)en-USAn. pullusen-US16.67en-US 90.70en-US 10.00en-US 2.06en-US 2.44en-US 1.02en-US 20.48en-US 14.80 (49)en-USAn. sinensisen-US0.00en-US 0.00en-US 50.00en-US 48.45en-US 39.02en-US 83.67en-US 36.86en-US 49.85 (165)en-USAn. sineroidesen-US0.00en-US 4.65en-US 0.00en-US 7.22en-US 48.78en-US 15.31en-US 12.66en-US 13.29 (44)en-USTotal collected (n)en-US12en-US 43en-US 40en-US 97en-US 41en-US 98en-US (331)en-USen-USben-USAn. belenraeen-US0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00 (0)en-USAn. kleinien-US0.00en-US 0.00en-US 0.00en-US 6.25en-US 0.00en-US 0.00en-US 1.04en-US 2.56 (1)en-USAn. lesterien-US0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00en-US 0.00 (0)en-USAn. pullusen-US0.00en-US 0.00en-US 8.33en-US 0.00en-US 0.00en-US 0.00en-US 1.39en-US 2.56 (1)en-USAn. sinensisen-US0.00 en-US0.00en-US 83.33en-US 81.25en-US 100.00en-US 50.00en-US 52.43en-US 76.92 (30)en-USAn. sineroidesen-US100.00en-US 100.00en-US 8.33en-US 12.50en-US 0.00en-US 50.00en-US 45.14en-US 17.95 (7)en-USTotal collected (n)en-US2en-US 1en-US 12en-US 16en-US 6en-US 2en-US (39)en-US Notes:en-US en-US Anophelesen-US larvae collected during the period.en-US en-USFigure en-US3en-US. Mosquito larvae of en-US Anophelesen-US en-US kleinien-US dorsal view, en-USshowing en-US waxy ornamentations of the thorax and abdomen (arrows). en-USKL(KSK-511-1004L) A en-USKL(KSK-523-1004L) B en-USKL(KSK-545-1005L) C

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52 http://www.cs.amedd.army.mil/amedd_journal.aspx en-UScone-shaped along the median parts. It usually en-US has a slightly pointed waxy ornamentation exen-US -en-US tending up to the anterior tip of the dorsum of en-US abdominal segment I (Figure 8C, collection no. en-US KSK-545-1009L). Abdomen has 2 distinct white en-US waxy ornamentations on dorsal parts of segments en-US III and V. Both ornamentations are barrel-shaped.en-US en-US Pupa.en-US No live specimen was available to examine. COmm MM ENT The seasonal occurrence and relative abundance of en-USAnophelesen-US larvae varied from one type of habitat to en-US another. These variations may be due to different en-US environmental conditions found in most habitats. en-US Although en-US Anophelesen-US (en-US Anophelesen-US ) larvae and pupae en-US have been previously described based on slide-en-US mounted larval and pupal specimens,en-US2,3,19en-US little is en-US known about the waxy ornamentation or body coven-US -en-US ering patterns of these immature mosquitoes in naen-US -en-US ture. In spite of detailed morphological descriptions en-US of the larvae and pupae in various publications,en-US2,3,19en-US en-US en-US due to much variation of supposed diagnostic charen-US -en-US acters, including position, types, forms, and number en-US of branches of setae and other body parts. During en-US en-US ornamentations of the larvae may be useful charen-US -en-US en-US Anophelesen-US en-US species, but there is still a need for larval rearing en-US en-US -en-US tion keys as well as PCR and DNA sequencing for en-US larvae, pupae, and adults may be used to ascertain en-US en-US waxy body ornamentations are also not very disen-US -en-US en-US third-instar and fourth-instar larvae of en-US Anophelesen-US en-US en-US as from laboratory reared materials are required to en-US further study the morphological variations or body en-US patterns based on body ornamentations as diagnosen-US -en-US tic characters, in the mosquito larvae and pupae. AcC KNOWLEDGm M ENTS We thank Ms Soo-Yun Kim and Ms J. Stoffer for as en-US-en-US en-US -en-US vae and pupae, and B. P. Rueda and C. R. Summers en-US for providing valuable comments and suggestions to en-US improve the manuscript.en-US This research was performed under a memorandum of en-US agreement between the Walter Reed Army Institute of en-US Research and the Smithsonian Institution, with instituen-US -en-US tional support provided by both organizations.en-US The opinions contained herein are those of the authors en-US en-US agencies.en-USBIOSURVEILLANCE AND MORPHOLOGICAL VARIATIONS OF LARVAE AND PUPAE OF COMMON MALARIAen-US en-US VECTORS, en-US ANOPHELESen-US (en-US ANOPHELESen-US ) HYRCANUS GROUP SPECIES IN THE REPUBLIC OF KOREAen-USKL(KSK-511-1006P) A en-USKL(KSK-514-1008P) C en-USKL(KSK-513-1004P) B en-USFigure en-US4en-US. en-US Mosquito pupae of en-US Anophelesen-US en-USkleinien-US dorsal view, showing waxy en-US ornamentations of the abdomen (arrow). en-USKL(KSK-522-1004P) A en-USSI(KSK-522-1001P) B en-USSI(KSK-523-1002P) C en-USFigure en-US5en-US.en-US Mosquito pupae of en-US Anophelesen-US en-USkleinien-US (A), and en-USAn.en-US en-USsinensisen-US (B,C), en-US dorsal view, showing waxy ornamentations of the abdomen (arrow). en-USPU(KSK-543-1006L) B en-USPU(KSK-543-1013L) C en-USPU(KSK-543-1005L) A en-USFigure en-US6en-US. Mosquito larvae of en-US Anophelesen-US en-US pullusen-US dorsal view, en-USshowing en-US waxy ornamentations of the thorax and abdomen (arrows).

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January June 2017 53 RREFERENc C ES 1. en-USRueda LM. Two new species of en-US Anophelesen-US en-US (en-US Anophelesen-US ) Hyrcanus group (Diptera: Culicien-US -en-US dae) from the Republic of South Korea. en-US Zooen-US -en-US taxa.en-US 2005;941:1-26. http://www.mapress.com/en-US zootaxa/2005f/zt00941.pdf. 2. en-USRueda LM, Kim HC, Klein T, et al. Distribution en-US and larval habitat characteristics of en-US Anophelesen-US en-US Hyrcanus Group and related mosquito species en-US (Diptera: Culicidae) in South Korea. en-US Jen-US en-US Vectoren-US en-US Ecol.en-US en-US 2006;31:199-206. 3. en-USTanaka K, Mizusawa K, Saugstad ES. en-US A Revien-US -en-US sion of the Adult and Larval Mosquitoes of Japan en-US (including the Ryukyu Archipelago and the Ogaen-US -en-US sawara Islands) and Korea (Diptera: Culicidae)en-US en-US Gainesville, FL: American Entomological Instien-US -en-US tute; 1979. 4. en-USLee WJ, Klein TA, Kim HC, et al. en-US Anophelesen-US en-US kleen-US -en-US ini,en-US en-US An.en-US en-US pullus,en-US and en-USAn.en-US en-US sinensisen-US : potential vectors en-US of en-US Plasmodiumen-US en-US vivaxen-US in the Republic of Korea. en-US Jen-US en-US Med Entomol.en-US 2007;44:1086-1090. 5. en-USKlein TA, Kim HC, Lee WC, et al. Reemergence, en-US persistence, and surveillance of vivax malaria and en-US its vectors in the Republic of Korea. In: Robinen-US -en-US son WK, Bajoni D, eds. en-US Proceedingsen-US en-US ofen-US en-US theen-US en-US Sixthen-US en-US Internationalen-US en-US Conferenceen-US en-US onen-US en-US Urbanen-US en-US Pestsen-US en-US Hunen-US -en-US gary,en-US en-US Budapest,en-US en-US Hungary.en-US 2008;325-351. Availen-US -en-US able at: http://www.icup.org.uk/icupsearchres.en-US asp?snum=0. Accessed February 8, 2017. 6. en-USJoshi D, Choochote W, Park MH, et al. The susen-US -en-US ceptibility of en-USAnophelesen-US en-US lesterien-US to infection with en-US Korean strain of en-USPlasmodiumen-US en-US vivaxen-US en-US Malariaen-US en-US J.en-US en-US 2009;8:42. 7. en-USJoshi D, Kim JY, Choochote W, Park MH, Min GS. en-US Preliminary vivax malaria vector competence for en-US three members of the en-USAnophelesen-US en-US hyrcanusen-US group en-US in the Republic of Korea. en-US Jen-US en-US Amen-US en-US Mosqen-US en-US Controlen-US en-US Asen-US -en-US soc.en-US 2009;27:312-314. 8. en-USen-US -en-US tribution records of the en-US Anophelesen-US (en-US Anophelesen-US ) en-US hyrcanusen-US species-group (Diptera: Culicidae) in en-US China. en-USZootaxa.en-US 2007;1407:43-55. 9. en-USRueda LM, Brown TL, Kim HC, et al. Species en-US composition, larval habitats, seasonal occurrence en-US and distribution of potential malaria vectors and en-US associated species of en-USAnophelesen-US (Diptera: Cuen-US -en-US licidae) from the Republic of Korea. en-US Malariaen-US en-US J.en-US en-US 2010;9:55-65. 10. en-USFoley DH, Klein TA, Lee IY, et al. Mosquito speen-US -en-US cies composition and en-US Plasmodiumen-US en-US vivaxen-US infection en-US rates on Baengnyeong-do (Island), Republic of Koen-US -en-US rea. en-USKoreanen-US en-USJen-US en-USParasitol.en-US 2011;49:313-316. 11. en-USRueda LM, Li C, Kim HC, Klein TA, Foley DH, en-US Wilkerson RC. en-USAnophelesen-US en-US belenraeen-US (Diptera: Cuen-US -en-US licidae), a potential vector of en-USPlasmodiumen-US en-US vivaxen-US in en-US the Republic of Korea. en-US Jen-US en-US Amen-US en-US Mosqen-US en-US Controlen-US en-US Assoc.en-US en-US 2010;26:430-432. 12. en-USWilkerson RC, Li C, Rueda LM, Kim HC, Klein TA, en-US en-US Anophelesen-US (en-US Anophelesen-US ) en-US lesterien-US from the Republic of en-US South Korea and its genetic identity with en-US An.en-US (en-US Ano.en-US ) en-US anthropophagusen-US from China (Diptera: Culicidae). en-US Zootaxa.en-US 2003;378:1-14. Available at: http://www.en-US mapress.com/zootaxa/2003f/zt00378.pdf. 13. en-USFoley DH, Klein TA, Kim HC, Brown T, Wilken-US -en-US erson RC, Rueda LM. Validation of ecological en-US niche models for potential malaria vectors, en-US Anophen-US -en-US elesen-US (en-US Anophelesen-US ) (Diptera: Culicidae), in the Reen-US -en-US public of Korea. en-USJen-US en-US Ameren-US en-US Mosqen-US en-US Controlen-US en-US Assocen-US en-US 2010;en-US 26:210-213.en-USFigure en-US7en-US. Mosquito pupae of en-USAnophelesen-US en-US pullusen-US dorsal view, en-USshowing en-US waxy ornamentations of the abdomen (arrows). en-USPU(KSK-514-1001P) A en-USPU(KSK-520-1001P) C en-USPU(KSK-523-1003P) B en-USFigureen-US en-US 8en-US en-USMosquito larvae of en-USAnophelesen-US en-US sinensis (A,B)en-US and en-US An. lesterien-US en-US (C), dorsal view, en-USshowing waxy ornamentations of the thorax and abdoen-US -en-US men (arrows). en-USSI(KSK-545-1007L) B en-USLE(KSK-545-1009L) C en-USSI(KSK-543-1003L) A

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54 http://www.cs.amedd.army.mil/amedd_journal.aspx 14. en-USFutch SH, McCoy CW, Childers CC. A guide to en-US en-US -en-US sity of Florida Institute of Food and Agricultural en-US Sciences; 2015:1-5. Extension Publication #HS-817. en-US en-US February 2, 2017. 15. en-USLabanoski G, Soika G. Aphids (Hemiptera, Aphien-US -en-US doidea) on trees and shrubs belonging to Betulacea en-US family in ornamental plant nurseries. en-USAphiden-US en-US anden-US en-US Otheren-US en-USHemipterousen-US en-USInsectsen-US 2011;17: 81-97. 16. en-USBarao KR, Silva DS, Moreira GRP. External moren-US -en-US phology of the immature stages of Neotropical helen-US -en-US iconians: X. en-US Heliconiusen-US en-US saraen-US en-US apseudesen-US (Lepidopen-US -en-US tera, Nymphalidae, Heliconiinae). en-US Iheringiaen-US en-US Seren-US en-US Zoolen-US 2015;105:523-533. Available at: http://dx.doi.en-US org/10.1590/1678-476620151054523533. 17. en-USSouth SH, Arnqvist G. Morphological variation en-US of an ornament expressed in both sexes of the en-US mosquito en-US Sabethesen-US en-US cyaneusen-US en-US Evolutionen-US en-US Ecolen-US en-US Res.en-US en-US 2009;11:1-21. 18. en-USLi C, Lee JS, Groebner JL, Kim HC, Klein TA, en-US OGuinn ML, Wilkerson RC. A newly recognized en-US species in the en-US Anophelesen-US Hyrcanus Group and moen-US -en-US en-US Republic of South Korea (Diptera: Culicidae). en-USZooen-US -en-US taxa.en-US 2005;939:1-8. 19. en-USHarrison BA, Scanlon JE. en-US Medical entomology en-US studies II. The subgenus en-US Anophelesen-US in Thaien-US -en-US land (Diptera: Culicidae). en-US Contren-US en-US Amen-US en-US Entomolen-US en-US Inst.en-US en-US 1975;12:1-307. AUTHORS Dr Rueda is an Adjunct Scientist of the Smithsonian In en-US-en-US stitution and former Research Entomologist and Chief en-US en-US Branch, Walter Reed Army Institute of Research, loen-US -en-US cated at the Smithsonian Institution, Museum Support en-US Center, Suitland, Maryland.en-US Dr Kim is a Research Entomologist, 5th Medical Detachen-US -en-US ment/Medical Department Activity-Korea, 65th Medical en-US Brigade, Republic of Korea.en-US Mr Chong is an Entomologist, 5th Medical Detachment/en-US Medical Department Activity-Korea, 65th Medical Brien-US -en-US gade, Republic of Korea.en-US Dr Klein is the senior Entomologist, Medical Departen-US -en-US en-US Republic of Korea.en-US Dr Debboun is the Director of the Mosquito & Vector en-US Control Division, Harris County Public Health, Houston, en-US Texas.en-USBIOSURVEILLANCE AND MORPHOLOGICAL VARIATIONS OF LARVAE AND PUPAE OF COMMON MALARIAen-US en-US VECTORS, en-US ANOPHELESen-US (en-US ANOPHELESen-US ) HYRCANUS GROUP SPECIES IN THE REPUBLIC OF KOREA

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en-USJanuary June 2017 en-US55en-USHuman Chagas disease is caused by the protozoan paraen-US -en-US site Trypanosoma cruzi, acquired primarily through en-US contact with infected excreta of triatomine insects en-US (known as kissing bugs). Although vector-borne en-US transmission predominates, humans can also become en-US infected congenitally, orally through contaminated food en-US or beverages, or hematogenously through blood transfuen-US-en-US sion or organ transplantation.en-US1en-USen-US of infection, considered the acute phase, symptoms are en-US en-US fatal myocarditis or meningoencephalitis occur rarely. en-US Approximately 70% to 80% of infected persons enter en-US a chronic indeterminate phase, characterized by lifeen-US -en-US long infection without symptoms, electrocardiographic en-US changes, and radiographic evidence of disease. The en-US remaining 20% to 30% develop chronic disease, often en-US presenting years or decades after infection as clinical en-US cardiac and/or digestive disease.en-US2en-USWith approximately 5 to 8 million people infected worlden-US -en-US wide,en-US1,3en-USen-US-en-US nization as one of the most important neglected tropical en-US diseases.en-US1en-US There are an estimated 240,000 prevalent casen-US -en-US en-US areas of Latin America.en-US4en-US Fewer than 30 locally-acquired en-US en-US 1955,en-US5en-US when a resident of Corpus Christi, Texas, became en-US en-US6en-US en-US In 2013, the Texas Department of State Health Services en-US en-US en-US -en-US pected human cases to local or regional health departen-US -en-US ments. Twelve autochthonous human infections were en-US en-US reporting,en-US7en-US one of which was associated with left venen-US -en-US tricular dysfunction.en-US8 CaA SE R REp P ORT en-USscreened positive foren-US T cruzi en-US infection when he donated en-US blood at Joint Base San Antonio (JBSA), Texas. Blood en-US en-US -en-US nation center is screened foren-US T cruzi en-USwith an enzyme-en-US linked immunosorbent assay from Ortho-Clinical Dien-US -en-US agnostics. Per standard protocol, he was referred to the en-US installations trainee health clinic, where he was found en-US to have normal vital signs and an unremarkable physical en-US exam. He reported being in excellent health and had not en-US experienced any recent chest pain, shortness of breath, en-US dizziness, or gastrointestinal symptoms.en-US A chemiluminescence immunoassay and enzyme strip en-US assay (Abbott Laboratories) were ordered and found en-US to be positive for anti-en-US T cruzi en-USIgG antibodies. A whole en-US blood sample was sent to the Reference Diagnostic Laben-US -en-US oratory at the Centers for Disease Control and Prevenen-US -en-US tion for further testing. An enzyme immunoassay was en-US reactive and an immunoblot of trypomastigote excreted-en-US en-US -en-US en-US to the Department of Infectious Disease at San Antonio en-US Military Medical Center (SAMMC) for further evaluaen-US -en-US tion and treatment.en-US After notifying the patient of his laboratory results, Inen-US-en-US fectious Disease conducted a 12-lead electrocardiogram en-USA Case of Chagas Cardiomyopathyen-US en-US Following Infection in South Central Texas ABSTRac AC T Between 5 and 8 million people globally are infected with Trypanosoma cruzi, the causative parasitic agent of en-USChagas disease. The vast majority of incident infections originate in pockets of Latin America where domestic en-US en-US -en-US en-US en-US who screened positive for T cruzi infection on blood donation and was subsequently found to have chronic Chaen-US -en-US en-US en-US and military implications are discussed.

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en-US56 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USen-US degree atrioventricular block, and left anterior hemi-en-US block with right bundle branch block. This prompted en-US referral to the Division of Cardiology at SAMMC. Caren-US -en-US diovascular physical exam was benign with normal heart en-US sounds, normal jugular venous pressure, normal apical en-US impulse, and no evidence of congestive heart failure. A en-US battery of noninvasive tests was performed in order to en-US assess for common cardiac manifestations of Chagas disen-US -en-US ease, including, but not limited to, left ventricular dilataen-US -en-US tion and dysfunction, wall motion abnormalities, aneuen-US -en-US rysms, diastolic dysfunction, pathologic bradyarrhythen-US -en-US mias and tachyarrhythmias, and ischemic heart disease.en-US9en-USThe majority of tests were within normal limits. Chest en-US x-ray showed no evidence of cardiomegaly. Holter monen-US -en-US itoring was negative for any pathologic dysrhythmias. en-US Transthoracic echocardiogram demonstrated normal dien-US -en-US astolic, valvular, and global systolic function. Exercise en-US testing with Bruce protocol established no exercise-inen-US -en-US duced arrhythmias, ischemic electrical changes, or angien-US -en-US nal symptoms. Cardiopulmonary exercise testing found en-US an appropriate VOen-US2en-USmaxen-US, early anaerobic threshold, and en-US normal VE/VCOen-US2en-US slope, consistent with a subclinical en-US reduction in exercise capacity with preserved ventilaen-US -en-US en-US en-US -en-US strating left ventricular cavity dilation with preserved en-US global systolic function (ejection fraction of 76%); the en-US imaging was otherwise normal with no wall motion aben-US -en-US normalities, late gadolinium enhancement, abnormal T1 en-US relaxation, or myocardial edema on T2 weighted images.en-US en-US ECG, and left ventricular cavity dilation, the patient was en-US determined to have chronic Chagasic cardiomyopathy. en-US en-US -en-US can College of Cardiology/American Heart Association en-US en-US and Stage B, respectively,en-US10,11en-US and at low risk for cardiac en-US death according to 2 validated risk calculators.en-US11,12en-US Since en-US en-US -en-US en-US13en-US the patient was processed for en-US medical discharge from training. Infectious Disease aden-US -en-US vised the patient to complete a 60-day regimen of oral en-US benznidazole,en-US14en-US but he declined. He was strongly enen-US -en-US couraged to seek follow-up in the civilian health care en-US sector and to notify household contacts that they should en-US be screened for Chagas disease.en-US15en-USPublic health personnel interviewed the patient to faen-US -en-US cilitate case reporting to the Texas Department of State en-US Health Services. The patient was raised on a ranch in en-US south central Texas and had never traveled outside the en-US en-US his home but never hunted or skinned animals. When en-US shown a display case with triatomine insects of various en-US species and at different stages of development, the paen-US -en-US tient immediately recognized them, saying they were en-US all over the place on the ranch, including within the en-US residence. He did not recall ever receiving a bite. A en-US number of reservoir animals were also present on the en-US property, including cats, dogs, raccoons, and armadilen-US -en-US los. The patient was not aware of any relatives having en-US Chagas disease, although he was adopted at a young age en-US and had no knowledge of his biological mother. He had en-US never received a blood transfusion. A week before his en-US blood donation, he had spent 5 days and 4 nights on the en-US en-US -en-US cise, during which he slept in a permethrin-treated bed en-US net and reported no known insect bites. COmm MM ENT Although neither congenital acquisition nor vectoren-USen-US -en-US tively ruled out, this patient was likely infected withen-US T en-US cruzi en-US while growing up on a ranch in south central Texen-US -en-US as. Ecologic modeling has predicted that this region of en-US en-US Chagas disease.en-US16en-US Situated at the interface of tropical and en-US temperate biomes, south central Texas has a number of en-US environmental and cultural factors that may facilitate en-US human exposure toen-US T cruzien-US : a diverse array of wildlife en-US reservoirs and indigenous triatomine species; the popuen-US -en-US larity of high-risk outdoor activities, especially hunting en-US and camping; and the presence of scattered colonias en-US (impoverished, primarily Hispanic communities). As en-US compared to modern urban and suburban houses, poorly en-US constructed ranches, cabins, and colonias are more susen-US -en-US ceptible to colonization by triatomine insects and wilden-US -en-US life reservoirs, thus increasing the likelihood of human en-US exposure to infected vectors.en-US17en-USen-US -en-US nized species of triatomine insects, listed in the Table, en-US most of which are competenten-US T cruzien-US vectors and likely en-US to be involved in enzootic transmission cycles among en-US indigenous wildlife reservoirs.en-US18en-US All species may exist as en-US nest parasites and feed on a variety of vertebrate hosts. en-US Competence for transmitting the parasite to humans is en-US affected by environmental distribution, dispersal capacen-US -en-US ity, feeding and defecation behaviors, and ability to inen-US-en-US vade human domiciles, attributes of which vary accorden-US -en-US ing to species.en-US18-20en-USIn south central Texas, en-US Triatoma gerstaeckerien-US inen-US -en-US sects have been found to enter human dwellings and en-US to feed upon humans and domestic animals.en-US21,22en-US This en-US A CASE OF CHAGAS CARDIOMYOPATHY FOLLOWING INFECTION IN SOUTH CENTRAL TEXAS

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en-USJanuary June 2017 en-US57 en-USmedium-to-large triatomine species inhabits much of en-US the Edwards Plateau and South Texas Brush Country en-US between the 96th and 103rd parallels, the southeastern en-US corner of New Mexico, and northeastern Mexico.en-US23en-US Theen-US en-US T cruzien-US infection rate of this species may exceed 60% en-US in south central Texas,en-US21,22en-US and adult insects often have en-US detectable human blood in their midgut.en-US24en-USAlthough the case patient was likely infected prior to aren-US -en-US rival at JBSA, this report highlights the risk for autochen-US -en-US en-US and underscores the importance of preventing Chagas en-US and other vector-borne diseases while training in endemen-US-en-US ic areas. In order to decrease vector habitats, engineeren-US -en-US ing controls should focus on reducing vegetation around en-US en-US without disrupting the training mission. Administrative en-UScontrols emphasizing site cleanliness should help minien-US -en-US mize the population of woodrats, an important reservoir en-US animal.en-US25en-US Finally, the 4 components of optimal personen-US -en-US al protective measures should be meticulously used: a en-US en-US openings secured, undershirt tucked into the pants, and en-US pant legs tucked into the boots); permethrin treatment of en-US the uniform blouse and pants; the application of either en-US DEET*-based (20% to 40% concentration) or picaridinen-USen-US-en-US based (20% concentration) insect repellent to exposed en-US skin; and sleeping in a permethrin-treated bed net.en-US26en-US Fien-US -en-US nally, diligent public health surveillance and health care en-US provider education for Chagas disease are warranted. RREFERENc C ES 1. en-USRassi A Jr, Rassi A, Marin-Neto JA. Chagas disen-US -en-US ease. en-USLanceten-US 2010;375(9723);1388-1402. 2. en-USBern C. Chagas disease. en-USN Engl J Meden-US en-US 2015;373(5):456-466. 3. en-USWorld Health Organization. Chagas disease in Latin en-US America: an epidemiological update based on 2010 en-US estimates. en-USWkly Epidemiol Recen-US 2015;90(6):33-43. 4. en-USen-US Wirtz VJ. Estimating the burden of Chagas disen-US -en-US en-US PLoS Negl Trop Disen-US en-US 2016;10(11):e0005033. 5. en-USMontgomery SP, Parise ME, Dotson EM, Bien-US -en-US alek SR. What Do We Know About Chagas Disen-US -en-US en-US Am J Trop Med Hygen-US en-US 2016;95(6):1225-1227. 6. en-USWoody NC, Woody HB. American Trypanosomiaen-US -en-US en-US en-USJAMAen-US 1955;159(7):676-677. 7. en-USTexas Department of State Health Services. Chaen-US -en-US gas disease [internet]. Available at: https://www.en-US en-US er=id&ItemID=22929. Accessed January 10, 2017. 8. en-USGarcia MN, Murray KO, Hotez PJ, et al. Developen-US -en-US ment of Chagas cardiac manifestations among Texen-US -en-US as blood donors. en-US Am J Cardiolen-US 2015;115(1):113-117. 9. en-USNunes MA, Dones W, Morillo CA, Encina JE, Rien-US -en-US beiro AL. Chagas disease: an overview of clinical en-US and epidemiological aspects. en-USJ Am Coll Cardiolen-US en-US 2013;62:767-776. 10. en-USAcquatella H. Echocardiography in Chagas heart en-US disease. en-USCirculationen-US 2007;115:1124-1131. 11. en-USde Souza AC, Salles G, Hasslocher-Moreno AM, et en-US al. Development of a risk score to predict sudden en-US death in patients with Chagas heart disease. en-USInt J en-US Cardiolen-US 2015;187:700-704. en-US*en-USN,N-diethyl-meta-toluamideen-US en-US Hydroxyethyl isobutyl piperidine carboxylate en-USTriatoma in the United States.en-USGenus and species (subspecies)en-US Discovereren-US Photographen-US Paratriatoma hirsutaen-US Barberen-US Figure en-US1en-USTriatoma gerstaeckerien-US Stlen-US Triatoma incrassataen-US Usingeren-US Figure en-US2en-USTriatoma indictivaen-US Neivaen-US Triatoma lecticulariaen-US Stlen-US Figure en-US3en-USTriatoma neotomaeen-US Neivaen-US Triatoma protracta protractaen-US Uhleren-US Figure en-US4en-USTriatoma protracta woodien-US Usingeren-US Triatoma recurvaen-US Stlen-US Figure en-US5en-USTriatoma rubidaen-US Uhleren-US Triatoma rubrofasciataen-US DeGeeren-US Figure en-US6en-USTriatoma sanguisugaen-US Leconte en-USParatriatoma hirsutaen-USAdulten-US en-US 12-14.5 mmen-USPhoto by Christiane Weirauch.en-USTriatoma gerstaeckerien-USAdulten-US en-US 23-28.5 mmen-USPhoto by Edward Wozniak en-USFigure en-US1en-US. en-US Triatomaen-US in the United States (continued).

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58 http://www.cs.amedd.army.mil/amedd_journal.aspx 12. en-USRassi A Jr, Rassi A, Little WC, et al. Developen-US -en-US ment and validation of a risk score for predicten-US -en-US ing death in Chagas heart disease. en-US N Engl J Meden-US en-US 2006;355(8):799-808. 13. en-USDepartment of Defense Instruction 6130.03: Medien-US -en-US cal Standards for Appointment, Enlistment, or en-US Induction in the Military Servicesen-US Washington, en-US en-US Available at: http://dtic.mil/whs/directives/corres/en-US pdf/613003p.pdf. Accessed January 10, 2017. 14. en-USBern C, Montgomery SP, Herwaldt BL, et al. en-US Evaluation and treatment of Chagas disease in en-US en-US JAMAen-US en-US 2007;298(18):2171-2181. 15. en-USWagner N, Jackson Y, Chappuis F, Posfay-Barbe en-US KM. Screening and management of children at risk en-US for Chagas disease in nonendemic areas. en-US Pediatr en-US Infect Dis Jen-US 2016;35(3):335-337. 16. en-USSarkar S, Strutz SE, Frank DM, Rivaldi CL, Sisen-US -en-US en-US Texas. en-USPLoS Negl Trop Disen-US 2010;4(10):e836. 17. en-USGarcia MN, Woc-Colburn L, Aguilar D, Hotez PJ, en-US Murray KO. Historical perspectives on the epideen-US -en-US miology of human Chagas disease in Texas and en-US recommendations for enhanced understanding en-US en-US States. en-USPLoS Negl Trop Disen-US 2015;9(11):e0003981.en-USA CASE OF CHAGAS CARDIOMYOPATHY FOLLOWING INFECTION IN SOUTH CENTRAL TEXASen-USTriatoma incrassataen-USAdulten-US en-US 17.5-19.8 mmen-USNo photo available.en-US.en-USTriatoma indictivaen-USAdulten-US en-US 18-22 mmen-USPhoto by Christina Wozniak. en-USFigure en-US2en-US. en-US Triatomaen-US in the United States (continued). en-USTriatoma lecticulariaen-USAdulten-US en-US 19.5-25 mmen-USPhoto by Edward Wozniak.en-USTriatoma neotomaeen-USAdulten-US en-US 16.5-19.5 mmen-USPhoto by Mike Quinnen-US en-US TexasEnto.net. en-USFigure en-US3en-US. en-US Triatomaen-US in the United States (continued). en-USTriatoma protracta protractaen-USAdulten-US en-US 16-23 mmen-USPhoto by Justin Schmidt and en-US Steven Klotz.en-US Triatoma protracta woodien-USAdulten-US en-US 14-16 mmen-USPhoto by Edward Wozniak. en-USFigure en-US4en-US. en-US Triatomaen-US in the United States (continued). en-USFigure en-US5en-US. en-US Triatomaen-US in the United States (continued). en-USTriatoma recurvaen-USAdulten-US en-US 25.5-33 mmen-USPhoto by Justin Schmidt and en-US Steven Klotz.en-US Triatoma rubidaen-USAdulten-US en-US 15.5-23 mmen-USPhoto by Edward Wozniak.

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January June 2017 59 18. en-USKlotz SA, Dorn PL, Mosbacher M, Schmidt JO. en-US en-US borne disease in humans. en-USEnviron Health Insightsen-US en-US 2014;8(suppl 2):49-59. 19. en-USKjos SA, Snowden KF, Olson JK. Biogeograen-US -en-US phy and en-US Trypanosomaen-US en-US cruzien-US infection prevalence en-US en-US Vector en-US Borne Zoonotic Disen-US 2009;9(1):41-50. 20. en-USMartnez-Ibarra JA, Alejandre-Aguilar R, Pareen-US -en-US des-Gonzlez E, et al. Biology of three species of en-US North American Triatominae (Hemiptera: Reduen-US -en-US viidae: Triatominae) fed on rabbits. en-US Mem Inst Osen-US -en-US waldo Cruzen-US 2007;102(8):925-930. 21. en-USCurtis-Robles R, Wozniak EJ, Auckland LD, Hamen-US -en-US er GL, Hamer SA. Combining public health educaen-US -en-US tion and disease ecology research: using citizen scien-US -en-US ence to assess Chagas disease entomological risk en-US in Texas. en-USPLoS Negl Trop Disen-US 2015;9(12):e0004235. en-US doi: 10.1371/journal.pntd.0004235. 22. en-USWozniak EJ, Lawrence G, Gorchakov R, et al. The en-US biology of the Triatomine bugs native to south cenen-US -en-US tral Texas and assessment of the risk they pose for en-US autochthonous Chagas disease exposure. en-US J Parasien-US -en-US tolen-US 2015;101(5):520-528. 23. en-USBern C, Kjos S, Yabsley MJ, Montgomery SP. Tryen-US -en-US panosoma en-US cruzien-US en-US States. en-USClin Microbiol Reven-US 2011;24(4):655-681. 24. en-USGorchakov R, Trosclair LP, Wozniak EJ, et al. en-US Tryen-US -en-US panosomaen-US en-US cruzien-US infection prevalence and blooden-US -en-US meal analysis in Triatomine vectors of Chagas en-US disease from rural peridomestic locations in Texas, en-US 2013-2014. en-USJ Med Entomolen-US 2016;53(4):911-918. 25. en-USShender L, Niemela M, Conrad P, Goldstein en-US T, Mazet J. Habitat management to reduce huen-US -en-US man exposure to en-US Trypanosomaen-US en-US cruzien-US and western en-US conenose bugs (en-US Triatoma protractaen-US ). en-US Ecohealthen-US en-US 2016;13(3):525-534. 26. en-USAFPMB Technical Guide No. 36: Personal Protecen-US -en-US tive Measures Against Insects and Other Arthroen-US -en-US en-US Silver Spring, MD: en-US Armed Forces Pest Management Board: November en-US 6, 2015. Available at: http://www.acq.osd.mil/eie/en-US afpmb/docs/techguides/tg36.pdf. Accessed Januen-US -en-US ary 10, 2017. AUTHORS Maj Webber is the Preventive Medicine Element Chief, en-US559th Trainee Health Squadron, Wilford Hall Ambulaen-US -en-US tory Surgical Center, JBSA-Lackland, Texas.en-US en-US State Guard Medical Brigade, Camp Mabry, Texas.en-US CPT Chang is a Fellow in the Department of Infectious en-US Disease, San Antonio Military Medical Center, JBSA-en-US Fort Sam Houston, Texas.en-US Maj Bush is a Fellow in the Cardiology Division, San en-US Antonio Military Medical Center, JBSA-Fort Sam Housen-US -en-US ton, Texas.en-US Maj Wilson is Medical Director, 559th Trainee Health en-US Squadron, Wilford Hall Ambulatory Surgical Center, en-US JBSA-Fort Sam Houston, Texas.en-US LTC Watts is Chief of Cardiology, Cardiology Division, en-US San Antonio Military Medical Center, JBSA-Fort Sam en-US Houston, Texas.en-US Lt Col Yun is Infectious Disease Fellowship Program Dien-US -en-US en-US -en-US tion Consortium, San Antonio Military Medical Center, en-US JBSA-Fort Sam Houston, Texas. Triatoma rubrofasciata en-USAdulten-US en-US 19.5-25 mmen-USPhoto by Gabe Hamer.en-US Triatoma sanguisugaen-USAdulten-US en-US 15.5-23 mmen-USPhoto by Edward Wozniak. en-USFigure en-US6en-US. en-US Triatomaen-US in the United States (end).

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en-US60 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USen-US deployed military forces and is a public health priority.en-US1en-US en-US It is an emerging zoonotic disease caused by obligate inen-US -en-US tracellular parasites of the genus en-USLeishmaniaen-US which are en-US transmitted by en-US Phlebotomineen-US en-US en-US Currently, over en-US 350 million people are at risk and 12 million people in en-US 90 countries are infected.en-US2en-US The number of new cases of en-US the non-fatal form of the disease, cutaneous leishmanien-US -en-US asis (CL), and the potentially fatal visceral (VL) form en-US of the disease is 1.5 and 0.5 million annually. The most en-US prevalent regions at risk are the Middle East, Africa (prien-US -en-US marily east and north), India, Asia, Central and South en-US America (primarily Honduras and Brazil). Leishmanien-US -en-US en-US States. Visceral leishmaniasis is caused by en-US Leishmania en-US donovanien-US complex en-USL donovanien-US and en-USL infantumen-US in the Old en-US World and en-USL infantumen-US /en-US L chagasi en-USin the New World. Cuen-US-en-US taneous leishmaniasis is caused primarily by en-US L tropicaen-US en-US and en-US L majoren-US complex in the Old World and en-US L mexicanaen-US en-US complex (en-US L mexicana, L amazonensis, and L venezuen-US -en-US elensisen-US ); and subgenus en-USViannia en-US complex en-US L brazilliensisen-US en-US and en-US L guyanensisen-US in the New World. A licensed vaccine en-US or drug prophylaxis does not exist.en-US Visceral leishmaniasis is fatal if untreated.en-US3,4en-US Cutaneous en-US leishmaniasis can cause severe scarring with permanent en-US en-US5,6en-US Both forms of en-US the disease often require lengthy and painful treatment en-US and may present complex issues associated with drug en-US en-US7en-US Early and accurate en-US en-US -en-US ment decreases VL mortality, CL physical impairment en-US en-US Visceral and cutaneous leishmaniasis clinical samples en-US are obtained from venous blood, spleen and bone maren-US -en-US row aspirate and skin lesion biopsy, respectively. Laben-US -en-US oratory methods used for diagnoses are primarily mien-US -en-US croscopy and immunoassay.en-US7,8en-US Isoenzyme analysis is en-US typically used to identify en-US Leishmaniaen-US species. However, en-US these methods can take days to weeks to produce results. en-US Commercially available immunochromatographic (ICT) en-US strip assays are available that detect en-US L donovanien-US antien-US -en-US body in human serum, providing an aid in presumptive en-US diagnosis of VL. Moreover, ICT strip assays are easily en-US transported and require minimal training, 2 key traits to en-US en-US9en-US en-US Detection by ICT augmented by molecular-based methen-US -en-US en-US10,11en-USPolymerase chain reaction (PCR) detection tests are en-US en-US12-17en-US en-US However, detection by PCR is challenged by the number en-US of infecting parasites from potentially low load CL paen-US -en-US tient samples of 2 to 11e6 parasites/skin biopsy and VL en-US sample loads of 30 to 2en-US e5en-US parasites/mL blood with a meen-US -en-US en-US18,19en-US The load of CL parasites en-US in blood is presumably at single log or less concentraen-US -en-US tion based on PCR and isoenzyme test results.en-US20,21en-USDirect Detection of en-USLeishmania en-US fromen-US en-US Clinical Samples J ohn N. Waitumbi, PhD R atree Takhampunya, PhD N ancy Nyakoe, MS M arshall T. Van de Wyngaerde, MS C harles Magiri J ames C. McAvin, MS M iguel Quintana, PhD R ussell E. Coleman, PhD ABSTRac AC T The ability to rapidly and accurately diagnose leishmaniasis is a military priority. Testing was conducted to en-USen-US Leishmaniaen-US genus and visceral en-USLeishmaniaen-US en-US en-US en-US without the disease from Baringo District, Kenya, were tested. en-US Leishmaniaen-US genus assay sensitivity was 100% en-US en-US Leishmaniaen-US en-US 80% (4/5). Cutaneous leishmaniasis (CL) skin scrapes of patients from Honduras were also evaluated. en-US Leishen-US -en-US maniaen-US genus assay sensitivity was 100% (10/10). Visceral en-US Leishmaniaen-US en-US en-US en-USLeishmaniaen-US direct detection from clinical samples.

