Delaware Journal of Public Health - One Health

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Delaware Journal of

Volume 7 | Issue 1

January 2021

Public Health A publication of the Delaware Academy of Medicine / Delaware Public Health Association |

Delaware Journal of

Delaware Academy of Medicine

Board of Directors: OFFICERS Omar A. Khan, M.D., M.H.S. President S. John Swanson, M.D. President Elect

January 2021

Public Health Volume 7 | Issue 1

A publication of the Delaware Academy of Medicine / Delaware Public Health Association

Lynn Jones Secretary David M. Bercaw, M.D. Treasurer Daniel J. Meara, M.D., D.M.D. Immediate Past President Timothy E. Gibbs, M.P.H. Executive Director, Ex-officio DIRECTORS Stephen C. Eppes, M.D. Eric T. Johnson, M.D. Joseph F. Kestner, Jr., M.D. Professor Rita Landgraf Brian W. Little, M.D., Ph.D. Arun V. Malhotra, M.D. John P. Piper, M.D. EMERITUS Robert B. Flinn, M.D. Barry S. Kayne, D.D.S.

Delaware Public Health Association

Advisory Council:

Omar Khan, M.D., M.H.S. President Timothy E. Gibbs, M.P.H. Executive Director Louis E. Bartoshesky, M.D., M.P.H. Gerard Gallucci, M.D., M.H.S. Richard E. Killingsworth, M.P.H. Erin K. Knight, Ph.D., M.P.H. Melissa K. Melby, Ph.D. Mia A. Papas, Ph.D. Karyl T. Rattay, M.D., M.S.

3 | In This Issue Omar A. Khan, M.D., M.H.S. Timothy E. Gibbs, M.P.H.

4 | Guest Editor Karen M. Lopez, D.V.M., M.P.H.

6 | O ne Health Delaware: A Novel Approach to Health Equity Through Cross Professional Collaboration Kristin Jankowski, V.M.D., C.C.R.P.

8 | F urthering the One Health Mission: Template for Establishing Student-Run One Health Groups on College Campuses Halle Fitzgerald Mugdha Parulekar Eliana Schach Gloria Bachmann, M.D., M.M.S.

14 | V ibriosis: What You and Your Patients Need To Know Andrew Bell, Michael Bott

22 | Microbial Source Tracking in the Love Creek Watershed, Delaware (USA) Christopher R. Main, Ph.D. Robin Tyler, Ph.D. Sergio Huerta, M.D.

32 | Using Meat Labels to Communicate the Risk of Antimicrobial-Resistant Bacterial Infections from Foods of Animal Origin: The Case for a Balanced One Health Approach to Raising Food Animals G. Donald Ritter, D.V.M., A.C.P.V.

38 | C OVID-19 Acutely Impacted the Delmarva Poultry Industry in Early 2020 Christopher Brosch, M.Sc. Georgie Cartanza

40 | Global Health Matters Fogarty International Center

52 | Live Bird Markets of the Northeastern United States Jarra F. Jagne, D.V.M., D.A.C.V.P.M. Joy Bennett, D.V.M., M.P.H., D.A.C.V.P.M. Eireann Collins, D.V.M.

58 | Pollinators are Essential Workers Emily Wine, M.S.

62 | C OVID-19 Pandemic Strengthens Human-Animal Bond Sheri L. Wood, D.V.M.

William J. Swiatek, M.A., A.I.C.P.

Omar Khan, M.D., M.H.S. Editor-in-Chief Karen Lopez, D.V.M., M.P.H. Guest Editor Liz Healy, M.P.H. Managing Editor Kate Smith, M.D., M.P.H. Copy Editor Suzanne Fields Image Director ISSN 2639-6378

Douglas D Riley D.V.M.

66 | Lone Star Ticks (Amblyomma americanum): An Emerging Threat in Delaware Ashley C. Kennedy, Ph.D., M.S., B.C.E. Emily Marshall, M.S.

72 | Sentinel Chickens and Their Role in Mosquito-Borne Virus Surveillance in Delaware Shaun McIntire Matt Esposito John Badger

76 | Emergency Patient Voting Initiative in a Community Hospital During a Global Pandemic: Lessons and a Call-To-Action for Expanded Voter Access Carly Chamberlain, D.O. Henrique Jaime, M.D. Diana Wohler, M.D.

78 | From the History and Archives Collection Anthrax Sharon Folkenroth Hess, M.A.

82 | One Health - RESOURCES 83 | One Health - LEXICON 84 | Index of Advertisers

Delaware Journal of Public Health Timothy E. Gibbs, M.P.H. Publisher

64 | Delaware Partnership for One Health

COVER What is One Health? One Health is an approach that recognizes that the health of people is closely connected to the health of animals and our shared environment. One Health is not new, but it has become more important in recent years. This is because many factors have changed interactions between people, animals, plants, and our environment.

The Delaware Journal of Public Health (DJPH), first published in 2015, is the official journal of the Delaware Academy of Medicine / Delaware Public Health Association (Academy/DPHA).

only the opinions of the authors and do not necessarily reflect the official policy of the Delaware Public Health Association or the institution with which the author(s) is (are) affiliated, unless so specified.

Submissions: Contributions of original unpublished research, social science analysis, scholarly essays, critical commentaries, departments, and letters to the editor are welcome. Questions? Write or call Liz Healy at 302-733-3989.

Any report, article, or paper prepared by employees of the U.S. government as part of their official duties is, under Copyright Act, a “work of United States Government” for which copyright protection under Title 17 of the U.S. Code is not available. However, the journal format is copyrighted and pages June not be photocopied, except in limited quantities, or posted online, without permission of the Academy/ DPHA. Copying done for other than personal or internal reference use-such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale- without the expressed permission of the Academy/DPHA is prohibited. Requests for special permission should be sent to

Advertising: Please write to or call 302-733-3989 for other advertising opportunities. Ask about special exhibit packages and sponsorships. Acceptance of advertising by the Journal does not imply endorsement of products. Copyright © 2020 by the Delaware Academy of Medicine / Delaware Public Health Association. Opinions expressed by authors of articles summarized, quoted, or published in full in this journal represent

I N T H I S I S SU E One Health For thousands of years, Native Americans, Alaskan Natives, and First Nation peoples in the rest of the Americas have understood innately, and honored consistently, the concepts of One Health that many people today are just coming to grasp and apply. According to the Centers for Disease Control and Prevention: “One Health is an approach that recognizes that the health of people is closely connected to the health of animals and our shared environment. One Health is not new, but it has become more important in recent years. This is because many factors have changed interactions between people, animals, plants, and our environment.” Past issues of the Journal have touched on aspects linked to One Health, including Climate and Health, Nutrition, Creating Healthy Communities, Cancer, and Communicable Disease. In reality, virtually every issue of the Journal has some component with linkage to One Health. For this issue, we engaged Karen Lopez, D.V.M., M.P.H., Delaware’s Deputy State Veterinarian as our guest editor, and we thank her for her connections and hard work that led to this issue’s culmination. For many readers, One Health will initially conjure up thoughts of rescue animals, such as those (both canine and feline) who will soon be in the White House with President-Elect Joe Biden and Dr. Jill Biden. For those of us old enough, we might recall the massive mosquito spraying efforts of our childhood when we chased after the mist from the planes (clearly not an advisable practice). Still others will think of our poultry industry, or the periodic scare from a potential rabies-carrying animal. And it goes much deeper than all of those combined. As a side note, we are very pleased to announce that the Delaware Journal of Public Health is now included, at an article level, in CrossRef; we’ll have more exciting news to share with you in our spring issue. As always, we hope that you enjoy this issue of the Journal, and we welcome your feedback.

Omar A. Khan, M.D., M.H.S. President

doi: 10.32481/djph.2021.01.001

Timothy E. Gibbs, M.P.H. Executive Director


Karen M. Lopez, D.V.M., M.P.H. Diplomate – American College of Veterinary Preventive Medicine; Deputy State Veterinarian, Delaware Department of Agriculture

“I can only compare the experience to that of a child meeting his or her favorite superhero or sports star. She was my own personal professional hero, and I was getting to have dinner with her that night!” I first learned of Conservation through Public Health (CTPH), a non-profit, non-governmental organization based in Uganda, during my second year of veterinary school, while attending a presentation made by an upperclassman on her experience doing a research project with the center over the summer. That was my first introduction to Dr. Gladys Kalema-Zikusoka. She is the veterinarian that made the connection that cases of scabies in the mountain gorillas living in Bwindi Impenetrable National Park were associated with scabies illnesses in the human communities surrounding the forest. The first outbreak occurred in 1996 with a subsequent outbreak in 2001-2002. Fortunately for this endangered species, treatment with Ivermectin led to successful resolution of illness in the gorillas, aside from one fatal case in a gorilla infant. CTPH was founded upon this realization that the health of the gorillas was dependent on the health of humans – and vice-versa – as the species encroached on each other’s habitats.1 For the reader of this journal issue, it also serves as a textbook example of the One Health concept. The Centers for Disease Control and Prevention (CDC) define One Health as “a collaborative, multi-sectoral, and transdisciplinary approach – working at the local, regional, national, and global levels – with the goal of achieving optimal health outcomes recognizing the interconnection between people, animals, plants, and their shared environment.”2

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Classically, zoonotic diseases have served to exemplify the One Health concept, and indeed, several of these diseases and their collaborators will be highlighted in this issue. But the interrelationships between human, animal, and environmental health extend beyond hosts, pathogens, and their environments to issues concerning occupational health, mental health, chronic disease, and food security.2 The 2018 fatal case of rabies in a Delaware woman served as an impetus for the launch of a small One Health project here in the First State. A multi-agency educational committee consisting of representation from Delaware Departments of Agriculture, Natural Resources and Environmental Conservation/Division of Fish & Wildlife, Health and Social Services/Division of Public Health and the Public Health Laboratory was formed to address a perceived lack of public knowledge on the risk of rabies. The educational project debuted at the 2019 Delaware State Fair, where simple public messaging encouraging rabies vaccination of pets and keeping a safe distance from wildlife was shared through games, prizes, and informational materials.3 We believe that education such as this could have prevented the tragic death of the Delaware citizen the year prior, where neither interactions with domestic nor wild animals could be ruled out as routes of exposure for rabies. This was the first confirmed case of human rabies in Delaware since 1941. Plans to continue outreach at future Delaware State Fairs and other events in the state have been postponed at this time due to lack of personnel and financial resources for the endeavor due to COVID-19, but our intention is to resume activities once feasible. How did I come to have the opportunity to meet my hero over dinner back in 2016? Well, I was coming to the end of my own One Health expedition as a volunteer with Veterinarians Without Borders during the last few months of my veterinary public health and preventive medicine residency. I had spent the last four weeks traveling throughout the West Nile region of Uganda with several other American veterinarians, educating local veterinarians, animal health technicians, cattle traders, butchers, and farmers on high consequence animal diseases and zoonotic disease prevention. I found myself in Kampala preparing to depart for my next destination, emailing with one of my mentors who was a personal friend of Dr. Kalema-Zikusoka. Knowing how exciting it would be for me to meet her while I was in country, phone calls were made, emails were sent, and the next thing I knew, Gladys was my dinner guest that evening. I giddily listened to her discuss CTPH projects: testing of gorilla fecal samples from night nests to evaluate for the presence of pathogens of concern to the gorillas and humans, family planning education and intervention with collaboration from local religious leaders, transport of human sputum samples by volunteers to regional hospitals to test for tuberculosis followed by initiation of treatment of case patients, and group livestock income-generating projects to support the Village Health and Conservation Team volunteers working in the community.4,5 doi: 10.32481/djph.2021.01.002

Perhaps you are a reader who has never previously heard of One Health. On the other hand, you may be a regular transdisciplinary collaborator who is well versed in the concept. Regardless, I hope that this issue brings to light some of the One Health issues facing our state and region, and draws attention to some of our outstanding colleagues dedicated to One Health issues. My wish, though… my wish would be that this issue reaches even one impressionable reader and lights a spark of realization in him/her that the grand health challenges that we face can only be solved by working together through a One Health approach. Dinner is on me.

REFERENCES 1. Conservation through Public Health. (2019). About us. Retrieved from:

3. Lopez, K. (2019). Rabies outreach: 2019 Delaware State Fair. Proceedings of the 123rd Annual United States Animal Health Association Meeting. (n.p.) 4. Conservation through Public Health. (2019). Alternative livelihoods. Retrieved from: 5. Gaffikin, L., & Kalema-Zikusoka, G. (2010). Integrating human and animal health for conservation and development: Findings from a program evaluation in southwest Uganda. Conservation through Public Health, Evaluation and Research Technologies for Health, and John Snow, Inc. Retrieved from: cfm?id=11196&lid=3

2. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infection Diseases. (2018, Nov 5). One health basics. One Health. Retrieved from:


One Health Delaware: A Novel Approach to Health Equity Through Cross Professional Collaboration Kristin Jankowski, V.M.D., C.C.R.P. Assistant Clinical Professor, Small Animal Community Practice, UC Davis Veterinary Medical Teaching Hospital; Affiliated Faculty, One Health Institute, School of Veterinary Medicine, UC Davis

Delaware Humane Association’s (DHA) One Health Delaware is a free, once monthly clinic that provides both veterinary and human healthcare to an underserved community in Wilmington, Delaware. The CDC states that, “Differences in social determinants of health contribute to the stark and persistent chronic disease disparities in the United States among racial, ethnic, and socioeconomic groups,1 systematically limiting opportunities for members of some groups to be healthy.”2 The goal of One Health Delaware is to utilize the human-animal bond to help bring preventive healthcare to families no matter their income, ethnicity, or immigration status. An additional benefit is to provide clinical experience to health professional students while modeling compassionate care without racial bias and enhancing One Health thinking across professions in a time of great global need.

of the community as a whole.

One Health Delaware is led by DHA, but is run with the volunteer help of veterinarians and technicians who join student volunteers from University of Pennsylvania School of Veterinary Medicine, University of Delaware, and Wilmington University Nurse Practitioner Program. The clinic runs in the community room of the Henrietta Johnson Medical Center, which is a Federally Qualified Health Center (FQHC) in the Southbridge section of Wilmington, Delaware. The team provides services for both the pets and people, side by side. The pets receive wellness exams, vaccinations, and health screenings. The families attending the clinic can access a variety of health and social services including blood pressure screenings, flu vaccines, or help enrolling for health insurance. All services are provided free of charge. They also have opportunities to schedule future health appointments, enroll in SNAP benefits, or sign up for healthy eating classes. Nurses and nursing students provide wellness information and opportunities to discuss any concerns. Spanish interpretation is provided by University of Delaware undergraduate students.


This inclusive healthcare model shows promise to provide access to services in both rural and urban areas for people and pets and could become an impactful way to reach populations that have been previously underserved. Pilot data collection during the first year of the clinic showed a profound interest in families coming back to Henrietta Johnson Medical Center for both veterinary and human healthcare. Researchers from the University of Pennsylvania School of Veterinary Medicine are currently measuring the clinic’s impact on the clients, veterinary students, and volunteers of the clinic. It is my sincere hope that this small One Health project in the First State of Delaware could serve as a model for One Health clinic opportunities across the country. Correspondence: Kristin Jankowski, 1. Braveman, P., Egerter, S., & Williams, D. R. (2011). The social determinants of health: Coming of age. Annual Review of Public Health, 32, 381–398. 2. Braveman, P. & Gottlieb, L. (2014, Jan-Feb). The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep, 129 Suppl 2(Suppl 2), 19-31. PMID: 24385661; PMCID: PMC3863696.

According to the American Veterinary Medical Association, the human-animal bond is “a mutually beneficial and dynamic relationship between people and animals that is influenced by behaviors essential to the health and wellbeing of both.” One Health Delaware supports these relationships by providing an opportunity for clients to present their concerns and ask questions about themselves and their pets. Meanwhile, the medical professionals and student volunteers provide them with support, educational materials, and their time. This open platform encourages further development of the emotional and physical wellbeing of both pet and owner by creating a welcoming environment free of judgement or financial barriers. We aspire to give our clients the power to take an active role in their pet’s healthcare with the hope that this translates to empowerment in their own healthcare decisions. With the creation of this pop-up, open-door, One Health clinic in their neighborhood, we offer a unique opportunity to use the human-animal bond for the benefit 6 Delaware Journal of Public Health – January 2021

doi: 10.32481/djph.2021.01.003

Accessible version:

ADOPT THESE HEALTHY PET HABITS Pets can be good for our health, but they can also carry germs that make people sick. Pets can carry germs even if they look clean and healthy. Learn how to enjoy pets while staying healthy!

Healthy Pet Habits

Healthy Pet Habits

KEEP IT CLEAN! • Wash hands after touching, feeding, or caring for your pets.


• Scoop the poop: clean up after pets in your house, yard, and in public places.

• Do your homework before getting a new pet. • Some pets aren’t safe for kids under 5, older adults, people with weakened immune systems, or pregnant women.



Healthy Pet Habits

Healthy Pet Habits

PLAY SAFELY! • Don’t kiss your pets or let them lick your face. • Take care to avoid bites and scratches. • Always supervise young children around pets.


TAKE YOUR PET TO THE VET! • Regular veterinary visits help keep pets healthy, which helps keep you healthy. • Take your pet to the vet if you think it might be sick.


Remember, healthy pets = healthy people!


Furthering the One Health Mission: Template for Establishing Student-Run One Health Groups on College Campuses. Halle Fitzgerald, Mugdha Parulekar, Eliana Schach, Gloria Bachmann, M.D., M.M.S. Rutgers Robert Wood Johnson Medical School-Women’s Health Institute and members of the NJ One Health Committee

ABSTRACT Introduction: Although it has been well-established that animal health and environmental health impact human health, there is a lack of inclusion of One Health in the education of medical and undergraduate students1. Most students, in fact, are not aware of the One Health initiative. Rationale: Due to the fundamental lack of One Health knowledge across all involved disciplines but particularly healthcare fields, educating students at the institutional level is desirable to provide early exposure. Education should influence more integrated practice for future citizens, including those in the health professions. Methods: A framework for commencing a successful One Health student club is outlined, with steps that include distinguishing the club, writing a Constitution, advertising to students, holding elections, formally establishing the University recognized club and expanding its presence on campus. Results: An undergraduate student One Health group at Rutgers University was established, and another one is currently being established at Rutgers Robert Wood Johnson Medical School. Despite the fact that One Health is an established, global initiative, there was a great deal of education necessary to alert students as to what One Health is. Although there also were multiple operational issues that had to be addressed, once commenced at the undergraduate level, it has been a very successful campus initiative. Discussion: From the experience at Rutgers University, One Health student groups can be established that further the message of One Health. Public health implications: Having a One Health presence at educational institutions via student groups will raise awareness of One Health principles, especially as they relate to public health.



Four states commenced and now have an ongoing One Health Regional Consortium (Delaware, Maryland, New Jersey and Pennsylvania). One of the initiatives that has been stressed is the education of students about One Health principles. Traditional health care fields have minimized the study of other animals and the environment in the training of future public health professionals and providers; for example, currently, there are only five medical schools that address One Health through student groups or teaching1. One of the outcomes from the last One Health Regional Consortium meeting was that the New Jersey Steering Committee took on the initiative for learners to establish a template for creating One Health student groups on campus. Due to the fundamental lack of One Health knowledge across all involved disciplines, educating students at the institutional level is desirable to provide early exposure to One Health ideals and thus inform practice and public health guidelines for future professionals. Therefore, the goals of these student groups are to increase awareness of One Health and instill the idea that people from different areas of study can and should collaborate to improve the environment, overall wellness of all humans and animals and public health outcomes. In addition to educating about One Health, another goal is to bring together students of different professions to promote collaboration on interdisciplinary projects and to possible set up a non-credit elective, especially as it relates to medical students.

Undergraduate Club Framework

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The following steps were used to establish a One Health Club at the undergraduate level:

Distinguishing the Club

The main challenge of establishing an undergraduate level One Health Club is distinguishing the club from the hundreds of other organizations on campus Health and environmental organizations are both popular categories. A search of existing organizations was first performed to ensure there was not one already that was too similar in mission. In our research, we found that there were 21 health-related organizations, 13 organizations related to environmental science or conservation efforts, and 3 organizations related to animal science. However, none of them combined these three aspects of One Health into one mission.

Writing a Constitution

Next, a Constitution was written in order to outline the pillars that the One Health Club would be based on. The Constitution includes the club’s statement of purpose, types of initiatives, membership requirements, voting and running eligibility for executive board. We included the following goals for the club: 1. Raise awareness in the local community about the interconnectedness of human, animal, and environmental health. Many infectious human diseases have an animal doi: 10.32481/djph.2021.01.004

origin and these spillovers can be prevented, or their consequences minimized, by better management and preparedness. Human physical and mental health also depends directly on clean air, water, and environment. 2. Educate students about the biological mechanisms that lead to a diseased world by involving them in cross-disciplinary research projects that combine human, animal, and environmental health. 3. Advocate for policies and laws that promote this One Health integrative approach at the community and state level. Departments such as Wildlife, Agriculture, and Health should formally work together in order to streamline responses to health challenges. 4. Foster a network of students from various career paths including veterinary science, environmental science, and pre-medicine to promote One Health values and collaboration across professional fields. When writing the Constitution, emphasis was made to gear the content to a general audience that is unfamiliar with One Health. It is not sufficient to simply state that human, animal, and environmental health are related. Rather, it was necessary to provide specific examples when outlining the purpose of the club and how certain projects would further the mission.

Outreach to Students

At Rutgers University New Brunswick, approving a club at the undergraduate level requires some proof of interest beforehand. A preliminary executive board and at least ten members must sign on to the club prior to approval. Even if this is not a requirement at each institution, it is recommended that gauging general interest be done to enable a strong club start. It is also best practice to have members, including the executive board, from the different graduation years be represented to ensure sustainability of the club. Although there was no centralized method to disseminate information about the club to undergraduate students, channels of communication were identified for students in majors applicable to One Health. The Rutgers Health Professions Office, the School of Environmental and Biological Sciences, and several LivingLearning Communities were included. In this way, pre-medical, pre-veterinary, environmental science, and public health students were alerted. A simple, informative flyer including the mission of the club, contact information, and the timing of the first interest meeting was devised. This flyer was shared via email and through social media group chats.

Holding Elections

Six leadership positions were identified: President, Vice President, Secretary, Treasurer, Advocacy Chair, and Program Coordinator. Of note are the Advocacy Chair and Program Coordinator positions. The Advocacy Chair is responsible for reaching out to advocacy organizations for partnerships and handling other off-campus communications. The Program Coordinator is responsible for coordinating on-campus events and research initiatives. The elections were held via a Rutgers Qualtrics survey, which enabled confidentiality while preventing doublevoting. One addition that is planned is including a Social Media/ Marketing Chair position.

Formally Establishing the Club

A formal application was submitted to the student involvement organization in order to gain approval to become a recognized club.

Expanding Presence on Campus

Undergraduate institutions are very large and for the club to gain recognition, it is important to broaden horizons and presence on campus. Holding guest speaker events that are open to all students and faculty is a big factor for the club and the initiative to gain more attention. Collaborating with larger well known student organizations at the institution also is key to raise awareness of the One Health initiative as well as recruit new potential members for the club. The club not only wants to facilitate the education of its own members but also to other students on campus. One way we have been forming connections is through our club Instagram account. Through this account we post educational posts about One Health and reach out to other One Health-related organizations. These other organizations then share our posts on their accounts, and we are able to reach a wider audience.

MEDICAL SCHOOL INTEREST GROUP AND SURVEY At the Medical School level, establishing a student group requires proof of sustainability and student interest due to the much smaller class size than a typical undergraduate student body. A one page proposal was submitted outlining the necessity for an Interest Group with an associated brief literature review as evidence, a chosen faculty advisor, a mission statement, as well as a list of planned activities. This proposal was submitted to the deans and the student government and is now pending.

RESULTS Undergraduate Club

Within the first two weeks of sending out informational flyers, we received responses from 66 people who were interested in joining the club. Once formed, 40% of the club ran for the six leadership positions. The advantage of interdisciplinarity has already been demonstrated as many club members are connecting with others beyond their major and creating new projects related to public health, economics, and healthcare disparities. None of these members were initially familiar with the concept of One Health, but they were attracted by the interdisciplinary nature of the club. The One Health Club was approved for provisional status; after demonstrating effective use of funds and sustained interest in the club by at least ten members for one full semester, the full active status will be granted. Since starting in May 2020, the One Health Club has been very active and in addition to seminars by prominent persons in the field, the Club members are actively pursuing projects such as a One Health children’s book that simplifies the concept of One Health to elementary school children. The Club also is engaged in a social media campaign, speaking presentations at schools, and a high school scholarship essay contest. For the Medical School Group, there is data collection ongoing at this time to add to the proposal and demonstrate the need for a student group. 9

DISCUSSION It is important to educate undergraduate and graduate students about One Health due to the pervasive lack of current information on the topic. It is key to introduce these concepts at the undergraduate level, where students tend to partake in multiple extracurricular organizations and explore diverse areas of study. That is, graduate students, such as medical students tend to be more restricted in their pursuit of extracurriculars due to time constraints and a more focused area of study. Introducing these concepts at an earlier level of education and to a broader scope of learners will lead to more widespread knowledge sharing. This education can then be propagated through graduate schools, medical schools, veterinary schools, masters programs in public health, etc. When creating the One Health Club at Rutgers University, it proved more difficult to raise awareness of the club due to having education in a virtual format due to COVID-19. Therefore, it was essential to resort to virtual marketing tactics to spread awareness and gain more widespread student recognition. Currently, at the Club, we are planning to add a social media/marketing chair as it is especially important during times of pandemic.

PUBLIC HEALTH IMPLICATIONS Through One Health, communities and government can collaborate and create effective public health interventions. History has shown us that public health interventions, such as the fortification of grain products with folate in 1998, make the largest impacts on global wellness overall. Making governmental changes will positively impact the health of our environment, animals, and therefore people. Additionally, more people knowing about One Health will change the way that health care for

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humans and other animals is practiced. These are the reasons for commencing One Health student groups on college campuses. And of course, One Health plays a large role in the future of global health and specifically in human wellness, most recently evidenced by the development and consequences of COVID-19. Integrating different health disciplines with the public health sector can revolutionize the way that health care is practiced and disease prevention takes place, so that as a society we are better prepared for future local and global disasters.

RESOURCES Cheryl Stroud, Bruce Kaplan, Jenae E. Logan & Gregory C. Gray (2016) One Health training, research, and outreach in North America, Infection Ecology & Epidemiology, 6:1, Rabinowitz, P.M., Natterson-Horowitz, B.J., Kahn, L.H. et al. Incorporating one health into medical education. BMC Med Educ 17, 45 (2017). Lucey, Daniel R., et al. “One Health Education for Future Physicians in the Pan-Epidemic ‘Age of Humans.’” International Journal of Infectious Diseases, Elsevier, 22 Aug. 2017, Teaching “One Medicine, One Health” Kahn, Laura H. et al. The American Journal of Medicine, Volume 121, Issue 3, 169 - 170 Togami, E., J. L. Gardy, G. R. Hansen, G. H. Poste, D. M. Rizzo, M. E. Wilson, and J. A. K. Mazet. 2018. Core Competencies in One Health Education: What Are We Missing? NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC.