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en-USJanuary June 2017 en-US61en-USen-US Leishmaniaen-US en-US genus (LEIS) and visceral en-US Leishmaniaen-US (LVL) TaqMan en-US en-US which clearly show promise as an aid in diagnosis. METHODS Clinical Samples en-USTest panels were prepared consisting of well characteren-US -en-US en-US en-US skin scrapes.en-US Blood samples of patients with VL and controls without en-US the disease were obtained in endemic areas of Baringo en-US District, Kenya, during routine surveillance for VL.en-US22en-US en-US These samples were used to construct a test panel of 14 en-US VL patients and 19 control samples. Testing was conen-US -en-US en-US in February 2012. Clearance was obtained from the en-US institutional ethical committee of the Kenya Medical en-US Research Institute (KEMRI ERC #1282) and the Instien-US -en-US tutional Review Board (IRB), Walter Reed Army Instien-US -en-US tute of Research (WRAIR), Silver Spring, Maryland en-US (WRAIR IRB #1402).en-US Prior to evaluations conducted in Kenya reported here, en-US LEIS and LVL assays were tested under a separate study en-US using total nucleic acid extracts from isolates of 10 CL en-US patient skin scrape samples obtained in Honduras. Samen-US -en-US ples were provided by the Honduras Ministry of Public en-US Health. Serology was used to identify the causative agent en-US as en-US L mexicanaen-US Extracts were prepared and transported en-US en-US -en-US tion and Preventive Medicine-West (CHPPM-W), Fort en-US Lewis, WA. Testing was conducted at the Department of en-US Entomology, CHPPM-W. Test results were used for PCR en-US assay evaluation purposes only. Aliquots of specimens en-US routinely ordered for conventional diagnostic purposes en-US en-US removed prior to the receipt of specimens in compliance en-US with the human use protocol, Surveillance of Emergen-US -en-US ing Infectious Disease Agents in Human Populations of en-US en-US approved 2001 (FY01-08).en-USNucleic Acid Preparationen-USExtracts were prepared using commercially available, en-US off the shelf, preformatted, guanidinium thiocyanate en-US en-US the manufacturers instructions (QIAGEN, Valencia, en-US California).en-USPCR Assay Designen-USPreviously established en-US Leishmaniaen-US genus primer and en-US probe sequences were obtained from the literature for en-US LEIS freeze-dried assay development.en-US23en-US Design of LVL en-US primer and probe oligonucleotides and LVL and LEIS en-US PCR reaction conditions were previously described.en-US24en-US en-US Leishmaniaen-US genus and LVL assay optimization, limit en-US en-US -en-US ity test results are previously described.en-US24en-US Primer and en-US probe synthesis, proprietary master mix preparation en-US and freeze-drying process, and quality control were en-US conducted commercially (BioFire Diagnostics Inc., Salt en-US en-USAnalysesen-USThe analytic platform was a Department of Defense apen-US -en-US en-US en-US en-US as shown in the Figure. The analytic system and PCR en-US cycling conditions were previously described.en-US24en-US The en-US comparator test for this study was a well-established en-US L en-US donovanien-US PCR assay targeting a 360 base-pair region of en-US the 6-phosphate isomerase gene.en-US25en-US Comparator test analen-US -en-US ysis was conducted using a SmartCycler (Cepheid, Inc, en-US Sunnyvale, California). Blind testing was conducted.en-USData Management and Statistical Analysesen-USen-US entered electronically in the RAPID operating system en-US run protocol. A single data point at the end of each anen-US -en-US nealing extension cycle was collected and reported as en-US en-US -en-US tivity during primer extension. The criterion for a posien-US -en-US en-US en-US an algorithm provided in the RAPID analytical software en-US (Roche Molecular Biochemicals, Basel, CH). The Ct is en-US en-US -en-US en-US Samples with a mean Ct more than 40 were considered en-US negative, whereas samples with a mean Ct of 40 or less en-US were considered positive by RAPID analyses. Sample reen-US -en-US sults and statistical analyses were automatically archived. RRESULTS Test panels consisting of well characterized nucleic acid en-USextracts of blood samples from 14 VL positive patients en-US and 19 controls without VL, and 10 CL positive patient en-US skin scrape samples were used to evaluate LEIS and en-US en-US -en-US sults are presented in the Table.en-US THE ARMY MEDICAL DEPARTMENT JOURNAL

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en-US62 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USVisceral Leishmaniasis Diagnostic Sensitivityen-US en-US from Blood Samplesen-USVisceral leishmaniasis test results were LEIS sensitiven-US -en-US en-US en-US LEIS Ct and standard deviation were 26.96 and 4.32, reen-US -en-US spectively, where n=14, SE=1.16 (95% CI, 24.69-29.23). en-US en-US positive results occurred for 3 samples. The Ct values en-US were 30.63, 30.9, and 31.48. The sensitivity of the LVL en-US assay was 93% (13/14). Mean LVL Ct and standard deen-US -en-US viation were 31.80 and 4.36, respectively, where n=13, en-US en-US assay was 80% (4/5). One false positive occurred with a en-US Ct value of 34.49.en-USCutaneous Leishmaniasis Diagnostic Sensitivityen-US en-US from Skin Lesion Samplesen-USTest panel results of CL skin scrapes of patients from en-US Honduras were LEIS sensitivity 100% (10/10). Honduen-US -en-US ras test panel LEIS results were mean Ct and standard en-US deviation of 26.51 and 2.87, respectively, where n=10, en-US en-US en-US above background was observed.en-USControlsen-USen-US -en-US en-US en-US en-US24en-US Negative template control reactions en-US en-US -en-US rescence above background was observed in testing of en-US en-US DNA (1ng/reaction). COmm MM ENT This preliminary evaluation of LEIS and LVL TaqMan en-USen-US en-US Leishmania en-US direct detection from VL patient blood and en-US CL skin scrape samples. However, enhancement of our en-US method and additional testing are needed.en-US The LEIS assay serves as a valuable screening tool en-US for subsequent en-USLeishmaniaen-US en-US molecular and/or isoenzyme analyses. The diagnostic en-US sensitivity of the LVL assay was 93% (n=14) which is en-US approximately in line with previous reports describen-US -en-US ing direct detection from VL patient blood samples en-US by real-time PCR; 79% (n=15), 80% (n=45), and 94% en-US (n=100).en-US13-15en-US However, it is unlikely that we can reliably en-US reproduce greater than 90% sensitivity results without en-US enhancing our methods. False negative results are inen-US-en-US evitable because VL patient blood samples potentially en-US harbor parasites at concentrations as low as a single log. en-US While PCR limit of detection is achieved at single copy en-US and regularly at single log concentrations, there is no en-US expectation of reliable and reproducible results from low en-US load samples using conventional methods. The issue is en-US that only a fraction of the sample is extracted when usen-US -en-US ing commercial preformatted kits (100 L-200 L) or en-US robotic systems (100 L-400 L).en-US26-28en-US Thus, for samples en-US with a low parasite load, the resulting extract concenen-US -en-US tration of target template is likely to be diluted below en-US en-US -en-US ity are likely to better represent consistently achievable en-US direct detection given the limitations of conventional en-US sample preparation methodologies.en-US en-US LVL (80%, 4/5) assays from VL patient blood samples en-US were probably underestimated. Both LEIS and LVL en-US en-US healthy control, indicating incorrect reporting by the en-US L donovanien-US comparator test result. Better than reported en-US en-US use of our early development phase Human en-US Leishmaen-US -en-US niaen-US (LHL) assay which is designed to detect VL and en-US CL causative agents. Both, LEIS and LHL results were en-US positive (Ct 31.48 and 35.82, respectively) and negative en-US by LVL for the same healthy control, indicating that the en-US sample harbored a CL causative agent.en-US en-US -en-US ed with VL diagnosis from noninvasively obtained body en-US en-US Direct detection of VL parasites from noninvasively en-US en-US single log loads. Various degrees of success have been en-US en-US n=37 and 83%, n=148).en-US29-31en-US Detection from canine oral en-USen-USDiseaseen-US Sourceen-US Originen-US Sensitivityen-US LEIS PCRen-US en-US Ct Mean/SDen-US en-US Sensitivityen-US LVL PCRen-US en-US Ct Mean/SDen-US en-US VLen-US Blooden-US Kenyaen-US 100%(14/14)en-US 26.96/4.32en-US 84%(16/19)en-US 93%(13/14)en-US 31.80/4.36en-US 80%(4/5)en-US CLen-US Lesionen-US Hondurasen-US 100%(10/10)en-US 26.51/2.87en-US 100%(10/10)en-USVL indicates visceral leishmaniasis; CL, cutaneous leishmaniasis; Ct, critical threshold; LEIS, en-US Leishmaniaen-US genus; LVL, visceral en-US Leismaniaen-US ; and PCR, polymerase chain reaction [detection test]. en-USDIRECT DETECTION OF en-USLEISHMANIA en-US FROM CLINICAL SAMPLES

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en-USJanuary June 2017 en-US63 en-USen-US32en-US In these en-US studies, conventional sample preparation methods were en-US augmented with centrifugation to concentrate parasites en-US prior to extraction.en-US We are currently developing an alternative approach. en-US en-US -en-US gates variables affecting relative yields of pathogens en-US en-US en-US samples obtained from the same patient over time. It has en-US been shown that centrifugation of high SG urine results en-US en-US low SG urine samples.en-US33en-US To help ensure consistently high en-US en-US eliminate SG variables. Preliminary results of our lepen-US -en-US tospirosis diagnostic system show promise in increasen-US -en-US ing analytical limit of detection by 1-2 log concentration en-US compared to centrifugation. This will be described in a en-US future article. The low cost, simple, and portable characen-US -en-US en-US -en-US en-US The results of LEIS and LVL detection assay testing en-US en-US for en-US Leishmaniaen-US direct detection from clinical samples. en-US It is our intent to augment analytical capabilities with en-US en-US -en-US analytical technologies. AcC KNOWLEDGEm M ENTS Our thanks to the health facilities in Kenya that provided en-USLeishmania samples and the Ministry of Health of Honen-US -en-US duras. Funding for the Kenyan study was from the Armed en-US Forces Health Surveillance Branch and its Global Emergen-US -en-US ing Infections Surveillance and Response Section. This en-US work was funded in part by the Military Infectious Disen-US -en-US en-US -en-US land, and the Air Force Medical Support Agency, Reen-US -en-US en-US of the Surgeon General, Falls Church, Virginia. The opinen-US -en-US ions or assertions contained herein are the private views of en-US en-US en-US-en-US partment of the Navy, Department of the Air Force, or the en-US Department of Defense. RREFERENc C ES 1. en-USBurnette WN, Hoke CH, Scovill J, et al. Infectious en-US diseases investment decision algorithm: a quantitaen-US -en-US tive algorithm for prioritization of naturally occuren-US -en-US en-US Mil Meden-US 2008;173(2):174-181. 2. en-USWorld Health Organization. Leishmaniasis [interen-US -en-US net]. Available at: en-UShttp://www.who.int/leishmanien-US -en-US asisen-US en-USAccessed December 1, 2016. 3. en-USMoore EMen-US en-US Lockwood DNen-US Treatment of visceral en-US leishmaniasis. en-USJ Glob Infecten-US en-USDisen-US .en-US en-US2010;2(2):151-158. 4. en-USReithinger Ren-US ,en-US en-US Mohsen Men-US ,en-US en-US Wahid Men-US ,en-US en-US en-US of thermotherapy to treat cutaneous leishmaniasis en-US caused by Leishmania tropica in Kabul, Afghanien-US -en-US stan: a randomized, controlled trial. en-US Clin Infect Disen-US .en-US en-US 2005;40(8):1148-1155. 5. en-USGoto Hen-US en-US Lindoso JAen-US Current diagnosis and treaten-US -en-US ment of cutaneous and mucocutaneous leishmanien-US -en-US asis. en-US Expert Rev Anti Infect Theren-US .en-US en-US 2010;8(4):419-433. 6. en-USCenters for Disease Control and Prevention. Paraen-US -en-US en-US www.cdc.gov/parasites/leishmaniasis/. Accessed en-US December 1, 2016. 7. en-USSrivastava P, Dayama A, Mehrotra S, Sundar S: Dien-US -en-US agnosis of visceral leishmaniasis.en-GB en-US Trans R Soc Trop en-US Med Hygen-US 2011;105(1):1-6. 8. en-USVasoo Sen-US en-US Pritt BSen-US Molecular diagnostics and paraen-US -en-US sitic disease. en-USClin Lab Meden-US .en-US 2013;33(3):461-503. 9. en-USAnderson BL, Litwin CM, Welch RJ. Immunoen-US -en-US chromatographic strip test for detection of anti-en-US K39 immunoglobulin G antibodies for diagnosis en-US of visceral leishmaniasis. en-USClin Vaccine Immunolen-US en-US 2008;15(9):1483-1484. 10. en-USCunningham J, en-US Hasker Een-US en-US Das Pen-US et al. A global comen-US -en-US parative evaluation of commercial immunochroen-US -en-US matographic rapid diagnostic tests for visceral leishen-US -en-US maniasis. en-USClin Infect Disen-US .en-US 2012;55(10):1312-1319. 11. en-USQuinnell RJen-US en-US Carson Cen-US en-US Reithinger Ren-US en-US Garcez LMen-US en-US Courtenay Oen-US Evaluation of rK39 rapid diagnostic en-US tests for canine visceral leishmaniasis: longitudien-US -en-US nal study and meta-analysis. en-US PLoS Negl Trop Disen-US .en-US en-US 2013;7(1):e1992. 12. en-USSrivastava en-US Pen-US en-US Mehrotra Sen-US en-US Tiwary Pen-US en-US Chakravarty en-US Jen-US en-US Sundar Sen-US. Diagnosis of Indian visceral leishen-US -en-US maniasis by nucleic acid detection using PCR. en-US PLoS Oneen-US .en-US 2011;6(4):e19304. doi: 10.1371/journal.en-US pone.0019304. 13. en-USPereira MRen-US en-US Rocha-Silva Fen-US en-US Graciele-Melo Cen-US en-US Laen-US -en-US fuente CRen-US en-US Magalhes Ten-US en-US Caligiorne RBen-US Comparien-US -en-US son between conventional and real-time PCR assays en-US for diagnosis of visceral leishmaniasis. en-USBiomed Res en-US Inten-US .en-US 2014;2014:639310. doi: 10.1155/2014/639310. en-US Epub 2014 Feb 6. 14. en-USToz SOen-US en-US Culha Gen-US, en-US Zeyrek FYen-US et al. A real-time en-US ITS1-PCR based method in the diagnosis and speen-US -en-US en-US human and dog clinical samples in Turkey. en-US PLoS en-US Negl Trop Disen-US .en-US 2013;7(5):e2205. doi: 10.1371/jouren-US en-US nal.pntd.0002205. 15. en-USMohammadiha Aen-US en-US Mohebali Men-US en-US Haghighi Aen-US et al. en-US Comparison of real-time PCR and conventional PCR en-US with two DNA targets for detection of Leishmania en-US (Leishmania) infantum infection in human and dog en-US blood samples. en-US Exp Parasitolen-US .en-US 2013;133(1):89-94. en-US doi: 10.1016/j.exppara.2012.10.017. Epub 2012 Nov 1.

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64 http://www.cs.amedd.army.mil/amedd_journal.aspx 16. en-USJara Men-US en-US Adaui Ven-US en-US Valencia BMen-US et al. Real-time PCR en-US en-US -en-US nia (Viannia) organisms in skin and mucosal leen-US -en-US sions: exploratory study of parasite load and clinical en-US parameters. en-USJ Clin Microbiolen-US 2013;51(6):1826-1833. 17. en-USMeymandi SSen-US en-US Bahmanyar Men-US en-US Dabiri Sen-US en-US en-US MRen-US en-US Bahmanyar Sen-US en-US Meymandi MSen-US Comparison of en-US cytologic giemsa and real-time polymerase chain en-US reaction technique for the diagnosis of cutaneen-US -en-US ous leishmaniasis on scraping smears. en-US Acta Cytolen-US .en-US en-US 2010;54(4):539-545. 18. en-USMary C, Faraut F, Lascombe L, Dumon H. en-USQuanen-US -en-US en-US time PCR assay with high sensitivity.en-US en-US J Clin Microen-US -en-US biolen-US 2004;42(11):5249-5255. 19. en-USvan der Meide WF, Schoone GJ, Faber WR, et al. en-US Quantitative nucleic acid sequence-based assay as en-US en-US -en-US tion ofen-US en-US Leishmaniaen-US en-US parasites in skin biopsy samplesen-US en-US J Clin Microbiolen-US 2005;43(11):5560-5566. 20. en-USMartins Len-US en-US Alexandrino Aen-US en-US Guimares Gen-US Detecen-US -en-US tion of Leishmania braziliensis DNA in American en-US tegumentary leishmaniasis patients. en-USRev Saude Puen-US -en-US blicaen-US .en-US 2010 Jun;44 (3):571-574. 21. en-USNakkash-Chmaisse H, Makki R, Nahhas G, Knio en-US K, Nuwayri-Salti N. Detection of Leishmania paraen-US -en-US sites in the blood of patients with isolated cutaneous en-US leishmaniasis. en-US Int J Infect Disen-US 2011;15(7):e491-494. 22. en-USBasiye FLen-US en-US Mbuchi Men-US en-US Magiri Cen-US et al. Sensitivity en-US en-US NASBA-oligochromatography for diagnosis of visen-US -en-US ceral leishmaniasis in Kenya. en-US Trop Med Int Healthen-US .en-US en-US 2010;15(7):806-810. 23. en-USWortmann G, Sweeney C, Houng HS, Aronson N, en-US Stiteler J, Jackson J, Ockenhouse C. Rapid diagnosis en-US en-US reaction. en-USAm J Trop Med Hygen-US 2001;65(5):583-587. 24. en-USMcAvin JC, Swanson KI, Chan AST, Quintana M, en-US Coleman RE.en-US Leishmaniaen-US en-US en-US Mil Meden-US 2012;177(4):460-466. 25. en-USen-US of vector diagnostics during military deployments: en-US recent experience in Iraq and Afghanistan. en-US Mil en-US Meden-US. 2009;174 (9):904-920. 26. en-USFahle GAen-US Fischer SH. Comparison of six commeren-US -en-US cial DNA extraction kits for recovery of cytomegaen-US -en-US lovirus DNA from spiked human specimens. en-US J Clin en-US Microbiolen-US .en-US 2000;38(10):3860-3863. 27. en-USPodnecky NL, Elrod MG, Newton BR, et al. en-US Comparison of DNA extraction kits for detecen-US -en-US tion of Burkholderia pseudomallei in spiked huen-US -en-US man whole blood using Real-Time PCR. en-USPLoS en-US ONEen-US 2013;8(2):e58032. DOI:10.1371/journal.pone.en-US en-US 0058032. 28. en-USYang Gen-US ,en-US en-US Erdmanen-US en-US DEen-US ,en-US en-US Kodani Men-US ,en-US en-US Kools Jen-US ,en-US en-US Bowen en-US MDen-US ,en-US en-US Fields BSen-US Comparison of commercial sysen-US -en-US tems for extraction of nucleic acids from DNA/en-US RNA respiratory pathogens. en-US J Virol Methodsen-US .en-US en-US 2011;171(1):195-199. 29. en-USFisa Ren-US en-US Riera Cen-US en-US Lpez-Chejade Pen-US et al. Leishmaen-US -en-US nia infantum DNA detection in urine from patients en-US with visceral leishmaniasis and after treatment en-US control. en-USAm J Trop Med Hygen-US .en-US 2008;78(5):741-744. 30. en-USVaish M, Mehrotra S, Chakravarty J, Sunen-US -en-US dar S. Noninvasive molecular diagnosis of huen-US -en-US man visceral Leishmaniasis. en-US J Clin Microbiolen-US en-US 2011;49(5):2003-2005. 31. en-USGalaen-US Y, en-USChabchoub Nen-US en-US Ben-Abid Men-US et al. Diagnoen-US -en-US sis of Mediterranean visceral leishmaniasis by deen-US -en-US tection of Leishmania antibodies and Leishmania en-US en-US -en-US col device. en-USJ Clin Microbiolen-US 2011;49(9):3150-3153. 32. en-USLombardo G, Pennisi MG, Lupo T, Migliazzo A, en-US Capr A, Solano-Gallego L. en-US Detection of Leishen-US -en-US mania infantum DNA by real-time PCR in caen-US -en-US nine oral and conjunctival swabs and comparison en-US with other diagnostic techniques.en-US en-US Vet Parasitolen-US en-US 2012;184(1):10-17. 33. en-USRauter C, en-US Muelleren-US M, Diterich I, Zeller S, Hasen-US -en-US sler D, Meergans T, Hartung T. Critical evaluen-US -en-US ation of urine-based PCR assay for diagnosis en-US of Lyme Borreliosis. en-USClin Diagn Lab Immunolen-US en-US 2005;12(8):910-917. AUTHORS Dr Waitumbi, Ms Nyakoe, and Mr Magiri are with the en-USen-US en-US MAJ Bast is Deputy Director/Research Entomologist en-US en-US -en-US gia, in Tbilisi, Georgia.en-US en-US -en-US mand Region-South, Joint Base San Antonio Fort Sam en-US Houston, Texas.en-US Dr Takhampunya is with the Armed Forces Research Inen-US -en-US stitute of Medical Sciences, Bangkok, Thailand.en-US LTC Schuster is with the Directorate of Combat and Docen-US -en-US trine Development, AMEDD Center & School, Health en-US Readiness Center of Excellence.en-US Mr Van de Wyngaerde is with the Walter Reed Institute en-US of Research, Silver Spring, Maryland.en-US en-US Biosciences Research Management, Inc, St Louis, en-US Missouri.en-US en-US -en-US telle National Biodefense Institute, Frederick, Marylanden-US.en-USDIRECT DETECTION OF en-USLEISHMANIA en-US FROM CLINICAL SAMPLES

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en-USJanuary June 2017 en-US65en-USen-US Family Psychodidae, Order Diptera) are vicious biting en-US insects that cause extreme nuisance and transmit disen-US -en-US eases to humans. In Africa and Asia (Figure 1), the perien-US -en-US domestic species bite insatiably and also are of major en-US public health concern in many parts of the world, paren-US -en-US ticularly in the Old World, where they are capable of en-US transmitting pathogens, including protozoans (en-US Leishmaen-US -en-US niaen-US en-US1en-US en-US Phleen-US -en-US botomusen-US females suck blood, including humans, while en-US Sergentomyiaen-US females primarily feed on reptiles, and en-US rarely bite humans.en-US2en-US Subgenera (en-US Adleriusen-US en-US Euphlebotoen-US -en-US musen-US en-US Larroussiusen-US en-US Phlebotomusen-US en-US Paraphlebotomusen-US and en-US Synphlebotomusen-US ) in the genus en-USPhlebotomusen-US contain en-US species that are vectors or suspected vectors in the Old en-US World.en-US2en-USen-US World (Southwest Asia, Central Asia, and Africa includen-US -en-US ing Western Indian Ocean Islands ), only about 27 speen-US -en-US cies are capable of transmitting protozoan en-US Leishmaniaen-US en-US parasites that cause visceral leishmaniasis (kala-azar) en-US and various forms of cutaneous leishmaniasis (oriental en-US sore, espundia, etc) in humans.en-US2-4en-USen-US -en-US cies have been associated with en-USPhlebovirusen-US and other en-US viruses.en-US3-6en-US Numerous reports are available on the biolen-US -en-US ogy, and medical importance (as disease vectors) of sand en-US en-US2,7-10en-US In the Old World, the en-US human biting en-US Phlebotomusen-US en-US -en-US en-US (particularly in dry, semiarid areas), with some human en-US biting species in Africa south of the Sahara.en-US2en-USen-US leishmaniasisen-US en-US en-US en-US11en-US In en-US Afghanistan (Operation Enduring Freedom, OEF) and en-US en-US -en-US en-US about 1,287 incident diagnoses/reports of leishmanien-US -en-US asis, both cutaneous (1,283 cases) and visceral (4 cases) en-US forms, were reported from 2001-2006 among OEF/OIF en-US deployed troops.en-US12en-USen-US -en-US en-US Base, Iraq, from April 2003 to November 2004, and they en-US en-US operations, including the leishmanial threat to deployed en-US troops in Iraq.en-US13-15en-USIn this article, we examine the types and related specien-US -en-US en-US en-USNew Records, Distribution, and Updateden-US en-US Checklists of Old World Phlebotomineen-US en-US Sand Flies, With Emphasis on Africa,en-US en-US Southwest Asia, and Central Asia L eopoldo M. Rueda, PhD S arah Benyamin, BS J ames E. Pecor, BS P hilippe fr-FRBousssen-US PhD M atthew Wolkoff, BA M ustapha Debboun, PhD, BCE D avid Pecor, BS ABSTRac AC T en-USDiptera) in the Old World (Africa including West Indian Ocean Islands, Southwest Asia, and Central Asia) en-US based on specimen collections housed in different repositories worldwide. About 124 species have primary en-US types housed in 5 repositories including holotypes (45 species, 4 subspecies), syntypes (28 species, 3 subspeen-US -en-US cies), types (14 species), allotypes (10 species), paratypes (36 species, 3 subspecies), lectotypes (13 species), en-US and cotype (5 species), mounted on 671 slides. New abbreviations were proposed for 2 subgenera in the genus en-US Phlebotomusen-US and 6 subgenera in the genus en-US Sergentomyiaen-US New country records were noted in en-US Phlebotomusen-US (4 en-US species in 4 subgenera in 7 countries) and en-US Sergentomyiaen-US (10 species in 4 subgenera in 8 countries). For species en-US diversity in the Old World, en-US Phlebotomusen-US includes 92 species and 7 subspecies in 9 subgenera, while en-US Sergenen-US -en-US tomyiaen-US includes 166 species and 16 subspecies in 12 subgenera. A total of 95 species and 7 subspecies of 2 en-US genera (en-US Phlebotomusen-US and en-US Sergentomyiaen-US ) were recorded in Africa while about 26 species and 16 subspecies in en-US Southwest Asia and Central Asia.

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en-US66 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USen-US en-US en-US Montpellier, France; en-GBen-US National dHistoire Naen-US -en-US turelle en-USEntomologie (MNHE), Paris, France; Institut en-US Pasteur (IP), Paris, France; en-GBen-GB Centrale (MRAC), Dept Entomologie, Tervuren, Belen-GB -en-GB gium. Additional specimens were borrowed from the en-GB en-GB -en-GB en-GB (KEMRI), Nairobi, Kenya; en-US Florida State Collection of en-US Arthropods (FSCA), Gainesville, Florida; en-GB en-GB en-GB -en-GB en-GB16en-GB) of selected en-GB en-GB vectors), based on specimens from different depositories en-GB are presently posted on the Walter Reed Biosystematics en-GB en-US17en-USen-US their geographical distribution, past and present taxoen-US -en-US nomic arrangement, and related information. The speen-US -en-US en-US -en-US cording to the number of collections for each country en-US over certain periods, were analyzed and reported. Other en-US en-US -en-US cluding non-types, from the Old World) from the 6 reen-US -en-US en-US were also examined and recorded, and will be posted en-US en-US -en-US map.si.edu).en-US18en-US These data may be helpful in en-US en-US-en-US en-US -en-US dictive distribution models. In addition to en-US en-US -en-US bution, the collection holdings in these reen-US -en-US positories, particularly the primary types, en-US will assist future phlebotomine researchers en-US in their taxonomic and related studies. MaA TERIa A LS aA ND METHODS en-US-en-US mens used in this study were deposited en-US en-US MNHE, IP, MRC), or borrowed from varien-US -en-US en-US The slide mounted specimens were exen-US -en-US amined and their collection data were reen-US -en-US corded. All collection data from selected en-US repositories were recorded verbatim and en-US entered into a standard specimen label data en-US capture spreadsheet. The data were georeen-US -en-US ferenced using the point-radius method of en-US georeferencing locality descriptions that en-US do not have associated geographic coordinates. The en-US georeferenced data were processed and used for analyen-US -en-US ses. The primary types (holotypes, allotypes, paratypes, en-US en-US -en-US cords and related information. Photographs of primary en-US en-US be processed for another report. RRESULTS Species Types and Abbreviations en-USThe proposed abbreviations for genera and subgenera en-US of Phlebotominae (Psychodidae, Diptera) of the Old en-US World is shown in Table 1, based primarily on Maren-US -en-US condes,en-US20en-US with additions of new abbreviations for the 2 en-US subgenera in genus en-US Phlebotomusen-US ie, en-US Legeromyiaen-US en-US Legen-US .; en-US Madaphlebotomusen-US en-US Maden-US .; and the 6 subgenera in genus en-US Sergentomyiaen-US ie, en-US Capensomyiaen-US en-US Capen-US .; en-US Parvidensen-US en-US Paven-US .; en-US Rondanomyiaen-US en-US Ronen-US .; en-US Spelaeomyiaen-US ,en-US en-US Speen-US .; en-US Trouilletomyiaen-US en-US Troen-US ., and en-USVattieromyiaen-US en-USVaten-US .en-US The list of Old World Phlebotomine species with type en-US specimens deposited in the various repositories is en-US shown in Table 2 (see pages 71-73), using the available en-US taxonomic arrangements.en-US19en-US The number of slides for en-US each type, species, sex, and the country of type origin en-US are also included in Table 2. About 124 species have en-US primary types deposited in 5 repositories (MNH, IRD, en-US MNHE, IP, MRC), including holotypes (45 species, 4 en-US subspecies), syntypes (28 species, 3 subspecies), types en-US NEW RECORDS, DISTRIBUTION, AND UPDATED CHECKLISTS OF OLD WORLDen-US en-US PHLEBOTOMINE SAND FLIES, WITH EMPHASIS ON AFRICA, SOUTHWEST ASIA, AND CENTRAL ASIAen-USFigure en-US1en-US. en-US Map showing different countries in the Old World, particularly Africa, en-US Southwest Asia, and Central Asia, and respective country codes (see Table 4 for en-US en-US types.

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en-USJanuary June 2017 en-US67 en-US(14 species), allotypes (10 species), paratypes (36 speen-US -en-US cies, 3 subspecies), lectotypes (13 species), and cotype en-US (5 species), mounted on 671 slides. Those specimens on en-US slides labeled Type could be considered as holotypes, en-US but proper designations should be done later.en-USNew Country Records and Updated Checklist of en-US Phlebotomine Speciesen-USen-US in different countries of Africa (including Western Inen-US-en-US dian Ocean Islands), Southwest Asia, and Central Asia en-US is presented in Table 3 (see pages 74-82). It also includes en-US distribution of these species in Africa (58 countries), en-US Southwest and Central Asia (26 countries) and other en-US countries (35), as well as their selected references.en-US3,9,32-49en-US en-US Several islands of Western Indian Ocean, ie, Comoros, en-US en-US (France), and Seychelles are included as Africa for the en-US purposes of this article.en-US50en-USThe genus en-USPhlebotomusen-US includes en-US 92 species and 7 subspecies in en-US 9 subgenera (en-US Adleriusen-US 17 speen-US -en-US cies; en-US Anaphlebotomusen-US 6 species; en-US Euphlebotomusen-US 5 species; en-US Laren-US -en-US roussiusen-US 27 species, 5 subspeen-US -en-US cies); en-US Legeromyiaen-US 1 species; en-US Madaphlebotomusen-US 4 species; en-US Paraphlebotomusen-US 12 species, 2 en-US subspecies; en-US Phlebotomusen-US 6 speen-US -en-US cies; en-US Synphlebotomusen-US 10 species; en-US Transphlebotomusen-US 2 species). en-US The genus en-USSergentomyiaen-US includes en-US 166 species and 16 subspecies in en-US 12 subgenera (en-US Capensomyiaen-US 10 en-US species; en-US Demeilloniusen-US 1 species; en-US Grassomyiaen-US 6 species, 2 subspeen-US -en-US cies; en-US Neophlebotomusen-US 22 species; en-US Parrotomyiaen-US 16 species, 4 suben-US -en-US species; en-US Rondanomyiaen-US 1 species, en-US 2 subspecies; en-US Sergentomyiaen-US 45 en-US species, 6 subspecies; en-US Sintoniusen-US en-US 27 species; en-US Spelaeomyiaen-US 6 speen-US -en-US cies; en-US Trouilletomyiaen-US 2 species; en-US Vattieromyiaen-US 4 species), and one en-US ungrouped taxon (24 species). en-US Further, we recorded a total of en-US 95 species and 7 subspecies of 2 en-US genera (en-US Phlebotomusen-US and en-US Sergenen-US -en-US tomyiaen-US ) in Africa, while about 26 en-US species and 16 subspecies in Southwest Asia and Central en-US Asia. About 22 species of both genera had wide distribuen-US-en-US tions and were found in 35 countries other than Africa, en-US Southwest Asia, and Central Asia.en-US The new records of species in different countries are en-US shown in Table 3 (with country codes (CN) as listed in en-US Table 4, see page 83). In the genus en-US Phlebotomusen-US 4 speen-US -en-US en-US countries. These species included the following: en-USPhleen-US -en-US botomusen-US (en-US Adleriusen-US ) en-US chinensisen-US Newstead, Iran (CN 66); en-US Phen-US (en-US Anaphlebotomusen-US ) en-US rodhainien-US Parrot, Cte dIvoire en-US (CN 14), Ghana (CN 22), Mozambique (CN 36); en-US Phen-US en-US(en-US Paraphlebotomusen-US ) en-US jacusielien-US Theodor, Lebanon (CN en-US 73); and en-US Phen-US (en-US Phlen-US .) en-US papatasien-US (Scopoli), Kenya (CN 25). In en-US the genus en-USSergentomyiaen-US 10 species in 4 subgenera were en-US en-US included the following: en-US Sergentomyiaen-US (en-US Grassomyiaen-US ) en-US ghesquiereien-US (Parrot), Ghana (CN 22) Somalia (CN 47); en-US Seen-US (en-US Neophlebotomusen-US ) en-US decipiensen-US (Theodor), Tanzania en-US (CN 52); en-US Seen-US (en-US Neoen-US .) en-US durenien-US Parrot, Ethiopia (CN 19); en-US Seen-US en-US (en-US Paren-US .) en-US freetownensisen-US en-US freetownensisen-US (Sinton), Democratic en-US Republic of Congo (CN 12); en-US Seen-US (en-US Paren-US .) en-US magnaen-US (Sinton) en-US Ghana (CN 22); en-US Seen-US (en-US Sergentomyen-US -en-US iaen-US ) en-US antennataen-US (Newstead), Tanen-US -en-US zania (CN 52); en-US Seen-US (en-US Seren-US .) en-US buxtonien-US en-US (Theodor), Cte dIvoire CN (14); en-US Seen-US (en-US Seren-US .) en-US magnidentataen-US Davidson, en-US Kenya (CN 25); en-US Seen-US (en-US Seren-US .) en-US minutaen-US en-US minutaen-US Rondani, Kenya (CN 25); en-US and en-US Seen-US (en-US Seren-US .) en-US schwetzien-US (Adler, en-US Theodor & Parrot), Tanzania (CN en-US 52).en-US Three taxaen-US46en-US were not included in en-US the updated list shown in Table en-US en-US taxonomic identities, namely: en-US Seen-US en-US (en-US Seren-US .) en-US bereirien-US en-US Seen-US (en-US Seren-US .) en-US distincen-US -en-US tusen-US (as en-US distinctaen-US ), and en-US Seen-US (en-US Seren-US .) en-US fermatusen-US (as en-US en-US ). They canen-US -en-US not be treated as subspecies of en-USSeen-US en-US (en-US Seren-US .) en-US bedfordien-US because of their en-USoverlapping distributions.en-US3en-US These en-US 3 taxa were treated by Davidsonen-US51en-US en-US as good species based on a unique en-US and maybe aberrant holotype feen-US -en-US male of en-USSeen-US en-US bedfordien-US Seccombe et en-US alen-US3en-US did not support it due to the en-US absence of statistical and/or bioen-US -en-US logical analysis of sympatric popen-US -en-US ulations. They noted that the moren-US -en-US phological, ecological, and geoen-US -en-US graphical data of Davidsonen-US51en-US may en-US help in future taxonomic studies. en-US Niang et alen-US46en-US provided diagnostic morphological feaen-US -en-US tures and distribution records of these 3 taxa, in addition en-US to en-US Seen-US en-US bedfordien-US Although it was suggesteden-US46,51en-US that the en-US distribution of en-USSeen-US en-US bedfordien-US en-USTable en-US1en-US. Proposed abbreviations for genera and en-US subgenera of Phlebotominae (Psychodidae, Dipen-US -en-US tera) of the Old World.en-USGenusen-US Subgenusen-US Abbreviationen-US *en-US Phlebotomusen-US Ph.en-US Adleriusen-US Adl.en-US Anaphlebotomusen-US Ana.en-US Euphlebotomusen-US Euo.en-US Larroussiusen-US Lar.en-US Legeromyiaen-US Leg.en-US **en-US Madaphlebotomusen-US Mad.en-US **en-US Paraphlebotomusen-US Par.en-US Phlebotomusen-US Phl.en-US Synphlebotomusen-US Syn.en-US Transphlebotomusen-US Tra.en-US Sergentomyiaen-US Se.en-US Capensomyiaen-US Cap.en-US **en-US Grassomyiaen-US Gra.en-US Neophelebotomusen-US Neo.en-US Parrotomyiaen-US Par.en-US Parvidensen-US Pav.en-US **en-US Rondanomyiaen-US Ron.en-US **en-US Sergentomyiaen-US Ser.en-US Sintoniusen-US Sin.en-US Spelaeomyiaen-US Spe.en-US **en-US Trouilletomyiaen-US Tro.en-US **en-US Vattieromyiaen-US Vat.en-US **en-US Chiniusen-US Ch.en-US*en-USPrimarily based on Marcondes.en-US29en-US**en-USProposed new abbreviation

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68 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USother reportsen-US3,19,47 en-USand recent examinations of specien-US -en-US mens from different depositories or museums showed en-US its wider distribution (Table 3). Recent analysisen-US49en-US of the en-US en-US en-US the presence of en-USSe. congolensisen-US (Bequart & Walravens), en-US Se. salisburiensisen-US (Abonnenc) and en-US Se. bedfordien-US Maun en-US form from Botswana. Krugeren-US49en-US proposed this form for en-US Se. caliginosaen-US Davidson and unassigned specimens of en-US Se. bedfordien-US group found in Botswana. Since no formal en-US name is available for this form, we temporarily include en-US it with en-US Se. bedfordien-US en-US en-US en-US records will not be accurate. COmm MM ENT en-US-en-US mary types and voucher specimens, are very important en-US en-US -en-US en-US MNHE, IP, MRC) have voucher specimens of the maen-US -en-US jor species incriminated and/or suspected as vectorsen-US7en-US of en-US various en-US Leishmaniaen-US species involved in the transmission en-US of human leishmaniasis in the Old World. Nine of 15 en-US suspected vector species and 6 of 10 incriminated vecen-US -en-US tor speciesen-US9en-US of en-USLeishmaniaen-US in the Old World have prien-US -en-US mary types deposited in the 2 repositories (MNH, IP). en-US For example, MNH has the holotypes and/or syntypes en-US of incriminated vectors, ie, en-US Phlebotomusen-US (en-US Larroussiusen-US ) en-US perniciosusen-US Newstead, en-USPhen-US (en-US Laren-US .) en-US orientalisen-US Parrot, en-USPhen-US en-US (en-US Phlebotomusen-US ) en-US duboscqien-US Neveu-Lemaire, and suspecten-US -en-US ed vectors, ie, en-US Phen-US (en-US Synphlebotomusen-US ) en-US celiaeen-US Minter, en-US Phen-US en-US (en-US Laren-US .) en-US en-US en-US en-US Parrot, en-US Phen-US (en-US Laren-US .) en-US smirnovien-US en-US en-US Phen-US (en-US Laren-US .) en-US tobbien-US Adler & Theodor). Consideren-US -en-US ing the importance of the distribution records of sand en-US en-US en-US Old World in order to obtain fresh voucher specimens en-US for both molecular and morphological studies, and for en-US en-US repositories.en-US Concerning specimen collections from various repositoen-US -en-US en-US -en-US en-US24en-US en-US particularly Africa, Southwest Asia, and Central Asia en-US en-US en-US -en-US phological keys for males and females of the Old World en-US were created by author L. M. Rueda, with assistance en-US en-US -en-US en-US17en-US as:enen en-USen-US -en-US en-US -en-US en-US AFRICOM).enen en-USen-US Phleen-US -en-US botomusen-US subgenera of Southwest and Central Asia en-US enen en-USen-US -en-US genus en-US Larroussiusen-US of en-US Phlebotomuen-US s, Africa (AFen-US -en-US RICOM), with emphasis on medically important en-US species.enen en-USen-US -en-US genus en-US Paraphlebotomus en-US of en-US Phlebotomusen-US Africa en-US (AFRICOM), with emphasis on medically imporen-US -en-US tant species.enen en-USen-US -en-US genus en-US Phlebotomusen-US of en-US Phlebotomusen-US Africa (AFen-US -en-US RICOM), with emphasis on medically important en-US species.enen en-USen-US -en-US genus en-US Larroussiusen-US of en-USPhlebotomuen-US s, Southwest and en-US Central Asia (CENTCOM), with emphasis on meden-US -en-US ically important species.enen en-USen-US -en-US nus en-US Paraphlebotomusen-US of en-US Phlebotomusen-US Southwest en-US and Central Asia (CENTCOM), with emphasis on en-US medically important species.enen en-USen-US -en-US genus en-US Phlebotomusen-US of en-US Phlebotomusen-US Southwest en-US and Central Asia (CENTCOM), with emphasis on en-US medically important species.en-US en-US for species of en-US Phlebotomusen-US (en-US Larroussiusen-US ) male adults en-US from Africa is shown in Figure 2, and posted at the en-US en-US17en-US Male genitalia are important morphoen-US -en-US logical characters to identify different species of sand en-US en-US en-US Phen-US (en-US Paraphleboen-US -en-US tomusen-US ) en-US alexandrien-US Sinton, paratype; en-USPhen-US (en-US Adleriusen-US ) en-US anen-US-en-US gustusen-US Artemiev, paratype; en-US Phen-US (en-US Larroussiusen-US ) en-US aculeatusen-US en-US Lewis, Minter & Ashford, paratype; en-USPhen-US (en-US Laren-US .) en-US longipesen-US en-US Parrot & Martin, paratype; en-US Phen-US (en-US Phlebotomusen-US ) en-US minterien-US en-US Lewis, holotype; en-USPhen-US (en-US Synphlebotomusen-US ) en-US celiaeen-US Minter, en-US holotype; en-US Phen-US (en-US Synen-US .) en-US vansomerenaeen-US Heisch, Guggisberg en-US & Teesdale, paratype; and en-USSeen-US (en-US Sergentomyiaen-US ) en-US ashfordien-US en-US Davidson, paratype.en-US en-US -en-US en-US safe keeping. These slides were temporarily mounted en-US NEW RECORDS, DISTRIBUTION, AND UPDATED CHECKLISTS OF OLD WORLDen-US en-US PHLEBOTOMINE SAND FLIES, WITH EMPHASIS ON AFRICA, SOUTHWEST ASIA, AND CENTRAL ASIA

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January June 2017 69 en-USusing Hoyers medium before, and they will be remounten-US -en-US en-US data from slide labels and collection sheets will be reen-US -en-US trieved, recorded, and processed. Additional collection en-US en-US military entomological surveillance efforts and newly en-US en-US -en-US torMap regularly, to enable further analysis of species en-US en-US -en-US els that will be useful for leishmaniasis risk assessments.en-US en-US -en-US beled as types should be carefully examined, and if en-US necessary, must be designated as holotype or approprien-US -en-US ate type to avoid future confusions in taxonomic clarien-US -en-US en-US taxa/species without designated holotype, but which en-US have slides labeled syntypes or types should have en-US proper designations. AcC KNOWLEDGm M ENTS We express our sincere appreciation and gratitude en-USen-US types and other specimens, and for their hospitality en-US during the visits of Dr Rueda to examine their collections:en-US en-US D. Fontenille, F. Simard and N. Rahola, Maladies Inen-US -en-US en-US en-US -en-US ment, Montpellier, France; D. Sivell, en-GB T. M. Howard and en-GB Z. Adams, Entomological Collections, Molecular Collecen-GB -en-GB tions and Plants, Department of Life Sciences, The Naten-GB -en-GB en-GB en-GB -en-GB tomologie, Tervuren, Belgium; en-USC. en-USDaugeron, en-GBen-US Naen-US -en-US tional dHistoire Naturelle en-USEntomologie, Paris, France; en-US P. Reiter, en-USA.-B. Failloux, J. C. Ganthier, en-USInstitut Pasteur, en-US Paris, France. en-GBWe also thank K.A. Barbara, J.W. Diclaro, en-GB en-GB en-GB en-GB -en-GB en-GB en-GB -en-GB ton, DC.en-US This research was performed under a Memorandum of en-US Agreement between the Walter Reed Army Institute of en-US Research and the Smithsonian Institution, with instituen-US -en-US tional support provided by both organizations. The opinen-US -en-US ions contained herein are those of the authors and do not en-US Figure en-US2en-US. en-US Example of screen shot of LUCIDen-US16en-US interactive key for species of en-US Phlebotomus (Larroussius)en-US male adults, Africa (source: en-US US Africa Command).

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70 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USNEW RECORDS, DISTRIBUTION, AND UPDATED CHECKLISTS OF OLD WORLDen-US en-US PHLEBOTOMINE SAND FLIES, WITH EMPHASIS ON AFRICA, SOUTHWEST ASIA, AND CENTRAL ASIA en-USFigure en-US3en-US. en-US Male genitalia of en-US Phlebotomusen-USen-US Phlebotomus (Paraphlebotomus) alexandrien-US Sinen-US -en-US ton, paratype; (B). en-US Phlebotomus (Adlerius) angustusen-US Artemiev, paratype; (C). en-US Phlebotomus (Larroussius) en-US aculeatusen-US Lewis, Minter & Ashford, paratype; (D). en-US Phlebotomus (Phlebotomus) minterien-US Lewis, holotype. en-USFigure en-US4en-US. en-US Male genitalia of en-US Phlebotomusen-US and en-US Sergentomyiaen-USen-US Phlebotomus (Larroussius) en-US longipes en-US Parrot & Martin, paratype; (B). en-US Phlebotomus (Synphlebotomus) celiaeen-US Minter, holotype; (C). en-US Sergentomyia (Sergentomyia) ashfordien-US Davidson, paratype; (D). en-USPhlebotomus (Synphlebotomus) vansoen-US-en-US merenaeen-US Heisch, Guggisberg & Teesdale, paratype.

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January June 2017 71 en-USTable en-US2en-US (part en-US1en-US of en-US3en-USen-US Asia, examined from different repositories, including country of type origin.en-USSpeciesen-USaen-USDepositoryen-US en-USben-USType (number of slides by en-UScen-USsex)en-US Country of Type Originen-US Phlebotomusen-US aculeatusen-US NH: P (en-US1en-US F, en-US1en-US M)en-US Kenyaen-US Phlebotomusen-US alexandrien-US NH: P (en-US3en-US F)en-US Iraqen-US Phlebotomusen-US angustusen-US NH: P (en-US1en-US F, en-US5en-US M, en-US4en-US U)en-US Afghanistanen-US Phlebotomusen-US arabicusen-US NH: L (M); PL (en-US5en-US F)en-US Yemenen-US Phlebotomusen-US ariasien-US NH: P (en-US14en-US M)en-US Ethiopiaen-US Phlebotomusen-US ashfordien-US NH: H (F); P (en-US1en-US F, en-US1en-US M)en-US Ethiopiaen-US Phlebotomusen-US bergerotien-US NH: S (en-US2en-US F, en-US4en-US M)en-US Algeriaen-US Phlebotomusen-US caudatusen-US NH: H (M)en-US Afghanistanen-US Phlebotomusen-US celiaeen-US NH: H (M)en-US Kenyaen-US Phlebotomusen-US chabaudien-US IP: H (M); IR: P (en-US2en-US U)en-US Tunisiaen-US Phlebotomusen-US chadliien-US NH: P (en-US3en-US F, en-US4en-US M)en-US Kenyaen-US Phlebotomusen-US comatusen-US NH: P (en-US2en-US M)en-US Afghanistanen-US Phlebotomusen-US duboscqien-US NH: H (M)en-US Mauritaniaen-US Phlebotomusen-US elgonensisen-US ME: P (en-US1en-US F, en-US1en-US M)en-US Kenyaen-US Phlebotomusen-US fantalensisen-US NH: H (M), P (en-US6en-US M)en-US Ethiopiaen-US Phlebotomusen-US gibiensisen-US NH: H (M); P (en-US6en-US F, en-US20en-US M)en-US Ethiopia (H; P: en-US6en-US F, en-US16en-US M); Kenya (en-US4en-US M)en-US Phlebotomusen-US gigasen-US BE: L (F); T (en-US1en-US F, en-US1en-USM)en-US Dem. Rep. Congoen-US Phlebotomusen-US guggisbergien-US NH: L (M); PL (en-US3en-US F, en-US1en-US M)en-US Kenyaen-US Phlebotomusen-US halepensisen-US NH: S (en-US5en-US M)en-US Iranen-US Phlebotomusen-US jacusielien-US NH: H (M)en-US Israelen-US Phlebotomusen-US kabulensisen-US NH: P (en-US2en-US M)en-US Afghanistanen-US Phlebotomusen-US kandelakii burneyien-US NH: H (M); P (en-US11en-US F, en-US23en-US M)en-US Pakistanen-US Phlebotomusen-US katangensisen-US BE: T (en-US1en-US M)en-US Dem. Rep. Congoen-US Phlebotomusen-US kyreniaeen-US NH: S (en-US11en-US F, en-US9en-US M)en-US Cyprusen-US Phlebotomusen-US longipesen-US NH: S (en-US3en-US F, en-US6en-US M)en-US Ethiopiaen-US Phlebotomusen-US marismortuien-US NH: S (en-US4en-US F, en-US1en-US M)en-US Israelen-US Phlebotomusen-US mesghaliien-US NH: H (M); P (en-US15en-US F, en-US12en-US M)en-US Kenya (H; P: en-US13en-US F, en-US8en-US M); Iran (P: en-US2en-US F, en-US4en-US M)en-US Phlebotomusen-US minterien-US NH: H (M); P (en-US1en-US M)en-US Tanzaniaen-US Phlebotomusen-US mongolensisen-US NH: S (en-US1en-US F, en-US1en-US M)en-US Afghanistanen-US Phlebotomusen-US naqbeniusen-US NH: H (M), P (en-US10en-US F, en-US10en-US M)en-US Saudi Arabiaen-US Phlebotomusen-US nurien-US NH: H (M); P (en-US17en-US M)en-US Pakistanen-US Phlebotomusen-US orientalisen-US NH: S (en-US1en-US F, en-US2en-US M)en-US Ethiopiaen-US Phlebotomusen-US pediferen-US NH: H (M); P (en-US4en-US F, en-US4en-US M)en-US Kenyaen-US Phlebotomusen-US perfiliewi galilaeusen-US NH: S (en-US10en-US F, en-US13en-US M)en-US Cyprus (S: en-US1 en-US F, en-US5en-US M); Israel (S: en-US9en-US F, en-US8en-US M)en-US Phlebotomusen-US perfiliewi perfiliewien-US NH: S (en-US2en-US M)en-US Ukraineen-US Phlebotomusen-US perniciosusen-US NH: S (en-US6en-US M)en-US Maltaen-US Phlebotomusen-US rodhainien-US BE: T (en-US1en-US M); A (F)en-US Mozambiqueen-US Phlebotomusen-US rupesteren-US NH: P (en-US1en-US F, en-US4en-US M)en-US Afghanistanen-US Phlebotomusen-US saevusen-US NH: S (en-US1en-US F)en-US Ethiopiaen-US Phlebotomusen-US salangensisen-US NH: P (en-US1en-US F, en-US10en-US M)en-US Afghanistanen-US Phlebotomusen-US smirnovien-US NH: S (en-US1en-US M)en-US Belarusen-US Phlebotomusen-US syriacusen-US NH: S (en-US5en-US F, en-US2en-US M)en-US Israelen-US Phlebotomusen-US tobbien-US NH: S (en-US10en-US F, en-US16en-US M, en-US11en-US U)en-US Iran (S: en-US5en-US F, en-US5en-US M); Israel (S: en-US5en-US F, en-US11en-US M, en-US9en-US U)en-US Phlebotomusen-US vansomerenaeen-US NH: P (en-US1en-US M)en-US Kenyaen-US Phlebotomusen-US wenyonien-US NH:: S (en-US3en-US M)en-US Iranen-USaen-USDepository Codes: BE Royal Museum of Central Africa, Tervuren, Belgium ME Museum of Ent omology, Florida State Collection of IP Institut P asteur, Paris, France Ar thropods IR Inst. R es. Dev., Montpellier, France NH Museum of Natural Hist ory, London, UK en-USben-USType Codes: H holotype ( en-US1 specimen) PL paralect otype L lectotype ( en-US1 specimen) S syntype P paratype T type en-UScen-USSex Codes: F female M male U undetermined

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72 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USNEW RECORDS, DISTRIBUTION, AND UPDATED CHECKLISTS OF OLD WORLDen-US en-US PHLEBOTOMINE SAND FLIES, WITH EMPHASIS ON AFRICA, SOUTHWEST ASIA, AND CENTRAL ASIA en-USTable en-US2 (continued; en-USpart en-US2en-US of en-US3)en-USen-US examined from different repositories, including country of type origin.en-USSpeciesen-USaen-USDepositoryen-US en-USben-USType (number of slides by en-UScen-USsex)en-US Country of Type Originen-US Sergentomyiaen-US adlerien-US NH: S (en-US1en-US M)en-US Ghanaen-US Sergentomyiaen-US africana africanaen-US NH: L (en-US1en-US F); P (en-US1en-US F)en-US Nigeriaen-US Sergentomyiaen-US africana asiaticaen-US NH: S (en-US4en-US F, en-US7en-US M)en-US Palestineen-US Sergentomyiaen-US ansariien-US IR: T (en-US1en-US M, en-US1en-USF)en-US Iranen-US Sergentomyiaen-US antennataen-US NH: H (F); P (en-US1en-US M)en-US Ghanaen-US Sergentomyiaen-US azizien-US NH: S (en-US1en-US F)en-US Cyprusen-US Sergentomyiaen-US baghdadisen-US NH: S (en-US12en-US F, en-US10en-US M)en-US Iraqen-US Sergentomyiaen-US balmicolaen-US NH: P (en-US1en-US M)en-US Cameroonen-US Sergentomyiaen-US bedfordien-US NH: H (F); BE: P (en-US7en-US F, en-US18en-US M)en-US South Africa (H: F); D. R. Congo (P: en-US7en-US F, en-US18en-US M)en-US Sergentomyiaen-US blossien-US NH: S (en-US2en-US F)en-US Kenyaen-US Sergentomyiaen-US buxtonien-US NH: L (F); P (en-US2en-US M); P (en-US2en-US M)en-US Ghana (L: f), P: en-US2en-US M; Mali (P: en-US2en-US M)en-US Sergentomyiaen-US christophersien-US NH: L (F); P (en-US1en-US F)en-US Pakistanen-US Sergentomyiaen-US clastrierien-US NH: P (en-US1en-US F, en-US1en-US M)en-US Guineaen-US Sergentomyiaen-US clydeien-US NH: L (F); P (en-US1en-US M)en-US Pakistanen-US Sergentomyiaen-US collartien-US BE: C (en-US1en-US F, en-US1en-US M); NH: S (en-US6en-US F, en-US5en-US M) en-USDem. Rep. Congoen-US Sergentomyiaen-US cornetien-US IR: H (F); P (en-US1en-US F)en-US Senegalen-US Sergentomyiaen-US crosaraien-US BE: C (en-US7en-US F)en-US Dem. Rep. Congoen-US Sergentomyiaen-US darlingien-US IP: P (en-US1en-US F, en-US1en-US M); IR: P (en-US4en-US U)en-US Sudanen-US Sergentomyiaen-US decipiensen-US BE:T (en-US11en-US F, en-US13en-US M)en-US Dem. Rep. Congoen-US Sergentomyiaen-US dentata dentataen-US NH: H (M); P (en-US2en-US F)en-US Pakistanen-US Sergentomyiaen-US diapagaien-US IR: P (en-US1en-US M); NH: P (en-US1en-US M)en-US Burkina Fasoen-US Sergentomyiaen-US dolichopaen-US IP: H (M); A (F); P (en-US1en-US F, en-US1en-US M)en-US Djiboutien-US Sergentomyiaen-US dubiaen-US NH: S (en-US3en-US F)en-US Ghana (S: en-US2en-US F); Nigeria (en-US1en-US F)en-US Sergentomyiaen-US durenien-US BE: T (en-US1en-US M); NH: S (en-US1en-US F)en-US Dem. Rep. Congoen-US Sergentomyiaen-US dyemkoumaien-US IR: T (M)en-US Cte d'Ivoireen-US Sergentomyiaen-US edentulusen-US IR: H (F); P (en-US2en-US F)en-US Senegalen-US Sergentomyiaen-US emiliien-US IR: H (M); P (en-US4en-US M); IP: P (en-US1en-US M)en-US Rep. Congo (H: M, P: en-US4en-US M); Dem. Rep. Congo (P: en-US1en-US M)en-US Sergentomyiaen-US fallax cyprioticaen-US NH: S (en-US1en-US F, en-US1en-US M)en-US Cyprusen-US Sergentomyiaen-US formicaen-US NH: P (en-US1en-US F)en-US Namibiaen-US Sergentomyiaen-US freetownensis freetownensisen-US NH: H (F)en-US Sierra Leoneen-US Sergentomyiaen-US freetownensis furanusen-US NH: H (F)en-US Sudanen-US Sergentomyiaen-US garnhamien-US NH: P (en-US2en-US M)en-US Kenyaen-US Sergentomyiaen-US gracilisen-US NH: L (en-US1en-US F); P (en-US1en-US M)en-US Kenyaen-US Sergentomyiaen-US graingerien-US NH: H (F)en-US Kenyaen-US Sergentomyia en-USgrillotien-US IR: H (F)en-US Rep. Congoen-US Sergentomyiaen-US grjebineien-US IR: H (F); A (M)en-US Rep. Congoen-US Sergentomyiaen-US hamonien-US IP: H (M); A (F)en-US Senegalen-US Sergentomyiaen-US harveyien-US NH; H (F); P (en-US6en-US F, en-US2en-US M)en-US Kenyaen-US Sergentomyiaen-US heischien-US NH: H (F)en-US Kenyaen-US Sergentomyiaen-US herollandien-US NH: P (F)en-US Malien-US Sergentomyiaen-US hodgsonien-US NH: L (F); P (en-US1en-US M)en-US Pakistanen-US Sergentomyiaen-US inermisen-US IR: A (M); NH: S (en-US11en-US F)en-US Guinea (M); Nigeria (en-US11en-US F)en-USaen-USDepository Codes: BE Royal Museum of Central Africa, Tervuren, Belgium ME Museum of Ent omology, Florida State Collection of Arthropods en-US IP Institut P asteur, Paris, France NH Museum of Natural Hist ory, London, UK en-US IR Inst. R es. Dev., Montpellier, France NM National Museum of Natural Hist ory, Paris en-US KE Kenya National Museum, Nairobi UM US National Museum of Natural Hist ory, Smithsonian Institution en-US Suitland, Mar yland en-USben-USType Codes: A allotype ( en-US1 specimen) P paratype en-US C cotype PL paralect otype en-US H holotype ( en-US1 specimen) S syntype en-US L lectotype ( en-US1 specimen) T type en-UScen-USSex Codes: F female en-US M male en-US U undetermined

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January June 2017 73 en-USTable en-US2 (continued; en-USpart en-US3en-US of en-US3)en-USen-US Central Asia, examined from different repositories, including country of type origin.en-USSpeciesen-USaen-USDepositoryen-US en-USben-USType (number of slides by en-UScen-USsex)en-US Country of Type Originen-US Sergentomyiaen-US ingramien-US NH: H (M); P (en-US1en-US M)en-US Ghanaen-US Sergentomyiaen-US iranicaen-US NH: H (F); P (en-US2en-US M)en-US Iranen-US Sergentomyiaen-US kirkien-US NH: S (en-US2en-US F)en-US South Sudanen-US Sergentomyiaen-US kitonyiien-US NH: H (F); P (en-US8en-US F)en-US Kenyaen-US Sergentomyiaen-US lesleyaeen-US NH: H (F); P (en-US1en-US M)en-US Sudanen-US Sergentomyiaen-US lewisianaen-US IR: H (F); A (M); P (en-US5en-US F, en-US8en-US M)en-US Senegal en-US Sergentomyiaen-US logonensisen-US IR: T (F)en-US Cameroonen-US Sergentomyiaen-US machadoien-US IR: P (en-US1en-US M); NH: P (en-US5en-US F, en-US2en-US M)en-US Angolaen-US Sergentomyiaen-US macinthosien-US IR: H (F)en-US South Africaen-US Sergentomyiaen-US madagascariensisen-US IR: H (M); A (F); P (en-US1en-US F); NH: P (en-US2en-US F)en-US Madagascaren-US Sergentomyiaen-US magnidentataen-US NH: H (F); P (en-US1en-US F)en-US Kenyaen-US Sergentomyiaen-US meillonien-US NH: H (M)en-US South Africaen-US Sergentomyiaen-US minutaen-US NH: P (en-US2en-US F, en-US5en-US M)en-US Ghana (en-US1en-US M, en-US1en-US F); Zimbabwe (en-US1en-US F, en-US4en-US M)en-US Sergentomyiaen-US mirabilisen-US BE: T (en-US1en-US F, en-US1en-US M)en-US Dem. Rep. Congoen-US Sergentomyiaen-US montanaen-US NH: H (F); P (en-US1en-US F)en-US Ethiopiaen-US Sergentomyiaen-US mouchetien-US IR: H (F)en-US Cameroonen-US Sergentomyiaen-US ovazzaien-US IR: H (F)en-US Guineaen-US Sergentomyiaen-US palestinensisen-US NH: H (F)en-US Palestineen-US Sergentomyia en-USpunjabensisen-US NH: S (en-US1en-US M)en-US Pakistanen-US Sergentomyiaen-US renauxien-US BE: P (en-US1en-US F)en-US Dem. Rep. Congoen-US Sergentomyiaen-US richardien-US BE: H (en-US1en-US F)en-US Dem. Rep. Congoen-US Sergentomyiaen-US rimien-US NH: P (en-US2en-US F, en-US1en-US M)en-US Namibia (en-US1en-US F, en-US1en-USM); South Africa (en-US1en-US F)en-US Sergentomyiaen-US robertien-US IR: P (F)en-US Dem. Rep. Congoen-US Sergentomyiaen-US rogerien-US IR: H (F); A (M); P (en-US3en-US F)en-US Senegal en-US Sergentomyiaen-US rosannaeen-US NH: H (F); P (en-US3en-US F, en-US4en-US M)en-US Kenyaen-US Sergentomyiaen-US schoutedenien-US BE: L (M); P (en-US3en-US M); C (en-US2en-US F)en-US Dem. Rep. Congoen-US Sergentomyiaen-US schwetzien-US BE: C (en-US5en-US F, en-US1en-US M); NH: S (en-US1en-US M)en-US Dem. Rep. Congoen-US Sergentomyiaen-US sidioliensisen-US IR: H (F); A (M); P (en-US4en-US M)en-US Senegal en-US Sergentomyiaen-US simillimaen-US NM: P (en-US2en-US M)en-US Ivory Coasten-US Sergentomyiaen-US sonyaeen-US NH: H (F); P (en-US2en-US F, en-US5en-US M)en-US Omanen-US Sergentomyiaen-US squamipleurisen-US NH: L (en-US1en-US F)en-US Sudanen-US Sergentomyiaen-US taizien-US NH: H (F); P (en-US2en-US F)en-US Yemenen-US Sergentomyiaen-US tauffliebien-US IP: H (M); A (F); P (en-US1en-US M)en-US Senegalen-US Sergentomyiaen-US teesdaleien-US NM: T (en-US1en-US M)en-US Kenyaen-US Sergentomyiaen-US thomsonien-US NH: P (en-US1en-US F)en-US Malawien-US Sergentomyiaen-US tiberiadisen-US NH: L (F)en-US Israelen-US Sergentomyiaen-US trouilletien-US IR: T (F)en-US Rep. Congoen-US Sergentomyiaen-US wansonien-US BE: T (en-US1en-US F, en-US1en-US M); C (en-US1en-US F, en-US1en-US M)en-US Dem. Rep. Congoen-US Sergentomyiaen-US yusafien-US NH: L (M); P (en-US1en-US F)en-US Kenyaen-US Sergentomyiaen-US yvonnaeen-US BE: T (F)en-US Dem. Rep. Congoen-USaen-USDepository Codes: BE Royal Museum of Central Africa, Tervuren, Belgium ME Museum of Ent omology, Florida State Collection of Arthropods en-US IP Institut P asteur, Paris, France NH Museum of Natural Hist ory, London, UK en-US IR Inst. R es. Dev., Montpellier, France NM National Museum of Natural Hist ory, Paris en-US KE Kenya National Museum, Nairobi UM US National Museum of Natural Hist ory, Smithsonian Institution en-US Suitland, Mar yland en-USben-USType Codes: A allotype ( en-US1 specimen) P paratype en-US C cotype PL paralect otype en-US H holotype ( en-US1 specimen) S syntype en-US L lectotype ( en-US1 specimen) T type en-UScen-USSex Codes: F female en-US M male en-US U undetermined

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74 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USNEW RECORDS, DISTRIBUTION, AND UPDATED CHECKLISTS OF OLD WORLDen-US en-US PHLEBOTOMINE SAND FLIES, WITH EMPHASIS ON AFRICA, SOUTHWEST ASIA, AND CENTRAL ASIA en-USTable en-US3en-US (part en-US1en-US of en-US9en-USen-US en-US4en-US.en-USSpeciesen-US Africa*en-US Southwesten-US en-US Asia anden-US en-US Central Asia*en-US Otheren-US en-US Countriesen-US Selecteden-US en-US Referencesen-US Phlebotomus (Adlerius) angustusen-US Artemiev, en-US1978en-US60, 77, 81, 84 en-US 3, 19en-USPhlebotomus (Adlerius) arabicusen-US Theodor, en-US1953en-US10, 19, 27en-US 64,77, 85en-US 3, 19, 46, 47, Xen-USPhlebotomus (Adlerius) balcanicusen-US Theodor, en-US1958en-US62, 65, 66, 80en-US 96, 102, 109, en-US 111, 118en-US 3, 19, 43, 47en-USPhlebotomus (Adlerius) brevisen-US Theodor & Mesghali, en-US1964en-US62, 65, 66, 80en-US 96, 104en-US 3, 19, 43, 45en-USPhlebotomus (Adlerius) chinensisen-US Newstead, en-US1916en-US66*en-US Xen-USPhlebotomus (Adlerius) comatusen-US Artemiev, en-US1978en-US60, 75en-US 107en-US 3, 19en-USPhlebotomus (Adlerius) halepensisen-US Theodor, en-US1958en-US62, 65, 68, 66, en-US 78, 80en-US 107en-US 3, 19, 43en-USPhlebotomus (Adlerius) hindustanicusen-US Theodor, en-US1958en-US65, 75en-US 98, 107en-US 3, 19en-USPhlebotomus (Adlerius) kabulensisen-US Artemiev, en-US1978en-US60, 65, 66en-US 3, 19, 3en-USPhlebotomus (Adlerius) kyreniae en-USTheodor, en-US1958en-US80en-US 94en-US 3, 19en-USPhlebotomus (Adlerius) longiductusen-US Parrot, en-US1928en-US60, 66, 75, 84en-US 92, 98, 109en-US 3, 19, 43en-USPhlebotomus (Adlerius) naqbeniusen-US Lewis & Buttiker, en-US1986en-US77en-US 3, 19en-USPhlebotomus (Adlerius) rupester en-USArtemiev, en-US1978en-US60en-US 3, 19en-USPhlebotomus (Adlerius) salangensisen-US Artemiev, en-US1978en-US60, 66en-US 3, 19en-USPhlebotomus (Adlerius) simici en-USNitzulescu, en-US1931en-US66, 68, 78, 80en-US 96, 102en-US 3, 19en-USPhlebotomus (Adlerius) turanicusen-US Artemiev, en-US1974en-US60, 79, 81, 84en-US 3, 19en-USPhlebotomus (Adlerius) zulfagarensis en-USArtemiev, en-US1978en-US66, 81en-US 3, 19en-USPhlebotomus (Anaphlebotomus) colabaensisen-US Young & Chalam, en-US1927en-US75en-US 98en-US 3, 19en-USPhlebotomus (Anaphlebotomus) hubertien-US Depaquit, Leger & Robert, en-US2002en-US en-US29en-US 36en-USPhlebotomus (Anaphlebotomus) rodhaini en-USParrot, en-US1930 en-US2, 3, 4, 7, 9, 12, en-US 13, 14*, 19, 21, en-US 22*, 23, 25, 27, en-US 36*, 39, 44, 48, en-US 50, 53, 55en-US 3, 19, 44, 47, en-US 49, Xen-USPhlebotomus (Anaphlebotomus) rousettus en-USDavidson, en-US1981en-US48en-US 3, 19en-USPhlebotomus (Anaphlebotomus) vincentien-US Randrianambinintsoa & en-US Depaquit, en-US2013en-US en-US29en-US 36en-USPhlebotomus (Euphlebotomus) argentipesen-US Annandale and Brunetti, en-US1908en-US75en-US 87, 98, 99, 101, en-US 103, 106, 107, en-US 113, 117, 120en-US 3, 19en-USPhlebotomus (Euphlebotomus) autumnalisen-US Artemiev, en-US1980en-US60en-US 3, 19en-USPhlebotomus (Euphlebotomus) caudatusen-US Artemiev, en-US1978en-US60en-US 3, 19en-USPhlebotomus (Euphlebotomus) mesghaliien-US Rashti & Nadim, en-US1970en-US60, 66en-US 3, 19, 43en-USPhlebotomus (Euphlebotomus) nadimien-US Javadian, Jalali-Galousang & en-US Seyedi-Rashti, en-US1997en-US66en-US 3, 19, 43en-USPhlebotomus (Larroussius) aculeatusen-US Lewis, Minter & Ashford, en-US1974en-US19, 25en-US 3, 19, Xen-USPhlebotomus (Larroussius) ariasi en-USTonnoir, en-US1921en-US1, 35, 54en-US 95, 100, 108, en-US 112en-US 3, 19, Xen-USPhlebotomus (Larroussius) ashfordien-US Gebre-Michael and Lane, en-US1996en-US19en-US 3, 19, 28, Xen-USPhlebotomus (Larroussius) chadliien-US Rioux, Juminer and Gibily, en-US1966en-US1, 35, 54en-US 3, 19en-USPhlebotomus (Larroussius) elgonensisen-US Ngoka, Madel & Mutinga, en-US1975en-US19, 25, 29en-US 3, 19, 46, Xen-USPhlebotomus (Larroussius) fantalensis en-USLewis, Minter & Ashford, en-US1974en-US19en-US 3, 19en-USPhlebotomus (Larroussius) gibiensisen-US Lewis, Minter & Ashford, en-US1974en-US19en-US 3, 19en-USPhlebotomus (Larroussius) guggisbergi en-USKirk & Lewis, en-US1952en-US25, 52, 55en-US 3, 19en-USPhlebotomus (Larroussius) ilami en-US Javadian, Jalali-Galousang & en-US Seyedi-Rashti, en-US1997en-US66en-US 43, 45en-US*New country species record. Notes: Africa includes several Western Indian Ocean islands (Comoros, Madagascar, Mauritius, Mayotte, Runion, and en-US Seychelles); X indicates observed.

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January June 2017 75 en-USTable en-US3 (continued; en-USpart en-US2en-US of en-US9)en-USen-US en-US4en-US.en-USSpeciesen-US Africa*en-US Southwesten-US en-US Asia anden-US en-US Central Asia*en-US Otheren-US en-US Countriesen-US Selecteden-US en-US Referencesen-US Phlebotomus (Larroussius) kandelakii kandelakiien-US Shchurenkova, en-US1929en-US60, 61, 62, 65, en-US 66, 73, 80en-US 3, 19, 43en-USPhlebotomus (Larroussius) kandelakii burneyien-US Lewis, en-US1967en-US66, 75en-US 3, 19en-USPhlebotomus (Larroussius) keshishiani en-USShchurenkova, en-US1936en-US60, 66, 75, 79en-US 3, 19, 43en-USPhlebotomus (Larroussius) langeroni en-US Nitzulescu, en-US1930en-US1, 35, 54en-US 64, 66en-US 3, 19en-USPhlebotomus (Larroussius) longicuspisen-US Nitzulescu, en-US1930en-US1, 5, 28, 35, 54en-US 112en-US 3, 19, 25en-USPhlebotomus (Larroussius) longipes en-USParrot & Martin, en-US1939en-US19, 25, 50en-US 3, 19, Xen-USPhlebotomus (Larroussius) majoren-US Annandale, en-US1910en-US66, 75en-US 107, 117en-US 3, 19en-USPhlebotomus (Larroussius) mariaeen-US Rioux, Croset, Leger & Baillyen-US Choumara, en-US1974en-US35en-US 3, 19en-USPhlebotomus (Larroussius) neglectusen-US Tonnoir, en-US1921en-US66, 80, 82en-US 86, 88, 96, 100, en-US 110en-US 3, 19, 43en-USPhlebotomus (Larroussius) notus en-USArtemiev & Neronov, en-US1984en-US60en-US 3, 19en-USPhlebotomus (Larroussius) orientalisen-US Parrot, en-US1936en-US10, 15, 16, 19, en-US 25, 38, 41, 50, en-US 55en-US 64, 77, 85en-US 3, 19, 46, Xen-USPhlebotomus (Larroussius) pediferen-US Lewis, Mutinga & Ashford, en-US1972en-US19, 25, 50en-US 3, 19, Xen-USPhlebotomus (Larroussius) perfiliewi perfiliewi en-US Parrot, en-US1930en-US1,35, 54 en-US 62, 66, 80, 82 en-US 96, 97, 100, en-US 104, 109 en-US 3, 19, 43en-USPhlebotomus (Larroussius) perfiliewi galilaeus en-USTheodor, en-US1958en-US68, 80en-US 94en-US 3, 19en-USPhlebotomus (Larroussius) perfiliewi transcaucasicusen-US Perfil'ev, en-US1937en-US62, 65, 66. 67, en-US 80en-US 3, 19en-USPhlebotomus (Larroussius) perniciosusen-US Newstead, en-US1911en-US1, 28, 35en-US 60, 65, 78, 80,en-US 94, 95, 100, en-US 104, 108, 111, en-US 112en-US 3, 19en-USPhlebotomus (Larroussius) smirnovi en-USPerfil'ev, en-US1941en-US66, 70, 81, 84en-US 92en-US 3, 19en-USPhlebotomus (Larroussius) somaliensis en-USAbonnenc, Adam & Bailly-en-US Choumara, en-US1959en-US19, 47en-US 3, 19, X en-USPhlebotomus (Larroussius) syriacus en-USAdler & Theodor, en-US1931en-US61, 62, 65, 68, en-US 69, 78, 80, 82en-US 3, 19en-USPhlebotomus (Larroussius) tobbi en-USAdler & Theodor, en-US1930en-US62, 65, 66, 67, en-US 68, 73, 78, 80 en-US 86, 94, 96, 100en-US 3, 19, 43en-USPhlebotomus (Larroussius) wenyoni en-USAdler & Theodor, en-US1930en-US66, 67, 80, 81en-US 3, 19, 43en-USPhlebotomus (Legeromyia) multihamatusen-US Rahola, Depaquit, en-US Makanga & Paupy, en-US2013en-US20en-US 35en-USPhlebotomus (Madaphlebotomus) berentiensisen-US (Leger & Rodhain, en-US1978en-US)en-US29en-US 3, 19, 26, 33en-USPhlebotomus (Madaphlebotomus) fertei en-USDepaquit, Leger & Robert, en-US2002en-US29en-US 21, 26, 36en-USPhlebotomus (Madaphlebotomus) fontenilleien-US Depaquit, Leger & en-US Robert, en-US2004en-US29en-US 23, 26en-USPhlebotomus (Madaphlebotomus) vaomalalaeen-US Randrianambininten-US -en-US soa, Leger & Depaquit, en-US2013en-US29en-US 26, 37en-USPhlebotomus (Madaphlebotomus) vincentien-US Randrianambinintsoa & en-US Depaquit, en-US2013en-US29en-US 37en-USPhlebotomus (Paraphlebotomus) alexandrien-US Sinton, en-US1928en-US1, 15, 16, 19, en-US 38, 50, 54en-US 60, 62, 66, 67, en-US 68, 69, 70, 71, en-US 74, 75, 77, 80, en-US 81, 83, 85 en-US 92, 94, 96, 98, en-US 105, 109, 112 en-US 3, 19, 43, Xen-USPhlebotomus (Paraphlebotomus) andrejevi en-USShakirzyanova, en-US1953en-US60, 66, 70, 84en-US 92, 105en-US 3, 19, 43en-USPhlebotomus (Paraphlebotomus) caucasicusen-US Marzinowsky, en-US1917en-US60, 61, 62, 65, en-US 66, 70, 84en-US 92en-US 3, 19, 43en-USPhlebotomus (Paraphlebotomus) chabaudi en-USCroset, Abonnenc & en-US Rioux, en-US1970en-US1, 28, 35, 54en-US 112en-US 3, 19en-US*New country species record. Notes: Africa includes several Western Indian Ocean islands (Comoros, Madagascar, Mauritius, Mayotte, Runion, and en-US Seychelles); X indicates observed.

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76 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USNEW RECORDS, DISTRIBUTION, AND UPDATED CHECKLISTS OF OLD WORLDen-US en-US PHLEBOTOMINE SAND FLIES, WITH EMPHASIS ON AFRICA, SOUTHWEST ASIA, AND CENTRAL ASIA en-USTable en-US3 (continued; en-USpart en-US3en-US of en-US9)en-USen-US en-US4en-US.en-USSpeciesen-US Africa*en-US Southwesten-US en-US Asia anden-US en-US Central Asia*en-US Otheren-US en-US Countriesen-US Selecteden-US en-US Referencesen-US Phlebotomus (Paraphlebotomus) gemetchi en-USGebre-Michael and en-US Balkew, en-US2003en-US19en-US 29en-USPhlebotomus (Paraphlebotomus) jacusieli en-USTheodor, en-US1947en-US73*, 82, 66, 68, en-US 80en-US 3, 19, 43, Xen-USPhlebotomus (Paraphlebotomus) kazeruni en-USTheodor & Mesghali, en-US1964en-US1, 16, 27, 35 en-US 60, 66, 69, 77, en-US 80 en-US 3, 19, 43, 47, Xen-USPhlebotomus (Paraphlebotomus) marismortuien-US Theodor, en-US1947en-US68en-US 3, 19en-USPhlebotomus (Paraphlebotomus) mireillae en-US Kellick-Kendrick, Tang, en-US Johnson, Ngumbi & Robert, en-US1997en-US en-US19, 25en-US 46, Xen-USPhlebotomus (Paraphlebotomus) mongolensisen-US Sinton, en-US1928en-US60, 62, 66, 70, en-US 84en-US 92en-US 3, 19, 43en-USPhlebotomus (Paraphlebotomus) nurien-US Lewis, en-US1967en-US60, 66, 75en-US 3, 19en-USPhlebotomus (Paraphlebotomus) saevusen-US Parrot & Martin, en-US1939en-US7, 19, 25, 50en-US 77, 85en-US 3, 19en-USPhlebotomus (Paraphlebotomus) sergenti sergenti en-USParrot, en-US1917en-US1, 15, 16, 18, 19, en-US 25, 27, 28, 31, 35, en-US 37, 38, 47, 54en-US 60, 61 64, 65, en-US 66, 67, 68, 69, en-US 70, 73, 75, 77, en-US 78, 80, 85 en-US 94, 95, 96, 98, en-US 100, 104, 107, en-US 108, 109, 111, en-US 112en-US 3, 19, 43, 47, Xen-USPhlebotomus (Paraphlebotomus) sergenti similis en-USPerfil'ev, en-US1963en-US63, 66, 82en-US 118, 119en-US 3, 19, 43en-USPhlebotomus (Phlebotomus) bergerotien-US Parrot, en-US1934en-US1, 5, 10, 15, 16, en-US 18, 19, 32, 35, 38, en-US 44, 47, 50en-US 66, 68, 69, 75, en-US 77, 83, 85en-US 3, 19, 43, 46, Xen-USPhlebotomus (Phlebotomus) duboscqi en-US Neveu-Lemaire, en-US1906en-US5, 7, 9, 10, 19, 21, en-US 22, 25, 31, 32, 33, en-US 38, 39, 44, 46, en-US 50, 53, 59en-US 77, 85en-US 3, 19, 40, 46, Xen-USPhlebotomus (Phlebotomus) gigasen-US Parrot & Schwetz, en-US1937en-US2, 7, 9, 12, 13, en-US 20, 23, 31en-US 3, 19, 46, Xen-USPhlebotomus (Phlebotomus) minteri en-US Lewis, en-US1982en-US52en-US 3, 19en-USPhlebotomus (Phlebotomus) papatasien-US (Scopoli, en-US1786)en-US1, 16, 18, 19, 25*, en-US 28, 35, 38, 47, en-US 50, 54en-US 60, 61, 62, 65, en-US 66. 67. 68, 69, en-US 70, 71, 73, 74, en-US 75, 77, 78, 80, en-US 81, 84, 85en-US 87, 89, 94, 96, en-US96, 97, 98, 100, en-US 104, 107, 109, en-US 112, 113en-US 3, 19, 42, 43, Xen-USPhlebotomus (Phlebotomus) salehien-US Mesghali, en-US1965en-US66en-US 98en-US 3, 19, 43, Xen-USPhlebotomus (Synphlebotomus) ansariien-US Lewis, en-US1957en-US66en-US 3, 19, 43en-USPhlebotomus (Synphlebotomus) celiaeen-US Minter, en-US1962en-US19, 25en-US 46, Xen-USPhlebotomus (Synphlebotomus) eleanoraeen-US Sinton, en-US1931en-US66en-US 98en-US 3, 19, 43en-USPhlebotomus (Synphlebotomus) grovei en-USDownes, en-US1971en-US37en-US 3, 19en-USPhlebotomus (Synphlebotomus) katangensis en-USBequaert & Walraen-US -en-US vens, en-US1930en-US12, 58en-US 3, 19, 46, Xen-USPhlebotomus (Synphlebotomus) martini en-USParrot, en-US1936en-US19, 25, 47, 50, 55en-US 3, 19, Xen-USPhlebotomus (Synphlebotomus) rossien-US de Meillon & Lavoipierre, en-US1944en-US37, 48, 58en-US 3, 19en-USPhlebotomus (Synphlebotomus) saltiaeen-US Leger, Haddad and en-US Chaker, en-US1997en-US73en-US 32en-USPhlebotomus (Synphlebotomus) taylori en-USDavidson, en-US1982en-US58en-US 3, 19en-USPhlebotomus (Synphlebotomus) vansomerenaeen-US Heisch, Guggisen-US -en-US berg & Teesdale, en-US1956en-US19, 25en-US 3, 19en-USPhlebotomus (Transphlebotomus) canaaniticusen-US Adler & Theodor, en-US1931en-US68, 69, 78en-US 3, 19en-USPhlebotomus (Transphlebotomus) mascittii en-USGrassi, en-US1908en-US1en-US 6en-US 94, 95, 96, 100, en-US 102, 112, 115en-US 3, 19en-USSergentomyia (Capensomyia) caffraricaen-US (de Meillon & Lavoipierre, en-US1944en-US)en-US48en-US 3, 19en-USSergentomyia (Capensomyia) capensisen-US (de Meillon, en-US1955en-US)en-US 48en-US en-US*New country species record. Notes: Africa includes several Western Indian Ocean islands (Comoros, Madagascar, Mauritius, Mayotte, Runion, and en-US Seychelles); X indicates observed.