The FDA’s recent emergency use authorization for a COVID-19 vaccine gives us a real shot at ending this pandemic. It’s time to get back to normal. But we all must do our part – and this begins with accessing the right information. Get your questions answered and learn more: Together, let’s make COVID-19 history.


The DPH Bulletin

From the Delaware Division of Public Health

December 2020 Free mail-order naloxone now available for those struggling with addiction

Delawareans struggling with addiction can now order free naloxone by mail, thanks to the efforts of DPH’s Office of Health Crisis Response (OHCR). The lifesaving medication, also known by its brand name, Narcan, can reverse opioid drug overdoses by restoring someone’s breathing that has become suppressed from an overdose.

Bayhealth nurse Elizabeth Cote, RN received the first COVID-19 vaccination on December 14 at Kent General Hospital in Dover, Delaware. Photo courtesy of the State of Delaware.

COVID-19 vaccine arrives in Delaware Delaware received its first shipment of the Pfizer BioNTech COVID-19 vaccine on December 14 and a second shipment on December 16. “The Pfizer vaccine’s arrival is the first step in a process of getting back to our pre-pandemic normal,” said Governor John Carney. “The vaccine’s arrival does not mean we are in the clear. In fact, now more than ever, we need to step up our efforts to keep each other safe. That means wear a mask, wash your hands, and do not gather with your friends and family outside of your household. We know that’s hard, particularly at this time of year, but we are almost through this.” While the Division of Public Health (DPH) does not plan to mandate the vaccine, it strongly encourages people, particularly health care workers, to get vaccinated once doses become available. Most of the initial 8,775 Pfizer vaccine doses received this week have or will be distributed to the state’s six health care systems to vaccinate front-line health care providers. The general public can expect to receive vaccines in the spring or summer of 2021 through their primary health care providers, health centers and pharmacies. Children under the age of 16 are not approved to get the vaccine. The Pfizer vaccine was tested on more than 40,000 Americans, including people of color, in three clinical trials. It has a 90 percent effectiveness rate with minor side effects such as muscle soreness and redness. The Pfizer vaccine does not contain a live virus and cannot give individuals COVID-19. Individuals can email their questions concerning the vaccine to 12 Delaware Journal of Public Health – January 2021

Mail-order naloxone is available through a Memorandum of Understanding between the Delaware Department of Health and Social Services (DHSS) and the New York-based harm-reduction nonprofit NEXT Distro. NEXT Distro operates in 35 states and has distributed free naloxone to 16,000 households in the United States since 2018. DPH will receive the request from NEXT Distro’s virtual platform and will send naloxone within a few days, keeping contact information confidential. Increasing access to naloxone is critical to preventing overdose deaths as more people are struggling with anxiety, depression, and financial stress stemming from the COVID-19 pandemic. Receiving in-person support and treatment is more challenging due to social distancing, which prevents meeting at in-person support groups. According to the Delaware Overdose Fatality Commission 2018 Annual Report, 79 percent of the overdoses studied occurred in residences, and naloxone was not available 93 percent of the time. OHCR reminds people that they have “The Power to Save a Life” by having Narcan available and downloading the free OpiRescue DE app for step-bystep instructions on its use. To order naloxone by mail, visit the Overdose Prevention page on and access NEXT Distro’s Delaware program. Individuals must watch a video, take a short quiz, and complete a request form. During addiction or mental health emergencies, call the DHSS 24/7 Delaware Hope Line at 1-833-9HOPEDE.

CDC: Excessive alcohol use poses risk to women’s health Alcohol affects women differently than men, according to the Centers for Disease Control and Prevention (CDC). Although men are more likely to drink alcohol and consume larger amounts, biological differences in body structure and chemistry lead most women to absorb more alcohol and take longer to metabolize it. The CDC warns that women who drink excessive amounts of alcohol are at risk of violence including homicide, suicide, sexual assault, and intimate partner violence. Excessive drinking can result in risky sexual behaviors, unintended pregnancies, miscarriages, and stillbirths, according to the CDC. The CDC lists these long-term health problems for women who drink excessively: cirrhosis and alcohol-related liver diseases, cognitive decline and shrinkage of the brain, damage to the heart muscle, and increased risk of cancers of the mouth, throat, esophagus, liver, and colon. Alcohol use is also associated with breast cancer. The CDC defines binge drinking for women when four or more drinks are consumed in about two hours, leading to a blood alcohol concentration of 0.08 g/dl or greater; and heavy drinking as eight or more drinks per week. No alcohol – including all wine and beer – is safe to consume during pregnancy or while trying to become pregnant because it can cause miscarriage or stillbirth and greatly increases the chances of Fetal Alcohol Spectrum Disorder (FASD), which the CDC says is associated with intellectual disabilities and birth defects. Some FASD signs and symptoms listed by the CDC are low body weight, poor coordination and attention spans, hyperactive behavior, poor memory, and difficulty in school (especially with math), and speech and language delays. For more information about women and alcohol use disorder, visit For FASD information, visit For free 24/7 counseling, coaching, therapy, and links to mental health, addiction, and crisis services, visit or call the Delaware Hope Line at 833-9-HOPEDE.

The DPH Bulletin – December 2020

State’s cancer mortality rates decrease between 2002-2006 and 2012-2016

Over the last decade, Delaware’s mortality rate for all cancer sites combined (all-site cancer) declined 10 percent between the five-year periods of 2002-2006 and 2012-2016, according to the latest cancer data released by DPH. In the same time span, Delaware’s all-site cancer mortality rate also declined for African American males and females and Hispanic females, which DPH attributed to increased screening and early detection efforts. Additionally, mortality rates decreased for female breast, colorectal, lung, prostate, and Non-Hodgkin Lymphoma. For the most recent five-year period of 2012-2016, the state’s all-site cancer mortality rate was 8 percent higher than the U.S. rate. Cancer Incidence and Mortality in Delaware, 20122016 provides data for all-site cancer and eight sitespecific cancer types: breast, colorectal, lung, melanoma, Non-Hodgkin Lymphoma, prostate, thyroid, and uterine. It also includes information about risk factors, screening, state of diagnosis, data trends, and a section on cancer survivorship in Delaware. A secondary analysis of all-site cancer incidence rates by census tract accompanies the report. Regarding incidence, or diagnosis of new cancer cases, in 2012-2016, Delaware remained ranked second highest nationally for all-site cancer incidence, which was statistically significantly higher than the U.S. Delaware males rank third compared to U.S. males and Delaware females rank fifth in the U.S. compared to U.S. females. For information about DPH’s cancer prevention and treatment work, call the Delaware Comprehensive Cancer Control Program at 302-744-1020 or visit To learn how to prevent, detect, and treat chronic diseases, visit the Healthy Delaware website: Read the Delaware Cancer Consortium’s recommendations at Percentage of cancer among cancer survivors, Delaware, 2018 One type of cancer Two types of cancer Three or more types of cancer

Source: Delaware Department of Health and Social Services, Division of Public Health, Delaware Behavioral Risk Factor Survey, 2018.

Page 2 of 2 13

Vibriosis: What You and Your Patients Need To Know Andrew Bell Shellfish Standardization Officer, Shellfish & Recreational Water Program, Delaware Department of Natural Resources and Environmental Control Michael Bott Program Lead, Shellfish & Recreational Water Program, Delaware Department of Natural Resources and Environmental Control

The rapid progression, limited treatment options, and high fatality rate of vibriosis in high-risk individuals, coupled with the apparent increasing incidence of vibriosis, underscore the need for prevention by patients as well as quick diagnosis and treatment by healthcare providers. Yet, vibriosis is an under-recognized and under-reported illness,1 and awareness of the potential for infection is low among high-risk patients.2 Prompt diagnosis and treatment of vibriosis in high-risk patients is necessary to prevent death, and educating high-risk patients on how to avoid infection will save lives.2

underlying health conditions or with weakened immune systems may develop life-threatening illness. For this reason, high-risk individuals should never eat raw or partially cooked seafood. Additionally, all individuals should prevent contact between an open wound and salt or brackish water. Healthcare providers are the frontline of educating high-risk individuals on these lifesaving prevention measures.

Vibriosis is the human illness caused by pathogenic strains of the Vibrio genus of bacteria (excluding Vibrio cholerae strains O1 and O139, which cause the separate illness of cholera and which are not the focus of this article). Vibrio bacteria are a natural part of the estuarine ecosystem,2–7 with higher levels present in warm water of moderate salinity.2,5–10 There are two common modes of infection: wound contact and seafood consumption, particularly consumption of bivalve shellfish (oysters, clams, mussels, and scallops).1–3,6,7

There are over 80 species of Vibrio bacteria, over 20 of which can cause vibriosis.3 The species which most frequently cause vibriosis in the US are Vibrio parahaemolyticus (Vp) and Vibrio vulnificus (Vv, see Figure 1).3 Though Vp is more common, especially in Delaware and the surrounding region, Vv is the most lethal of the Vibrios.5,9 In fact, Vv has the highest fatality rate of any foodborne pathogen,6,7 and causes over 95% of seafood-related deaths in the US.7 About 1 in 5 people with serious Vv illnesses die, sometimes within only several days of illness onset, and many others require intensive care or limb amputations.3 Overall, an estimated 80,000 cases of vibriosis, with 500 hospitalizations and 100 deaths, occur each year in the United States.3

While healthy individuals are unlikely to develop illness from the opportunistic Vibrio pathogen, individuals with certain

These statistics emphasize the critical need for patient education and prompt treatment by healthcare providers.

Figure 1. A micrograph of a Vibrio vulnificus cell. Image credit: Janice Haney Carr/CDC via Wikimedia Commons 14 Delaware Journal of Public Health – January 2021

doi: 10.32481/djph.2021.01.005

AN ENVIRONMENTAL, SEASONAL PATHOGEN Vibrionaceae is a family of Gram-negative, rod- to curve-shaped, flagellated bacteria found throughout the coastal waters of the United States and other temperate to tropical coastal areas worldwide.9 Vibrio is not the result of pollution, but is instead a natural part of the microbiota of estuarine waters.2–7 Vibrio is therefore naturally present in many types of raw seafood, including finfish, crustaceans, and seaweed10; however, the bacteria is present in especially high numbers in bivalve shellfish (oysters, clams, mussels, and scallops. This is because these animals concentrate Vibrio from the surrounding water in their tissues as part of their filter-feeding process.5,10,11 The target of filter-feeding bivalve shellfish is algae and other food particles, but along with these particles, bivalve shellfish also filter out viruses and bacteria, including Vibrio. A single oyster can filter up to 50 gallons of water per day, and as a result, the concentration of Vibrio within oysters may be 100 times greater than that of the surrounding water.12,13 Adding to the human health risk is that bivalve shellfish, especially oysters, are often consumed raw or partially cooked, so any Vibrio present is not destroyed by cooking.12,13 Vibrio reproduces rapidly in waters that are warm5–9 and moderately salty2,8–10; it is therefore most prevalent during warmer months in estuarine waters such as bays, where saltwater from oceans mixes with freshwater from rivers. Thus, infections show a strong seasonal trend, with nationwide cases rising in April before peaking in July and then decreasing in November.2 Though infections occur throughout the year, about 80% nationwide occur from May through October.3 This seasonal trend is especially pronounced for foodborne Vibrio infections.14 Likewise, while infections occur throughout coastal areas in the United States, Vibrio, and in particular Vibrio vulnificus, is most common in the Gulf of Mexico, where levels of the bacteria can reach 1,000 cells/ mL in seawater and 100,000 cells/gram in oyster meat during warm months.8 While V. parahaemolyticus is the most common and V. vulnificus is the most lethal cause of vibriosis, other marine-related species which may cause vibriosis include V. alginolyticus, V. fluvialis, V. hollisae, V. metschinikovii, and V. cholerae2 (V. cholerae serogroups O1 and O139 cause the different illness of cholera, generally in developing countries where poor sanitation allows sewage to contaminate drinking water).1,3,9 Among pathogenic species of Vibrio, not all strains are capable of causing human illness2; conversely, pathogenic strains comprise a small percentage of the total Vibrio species present in waters and seafood.9,10 Vibrios are highly susceptible to cooking, and all strains can be killed by common disinfectants.9

AN UNCOMMON BUT SERIOUS & RISING ILLNESS In 2014 (the most recent year for which the Centers for Disease Control and Prevention (CDC) has published a Cholera and Other Vibrio Illness Surveillance [COVIS] annual summary report), over 1,200 Vibrio infections (excluding V. cholerae O1 and O139) were reported to COVIS.14 The species most frequently reported was V. parahaemolyticus at 48%, while V. vulnificus was reported in 10% of patients.14 Of patients with Vp, 15% were hospitalized and 1% died, while of patients with the more lethal Vv, 79% were hospitalized and 18% died.14