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January June 2017 77 en-USTable en-US3 (continued; en-USpart en-US4en-US of en-US9)en-USen-US en-US4en-US.en-USSpeciesen-US Africa*en-US Southwesten-US en-US Asia anden-US en-US Central Asia*en-US Otheren-US en-US Countriesen-US Selecteden-US en-US Referencesen-US Sergentomyia (Capensomyia) drakensbergien-US Davidson, en-US1979en-US48en-US 3, 19en-USSergentomyia (Capensomyia) haeselbarthi en-US(Abonnenc, en-US1967en-US)en-US48en-US 3, 19en-USSergentomyia (Capensomyia) kalahariaen-US Davidson, en-US1979en-US37, 48en-US 3, 19en-USSergentomyia (Capensomyia) luteola en-USDavidson, en-US1983en-US48en-US 3, 19en-USSergentomyia (Capensomyia) meeseri en-US(de Meillon & Hard, en-US1953en-US)en-US48, 55, 58en-US 3, 19en-USSergentomyia (Capensomyia) namaen-US Davidson, en-US1953en-US37, 48en-US 3, 19, Xen-USSergentomyia (Capensomyia) namibensisen-US (de Meillon & Hardy, en-US1953en-US)en-US37, 48en-US 3, 19, Xen-USSergentomyia (Capensomyia) xera en-USDavidson, en-US1979en-US37, 48en-US 3, 19, Xen-USSergentomyia (Demeillonius) transvaalensis en-US Sinton, en-US1933en-US48en-US 3, 19en-USSergentomyia (Grassomyia) dreyfussi dreyfussi en-US (Parrot, en-US1933en-US)en-US1, 15, 18, 19, en-US 25, 35, 47, 54, en-US 66 en-US 66, 69, 77, 85 en-US 3, 19, 43en-USSergentomyia (Grassomyia) dreyfussi turkestanicaen-US Theodor & en-US Mesghali, en-US1964en-US60, 68, 81en-US 3, 19en-USSergentomyia (Grassomyia) ghesquierei en-US(Parrot, en-US1929en-US)en-US3, 5, 12, 13, 14, en-US 19, 21, 22*, 23, en-US 44, 47*en-US 3, 19, Xen-USSergentomyia (Grassomyia) indicaen-US (Theodor, en-US1931en-US)en-US66, 75en-US 90, 92, 93, 98, en-US 99, 101, 103, en-US 107, 116, 117en-US 3, 19en-USSergentomyia (Grassomyia) inermisen-US (Theodor, en-US1938en-US)en-US2, 3, 4, 5, 9, 10, en-US 19, 21, 22, 23, en-US 25, 30, 39, 44, en-US 48, 50en-US 3, 19, 49en-USSergentomyia (Grassomyia) madagascariensisen-US (Abonnenc, en-US1969en-US)en-US29en-US 3, 19en-USSergentomyia (Grassomyia) squamipleuris en-US(Newstead, en-US1912en-US)en-US2, 3, 5, 9, 10, en-US 12, 13, 14, 15, en-US 16, 19, 21, 22, en-US 23, 25, 29, 30, en-US 31, 36, 39, 44, en-US 46, 48, 50, 52, en-US 53, 55, 57 en-US 66, 67, 68, 77en-US 3, 19, 27, 43, Xen-USSergentomyia (Neophlebotomus) angolensis en-US(Abonnenc, en-US1968 en-US)en-US2, 13en-US 3, 19en-USSergentomyia (Neophlebotomus) collarti en-US(Adler, Theodor & Parrot, en-US1929en-US)en-US2, 7, 9, 12, 13, en-US 14, 21, 22, 23, en-US 39, 42, 46, 50, en-US 52, 55en-US 3, 19, Xen-USSergentomyia (Neophlebotomus) cornetien-US Pastre, en-US1975en-US44en-US 3, 19, Xen-USSergentomyia (Neophlebotomus) decipiens en-US (Theodor, en-US1931en-US)en-US7, 9, 12, 13, 14, en-US 23, 25, 39, 44, en-US 50, 52*, 55en-US 3, 19, Xen-USSergentomyia (Neophlebotomus) dolichopaen-US (Abonnenc & Courtois, en-US1970en-US)en-US15en-US 66, 85en-US 3, 19, Xen-USSergentomyia (Neophlebotomus) durenien-US Parrot, en-US1934en-US2, 5, 9, 10, 12, en-US 13, 14, 19*, 21, en-US 22*, 23, 25, 27, en-US 39, 44, 50, 52en-US 3, 19, Xen-USSergentomyia (Neophlebotomus) dyemkoumai en-US (Abonnenc, en-US1964en-US)en-US13, 14en-US 3, 19, 46en-USSergentomyia (Neophlebotomus) grejbinei (en-US Vattier-Bernard, en-US1971en-US)en-US12, 13en-US 3, 19en-USSergentomyia (Neophlebotomus) grillotien-US (Vattier-Bernard & Bimanen-US -en-US gou, en-US1975en-US)en-US13en-US 3, 19en-USSergentomyia (Neophlebotomus) harveyi en-US (Heisch, Guggisberg & en-US Teesdale), en-US1956en-US25en-US 3, 19en-USSergentomyia (Neophlebotomus) hodgsonien-US (Sinton, en-US1933en-US)en-US60, 66, 75en-US 98, 117en-US 3, 19en-US*New country species record. Notes: Africa includes several Western Indian Ocean islands (Comoros, Madagascar, Mauritius, Mayotte, Runion, and en-US Seychelles); X indicates observed.

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78 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USNEW RECORDS, DISTRIBUTION, AND UPDATED CHECKLISTS OF OLD WORLDen-US en-US PHLEBOTOMINE SAND FLIES, WITH EMPHASIS ON AFRICA, SOUTHWEST ASIA, AND CENTRAL ASIA en-USTable en-US3 (continued; en-USpart en-US5en-US of en-US9)en-USen-US en-US4en-US.en-USSpeciesen-US Africa*en-US Southwesten-US en-US Asia anden-US en-US Central Asia*en-US Otheren-US en-US Countriesen-US Selecteden-US en-US Referencesen-US Sergentomyia (Neophlebotomus) ingrami en-US (Newstead, en-US1914en-US)en-US2, 3, 5, 7, 9, en-US 12, 13, 14, 19*, en-US 21, 22, 23, 25, en-US 27, 39, 44, 50, en-US 53, 55en-US 19, 47, Xen-USSergentomyia (Neophlebotomus) kirkien-US (Parrot, en-US1948en-US)en-US25, 30, 50en-US 3, 19en-USSergentomyia (Neophlebotomus) kitonyii en-US (Minter, en-US1963en-US)en-US19, 25en-US 3, 19, Xen-USSergentomyia (Neophlebotomus) machadoi en-US (Abonnenc, en-US1968en-US)en-US2en-US 3, 19, Xen-USSergentomyia (Neophlebotomus) macintoshi en-US (Abonnenc & Pastre, en-US1972en-US)en-US48en-US 3, 19en-USSergentomyia (Neophlebotomus) notata en-US(Parrot, en-US1938en-US)en-US19en-US 3, 19en-USSergentomyia (Neophlebotomus) pawlowskyien-US Perfil'ev, en-US1933en-US60, 61, 66, 67, en-US 80, 81, 84en-US 3, 19en-USSergentomyia (Neophlebotomus) serrataen-US (Parrot & Malbrant, en-US1945en-US)en-US12, 13, 19, 25, en-US 50, 55en-US 3, 19en-USSergentomyia (Neophlebotomus) sonyaeen-US Lewis, en-US1982en-US74, 77en-US 3, 19en-USSergentomyia (Neophlebotomus) teesdalei en-USMinter, en-US1963en-US25en-US 3, 19, Xen-USSergentomyia (Neophlebotomus) trouilletien-US Vattier-Bernard, en-US1976en-US13en-US 3, 19en-USSergentomyia (Parrotomyia) africana africanaen-US (Newstead, en-US1912en-US)en-US3, 5, 7, 9, 12, en-US 13, 15, 14, 19, en-US 21, 22,23, 25, en-US 27, 31, 32, 38, en-US 39, 44, 46, 48, en-US 50, 53, 55, 57, en-US 85en-US 66en-US 3, 27, 34, 43, en-US 46, 47, Xen-USSergentomyia (Parrotomyia) africana asiaticaen-US (Theodor, en-US1933en-US)en-US35en-US 68, 69, 75, 77en-US 98en-US 3, 19en-USSergentomyia (Parrotomyia) babu babuen-US (Annandale, en-US1910en-US)en-US33en-US 60, 75en-US 87, 98en-US 3, 19en-USSergentomyia (Parrotomyia) baghdadisen-US Adler & Theodor, en-US1929en-US60, 66, 67, 75en-US 98en-US 3, 19, 43, Xen-USSergentomyia (Parrotomyia) bailyien-US (Sinton, en-US1931en-US)en-US66, 75en-US 90, 92, 98, 101, en-US 117, 120 en-US3, 19en-USSergentomyia (Parrotomyia) crosaraien-US (Parrot & Wanson, en-US1946en-US)en-US2, 12, 13, 27en-US 3, 19, 47, Xen-USSergentomyia (Parrotomyia) eremitis en-US (Parrot & Bouquet de Joliniere, en-US1945en-US)en-US1, 27, 50, 53en-US 3, 19, 47, Xen-USSergentomyia (Parrotomyia) freetownensis freetownensisen-US (Sinton, en-US1930en-US)en-US2, 3, 9, 14, 18, en-US 12*, 13, 19, 25, en-US 23, 32, 44, 46, en-US 48, 50, 58, 77en-US 3, 19, Xen-USSergentomyia (Parrotomyia) freetownensis furanusen-US (Lewis & Kirk, en-US1958en-US)en-US50en-US 3, 19en-USSergentomyia (Parrotomyia) grekovi en-US Khodukin, en-US1929en-US60, 66, 70, 75, en-US 79, 81, 82, 84en-US 98en-US 3, 19, 43en-USSergentomyia (Parrotomyia) magnaen-US (Sinton, en-US1932en-US)en-US2, 5, 7, 9, 12, en-US 14, 21, 19, 22*, en-US 23, 31, 32, 39, en-US 53, 44, 48, 50, en-US 58en-US 77en-US 3, 19, Xen-USSergentomyia (Parrotomyia) palestinensisen-US (Adler & Theodor, en-US1927en-US)en-US1, 15, 16, 18, en-US 19, 35, 50en-US 62, 66, 67, 68, en-US 69, 75, 77en-US 98en-US 3, 19, 43, Xen-USSergentomyia (Parrotomyia) rhodesiensisen-US (de Meillon & Hardy, en-US1953en-US)en-US58en-US 3, 19en-USSergentomyia (Parrotomyia) shorttii en-US(Adler & Theodor, en-US1927en-US)en-US75en-US 87, 98, 106en-US 3, 19en-USSergentomyia (Parrotomyia) sogdianaen-US (Parrot, en-US1928en-US)en-US66, 79, 84en-US 3, 19, 43en-USSergentomyia (Parrotomyia) sumbaricaen-US Perfil'ev, en-US1933en-US60, 66, 67, 81, en-US 84en-US 92en-US 3, 19, 43, Xen-USSergentomyia (Parrotomyia) yvonnaeen-US (Parrot & Schwetz, en-US1937en-US)en-US12en-US 3, 19, Xen-US*New country species record. Notes: Africa includes several Western Indian Ocean islands (Comoros, Madagascar, Mauritius, Mayotte, Runion, and en-US Seychelles); X indicates observed.

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January June 2017 79 en-USTable en-US3 (continued; en-USpart en-US6en-US of en-US9)en-USen-US en-US4en-US.en-USSpeciesen-US Africa*en-US Southwesten-US en-US Asia anden-US en-US Central Asia*en-US Otheren-US en-US Countriesen-US Selecteden-US en-US Referencesen-US Sergentomyia (Parrotomyia) zielkeien-US Seccombe, Ready and Huden-US -en-US dleston, en-US1993en-US48en-US 3, 19en-USSergentomyia (Parvidens) aridaen-US Davidson, en-US1982en-US37, 58en-US 3, 19, Xen-USSergentomyia (Parvidens) heischi en-US Kirk & Lewis, en-US1950en-US19, 25, 36, 37, en-US 50en-US 3, 19, Xen-USSergentomyia (Parvidens) iranicaen-US (Lewis & Mesghali, en-US1961en-US)en-US66en-US 3, 19, 43en-USSergentomyia (Parvidens) lesleyaeen-US (Lewis & Kirk, en-US1946en-US)en-US19, 32, 50en-US 3, 19en-USSergentomyia (Rondanomyia) goodmani goodmanien-US Depaquit & en-US Robert, en-US2005en-US29en-US 22en-USSergentomyia (Rondanomyia) goodmani comorensisen-US Depaquit, en-US Randrianamnini & Leger, en-US2012en-US11en-US 39en-USSergentomyia (Sergentomyia) antennataen-US (Newstead, en-US1912en-US)en-US1, 3, 5, 7, 9, en-US 10, 19, 12, 14, en-US 15, 16, 19, 20, en-US 21, 22, 23, 25, en-US 27, 30, 31, 32, en-US 35, 39, 44, 46, en-US 47, 48, 50, 52*, en-US 53, 54en-US 66, 67, 68, 69, en-US 71, 77, 83, 55en-US 3, 19, 43, 46, en-US 47, Xen-USSergentomyia (Sergentomyia) arpaklensisen-US Perfil'ev, en-US1933en-US81, 84en-US 3, 19en-USSergentomyia (Sergentomyia) ashfordien-US Davidson, en-US1987en-US19en-US 3, 19en-USSergentomyia (Sergentomyia) bedfordien-US (Newstead, en-US1914en-US)en-US2, 3, 4**, 7, 9, en-US 10, 12, 14, 19, en-US 21, 22, 23,25, en-US 27,31, 36, 37, en-US 39, 44, 48, 50, en-US 52, 53, 55, 58en-US 3, 19, 47, 49, Xen-USSergentomyia (Sergentomyia) bergerardien-US Trouillet & Vattier-Bernard, en-US1978en-US13en-US 3, 19en-USSergentomyia (Sergentomyia) bimangouien-US Davidson, en-US1990en-US13en-US 3, 19en-USSergentomyia (Sergentomyia) blossien-US (Kirk & Lewis, en-US1952en-US)en-US25en-US 3, 19, Xen-USSergentomyia (Sergentomyia) buxtonien-US (Theodor, en-US1933en-US)en-US3, 5, 10, 14*, en-US 21, 22, 31, 38, en-US 39, 44en-US 3, 19, Xen-USSergentomyia (Sergentomyia) caliginosaen-US Davidson, en-US1987en-US30, 36, 48, 57, en-US 58en-US 3, 19en-USSergentomyia (Sergentomyia) cinctaen-US (Parrot & Martin, en-US1944en-US)en-US9, 15, 16, 19, en-US 22, 25, 50, 55en-US 3, 19, Xen-USSergentomyia (Sergentomyia) congolensisen-US (Bequaert &Walravens, en-US1930en-US)en-US4, 12en-US 3, 49, Xen-USSergentomyia (Sergentomyia) davidsoni en-US Seccombe, Ready and en-US Huddleston, en-US1993en-US18, 19, 50en-US 3, 19, Xen-USSergentomyia (Sergentomyia) dentata dentataen-US (Sinton, en-US1933en-US)en-US60, 62, 65, 66, en-US 67, 75, 78, 80, en-US 83, 85en-US 3, 19, 43en-USSergentomyia (Sergentomyia) dentata agdamicaen-US Artemiev, en-US1982en-US61, 62, 65, 66, en-US 67en-US 3, 19en-USSergentomyia (Sergentomyia) dentata bruchonien-US Parrot, en-US1935en-US80en-US 96en-US 3, 19en-USSergentomyia (Sergentomyia) dubiaen-US (Parrot, Mornet & Cadenat, en-US1934en-US)en-US5, 7, 13, 14, 21, en-US 22, 23, 31, 32, en-US 39, 44en-US 3, 19, Xen-USSergentomyia (Sergentomyia) fallax fallaxen-US Parrot, en-US1921en-US1, 5, 15, 16, 19, en-US 35, 38, 54en-US 60, 64, 77, 85en-US 3, 19, Xen-USSergentomyia (Sergentomyia) fallax afghanicaen-US Artemiev, en-US1974en-US60en-US 3, 19en-USSergentomyia (Sergentomyia) fallax cyprioticaen-US (Adler, en-US1946en-US)en-US67, 68, 73, 80en-US 94en-US 3, 19en-USSergentomyia (Sergentomyia) formica en-USDavidson, en-US1987en-US37, 48, 58en-US 3, 19en-USSergentomyia (Sergentomyia) gracilisen-US (Kirk & Lewis, en-US1952en-US)en-US25en-US 3, 19en-US*New country species record; **en-US Sergentomyiaen-US (en-USSergentomyiaen-US) en-US bedfordien-US Maun form. Notes: Africa includes several Western Indian Ocean islands (Comoros, en-US Madagascar, Mauritius, Mayotte, Runion, and Seychelles); X indicates observed.

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80 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USNEW RECORDS, DISTRIBUTION, AND UPDATED CHECKLISTS OF OLD WORLDen-US en-US PHLEBOTOMINE SAND FLIES, WITH EMPHASIS ON AFRICA, SOUTHWEST ASIA, AND CENTRAL ASIA en-USTable en-US3 (continued; en-USpart en-US7en-US of en-US9)en-USen-US en-US4en-US.en-USSpeciesen-US Africa*en-US Southwesten-US en-US Asia anden-US en-US Central Asia*en-US Otheren-US en-US Countriesen-US Selecteden-US en-US Referencesen-US Sergentomyia (Sergentomyia) impudicaen-US Abonnenc, en-US1968en-US2, 13, 27, 55en-US 3, 19, 44, Xen-USSergentomyia (Sergentomyia) logonensisen-US (Rageau, en-US1951en-US)en-US7, 9en-US 3, 19, Xen-USSergentomyia (Sergentomyia) magnidentataen-US Davidson, en-US1987en-US25, 47*en-US 3, 19, Xen-USSergentomyia (Sergentomyia) mervynaeen-US Pringle, en-US1953en-US54en-US 60, 66, 75en-US 3, 19, 43en-USSergentomyia (Sergentomyia) minuta minutaen-US Rondani, en-US1843en-US25*en-US 80, 82en-US 95, 96, 100, en-US 104, 108, 109, en-US 112en-US 3, 19, Xen-USSergentomyia (Sergentomyia) minuta parroti en-US(Adler & Theodor, en-US1927en-US)en-US1, 28, 35, 54en-US 78en-US 94, 96, 112en-US 3, 19en-USSergentomyia (Sergentomyia) murgabiensis murgabiensisen-US Perfil'ev, en-US1939en-US60, 66, 70, 81en-US 3, 19en-USSergentomyia (Sergentomyia) murgabiensis pashtunicaen-US Artemiev, en-US1974en-US60, 66, 75en-US 105en-US 3, 19en-USSergentomyia (Sergentomyia) murgabiensis sintonien-US Pringle, en-US1953en-US16en-US 60, 66, 67, 71, en-US 80, 81en-US 3, 19en-USSergentomyia (Sergentomyia) pastorianaen-US (Parrot, Mornet & Cadeen-US -en-US nat, en-US1945en-US)en-US14, 19, 22, 23, en-US 39, 46, 50, 55en-US 3, 19, Xen-USSergentomyia (Sergentomyia) punjabensisen-US (Sinton, en-US1933en-US)en-US75en-US 113, 117en-US 3, 19en-USSergentomyia (Sergentomyia) renauxi en-US (Parrot & Schwetz, en-US1937en-US)en-US12, 13en-US 3, 19, Xen-USSergentomyia (Sergentomyia) richardien-US (Parrot & Wanson, en-US1946en-US)en-US7, 12, 27, 53, 55en-US 3, 19, Xen-USSergentomyia (Sergentomyia) rima en-USDavidson, en-US1987en-US30, 36, 37, 48, en-US 57, 58en-US 3, 19, Xen-USSergentomyia (Sergentomyia) ruttledgeien-US (Lewis & Kirk, en-US1946en-US)en-US50, 55en-US 3, 19en-USSergentomyia (Sergentomyia) salisburiensisen-US (Abonnenc, en-US1967en-US)en-US4, 37, 48, 49, en-US 57, 58en-US 3, 19, 49, Xen-USSergentomyia (Sergentomyia) schoutedeni schoutedenien-US (Adler, en-US Theodor & Parrot, en-US1929en-US)en-US3, 7, 12, 14, 23, en-US 25, 26, 39, 50, en-US53, 55en-US 3, 19, Xen-USSergentomyia (Sergentomyia) schoutedeni nocensen-US (Parrot, en-US1951en-US)en-US25, 50en-US 3, 19en-USSergentomyia (Sergentomyia) schwetzi en-US (Adler, Theodor & Parrot, en-US1929en-US)en-US1, 2, 3, 5, 7, 9, en-US 10, 12, 13, 14, en-US 15, 16, 19, 20, en-US 21, 22, 23, 25, en-US 27, 31, 32, 35, en-US 35, 37, 39, 44, en-US 46, 47, 48, 50, en-US 52*, 53, 55en-US 77, 85en-US 24, 25, 27, Xen-USSergentomyia (Sergentomyia) serridentataen-US Davidson, en-US1990en-US7, 55en-US 3, 19, Xen-USSergentomyia (Sergentomyia) silvaen-US Trouillet, en-US1985en-US13en-US 3, 19en-USSergentomyia (Sergentomyia) taizien-US Lewis, en-US1974en-US15, 16en-US 77, 85en-US 3, 19, Xen-USSergentomyia (Sergentomyia) teteicaen-US Artemiev, en-US1985en-US36en-US 3, 19en-USSergentomyia (Sergentomyia) theodori (Parrot, en-US1919en-US)en-US16en-US 60, 66, 67, 68, en-US 69, 73, 75, 77, en-US 78, 80en-US 94, 96, 98, 101en-US 3, 19, 43en-USSergentomyia (Sergentomyia) waqqasien-US Artemiev, en-US1982en-US67en-US 3, 19en-USSergentomyia (Sergentomyia) yusafien-US (Sinton, en-US1930en-US)en-US25, 39, 52, 55, en-US 57en-US 85en-US 3, 19, 46, Xen-USSergentomyia (Sergentomyia) zumpti en-US(Abonnenc, en-US1967en-US)en-US37, 48en-US 3, 19en-USSergentomyia (Sintonius) adami en-US(Abonnenc, en-US1960en-US)en-US9, 31en-US 3, 19, Xen-USSergentomyia (Sintonius) adleri en-US(Theodor, en-US1933en-US)en-US3, 5, 7, 9, 10, en-US 14, 15, 16, 19, en-US 21, 22, 25, 38, en-US 39, 44, 50, 53, en-US 55en-US 66, 69, 77, 83en-US 3, 19, 27, 46, Xen-US*New country species record. Notes: Africa includes several Western Indian Ocean islands (Comoros, Madagascar, Mauritius, Mayotte, Runion, and en-US Seychelles); X indicates observed.

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January June 2017 81 en-USTable en-US3 (continued; en-USpart en-US8en-US of en-US9)en-USen-US en-US4en-US.en-USSpeciesen-US Africa*en-US Southwesten-US en-US Asia anden-US en-US Central Asia*en-US Otheren-US en-US Countriesen-US Selecteden-US en-US Referencesen-US Sergentomyia (Sintonius) affinis affinisen-US (Theodor, en-US1933en-US)en-US9en-US, en-US19en-US, en-US23en-US, en-US25en-US, en-US50en-US 3en-US, en-US19en-US, en-US46en-US, Xen-US Sergentomyia (Sintonius) affinis voraxen-US (Parrot, en-US1948en-US)en-US2, 3, 5, 9, 10, en-US 19, 22, 23, 25, en-US 31, 39, 44, 50en-US 3, 19, Xen-USSergentomyia (Sintonius) balmicolaen-US Abonnenc, Adam & Bailly-en-US Choumara, en-US1959en-US7en-US 3, 19en-USSergentomyia (Sintonius) calcarataen-US (Parrot, en-US1948en-US)en-US10, 15, 18, 19, en-US 50en-US 77en-US 3, 19, Xen-USSergentomyia (Sintonius) choumaraien-US (Abonnenc, en-US1960en-US)en-US47en-US 3, 19en-USSergentomyia (Sintonius) christophersien-US (Sinton, en-US1927en-US)en-US1, 5, 9, 10, 15, en-US 16, 18, 19, 21, en-US 23, 25, 29, 35, en-US 38, 39, 44, 50, en-US 54, 55en-US 60, 66, 69, 74, en-US 75, 77, 85en-US 98en-US 3, 19, 27, 43, en-US 46, Xen-USSergentomyia (Sintonius) clastrieri en-US(Abonnenc, en-US1964en-US)en-US15, 23en-US 3, 19en-USSergentomyia (Sintonius) clydeien-US (Sinton, en-US1928en-US)en-US1, 5, 7, 9, 10, en-US 15, 16, 18, 19, en-US 21, 22, 25, 31, en-US 35, 38, 39, 44, en-US 45, 47, 50, 53, en-US 54, 55en-US 60, 66, 67, 68, en-US 70, 71, 75, 77, en-US 79, 81, 83, 85en-US 3, 19, 44, Xen-USSergentomyia (Sintonius) diapagaien-US (Abonnenc, en-US1962en-US)en-US5, 31en-US 3, 19en-USSergentomyia (Sintonius) edentulusen-US Pastre, en-US1982en-US44en-US 3, 19, Xen-USSergentomyia (Sintonius) graingerien-US (Heisch, Guggisberg & Teesdale, en-US1956en-US)en-US25en-US 3, 19en-USSergentomyia (Sintonius) herollandien-US (Abonnenc, en-US1960en-US)en-US31, 44en-US 3, 19, Xen-USSergentomyia (Sintonius) hospitii en-US(Sinton, en-US1924en-US)en-US75en-US 98en-US 3, 19 en-USSergentomyia (Sintonius) lewisianaen-US Pastre, en-US1982en-US44en-US 3, 19, Xen-USSergentomyia (Sintonius) mbandakaien-US Abonnenc, en-US1970en-US12en-US 3, 19en-USSergentomyia (Sintonius) meillonien-US Sinton, en-US1932en-US25, 36, 37, 48, en-US 51, 58en-US 3, 19, Xen-USSergentomyia (Sintonius) rogerien-US Pastre, en-US1982en-US44en-US 3, 19, Xen-USSergentomyia (Sintonius) sattiien-US Qutubuddin, en-US1962en-US50en-US 3, 19en-USSergentomyia (Sintonius) sidioliensisen-US Pastre, en-US1982en-US44en-US 3, 19, Xen-USSergentomyia (Sintonius) suberectaen-US (Sinton, en-US1932en-US)en-US25, 50en-US 3, 19, Xen-USSergentomyia (Sintonius) tauffliebien-US (Abonnenc & Cornet, en-US1971en-US)en-US13, 14, 44en-US 3, 19, Xen-USSergentomyia (Sintonius) thomsonien-US (Theodor, en-US1938en-US)en-US10, 19, 25, 30en-US 3, 19en-USSergentomyia (Sintonius) tiberiadis tiberiadisen-US (Adler, Theodor & en-US Lourie, en-US1930en-US)en-US15, 16, 18, 19, en-US 50en-US 60, 66, 68, 74, en-US 77, 83, 85en-US 3, 19, 43, Xen-USSergentomyia (Sintonius) tiberiadis pakistanicaen-US Artemiev & en-US Saf'janova, en-US1974en-US60, 75, 81en-US 3, 19en-USSergentomyia (Sintonius) wansonien-US (Parrot, en-US1938en-US)en-US2, 5, 9, 12, 13, en-US 19, 31, 55en-US 66en-US 3, 19, Xen-USSergentomyia (Spelaeomyia) bailyi en-US (Sinton, en-US1931en-US)en-US7en-US 75en-US 92, 98, 117, en-US 120en-US 3, 19en-USSergentomyia (Spelaeomyia) darlingien-US (Lewis & Kirk, en-US1954en-US)en-US5, 9, 31,50en-US 3, 19, Xen-USSergentomyia (Spelaeomyia) emilii en-US (Vattier-Bernard, en-US1966en-US)en-US5, 9, 13en-US 3, 19, Xen-USSergentomyia (Spelaeomyia) huntien-US (Lewis & Kirk, en-US1946en-US)en-US9, 50en-US 3, 19en-USSergentomyia (Spelaeomyia) mirabilis en-US (Parrot & Wanson, en-US1939en-US)en-US2, 9, 12, 13, en-US 52, 55en-US 3, 19, Xen-USSergentomyia (Spelaeomyia) moucheti en-US (Vattier-Bernard & Abonen-US -en-US nenc, en-US1967en-US)en-US7, 9, 13en-US 3, 19en-US*New country species record. Notes: Africa includes several Western Indian Ocean islands (Comoros, Madagascar, Mauritius, Mayotte, Runion, and en-US Seychelles); X indicates observed.

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82 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USNEW RECORDS, DISTRIBUTION, AND UPDATED CHECKLISTS OF OLD WORLDen-US en-US PHLEBOTOMINE SAND FLIES, WITH EMPHASIS ON AFRICA, SOUTHWEST ASIA, AND CENTRAL ASIA en-USTable en-US3 (continued; en-USpart en-US9en-US of en-US9)en-USen-US en-US4en-US.en-USSpeciesen-US Africa*en-US Southwesten-US en-US Asia anden-US en-US Central Asia*en-US Otheren-US en-US Countriesen-US Selecteden-US en-US Referencesen-US Sergentomyia (Trouilletomyia) boironisen-US Ranadrianambinintspa & en-US Depaquit, en-US2014en-US29en-US 38en-USSergentomyia (Trouilletomyia) huberti en-US Depaquit, Leger & Robert, en-US2002en-US29en-US 24en-USSergentomyia (Vattieromyia) ankaen-US Depaquit, Leger & Robert, en-US2008en-US29en-US 24en-USSergentomyia (Vattieromyia) namoen-US Depaquit, Leger & Robert, en-US2008en-US29en-US 24en-USSergentomyia (Vattieromyia) pessonien-US Depaquit, Randrianamnini & en-US Leger, en-US2012en-US11en-US 39en-USSergentomyia (Vattieromyia) schlerpsiphonen-US Depaquit, Leger & en-US Robert, en-US2008en-US29en-US 24en-USSergentomyia (Ungrouped)** berentiensisen-US Leger & Rodhain, en-US1978en-US29en-US 3, 19en-USSergentomyia (Ungrouped) bernardaeen-US Trouillet, en-US1982en-US13en-US 3, 19en-USSergentomyia (Ungrouped) cuniculaen-US Davidson, en-US1979en-US37en-US 3, 19en-USSergentomyia (Ungrouped) dissimillimaen-US (Abonnenc, en-US1972en-US)en-US5, 13, 14, 23en-US 3, 19en-USSergentomyia (Ungrouped) garnhamien-US (Heisch, Guggisberg & Teesen-US -en-US dale, en-US1956en-US)en-US25, 52en-US 3, 19en-USSergentomyia (Ungrouped) hamonien-US (Abonnenc, en-US1958en-US)en-US2, 5, 7, 9, 12, en-US 13, 14, 31, 44, en-US 50en-US 3, 19, Xen-USSergentomyia (Ungrouped) hirtaen-US (Parrot & Bouquet de Joliniere, en-US1945en-US)en-US1en-US 3, 19en-USSergentomyia (Ungrouped) horridulaen-US Vattier-Bernard & Trouillet, en-US1982en-US13en-US 3, 19en-USSergentomyia (Ungrouped) lepontien-US Vattier-Bernard, en-US1973en-US13en-US 3, 19en-USSergentomyia (Ungrouped) lumsdenien-US Kirk & Lewis, en-US1950en-US13, 55en-US 3, 19en-USSergentomyia (Ungrouped) majungaensisen-US Depaquit, Leger and en-US Robert, en-US2007en-US29en-US 48en-USSergentomyia (Ungrouped) metzien-US Davidson, en-US1979en-US37, 48en-US 3, 19, Xen-USSergentomyia (Ungrouped) montanaen-US (Sinton, en-US1924en-US)en-US75en-US 98, 107en-US 3, 19en-USSergentomyia (Ungrouped) moreli en-US (Abonnenc & Hamon, en-US1958en-US)en-US13, 14, 27, 55en-US 3, 43, 47, Xen-USSergentomyia (Ungrouped) multiden-US ens (Heisch, Guggisberg & Teesen-US -en-US dale, en-US1956en-US)en-US15, 19, 25en-US 85en-US 3, 19en-USSergentomyia (Ungrouped) ovazzaien-US (Pastre, en-US1973en-US)en-US23en-US 3, 19en-USSergentomyia (Ungrouped) roberti en-USVattier-Bernard & Trouillet, en-US1081en-US13en-US 3, 19en-USSergentomyia (Ungrouped) rosannaeen-US (Heisch, Guggisberg & Teesen-US -en-US dale, en-US1956en-US)en-US25en-US 3, 19en-USSergentomyia (Ungrouped) simillimaen-US (Newstead, en-US1914en-US)en-US3, 5, 7, 9, 12, en-US 13, 14, 19, 22, en-US 23, 24, 27, 37, en-US 39, 46, 50, 53, en-US 55en-US 3, 43, 47, Xen-USSergentomyia (Ungrouped) villosaen-US Davidson, en-US1979en-US37, 48, 58en-US 3, 19, Xen-USSergentomyia (Ungrouped) vulpesen-US Davidson, en-US1979en-US37, 48en-US 3, 19, Xen-USSergentomyia (Ungrouped) welwitschiien-US Davidson, en-US1979en-US37, 48en-US 3, 19, Xen-USSergentomyia (Ungrouped) wurtzien-US (Parrot, en-US1938en-US)en-US19en-US 3, 19en-USSergentomyia (Ungrouped) wynnaeen-US (Watson, en-US1951en-US)en-US25, 55en-US 3, 19en-US*New country species record. Notes: Africa includes several Western Indian Ocean islands (Comoros, Madagascar, Mauritius, Mayotte, Runion, and en-US Seychelles); X indicates observed.en-US ** Ungrouped indicates subgenus uncertain.

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January June 2017 83 en-USTable en-US4en-US. List of countries and their numerical codes as shown in Figure en-US1 en-USand Table en-US3en-US.en-USCodeen-US en-US No.en-US Country*en-US Code en-US en-US No.en-US Country*en-US Codeen-US en-US No.en-US Country*en-US Code en-US en-US No.en-US Country*en-US1en-USAlgeriaen-US31en-USMalien-US62en-USAzerbaijanen-US92en-USChina (mainland)en-US2en-USAngolaen-US32en-USMauritaniaen-US63en-USBahrainen-US93en-USChina (Hong Kong)en-US3en-USBeninen-US33en-USMauritiusen-US64en-USEgypten-US94en-USCyprusen-US4en-USBotswanaen-US34en-USMayotte (France)en-US65en-USGeorgiaen-US95en-USFranceen-US5en-USBurkina Fasoen-US35en-USMoroccoen-US en-US (excluding Western Sahara)en-US66en-USIranen-US96en-USGreeceen-US6en-USBurundien-US36en-USMozambiqueen-US67en-USIraqen-US97en-USHungaryen-US7en-USCameroonen-US37en-USNamibiaen-US68en-USIsraelen-US98en-USIndiaen-US8en-USCape Verdeen-US38en-USNigeren-US69en-USJordanen-US99en-USIndonesiaen-US9en-USCentral African Republicen-US39en-USNigeriaen-US70en-USKazakhstanen-US100en-USItalyen-US10en-USChaden-US40en-USRunion (France)en-US71en-USKuwaiten-US101en-USLaosen-US11en-USComorosen-US41en-USRwandaen-US72en-USKyrgyzstanen-US102en-USMacedoniaen-US12en-USCongo, Democraticen-US en-US Republic ofen-US42en-USSaint Helena, Ascension and en-US Tristan da Cunha (UK)en-US73en-USLebanonen-US103en-USMalaysiaen-US13en-USCongo, Republic of en-US43en-USSo Tom and Prncipeen-US74en-USOmanen-US104en-USMaltaen-US14en-USCte d'Ivoire en-US44en-USSenegalen-US75en-USPakistanen-US105en-USMongoliaen-US15en-USDjiboutien-US45en-USSeychellesen-US76en-USQataren-US106en-USMyanmaren-US16en-USEgypten-US46en-USSierra Leoneen-US77en-USSaudi Arabiaen-US107en-USNepalen-US17en-USEquatorial Guineaen-US47en-USSomaliaen-US78en-USSyriaen-US108en-USPortugalen-US18en-USEritreaen-US48en-USSouth Africaen-US79en-USTajikistanen-US109en-USRomaniaen-US19en-USEthiopiaen-US49en-USSouth Sudanen-US80en-USTurkeyen-US110en-USRussiaen-US20en-USGabonen-US50en-USSudanen-US81en-USTurkmenistanen-US111en-USSerbia & Montenegroen-US en-US (former Yugoslavia)en-US21en-USGambiaen-US51en-USSwazilanden-US82en-USUkraineen-US112en-USSpainen-US22en-USGhanaen-US52en-USTanzaniaen-US83en-USUnited Arab Emiratesen-US113en-USSri Lankaen-US23en-USGuineaen-US53en-USTogoen-US84en-USUzbekistanen-US en-US (including Crimea)en-US114en-USSri Lanka (Ubduam)en-US24en-USGuinea-Bissauen-US54en-USTunisiaen-US85en-USYemenen-US115en-USSwitzerlanden-US25en-USKenyaen-US55en-USUgandaen-US86en-USAlbaniaen-US116en-USTaiwanen-US26en-USLesothoen-US56en-USWestern Saharaen-US87en-USBangladeshen-US117en-USThailanden-US27en-USLiberiaen-US57en-USZambiaen-US88en-USBosnia & Herzegovinaen-US118en-USUkraineen-US28en-USLibyaen-US58en-USZimbabween-US89en-USBulgariaen-US119en-USUkraine (Crimea)en-US29en-USMadagascaren-US60en-USAfghanistanen-US90en-USCambodiaen-US120en-USVietnamen-US30en-USMalawien-US61en-USArmenia en-US91en-USCameroonen-US*en-USAfrica (code nos. en-US 1-58en-US, including West Indian Ocean Islands); Southwest Asia and Central Asia (code nos. en-US 60-85en-US, including Middle East/CENTCOM; part of en-US EUCOM, former Russian Republics); other countries (Code nos. en-US 86-121en-US) RREFERENc C ES 1. en-USSand Fly-Borne Diseases [internet]. CVBD Companion en-US Vector-borne Diseases website. Bayer HealthCare AG, en-US Leverkusen, Germany. Available at: http://www.cvbd.en-US en-US 2015. 2. en-USen-US -en-US key RW, eds. en-US Medicalen-US en-US Insectsen-US en-US anden-US en-US Arachnidsen-US London, en-US 3. en-USSeccombe AK, Ready PD, Huddleston LM, eds. en-US A en-US en-US -en-US tera: Psychodidae, Phlebotominae)en-US en-US -en-US cept; 1993. Issue 8, en-US Occasional Papers on Systematic en-US Entomologyen-US 4. en-USYoung DG, Duncan MA. en-US en-US en-US Mexico, the West Indies, Central and South America en-US (Diptera: Psychodidae)en-US Gainsville, FL: Associated en-US Publishers; 1994. Available at: http://www.dtic.mil/dtic/en-US tr/fulltext/u2/a285737.pdf. Accessed March 15, 2017. 5. en-USDepaquit J, Grandadam M, Fouque F, Andry PE, en-USen-US Eurosuren-US-en-US veillanceen-US 2010;15(10):1-8. 6. en-USTesh RB. The genus en-US Phlebovirusen-US and its vectors. en-US Annuen-US en-US Reven-US en-US Entomolen-US 1998;33:169-181. 7. en-USen-US of disease agents. en-USAnnuen-US en-US Reven-US en-US Entomolen-US 2013;58:227-250.

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Sand-en-US en-US two new species from the genus en-US Phlebotomusen-US : en-US Phen-US en-US ilamien-US en-US and en-USPhen-US en-USnadimien-US en-USIranianen-US en-USJen-US en-USPublicen-US en-USHealthen-US. 1997;25:13-20. 46. en-USNiang A, Hervy JP, Depaquit J, et al. en-US Sanden-US en-US en-US en-US ofen-US en-US theen-US en-US Afen-US -en-US rotropicalen-US en-US Region:en-US en-US en-US en-US anden-US en-US trainingen-US en-US programen-US en-US CD ROM, Collection Didactiques, Institut de Recherche en-US 47. en-USObenauer PJ, Rueda LM, El-Hossary SS, et al. New reen-US -en-US en-US (Diptera: Psychodidae) from Liberia. en-US Jen-US en-US Meden-US en-US Entomolen-US en-US 2016;1-4. doi: 10.1093/jme/tjv255. 48. en-USDepaquit J, fr-FR en-US N, Robert V. Les fr-FR en-US en-US de Madagascar (Diptera: Psychodidae). V. Descripen-US -en-US tion de en-USSergentomyiaen-US en-US majungaensisen-US n. sp. en-US Parasiteen-US. en-US 2007;14:219-223. 49. en-USen-US -en-US en-US -en-US cord of genus en-US Phlebotomus. Acta Tropicaen-US 2017;March en-US 18. Epub ahead of print. Available at: http://dx.doi.en-US org/10.1016/j.actatropica.2017.03.009. Accessed March en-US 27, 2017. 50. en-USList of Islands in the Indian Ocean, Western Indian en-US Ocean [internet]. Available at: https://en.wikipedia.org/en-US wiki/List_of_islands_in_the_Indian_Ocean. Accessed en-US February 20, 2017. 51. en-USDavidson IH. en-US en-US en-US ofen-US en-US Africaen-US en-US Southen-US en-US ofen-US en-US theen-US en-US Saharaen-US en-US Johannesburg, South Africa: South African Medical Inen-US -en-US stitute; 1990. AUTHORS Dr Rueda is an Adjunct Scientist of the Smithsonian In en-US-en-US stitution and formerly Research Entomologist and Chief en-US en-US Branch, Walter Reed Army Institute of Research, loen-US -en-US cated at the Smithsonian Institution, Museum Support en-US Center, Suitland, Maryland.en-US Mr J. Pecor is a Museum Specialist of the Walter Reed en-US en-US Army Institute of Research, located at the Smithsonian en-US Institution, Museum Support Center, Suitland, Maryland.en-US en-US Texas at Tyler, Tyler, Texas and formerly Research Asen-US -en-US en-US -en-US ogy Branch, Walter Reed Army Institute of Research, en-US located at the Smithsonian Institution, Museum Support en-US Center, Suitland, Maryland.en-US Mr D. Pecor is a VectorMap Data Management Technien-US -en-US en-US -en-US ogy Branch, Walter Reed Army Institute of Research, en-US located at the Smithsonian Institution, Museum Support en-US Center, Suitland, Maryland.en-US Ms Benyamin is an Associate Scientist of BioReliance, en-US Rockville, Maryland and formerly O-RISE Technical en-US Research Assistant of the Walter Reed Biosystematics en-US en-US of Research, located at the Smithsonian Institution, Muen-US -en-US seum Support Center, Suitland, Maryland.en-US Dr Bousss is an Entomologist at the Institut de Recheren-US -en-US en-US en-US (MIVEGEC), Montpellier, France.en-US Dr Debboun is the Director of the Mosquito & Vector en-US Control Division, Harris County Public Health, Houston, en-US Texas.

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en-US86 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USVector-borne and zoonotic diseases pose a threat to acen-US -en-US en-US States. Deaths among service members from vector-en-US borne diseases have dropped in recent decades, but en-US morbidity from vector-borne diseases and injuries from en-US stinging arthropods remain a real threat.en-US1-4en-USen-US en-US en-US of Aerospace Medicine at Wright-Patterson Air Force en-US Base, OH, through the Epidemiology Consult Service. en-US Entomology services include the capability to identify en-US both wide range of arthropods from around the world en-US and pathogen surveillance including the detection of en-US several arboviruses, en-US Bartonellaen-US spp., en-US Leishmaniaen-US spp., en-US Plasmodiumen-US spp., and en-US Rickettsiaen-US spp.en-US5-10en-US Many of these en-US en-US for both threat assessments and as part of standard pest en-US management operations.en-US Long-term data on both vectors and associated pathoen-US -en-US gens are maintained for later review and determination en-US en-US the Middle East, analysis of trends in pathogen surveilen-US -en-US lance continues to be relevant. Several mosquito-borne en-US arboviruses including West Nile virus (WNV) and en-US Sindbis virus (SINV) were historically reported from en-US both military members and local mosquitoes in the reen-US -en-US gion.en-US11,12en-US We reviewed the arbovirus surveillance data for en-US Incirlik Air Base (AB) in Turkey from 2011-2016 with a en-US discussion of 2 major viruses.en-US Incirlik AB is in a strategically relevant location. It is en-US located in far southern Turkey relatively near Syria and en-US other Middle Eastern countries, including Iraq, Lebaen-US -en-US non, and Israel. Surveillance is relevant for ongoing en-US force health protection. In addition, pathogens detected en-US in Incirlik could be useful in understanding viruses en-US circulating in neighboring countries. Several mosquito-en-US borne viruses such as West Nile and Sindbis are endemen-US -en-US ic in Turkey.en-US13,14 METHODS en-USbases in the Middle East, but Incirlik AB, which opened en-US in February 1955, has one of the longest established en-US records. Most bases conduct vector and pathogen suren-US -en-US veillance programs. Mosquitoes on many of these basen-US -en-US es breed in water retention ponds or subsurface catch en-US basins below parking lots or streets. Mosquitoes were en-US trapped on the air base using the solid-state Army minen-US -en-US iature traps with dry ice. Traps were set out seasonally en-US from April through October and run on a weekly basis. en-US Mosquito fogging typically occurred 3 days a week. Two en-US traps were used, both near the perimeter fence, one near en-US the sewage treatment plant, and one near base quarters. en-US Mosquitoes were killed by freezing and shipped dry to en-US en-US -en-US cation and pathogen detection. Mosquitoes were moren-US -en-US en-US15,16en-US Voucher en-US en-US Museum of Biological Diversity, Columbus, OH, or the en-US en-US en-US -en-US cies and tested for arboviruses. Pools ranged from 1-25 en-US mosquitoes depending on submission numbers. Most en-USOperational Mosquito and Vector-Borneen-US en-US Diseases Surveillance at Incirlik Air Base,en-US en-US Turkey W ill K. Reeves, PhD, MS M yrna M. Miller, DVM, PhD Or han Bayik, PHS ABSTRac AC T Arboviruses on Incirlik Air Base, Turkey, pose a threat to military personnel and civilians, but might also be en-USen-US -en-US en-US Aedesen-US en-US caspiusen-US en-US Anophelesen-US en-US clavigeren-US en-US Culexen-US en-US mimeticusen-US en-US Cxen-US en-US perexiguusen-US en-US Cxen-US en-US pipiensen-US en-US Cxen-US en-US sinaiticusen-US and en-US Culisetaen-US en-US longiareolataen-US en-US Almost all of the mosquitoes (more than 90%) were en-US Cxen-US en-US perexiguusen-US or en-US Cxen-US en-US pipiensen-US Both West Nile virus and en-US Sindbis virus were detected in 6 mosquito pools among collections made in 2013, 2014, and 2015en-US.

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en-USJanuary June 2017 en-US87en-USmosquitoes were tested with a RAMP* WNV test and en-US the VecTOR Test Systems (Thousand Oaks, Califoren-US -en-US nia) en-USAlphavirusen-US panel that detects chikungunya (CHIK), en-US equine encephalitis, Mayaro, SINV, Venezuelan equine en-US encephalitis, and Western equine encephalitis viruses. en-US en-US deployment and rapid screening of mosquitoesen-US17en-US were en-US en-US School of Aerospace Medicine. Both the VecTOR Test en-US Systems and RAMP assays were performed in accoren-US -en-US dance with manufacturers guidelines. We occasionen-US -en-US ally used commercially available inactivated West Nile en-US and chikungunya virus antigens as a positive control to en-US validate the assay sensitivity as suggested.en-US18en-US As a furen-US -en-US en-US-en-US verse transcription polymerase chain reaction en-US(en-USRT-PCR). en-US en-US protocols by Lanciotti et al.en-US19en-US The PCR products were en-US sequenced and compared to sequences in GenBank usen-US -en-US ing the BLASTen-USen-US program.en-US There were 6 pools of en-US Culexen-US en-US perexiguusen-US Theobald or en-USCxen-US en-US pipiensen-US L. that tested positive for arboviruses as shown en-US in the Table. There were 4 pools positive for WNV: one en-US each on October 2 and 9, 2013; August 29, 2014; and en-US September 16, 2015. We validated the October 9, 2013 en-US results with both the RAMP and VecTOR Test Systems en-US WNV assays. The RAMP scores ranged from 150 to the en-US maximum limit of 740. Both pools tested by RT-PCR en-US were positive with cycle threshold scores of 18.14 and en-US 21.04 respectively which was less than the viral culture en-US positive controls. The 919 base-pair sequence of WNV en-US envelope protein was a 100% match to WNV isolate en-US Spain/2010/H-1b (GenBank # JF719069).en-US In addition, 2 pools of combined en-USCxen-US en-US perexiguusen-US and en-USCxen-US en-US pipiensen-US from June 18 and 25, 2014, tested strongly posien-US -en-US tive for an en-US Alphavirusen-US on the VecTOR Test System assay. en-US en-US Sindbis is the detectable virus in the region.en-US13 COmm MM ENT We detected West Nile and Sindbis viruses in pools en-USof en-US Culexen-US spp. from Incirlik AB. The WNV was in the en-US Western Mediterranean WNV subtype in the WNV linen-US -en-US eage 1 based on sequence similarity. While often underen-US -en-US appreciated, both viruses are a true threat to the military. en-US Petersen et alen-US20en-US estimated that WNV caused hundreds en-US en-US from 1999 to 2010. Further, WNV was the leading cause en-USen-US -en-US viduals since the 1970s.en-US2en-US Sindbis virus infection causes en-US severe arthritis, fever, and, in rare cases, encephalitis.en-US21en-USWest Nile virus was detected in a total of 6 collections en-US made in 2013, 2014, and 2015. This indicates that the vien-US -en-US rus circulates at some regularity and could pose a threat en-US to both active duty, contractors, civilian personnel, and en-US dependents. We separated mosquito collection data been-US -en-US tween sewage or waste water treatment plants and resien-US -en-US dential areas and detected infected mosquitoes in both en-US areas. This virus requires avian hosts for the natural en-US enzootic cycle but mosquitoes can be transovarially inen-US -en-US fected.en-US22en-US We could not determine the route of infection en-US in mosquitoes from Incirlik AB.en-US en-US in the Middle East. Detection of 2 potentially serious en-US arbovirus threats on a military base in southern Turkey en-US could raise concerns for similar disease threats in neighen-US -en-US en-US with little to no infrastructure. Infections by either West en-US Nile or Sindbis virus often lead to mild disease but can en-US lead to fatal or debilitating infections and might result in en-US costly medical evacuations.en-US In summary, we reviewed 6 years (2011-2016) of WNV en-US and SINV detection in mosquitoes from Incirlik AB. en-US Culexen-US en-US perexiguusen-US was the most commonly associated en-US mosquito with WNV from the base. It is a member of the en-US Cxen-US en-US univittatusen-US Theobald complex and several of these en-US have previously been associated with both WNV and en-US SINV with evidence of vertical transmission of WNV.en-US23en-US en-US Our surveillance data suggests that there are repeated en-US and predictable threats from WNV and possibly SINV en-US on the base. AcC KNOWLEDGEm M ENTS We thank the Public Health and Civil Engineering per en-US-en-US sonnel at Incirlik AB for mosquito surveillance and timeen-US -en-US ly submission of samples. We also thank the current and en-US en-US of Aerospace Medicine.en-US This research was partially funded by the Global Emergen-US -en-US ing Infections Surveillance and Response System.en-US en-US -en-US publication and Security Review, Security Review# en-US 17-S-1077. RREFERENc C ES 1. en-USAnna MM, Escobar JD, Chapman AS. Reported en-US en-US 2000-2011. en-US MSMRen-US 2012;19:11-14.en-USTHE ARMY MEDICAL DEPARTMENT JOURNAL en-US*en-US RAMP en-US (en-USrapid analyte measurement platform) is a registered en-US trademark of Response Biomedical, Vancouver, Canada.en-USen-USBasic Local Alignment Search Tool; National Center for Biotechen-US-en-US nology Information, Bethesda, MD.

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en-US88 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspx 2. en-USReeves WK, Bettano AL. A review of mortalen-US -en-US ity from parasitic and vector-borne diseases in en-US en-US Jen-US en-US Parasitolen-US en-US 2014;100:189-192. 3. en-USReeves WK, Rowe NM, Kugblenu RK, Magnuson en-US CL. Case series: chikungunya and dengue at a foren-US -en-US ward operating location. en-US MSMRen-US 2015;22:9-10. 4. en-USVoss JD, Kugblenu R, Salter K, Johnson L, Reeves en-US WK. Case series of 23 deaths from Hymenoptera en-US en-US Jen-US en-USHymenopten-US en-USResen-US 2016;48:95-99. 5. en-USWolf SP, Reeves WK. en-USRickettsiaen-US en-US felisen-US (Ricketten-US -en-US en-US -en-US phonaptera: Pulicidae) in the Philippines. en-USJen-US en-US Entoen-US -en-US molen-US en-USScien-US 2012;47:95-96. en-USMosquito surveillance data from Incirlik Air Base, Turkey, from en-US2011-2016en-US with WNV virus and Sindbis virus screening data.en-USLocality nameen-US Collection Datesen-US Species* and Numberen-US Arbovirus Test Resultsen-US Housingen-US2en-US June-en-US19en-US August en-US2011en-USCulex perexiguus en-US(95)en-USCulex pipiens en-US(23)en-USAedes caspius en-US(1)en-USCuliseta longiareolata en-US(7)en-USWNV/Alphavirus Negativeen-US Housingen-US27en-US April-en-US14en-US September en-US2012en-USCulex perexiguus en-US(133)en-USCules pipiens en-US(388)en-USCulex mimeticus en-US(7)en-USAedes caspius en-US(7)en-USCuliseta longiareolata en-US(6)en-USWNV/Alphavirus Negativeen-US Running Tracken-US1en-US June en-US2012en-USCulex perexiguus en-US(5)en-USCulex pipiens en-US(13)en-USWNV/Alphavirus Negativeen-US Housingen-US18en-US April-en-US20en-US November en-US2013en-USCulex perexiguus en-US(73)en-USCulex pipiens en-US(339)en-USCulex sinaiticus en-US(148)en-USAedes caspius en-US(17)en-USCuliseta longiareolata en-US(7)en-USOne pool of en-US25en-US en-USCulex perexiguus en-USfrom en-US9en-US October en-US2013en-US was en-US positive for WNV virus.en-US Sewage Treatment en-US Planten-US18en-US April-en-US20en-US November en-US2013en-USCulex perexiguus en-US(821)en-USCulex pipiens en-US(252)en-USCulex sinaiticus en-US(301)en-USAedes caspius en-US(32)en-USOne pool of en-US25en-US en-USCulex perexiguus en-USfrom en-US2en-US October en-US2013en-US was en-US positive for WNV virus.en-US Flight Lineen-US8en-US Aprilen-US-6en-US November en-US2013en-USCulex pipiens en-US(8)en-USWNV/Alphavirus Negativeen-US Housingen-US16en-US May-en-US29en-US August en-US2014en-USAnopheles claviger en-US(1)en-USCulex perexiguus en-US(658)en-USCulex pipiens en-US(153)en-USCuliseta longiareolata en-US(1)en-USWNV/Alphavirus Negativeen-US Dining Facility en-US2en-US July en-US2014en-USCulex perexiguus en-US(1)en-USCulex pipiens en-US(3)en-USWNV/Alphavirus Negativeen-US Sewage Treatment en-US plant en-US23en-US April-en-US29en-US August en-US2014en-USCulex perexiguus en-US(327)en-USCulex pipiens en-US(90)en-USAedes capensisen-US en-US(9)en-USTwo pools of combined en-USCulexen-US spp. en-US(25en-US eachen-US)en-US from en-US18en-US and en-US25en-US June en-US2014en-US tested positive for en-US Alphavirusen-US One pool of en-US25en-US en-USCulex perexiguus en-USfrom en-US29en-US August en-US2014en-US was positive en-US for WNV virus.en-US Housingen-US6en-US May-en-US23en-US September en-US2015en-USCulex perexiguus en-US(331)en-USCulex pipiens en-US(280)en-USAedes caspius en-US(11)en-USCuliseta longiareolata en-US(14)en-USOne pool of en-US25en-US en-USCulex perexiguus en-USfrom en-US16en-US September en-US2015en-US en-US was positive for WNV virus.en-US Sewage Treatment en-US Planten-US1en-US May-en-US16en-US September en-US2015en-USCulex perexiguus en-US(831)en-USCulex pipiens en-US(198)en-USAedes caspius en-US(2)en-USCuliseta longiareolata en-US(3)en-USWNV/Alphavirus Negativeen-US Housingen-US12en-US April-en-US12en-US August en-US2016en-USCulex perexiguus en-US(11)en-USCulex pipiensen-US en-US(33)en-USCuliseta longiareolata en-US(3)en-USWNV/Alphavirus Negativeen-US Sewage Treatment en-US Planten-US31en-US March-en-US16en-US October en-US2016en-USCulex perexiguus en-US(225)en-USCulex pipiens en-US(182)en-USAedes capensisen-US en-US(3)en-USWNV/Alphavirus Negativeen-US*en-USScientific species identification:en-US Aedes capensis Edwards en-USCulex perexiguus en-USTheobalden-US Aedes caspius en-US(en-US Pallasen-US ) en-USCules pipiens en-USL.en-US Culiseta longiareolata Macquart en-USCulex sinaiticus en-USKirkpatricken-US Culex mimeticus en-USNo en-USOPERATIONAL MOSQUITO AND VECTOR-BORNE DISEASES SURVEILLANCEen-US en-US AT INCIRLIK AIR BASE, TURKEY

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en-USJanuary June 2017 en-US89 6. en-USen-US Presence of en-USBartonellaen-US and en-USRickettsiaen-US spp. in cat en-US en-US American Samoa. en-US Jen-US en-US Asiaen-US en-US Pacen-US en-US Entomolen-US 2013;16: en-US 461-463. 7. en-USTaylor SJ, Durden LA, Foley EH, Reeves WK. The en-US bat tick en-USCariosen-US en-US aztecien-US (Acari: Argasidae) from Been-US -en-US lize, with an endosymbiotic Coxiellaceae. en-USSpeleoen-US -en-US biologyen-US en-USnotesen-US 2016;8:16-21. 8. en-USReeves WK, Epler JH. New records and a review en-US of the Chironomidae (Diptera) of Kuwait and the en-US en-US Chironomusen-US en-US Jen-US en-US Chironen-US -en-US omidaeen-US en-US Resen-US 2016;29:29-32. Available at: http://en-US www.ntnu.no/ojs/index.php/chironomus/article/en-US view/2032. Accessed April 12, 2017. 9. en-USReeves WK, Breidenbaugh MS, Thomas EE,en-US en-US Glowacki MN. Mosquitoes of Thule Air Base,en-US en-US Greenland. en-US Jen-US en-US Amen-US en-US Mosquitoen-US en-US Conten-US en-US Assocen-US 2013;29:en-US en-US 383-384. 10. en-USFoley EH, Reeves WK. en-US Rickettsiaen-US en-US massiliaeen-US from en-US the Azores. en-USJen-US en-USAgricen-US en-USUrbanen-US en-USEntomolen-US 2014;30:25-27. 11. en-USWills WM, Jakob WL, Francy DB, et al. Sindbis en-US virus isolations from Saudi Arabian mosquitoes. en-US Transen-US en-USRoyen-US en-USSocen-US en-USTropen-US en-USMeden-US en-USHygen-US 1985;79:63-66. 12. en-USRichards AL, Hyams KC, Merrell BR, et al. Medien-US -en-US cal aspects of Operation Desert Storm. en-USN Engl J en-US Med.en-US 1991;325:970-971. 13. en-USMeo O. Hemagglutination-inhibiting antibodies en-US to Sindbis virus in the population of the southeast en-US region of Turkey. en-USMikrobiyolen-US en-USBulen-US 1981;15(1):1-6. 14. en-USErgunay K, Bakonyi T, Nowotny N, Ozkul A. en-US Close relationship between West Nile virus from en-US Turkey and lineage 1 strain from Central African en-US Republic. en-USEmergen-US en-USInfecten-US en-USDisen-US 2015;21:352-355. 15. en-USHarbach RE. The Mosquitoes in the subgenus en-US Culexen-US in Southwestern Asia and Egypt (Diptera: en-US Culicidae). en-US Contributionsen-US en-US ofen-US en-US theen-US en-US Americanen-US en-US Entomoen-US -en-US logicalen-US en-US Instituteen-US 1988;24:1-246. Available at: http://en-US en-US doc=GetTRDoc.pdf&AD=ADA512480. Accessed en-US April 12, 2017. 16. en-USParrish DW. The mosquitoes of Turkey. en-US Mosqen-US en-US Newsen-US en-US 1959;19:264-266. 17. en-USen-US vector diagnostics during military deployments: reen-US -en-US cent experience in Iraq and Afghanistan. en-US Milen-US en-US Meden-US. en-US 2009;174:904-920. 18. en-USBurkhalter KL, Savage HM. Evaluating the use of en-US commercial West Nile virus antigens as positive en-US controls in the rapid analyte measurement platform en-US West Nile virus assay. en-USJen-US en-US Amen-US en-US Mosquitoen-US en-US Conten-US en-US Assocen-US en-US 2015;31:371-374. 19. en-USLanciotti, S, Kerst AJ, Nasci RS, et al. Rapid deen-US -en-US tection of West Nile virus from human clinical en-US en-US samples by a TaqMan reverse transcriptase-PCR en-US assay. en-USJ Clin Microbiolen-US 2000;38:4066-4071. 20. en-USPetersen LR, Carson PJ, Biggerstaff BJ, Custer B, en-US Borchardt SM, Busch MP. Estimated cumulative en-US en-US 1999-2010. en-USEpidemiolen-US en-USInfecten-US 2013;141:591-595. 21. en-USNiklasson B, Espmark A, LeDuc JW, Gargan TP, en-US Ennis WA, Tesh RB, Main AJ Jr. Association of a en-US Sindbis-like virus with Ockelbo disease in Sweden. en-US Amen-US en-USJen-US en-USTropen-US en-USMeden-US en-USHygen-US 1984;33:1212-1217. 22. en-USAnderson JF, Main AJ. 2006. Importance of vertien-US -en-US cal and horizontal transmission of West Nile virus en-US by en-US Culex pipiensen-US en-US Jen-US en-USInfecten-US en-USDisen-US 2006;194:1577-1579. 23. en-USMiller BR, Nasci RS, Godsey MS, Savage HM, en-US en-US evidence for natural vertical transmission of West en-US Nile virus in en-US Culexen-US en-US univittatusen-US complex mosquien-US -en-US toes from rift valley province, Kenya. en-US Amen-US en-US Jen-US en-US Tropen-US en-US Meden-US en-USHygen-US 2000;62:240-246. AUTHORS When this study was conducted, Dr Reeves was the en-USen-US Aerospace Medicine. He currently is a regulatory analyst en-US en-US Health Inspection Service, Biotechnology Regulatory en-US Service, Fort Collins, Colorado.en-US Dr Miller is the chief virologist at the Wyoming State en-US Veterinary Laboratory, Laramie, Wyoming.en-US Mr Bayik is the Public Health Specialist and Food Safety en-US and Medical Entomology Program Manager at the Inciren-US -en-US lik Air Base, Turkey.en-US When this study was conducted, Maj Chapman was a en-US en-US -en-US space Medicine. She currently is the Assistant Continen-US -en-US en-US -en-US ment Board, Silver Spring, Maryland.

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en-US90 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USVector-borne diseases (VBDs) are among the leading en-US causes of morbidity and mortality worldwide. The hisen-US -en-US en-US of the Continental Army in the 1770s.en-US1en-US From the incepen-US -en-US en-US -en-US en-US en-US en-US -en-US stitutions are major components in this effort. Additionen-US -en-US ally, the armed forces have worked to prevent the spread en-US of disease through active public health measures such as en-US the establishment of vector control programs at military en-US en-US en-US2en-US While VBDs en-US are of considerable concern for internationally deployed en-US active military and civilian personnel, the concern for en-US en-US been a reality for centuries. Endemic, emerging, and en-US en-US States and its territories, creating foci of disease transen-US -en-US mission. Military personnel are particularly susceptible en-US to VBDs due to their increased contact with vectors duren-US -en-US ing outdoor training exercises, military response misen-US -en-US USUS MILITa A Ry Y E ENTOm M OLOGy Y I INFRa A STRUc C TURE Vector control and pest management across the Depart en-US-en-US ment of Defense (DoD) involves a multitude of organizaen-US -en-US tions both internal and external to the DoD. Born from en-US a need to address the countless casualties and mission en-US cost attributed to VBDs during World War II, the Army en-US War Department established the Army Committee for en-US Insect and Rodent Control (ACIRC) in 1944. In 1956, en-US DoD Instruction 5154.12en-US established the Armed Forces en-US Pest Control Board replacing the ACIRC. By 1979, the en-US title was amended to its current form, Armed Forces en-US en-US goal of balancing vector and pest control with environen-US -en-US mental protection. The AFPMB is composed of pest en-US management and medical entomologists from the Air en-US Force, Army, Navy, and the Defense Logistics Agency en-US en-US Assistant Secretary of Defense for Acquisition, Technolen-US -en-US ogy and Logistics to recommend policy, provide guiden-US -en-US ance, and coordinate the exchange of information on en-US all matters related to pest management throughout the en-US DoD. Service entities including the Army Public Health en-US Center, Navy Entomology Center of Excellence, Walter en-US Reed Army Institute of Research, Walter Reed Biosysen-US -en-US en-US Center assist in the coordination and implementation of en-US en-US and guidance. The AFPMB is the lead pest manageen-US -en-US en-US en-US and other foreign organizations as well, including the en-US en-US en-US -en-US vention (CDC), North Atlantic Treaty Organization, and en-US the World Health Organization.en-US en-US forces date from the late 1800s, when mosquitoes were en-US en-US3en-US en-US Vector management programs evolved into their modern en-US form during the 1970s with the development of integraten-US -en-US ed mosquito control programs focused on a multifaceted en-US approach designed to manage the target pest with inteen-US -en-US grated measures to mitigate risk of vector disease transen-US -en-US mission while balancing risk of pesticide exposure and en-US environmental risk. The introduction of West Nile virus en-US en-US4en-US and the recent chien-US -en-US kungunya-Zika Latin American epidemics have created en-US a shift in the paradigm of vector control programs.en-US5en-US Proen-US -en-US grams have now begun to balance the concern for envien-US -en-US ronmental effects of pesticide use on a large scale with en-US the threat of invasive mosquito species and their respecen-US -en-US tive capacities to introduce emerging VBDs within our en-US borders. Currently, several endemic VBDs continue to en-US threaten our military and civilian populations residing en-USVector-Borne Diseases of Public Healthen-US en-US Importance for Personnel on Militaryen-US en-US Installations in the United States Melissa N. Garcia, PhD, MPH W alter Roachell, MS Thomas L. Cropper, DVM, MPVM, ACVPM Shannon E. Ronca, P hD, MPH Sarah M. Gunter, PhD, MPH Ralph A. Stidham, DHSc, MPH

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en-USJanuary June 2017 en-US91en-USen-US diseases in Latin America threaten introduction into en-US our resident mosquito populations,en-US6,7en-US and new pathogens en-US en-US -en-US lance and innovative pathogen detection research invesen-US -en-US tigations.en-US8-10en-US In this article, we present an overview of en-US vector-borne diseases acquired by military personnel en-US en-US -en-US en-US and conclusions to reduce disease transmission in this en-US population. MOSQUITO-BORNE D DISEa A SES West Nile Virus en-USWest Nile virus (WNV) is transmitted by a variety of en-US en-US Culexen-US en-US pipiensen-US Linneaeus in the north, en-US Cx.en-US en-US quinquefasen-US-en-US ciatusen-US Say in the south, and en-US Cx.en-US en-US tarsalisen-US Coquillett in the en-US western states. Over 2,000 cases of WNV occur annuen-US -en-US en-US11en-US with cyclic peak annual outen-US -en-US breaks.en-US12en-US Although many infected humans will not show en-US signs of disease, 20% develop febrile illness, and 1% en-US en-US meningitis, encephalitis or meningoencephalitis).en-US13en-US Neuen-US -en-US roinvasive disease is a particularly concerning clinical en-US manifestation, as these patients have the highest risk of en-US long-term morbidity and death.en-US11en-US Diagnosis is made by en-US detection of WNV viremia, or antibodies in the serum en-US en-US -en-US plicated by the short duration of viremia antecedent to en-US symptom onset and the sustained presence of IgM infecen-US -en-US tion several months to years post-onset.en-US14en-US Evidence for en-US persistent infection and/or sequelae exists, with patients en-US continuing to report morbidity up to 11 years post-infecen-US -en-US tion.en-US15,16en-US The economic burden from WNV infection is en-US considerable with each individual case of acute neuroen-US -en-US invasive disease resulting in up to $51,240 in healthcare en-US costsen-US17en-US and up to $400,000 in long-term loss of producen-US -en-US tivity wages.en-US18en-US Currently, there are no Food and Drug Aden-US-en-US ministration approved treatments or vaccines for WNV en-US infection; however, vaccine clinical trials are undergoen-US -en-US ing.en-US19en-USen-US 44 DoD sites,en-US20en-US resulting in nationwide vector control en-US efforts.en-US21en-US The Armed Forces Health Surveillance Center en-US en-US Army, Navy, Marine Corps, Air Force, and Coast Guard en-US personnel from 2006-2015.en-US22en-US An additional 245 cases en-US were reported during that time, but the military branch en-US of the patients was unknown and those cases could inen-US-en-US clude contractors, civilians, and foreign nationals.en-USDengue Virusen-USDengue virus (DENV)en-US en-US is transmitted by en-US Aedesen-US en-US aeen-US -en-US gyptien-US (L.) and en-US Ae.en-US en-US albopictusen-US Skuse mosquitos found en-US en-US Ae.en-US en-US albopictusen-US vector geographic range reaching north to en-US Minnesota and Maine.en-US23en-US Globally, 4 serotypes (DENV en-US en-US having recently been proposed in Malaysia.en-US24en-US Infection en-US with one serotype does not provide cross-protection en-US from other serotypes, and multiple serotype exposures en-US increases ones odds of developing severe clinical outen-US -en-US comes, such as dengue hemorrhagic fever and shock en-US en-US (fever, headache, joint, muscle, and bone pain), with en-US symptom onset typically occurring 4-7 days after vector en-US transmission and lasting 3-10 days after symptom onset. en-US As the fever is residing, warning signs for serious clinien-US -en-US cal manifestations can present, including capillary leaken-US -en-US age, marked temperature change, thrombocytopenia, en-US change in mental status, rapid weak pulse, and hemoren-US -en-US rhagic manifestations that can rapidly progress to circuen-US -en-US latory system failure and shock.en-US25en-US Although the majority en-US en-US autochthonous transmission has occurred along the Texen-US -en-US as/Mexico border, as well as in Florida and Hawaii. en-US26-30en-US en-US en-US en-US en-US and pain relievers may improve outcomes among critien-US -en-US cally ill patients. Vaccine trials are underwayen-US31en-US; but conen-US -en-US trolling mosquito populations in the interim is the best en-US method for disease prevention. Between 2006 and 2015, en-US approximately 700 cases of dengue fever were reported en-US in military personnel.en-US32en-US Due to the rarity of the locally-en-US en-US assume most individuals acquired the infection during en-US deployment to endemic regions. While only focal outen-US -en-US breaks of autochthonous transmission have occurred in en-US en-US Ae.en-US en-US albopictusen-US and en-US Ae.en-US en-US aegyptien-US exist should monitor for en-US the potential of autochthonous infections.en-US26-30en-USOther Endemic Arboviral Infections of Concernen-USSt. Louis encephalitis (SLE) is a en-US Culexen-US sp. transmitted en-US en-US33en-US as en-US en-US new vector control authorities across the country. While en-US SLE is less prevalent due to the recent establishment of en-US WNV, cases are still reported annually and it is a regular en-US contributor to neuroinvasive disease nationally.en-US34en-US Alphaen-US -en-US viruses are another group of positive-sense RNA virusen-US -en-US es transmitted through the bite of an infected mosquito en-US and are a member of the Togaviridae family.en-US35en-US They en-US typically result in encephalitis or arthralgia. Western en-US equine encephalitis (WEE), Eastern equine encephalitis en-US (EEE), and Venezuelan equine encephalitis (VEE) vien-US -en-US ruses are encephalitic alphaviruses, while chikungunya en-US THE ARMY MEDICAL DEPARTMENT JOURNAL

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en-US92 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USis an arthralgic alphavirus. en-US Aedes,en-US en-US Culex,en-US en-US Psorohpora,en-US en-US and Cen-US ulisetaen-US are all known to transmit alphavirus infecen-US -en-US tions. For the encephalitic alphaviruses, most infections en-US are asymptomatic, but febrile illness can onset 2-10 days en-US after infection and progress to encephalitis in approxien-US -en-US mately 5% of people.en-US35en-US Most EEE cases are reported in en-US Florida, Georgia, Massachusetts, and New Jersey, but en-US transmission is most common around the freshwater en-US hardwood swamps in Atlantic states, Gulf Coast states, en-US and the Great Lakes regions.en-US36en-US Most WEE cases ocen-US -en-US cur in Texas, Colorado, Oklahoma, and New Mexico.en-US35en-US en-US Most VEE cases occur in Central and South America, en-US but spillover cases have occurred in Texas.en-US37en-US Complicaen-US -en-US tions of encephalitis can occur with lifetime care costs en-US exceeding $4.6 million per patient.en-US35en-US According to the en-US Armed Forces Health Surveillance Center, at least 107 en-US cases of mosquito-borne viral encephalitedes (contriben-US -en-US utable to either WEE, EEE, or other less common aren-US -en-US boviruses) were reported between 2005 and 2014, with en-US cases originating annually from the Marines, Army, Air en-US Force, and Navy,en-US38en-US further demonstrating their contribuen-US -en-US tory role in serviceman illness. TTIc C K-BORNE DISEa A SES Lyme disease en-USLyme disease, also referred to as Lyme borreliosis, is en-US caused by different genospecies of the bacterium en-US Boren-US -en-US reliaen-US en-US burgdorferien-US Johnson sensu lato.en-US39en-US This vector-en-US borne infection is endemic to the majority of the northen-US -en-US ern hemisphere with active transmission ongoing in en-US en-US40en-US Multiple species en-US of the en-US Ixodesen-US ticks are capable of propagating sylvatic en-US en-US only two are implicated in human transmission: the en-US black legged tick (also called the deer tick) (en-US Ixodesen-US en-US scapen-US -en-US ularisen-US Say), and the western black-legged tick (en-US I.en-US en-US en-US -en-US cusen-US Cooley and Kohls).en-US41en-US Initial symptoms after expoen-US -en-US sure through the bite of an infected tick often include the en-US development of a rash around the sight of inoculation en-US referred to as erythema migrans, colloquially called a en-US bulls-eye rash. In addition, many patients concurrently en-US experience fatigue, headache, arthralgia, malaise, and en-US myalgia. Rarely the disease can disseminate after initial en-US infection and cause symptoms including carditis, neuen-US -en-US rologic complications, and arthritis.en-US42en-US Oral antibiotics en-US such as doxycycline, amoxicillin, or cefuroxime axetil en-US are commonly prescribed for treatment of Lyme disen-US -en-US ease.en-US43en-US Patients treated rapidly after onset of infection en-US often recover completely. However, delayed diagnosis en-US and treatment may lead to a higher likelihood of develen-US -en-US oping severe disease. Lyme disease is among the most en-US en-US an annual incidence of around 300,000 cases.en-US44en-US It has en-US long been proposed that individuals with occupations or en-US hobbies that require extended time spent outdoors, such en-US as military training exercises, in endemic areas are at en-US elevated risk for contracting Lyme disease.en-US45en-USHistorically, the armed forces have struggled with Lyme en-US disease infection in military trainees, active duty Solen-US -en-US diers, military dependents, and civilian contractors en-US working on military bases and installations. Reports of en-US infection date back to 2 years after the pathogen was en-US en-US incidence rate of 1,063 cases per 100,000 personnel been-US -en-US en-US -en-US cal diagnosis as serologic testing was not yet available, en-US introducing the possibility that this number underrepreen-US -en-US sents the true burden of disease due to misdiagnosis.en-US46en-US en-US en-US en-US -en-US seminated Lyme disease had developed, and presented en-US with rare symptoms including carditis and neurologic en-US complications.en-US47,48en-US The late 1990s was a period of low en-US incidence. It was estimated that only 6 seroconversions en-US occurred during military duty per 100,000 persons.en-US49,50en-US en-US Reports of Lyme disease among all branches of the milien-US -en-US tary steadily increased in the early 2000s.en-US51,52en-USIn 2006, an entire 110-person unit was preemptively en-US treated for Lyme disease after a training exercise at Fort en-US Dix, New Jersey. Between one and 2 weeks after the exen-US -en-US ercise, at least 5 personnel were diagnosed with erytheen-US -en-US ma migrans. Watchful waiting was judged to be too high en-US of a risk for this unit as they were preparing to deploy to en-US an austere location in less than 2 weeks. Given the risk en-US of cardiac and neurologic complications presenting in en-US such circumstances, the entire unit received a 2-week en-US course of doxycycline for early Lyme.en-US53en-US In 2011, a spike en-US in cases was reported, at its peak 16 per 100,000 acen-US -en-US tive duty personnel and 25 per 100,000 reservists were en-US screened positive for en-US B.en-US en-US burgdorferien-US exposure.en-US54en-US Incien-US -en-US dence of military exposure appear to correlate with base en-US location, with the highest incidence in the northeastern en-US en-US55en-US Reports indicate that a correlation exen-US -en-US ists between pathogen quantity in ticks removed from en-US military personnel and human prevalence of disease at en-US a given base, indicating that this may serve as an effec en-US-en-US tive surveillance tool for detection of high risk areas and en-US prevention of disease outbreaks.en-US56en-US This method might be en-US particularly useful to distinguish between transmission en-US sources for returning serviceman from European instalen-US -en-US lations where transmission is also possible.en-US57en-USEhrlichiosisen-USen-US -en-US rlichiosis is caused by infection with either en-US Ehrlichiaen-US en-US chaffeensisen-US Dumler (human monocyte ehrlichiosis) or en-US E.en-US en-US VECTOR-BORNE DISEASES OF PUBLIC HEALTH IMPORTANCE FOR PERSONNELen-US en-US ON MILITARY INSTALLATIONS IN THE UNITED STATES

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en-USJanuary June 2017 en-US93 en-USewingiien-US Dumler.en-US58en-US This zoonotic pathogen is an obligate en-US intracellular bacterium that often infects monocytes, en-US forming distinct en-USEhrlichiaen-US colonies. Cases are most ofen-US -en-US ten reported in the southcentral and eastern regions of en-US en-US region of naturally occurring lonestar ticks (en-US Amblyomen-US -en-US maen-US en-US americanumen-US Linnaeus), the primary vector for both en-US Ehrlichiaen-US species.en-US59en-US Within one to 2 weeks of exposure, en-US patients typically develop general febrile illness and a en-US subset present with a wide range of rash (maculopapuen-US -en-US en-US ehrlichiosis can cause more severe symptoms including en-US en-US case fatality.en-US60en-US The primary treatment is oral doxycycline en-US for both adult and pediatric cases.en-US61en-US It is recommended en-US that the antibiotic be prescribed even in suspected cases en-US due to the severe and even fatal nature of this infection.en-US en-US agent of human ehrlichiosis includes a case-report of an en-US en-US at Fort Chaffee, Arkansas.en-US62en-US Following this discovery, en-US a prospective serologic investigation was launched to en-US determine seroprevalence of en-US Ehrlichiaen-US at Fort Chaffee en-US and surrounding bases. Seroconversion was detected in en-US 1.3% of the Soldiers with available pre-exposure samples en-US (n=1,194) with 33.3% of seropositive personnel reporten-US -en-US ing a previous clinical history consistent with ehrlichioen-US -en-US sis. Additionally, seropositive military personnel were en-US en-US -en-US ment (RR=3.56, en-USPen-US <.2), indicating that active tick-borne en-US transmission of en-USEhrlichiaen-US en-US -en-US ercises at bases within Arkansas.en-US63en-US A second outbreak en-US was detected at a New Jersey base, where 12% of peren-US -en-US sonnel screened seropositive (n=74) with all 9 cases reen-US -en-US en-US grass.en-US64en-US Additional sporadic human case reports and en-US Ehen-US -en-US rlichiaen-US pathogen positive ticks collected from military en-US personnel indicate this is an ongoing threat to military en-US en-US en-US52,65,66en-USRocky Mountain Spotted Feveren-USRocky Mountain spotted fever (RMSF, infectious agent en-US Rickettsiaen-US en-US rickettsiaen-US en-US States,en-US67en-US and is sometimes referred to as spotted fever en-US group rickettsiosis when including other less commonly en-US transmitted rickettsial pathogens (en-US R.en-US en-US parkerien-US Lackman en-US and en-US Rickettsiaen-US spp. 364D). Transmission has been noted en-US throughout the contiguous 48 states, with a burden of en-US disease occurring in the southcentral states. The primaen-US-en-US ry vector for RMSF is the American dog tick (en-US Dermaen-US -en-US centoren-US en-US variablilis en-US (Say)).en-US68en-US Symptoms of disease present en-US 2 to 14 days after exposure and typically begin with a en-US en-US -en-US en-US of disease. Typically, it is not until the characteristic rash en-US associated with infection forms 2 to 5 days following en-US onset of symptoms, that the disease is positively identien-US -en-US en-US68en-US Some individuals will have a more severe infecen-US -en-US tion that can lead to vasculitis, and abnormal bleeding en-US in the brain and/or vital organs. Those who experience en-US severe disease symptoms often suffer from sequelae as en-US en-US as no serologic test are available to detect acute infecen-US -en-US tion, and is largely determined by clinical symptoms en-US en-US prompt doxycycline administration is critical to limit en-US disease severity.en-US67 en-US Given the frequency of movements en-US of military trainees from one geographic location to en-US another, this often presents well outside its usual geoen-US -en-US graphic range. A thorough travel history is an essential en-US component for the patient exam of any military personen-US-en-US nel presenting with an acute febrile illness in order to en-US consider geographically limited but life-threatening inen-US -en-US fections like RMSF.en-US Rocky Mountain spotted fever has affected military en-US en-US -en-US ed States since 1982. A serosurvey of dogs (N=467) en-US housed at 4 different military bases across the country en-US found 32% were seropositive, with a range of 4.3% to en-US 63.4% depending on region. Additionally, a higher rate en-US of RMSF exposure was reported (87%) in the working/en-US sporting dogs breeds screened.en-US69en-US Prevalence in canine en-US populations were seemingly in parallel with human seen-US -en-US roprevalence in the same geographic region during this en-US time period, suggesting that dogs may provide an efen-US -en-US en-US69,70en-US At the same Arkansas en-US base where Yevich and colleaguesen-US63en-US reported en-US Ehrlichen-US -en-US iaen-US infections, a serosurveillance study detected 2.5% en-US of military personnel (n=1,194) had seroconverted for en-US RMSF. While less than a quarter of individuals that deen-US -en-US veloped antibodies for RMSF had clinical symptoms en-US (8/30), disease status was strongly associated with hisen-US -en-US tory of tick bite (RR=4.3 en-US Pen-US <.001).en-US63en-US Reports continue en-US en-US en-US71en-US detecting seroconversion in military en-US troops,en-US52,72en-USen-US -en-US plicated in human bites.en-US65en-USTick-borne Relapsing Feveren-USTick-borne relapsing fever (TBRF) occurs when en-US Boren-US -en-US reliaen-US spirochetes (predominantly en-USB.en-US en-US hermsiien-US Steinhaus en-US and en-US B.en-US en-US turicataeen-US Steinhaus) are transmitted to humans en-US by en-US Ornithodorosen-US ticks. These soft-shelled Argasidae en-US ticks differ from hard Ixodidae ticks in several key charen-US -en-US acteristics: they have multiple nymphal stages; they feed