Recently, an increase in reported infections has been apparent,7 with the CDC estimating that the average annual incidence of Vibrio infections increased 54 percent from 2006 to 2017.3 This increased incidence is driven largely by an increase in wound infections7 and also likely by the use of new detection methods by healthcare providers, in particular culture-independent diagnostic testing (CIDT). In Delaware, while there has never been a reported Vibrio infection related to bivalve shellfish consumption, reports of wound infections have reached a record high in recent years, with 12 infections reported in 2016 and 2017 (see Figure 2).15 The factors underlying this apparent trend are complex and numerous. First, improvements in the identification and diagnosis of vibriosis have occurred over the past several decades, increasing the national reported incidence.7 Specifically, state participation in COVIS gradually increased since its establishment in the 1980s, until all Vibrio infections became nationally notifiable in 2007.7 More recently, the use of CIDT for Vibrio diagnosis has increased case reports significantly. In this way, it is likely that the increase in vibriosis has been partly driven by better surveillance in recent decades. However, other trends suggest that the incidence of Vibrio infections may indeed be increasing naturally. Namely, consumption of oysters is increasing in the United States,12 with raw bars becoming trendy destinations in recent years. In Delaware, for example, the bivalve shellfish industry has recently expanded, with new legislation establishing an oyster aquaculture industry passed in 2014. Couple the increase in oyster consumption with an increasingly susceptible population, as the numbers of elderly and other individuals with risk factors predisposing them to more progressive cases of vibriosis increase, and these trends may have been partly responsible for the recent increase in vibriosis incidence.7

THE HIGH-RISK GROUP While any exposed person can become infected with Vibrio and develop symptoms such as gastroenteritis, in healthy individuals the illness is uncommon and typically mild and temporary.2–5,10,11 This is particularly true for cases related to seafood consumption.2,10 However, persons with underlying chronic medical conditions or a weakened immune system often develop serious illness that may lead to septicemia and death.2,3,9–11 Thus, while all raw shellfish consumers and all persons who work or recreate in saline waterbodies are theoretically at-risk for Vibrio infection, a subpopulation of individuals has increased risk of serious illness.2,9,10 These individuals must be educated on how to prevent infection, since even with medical treatment, septicemia and death are common outcomes for them. The percentage of the adult population in the US who are at risk for Vv-related septicemia is estimated at 7% to 20%.6,10 Ninetyfour percent of molluscan shellfish consumption cases occur in people with pre-existing conditions, especially liver disease: in one case series of Vv infections, 53% of cases had liver disease, 34% had alcohol use disorder, and 16% had diabetes.2 Elevated levels of iron in the blood, usually due to liver disease, is a particularly strong risk factor for severe vibriosis,2,3,6,9,16 with one study indicating that persons with chronic liver disease are 80 times more likely than healthy individuals to develop Vv septicemia and 200 times more likely to die.2,7 15

Figure 2. US Vibrio vulnificus cases by transmission type

There is both a gender disparity and an age aggregation associated with the incidence of vibriosis, particularly in cases related to seafood consumption and in Vv cases. Of Vv cases reported to COVIS from 1988 to 2010, 86% occurred in males, suggesting that males are approximately six times more likely to be diagnosed with a Vv infection than females.7 The reasons for this gender disparity are unknown, but it is likely that greater incidence of underlying risk conditions (particularly liver cirrhosis) is an important factor.7 Further, both the incidence and fatality rates for Vv cases are strongly correlated with age: very few cases, with only one fatality, were reported in persons under 25 years old, while persons 40 to 60 years of age comprise 50% of infections and 50% of fatalities.7 Thus, while anyone can be diagnosed with vibriosis, it is more common in males of middle age or above. The high-risk group for severe vibriosis include the elderly and persons with the following underlying conditions: • Liver disease (from hepatitis, cirrhosis, alcoholism, or cancer)1–4,6,7,9,10,16 • Iron overload disease (hemochromatosis) / abnormal iron metabolism (hemosiderosis)1,2,4,10 • Diabetes2–6,10,11 • Renal disease/failure2,10,17 • Cancer or malignancy (including leukemia, lymphoma, Hodgkin’s disease)1–6,10 • HIV/AIDS2,3,5,10 • Gastrointestinal disorders (including ulcers)2,4,6,10 • Gastric surgery3,5,10 • Disorders or medicine leading to low gastric acid2,5,8,10 • Heart disease10 • Hematological conditions3,6 • Hemolytic anemia2 • Thalassemia3 • Transplant recipients10 • Any other illness or medical treatment that weakens the body’s immune system (including chemotherapy and use of steroids or other immunosuppressive medication)1,2,4,6,8,10 16 Delaware Journal of Public Health – January 2021

TWO MODES OF INFECTION Vibrio can infect persons via seafood consumption or wound exposure to salt/brackish water, raw seafood, or drippings from raw seafood.1–3,6,7 The pathogen is opportunistic and the severity of an individual case depends on many factors, including the strain and the dose of bacteria and the patient’s underlying health conditions.11 The fatal dose for an at-risk individual is unknown.11 Overall, the most common mode of transmission is consumption of raw or undercooked seafood, particularly oysters1: in one study of United States vibriosis cases, 56% were classified as foodborne, 35% as wound infections, and 9% as having an unknown transmission route.14 More specifically, for Vibrio parahaemolyticus, about 86% of cases are foodborne,9 while for Vibrio vulnificus, wound infections comprise 46% of cases, followed closely by foodborne infections at 43%.7 In cases related to food consumption, raw or partially cooked oysters are the most commonly associated food,10 although many other seafood products have been linked to vibriosis, especially to Vp (see Figure 3).9 In one case series, among patients with foodborne vibriosis who reported eating a single seafood item, 69% ate oysters, 10% ate finfish, 6% ate crab, and 4% ate clams.14 More specifically, over 90% of bivalve Vv cases are associated with raw oysters from the Gulf Coast.2,7,9,10 Improper refrigeration of seafood products allows the exponential growth of opportunistic Vibrio and increases the likelihood of infection, while thorough cooking destroys the bacteria.9 Thus, illnesses typically are caused by consumption of either raw/partially cooked seafood or cooked seafood that has been contaminated with raw seafood.9 Because the common pathogenic strains of Vibrio are destroyed almost immediately in freshwater, it is not usually transmitted via the fecal-oral route,9,10 and thus it typically occurs as sporadic cases and not as outbreaks.2,18 In addition to ingestion, persons (especially those in the highrisk group) can become infected with Vibrio when cuts, burns, sores, or other wounds are exposed to seawater, raw seafood, or raw seafood drippings.2,5,9,14,17 Pre-existing wounds may contact

seawater or seafood, or wounds may be incurred during an activity such as fishing or while preparing food.9 Persons with jobs that require marine- or food-related activities may have increased exposure2; for example, shucking oysters or picking crabs can result in a cut to the hand, exposing the body to Vibrio. Even a wound as small as an insect bite may allow infection in high-risk persons.19 Additionally, Vibrio wound infections may increase following flooding caused by a hurricane or storm surge: after Hurricane Katrina, 14 wound infections, 3 of which resulted in death, occurred among Louisiana and Mississippi residents exposed to floodwater.2 Overall, among patients with nonfoodborne transmission, 79% had skin exposure to a waterbody within seven days before symptoms began, 17% had contact with marine wildlife, and 17% handled seafood.14 Other, unusual modes of Vibrio infection have occurred. For example, in one case, corneal ulcers resulting from Vv occurred in an employee at an oyster shucking plant after small oyster shell fragments had contacted his eyes.2 Another usual case occurred after a folk healer treated a chronic sore on a patient’s leg by spraying it with fresh fish blood.2

THE RESULTING ILLNESS While any individual may be infected by Vibrio, cases in healthy persons are generally mild, temporary, and self-limiting.2,9 In foodborne cases, healthy persons may develop gastroenteritis symptoms but this usually remains localized and rarely requires

hospitalization; most people with a mild case of vibriosis recover after about three days with no lasting effects.3,9 Symptoms typically occur within 12-72 hours and may include fever/chills, stomach pain/nausea, vomiting, diarrhea, and headache.3,4,9,18 In wound infections, healthy persons may develop cellulitis around the wound which requires treatment, but severe symptoms and death remain unlikely.2 For all reported vibriosis cases, less than 40% require hospitalization or antibiotic treatment.9 In high-risk persons, however, symptoms may rapidly progress and lead to death in as little as 2 days, making prompt treatment of paramount importance.4 In foodborne cases, the bacteria may invade the bloodstream via the digestive tract, causing fever/ chills that is usually accompanied by nausea, vomiting, diarrhea, and swollen/painful extremities.5,9,10,16 Blood pressure commonly drops sharply, potentially leading to shock and death.2,5 Also, the majority of high-risk patients develop skin lesions: initially the skin appears red, then painful blisters quickly develop and erode into necrotic ulcers, similar to those found in wound infection cases.5,9 In the high-risk subpopulation, septicemia may occur in as little as 24 hours,2 and for Vv septicemia there is a 50-60% mortality rate.2,6 For high-risk persons who develop vibriosis after wound exposure, infections usually begin with swelling, redness, and pain surrounding the infected site.5 Blisters commonly develop and rapidly progress to tissue necrosis.5 Around 50% of patients with Vv-infected wounds require surgical debridement or amputation

Figure 3. High-risk persons should not eat uncooked seafood, including oysters on the half-shell. Image credit: Jeremy Keith via Flickr 17

to prevent the infection from spreading to the bloodstream, in which case death commonly occurs.5 Thus, wound infections in high-risk persons can have permanent, life-changing results.7 In total for Vv hospitalizations, the outcome is death in 35% of septicemia cases and 20% of wound infection cases.9 Strikingly, there is a very short time period – as little as 24 hours – between the onset of symptoms and the final outcome,7 making prompt diagnosis critical. Vibriosis is diagnosed by stool, wound, or blood culture, depending on the type of infection at hand.3,5,9 Key questions for the screening of patients include: • Have you recently eaten raw or partially cooked seafood?8 • Have you had any recent skin contact with salt/brackish water?8 • Have you recently handled raw seafood, seafood drippings, or anything that was used to hold or prepare raw seafood?8

VIBRIOSIS SURVEILLANCE Doctors, hospitals, and/or labs are required to report confirmed and probable cases of Vibrio infection to state health agencies, who are then required to report cases of this nationally notifiable pathogen to the federal government.2 Reporting is critical because it may result in a state following national protocols to recall shellfish product or temporarily close shellfish waters to harvest, thereby preventing future illnesses. Further, because severe vibriosis has such a high fatality rate, prevention is imperative, and good surveillance allows federal and state government agencies to evaluate prevention strategies for efficacy.2 For example, a state with a confirmed Vv illness is required to develop and implement a Vv Control Plan for bivalve shellfish that may include time-to-temperature restrictions to prevent Vibrio growth in shellfish after harvest, shading on board harvest vessels, or other important measures. Health departments report Vibrio cases to the Cholera and Other Vibrio Illness Surveillance (COVIS) system.3 The COVIS report form includes the following information: a description of the person’s illness and underlying health conditions; recent seafood consumption; recent exposure to bodies of water, raw or live seafood or their drippings, or marine life; and the source of any implicated seafood.3 Unfortunately, Vibrio infections are underdiagnosed and under-reported2: the CDC estimates that for every 1 foodborne Vv case reported another 1.87 cases occur,2 while only 1 in 20 cases of Vp are reported.9

AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE Treatment for vibriosis in high-risk patients is of limited effectiveness, and thus prevention is critical. There is a 35% mortality rate from Vv septicemia in the high-risk subpopulation,9 and a median time period of only 48 hours from hospital admission to death.5 Even patients who survive severe infection are frequently left with life-altering consequences such as limb amputations. For these reasons, infection prevention is crucial and will save lives. Despite the criticality of vibriosis prevention, awareness of the risks of Vibrio infection is low among the high-risk subpopulation as well as the population at large (see Table 1). In one survey of oyster consumers, 50% knew that people with liver disease can become extremely ill from eating raw oysters, 34% knew the same for people with weakened immune systems, and only 19% knew that diabetics are at risk of illness from raw oysters.2 Compounding the problem of low awareness is that high-risk persons who eat raw oysters do so more frequently (ten times per year) than other consumers (six times per year).2 If awareness of the risks of Vibrio infection among high-risk persons is increased, lives will be saved. Health care providers, as trusted sources of important health information, are the frontline of vibriosis education. A survey showed that raw oyster consumers who are informed by health care providers of the risk of Vibrio infection are more concerned about raw oyster consumption than those who receive the same information from other sources.2 When a patient with a condition which makes them susceptible to severe vibriosis is diagnosed or seen, inform them to abstain from eating raw or partially cooked seafood, especially filterfeeding oysters and clams.5,17 Instead, encourage them to eat fully-cooked shellfish, which have numerous important health benefits. Also inform high-risk patients to avoid contact of wounds with salt/brackish water and seafood, to take care to avoid sustaining a wound when preparing seafood and when participating in marine-related activities such as fishing, and to seek immediate medical treatment if they experience symptoms following any wound contact.5,17



Though I am in the high-risk group, eating only a few raw shellfish can’t hurt me.

A fatality has been documented where the patient consumed only three raw oysters.11

I’ll be fine if I avoid raw shellfish from polluted waters.

Vibrio is a naturally-occurring part of the environment and has no connection to pollution.11

If I avoid oysters in months without the letter “R”, I’ll be fine.

Though Vibrio is more abundant during warmer months, many cases occur during the cooler months from September through April.11

Experienced oyster connoisseurs can tell a good oyster from a bad one.

Vibrio does not change the appearance, taste, or odor of shellfish.11,17

I’ll be fine if I drink alcohol along with the raw shellfish.

Alcohol has little effect on harmful bacteria.11

I’ll be fine if I smother raw shellfish in hot sauce or lemon juice.