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94 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USrapidly, typically between 15 and 90 minutes; as adults, en-US they can feed and reproduce repeatedly, are capable of en-US surviving for several years between blood mealsen-US73en-US; and en-US the spirochetes may colonize their salivary glands, rathen-US -en-US er than the midgut, allowing for rapid deposition after en-US host attachment.en-US74en-US An infected human usually displays en-US en-US -en-US tered mental status, after a mean incubation period of en-US 7 days (range: 4-18 days). Although severe disease is en-US atypical, acute respiratory distress syndrome and other en-US serious sequelae have been reported. More commonly, en-US the initial illness resolves in 3 days (range: 0.5-17 days), en-US followed by an afebrile interval of approximately one en-US week and then a relapse of fever. Since borreliae can en-US vary their surface protein antigens repetitively, multiple en-US relapses are possible. Febrile episodes typically become en-US shorter and less severe over time. The mortality rate en-US is well below 5%, with some fatalities attributed to a en-US Jarisch-Herxheimer reaction after antibiotic initiation.en-US73en-US en-US en-US of spirochetes on thick or thin smears using Giemsa or en-US Wright stains during febrile episodes, although serologen-US -en-US ic and molecular techniques are becoming increasingly en-US available.en-US75en-US The mainstay therapy for infected adults is en-US a 7-10 day course of oral doxycycline (100 mg every en-US 12 hours); other oral and parenteral antibiotics are also en-US effective.en-US73en-USIsolated cases or small clusters of TBRF are possible en-US en-US -en-US gions of the country, most notably Florida, Texas, and en-US en-US to the natural habitat of en-US Ornithodorosen-US ticks, such as in en-US limestone caves or rodent-infested cabins, is particularly en-US risky.en-US76en-US In the summer of 2015, an Army Soldier conen-US -en-US en-US -en-US western Texas, likely while sleeping in an abandoned en-US barn-like structure. He was hospitalized with fever and en-US marked thrombocytopenia but recovered rapidly after en-US initiation of doxycycline. Postexposure prophylaxis was en-US provided to 10 soldiers in his detachment, none of whom en-US became ill.en-US77en-USen-US of en-US B.en-US en-US turicataeen-US78en-US and should remind military public en-US health personnel to emphasize tick control and personal en-US en-US -en-US demic areas. When these measures cannot be followed, en-US or when the risk remains high despite their implemenen-US -en-US tation, postexposure prophylaxis with oral doxycycline en-US should be considered.en-US79en-USOther Tick-borne Diseases of Concernen-USSeveral additional endemic tick-borne diseases exist in en-US en-US Anaplasmaen-US en-US phagoen-US -en-US cytophilumen-US Dumler rickettsial infection) is transmitted en-US to humans by en-US I.en-US en-US scapularisen-US ticks and results in apen-US -en-US proximately 2,600 incident cases annually, primarily in en-US northeastern and midwestern states.en-US80en-US A recent seropen-US -en-US en-US a 0.11%-2.6% en-US A.en-US en-US phagocytophiliumen-US positive rate among en-US a geographically diverse sample of servicemen, idenen-US -en-US tifying this pathogen as an important cause of illness en-US in military populations.en-US72en-US Colorado tick fever is another en-US cause of undifferentiated febrile illness, occurring prien-US -en-US marily at altitudes of 4,000 ft to 10,000 ft and transmiten-US -en-US ted by en-US D.en-US en-US andersonien-US Stiles.en-US81,82en-US It can result in serious en-US complications, including pericarditis, meningitis, and/or en-US encephalitis. Tularemia infection (caused byen-US Francisellaen-US en-US tularensisen-US Dorofeev) is a potentially life threatening illen-US -en-US ness that can be transmitted by en-US Dermacentoren-US sp., en-US Amblyen-US -en-US omma en-US sp., and en-US Ixodesen-US sp. ticks, among other nonvector en-US transmission sources. Tularemia has been reported from en-US all contiguous states, but is most common in southcenen-US -en-US en-US83en-US Powassan enen-US -en-US cephalitis is a rare but serious viral tick-borne disease en-US en-US transmitted by en-USI.en-US en-US cookeien-US Packard vector, although other en-US Ixodesen-US sp. and en-USD.en-US en-USandersonien-US can be vectors.en-US81,82 OOTHER VEc C TOR-BORNE DISEa A SES Chagas Disease en-USAn estimated 6 to 8 million people are infected with en-US Chagas disease.en-US84en-US The disease results from infection en-US with the protozoan parasite en-US Trypanosomaen-US en-US cruzien-US Chagas en-US is transmitted to humans through one of several routes: en-US vector-borne, congenital, blood-borne, oral, and organ en-US transmission. It is most commonly acquired via vector-en-US borne transmission.en-US84en-US More than 130 triatomine species en-US in the Americas can be infected by and transmit en-US T.en-US en-US cruen-US -en-US zien-US .en-US85en-USen-US in southwestern states; en-USTriatomaen-US en-US sanguisugaen-US LeConte en-US is the most widely distributed, yet en-US T.en-US en-US gerstaeckerien-US Geren-US -en-US staecker is the most commonly collected.en-US85en-US Autochthoen-US -en-US nous infection potential increases as triatomine species en-US adapt to human dwellings, and as human living environen-US -en-US en-US sylvatic disease.en-US86en-USInfection occurs when a en-US T.en-US en-US cruzien-US positive triatomine en-US feeds and excreta contaminates the bite wound or muen-US -en-US cosal tissue, entering the bloodstream. After an incubaen-US -en-US tion period of 1 to 2 weeks, an acute phase of 8 to 12 en-US weeks follows. During the acute phase, patients may be en-US en-US -en-US mation at the bite site; however, less than 1% will have en-US severe acute disease that manifests as acute myocarditis en-US and/or pericardial effusion.en-US87en-US Chronic infection occurs en-US in 3 forms: indeterminate, cardiac, or gastrointestinal en-US disease. Most infections remain in an indeterminate en-US VECTOR-BORNE DISEASES OF PUBLIC HEALTH IMPORTANCE FOR PERSONNELen-US en-US ON MILITARY INSTALLATIONS IN THE UNITED STATES

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January June 2017 95 en-USphase for life and have positive anti-en-US T.en-US en-US cruzien-US serology, en-US but no clinical signs or symptoms.en-US86en-US Approximately en-US 20% to 30% of indeterminate cases progress to cardiac en-US and/or gastrointestinal disease years or decades later. en-US Cardiac disease is detected by abnormal electrocardioen-US -en-US gram, and symptomatic disease may present as aneuen-US -en-US rysm, thrombus formation, or congestive heart failure.en-US87en-US en-US Less commonly, progression leads to gastrointestinal en-US disease affecting the esophagus and/or colon, leading en-US to motility disorders, megaesophagus, or megacolon.en-US88en-US en-US Treatment with nifurtimox or benznidazole may be en-US indicated for acute and indeterminate chronic disease en-US to decrease symptoms and clinical course, but must be en-US obtained from the CDC and administered under an inen-US -en-US vestigational protocol.en-US88en-US Two case reports of servicemen en-US with military and childhood exposures have been puben-US -en-US lished, highlighting the potential for disease transmisen-US -en-US en-US89,90 OOTHER E ENDEm M Ic C V VEc C TOR-BORNE DDISEa A SES OF CONc C ERN Leishmaniasis is a parasitic infection (20+ en-USLeishmaniaen-US en-US en-US Phlebotomusen-US en-US sp.), and can manifest clinically as either cutaneous or en-US visceral forms of disease. Two genetic lineages exist that en-US correspond to either Old World infections (Asia, Middle en-US East, and Africa) or New World infections (Western en-US Hemisphere). While vector-borne transmission is most en-US common, anthroponotic transmission has occurred,en-US91en-US en-US heightening concern of this disease among our armed en-US forces personnel living in close quarters. While military en-US cases have not been reported, autochthonous leishmanien-US -en-US asis human cases have been reported from Oklahoma en-US and Texas,en-US92en-US implicating these states as possible transen-US -en-US mission risk areas for military operations and training. en-US Trench fever (en-US Bartonellaen-US en-US quintanaen-US Schmincke infecen-US -en-US tion) is transmitted by the human body louse (en-US Pediculusen-US en-US humanusen-US en-US humanusen-US Linnaeus), and manifests clinically en-US en-US or endocarditis.en-US93en-US While trench fever was historically a en-US major concern in World War I, it has yet to be reported en-US among contemporary service personnel; however, high en-US rates of infected body louse among American homeen-US -en-US less populationsen-US94en-US indicates a potential risk to military en-US personnel in contact with these populations, ie, those en-US serving in natural disaster response operations. Murine en-US typhus is a typhus group rickettsiosis transmitted by en-US en-US Xenopsyllaen-US en-US cheopisen-US en-US (en-US Ctenocephalidesen-US en-US felisen-US en-US en-US -en-US tosplenomegaly. Murine typhus is a reemerging disease en-US with geographic distribution in Hawaii,en-US95,96en-US Texas,en-US97en-US and en-US California.en-US98 DDISEa A SES OF F FUTURE CONc C ERN Should the disorder infect the Army, in the natural way, en-USand rage with its usual virulence, we should have more en-US to dread from it, than from the Sword of the Enemy.en-USLetter from General George Washingtonen-US en-US to the Continental Army Surgeon General,en-US en-US Dr William Shippen, February 6, 1777.en-US99en-USWhether engaging in stateside-based training activities, en-US traditional major combat operations, or humanitarian en-US en-US -en-US nel have always had to grapple with ubiquitous vector-en-US borne diseases which have rivaled bayonets, bullets, en-US missiles, and mortars throughout history as the causes en-US of morbidity, mortality, disability, and diminished open-US -en-US erational effectiveness. While certain diseases have lost en-US their military importance (yellow fever,en-US100en-US plague,en-US101en-US en-US and epidemic typhus,en-US102,103en-US), others remain of concern en-US (dengue fever,en-US102,104en-US leishmaniasis,en-US102,105-107en-US West Nile enen-US-en-US cephalitis,en-US108en-US and malariaen-US100,109en-US), and emerging diseases en-US have recently occurred (Zika virusen-US110en-US and chikungunya en-US feveren-US111en-US) that affect operational forces.en-US Leishmaniasis, characterized by the CDC as a neglecten-US -en-US ed tropical disease, persists as a pestilence of future en-US concern. The facts that the incidence of cutaneous leishen-US -en-US en-US and Afghanistan was substantial,en-US112en-US and it is endemic en-US in 88 countriesen-US113en-US are reasons to keep this condition on en-US military preventive medicines radar. Notably, there has en-US also been an upsurge of cutaneous leishmaniasis among en-US Syrian refugees in traditionally nonendemic locations,en-US114en-US en-US including Europe.en-US113,115en-US Furthermore, leishmaniasis has en-US en-US -en-US en-US116,117en-US complicating the ability to accuen-US -en-US rately identify origin of infection in returning military en-US personnel.en-US Mayaro virus, of the genus en-US Alphavirusen-US in the family Toen-US -en-US gaviridae, is a close relative of chikungunya that proen-US -en-US duces an analogous debilitating arthralgic disease in en-US South America. Mayaro could be endemic in regions en-US en-US symptoms it shares with other mosquito-borne viruses. en-US First isolated from febrile forest workers in Trinidad en-US in 1954,en-US118en-US the etiologic agent of Mayaro fever has been en-US en-US Bolivia, Brazil,en-US119en-US and Haiti.en-US120en-US The apparent primary en-US vectors, en-US Haemagogusen-US mosquitoes, inhabit rural seten-US -en-US tings, a reason that may justify the relative paucity of en-US cases and inhibited endemicity. Conversely, en-US Ae.en-US en-US aegyptien-US en-US mosquitoes have been shown to be competent vectors en-US of Mayaro virus,en-US121en-US signifying that an urban-dwelling en-US arthropod could potentially be a vector of this virus on

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96 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USa global scale. Because Mayaro virus symptoms can reen-US -en-US semble those of both chikungunya and dengue, it may en-US be underdiagnosed. While the Mayaro virus has not en-US been linked with fatal human disease like dengue, prien-US -en-US mary infections are often more debilitating, with loss en-US of productivity for weeks or even months due to severe en-US arthralgia.en-US Military preventive medicine personnel should also be en-US on guard for the Oropouche virus,en-US122en-US the Amazonian en-US cousin of the Mayaro virus, which is spread through en-US Culexen-US sp. mosquitos and en-US Culicoidesen-US en-US paraensisen-US Goeldi en-US midges.en-US123en-US Both vectors are known to have a broader en-US distributionen-US124en-US than the en-US Aedesen-US sp. mosquitoes that carry en-US Zika virus.en-US125en-US Lastly, Ross River virus, which was previen-US -en-US ously thought to be indigenous to Australia and Papua en-US New Guinea by sustaining itself in marsupials,en-US126en-US has en-US en-US of these new geographic regions suggest the potential en-US for further geographic expansion and global epidemic en-US potential. Collectively, these arboviral pathogens not en-US only infect people via enzootic spillover, but they use en-US en-US -en-US dous risk for urbanization.en-US127en-US The latest epidemic acen-US -en-US tivity of Zika and chikungunya should underscore the en-US en-US members returning from endemic areas and serve as a en-US caution that presumably obscure viruses like Mayaro en-US virus, Oropouche virus, and Ross River virus should en-US not be underestimated as potentially emerging human en-US pathogens. CONc C LUSION Vector-borne diseases have been an important cause of en-USmorbidity and mortality since the inception of our naen-US -en-US tion. In line with the general population, military and en-US civilian personnel acquire diseases while on stateside en-US military installations, active missions, and training exen-US -en-US ercises. Military personnel with occupational duties reen-US -en-US sulting in extended time outdoors are potentially at an en-US increased risk for VBD transmission. Development and en-US implementation of integrated vector management plans en-US can be useful tools to reduce vector exposure and transen-US -en-US mission risk during disease outbreaks, in endemic disen-US -en-US ease areas, or in the event of emerging VBDs. As identien-US -en-US en-US our military personnel routinely acquire a wide range en-US of VBDs spread through mosquitoes, ticks, triatomines, en-US en-US VBDs of greatest public health concern to serviceman en-US en-US -en-US ed States. Vector surveillance, insecticide applications, en-US and personal protection measures are warranted to preen-US -en-US vent future infections. AcC KNOWLEDGEm M ENT We thank LTC Brian Evans and COL Jaime Blow for en-UStheir contribution to the Armed Forces Pest Management en-US Board information in this article. 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Prelimien-US -en-US nary serologic investigation of Rickettsia amblyen-US -en-US ommii in the aetiology of Southern tick associen-US -en-US ated rash illness (STARI). en-US Clinen-US en-US Microbiolen-US en-US Infecten-US en-US 2009;15(suppl 2):235-236. 11. en-USCenters for Disease Control and Prevention. West en-US Nile virus disease cases and deaths reported to en-US CDC by year and clinical presentation, 1999-2015 en-US [internet]. 2016. Available at: https://www.cdc.gov/en-US westnile/resources/pdfs/data/1-wnv-disease-cases-en-US by-year_1999-2015_07072016.pdf. Accessed April en-US 7, 2017.en-USVECTOR-BORNE DISEASES OF PUBLIC HEALTH IMPORTANCE FOR PERSONNELen-US en-US ON MILITARY INSTALLATIONS IN THE UNITED STATES

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Suren-US -en-US vival analysis, long-term outcomes, and percentage en-US of recovery up to 8 years post-infection among the en-US Houston West Nile virus cohort. en-USPLoSen-US en-US Oneen-US 2014;9: en-US e102953. 17. en-USBarber LM, Schleier JJ, Peterson RKD. Economic en-US cost analysis of West Nile virus outbreak, Sacraen-US -en-US en-US Emergen-US en-US Inen-US -en-US fecten-US en-USDisen-US 2010;16:480-486. 18. en-USStaples JE, Shankar MB, Sejvar JJ, Meltzer MI, en-US Fischer M. Initial and long-term costs of patients en-US hospitalized with West Nile virus disease. en-US Amen-US en-US Jen-US en-US Tropen-US en-USMeden-US en-USHygen-US 2014;90:402-409. 19. en-USAmanna IJ, Slifka MK. Current trends in West en-US Nile virus vaccine development. en-US Experten-US en-US Reven-US en-US Vacen-US -en-US cinesen-US 2014;13:589-608. 20. en-USWitt CJ, Brundage M, Cannon C, et al. Department en-US of Defense West Nile virus surveillance in 2002. en-US Milen-US en-USMeden-US. 2004;169:421-428. 21. en-USStein KJ, Claborn DM. Telephonic survey of en-US surveillance and control procedures for the mosen-US -en-US quito vectors of West Nile virus near naval inen-US -en-US en-US Milen-US en-US Meden-US. en-US 2005;170:658-662. 22. en-USDefense Health Agency. West Nile fever in active en-US en-US -en-US ries 2006-2015 [internet]. 2016. Defense Medical en-US Surveillance System. Available at: https://health.en-US mil/Military-Health-Topics/Health-Readiness/en-US Armed-Forces-Health-Surveillance-Branch/en-US Data-Management-and-Technical-Support/en-US Defense-Medical-Surveillance-System. 23. en-USCenters for Disease Control and Prevention. Estien-US -en-US mated range of en-USAedes albopictusen-US and en-USAedes aegyptien-US en-US en-US -en-US ary 19, 2017. Available at: https://www.cdc.gov/en-US zika/vector/range.html. 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January June 2017 101 117. en-USDuprey ZH, Steurer FJ, Rooney JA, Kirchhoff en-US LV, Jackson JE, Rowton ED, Schantz PM. Canine en-US en-US 2000-2003. en-US Emergen-US en-USInfecten-US en-USDisen-US 2006;12:440-446. 118. en-USAnderson CR, Downs WG, Wattley GH, Ahin NW, en-US Reese AA. Mayaro virus: a new human disease en-US agent. II. Isolation from blood of patients in Trinien-US -en-US dad, B.W.I. en-USAmen-US en-USJen-US en-USTropen-US en-USMeden-US en-USHygen-US 1957;6:1012-1016. 119. en-USHalsey ES, Siles C, Guevara C, Vilcarromero S, en-US Jhonston EJ, Ramal C, Aguilar PV, Ampuero JS. en-US Mayaro virus infection, Amazon Basin region, Peru, en-US 2010-2013. en-USEmergen-US en-USInfecten-US en-USDisen-US 2013;19:1839-1842. 120. en-USLednicky J, De Rochars VM, Elbadry M, et al. en-US Mayaro virus in child with acute febrile illness, en-US Haiti, 2015. en-USEmergen-US en-USInfecten-US en-USDisen-US 2016;22:2000-2002. 121. en-USLong KC, Ziegler SA, Thangamani S, Hausser NL, en-US Kochel TJ, Higgs S, Tesh RB. Experimental transen-US -en-US mission of Mayaro virus by en-USAedesen-US en-US aegyptien-US en-US Amen-US en-US Jen-US en-US Tropen-US en-USMeden-US en-USHygen-US 2011;85:750-757. 122. en-USVasconcelos HB, Nunes MR, Casseb LM et al. Moen-US -en-US lecular epidemiology of Oropouche virus, Brazil. en-US Emergen-US en-USInfecten-US en-USDisen-US 2011;17:800-806. 123. en-USPinheiro FP, Travassos da Rosa AP, Gomes ML, en-US LeDuc JW, Hoch AL. Transmission of Oropouche en-US virus from man to hamster by the midge en-US Culicoidesen-US en-US paraensisen-US en-USScienceen-US 1982;215:1251-1253. 124. en-USWeaver SC, Reisen WK. Present and future arbovien-US -en-US ral threats. en-USAntiviralen-US en-USResen-US 2010;85:328-345. 125. en-USMusso D, Gubler DJ. Zika virus. en-US Clinen-US en-US Microbiolen-US en-US Reven-US 2016;29:487-524. 126. en-USKlapsing P, MacLean JD, Glaze S, McClean KL, en-US Drebot MA, Lanciotti RS, Campbell GL. Ross en-US River virus disease reemergence, Fiji, 2003-2004. en-US Emergen-US en-USInfecten-US en-USDisen-US 2005;11:613-615. 127. en-USen-US -en-US sion of zoonotic arboviral diseases: mechanisms en-US and potential strategies for prevention. en-USTrendsen-US en-US Mien-US -en-US crobiolen-US 2013;21:360-363. AUTHORS Dr Garcia is an Instructor at the National School of en-USTropical Medicine, Baylor College of Medicine, Houston, en-US Texas.en-US Dr Cropper is Director, Trainee Health Surveillance, en-US Joint Base San Antonio-Lackland, Texas.en-US Dr Gunter is a Postdoctoral Associate with the National en-US School of Tropical Medicine, Baylor College of Medien-US -en-US cine, Houston, Texas.en-US Dr Kramm is the Air Force Installations and Mission en-US Support Center Entomologist, Joint Base San Antonio-en-US Lackland, Texas.en-US Maj Pawlak is a Preventive Medicine Physician, 559th en-US Trainee Health Squadron, Wilford Hall Ambulatory Suren-US -en-US gical Center, Joint Base San Antonio-Lackland, Texas.en-US en-US -en-US lic Health Command-Central, Joint Base San Antonio-en-US Fort Sam Houston, Texas.en-US Dr Ronca is a Postdoctoral Associate with the National en-US School of Tropical Medicine, Baylor College of Medien-US -en-US cine, Houston, Texas.en-US Dr Stidham is an Epidemiologist with the Epidemiolen-US -en-US en-US Health Command-Central, Joint Base San Antonio-Fort en-US Sam Houston, Texas.en-US Maj Webber is the Preventive Medicine Element Chief, en-US 559th Trainee Health Squadron, Wilford Hall Ambulaen-US -en-US tory Surgical Center, Joint Base San Antonio-Lackland, en-US Texas.en-US Lt Col Yun is assigned to the Infectious Disease Service, en-US San Antonio Military Medical Center, JBSA-Fort Sam en-US Houston, Texas, and is the Director of the San Antonio en-US en-US -en-US fectious Disease Fellowship Program.

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en-US102 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspx TTRa A Uma MA TIc C B BRa A IN I INJURy Y IN THE U UNITED S STa A TES Traumatic brain injury (TBI) is a disruption in brain en-USfunction or pathology due to an external force that exen-US -en-US ceeds the protective capacity of the head and causes en-US neuropsychiatric impairment, either permanent or temen-US-en-US porary. Complications of TBI include seizures, spasticen-US -en-US ity, gait abnormalities, agitation, depression, headaches, en-US insomnia, cognitive decline, dementia, gastrointestinal en-US and urogenital complications, and chronic traumatic enen-US-en-US en-US million people suffer a TBI annually, of which 275,000 en-US require hospitalization.en-US1 en-USFalls and motor vehicle accien-US -en-US en-US1en-US en-US Traumatic brain injury is a leading cause of death and en-US disability for individuals between the ages of one and en-US 44 years, and it is estimated that almost 2% of the popuen-US -en-US lation currently live with complications and disabilities en-US related to a prior TBI.en-US2 TTRa A Uma MA TIc C B BRa A IN I INJURy Y IN THE US US MILITa A Ry Y Traumatic brain injury is a major health concern for the en-USen-US -en-US en-US there have been a higher proportion of explosive-related en-US head injuries in comparison to previous wars.en-US3,4en-US Data en-US from Operation Enduring Freedom, Operation Iraqi en-US Freedom, and Operation New Dawn show that blast-en-US related injuries are a major cause of TBI for military en-US troops.en-US5en-US As illustrated in the Figure, from 2000-2016, en-US there were 357,048 medical diagnoses of traumatic brain en-US en-US en-US6en-US A mild TBI is characterized by en-US the Department of Defense as a confused or disoriented en-US state that lasts less than 24 hours; or loss of consciousen-US -en-US ness for up to 30 minutes; or memory loss lasting less en-US en-US often a lack of any external evidence of damage to the en-US head. A CT scan is generally not indicated for these paen-US-en-US tients, and if obtained, is often found to be normal.en-US6en-US Curen-US -en-US en-US -en-US ing studies that are routinely performed that can detect en-US any long-lasting damage to these patients.en-US7en-US Due to the en-US en-US more mild TBIs that remain undiagnosed in the military. TTRa A Uma MA TIc C B BRa A IN I INJURy Y aA ND aA H HISTORy Y OF NNEUROp P Syc YC HIa A TRIc C D DyY SFUNc C TION IN W WaA R: S SHELL SSHOc C K, POSTTRa A Uma MA TIc C S STRESS D DISORDER, aA ND DDEm M ENTIa A The development of neuropsychiatric symptoms in mili en-US-en-US tary veterans exposed to high-intensity explosives has en-US been recognized since World War I (WWI). Military en-US troops involved in trench warfare were often barraged en-US with artillery, with many Soldiers developing the neuen-US -en-US ropsychological impairment known as shell shock.en-US8,9en-US en-US Symptoms of shell shock included fatigue, confusion, en-US nightmares and impaired sight or hearing. Soldiers were en-US often diagnosed once they became unable to function/en-US perform their duties, usually without any obvious cause en-US en-US physical signs of disease, they were often accused of en-US cowardice or malingering. It was later recognized that en-USBlast-Associated Traumatic Brain Injury in theen-US en-US Military as a Potential Trigger for Dementiaen-US en-US and Chronic Traumatic Encephalopathy J amal Hasoon, MD ABSTRac AC T en-US-en-US nel throughout the world, particularly in Iraq and Afghanistan. From 2000-2016, more than 350,000 military en-US en-US en-US en-US military. Traumatic brain injury is a serious public health concern since it can lead to long-term neuropsychien-US -en-US atric changes such as posttraumatic stress disorder and various forms of dementia. Blast-related TBI has also en-US been linked with neuropsychiatric dysfunction that is commonly seen in athletes that have suffered chronic en-US traumatic encephalopathy. Further research is needed to aid in prevention, diagnostic studies, and care of milien-US -en-US tary service members and veterans who have suffered a TBI.

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en-USJanuary June 2017 en-US103en-USshell shock shared similar symptoms to posttraumatic en-US stress disorder (PTSD), which would later be recogen-US -en-US nized during the Vietnam War.en-US en-US there has been more insight into the neuropsychologien-US -en-US cal dysfunction of military personnel who suffer from en-US PTSD. Similar to the shell shock observed in WWI, en-US en-US -en-US backs during trauma-related cues, cognitive and behaven-US -en-US ioral changes, depression, anxiety, and a higher risk of en-US suicide. Although there is tremendous overlap between en-US PTSD and shell shock in several ways, it is important to en-US acknowledge that patients can also develop PTSD withen-US -en-US out evidence of TBI or head trauma. Examples include en-US victims of rape, natural disaster survivors, or individuals en-US who have suffered severe psychological stressors. Howen-US -en-US ever, evidence shows a TBI alone can be a potential trigen-US -en-US en-US -en-US try Soldiers deployed to Iraq for one year demonstrated en-US that 44% of Soldiers who suffered a mild TBI with suben-US -en-US sequent loss of consciousness met the criteria for PTSD.en-US10en-US en-US Another study found blast-related injuries on mice under en-US anesthesia produced PTSD behavioral changes in the en-US absence of psychological stressors.en-US11en-US Traumatic brain en-US injury appears to be a very strong risk factor for the en-US development of PTSD. It is also very likely that the maen-US-en-US jority of Soldiers who suffered from shell shock in WWI en-US en-US Traumatic brain injury has also been recognized as a poen-US -en-US tential risk factor for the development of dementia and en-US neurodegeneration.en-US12en-US Individuals who suffer from deen-US -en-US mentia typically demonstrate a decline in cognitive abilen-US -en-US ity that is often severe enough to interfere with daily life. en-US These individuals may demonstrate memory loss, cogen-US -en-US nitive decline, and behavioral or psychological changes. en-US en-US -en-US talized during WWII demonstrated an association been-US -en-US tween TBI in early to midlife with the development of en-US dementia later in life.en-US13en-US Veterans who sustained a TBI en-US that resulted in loss of consciousness or posttraumatic en-US amnesia longer than 30 minutes but less than 24 hours en-US were more than twice as likely to develop dementia.en-US13en-US en-US Veterans who sustained a TBI severe enough to cause en-US loss of consciousness or posttraumatic amnesia greater en-US than 24 hours were more than 4 times likely to develop en-US dementia compared to the control counterparts.en-US13en-US These en-US en-US may manifest much later in life, and our veterans may en-US actually have a higher risk of developing dementia comen-US -en-US pared to the civilian population.en-US THE ARMY MEDICAL DEPARTMENT JOURNAL

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en-US104 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspx TTRa A Uma MA TIc C B BRa A IN I INJURy Y aA ND CHRONIc C T TRa A Uma MA TIc C EENc C Ep P Ha A LOpa PA THy Y Chronic traumatic encephalopathy (CTE) is a neurode en-US-en-US generative disease that is thought to develop secondary en-US to repetitive head trauma, including concussive and suben-US -en-US concussive injuries. The clinical presentation of CTE en-US varies, and often overlaps with other neuropsychologien-US -en-US cal disorders including Alzheimers, Parkinsons, and en-US PTSD. Patients with CTE often exhibit both cognitive en-US and behavioral impairment including chronic headen-US -en-US en-US -en-US sion, depression, suicidal tendencies, and also demenen-US -en-US tia.en-US14,15en-US Behavioral changes are typically seen earlier in en-US the disease, and these patients may often be diagnosed en-US with PTSD. Later in the disease process, patients show en-US symptoms such as memory loss and cognitive decline en-US consistent with dementia.en-US Chronic traumatic encephalopathy is a newly recogen-US -en-US en-US -en-US en-US postmortem. It is often regarded as a disease that deen-US -en-US velops from repetitive head trauma in athletes, such en-US as football players and wrestlers, who suffer multiple en-US concussive injuries. However, new data suggests milien-US -en-US tary personnel may be at risk for developing CTE, and en-US en-US the neuropathologic changes seen in CTE.en-US16en-US Brain paen-US -en-US thology of postmortem athletes who have suffered reen-US -en-US petitive concussive injuries have demonstrated distinct en-US neuropathologic changes that differentiate CTE from en-US other known forms of dementia.en-US15-17en-US Comparison of en-US brains from postmortem military veterans exposed to en-US blast injuries demonstrated neuropathology that was en-US indistinguishable from the neuropathology of young en-US athletes with CTE.en-US16en-US Furthermore, experiments on roen-US -en-US dents exposed to an isolated blast-related injury demonen-US -en-US strated neuropathology similar to that of patients found en-US to have CTE from repetitive head trauma.en-US16 en-USThis study en-US in rodents also showed that TBI from blast-related head en-US injuries resulted in progressive neurodegeneration that en-US continued for more than one year after the initial injury. en-US These studies demonstrate that isolated blast-associated en-US TBIs could trigger the development of CTE-like sympen-US -en-US toms and neuropathology.en-US16 COmm MM ENT Traumatic brain injury is a serious public health con en-US-en-US en-US our military troops have a greater risk of TBIs due to en-US the increased use of improvised explosive devices and en-US subsequent blast-related injuries. Evidence shows that a en-US mild TBI is a risk factor for developing long-term neuen-US -en-US ropsychiatric conditions such as PTSD, dementia, and en-USeven CTE. Since CTE is a newly discovered disease that en-US en-US be overlooked as a differential diagnosis and mistaken en-US for other neuropsychiatric diseases. Chronic traumatic en-US encephalopathy should be considered in patients that en-US have a previous history of a TBI and are being evaluen-US -en-US ated for a neuropsychiatric disorder. Furthermore, the en-US diagnosis of CTE may better explain the development of en-US symptoms in veterans found to have shell shock, PTSD, en-US or other forms of dementia. Any patient with a history en-US of TBI should be counseled and closely followed to enen-US -en-US sure appropriate care and social support. With increasen-US -en-US ing awareness that military service members are at risk en-US for TBI-related neurodegenerative diseases, further reen-US -en-US search into diagnostic studies, preventive strategies, and en-US eventually therapeutic interventions is essential for the en-US wellbeing of our veterans. RREFERENc C ES 1. en-USFaul M, Xu L, Wald MW, Coronado VG. en-US Taumaticen-US en-US Brainen-US en-US Injuryen-US en-US inen-US en-US theen-US en-US Uniteden-US en-US States:en-US en-US Emergencyen-US en-US Deen-US -en-US partmenten-US en-US Visits,en-US en-US Hospitalization,en-US en-US anden-US en-US Deathsen-US en-US 2002-en-US 2006en-US Atlanta, GA: Centers for Disease Control en-US and Prevention, National Center for Injury Prevenen-US -en-US tion and Control; 2010. Available at: https://www.en-US cdc.gov/traumaticbraininjury/pdf/blue_book.pdf. en-US Accessed April 14, 2017. 2. en-USCicerone KD, Kalmar K. Persistent post-concusen-US -en-US sive syndrome: structure of subjective complaints en-US after mild traumatic brain injury. en-USTheen-US en-US Journalen-US en-US ofen-US en-US Headen-US en-USTraumaen-US en-USRehabilitationen-US 1995;10(3):1-18. 3. en-USOwens BD, Kragh JF Jr, Wenke JC, Macaitis J, en-US Wade CE, Holcomb JB. Combat wounds in Operaen-US -en-US tion Iraqi Freedom and Operation Enduring Freeen-US -en-US dom. en-USJen-US en-USTraumaen-US 2008;64:295-299. 4. en-USen-US Mild traumatic brain injury screening and evaluaen-US -en-US tion implemented for OEF/OIF Veterans, but chalen-US -en-US lenges remain. February 2008 [internet]. Availen-US -en-US able at: https://digital.library.unt.edu/ark:/67531/en-US metadc302992/m1/1/. Accessed April 14, 2017. 5. en-USWojcik BE, Stein CR, Bagg K, Humphrey RJ, en-US Orosco J. Traumatic brain injury hospitalizations en-US en-US Iraq. en-USAmen-US en-USJen-US en-USPreven-US en-USMeden-US. 2010;38(suppl):S108-S116. 6. en-USDefense and Veterans Brain Injury Center. DoD en-US Worldwide Numbers for TBI [internet]. 2016. en-US Available at: http://dvbic.dcoe.mil/dod-worldwide-en-US numbers-tbi. Accessed April 14, 2017. 7. en-USMac Donald CL, Johnson AM, Cooper D, et en-US al. Detection of blast-related traumatic brain inen-US -en-US en-US Nen-US en-US Englen-US en-US Jen-US en-US Meden-US. en-US 2011;364(22):2091-2100.en-USBLAST-ASSOCIATED TRAUMATIC BRAIN INJURY IN THE MILITARY AS A POTENTIAL TRIGGER FORen-US en-US DEMENTIA AND CHRONIC TRAUMATIC ENCEPHALOPATHY

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en-USJanuary June 2017 en-US105 8. en-USMott FW. The effects of high explosives en-US upon the central nervous system, II. en-US Lanceten-US en-US 1916;4826:441-449. 9. en-USMott FW. The effects of high explosives en-US upon the central nervous system, III. en-US Lanceten-US en-US 1916;4828:545-553. 10. en-USHoge CW, McGurk D, Thomas JL, Cox AL, Enen-US -en-US gel CC, Castro CA. Mild traumatic brain injury en-US en-US Nen-US en-US Englen-US en-US Jen-US en-US Meden-US. en-US 2008;358:453-463. 11. en-USElder GA, Dorr NP, De Gasperi R, et al. Blast expoen-US -en-US sure induces post-traumatic stress disorder-related en-US traits in a rat model of mild traumatic brain injury. en-US Jen-US en-USNeurotraumaen-US 2012;29:2564-2575. 12. en-USFleminger S, Oliver DL, Lovestone S, Rabe-Hesen-US -en-US keth S, Giora A. Head injury as a risk factor for en-US Alzheimers disease: the evidence 10 years on; a en-US partial replication. en-USJen-US en-US Neurolen-US en-US Neurosurgen-US en-US Psychiatryen-US en-US 2003;74:857-862. 13. en-USPlassman BL, Havlik RJ, Steffens DC, et al. Docuen-US -en-US mented head injury in early adulthood and risk of en-US Alzheimers disease and other dementias. en-US Neurolen-US -en-US ogyen-US 2000;55:1158-1166. 14. en-USStern RA, Daneshvar DH, Baugh CM, et al. Clinien-US -en-US en-US chronic traumatic encephalopathy in athletes. en-USNeuen-US -en-US rologyen-US 2013;81:1122-1129. 15. en-USBaugh CM, Stamm JM, Riley DO, et al. Chronen-US -en-US ic traumatic encephalopathy: neurodegeneraen-US -en-US tion following repetitive concussive and suben-US -en-US concussive brain trauma. en-US Brainen-US en-US Imagingen-US en-US Behaven-US en-US 2012;6:244-254. 16. en-USGoldstein LE, Fisher AM, Tagge CA, et al. Chronen-US -en-US ic traumatic encephalopathy in blast-exposed en-US military veterans and a blast neurotrauma mouse en-US model. en-US Scien-US en-US Translen-US en-US Meden-US. 2012;4(134):134ra60. en-US Available at: https://doi.org/10.1126/scitranslen-US en-US med.3003716. Accessed April 14, 2017. DOI: en-US 10.1126/scitranslmed.3003716. 17. en-USGavett BE, Stern RA, McKee AC. Chronic trauen-US -en-US matic encephalopathy: a potential late effect of en-US sport-related concussive and subconcussive head en-US trauma. en-USClinen-US en-USSportsen-US en-USMeden-US. 2011;30(1):179-188. AUTHOR Dr Hasoon is a resident physician in the Department of en-USAnesthesiology at the Baylor College of Medicine, Housen-US -en-US ton, Texas.

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en-US106 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USWhen service members return to their normal routines en-US following the end of a war, some of them develop illen-US -en-US nesses. These may be associated with heredity, personal en-US risk factors such as smoking, normal aging, or the result en-US of their occupational exposures. When someone develen-US -en-US ops a serious illness, it is common for them to review en-US their past to look for a potential cause. This is human en-US nature and part of the why did this happen to me? asen-US -en-US sessment. For many, their military deployments are likeen-US -en-US ly to be considered. Deployments represent changes to en-US routines such as eating and sleeping and lack of control en-US over daily life, and may also include changes in hygiene en-US and unpleasant exposures to things such as trash burnen-US-en-US ing; old, abandoned warehouses and industrial sites; and en-US sources of radiation. For many, a deployment may be the en-US most unusual and noteworthy experience in their memen-US -en-US ory. Therefore, it is not uncommon for returning service en-US members to ask their health care providers whether or en-US not the deployment was a factor in their illness. Associaen-US -en-US tions between exposures to burning trash, blowing sand en-US (particulate matter), old chemical weapons, and subseen-US -en-US quent illnesses have been considered following Operaen-US -en-US tions Iraqi Freedom, Enduring Freedom, and New Dawn. en-US Generally, few clear associations have emerged. The en-US challenges of practicing environmental epidemiology in en-US AppPP ROac AC HES IN E ENVIRONm M ENTa A L E EpP IDEm M IOLOGy Y Epidemiological studies may be conducted to assess en-USpotential relationships between exposures during deen-US -en-US ployment and health outcomes. en-US Epidemiologyen-US en-US en-US with disease and development of public health measures en-US for disease reduction. en-US Environmental epidemiologyen-US is en-US the study of the effect on human health of physical, bioen-US -en-US logic, and chemical factors in the external environment, en-US broadly conceived.en-US1en-US It examines associations between en-US exposures and outcomes to determine if an association en-US places a segment of the population at increased risk of en-US certain outcomes, usually a disease. The magnitude of en-US the association measures how much increased risk of an en-US outcome can be associated with the exposure. Avoidance en-US of the exposure should then result in a proportionally en-US lowered risk for the outcome. Thus, one aim of public en-US health is to optimize health by limiting hazardous expoen-US -en-US sures. There are several different types of studies which en-US may be conducted, the selection of which depends on en-US the study question(s) being addressed, the frequency of en-US the exposure(s), and outcome(s) of interest, as well as en-US the expected strength of association between them, the en-US current state of knowledge related to the topic at hand, en-US en-US practicality and ethical considerations.en-USCross-sectional Studiesen-USA cross-sectional studyen-US en-US attempts to assess exposure and en-US outcome at the same time. It provides a snapshot view en-US (cross-section) of disease patterns in the population of en-US interest while assessing the degree of presumed or docuen-US -en-US mented exposure.en-US2en-USen-US study is that the snapshot captures only one moment in en-US time, and by looking at exposure and outcome at the same en-US time, it is not always possible to say with certainty that en-US the exposure en-USprecededen-US the outcome. This is a noteworthy en-US limitation of cross-sectional studies due to the fact that in en-US order to draw conclusions about exposure-outcome cauen-US -en-US en-US -en-US rect temporal sequencing. Also, because cross-sectional en-US studies are a snapshot, cases of illness can be counted en-US only if present at the time of the look, which presents en-US another disadvantage of this study design: it tends to en-US identify prevalent cases of long duration and may miss en-US capturing individuals who are lost to follow-up shorten-US -en-US ly after the outcome is established or acute outcomes en-US among individuals who recover quickly. Advantages of en-US cross-sectional studies include high generalizability and en-US minimal resource requirements, relatively speaking, due en-US to the fact that they can be conducted quickly.en-US An example of a cross-sectional study would be testing en-US pulmonary function in service members exposed to paren-US -en-US ticulate matter levels in the desert at the time of exposure. en-US The aforementioned limitation would be highlighted if a en-US unit demonstrated some impairment in pulmonary funcen-US -en-US tion, as it would not be possible to say for certain that it en-US was due to in-theater particulate matter exposure. It is en-USChallenges of Practicing Environmentalen-US en-US Epidemiology in the US Military C oleen Baird, MD, MPH J essica Sharkey, MPH J oel Gaydos, MD, MPH

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en-USJanuary June 2017 en-US107en-USpossible that some unit members had another type of en-US en-US -en-US monary function. Individuals who were so affected that en-US they had been evacuated from theater, or who were not en-US onsite at the time of the testing would not be included.en-USCohort Studiesen-USCohort studies assemble an exposed group and an unexen-US -en-US posed group, follow them forward in time for the occuren-US -en-US rence of health effects, and compare the rates in the 2 en-US groups. This study type is suitable when the at-risk popen-US -en-US en-US en-US en-US easy to identify the exposed versus the unexposed. The en-US advantages of this method are that accurate measures of en-US exposure are possible before the outcome occurs, and en-US that multiple outcomes can be monitored. A source of en-US bias in these studies is that the knowledge of exposure en-US status may alter the follow-up and subsequent diagnosis. en-US Other limitations include the fact that many years may en-US pass between exposure and outcome, which makes the en-US study costly, increases the likelihood of losing people to en-US follow-up, and is particularly impractical when looking en-US at rare diseases or diseases with long latency periods, en-US such as cancer. An unexposed population is used to proen-US -en-US vide a comparison rate for the health effects of interest. en-US However, it is critical that the exposed and unexposed en-US populations differ only with respect to exposure status, en-US something that is not always easily accomplished. To alen-US -en-US leviate some of the limitations, en-USnonconcurrenten-US or en-USretroen-US -en-US spectiveen-US en-US cohorten-US studies are often performed. This type en-US of study reconstructs exposed and unexposed groups en-US based on exposure in the past. These groups are then en-US compared with respect to the rate of the outcomes of en-US interest. The chief advantage is that since exposure ocen-US -en-US en-US develop may have already passed. The disadvantage ocen-US -en-US en-US occurrence.en-US3en-US For example, to study the effects of burn en-US pit exposure on the respiratory system, health outcomes en-US en-US with burn pits were compared to individuals who were en-US at base camps without burn pits. One key limitation was en-US that exposures associated with the burn pits had not en-US been well characterized.en-US4en-USCase-control Studiesen-USThe case-control method consists of identifying people en-US with the disease of interest (cases), and people without en-US the disease (controls). The unknown variable to be asen-US -en-US certained is the type, frequency, and duration of past en-US exposure(s). Critical to the validity of a case-control en-US study is careful selection of controls, in that they come en-US from the same population as the cases and exposed and en-US unexposed controls have the same likelihood of been-US -en-US ing selected for inclusion.en-US5en-US This type of study is useful en-US en-US the disease is rare and the exposure common, and alen-US -en-US though only one disease can be investigated at a time, en-US multipleen-US risk factors can be assessed. The major weaken-US -en-US ness of this method is that exposure is investigated en-US after disease status is established. This leads to recall en-US bias, where those who are diseased are more likely to en-US remember and report exposures than are those in good en-US health. Furthermore, accuracy can be particularly chalen-US -en-US lenging when conducting case-control studies due to the en-US fact that relevant exposures may have occurred many en-US en-US en-US association between deployment and the development en-US en-US cancer cases with controls who have no such diagnosis. en-US The main variable to be assessed would be whether or en-US not the cases had a stronger history of deployment. FFacAC TORS W WHIc C H AFFEc C T THE S SUcc CC ESS OF S STUDIES Given that these study designs each have strengths and en-USweaknesses, other factors affect the ability of any given en-US study to accomplish what it sets out to dosupport or en-US refute an association between an exposure and an outen-US -en-US en-US environmental epidemiology studies. Illustrating this en-US en-US Institute of Medicine (IOM) to form a committee, its en-US main charge being a determination of the association en-US between exposure to burn pits during deployment in en-US support of Operations Enduring and Iraqi Freedom and en-US subsequent long-term health effects.en-US6en-US en-US Although the IOM en-US en-US -en-US mittees conclusions regarding feasibility and design en-US en-US the major challenges of any epidemiologic study to be en-US both exposure assessment and outcome ascertainment. en-US Regardless of type of study selected, the committee reen-US -en-US iterated the elements characteristic of any well-designed en-US epidemiological study, including selection of a relevant en-US study population of adequate size, comprehensive asen-US -en-US sessment of exposure, careful evaluation of health outen-US -en-US comes, reasonable methods for controlling confounding en-US and minimizing bias, appropriate statistical analyses, en-US and adequate follow-up time.en-USMagnitude of the Disease Risken-USIf an exposure is strongly associated with an outcome, en-US following a group of people who are exposed and comen-US-en-US paring their incidence of illness with that of a group en-US without the exposure allows one to calculate the excess en-US THE ARMY MEDICAL DEPARTMENT JOURNAL

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en-US108 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USrisk which can be attributed to the exposure. This is the en-US cohort study design. For example, nonsmoking physien-US -en-US cians in England were compared with smoking physien-US -en-US cians, and followed over time to count the number of en-US lung cancers in each group. It became clear that cigaen-US -en-US rette smoking was associated with a risk of lung cancer, en-US perhaps 10 times greater than that seen in nonsmokers.en-US7en-US en-US In this study design, accurate information about the en-US magnitude of exposure is collected for all individuals en-US and all individuals should be followed for a period of en-US en-US .en-US If an exen-US -en-US posure produces a risk which is 4, 5, or even 10 times en-US greater than in people without the exposure, it is relaen-US -en-US tively straightforward to sort this out and quantify the en-US risk. In contrast, lung cancer risk from passive smoke en-US exposure is thought to be elevated to less than 2 times en-US that of nonexposed individuals.en-US8en-US This small difference en-US en-US with only a slightly elevated risk, that risk sometimes en-US blurs into the baseline upon investigation. This is due en-US to the fact that in order to detect a slightly elevated risk, en-US one must be able to distinguish it from the baseline, or en-US usual incidence of the outcome without any exposure. en-US This is the role of control groups. However, small risks en-US require that the studies include large numbers of people en-US en-US large numbers of service members deployed in the most en-US en-US be if the outcome is particularly rare. Typically, the inen-US-en-US creased risk associated with environmental exposures en-US is estimated to be small. It has been estimated that the en-US probable range of increased risk for an outcome due to en-US chronic, low level exposure is less than 2 times that of en-US someone without the exposure.en-US8en-US This has implications en-US for the number of people necessary in each group in oren-US -en-US der to detect a difference. This is especially so when en-US competing exposures such as smoking may lead to a en-US much higher elevation of risk, so the role of smoking en-US would have to be thoroughly assessed.en-USMagnitude of the Exposureen-USDetection of effects associated with exposure is also en-US en-US is great. Excess numbers of leukemias were easily deen-US -en-US tected following the exposure to radiation from atomic en-US bombs dropped on Hiroshima and Nagasaki because en-US the magnitude of exposure was so large.en-US9en-US High doses of en-US radiation are strongly associated with leukemia as an en-US outcome. In contrast, environmental exposures are clasen-US -en-US sically smalldoses lower than those known to produce en-US effects in animal studies. Often the exposures may be en-US chronic low-level exposures, occurring over weeks or en-US en-US they were not recognized.en-US10en-US Although some studies ask en-US individuals about whether or not they were exposed, they en-US do not always know. This can lead to en-US en-US biasen-US en-US-en-US en-US causal interpretations about their outcomes. One study en-US evaluated health outcomes for service members who en-US en-US for several weeks in Iraq.en-US11en-US The exposed group includen-US -en-US ed individuals within a 50 km radius of the site, based on en-US satellite images of the plume and rosters of units in the en-US area. However, some individuals may not have been presen-US -en-US en-USDose-response Relationshipen-USAn axiom of toxicology states, The dose makes the en-US poison. The implication of this is that the larger the en-US dose, the larger the effect. Associations between expoen-US -en-US sures and outcomes are strengthened when this relationen-US -en-US ship can be shown to be logical and uniform. This does en-US not necessarily mean that the greater the exposure, the en-US sicker the individual, but that more outcomes (eg, more en-US cases of cancer) occur in the higher exposure groups as en-US compared with those less exposed. For example, more en-US lung cancers would be expected in groups of individuen-US -en-US als who smoke 3 packs of cigarettes a day for 20 years en-US versus one pack a day for 5 years. This introduces again en-US the requirement for accurate, quantitative exposure data. en-US en-US -en-US posures in deployed settings. For example, the study en-US looking at health outcomes associated with having deen-US -en-US ployed to a base camp with a burn pit was reviewed en-US by the IOM for their report, Long Term Health Conseen-US -en-US quences of Exposure to Burn Pits in Iraq and Afghanien-US -en-US stan.en-US4en-US One of their criticisms was that the study did not en-US identify those with the highest exposures, such as those en-US who guarded the burn pits, compared to those with lessen-US -en-US er exposures.en-US6en-US However, this information on individuals en-US was not available. In another example, the study of the en-US health outcomes associated with those who were under en-US en-US en-UStinguish individuals who were at locations with higher en-US levels of exposure versus those at locations which were en-US en-US11en-US This is because the inforen-US -en-US mation on exact daily locations of individuals was not en-US available. Efforts must be made to accurately measure en-US en-US -en-US cient sampling capabilities at the location of an expoen-US -en-US sure, particularly an unplanned one, is a daunting task.en-USControlling for Confoundingen-USConfounding occurs when an association between exen-US -en-US posure and outcome is over or underestimated due to a en-US third factor. It is best explained by example. Studies have en-US shown that smoking causes an increase in pancreatic en-US CHALLENGES OF PRACTICING ENVIRONMENTAL EPIDEMIOLOGY IN THE US MILITARY

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en-USJanuary June 2017 en-US109 en-UScancer. An investigator attempted to ascertain the reen-US -en-US lationship between coffee consumption and pancreatic en-US cancer. He questioned cases with cancer and controls en-US about coffee consumption and found that cases had a en-US greater history of exposure to coffee. He concluded that en-US coffee consumption was associated with an increased en-US risk of pancreatic cancer. Critics challenged his conen-US -en-US clusion by pointing out that those who drink coffee are en-US more likely to smoke as well, and that by not questioning en-US subjects about smoking behaviors and adjusting for it, he en-US was in effect seeing the association between cigarettes en-US and pancreatic cancer, not coffee and pancreatic canen-US -en-US cer.en-US12en-US Cigarette smoking, the unmeasured true risk exen-US -en-US posure, was the confounder. In many studies of deployen-US -en-US ment and health outcomes, individual smoking status is en-US unavailable. Furthermore, the rate of smoking has been en-US shown to increase on deployments. Since outcomes such en-US as respiratory conditions and cancer are strongly associen-US -en-US ated with smoking, it is an important variable to consider.en-USLatency Perioden-USThe job of the epidemiologist is easier when the time en-US from exposure to outcome is short. This time is called en-US the latent period. An exposure to high levels of chloen-US -en-US rine gas leads quite quickly to respiratory distress. Inen-US -en-US ferring the association between exposure and outcome en-US is relatively clear. The same is true in that exposure to en-US someone with measles is quickly followed by measles en-US in a susceptible person, and ingestion of contaminated en-US food quickly leads to gastrointestinal illness in those en-US who ingest it. An outbreak or cluster of outcomes is en-US en-US -en-US ciations ensue.en-US en-US conditions are not met. Cancer outcomes typically have en-US latent periods on the order of decades. This presents en-US en-US forgotten because it does not lead to an acute outcome; en-US en-US may have elapsed that the individual no longer recalls en-US the exposure, or that the past dose or magnitude of the en-US exposure can only be estimated by memory.en-US10en-US This, as en-US mentioned, leads to recall bias.en-USSpecificity of the Health Effecten-USPhocomelia, the congenital absence of the proximal part en-US of a limb, is an uncommon defect in infants. When inen-US -en-US fants were seen to have this defect in greater than exen-US -en-US pected numbers, mothers were questioned about the use en-US of medications during pregnancy. It became apparent en-US that infants with the defect were more likely to be born en-US to women who had taken Thalidomide, compared with en-US women who had not.en-US13en-US In this instance, the outcome was en-US en-US these mothers to compare with mothers who had noren-US -en-US mal outcomes, and compare their prenatal exposures. en-US Another classic example was when occupational health en-US physicians noticed an increased incidence of an unusual en-US liver cancer called angiosarcoma in certain workers and en-US determined that they had an increased history of expoen-US -en-US sure to vinyl chloride. The key was that the outcome was en-US one with few other causes. Legionnaires disease was en-US discovered and described because an unusual pneumoen-US -en-US nia developed with high frequency in a group of men at en-US a convention in a single hotel, and was linked to the air en-US conditioning system.en-US14en-US Hantavirus illness in the southen-US -en-US en-US -en-US cian became alarmed that 2 cases of fatal respiratory illen-US -en-US ness occurred one week apart. Suspicion was raised that en-US there was some common exposure.en-US15en-USWhen the effect of a low-level hazardous exposure is en-US en-US effects from varied causes to the exposure. Individuals en-US who have registered for the burn pit registry have reen-US -en-US ported diverse medical conditions.en-US16en-US This is likely been-US -en-US cause they are reporting all health conditions that they en-US en-US to determine which effects might be associated with an en-US exposure. The lack of a comparison group made it difen-US -en-US en-US redeployed service members who were veterans of the en-US en-US health effects resulting from their exposures in 1991.en-US17en-USEvaluating the relationship between health effects that en-US en-US -en-US sures can also be challenging. Exposures to solvents, en-US which are metabolized in the liver, can lead to elevaen-US -en-US tions of liver enzymes in the blood, but so can a host of en-US other chemicals including alcohol and acetaminophen en-US (en-US confoundingen-US ). Respiratory symptoms may follow exen-US -en-US posure to burn pit smoke, dust storms, or other factors. en-US The investigations which attempt to relate exposures to en-US effects must take into account other possible exposures en-US and question the individuals about these and control for en-US these in the data analysis. MEa A SUREm M ENT OF H HEa A LTH E EFFEc C T When studying health effects, it is important to consider en-UShow the effect is measured. In some studies, health efen-US -en-US fects were measured as symptoms reported by the study en-US participants. en-US Reporting biasen-US may occur when people en-US with concerns report their symptoms.en-US1en-US Studies which en-US use databases that report disease by diagnostic codes are en-US subject to problems with miscoding. Analyses of healthen-US -en-US care encounter diagnostic codes following redeployment

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110 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USare subject to unique limitations. For example, acute en-US changes in health status during deployment due to exen-US -en-US posures in theater could be missed. Likewise, changes en-US in health status that occur over the long-term could be en-US delayed beyond the available follow-up period and are en-US therefore unobservable. This would be demonstrated, en-US and particularly problematic, in evaluations of cancers en-US en-US -en-US en-US positives, capturing as cases those individuals for whom en-US health care providers entered codes for conditions that en-US en-USMultiple Hypothesis Testingen-USSince health effects are not always known, a common en-US strategy employed in investigations is to question paen-US -en-US tients about multiple health effects. Questionnaires may en-US ask about respiratory symptoms, gastrointestinal sympen-US -en-US en-US en-US -en-US cantly high disease rate due to chance alone. Statistical en-US rules for study precision generally allow for 5% error en-US due to chance. This means that if 100 symptoms were en-US asked about, 5 of the 100 could appear to be increased en-US due to chance alone.en-US3en-USPower and Sample Sizeen-USThe power of a study is its statistical ability to detect en-US a difference between 2 groups if it truly exists (for exen-US -en-US ample, an elevated cancer rate) between the exposed and en-US the unexposed. The power of a study is intimately reen-US -en-US lated to the sample size, which is the number of people en-US in each of the 2 groups. It is also related to the prevaen-US -en-US lence of the disease of interest in the population. In oren-US -en-US en-US cancer in relatively young populations, are studied using en-US a case-control approach, or require large populations. en-US More common diseases can be studied in smaller popuen-US -en-US lations. However, to the extent that multiple causes (or en-US exposures) are involved, as they are with most chronic en-US diseases, larger populations are generally required in oren-US -en-US en-US -en-US en-US and the assessment of exposure can improve the power en-US of a study to detect an association. CONc C LUSIONS Some situations lend themselves to an epidemiologic in en-US-en-US vestigation of the strength of association. The strength en-US of an association, while not proof of causation between en-US en-US the two may be related. These situations occur when the en-US exposure is large and leads to a greatly increased risk of en-US en-USbefore the outcome, and ideally, the outcome follows en-US soon after the exposure. Ideally, current and past expoen-US -en-US en-US en-US generated. An accurate assessment of adverse health en-US effects in exposed and unexposed populations would en-US be made, and account would be taken of all potential en-US confounders. The sample size would be adequate, and en-US irrelevant hypothesis would not be included. Because en-US all studies have limitations, these conditions are never en-US achieved. However, practitioners of military preventive en-US medicine must continue to work to quickly identify poen-US -en-US tentially hazardous exposures, precisely measure the exen-US -en-US posures, and document those who were exposed and the en-US extent of their exposures to facilitate these evaluations. RREFERENc C ES 1. en-USSchneider D, Lilienfeld DE. en-USLilienfelds Foundaen-US -en-US tions of Epidemiologyen-US 4th ed. New York, NY: Oxen-US -en-US 2. en-USMorgenstern H, Thomas D. Principles of study en-US design in environmental epidemiology. en-US Environ en-US Health Perspen-US 1993;101(4):23-38. 3. en-USAschengrau A, Seage, GR: en-USEssentials of Epidemien-US -en-US ology in Public Healthen-US .en-US en-US en-US en-US Jones and en-US Bartlett Publishers International;en-US en-US2003en-US 4. en-USAbraham JH, Eick-Cost A, Clark LL, et al. A reten-US -en-US rospective cohort study of military deployment and en-US postdeployment medical encounters for respiratory en-US conditions. en-USMil Meden-US 2014;179:540-546. 5. en-USRothman KJ, Greenland S, Lash TL. Case-control en-US studiesen-US Encyclopedia of Quantitative Risk Analyen-US -en-US sis and Assessmenten-US Vol I. West Sussex, England: en-US John Wiley & Sons; 2008:192-204. 6. en-USInstitute of Medicine. en-US Long Term Health Conseen-US -en-US quences of Exposure to Burn Pits in Iraq and Afen-US -en-US ghanistanen-US Washington DC: The National Acaden-US -en-US emies Press; 2011:1-9,117-128. Available at: https://en-US www.nap.edu/read/13209/chapter/1. Accessed en-US April 6, 2017. 7. en-USDoll R, Hill AB. The mortality of docen-US -en-US tors in relation to their smoking habits. en-US BMJen-US en-US 1954;328(7455):1529-1533. 8. en-USHori M, Tanaka H, Wakai K, Sasazuki S, Katanoen-US -en-US da K. Secondhand smoke exposure and risk of lung en-US cancer in Japan: a systematic review and meta-en-US analysis of epidemiologic studies. en-US Jpn J Clin Oncolen-US en-US 2016;46(10):942-951. 9. en-USNational Research Council. en-USHealth Risks from Exen-US -en-US posure to Low Levels of Ionizing Radiationen-US en-US BEIR en-US VII Phase 2en-US Washington DC: The National Acaden-US -en-US emies Press; 2006:141-154. Available at: https://en-US www.nap.edu/read/11340/chapter/1. Accessed en-US April 6, 2017.en-USCHALLENGES OF PRACTICING ENVIRONMENTAL EPIDEMIOLOGY IN THE US MILITARY

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en-USJanuary June 2017 en-US111 10. en-USNational Research Council. en-USEnvironmental Epien-US -en-US demiology, Volume 1: Public Health and Hazarden-US -en-US ous Wastesen-US Washington, DC: National Academies en-US Press; 1991. 11. en-USBaird CP, DeBakey S, Reid L, Hauschild V, Petrucen-US -en-US celli B, Abraham JH. Respiratory health status of en-US US Army personnel potentially exposed to smoke en-US en-US J Occup en-US Environ Meden-US 2012;54(6):717-723. 12. en-USMacMahon B. Concepts of Multiple Factors. In: en-US Lee DHK, Kotin P, eds. en-US Multiple Factors in the en-US Causation of Environmentally Induced Diseaseen-US en-US New York, NY: Academic Press: 1972:chap1. 13. en-USTaussig HB. Thalidomide and phocomelia. Pedien-US -en-US atrics 1962;30(4):654-659. Available at: http://pedien-US en-US atrics.aappublications.org/content/30/4/654.short. en-US Accessed April 6, 2017. 14. en-USChin J, ed. en-US Control of Communicable Diseases en-US Manualen-US 17th ed. Washington, DC: American Puben-US -en-US lic Health Association; 2000. 15. en-USCenters for Disease Control and Prevention. en-US Outbreak of acute illness-southwestern United en-US States, 1993. en-USMMWR Morb Mortal Wkly Repen-US en-US 1993;42(22):421-424. 16. en-USNational Academies of Sciences, Engineering, and en-US Medicine. en-US Assessment of the Department of Veteren-US -en-US ans Affairs Airborne Hazards and Burn Pit Regen-US -en-US istryen-US Washington, DC: The National Academies en-US Press; February 28, 2017. Available at: https://www.en-US nap.edu/catalog/23677/assessment-of-the-departen-US en-US ment-of-veterans-affairs-airborne-hazards-and-en-US open-burn-pit-registry. Accessed April 6, 2017. 17. en-USInstitute of Medicine. en-US Adequacy of the Compreen-US -en-US hensive Clinical Evaluation Program: A Focused en-US Assessmenten-US Washington, DC: The National Acadeen-US -en-US mies Press; 1997. DOI: https://doi.org10.17226/6004. AUTHORS Dr Baird is the Program Manager for the Environmental en-USMedicine Program of the Occupational and Environmenen-US -en-US tal Portfolio, US Army Public Health Center, Aberdeen en-US Proving Ground, Maryland.en-US Ms Sharkey is an Epidemiologist for the Environmental en-US Medicine Program of the Occupational and Environmenen-US -en-US tal Portfolio, US Army Public Health Center, Aberdeen en-US Proving Ground, Maryland.en-US Dr Gaydos is an Occupational Medicine Physician for en-US the Clinical Public Health and Epidemiology Directoren-US -en-US ate, US Army Public Health Center, Aberdeen Proving en-US Ground, Maryland.

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en-US112 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USHistorically, lead has been an important commodity for en-US industry, including metal alloys, cosmetics, medicinal en-US preparations, and paint pigments. Concomitantly, lead en-US poisoning has been well described since early Greek en-US history (2nd century BC), and, more recently (19th en-US en-US in workers and children.en-US1en-US By the 20th century, more in-en-US depth studies revealed the cumulative toxic effects of en-US lead exposure, especially among the vulnerable populaen-US -en-US tion of children.en-US1,2en-USen-US an estimated 4 million households with potential childen-US -en-US en-US -en-US dren (ages 1-5 years) are known to have blood lead levels en-US (BLLs) above 5 g/dL, the recommended public health en-US action level of the Centers for Disease Control and Preen-US -en-US vention (CDC).en-US3,4en-US Although BLLs have demonstrated an en-US overall dramatic decline in the past few decades, lead en-US exposures among high risk populations (low-income, en-US African American, urban, and rural mining communien-US -en-US ties or developing countries) still exist.en-US5en-USInterestingly, lead toxicity can affect nearly every body en-US system. Because subclinical presentations are common en-US among lead exposed patients, this public health risk en-US frequently goes unrecognized. Throughout the world, en-US children remain a persistent at-risk population due to en-US prevalent hand to mouth behavior, close proximity to en-US lead exposures, and physiologic higher gastrointestinal en-US absorption per unit body weight and increased respiraen-US -en-US tory rates.en-US5en-US Regardless of the route of entry, the toxic en-US effects of lead exposures remain uniform.en-US1en-USen-US lead binds to erythrocytes which can then transfer to en-US multiple organs (brain, liver, kidneys, spleen, muscles, en-US lungs, and heart), and the majority of the lead can absorb en-US onto bones and teeth after several weeks.en-US1en-US Further, exen-US -en-US posures to lead at low levels (BLL less than 10 g/dL) in en-US en-US in central nervous system functioning and cognition.en-US6,7en-US en-US Children may exhibit pica, a unique manifestation en-US of elevated BLL which involve abnormal eating habits en-US with soil or paint chips.en-US5en-USWithin a childs environment, main lead exposures en-US derive from diet, contaminated soil, paint in homes en-US built before 1978, water pumped through leaded pipes, en-US imported clay pots, certain consumer products such as en-US candies, make-up, jewelry, certain imported home remen-US-en-US edies, electronics, and toys.en-US1,3,5en-US Indirect exposures from en-US adult recreational activities such as take-home lead dust en-US en-US8,9en-US More en-US importantly, certain parental occupations (ship yards, en-US manufacturers, and handlers in lead alloys including en-US batteries and ammunition) can also pose considerable en-US risk to the child.en-US10en-US Therefore, occupational lead expoen-US -en-US sures can indirectly expose the employees families and en-US children under the age of 6 years by take-home lead dust en-US on clothes, boots, hands, and face.en-US3,11-13en-USIn 1991, the CDC responded to this growing public health en-US concern by issuing new guidelines.en-US1,3en-US This included an en-US emphasis on the childs environmental history, parent en-US education, and follow-up for children with BLLs of 10 en-US g/dL or greater.en-US1en-US More recently, the American Acaden-US -en-US emy of Pediatrics emphasized lead screening history in en-US a 2005 guidance statement, and the CDC recommended en-US initial and follow-up screening (within 1 to 3 months) of en-US pregnant and lactating women, neonates, and infants of en-US women with BLLs of 5 g/dL or greater.en-US4en-US en-US In May 2012, en-US the Advisory Committee on Childhood Lead Poisoning en-US Prevention recommended the use of a reference range en-US for an elevated BLL based on the growing body of literaen-US -en-US ture that levels less than 10 g/dL do indeed adversely en-US affect children.en-US1,3-5,11,14en-US Thus, the current value (5 g/dL) en-US en-US3,15en-USen-US -en-US ing the complex toxic effects of lead exposures among en-US children underscores the importance of primary prevenen-US-en-US tion and vigilant surveillance and screening. CaA SE S STUDy Y An 18-month-old female was seen in the pediatric clinic en-USfor complaints of pica. She was known to eat unusual en-US items such as cat food, wood chips from the stair railen-US -en-US ings, chalk, and paint off the walls. The birth history reen-US -en-US vealed a normal term delivery via emergency C-section en-US with breech presentation without complications or hosen-US -en-US pitalizations. The mother of the child denied any past en-US surgical history, but the childs past medical history was en-US en-US medications. Also, her mother expressed concerns of en-US childs development delays in speech, but she denies any en-USIndirect Military Occupational Lead Exposureen-US en-US to Children at Home: A Case Report en-USAcknowledgment: The material in this article has been reviewed by the Walter Reed Army Institute of Research. en-US There is no objection to its presentation and/or publication.

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en-USJanuary June 2017 en-US113en-USen-US nail deformities. Family history was unremarkable and en-US there are no siblings or other family members in the liven-US -en-US ing environment whether foreign or domestic. There was en-US no history of travel or visitors from outside the country.en-US Since September, the family lived on the military instalen-US -en-US lation with well-developed housing (post-1980s) and no en-US history of lead in paint, soil, or water systems. The child en-US was formula fed with the introduction to whole milk en-US at 9 months old, and currently she is solely on whole en-US milk with a normal diet of solid foods. Her mother deen-US -en-US nied any foreign-made toys, ceramics, or products that en-US would contain lead. The mother consistently was a stay en-US at home mom. Her recreational activities included croen-US -en-US chet and bow hunting, but she denied any participation en-US of the latter since they moved to the current duty staen-US -en-US tion. At the time, The childs father was a Soldier in the en-US en-US arms munitions and Howitzers, but mostly he worked in en-US the motor pool. The mother stated that he worked with en-US lead products and had coveralls at the workplace; howen-US -en-US ever, he did not change his boots from work to home. en-US Although he washed his hands upon entering the home, en-US he denied taking any showers prior. According to the en-US mother, his boots and duty uniform was typically locaten-US -en-US ed in a common place, the laundry room, and were not en-US segregated. The child has had full access of the contamien-US -en-US nated clothing, and was known to play with the work en-US boots constantly. The fathers recreational activities inen-US -en-US en-US -en-US ing range activities since arrival at this post. Both father en-US and mother drove separate cars, and the child only traven-US -en-US eled with the mother in her vehicle. The mother denied en-US any history of cross contamination between the car seats.en-US A review of the medical history showed the 12-month en-US visit had normal results on the Ages and Stages Quesen-US -en-US tionnaire (ASQ) and lead screening. Although the suben-US -en-US sequent 15-month visit still revealed a negative lead en-US en-US -en-US en-US All growth parameters were appropriate for age. A folen-US -en-US low-up visit with the primary care provider revealed the en-US diagnosis of pica, although there was still a negative en-US lead screening. Laboratory results included a normal en-US hematocrit/hemoglobin (12.5/36.8) for her age group. en-US However, serum lead levels were elevated (6 g/dL). en-US en-US the work and home environment was conducted.en-US The installation Industrial Hygiene (IH) Department en-US conducted a home visit using Lead Check swabs (3M, St en-US en-US lead contamination only on the fathers uniform and en-US boots, with negative results in other high risk areas en-US within the home. The IH team then performed a health en-US hazard survey of the fathers workplace (Field Artillery en-US motor pool) including lead surface sampling. The worken-US -en-US ers in the motor pool provided routine wheeled vehicle en-US and armaments maintenance. Although lead exposure en-US can occur both via ingestion and inhalation, airborne en-US levels of lead in the motor pool were anticipated to be en-US very low risk, whereas the presence of residual lead on en-US en-US lead to exposure through eating, drinking, and tobacco en-US use. One important concern was take-home lead dust on en-US uniforms and boots which could contaminate privately en-US owned vehicles and home environments. All quantitaen-US -en-US tive samples were collected using Ghost Wipes with en-US a 100 cmen-US2en-US template. The samples were then sent for en-US en-US ASTM Method E1613.* The samples were reanalyzed by en-US the laboratory using Environmental Protection Agency en-US (EPA) Method 200.8en-USen-US to better quantify lead at the lower en-US levels. To note, the IH Group at Brookhaven National en-US Laboratory has established industrial guidelines for lead en-US dust based on standards developed by the Department of en-US en-US these guidelines, dust wipe samples standards included en-US 40 g/ften-US2en-US for nonlead operational areas. Final sampling en-US above the 40 g/ften-US2en-US cutoff revealed positive for the Solen-US -en-US diers front of uniform pants, top and bottom of boots, en-US and front of the mechanic coveralls, shown in the Table.en-US Primary exposures to lead were associated with routen-US -en-US ing maintenance activities. The lead sampling indicated en-US en-US precautionary procedures to minimize risk of lead expoen-US -en-US sure to Soldiers and family members. These procedures en-US included enforcing the use of dedicated coveralls in the en-US workplace and changing areas, not wearing uniform en-US boots into the home environment with segregation of en-US any potentially contaminated clothing items transported en-US THE ARMY MEDICAL DEPARTMENT JOURNAL en-US*en-UShttps://www.astm.org/Standards/E1613.htmen-USen-USen-US en-US ments/method_200-8_rev_5-4_1994.pdf en-USResults of analyses of the home and workplace sampling for en-US possible lead contamination.en-USItemen-US Lead Concentrationen-US en-US (g/ften-US2en-US)en-US Positive en-US en-US (>40 g/ften-US2en-US)en-US Front of uniform pantsen-US69.7en-USYesen-US Top and bottom of bootsen-US82.7en-USYesen-US Mechanic desk areaen-US
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en-US114 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspx en-USin a plastic bag, prohibited eating, drinking, or using toen-US -en-US bacco products in the maintenance section, and integraten-US -en-US ed washing areas for hands, face, and shower activities en-US before interacting with the home environment. COmm MM ENT Indirect occupational exposure to lead in the home en en-US-en-US vironment is a military-relevant topic with enormous en-US en-US were enacted to protect children from environmental and en-US industrial lead exposures which led to the sharp reducen-US -en-US tion in childrens BLL (1976 thru 1989).en-US2,16en-US Thus, legislaen-US -en-US tive actions have proven the effectiveness of public health en-US interventions in light of emerging research that elevated en-US BLLs in children can cause serious adverse outcomes.en-US17-19en-US en-US Although the follow-up lead levels, particularly for this en-US en-US -en-US its of lead levels after workplace interventions, improveen-US -en-US ments in early detection, surveillance, and prevention are en-US still needed to protect any long term effects to a childs en-US development in the military home. Future studies in en-US population risks in the environmental and occupational en-US setting among the military are warranted. RREFERENc C ES 1. en-USMeyer PA, Brown MJ, Falk H. Global approach to en-US reducing lead exposure and poisoning. en-US Mutat Resen-US en-US 2008;659:166-175. 2. en-USLevin R, Brown MJ, Kashtock ME, et al. Lead expoen-US -en-US en-US -en-US tion. en-US Environ Health Perspecten-US 2008;116:1285-1293. 3. en-USCenters for Disease Control and Prevention. en-US CDC en-US Response to Advisory Committee on Childhood en-US Lead Poisoning Prevention Recommendations in en-US Low Level Lead Exposure Harms Children: A Reen-US -en-US newed Call for Primary Preventionen-US June 7, 2012. en-US Available at: http://www.cdc.gov/nceh/lead/ACen-US en-US CLPP/CDC_Response_Lead_Exposure_Recs.pdf. en-US Accessed March 17, 2017. 4. en-USCenters for Disease Control and Prevention. en-US Low en-US Level Lead Exposure Harms Children: A Renewed en-US Call for Primary Prevention: Report of the Advien-US -en-US sory Committee on Childhood Lead Poisoning Preen-US -en-US vention of the Centers for Disease Control and Preen-US -en-US ventionen-US January 4, 2012. Available: at https://www.en-US en-US pdf. Accessed March 12, 2017. 5. en-USAhamed M, Siddiqui MK. Environmental en-US lead toxicity and nutritional factors. en-US Clin Nutren-US en-US 2007;26(4):400-408. 6. en-USNeedleman HL, Schell A, Bellinger D, Leviton A, en-US Allred EN. The long-term effects of exposure to en-US low doses of lead in childhood. An 11-year follow-en-US up report. en-USN Engl J Meden-US 1990;322:83-88. 7. en-USSurkan PJ, Zhang A, Trachtenberg F, Daniel DB, en-US McKinlay S, Bellinger DC. Neuropsychological en-US function in children with blood lead levels <10 mien-US -en-US crog/dL. en-USNeurotoxicologyen-US 2007;28(6):1170-1177. 8. en-USValway SE, Martyny JW, Miller JR, Cook M, Manen-US -en-US en-US -en-US ers. en-USAm J Public Healthen-US 1989;79:1029-1032. 9. en-USBonanno J, Robson MG, Buckley B, Modica M. en-US en-US Bull Environ Contam Toxicolen-US 2002;68:315-323. 10. en-USDolcourt JL, Hamrick HJ, OTuama LA, Wooten en-US J, Barker EL Jr. Increased lead burden in children en-US of battery workers: asymptomatic exposure resulten-US -en-US ing from contaminated work clothing. en-USPediatricsen-US en-US 1978;62:563-566. 11. en-USLanphear BP, Hornung R, Ho M, Howard CR, Eben-US -en-US erly S, Knauf K. Environmental lead exposure duren-US -en-US ing early childhood. en-USJ Pediatren-US 2002;140(1):40-47. 12. en-USLanphear BP, Roghmann KJ. Pathways of en-US lead exposure in urban children. en-US Environ Resen-US en-US 1997;74:67-73. 13. en-USCharney E, Sayre J, Coulter M. Increased lead aben-US -en-US sorption in inner-city children: where does the lead en-US come from?. en-US Pediatricsen-US 1980;65:226-231. 14. en-USGilbert SG, Weiss B. A rationale for lowering the en-US blood lead action level from 10 to 2 microg/dL. en-US Neurotoxicologyen-US 2006;27(5):693-701. 15. en-USen-US Cox C, Jusko TA, Lanphear BP. Intellectual imen-US -en-US pairment in children with blood lead concentraen-US -en-US tions below 10 microg per deciliter. en-US N Engl J Meden-US en-US 2003;348(16):1517-1526. 16. en-USPirkle JL, Kaufmann RB, Brody DJ, Hickman T, en-US en-US -en-US tion to lead, 1991-1994. en-USEnviron Health Perspecten-US en-US 1998;106:745-750. 17. en-USBellinger DC, Needleman HL. Intellectual Imen-US -en-US pairment and Blood Lead Levels. en-US N Engl J Meden-US en-US 2003;349(5):500-502. Correspondence. Availen-US -en-US able at: http://www.nejm.org/doi/full/10.1056/en-US NEJM200307313490515#t=article. Accessed April en-US 19, 2017. 18. en-USBellinger DC, Stiles KM, Needleman HL. Low-en-US level lead exposure, intelligence and academic en-US achievement: a long-term follow-up study. en-US Pediaten-US -en-US ricsen-US 1992;90:855-861. 19. en-USDietrich KN, Ris MD, Succop PA, Berger OG, en-US Bornschein RL. Early exposure to lead and juvenile en-US delinquency. en-US Neurotoxicol Teratolen-US 2001;23:511-518. AUTHOR LTC(P) Kwon is the Director, Preventive Medicine en-USBranch, Walter Reed Army Institute of Research, Silver en-US Spring, Maryland.en-USINDIRECT MILITARY OCCUPATIONAL LEAD EXPOSURE TO CHILDREN AT HOME: A CASE REPORT

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en-USJanuary June 2017 en-US115 I. INTRODUCTi I ON The Canadian poet and adventurer Robert W. Service en-UScould not have imagined the emotional journey he was en-US about to embark on when he enlisted in an American en-US Ambulance Unit in 1915 in Paris. Though unenthusien-US -en-US astic about combat, he did not mind taking a chance of en-US being killed while helping others. Only a few weeks afen-US -en-US ter enlisting in the ambulance service, the middle-aged en-US en-US Flanders. Despite the explosions all around him and the en-US wounded men in the rear of his car, he remarked that the en-US en-US after his thrill seeking brought him to a station closer to en-US the front lines, his sense of adventure was extinguished en-US by the horrors of war. After noting a French soldier died en-US in the rear of his ambulance, he wrote that I prefer to en-US forget thatThose who went through the horrors of war en-US never want to talk about it.en-US1en-USDespite Services contention that he did not want to talk en-US about wars horrors, his writing became his venue for en-US exploring his emotional reactions to combat. What is en-US most striking about his autobiographical writing is the en-US fact that Service developed both adaptive and idealisen-US -en-US tic endurance strategies to survive the horrors of war. en-US On the one hand, he wrote that we became very calen-US -en-US lous, grumbling if brains or guts soiled the car. We were en-US sorry for the poor devils but saw so many they were like en-US shadows.en-US2en-US In essence, he learned to treat his wounded en-US charges as shadows in order to avoid absorbing the en-US emotional impact of carrying the dying on a daily basis. en-US Conversely, Service also found solace in his mission. In en-US en-US Balen-US-en-US lads of a Bohemian, en-US Services narrator is an ambulance en-US driver like the author. The protagonist notes that My en-US only consolation is that the war must soon be over, and en-US that I will have helped.en-US3en-USThousands of ambulance drivers developed similar suren-US -en-US vival strategies as they volunteered in a war-torn Europe. en-US Droves of Americans volunteered in varying capacities en-US in different fronts in the years preceding their countrys en-US declaration of war on Germany in 1917. Individual reaen-US-en-US en-US -en-US rian George Plimpton categorizes volunteer ambulance en-US en-US -en-US venture seekers.en-US4en-USen-US many of these 3,500 documented volunteer ambulance en-US drivers that enlisted before the American entry in the en-US war were Ivy Leaguers who joined European armies out en-US of a romantic affection for France, or even to be closer to en-US en-US fervor later spread throughout the middle class as well.en-US5en-USWhatever their reasons for enlisting before 1917, Amerien-US -en-US can ambulanciers faced untold horrors in what was a en-USEnduring for the Patients Sake:en-US en-US The Emotional Experiences anden-US en-US Endurance of American Ambulanceen-US en-US Drivers in World War I Be njamin Cameron Schaffer en-US en-US2016en-USSpurgeon Neel Annual Award Winneren-USThe Army Medical Department Museum Foundation sponsors the Spurgeon Neel Annual en-US en-US tradition of the US Army Medical Department. The following essay by Benjamin Cameron en-US Shaffer was selected as the best submission of the 2016 competition.