This works no better than using plain water.11

Table 1. Common Shellfish Consumer Myths 18 Delaware Journal of Public Health – January 2021

SEAFOOD HEALTH BENEFITS Oysters, clams, and other seafood are an important part of a balanced diet and convey numerous important health benefits. For healthy persons, eating raw or partially cooked seafood is a decision that should be made with a knowledge of associated risks and in consultation with their doctor. Persons whose age or underlying medical conditions put them in the high-risk group should abstain from consuming raw or partially cooked seafood, but they may still enjoy it thoroughly cooked for its delicious taste and many health benefits. • Seafood is a source of high-quality protein that is rich in vitamins, minerals, and beneficial omega-3 fatty acids.8 Compared to other protein-rich animal foods, most seafood is lower in calories, total fat, and saturated fat.8 • Seafood consumption is linked to improved coronary health in adults and to improved cognitive and visual development in infants and children.8 Eating seafood regularly can decrease risk of heart attack, stroke, and high blood pressure.8 • For good health, consumers should eat 8 or more ounces per week of a variety of seafood types. A daily EPA+DHA intake of at least 250mg is recommended for most people, increased to 1000mg for people with cardiovascular disease.8

TIPS FOR HIGH-RISK PERSONS When Preparing and Eating Seafood:

• Abstain from eating raw or partially-cooked seafood, especially oysters and clams.5,17 Instead, enjoy thoroughly cooked seafood for its delicious taste and important health benefits. • Purchase seafood only from reputable sources.8 Purchase only shellfish whose shells are closed. Before cooking, discard any shellfish with shells already open.3,4 • Refrigerate seafood below 400F until use to prevent the exponential growth of Vibrio and any other pathogens present into an infectious dose.8,9 • Wash hands before and after handling raw or cooked seafood.3,8 Avoid contact between a wound and seafood or its drippings.3 Take care to prevent sustaining a wound when handling raw seafood and when shucking shellfish, and immediately wash any wounds sustained then cover them with an impermeable bandage.3 • Prevent contact between cooked seafood and raw seafood or its drippings.3,8,11 Wash utensils and surfaces before reusing to prevent cross-contamination.8,9 After kitchen surfaces are washed, sanitize them with a product sold as a kitchen sanitizer.9 • Cook seafood until it reaches an internal temperature of 1450F for at least 15 seconds.8,9 Increase temperature to 1550F for dishes like fishcakes and to 1650F for dishes like stuffed fish.9 • For shellfish in the shell, either boil until shells open then continue boiling for another 3-5 minutes, or add to a steamer when water is already steaming then cook for another 4-9 minutes.3,4 Use small pots so that shellfish in the middle are cooked fully. Only eat shellfish that open during cooking, discarding any shellfish that do not open fully after cooking.3,4 • For shucked shellfish, either boil for at least 3 minutes, fry in oil for at least 3 minutes at 3750F, broil 3 inches from heat for 3 minutes, or bake at 4500F for at least 10 minutes.3,4 • Seek immediate medical attention if you experience symptoms of illness following seafood consumption.3

When Working or Recreating in Natural Waters:

• Avoid contact between the water and cuts, burns, sores, or any other skin wounds.3,4,13 If water contact cannot be avoided, cover wounds with impermeable bandages.3,13 • Take precautions to prevent sustaining a wound while swimming, fishing, or participating in related activities. Carry potable water and soap or hand sanitizer to immediately clean any minor injuries that occur.3,13 • Wear gloves when handling raw seafood, crab pots, or other equipment.3,13 Wear water shoes to avoid cuts and scrapes.3,13 • Always shower after contacting natural waters, and wash hands before eating or handling food.13 • Seek immediate medical attention if you experience symptoms of illness following contact between a wound and natural water.3

OTHER PATHOGENS RELEVANT TO SHELLFISH & RECREATIONAL WATER In addition to Vibrio, there are many other pathogens that occur in marine waters and pose a potential threat to public health. Many of the pathogens of potential public health concern for raw bivalve shellfish do not proliferate during post-harvest handling and storage, unlike Vibrio which can quickly increase in harvested product if strict temperature controls are not followed.20 These pathogens and toxin-producing organisms, which originate and bio-accumulate to dangerous levels in shellfish waters, can be divided into two major categories: biotoxins produced by phytoplankton, and viral and bacterial pathogens from fecal contamination. First, biotoxins produced by some marine algae species can cause serious illness if individuals consume bivalve shellfish which have concentrated these toxins or when individuals have contact with waterbodies experiencing harmful algal blooms. Nationally, five specific toxins of concern are associated with bivalve shellfish, and thresholds have been established to protect consumers. To mitigate the public health threat from biotoxins, states monitor waterbodies for these five specific toxins, as well as for other toxins whose thresholds have not been established but may cause shellfish-borne illness.21 Unlike bacterial and viral pathogens, biotoxins are not destroyed by cooking and can still pose a risk of gastrointestinal and neurological illness if present in cooked products.8 Second, contamination of waters with bacterial and viral pathogens from fecal sources can pose a significant public health threat, especially for pathogens originating from humans. Some of these pathogens can also cause infection through food contamination by infected workers; these pathogens include Norovirus, Hepatitis A virus, Shigella spp., Enterohemorrhagic or Shiga Toxin-producing Escherichia coli, and Salmonella typhi.22 In particular, Norovirus is one of the most common pathogens found in water or shellfish impacted by human fecal contamination and has been implicated in illness outbreaks associated with bi-valve shellfish.23 Norovirus infections are most frequently observed from November through April, with symptoms including diarrhea, vomiting, nausea and stomach pain.23 Unlike biotoxins, viral and bacterial pathogens like Norovirus within shellfish can be killed by thorough cooking,12,13 although post-cooking cross contamination remains possible. 19

DNREC’S SHELLFISH & RECREATIONAL WATER PROGRAM The mission of the Shellfish & Recreational Water Program of the Delaware Department of Natural Resources & Environmental Control (DNREC) is to prevent human illness from consumption of bivalve shellfish and from recreational contact with natural waterbodies. To mitigate the risk of pathogens which are associated with fecal contamination, fecal indicator bacteria (FIB) are monitored in recreational waters and shellfish growing waters to identify times when there may be an elevated risk to public health. For recreational waters, DNREC monitors waters for elevated levels of Enterococcus FIB and issues swimming advisories when high levels are found. The U.S. Environmental Protection Agency established that Enterococcus was one of two FIB for marine and freshwater recreational waters “that have consistently performed well as indicators of illness in sewagecontaminated waters during epidemiological studies.”21 Similar to recreational waters, states are also required to conduct FIB monitoring of shellfish growing areas using either Fecal or Total Coliform bacteria.24 The sampling results are used to classify waters as approved or prohibited for shellfish harvest, and these harvest classifications are assessed annually to identify changes in water quality trends. These monitoring strategies are effective in identifying long term trends in water quality, but other monitoring for fecal contamination originating from isolated events such as waste water treatment plant failures and bypasses, illegal discharges from vessels, and other potential anthropogenic sources is conducted by state resource managers to evaluate public health risk. Vibrio bacteria are not sampled as part of this process, because they are a natural part of the estuarine ecosystem and so cannot be mitigated through shellfish harvest classifications and swimming advisories. In Delaware, Vibrio vulnificus poses the greatest risk to individuals who contract wound infections through injury or wound exposure to natural marine waters. Currently there is no established recreational water quality criteria for Vibrio infections, which underscores the importance of education to reduce the risk of illness. In bivalve shellfish, Vibrio can quickly increase to dangerous levels following harvest if proper precautions are not followed. To mitigate the risk of shellfish-borne Vibrio infections, DNREC establishes time-to-temperature requirements for bivalve shellfish through the State’s annual Vibrio parahaemolyticus (Vp) management plan. This plan establishes the timeframes and restrictions that shellfish harvesters and dealers must follow during months with increased risks of elevated Vibrio levels, currently June through September depending on the body of water from which the shellfish were harvested. Though there has never been a confirmed Vibrio illness linked to shellfish harvested from Delaware waters, risk assessments identify Vp as the primary Vibrio pathogen of concern, which is why the state implements a Vp management plan during warmer months. The bivalve shellfish industry works diligently to follow these requirements and to keep their products safe for raw consumption by healthy persons, if consumers are equipped with the education to keep shellfish products safe after purchase. 20 Delaware Journal of Public Health – January 2021

CONCLUSION Vibrio is an opportunistic pathogen that is naturally occurring in salt/brackish water and in uncooked seafood, especially oysters. Human infection can occur after an open wound is exposed to water or seafood containing Vibrio, or after uncooked seafood is consumed that contains Vibrio. While vibriosis is uncommon overall and is typically not serious in healthy people, in high-risk persons, especially those with liver problems, infection can be life-altering, if not lethal. Because of the rapid progression, limited effective treatment, and high mortality rate for vibriosis in highrisk individuals, infection prevention is of paramount importance. Yet, patient knowledge of how to avoid infection remains low. Healthcare providers are the front lines of patient education on vibriosis, and we urge you to inform high-risk patients to not eat raw seafood and to prevent contact between a wound and seawater. Through this education, you can save lives. Disclaimer: The information contained in this article is provided for information only. This information does not constitute medical advice, and it should not be relied upon as such. The Delaware Department of Natural Resources and Environmental Control (DNREC) does not engage in the practice of medicine. DNREC, under no circumstances, recommends particular treatments for specific individuals, and in all cases recommends that you consult your physician before pursuing any course of treatment. Correspondence: Andrew Bell,

REFERENCES 1. Centers for Disease Control and Prevention. (2017). Vibriosis (any species of the family Vibrionaceae, other than toxigenic Vibrio cholerae O1 or O139): 2017 case definition. 2. University of Georgia Marine Extension and Georgia Sea Grant. (2017). Your gateway to information on Vibrio vulnificus infection from consumption of raw shellfish or marine-related wounds. 3. Centers for Disease Control and Prevention. (2019). Vibrio species causing vibriosis. 4. Interstate Shellfish Sanitation Conference. (n.d.). The risk of eating raw molluscan shellfish containing Vibrio vulnificus: Advice for persons with liver disease, diabetes, or weakened immune systems. 5. Interstate Shellfish Sanitation Conference. (n.d.). Vibrio vulnificus fact sheet for health care providers. 6. Food and Agriculture Organization of the United Nations. (2005). Microbiological risk assessment series no.8: Risk assessment of Vibrio vulnificus in raw oysters: Interpretive summary and technical report. 7. Baker-Austin, C., & Oliver, J. D. (2018, February). Vibrio vulnificus: New insights into a deadly opportunistic pathogen.

Environmental Microbiology, 20(2), 423–430. Retrieved from 8. Seafood Health Facts. (n.d.). Seafood for health: Information for healthcare providers. 9. US Food and Drug Administration. (2012). Bad bug book: Handbook of foodborne pathogenic microorganisms and natural toxins. 10. Center for Food Safety and Applied Nutrition, US Food and Drug Administration. (2005, July). Quantitative risk assessment on the public health impact of pathogenic Vibrio parahaemolyticus in raw oysters. 11. Interstate Shellfish Sanitation Conference. (n.d.). Vibrio vulnificus and diabetes. vulnificus%20and%20diabetes.pdf 12. Food and Agriculture Organization of the United States. (2019, May). GLOBEFISH – information and analysis on world fish trade: Bivalves market very positive. 13. Brohawn, K. (2019). Marylander’s guide to skin wounds and water contact. 14. Centers for Disease Control and Prevention. (2016, May). National enteric disease surveillance: COVIS annual summary, 2014.

15. Lauria, M. (2018, Aug 2). Warnings lag in mid-Atlantic as deadly marine bacteria increases threat in summer. https://www. 16. Interstate Shellfish Sanitation Conference. (n.d.). Vibrio vulnificus and liver disease. vulnificus%20and%20liver%20disease.pdf 17. Brohawn, K. (2019). Vibrio infections: Information for health care providers. Providers_Final4,rev2019.pdf 18. Delaware Dept of Health and Social Services, Division of Public Health. (2011, June). Vibriosis (non-cholera Vibrio species infection). 19. Texas, A., & University, M. (2016, Jun 30). Texas A&M Corpus Christi Vibrio expert discusses flesh-eating bacteria found in Gulf of Mexico. html#.X4iNPnUpDb2 20. Interstate Shellfish Sanitation Conference. (2018). National Shellfish Sanitation Program (NSSP) Guide for the Control of Molluscan Shellfish 2017 Revision, 375. 21. US Environmental Protection Agency. (2012). Recreational Water Quality Criteria, 9. 22. Interstate Shellfish Sanitation Conference. (2018). National Shellfish Sanitation Program (NSSP) Guide for the Control of Molluscan Shellfish 2017 Revision, 104. 23. Centers for Disease Control and Prevention. (2019). Norovirus. 24. Interstate Shellfish Sanitation Conference. (2018). National Shellfish Sanitation Program (NSSP) Guide for the Control of Molluscan Shellfish 2017 Revision, 53.w


Microbial Source Tracking in the Love Creek Watershed, Delaware (USA) Christopher R. Main, Ph.D. Environmental Laboratory Section, Division of Water, Delaware Department of Natural Resources and Environmental Control Robin Tyler, Ph.D. Environmental Laboratory Section, Division of Water, Delaware Department of Natural Resources and Environmental Control Sergio Huerta, M.D. Laboratory Director, Public Health and Environmental Laboratories, State of Delaware

ABSTRACT Fecal contamination of waterways in Delaware pose an ongoing problem for environmental and public health. For monitoring efforts, Enterococcus has been widely adopted by the state to indicate the presence of fecal matter from warm-blooded animals and to establish Primary and Secondary Contact Recreation criteria. In this study, we examined sites within the Love Creek watershed, a tributary of the Rehoboth bay, using next-generation sequencing and SourceTracker to determine sources of potential fecal contamination and compared to bacterial communities to chemical and nutrient concentrations. Microbial community from fecal samples of ten different types of animals and one human sample were used to generate a fecal library for community-based microbial source tracking. Orthophosphate and total dissolved solids were among the major factors associated with community composition. SourceTracker analysis of the monthly samples from the Love Creek watershed indicated the majority of the microbial community were attributed to “unknown” sources, i.e. wildlife. Those that attribute to known sources were primarily domestic animals, i.e. cat and dog. These results suggest that at the state level these methods are capable of giving the start for source tracking as a means to understanding bacterial contamination.