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en-US116 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USnew kind of war. In addition to the more than 8 million en-US en-US On average, about 6,000 men died every day.en-US6en-US While en-US common soldiers experienced the carnage of machine en-US en-US en-US of rescuing casualties and the shocking aftermath of the en-US bloodshed.en-US In the face of carnage, American ambulance drivers had en-US disparate emotional and psychological reactions to their en-US hellish surroundings. Ana Carden-Coyne, a historian of en-US the British medical services, argues that morbid wounds en-US deeply affected even the most hardened surgeons who en-US contemplated their patients grim futures Despite the en-US en-US asserts that the only way they could deal with the sufen-US -en-US fering around them was simply to get on with their jobs, en-US allowing work to subsume their feelings.en-US7en-US Despite her en-US focus on British medics, Carden-Coynes argument for en-US the persistence of British doctors and nurses easily apen-US -en-US plies to the thousands of American ambulance drivers in en-US the Allied armies. The concept of forbearance through en-US wartime trauma is evident in scores of published jouren-US -en-US nals, poems, memoirs, and even autobiographical novels en-US written by American medics both during and after the en-US en-US First World War not only faced extreme emotional trauen-US -en-US ma and physical dangers, but developed adaptive and en-US idealistic forbearance strategies to survive their ordeal. en-US Whereas ambulanciers learned to inure themselves to en-US the horrors of war, they also developed positive survival en-US strategies which centered on the critical value of their en-US work in saving the wounded and dying. II. HiI STORi I OGRAPh H Y OF WARTi I ME E ENDURANCE AND MMETh H ODOLOGY This article is inspired by two current trends in the his en-US-en-US toriography of the First World War: the study of troop en-US endurance, and the study of the cultural and emotional en-US aspects of military medicine during the Great War. A en-US recent anthology produced by World War I scholars in en-US New Zealanden-US Endurance and the First World War: en-US Experiences and Legacies in New Zealand and Ausen-US-en-US traliaen-US is a concise study on the topic of endurance en-US during the Great War.en-US8en-US In the volume, historian David en-US Monger asserts that endurances presence has occupied en-US a quiet, yet underlying and central place in the historien-US -en-US ography of the war.en-US9en-US Out of the several authors Monger en-US lists that have directly and indirectly covered enduren-US -en-US ance, Stephen Loveridgeauthor of the article Seeing en-US en-US Equipment and Endurance in New Zealands War Efen-US -en-US fort,Michael Roperauthor of en-USThe Secret Battle: en-US Emotional Survival in the Great Waren-US and Alexander en-US Watsonauthor of en-US Enduring the Great War: Combat, en-US Morale and Collapse in the German and British Armies, en-US 1914-1919en-US have all particularly inspired this current en-US study on the endurance of medics. Watsons method of en-US en-US of calamities will be repeated here.en-US10en-USen-US -en-US rent studies on the emotional world of Allied medicsen-US11en-US en-US during World War Iparticularly the work of Christine en-US en-US Containing Trauma: Nursing Work in en-US the First World War. en-USen-US broadly uncover the hidden world of nursing work in en-US the war, her contention that nurses were forced to conen-US -en-US tain their own emotions lest they fail to be of much use en-US to [their] patients is particularly relevant to this study.en-US12 en-USen-US drivers resilience was partially based in the intrinsic en-US worthiness of their job will be explored throughout this en-US study.en-US13 en-USOut of all the scholarly work consulted in this en-US en-US the endurance strategies of American ambulance driven-US -en-US ers. All in all, this study seeks to extend groundbreaking en-US arguments for World War I endurance to ambulanciers en-US on the front line. III. T ThH E L LiI FE OF AN A AMBULANCi I ER en-USin the Great War. These idealistic young men mostly en-US came from Ivy League universities, and included future en-US en-US -en-US en-US en-US en-US American Volunteer Motor-Ambulance Corpsa unit en-US en-US -en-US trol of the American Red Crossand A. Piatt Andrews en-US American Ambulance Field Service.en-US14en-US Although there en-US are incomplete records of American women who served en-US as ambulance drivers, the preponderance of drivers en-US were men.en-US15en-USWhile these sections served with distinction throughout en-US en-US -en-US gions such as Greece, the structure of most of these oren-US -en-US ganizations shifted dramatically when the United States en-US entered the war. The United States Army Ambulance en-US en-US of the American armyarrived in France before most en-US American troops in the summer of 1917. While this orgaen-US -en-US nization was created by Washington to help the French en-US Army, the American Expeditionary Forces ambulance en-US system was separate, and not nearly as effective as the en-US ENDURING FOR THE PATIENTS SAKE: THE EMOTIONAL EXPERIENCES AND ENDURANCEen-US en-US OF AMERICAN AMBULANCE DRIVERS IN WORLD WAR I

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en-USJanuary June 2017 en-US117 en-USUSAAS.en-US16en-US Despite heavy protest from former section en-US leadersespecially from Richard Nortonthe three en-US main ambulance groups were absorbed by the USAAS. en-US One of the biggest complaints from the formerly-civilen-US -en-US ian drivers who continued on was the destruction of the en-US volunteer spirit that came with army enlistment.en-US17en-USThe experiences and trials of the men in any ambulance en-US section varied year by year, and from station to station. en-US Wherever they served, they excelled in their primary en-US task: quickly transporting the wounded to aid stations en-US and evacuation centers. One unit of Andrews Amerien-US -en-US can Field Service (formerly the American Ambulance en-US Field Service) was reported to have evacuated over en-US 56,000 wounded troops between 1915 and the wars end en-US in 1918.en-US18en-US Though experiences and procedures in hospien-US -en-US tal transport obviously varied from location to location, en-US en-US had two tasks: jitney duty and front line duty. Initially, en-US these volunteers were permitted to take part only in jiten-US -en-US ney transport, which involved the transport of en-US blesss en-US (the French term for wounded soldiers) from hospital to en-US hospital or from transport trains and ships to hospitals. en-US As the war progressed, ambulance drivers began worken-US -en-US ing the front lines. After a soldier was wounded, he en-US en-US and from there stretcher-bearers carried him to an aden-US-en-US vanced dressing clinic where doctors performed basic en-US operations. From here, ambulance drivers carried the en-US blesss en-USto triage stations and evacuation hospitals.en-US19en-USen-US the dangerous duties these drivers had on an average en-US day during the Lorraine Offensive in 1915. McConnell en-US en-US -en-US scribe it...for with us all days are so different...but the en-US action and experiences, which add the color, are never en-US en-US -en-US ning with breakfast and a discussion of German shrapen-US -en-US nel and shell that came in the night before. Then the men en-US take up their various duties. While some men are held en-US in reserve, others evacuate the wounded from various en-US posts both near and far. At the en-US poste de secours en-US(dressen-US -en-US ing station), McConnell would pick up French en-USblesss. en-US en-US damage from shrapnel and heavy casualties from shells. en-US en-US not having lost any drivers yet.en-US The last of the en-USpostes en-US en-US where drivers would have to watch out for craters in the en-US road and frequently take cover in bomb-proofs. With en-US the wounded in the car on the trip to the evacuation hosen-US -en-US pital, drivers started to take notice of shell damage, but en-US never dwelled too long on the risks they took.en-US20en-US Despite en-US en-US -en-US en-US at the front. Young ambulance drivers spent upwards en-US of 75% of their time En Repos. Activities while En en-US Repos ranged from car repair to adventuring around en-US Europe. Another favorite activity was writing letters or en-US in journals.en-US21en-US While the drivers spent most of their time en-US en-US drivers faced many of the same anxieties and emotional en-US crises as the soldiers in the trenches. V. E EMOTi I ONS AND S SOURCES In the wake of constant personal danger, the emotional en-USreactions of American ambulance drivers to their envien-US -en-US ronments varied by personal experience and location. en-US en-US in emotional studies of men during the war and of emoen-US -en-US en-US -en-US ation that must be made is that the ambulanciers grew en-US up in a society that valued stoicism and a stiff upper lip en-US when undergoing trauma. Ana Carden-Coye writes that en-US physical endurance was built into military and civilen-US -en-US ian codes of masculinitywhether located in the British en-US stiff upper-lip or new world images of American, Ausen-US -en-US tralian, and Canadian frontiersmen whose hardy bodies en-US had supposedly toiled with stoic silence. She also notes en-US that among individual British doctors, triumph over en-US adversity was the main narrative of British medical and en-US surgical innovation.en-US22en-US While Carden-Coyne focuses on en-US physical pain, the same stoicism can be applied to mens en-US emotions as well.en-US Carden-Coyne and other historians have also noted the en-US ability of soldiers to share their emotional responses to en-US horrors in various capacities. In her study on British en-US en-US argues that while British soldiers writings rarely comen-US -en-US en-US en-US themselves to be men, both physically and emotionalen-US -en-US ly.en-US23en-US While this article does not extensively examine the en-US gendered experiences of ambulanciers, it is important en-US to note how reactions to combat could play into their en-US perceptions of manhoodand ultimately their will to en-US persevere through trauma.en-US Michael Roper contends that although British soldiers en-US experienced a multitude of emotions, fear and dread en-US were constantly on the mind of most participants. Roper en-US writes that in response, these men were caught between en-US unprocessed emotions and the aforementioned rule of en-US the stiff upper lip. As we will see, the emotional reen-US -en-US sponses of medics to combat were also very complex

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118 http://www.cs.amedd.army.mil/amedd_journal.aspxen-USand largely rooted in fear. In terms of sources, Roper en-US warns that retrospective memoirs are generally more en-US en-US than letters or journals.en-US24en-US Some of the following acen-US -en-US counts are postwar memoirs, but the raw emotional exen-US -en-US periences recorded in the memoirs often match the more en-US contemporary accounts.en-US One problem that does arise with wartime publications en-US is the issue of subjectivity and writing for an audience. en-US en-US With the Amerien-US -en-US can Ambulance Service in Franceen-US25en-US and en-USFriends of en-US France, en-US were both recruitment books inspired by the aden-US -en-US ministration of the American Field Service. This genre en-US tended to make ambulance work sound gloriously exen-US -en-US citing and grandly humanitarian for recruitment and en-US funding purposes.en-US26en-US Nevertheless, these sources provide en-US valuable insights into the emotional journeys of ambuen-US -en-US en-US the emotional world of soldiers categorically in chapters en-US with titles such as Fear, Discomfort, etc. Some of en-US these emotional categories will be repeated here. Broaden-US -en-US ly speaking, some of the most intense emotions ambuen-US -en-US lance drivers experienced during their service included: en-US intense fear, exhaustion, and severe emotional traumaen-US en-USFearen-USFear is one of the most primal and intense emotions that en-US ambulance drivers, doctors, nurses, civilians and solen-US -en-US diers experienced together. The closer to the front an en-US individual was, the more intense their record of fear will en-US en-US anxiety in battle. According to military psychologist en-US and Vietnam veteran Walter F. McDermott, fear comes en-US en-US battle is over, anxietyan internal form of feararises en-US from the memories of combat. McDermott contends that en-US Post Traumatic Stress Disorder, though partially psychoen-US -en-US logical, often emerges from the bodys stress response en-US system continually being overstimulated, and forms of en-US anxiety often emerge as symptoms.en-US27en-USen-US -en-US bries 1918 memoir, en-US Behind the Wheel of a War Ambuen-US -en-US lance. en-US Imbrie joined Andrews AFS at the end of 1915, en-US when his section joined the French Army at Beauvais. en-US en-US en-US from 10 February, he wrote that I am unable to...deen-US -en-US scribe my sensations and I question whether a trained en-US psychologist would be much better off. There is someen-US -en-US en-US especially frightened; my feelings were more of curiosen-US -en-US en-US en-US en-US their terribleness became mine. Even after a year and en-US en-US en-US to a fear that grew worse each time.en-US28en-USFear was also recorded by ambulance drivers after the en-US United States entered the war in 1917. In his introducen-US -en-US tion to the diary of USAAS driver Guy Emerson Bowen-US -en-US en-US -en-US man had evolving notions of fear and courage. Carnes en-US contends that Bowerman wanted to appear brave before en-US his comrades. On the other hand, Bowermanlike Imen-US-en-US briecame to realize no one could become fully inured en-US en-US29en-US en-US For instance, in en-US March of 1918 he reported boldly listening to his Vicen-US -en-US trola record player while waiting either for a shell to en-US en-US that it was niceto know the Germans might be as badly en-US scared of French shells as he was of German artillery. en-US30en-US That Bowerman could attest to passively waiting for en-US en-US en-US in which he declared that true bravery is being afraid en-US but carrying on just the same.en-US31en-US In essence, no amount en-US of exposure to shells could completely eradicate fear. en-US en-US order to ensure self-preservation, but intense fear could en-US Fatigue and Mental Disturbances from Wars Horrors en-USAside from fear, battle fatigue was a frequent companion en-US en-US case of British soldiers postwar memoirs, exhaustion en-US remained a central memory of trench life for most men. en-US Not only did fatigue [sap] mens morale, but even unen-US -en-US dermined memoirists perceptions of themselves as men en-US both physically and emotionally.en-US32en-US Sleeplessness was a en-US major factor in fatigue. AFS driver Graham Carey, one en-US en-US en-US-en-US en-US wrote: At four I was so sleepy that I got into a railway en-US carriage that we have on a siding there and immediately en-US went sound asleep. At six-thirty, however, Richardson en-US and I were waked up and given two sitting cases to en-US transport.en-US33en-US As one could expect, the rampant sleeplessen-US -en-US ness drivers faced led to extreme mental fatigue. While en-US taking a break from the front in Paris, AFS driver Phillip en-US Sidney Rice described feeling too tired and dejected to en-US en-US -en-US ularly upset he was too poor to afford cigarettes, the only en-US remedy he had to the nerve-racking strain of war.en-US34en-USENDURING FOR THE PATIENTS SAKE: THE EMOTIONAL EXPERIENCES AND ENDURANCEen-US en-US OF AMERICAN AMBULANCE DRIVERS IN WORLD WAR I

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January June 2017 119 en-USExposure to the horrors of war was the primary culprit en-US behind this nerve-wracking strain. According to Mien-US -en-US chael Roper, many soldiers who were exposed to the en-US wars horrors suffered from periods of what has been en-US called battle stress, although never becoming incaen-US -en-US pacitated to the point where they were withdrawn from en-US the line.en-US35en-US More often than not, ambulance drivers also en-US suffered emotional strain without being diagnosed as a en-US en-US that hunger, homesickness, exhaustion and continual en-US danger were common amongst men in the trenches, en-US alongside a growing sense of the purposelessness of en-US en-US psychologically damaging aspect of trench warfare was en-US en-US -en-US mon for ambulance drivers.en-US36en-USA drivers most obvious exposure to the horrors of war en-US was through the transport of wounded men. In a poem en-US by driver Emery Pottle, the narrator tries to comfort a en-US wounded man in his ambulance: en-US Courage, mon braveen-US en-US Were almost there!/ God, how the fellow groans/ en-US And youd give your heart to ease the jolt/ Of the ambuen-US -en-US lance over the stones. The driver laments that only God en-US knew how he would go on, through the dreadful night, en-US en-US Towards the end of the poem, he laments: its just anen-US-en-US other en-US poilu en-US [French soldier] thats dead;/Youve hauled en-US them every day/Till your soul has ceased to wonder and en-US weep/ At wars wild, wanton play.en-US37en-US The narrators horen-US -en-US ror can be seen in his attempts to wake up the wounded en-US bless en-US en-US the carnage.en-US Perhaps one of the most well-known results of emoen-US -en-US tional trauma during the Great War was the phenomen-US-en-US enon of shell shock. The term, created in 1914 by British en-US psychologist Charles Meyers, was used to cover a wide en-US range of disturbing physical and emotional symptoms en-US after combat (i.e. vomiting and vivid nightmares). By en-US 1916, the term shell shock was dually applied to two en-US different sets of symptoms: physical effects from the en-US shell impact and hysteria caused by the horrors of en-US combat. The nature of the disease was so controversial en-US that doctors vehemently disagreed whether physical or en-US emotional trauma led to shell shock.en-US38en-US It was not until en-US the 1980s that doctors realized the permanent emotional en-US effects combat had on soldiers and formulated the idea en-US of post-traumatic stress disorder.en-US39en-USAmbulance drivers were vulnerable to shell shock as en-US well, Phillip Sidney Rice being a prime example. After en-US one particularly exhausting mission in Verdun in 1917, en-US Rices commander sent him to Paris for treatment for en-US battle fatigue.en-US40en-US In his memoir, Rice noted that he en-US was not alone. During the battle he noticed worn out en-US stretcher-bearers with their burdens and that his own en-US face seemed to pinch at the cheek bones with fatigue. en-US en-US broken down under the strain and been sent in to Paris. en-US en-US Towards the end of the battle he noticed he was playing en-US out very rapidly, was unable to relax and could not en-US sleep. After his mission, he awoke in the middle of the en-US night because of a terrible nightmare in which he en-US went through the whole experience of battle again.en-US41 VII. E ENDURANCE To survive innumerable tribulations, ambulanciers were en-USforced to develop mental endurance strategies. Despite en-US some similarities in coping techniques, soldiers and en-US ambulanciers typically developed emotional survival en-US en-US makes the case that American ambulanciers were both en-US in and out of the war. They experienced the mangled en-US en-US en-US double perspective that alleviated some of their emoen-US -en-US en-US in the worthiness of their jobs prevented them from en-US en-US asserting that drivers rarely resorted to fatalism like en-US their comrades in the trenches, and that they rarely sucen-US -en-US cumbed to self-doubt. As we have seen, drivers consisen-US -en-US tently doubted their ability to persevere through trials.en-US42 en-USen-US of strength in the perceived hardiness of their French en-US allies.en-US43en-US Conversely, drivers such as Service developed a en-US certain callousness to the wars horrors in order to suren-US -en-US vive their jobs. In the following examination, these two en-US types of endurance will be categorized as adaptive and en-US idealistic endurance. Adaptive Endurance en-USAlexander Watson notes how British and German solen-US -en-US en-US constant exposure. On the other hand, to survive, solen-US -en-US diers had to learn to judge risk without being overen-US -en-US whelmed by it and to make judgements based on their en-US chances of survival.en-US44en-US en-US Phillip Sidney Ricethe aforeen-US -en-US mentioned ambulance driver who suffered shell shocken-US certainly never learned to get used to shelling, but he en-US en-US enduring a trial as opposed to withdrawing in fear. Duren-US -en-US ing a bombardment in Verdun in September of 1917, en-US Rice reasoned with himself that if I do go on and am en-US hit, the agony will be over within a few minutes, but if I

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en-US120 en-UShttp://www.cs.amedd.army.mil/amedd_journal.aspxen-USturn back, the agony will be with me the rest of my life. en-US So I put on my gas mask and drove on.en-US45en-US A sense of en-US shame and duty forced him to keep driving.en-US Such inurement strategies were not universally effective. en-US Norton-Harjes driver Edward R. Coyle also initially aden-US -en-US opted an adaptive approach to overcoming his fear of en-US en-US more or less matter-of-fact way when one is continually en-US forced to accept them. Life seems a matter of fate and en-US little attention is paid to bursting shells.en-US46en-US According en-US to Coyle, drivers had to passively accept the harsh realen-US -en-US ity of shelling in order to carry on with their tasks. Deen-US -en-US spite this initial adaptive approach, Coyle was ultimately en-US crippled by fear during one particularly heavy bombarden-US-en-US ment in Verdun.en-US47en-USWhile Coyle realized the futility in questioning the presen-US -en-US ence of shelling in his routine, other drivers also learned en-US to develop a thick skin to overcome their fear of aren-US -en-US tillery. During a bombardment in the summer of 1915, en-US AFS driver Leslie Buswell was requested to transport en-US en-US grin and bear it, but it is a horrid feeling to have to go en-US out into a little street where shells are falling regularly...en-US and run a few yards down the street to a poste de secen-US -en-US ours where a shell has just landed and another is due en-US any moment.en-US48en-US en-US Just as with the others, Buswell realized en-US the inevitability of German shells, and forced himself to en-US carry on out of necessity rather than desire.en-US Ambulanciers also had to harden themselves to the conen-US -en-US en-US B. Campbell wrote about his units emotional response en-US when hospital trains came in with gas victims for the en-US en-US hail of shrapnel, and tested the mens emotions severely en-US en-US en-US to suffering as to be little affected by them.en-US49en-US en-US Although en-US his company became emotional when seeing gas vicen-US -en-US tims, he did admit some level of adaptation to the horen-US -en-US Idealistic Endurance en-USDespite the prevalence of adaptive coping strategies, en-US ambulanciers did develop positive endurance strateen-US -en-US gies. New Zealand historian Stephen Loveridge writes en-US en-US -en-US ciated with some larger or redeeming purpose, however en-US en-US reframe and control apparently impossible situations.en-US50en-US en-US On the other hand, Arlen J. Hansen notes that despite the en-US en-US adventure and education in their work.en-US51en-US Drivers interen-US -en-US nalized their mission to help the wounded, and even used en-US their belief in their jobs to help alleviate personal horrors. en-US Of course, self-effacing service was not always healthy en-US for individual drivers. Driver Leslie Buswell wrote that en-US en-US en-US -en-US sonal equation practically doesnt exist here.en-US52en-USDespite having to neglect personal needs, the ambuen-US -en-US lance service did provide a form of escapism for the en-US en-US of pre-mission anxiety, Phillip Sidney Rice described en-US seeing the horrors that the German Army wrought upon en-US en-US loving France.en-US53en-US While one could dismiss this essay as en-US mere propaganda, it is worth noting that Rice penned en-US this patriotic essay while having premonitions of his en-US own demise. Even in his fear, he was able to focus on en-US the larger mission at hand.en-US Even after the United States entry into the war, Amerien-US -en-US can drivers continued to adopt idealistic endurance en-US strategies. In June of 1918, Guy Emerson Bowerman, en-US en-US en-US a terrible thing it still has its compensations for those en-US en-US -en-US en-US en-US business is unromantic, but appreciated that there were en-US en-US en-US en-US54en-US In essence, despite en-US the horrors of war, Bowerman found purpose in his en-US work and comradery with other drivers.en-US en-US ones larger mission comes from a letter Leslie Buswell en-US en-US the whole war is growing on me day by day, and someen-US -en-US times when I have got into my bed or am trying to get en-US a few hours sleep on a stretcher...the horrors of blood...en-US haunt me, and I feel I can hardly go through another day en-US en-US that is soon forgotten when a call comes, and you see en-US those bandaged soldiers waiting to be taken to a hospien-US -en-US tal. I almost love my old car...en-US55en-US In essence, the call to en-US duty distracted Buswell from even the most traumatic en-US memories. VIII. CONc C LUSi I ON In conclusion, American medical personnel in World en-USWar I experienced varying emotional responses to the en-US ENDURING FOR THE PATIENTS SAKE: THE EMOTIONAL EXPERIENCES AND ENDURANCEen-US en-US OF AMERICAN AMBULANCE DRIVERS IN WORLD WAR I

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January June 2017 121 en-UScircumstances around them, and developed adaptive en-US and idealistic endurance strategies to survive the war. en-US While adaptation to trauma merely helped these medics en-US to survive the horrors around them, idealistic endurance en-US en-US transcended their trials. Some might contend that acen-US -en-US counts published during the war were mere propaganda, en-US or that postwar accounts were too far removed from the en-US en-US reasonable, they cannot negate the existence of sundry en-US emotional accounts and survival strategies found within en-US these medics journals, letters, and memoirs.en-US Unfortunately, the emotional experiences of American en-US ambulance drivers and physicians have been neglected en-US by historians for too long. As the centennial of the conen-US-en-US en-US has passed away, it falls upon current social and medical en-US historians to not only expand the scholarship on World en-US War I endurance, but to reexamine the emotional and en-US social experiences of the American medics who volunen-US -en-US teered in foreign armies and the United States military en-US during the Great War. EEND N NOTES 1. en-USRobert W. Service, en-US Harper of Heavenen-US in en-US Robert en-US W. Service: Selected Poetry and Proseen-US Ed, Mien-US -en-US chael Gnarowski (Toronto: Dundurn Press Limited, en-US 2012), pp. 324-335. Google Books eBook. 2. en-USRobert W. Service, en-USHarper of Heavenen-US p. 327. 3. en-USRobert W. Service, en-US Ballads of a Bohemianen-US (New en-US en-US Books eBook. 4. en-USGeorge Plimpton, Foreword, in en-US Gentlemen Volunen-US -en-US teers: The Story of American Ambulance Drivers in en-US the Great War, August 1914-September 1918en-US (New en-US York: Arcade Publishing, 1996), p. 7. Google eBook. 5. en-USen-US Gentlemen Volunteers: The Story en-US of American Ambulance Drivers I the Great War en-US August 1914-September 1918en-US (New York: Arcade en-US Publishing, 1996), pp. XV-XVI. 6. en-USen-US Canadian en-US Churches and the First World Waren-US en-US -en-US Master Divinity College Press, 2014). Pages not en-US numbered. Google Books. 7. en-USAna Carden-Coyne, en-USThe Politics of Wounds: Milien-US -en-US tary Patients and Medical Power in the First World en-US Waren-US (Oxford: Oxford University Press, 2014), pp. en-US 18-37. 8. en-USDavid Monger, Sarah Murray, and Katie Pickles, en-US Introduction, in en-USEndurance and the First World en-US War: Experiences and Legacies in New Zealand en-US and Australiaen-US (Newcastle upon Tyne: Cambridge en-US Scholars Publishing, 2014), pp. XII-XIII. Google en-US Books eBook. 9. en-USDavid Monger, Endurance and First World War en-US Scholarship in en-US Endurance and the First World en-US Waren-US pp. 1-2. 10. en-USAlexander Watson, en-USEnduring the Great War: Comen-US -en-US bat, Morale and Collapse in the German and Briten-US-en-US ish Armies, 1914-1918en-US (Cambridge: Cambridge en-US University Press, 2008), p. 7. 11. en-USThe term medic will be used here to describe medien-US -en-US cal personnel throughout the paper. This is not to en-US be confused with the combat medic of the Second en-US World War. 12. en-USen-US Containing Trauma: Nursing en-US Work in the First World Waren-US (Manchester: Manen-US -en-US chester University Press, 2009), pp. 1-9. 13. en-USen-USGentlemen Volunteersen-US p. 157. 14. en-USen-US Gentlemen Volunteersen-US pp. en-US XIV-XVII. 15. en-USen-USGentlemen Volunteersen-US p. 204. 16. en-USen-US -en-US can Casualty Evacuation in World War I, en-US ICON: en-US Journal of the International Committee for the Hisen-US -en-US tory of Technologyen-US Vol. 14 (2008), pp. 123-124. 17. en-USen-US Gentlemen Volunteersen-US pp. 161-179. 18. en-US 19. en-USen-US Gentlemen Volunteersen-US pp. en-US XV-XVI. 20. en-USen-US in en-US Friends of France: The Field Service of the en-US American Ambulance Described by its Membersen-US en-US en-US 71-81. 21. en-USen-US Gentlemen Volunteersen-US Google eBook, pp. en-US 140-157. 22. en-USAna Carden-Coyne, en-USThe Politics of Woundsen-US pp. en-US 162-183. 23. en-USen-US Men of War: Masculinity and the en-US First World War in Britainen-US en-US Macmillan, 2011), p. 9. 24. en-USMichael Roper, en-USThe Secret Battle: Emotional Suren-US -en-US vival in the Great Waren-US (Manchester: Manchester en-US University Press, 2009), pp. 14-20. 25. en-USAlso published as en-USAmbulance No. 10: Personal Leten-US -en-US ters from the Fronten-US 26. en-USen-USGentlemen Volunteersen-US pp. 53-54. 27. en-USWalter F. McDermott, en-US Understanding Combat Reen-US -en-US lated Post Traumatic Stress Disorderen-US en-US McFarland & Company, Inc., 2012), pp. 48-49.. en-US Kindle eBook. 28. en-USRobert Whitney Imbrie, en-US Behind the Wheel of a War en-US Ambulanceen-US (New York: Robert M. McBride & Co., en-US 1918), pp. 4-40.

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122 http://www.cs.amedd.army.mil/amedd_journal.aspx 29. en-USMark C. Carnes, Introduction, in Guy Emerson en-US en-US The Compensations of War: The en-US Diary of an American Ambulance Driver During en-US the Great Waren-US (Austin: University of Texas Press, en-US 1983), pp. XIV-XVII. 30. en-USen-US The Compensations en-US of Waren-US pp. 67-68. 31. en-USMark C. Carnes, en-US Introductionen-US , in Guy Emerson en-US 32. en-USen-USMen of Waren-US pp. 131-132. 33. en-USen-US Lyn Macdonald, ed. en-US The Roses of No Mans Landen-US en-US 34. en-USRice, en-USAn American Crusaderen-US p. 81. 35. en-USMichael Roper, en-USThe Secret Battleen-US p. 247. 36. en-USAlexander Watson, en-USEnduring the Great Waren-US pp. en-US 20-27. 37. en-USEmery Pottle, Un Blesse A Montauville in en-US Friends of Franceen-US pp. 136-138. 38. en-USen-US Veileden-US en-US Warriors: Allied Nurses of en-US the First World Waren-US (Oxford: Oxford University en-US Press, 2014), pp. 95-98. Kindle eBook. 39. en-USen-US -en-US ders, in en-USUnderstanding Combat Related Post Traen-US -en-US mautic Stress Disorderen-US Kindle eBook version. 40. en-USen-USGentlemen Volunteersen-US p. 69. 41. en-USPhillip Sidney Rice, en-US American Crusader at Verdunen-US en-US pp. 72-79. 42. en-USen-US Gentlemen Volunteersen-US pp. 155-157. 43. en-USen-USGentlemen Volunteersen-US pp. 44. en-USWatson, en-US Enduring the Great Waren-US Location 2647, en-US Kindle eBook Version. 45. en-USPhillip Sidney Rice, en-USAmerican Crusaderen-US pp. 76-78. 46. en-USEdward R. Coyle, en-USAmbulancing on the French en-US Fronten-US (New York: Britton Publishing Company, en-US 1918), pp. 41-42. 47. en-USEdward R. Coyle, en-USAmbulancing on the French en-US Fronten-US pp. 81-83. 48. en-USBuswell, en-US Ambulance No. 10: Personal Letters from en-US the Fronten-US en-US 1916) pp. 99-101. Google Books eBook. 49. en-USen-US in en-USFriends of Franceen-US pp. 121-122. 50. en-USSteven Loveridge, The Link Between Sentimental en-US Equipment and Endurance in New Zealands War en-US Effort, in en-USEndurance and the First World War: en-US Experiences and Legacies in New Zealand and en-US Australiaen-US eds. David Monger, Sarah Murray, and en-US Katie Pickles (Newcastle upon Tyne: Cambridge en-US Scholars Publishing, 2014), p. 54.Google Books en-US eBook. 51. en-US 52. en-USLeslie Buswell, en-USAmbulance No. 10en-US p. 87. 53. en-USPhillip Sidney Rice, en-USAmerican Crusaderen-US pp. en-US 98-101. 54. en-USen-US The Compensations en-US of Waren-US pp. 107-108. 55. en-USLeslie Buswell, en-USAmbulance No. 10en-US p. 98. BBiI BLi I OGRAPh H Y en-USPrimary Sourcesen-USen-US The Compensations of en-US War: The Diary of an American Ambulance Driver Duren-US -en-US ing the Great Waren-US ed,en-US en-US Mark C. Carnes. Austin: Univeren-US -en-US sity of Texas Press, 1983.en-US Buswell, Leslie. en-USWith the American Ambulance Field en-US Service in Franceen-US en-US Books eBook.en-US Ambulance No. 10: Personal Letters from the Front. en-US en-US Books eBook. Accessed 27 December 2015.en-US Coyle, Edward R. en-US Ambulancing on the French Fronten-US en-US New York: Britton Publishing Company, 1918. Accessed en-US November 26, 2015. Archive.org. https://archive.org/en-US stream/ambulancingonfre01coyl#page/n7/mode/2up.en-US en-US The Harvard Volunteers in en-US Europe: Personal Records of Experience in Military, en-US Ambulance, and Hospital Service. en-USen-US University Press, 1916.en-US en-US Imbrie, Robert Whitney. en-USBehind the Wheel of a War Amen-US -en-US bulanceen-US New York: Robert M. McBride & Co., 1918. en-US Accessed November 21, 2015 Archive.org. https://aren-US -en-US chive.org/stream/behindwheelofwar00imbr#page/n7/en-US mode/2up.en-US Macdonald, Lyn ed. en-US The Roses of No Mans Land. en-US Lonen-US -en-US en-US en-US Piatt, Andrew A, ed. en-US Friends of France: The Field Seren-US -en-US vice of the American Ambulance Described by its Memen-US -en-US bersen-US en-US en-US Emery Pottle, Un Blesse A Montauville.en-US Sidney Rice, Phillip. en-US An American Crusader at Verdunen-US en-US (Princeton: Princeton University Press, 1918. Google en-US Books eBook.en-US ENDURING FOR THE PATIENTS SAKE: THE EMOTIONAL EXPERIENCES AND ENDURANCEen-US en-US OF AMERICAN AMBULANCE DRIVERS IN WORLD WAR I

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January June 2017 123 en-USService, Robert W. en-US Harper of Heaven en-US inen-US Robert W. Seren-US -en-US vice: Selected Poetry and Prose,en-US ed. Michael.en-US Gnarowski. Toronto: Dundurn Press Limited, 2012. en-US Google Books eBook.en-US Ballads of a Bohemian. en-US en-US 1921. Google Books eBook.en-US Rhymes of a Red Cross Man. en-US en-US Google Books eBook. en-USSecondary Monographsen-USCarden-Coyne, Ana. en-US The Politics of Wounds: Military en-US Patients and Medical Power in the First World War. en-US Oxen-US -en-US ford: Oxford University Press, 2014.en-US en-US Containing Trauma: Nursing Work in en-US the First World War. en-US Manchester: Manchester Univeren-US -en-US sity Press, 2009.en-US Veiled Warriors: Allied Nurses of the First World Waren-US en-US Oxford: Oxford University Press, 2014. Kindle eBook.en-US en-US Gentlemen Volunteers: The Story of en-US American Ambulance Drivers I the Great War August en-US 1914-September 1918en-US New York: Arcade Publishing, en-US 1996.en-US en-US Canadian Churches and the en-US First World Waren-US en-US Press, 2014. Pages not numbered. Google Books.en-US McDermott, Walter F. en-US Understanding Combat Related en-US Post Tramautic Stress Disorder. en-USKindle eBook version.en-US en-US Men of War: Masculinity and the First en-US World War in Britainen-US en-US 2011.en-US Monger, David, Sarah Murray, and Katie Pickles, eds., en-US in en-US Endurance and the First World War: Experiences en-US and Legacies in New Zealand and Australia en-US (Newcastle en-US upon Tyne: Cambridge Scholars Publishing, 2014), pp. en-US XII-XIII. Google Books eBook.en-US Loveridge, Steven The Link Between Sentimenen-US -en-US tal Equipment and Endurance in New Zealands War en-US Effort.en-US Roper, Michael, en-US The Secret Battle: Emotional Survival en-US in the Great War. en-USManchester: Manchester University en-US Press, 2009.en-US Watson, Alexander Watson, en-USEnduring the Great War: en-US Combat, Morale, and Collapse I the German and Briten-US -en-US ish Armies, 1914-1918en-US Cambridge: Cambridge Univeren-US -en-US sity Press, 2008. en-USScholarly Articleen-USen-US -en-US sualty Evacuation in World War I, en-US ICON: Journal of the Inen-US -en-US ternational Committee for the History of Technologyen-US Vol. 14 en-US (2008).

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124 http://www.cs.amedd.army.mil/amedd_journal.aspx en-USThe US Army Health Readiness Center of Excellenceen-US The Army Medical Department Center and School ENVISION, DeE SIGN, TRAIN, EdD UCAte TE, I INSPIRe E Joint Base San Antonio-Fort Sam Houston, Texas

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SUBMIssSSION OF MMANUsSCRIPTsS TO THE ARMY MMEDICaAL DDEPaARTMENT JOURNaAL The en-USUnited States Army Medical Department Journal en-US is published quarterly to expand knowledge of domestic and international en-US military medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps, en-US and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewed print en-US medium to encourage dialogue concerning health care issues and initiatives. RREVIEW PPOLICY All manuscripts will be reviewed by the en-USAMEDD Journalen-US s Editorial Review Board and, if required, forwarded to the appropriate en-US subject matter expert for further review and assessment. IIDENTIFICATION OF PPOTENTIAL CCONFLICTsS OF IINTEREsST 1. en-USRelated to individual authors commitments:en-US en-US -en-US tionships that might bias the work or information presented in the manuscript. 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PPROTECTION OF HHUMAN SUBJECTsS AND AANIMALsS IN RREsSEARCH When reporting experiments on human subjects, authors must indicate whether the procedures followed were in accordance with en-USthe ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki en-US Declaration of 1975, as revised in 2000. If doubt exists whether the research was conducted in accordance with the Helsinki Declaration, en-US the authors must explain the rationale for their approach and demonstrate that the institutional review body explicitly approved the en-US doubtful aspects of the study. When reporting experiments on animals, authors should indicate whether the institutional and national en-US guide for the care and use of laboratory animals was followed. IINFORMED CCONsSENT Identifying information, including names, initials, or hospital numbers, should not be published in written descriptions, photographs, en-USen-US en-US en-US as well as in print after publication. Patient consent should be written and archived, either with the en-US Journalen-US the authors, or both, en-US as dictated by local regulations or laws. GUIDELINEsS FOR MMANUsSCRIPT SUBMIssSSIONsS 1. en-USManuscripts may be submitted either via email (preferred) or by regular mail. Mail submissions should be in digital format (preferen-US -en-US ably an MS Word document on CD/DVD) with one printed copy of the manuscript. Ideally, a manuscript should be no longer than en-US 24 double-spaced pages. However, exceptions will always be considered on a case-by-case basis. 2. en-USThe en-US American Medical Association Manual of Style en-USgoverns formatting in the preparation of text and references. All articles en-US should conform to those guidelines as closely as possible. Abbreviations/acronyms should be limited as much as possible. Incluen-US -en-US sion of a list of article acronyms and abbreviations can be very helpful in the review process and is strongly encouraged. 3. en-USA complete list of references cited in the article en-US musten-US be provided with the manuscript, with the following required data: en-USReference citations of published articles must include the authors surnames and initials, article title, publication title, en-US year of publication, volume, and page numbers. en-USReference citations of books must include the authors surnames and initials, book title, volume and/or edition if appropriate, en-US en-USReference citations for presentations, unpublished papers, conferences, symposia, etc, must include as much identifying en-US information as possible (location, dates, presenters, sponsors, titles). 4. en-USEither color or black and white imagery may be submitted with the manuscript. 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Submit manuscripts to:en-US DSN 471-6301en-US Comm 210-221-6301 Email: usarmy.jbsa.medcom-ameddcs.list.amedd-journal@mail.mil EDITOR, AMEDDDD JOURNaAL AHS C DDDD AME DDDD C&S 3630 STa ANLeEY RDRD STTE B0204 JBSA FORT SamAM HOUsSTON, T TX 78234-6100

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