INTRODUCTION The Department of Natural Resources and Environmental Control (DNREC) Environmental Laboratory Section (ELS) has been monitoring the waters of Delaware for several decades as a requirement of the Clean Water Act (CWA) (USEPA 1987 - Sections 106, 303, 304 and 305). Section 303(d) identifies “impaired” waters as those that do not meet the Water Quality Standards laid out in Section 304(a). It includes processes for determining the degree of pollution reduction from human related sources likely to result in attainment of the Total Maximum Daily Load (TMDL) and recommending and informing land and water management practices necessary to achieve the targeted pollution reduction. Routine long-term monitoring at established stations tracks water quality status and documents how State waters are responding to environmental stewardship efforts. One measurable type of potential human-related water pollution is fecal bacteria. These bacteria may derive from humans, various domesticated animals (i.e. dogs, cats, cows, etc.) or from wild animals. Bacteria within the genus Enterococcus has been widely adopted to indicate the presence of fecal matter from warm-blooded animals in 305(b) monitoring efforts. Delaware has risk-based numeric criteria for Primary Contact Recreation (PCR) and Secondary Contact Recreation (SCR) in freshwater and saltwater “determined by the Department (DNREC) to be of non-wildlife origin based on best scientific judgment using available information.”1 Important among the limitations of the Enterococcus test is that it does not differentiate as to what type of animal the detected bacteria are from. It could be any mix of warm-blooded animal types that might be in the watershed – i.e. mammals and birds, domestic and wildlife. 22 Delaware Journal of Public Health – January 2021

While these Enterococcus criteria are generally recognized to be protective of human health and the continuation of routine monitoring of waters is necessary to track status and trends, this test does not help in locating sources of bacterial contamination, which may be abatable. A supplemental, complimentary addition to the existing monitoring format is needed to facilitate where to apply pollution control practices and maximize the frugal utilization of the increasingly scarce resources available to bring about the environmental improvements intended under the CWA, such that waters meet standards criteria and attain designated uses,1 for example, PCR, SCR, fish, aquatic life and wildlife and harvestable shellfish waters. Delaware’s inland coastal bays (DIB) consist of three interconnected water bodies, Rehoboth, Indian River and Little Assawoman bays that drain approximately 300 square miles of mixed land use. Eutrophication of the DIB has increased over the last several decades with inputs from agricultural and urban sources.2,3 The Love Creek watershed (Figure 1) is a tributary of the Rehoboth bay and part of the National Estuary Program for over 20 years. The watershed has undergone extensive human development of various types in its tidal and non-tidal segments with the inevitability of substantially more, making for an ideal study site. Its environmental condition, aquatic and terrestrial, could benefit substantially from improved precision in identifying human-related pollution sources. Additionally, considerable periodic seabird activity in the tidal segment and relatively wide forested stream corridors in the non-tidal segment are evidence of a robust complement of indigenous wildlife (e.g. deer, raccoons). Microbial source tracking (MST) methods use specific bacterial profiles associated with hosts, e.g. human, farm animal, bird, to doi: 10.32481/djph.2021.01.006

Figure 1. Septic System density in the Love Creek watershed.

determine sources of fecal contamination in the environment. The most common MST method uses quantitative real-time polymerase chain reaction (qPCR) and primers that target the 16S rRNA genes of host associated bacteria,4,5 however, qPCR may suffer from specificity and sensitivity issues.6–8 In the last decade, advancements in high-throughput DNA sequencing has led to large-scale microbial community studies. Community based MST analysis is generated from unique microbial community profiles of environmental and fecal sources leveraged from next generation sequencing (NGS) techniques,9 Two methods may be used to define the microbial community: 1) assignment of operational taxonomic units (OTUs) via a clustering algorithm, usually to a 97% similarity between sequences, or 2) amplicon sequence variant (ASV) which can resolve difference in gene regions to a single nucleotide.10 SourceTracker is a Bayesian classification program, which provides an estimated percentage of the sequenced microbial community from an environmental samples can be attributed to a specific fecal source.6,11 SourceTracker uses a Gibbs sampling algorithm to examine the likely prior distribution of OTUs/ASVs within user-defined sources. This distribution within the sources can be used to determine the affiliation within sample (referred to as sinks) communities and the contribution of each source is then determined based on this distribution. The SourceTracker algorithm has been shown to be more accurate than random forest analysis, or naive Bayesian classification.11 SourceTracker has been used to determine contamination sources in the Russian River,12 ATM keypads,13 recreational beaches in Australia,4,14–16 lakes in St. Paul, Minnesota,6 and the upper Mississippi River.17,18 Our goals were to use next generation sequencing to create community based microbial profiles of fecal sources and monthly samples of sites within the Love Creek watershed.

Using SourceTracker we examined the bacterial inputs from various fecal sources into the monthly samples. In addition, we examined the impact of a significant rain event, within 24 hours, at the tidally driven sites. The results of this pilot study are broadly relevant to assessing fecal pollution within the waterways of Delaware.

MATERIAL AND METHODS Study Site and Sample Collection

The Love Creek watershed is drains approximately 24 square miles of land into the Rehoboth Bay (Figure 1) and is tidally driven to the dam at Goslee Pond (STORET: 308291).19 In the last two decades urban development has increased approximately 80% with a loss of forested uplands and agriculture.19 Water samples were collected monthly from March to October 2017 from seven sites in the Love Creek watershed (Table 1), with triplicate samples collected at the Rt. 24 Marina (STORET: 308021). Sites were considered marine waters when salinity was greater than 5.1 To examine the influence of rainfall on microbial transport, rainfall was monitored using the Delaware Environmental Observing System at the Millsboro Long Neck station (DLNK). Samples at the tidally driven sites (STORET: 308015, 308018, 308021, and 308024) were collected 24 hours after a rainfall event of approximately 62 mm of rain in two hours. Temperature, salinity, dissolved oxygen (mg l-1), pH, and specific conductivity were measured using a YSI 650 (YSI Inc., Yellow Springs, OH). Dissolved nutrients (NO3 plus NO2 [NOX], OP, organic carbon, and dissolved solids), and total nutrients (chlorophyll a, nitrogen, phosphorus, organic carbon, turbidity and suspended solids) concentrations were determined by APHA Standard Methods.20 Enterococcus concentrations were determined for each sample using Enterolert© (IDEXX, Westbrook, ME). 23

STORET Location




Love Creek mouth, Rehoboth Bay Community Dock




Love Creek lower, dock at end of West Lane




Love Creek middle, at Rt. 24 bridge




Love Creek upper, dock off Misty Lane




Love Creek at Robinsville Rd. (Goslee Pond outlet)




Bundicks Branch at Rt. 23 (Bill Ullman’s Station)




Goslee Creek at Jimtown Rd.




Table 1. Location Descriptions, STORET Numbers and Latitude and Longitude of Sampling Sites

Sample Filtering and Processing

Water samples were filtered within six hours of sampling under gentle vacuum (~380 mm Hg) on 0.45-µm polycarbonate filters (Millipore Isopore, Billerica, MA). Filters were immediately placed into CTAB buffer (100 mM Tris-HCl (pH 8), 1.4 M NaCl, 2% (wt/vol) cetyltrimethylammonium bromide (CTAB), 0.4% (vol/vol) 2-mercaptoethanol, 1% (wt/vol) polyvinylpyrrolidone, and 20 mM EDTA)21 and stored at -80°C until extraction. Fecal samples were collected in July 2016 during the Delaware State Fair. Bovine, chicken, goat, horse, pig, sheep, domesticated duck and goose samples were collected with as much metadata information as possible, i.e. location, feed, sex, etc. by Christopher Main and Karen Lopez, Deputy State Veterinarian for Delaware. Cat, dog and human samples were collected by or from Christopher Main and all samples were stored at -80°C until extraction. Before extraction, filters were heated at 65°C for 10 minutes. Following incubation, 700 µl of a 24:1 isoamyl:chloroform solution was added to each sample and briefly vortexed. Samples were gently rocked for 20 minutes and centrifuged at 14000 × g for 15 minutes. The top aqueous phase was used for further extraction using GeneJet Plant Extraction kit according to manufacturer’s instructions (Thermo Scientific, Waltham, MA). Fecal samples were extracted using a PureLink™ Microbiome DNA Purification Kit (Thermo Scientific) using a small portion of each fecal sample. All samples, water and fecal, were eluted to 100 µl of elution buffer and stored at -20°C until analysis. The V4 region of the bacterial rRNA gene was selected for community analysis.22 Extracted samples were sent to Molecular Research LP (Shallowater, TX) for library prep and amplicon sequencing.

Microbial community analysis

Raw samples were processed using FASTQ Processor to generate forward, reverse and barcode fastq files for QIIME2 analysis. Pairend reads were demultiplexed using the q2-demux emp-paired method and denoised using q2-dada2’s denoise-paired method.23 Sequencing of samples occurred in multiple runs requiring QIIME2 analysis occurring in tandem until after DADA2 24 Delaware Journal of Public Health – January 2021

analysis, which were then combined for further downstream analysis. Taxonomic composition was generated using a pretrained Naive Bayes classifier trained on the Greengenes 13_8 99% OTUs trimmed to include the V4 (515F/806R primer pairs). Prior to further downstream analysis, nontarget ASVs, i.e. chloroplast and mitochondria, were removed from sample table and representative sequences. Constrained analysis of principal coordinates (CAP) was carried out using the vegan R package24 to identify factors contributing to differences between sites with respect to environmental factors. Collinearity of environmental factors was examined using a Pearson’s correlation with factors considered collinear with an r2 of 0.8 and P < 0.05. Weighted Unifrac and Bray-Curtis dissimilarity matrices were used for CAP analysis for environmental samples including total N and P and without total N and P, models were selected by pseudo-AIC using a stepwise algorithm. Alpha and beta diversity, including weighted and unweighted Unifrac principal component analysis, analyses of ASVs was carried out using the phyloseq R package.25 Dissimlarity between groups was tested using non-parametric PERMANOVA tests with weighted and unweighted Unifrac beta diversity distances.13 All statistical analyses were evaluated at an α = 0.05. An ASV table was exported for use with SourceTracker11 using a parallel version SourceTracker to decrease computational time. Default parameters established in the sourcetracker_for_qiime. py pipeline were used with five runs being conducted. For each sample, the mean proportion (%) for each run were averaged for determination of fecal source contribution.

RESULTS Study Site and Field Samples

A total of 2,261 septic systems, with a density of 94.2 systems per square mile, are located within the Love Creek Watershed, with gravity systems being the dominant system type (Figure 1). Previous analysis by Homsey et al.19 showed a density of active septic permits of 55.5 permits per square mile, with 1,340 septic systems within the watershed, an increase of approximately 70% of septic systems within the watershed. Altogether, 74 samples were analyzed from seven sites within the Love Creek watershed between March and October 2017. Water temperatures during the collection period ranged from 8.3 to 29.7°C, salinity from 0.1 to 41.2, chlorophyll a from 0.3 to 382 mg l-1, dissolved oxygen from 5.01 to 17.3 mg l-1, turbidity from 1 to 44 mg l-1, total suspended solids from 1 to 75.9 mg l-1 and total dissolved solids from 70 to 32,300 mg l-1. Organic carbon concentrations ranged from 1.8 to 10.9 mg C l-1, dissolved NOX from 0.004 to 7.13 mg N l-1, NH3 from 0.01 to 0.281 mg N l-1, PO4 from 0.004 to 0.047 mg P l-1, total nitrogen from 0.242 to 7.35 mg N l-1, and total phosphorus 0.014 to 0.272 mg P l-1. Total Enterococcus levels ranged from non-detects to 6,130 mpn 100 ml-1 with 27 of 74 samples being above primary contact recreation levels. At Jimtown Road, five samples were above PCR, Bundicks Branch four samples above PCR, Misty Lane three samples above PCR, Route 24 eleven of twenty-four samples above PCR, and West Lane four of nine samples were above PCR. No samples for total Enterococcus at Goslee Pond and the mouth of Love Creek were above PCR levels (Figure 2).

Figure 2. Enterococcus levels as determined by Enterolert for each sampling site over the sampling period. PCR for freshwater (blue line) and marine waters (>5 ppt, red line) are also shown.

Microbial Community Analysis

Taxonomic analysis for 16S data showed that major taxa were largely consistent across sampling sites (Figure 3). The most abundant phyla across most sample locations were Proteobacteria, Bacteroidetes, and Actinobacteria (Figure 3A). Firmicutes, one of the most abundant gut microbes,26 was one of the top phyla for all sampling sites. At Jimtown Road and Bundicks Branch, Acidobacteria and OP3, were also in high abundance across all sampling time points. Both the Acidobacteria27 and OP326 have been identified from anoxic sediment samples suggesting a potential resuspension of sediments at these sites. At the class level, Gammaproteobacteria, Alphaproteobacteria, Betaproteobacteria, and Flavobacteriia showed the highest relative abundance across most of the sampling sites (Figure 3B). For fecal samples at the phylum level, the most abundant phyla were Firmicutes, Bacteroidetes, Proteobacteria, and Euryarchaeota (Figure 4A). Clostridia, Bacilli, Bacteroidia, and Methanobacteria were the dominant classes for fecal samples (Figure 4B). Chlorophyll a, dissolved oxygen saturation, NOX, specific conductivity, total dissolved solids (TDS) and turbidity were determined to be collinear (Total P, DO, Total N, Salinity, Salinity and total suspended solids, respectively). Previous research has shown a significant correlation to microbial community structure and total dissolved solids,17 therefore all CAP evaluations included total dissolved solids. Model selection by stepwise algorithm for weighted Unifrac on all selected factors were TDS, temperature, OP, pH, Salinity, NH3, total phosphorus and dissolved oxygen and without total N and P: TDS, temperature, OP, pH, Salinity, NH3, chlorophyll a and dissolved oxygen (Figure 5A) with 51.2% of the variation explained on CAP1 and 8.3% explained on CAP2. For Bray-Curtis factors were: salinity, temperature, OP, Enterococcus, total N, NH3, total organic C, total P, pH, chlorophyll a, and dissolved oxygen and without total N and P: salinity, temperature,

OP, Enterococcus, NOX, total organic C, NH3, pH, chlorophyll a, and dissolved oxygen (Figure 5B) with 21% of the variation accounted for on CAP1 and 9.7% accounted for on CAP2. Beta diversity analysis indicated a strong clustering of one distinct group with non-tidal sites (Jimtown Road, Bundicks Branch and Goslee Pond) separated from tidally driven sites for both weighted Unifrac with 56.9% of the variation accounted for on PCoA1 and 15.7% accounted for on PCoA2 and Bray-Curtis (Figure 6A and 6B respectively) with 24.1% of the variation on PCoA1 and 11.6% on PCoA2. Samples collected at the Route 24 marina and Misty Lane clustered together depending on sampling time salinity and temperature (Figures 5 and 6). PERMANOVA testing showed significant groupings for most environmental factors for both weighted Unifrac and Bray-Curtis (Table 2). Previous research13,28 has shown that a putative technical artifact resulting in splitting of 16S sequencing runs. For weighted Unifrac PERMANOVA analysis this artifact was not statistically significant for sample grouping (P = 0.0694), whereas Bray-Curtis was statistically significant (P = 0.0001). For fecal samples, the ruminant species clustered together for Bray-Curtis but were more dispersed in weighted Unifrac analysis. Additionally, avian samples were clustered in the Bray-Curtis analysis but not weighted Unifrac (Table 2).

Microbial Sources

SourceTracker analysis on the 16S data indicated that the majority of the bacterial community from all samples were derived from unknown sources (Figure 7, Figure 8). For the majority of sites, <40% of the microbial community was assigned to an identified source. At Jimtown Road, the majority of samples were from unknown sources, i.e. wildlife, with samples from April, July, August, September and October above PCR and SCR levels for Enterococcus (Figure 7A). 25

Figure 3. Relative Abundance of bacterial groups at the phylum level (A) and class level (B), showing the top 15 most abundant taxa from monthly samples.

Figure 4. Relative Abundance of bacterial groups at the phylum level (A) and class level (B), showing the top 15 most abundant taxa from fecal samples. 26 Delaware Journal of Public Health – January 2021

Figure 5. Constrained analysis of principal coordinates showing relationships among species compositions for sites and environmental factors (arrows) for weighted Unifrac (A) and Bray-Curtis (B) for all non-collinearity factors within the watershed (color) and sampling month (shape).

Figure 6. Beta diversity analyses of microbial community for weighted Unifrac PCoA (A) and Bray-Curtis (B) showing sampling location within the watershed (color) and sampling month (shape). 27

Environmental Factor

Weighted UniFrac P Value

Bray-Curtis P Value

Monthly Sampling



Site Location









Total dissolved solids






Chlorophyll a



Dissolved oxygen



Total P









Total N




Total organic C


NOx Sequence Run

0.0001 0.0694


Table 2. PERMANOVA test for statistical significance (Bold values represent P < 0.05)

Of those known samples, there was an increase in the amount of cat associated fecal bacteria as the summer progressed. Bundicks Branch had a greater proportion of the microbial community associated with known samples (Figure 7B) with July through September being above PCR and SCR levels. A decrease of known sources occurred from July to August and from September to October to approximately 5% of the microbial community associated to known sources. Samples collected from Goslee Mill Pond also showed an increase in known sources associated with cat fecal matter (Figure 7C), however none of the samples were near PCR during the sampling period (Figure 7). Three sampling periods, June rain event, September and October, at Misty Lane were above PCR levels for Enterococcus (Figure 8A). As with Jimtown Road, proportions of the microbial community associated with cat fecal matter increased as the summer progressed. In addition to cat, dog proportions increased over the summer as well, with both of these sources a large portion of the known sources in the microbial community. During the beginning of the sampling period, the housing unit was not occupied, beginning in July onwards the house was occupied with dogs evident on the premises. The Route 24 marina had four separate samples above PCR and SCR during the June rain event, and August through October. Both cat and dog sources were a large portion of the known sources at the marina (Figure 8B). West Lane showed four sampling periods above PCR levels and similar trends in known sources with large proportions of the microbial community associated with dog and cat fecal matter (Figure 8C). The mouth of Love Creek did not have any samples above contact levels, but did show increases in both cat and dog fecal matter associated microbes as the summer progressed (Figure 8D). 28 Delaware Journal of Public Health – January 2021

DISCUSSION Here we evaluated the microbial community and the relationships between environmental and chemical parameters, and the potential usage of next-generation sequencing (NGS) techniques for microbial source tracking (MST) in the Love Creek watershed. The watershed has undergone extensive development over the last several decades resulting in increased the number of potential human-related pollution sources, e.g. septic systems or domestic animals. In the non-tidal sites of Jimtown Road and Bundicks Branch high bacterial levels occurred during the warmer late summer months. Both of these sites are highly wooded with low population densities. At Jimtown Road, there is a high density of aging septic systems, however all samples were below 4% of mapping to known sources suggesting that most of the high bacteria levels are potentially from wildlife sources. Two samples at Bundicks Branch were above PCR followed by above SCR the next month. Interestingly, both points above SCR approximately 95% of the community were identified as unknown sources. Unlike Jimtown Road, Bundicks Branch the highest proportion comes from duck. In contrast, Goslee Mill Pond did not have any high levels of Enterococcus during any of the sampling periods suggesting that the pond may act similar to a settling point. Therefore potentially preventing upstream fecal contamination from moving further into the more populated waterways. Tidally driven sites, with the exception of the mouth of Love Creek, also experienced high Enterococcus levels during the warmer months. Land use at Misty Lane is similar to Jimtown Road, with primarily woods with a few smaller vacation homes. A large proportion of known sources are from both cat and dog for July and September. The Route 24 Marina and West Lane demonstrated similar trends for cat and dog and had three periods of Enterococcus levels above SCR and one above PCR. The collection site for Route 24 was directly at a public boat ramp which may increase exposure and health risks for recreational boaters. Additionally, the marina is located within a small development with older septic systems which are primarily used during the summer months with few year round residents. West Lane contains more established homes but at a higher density of septic systems. No high levels of Enterococcus were found at the mouth of Love Creek. Sampling occurred at a pier near the edge of the mouth, and may not be indicative of the whole mouth of Love Creek. As with many of the sites within the watershed, cat and dog signals increased during the warmer months, with cat being the largest proportion for both Route 24 and West Lane. The State of Delaware has seen the population of outdoor cats increase over the last several years. As evident by large portions of the known sources from cat signatures. Other sources, e.g. goat and horse, are also in high proportions in many of the sites. However, observations during collection do not indicate likely locations for these sources, requiring a “boots on the ground” approach for determining likely locations of sources. Both Bacteroidetes and Firmicutes, two of the major phyla within human fecal matter,26,29 were present in all our samples but not as prevalent as Proteobacteria. Other studies have shown that the prevalence of Proteobacteria in samples may be an indicator of run-off or storm water30,31 or from sewage infrastructure, i.e. a transient population.30 SourceTracker analysis indicated that almost all samples from the Love Creek watershed had human signatures from <0.1% to 13%. However,

Figure 7. SourceTracker analysis of bacterial assemblages from freshwater sites at Jimtown Road (A), Bundicks Branch (B) and Goslee Mill Pond (C). Sample times that were above PCR are indicated with a blue rectangle and times above both PCR and SCR are indicated with a red rectangle.

Figure 8. SourceTracker analysis of bacterial assemblages from marine sites at Misty Lane (A), Route 24 marina (B), West Lane (C) and the mouth of Love Creek (D). Sample times that were above PCR are indicated with a blue rectangle and times above both PCR and SCR are indicated with a red rectangle. 29

the human signature represents a single individual and does not constitute a representative library. Presently, it is not known how many samples would constitute a representative library14 and large variations may occur among human and other fecal samples.32 In contrast, Staley, et al.33 suggests that a minimum of ten individuals are sufficient for accurate fecal contamination detection. However, when few source are used and/or available, results may be better interpreted using broad category classifications, e.g. livestock rather than specific organism. Additionally, Staley, et al.33 demonstrated to increase accuracy of the SourceTracker analysis, geographically associated fecal samples are required. All samples used in this study were geographically located in Delaware. A large library and rarefaction depth may improve identification of sources by SourceTracker.14 However, previous research has suggested, from a statistical standpoint, rarefying data was inadmissible,34 as part of our workflow samples were not rarefied. In this study, we showed that using NGS methods and bacterial community structure can be combined to identify potential sources of fecal pollution in the Love Creek watershed. The use of SourceTracker and NGS are still part of emerging techniques for the tracking of fecal sources. Increasing the library size of known sources, sequencing depth, and greater diversity of sources will require further analysis.14 Nonetheless, this study is proof that at the state level these methods are capable of giving the start of source tracking. We recommend using these methods as a starting pointing for ground-truthing, as sources may not be evident. One limitation of these methods are the time to develop a library and the computational requirements for large datasets can be a significant challenge. With open-source tools such as QIIME2, SourceTracker and others, are efficient and simple to use, and with the advent of cloud computing large computational clusters are no longer required.

PUBLIC HEALTH IMPLICATIONS Current methodologies for determining bacterial contamination in the water bodies of Delaware use testing developed to measure the genus Enterococcus via Enterolert©. Primary Contact Recreation (PCR) and Secondary Contact Recreation (SCR) risk-based numeric criteria have been developed by DNREC “to be of non-wildlife origin based on best scientific judgment using available information.”1 However, one limitation of the use of Enterococcus as a fecal indicator species is the inability to differentiate between fecal sources, i.e. human-related sources and wildlife. Common MST methods use specific bacterial primers from hosts to measure quantities via quantitative real-time PCR (qPCR).4,5 However, the development of primers for fecal sources of interest may be time consuming and previous research has shown potential issues with specificity and sensitivity of qPCR.6–8 The usage of NGS methods to define the microbial community of aquatic and fecal samples using amplicon sequence variant (ASV), which can resolve the difference of sequences to a single nucleotide, increases the power of determining potential fecal contamination sources.9,10 SourceTracker uses Bayesian models to derive proportions of sources within sink samples, however it has been reported that sources are low concentrations have high variability in estimates.11 From a public health standpoint, even at low concentrations of fecal contamination may pose public health risks,5,15 thus the high variability in estimates may inhibit 30 Delaware Journal of Public Health – January 2021

detection. Henry et al.15 demonstrated that at low proportions (as low as 0.1%), successful detection by SourceTracker can occur. Correspondence: Dr. Christopher Main,

REFERENCES 1. DNREC. Surface Water Quality Standards (2014). Retrieved from: 2. Price, K. (1998). A framework for a Delaware Inland Bays environmental classification. Environmental Monitoring and Assessment, 51(1/2), 285–298. Retrieved from: 3. Sallade, Y. E., & Sims, J. T. (1997). Phosphorus transformations in the sediments of Delaware’s agricultural drainageways: II. Effect of reducing conditions on phosphorus release. Journal of Environmental Quality, 26(6), 1579. 4. Brown, C. M., Staley, C., Wang, P., Dalzell, B., Chun, C. L., & Sadowsky, M. J. (2017, August 1). A high-throughput DNA-sequencing approach for determining sources of fecal bacteria in a Lake Superior estuary. Environmental Science & Technology, 51(15), 8263–8271. 5. Harwood, V. J., Staley, C., Badgley, B. D., Borges, K., & Korajkic, A. (2014, January). Microbial source tracking markers for detection of fecal contamination in environmental waters: Relationships between pathogens and human health outcomes. FEMS Microbiology Reviews, 38(1), 1–40. 6. Brown, C. M., Mathai, P. P., Loesekann, T., Staley, C., & Sadowsky, M. J. (2019). Influence of Library Composition on SourceTracker Predictions for Community-Based Microbial Source Tracking. Environmental Science & Technology, 53(1), 60–68. research-article. 7. Green, H. C., Haugland, R. A., Varma, M., Millen, H. T., Borchardt, M. A., Field, K. G., . . . Shanks, O. C. (2014, May). Improved HF183 quantitative real-time PCR assay for characterization of human fecal pollution in ambient surface water samples. Applied and Environmental Microbiology, 80(10), 3086–3094. 8. Stewart, J. R., Boehm, A. B., Dubinsky, E. A., Fong, T. T., Goodwin, K. D., Griffith, J. F., . . . Weisberg, S. B. (2013, November 15). Recommendations following a multilaboratory comparison of microbial source tracking methods. Water Research, 47(18), 6829–6838. 9. Unno, T., Staley, C., Brown, C. M., Han, D., Sadowsky, M. J., & Hur, H.-G. (2018, September). Fecal pollution: New trends and challenges in microbial source tracking using nextgeneration sequencing. Environmental Microbiology, 20(9), 3132–3140. 10. Callahan, B. J., McMurdie, P. J., & Holmes, S. P. (2017, December). Exact sequence variants should replace operational taxonomic units in marker-gene data analysis. The ISME Journal, 11(12), 2639–2643.

11. Knights, D., Kuczynski, J., Charlson, E. S., Zaneveld, J., Mozer, M. C., Collman, R. G., . . . Kelley, S. T. (2011, July 17). Bayesian community-wide culture-independent microbial source tracking. Nature Methods, 8(9), 761–763.

23. Bolyen, E., Rideout, J. R., Dillon, M. R., Bokulich, N. A., Abnet, C., Al-Ghalith, G. A., . . . Caporaso, J. G. (2018). QIIME 2: Reproducible, interactive, scalable, and extensible microbiome data science. PeerJ.

12. Dubinsky, E. A., Butkus, S. R., & Andersen, G. L. (2016, November 15). Microbial source tracking in impaired watersheds using PhyloChip and machine-learning classification. Water Research, 105, 56–64.

24. Oksanen, J., Blanchet, F. G., Friendly, M., Kindt, R., Legendre, P., McGlinn, D., . . . Wagner, H. (2019). vegan: Community Ecology Package. Retrieved from:

13. Bik, H. M., Maritz, J. M., Luong, A., Shin, H., DominguezBello, M. G., & Carlton, J. M. (2016, November 16). microbial community patterns associated with automated teller machine keypads in New York City. MSphere, 1(6), e00226-16 14. Ahmed, W., Staley, C., Sadowsky, M. J., Gyawali, P., Sidhu, J. P. S., Palmer, A., . . . Toze, S. (2015, October). Toolbox approaches using molecular markers and 16S rRNA gene amplicon data sets for identification of fecal pollution in surface water. Applied and Environmental Microbiology, 81(20), 7067–7077. 15. Henry, R., Schang, C., Coutts, S., Kolotelo, P., Prosser, T., Crosbie, N., . . . McCarthy, D. (2016, April 15). Into the deep: Evaluation of SourceTracker for assessment of faecal contamination of coastal waters. Water Research, 93(March), 242–253. 16. McCarthy, D. T., Jovanovic, D., Lintern, A., Teakle, I., Barnes, M., Deletic, A., . . . Henry, R. (2017, February 1). Source tracking using microbial community fingerprints: Method comparison with hydrodynamic modelling. Water Research, 109, 253–265. 17. Staley, C., Gould, T. J., Wang, P., Phillips, J., Cotner, J. B., & Sadowsky, M. J. (2014, October 8). Bacterial community structure is indicative of chemical inputs in the Upper Mississippi River. Frontiers in Microbiology, 5(OCT), 524. 18. Staley, C., Gould, T. J., Wang, P., Phillips, J., Cotner, J. B., & Sadowsky, M. J. (2015, February 1). Species sorting and seasonal dynamics primarily shape bacterial communities in the Upper Mississippi River. The Science of the Total Environment, 505, 435–445. 19. Homsey, A., Walch, M., Boswell, S., & Bason, C. (2015). The State of Your Creek: Love Creek on Rehoboth Bay. 20. American Public Health Association. (2012). Standard methods for the examination of water and wastewater (22nd ed.). Washington, DC: American Public Health Association. 21. Dempster, E. L., Pryor, K. V., Francis, D., Young, J. E., & Rogers, H. J. (1999, July). Rapid DNA extraction from ferns for PCR-based analyses. BioTechniques, 27(1), 66–68. Retrieved from: 22. Parada, A. E., Needham, D. M., & Fuhrman, J. A. (2016, May). Every base matters: Assessing small subunit rRNA primers for marine microbiomes with mock communities, time series and global field samples. Environmental Microbiology, 18(5), 1403–1414.

25. McMurdie, P. J., & Holmes, S. (2013, April 22). phyloseq: An R package for reproducible interactive analysis and graphics of microbiome census data. PLoS One, 8(4), e61217. 26. Arumugam, M., Raes, J., Pelletier, E., Le Paslier, D., Yamada, T., Mende, D. R., . . . Bork, P., & the MetaHIT Consortium. (2011, May 12). Enterotypes of the human gut microbiome. Nature, 473(7346), 174–180. 27. Kielak, A. M., Barreto, C. C., Kowalchuk, G. A., van Veen, J. A., & Kuramae, E. E. (2016, May 31). The ecology of acidobacteria: Moving beyond genes and genomes. Frontiers in Microbiology, 7(MAY), 744. 28. Chase, J., Fouquier, J., Zare, M., Sonderegger, D. L., Knight, R., Kelley, S. T., . . . Caporaso, J. G. (2016, April 19). Geography and location are the primary drivers of office microbiome composition. mSystems, 1(2), 1–18. 29. Eckburg, P. B., Bik, E. M., Bernstein, C. N., Purdom, E., Dethlefsen, L., Sargent, M., . . . Relman, D. A. (2005, June 10). Diversity of the human intestinal microbial flora. Science, 308(5728), 1635–1638. 30. Shanks, O. C., Newton, R. J., Kelty, C. A., Huse, S. M., Sogin, M. L., & McLellan, S. L. (2013, May). Comparison of the microbial community structures of untreated wastewaters from different geographic locales. Applied and Environmental Microbiology, 79(9), 2906–2913. 31. García-Aljaro, C., Blanch, A. R., Campos, C., Jofre, J., & Lucena, F. (2019, March). Pathogens, faecal indicators and human-specific microbial source-tracking markers in sewage. Journal of Applied Microbiology, 126(3), 701–717. 32. Huse, S. M., Ye, Y., Zhou, Y., & Fodor, A. A. (2012). A core human microbiome as viewed through 16S rRNA sequence clusters. PLoS One, 7(6), e34242. 33. Staley, C., Kaiser, T., Lobos, A., Ahmed, W., Harwood, V. J., Brown, C. M., & Sadowsky, M. J. (2018, April 3). Application of SourceTracker for accurate identification of fecal pollution in recreational freshwater: A double-blinded study. Environmental Science & Technology, 52(7), 4207–4217. 34. McMurdie, P. J., & Holmes, S. (2014, April 3). Waste not, want not: Why rarefying microbiome data is inadmissible. PLoS Computational Biology, 10(4), e1003531. 31

Using Meat Labels to Communicate the Risk of Antimicrobial-Resistant Bacterial Infections from Foods of Animal Origin: The Case for a Balanced One Health Approach to Raising Food Animals G. Donald Ritter, D.V.M., A.C.P.V. Poultry Business Solutions LLC, Salisbury, Maryland

ABSTRACT Consumers are increasingly confused by the numerous meat labels confronting them in the meat case. Most meat labels do not provide actionable information and many labels only add to consumer confusion. While many consumers are willing to pay a premium for products with specific attributes, the trade-offs and unintended consequences associated with various animal raising programs are not transparent and often poorly understood. Adding to this confusion is a tendency toward the use of “absence labels” on meat products that can create a negative perception of unlabeled conventional products that may or may not include the attribute in question. Communicating with consumers about the complex issue of antimicrobial resistance (AMR) is challenging. A more balanced approach to raising food animals is a new consumer choice label program based on principles of One Health that provides transparent information to consumers with mandated antibiotic stewardship practices to reduce risk of AMR originating from food animals. This holistic program strives to provide optimal health outcomes for animals, people, and the environment and avoid the negative consequences sometimes associated with more narrowly focused programs.

INTRODUCTION The removal of all antibiotic use when raising food animals, a practice known as “no antibiotics ever” (NAE), has become a valuable marketing tool for many meat producers. A major concern of the use of antibiotics in food animals is that it may increase the risk of antibiotic-resistant bacterial infections in humans through several pathways.1 For antimicrobial resistance (AMR) to spread from farms to consumers via handling or consuming foods of animal origin, numerous sequential events must occur, and for many of these events the risk is uncertain. Non-foodborne spread of AMR from animal agriculture may also occur via other mechanisms such as direct contact with food animals, environmental spread of antibiotic-resistant bacteria from the farm or from secondary human-to-human transfer of farm acquired resistant bacteria in the community. Government mandated labels only address safe food handling, while voluntary labels target actual or perceived quality attributes related to specific animal raising practices. All voluntary label claims on meat and poultry products require prior approval from the United States Department of Agriculture, Food Safety Inspection Service (USDA-FSIS), while similar claims on milk and egg products are regulated by the Food and Drug Administration (FDA). One popular voluntary label claim, “no antibiotics ever,” is primarily marketed on chicken products and indicates the total absence of antibiotics used in raising the animals. Research suggests that there is widespread confusion and frustration among consumers surrounding such negative “absence labeling,” a practice that implies that similar unlabeled products may include the attribute or practice in question, which may or may 32 Delaware Journal of Public Health – January 2021

not be true. A survey completed by ORC International found that 73% of consumers believe that antibiotics are present in most chicken meat despite federal regulations prohibiting unsafe levels of antibiotic residues from being present in any meat sold in the United States.2,3 Removing all antibiotics from animal production may at times put the health and welfare of animals at unnecessary risk and has negative environmental impacts. A more enlightened approach to raising food animals is to follow a balanced and holistic program based on the principles of One Health that seeks to minimize these negative tradeoffs. Such a program provides guidelines outlining best responsible animal care practices for animal producers to follow with uniform labeling to provide a new consumer choice label on meat packages. This brief article will describe the risk of AMR infection from antibiotic use in food animals and new steps that are being taken to provide more transparency in voluntary meat labels regarding this important topic.

RISK OF AMR INFECTIONS FROM FOODS OF ANIMAL ORIGIN Assessing the risk to consumers of acquiring an AMR infection to on farm use of antibiotics is dependent on the occurrence of a specific series of events. First, AMR bacteria or resistance genes emerge on the farm as a direct result of antibiotic use. Secondly, farm-origin AMR bacteria or resistance genes contact humans. Thirdly, a person acquires infection with the AMR bacteria or associated bacteria carrying the resistance genes and lastly, additional public health costs due to antibiotic treatment failures of the affected person may be incurred. To perform an informative risk assessment of AMR infections for doi: 10.32481/djph.2021.01.007

consumers from antibiotic use in food animals, it is necessary to assess the risk of each of these events. In the case where the likely exposure risk to consumers comes from retail food products, consumer and retailer food handling practices must be accurately assessed. Factors upstream of these exposures in the supply chain, such as food safety practices used in the facility where the animal was processed, also need to be considered. Publicly available data, usually from ongoing monitoring programs operated by USDA-FSIS, are available to provide information about some of these factors both upstream and downstream from the consumer. However, established programs that collect samples from animals on the farm, at the processing plant, and from retail meat products use different methodologies and sample different parts of the animal such as animal bedding or feces (on farm), skin (processing facility), or meat (retail stores), making comparison between data sets problematic. To help address these issues, international groups such as the World Health Organization (WHO) Advisory Group on Integrated Surveillance of Antimicrobial Resistance (AGISAR) are trying to develop standardized surveillance methodologies. Currently, existing programs are reluctant to change their protocols but there is hope that standardization will eventually emerge from these efforts.4 Researchers have studied the prevalence and severity of AMR in food animals and retail meat samples from NAE and conventionally raised animals. Study conclusions are divided, with some researchers finding a correlation between NAE practices and reduced findings of AMR bacteria while others have found no difference in the AMR profiles in animals and meat from NAE vs conventionally raised producers.5,6 More research is needed to better understand the precise attribution of antibiotic use in food animals to subsequent AMR infections in humans.

NO ANTIBIOTIC EVER (NAE) PROGRAMS IN FOOD ANIMALS In recent years, consumers, animal activists and public health focused non-governmental organizations have raised concerns about the use of antibiotics in food animals and the potential risk of foodborne AMR infections for people. This has increased demand for meat and poultry from animals raised without ever receiving any antibiotics, a practice known in the marketplace as “no antibiotics ever” or “NAE”. NAE indicates that the source animals have never received any antibiotics (including ionophores, an animal use only antibiotic class) in feed, water or by injection during their lifetime.7 This practice is on the rise, especially in short-lived animals such as broiler chickens, with the proportion of U.S. broiler chickens raised in NAE programs climbing from 5% in 2012 to 50% in 2019.8 As of November 2020, approximately 55% of broilers were raised as NAE, according to data from Agri Stats, an economic benchmarking service for the broiler industry.8 However, while production of NAE broilers is currently over 50% of the supply chain, retail sales of chicken meat labeled and sold as NAE only account for approximately 10% of the total volume.9 This is because most consumers who seek out and buy NAE chicken are generally only willing to pay a premium for certain parts. Although some consumer surveys indicate that a growing number of consumers say they want to know more details about how their food is produced and are worried about issues such

as antibiotic use in food animals, other research suggests that when to comes down to buying meat, most consumers decide what to buy based on price, taste, and freshness while a small subset of consumers seeks out the “no antibiotics ever” label claim on meat packages.10 Premium prices are typically charged for NAE prime cuts like boneless breast meat, while other nonprime portions are usually sold as unlabeled commodity chicken with no price premium. This over-saturation of NAE produced product has reduced the price premium in the marketplace for NAE labeled chicken over time. For example, in 2013, the premium for NAE boneless skinless breast meat was 60-80 cents per pound, but this has dropped to about 20 cents per pound by 2020.8 Both factors make production of NAE broilers economically challenging at current levels. Despite the eroding premiums paid to NAE broiler producers, NAE chicken sold at retail costs consumers 50-200% more than conventionally raised chicken due to variable price premiums added by food retailers, who add a large additional margin on top of the higher cost charged to them by broiler producers.

UNINTENDED CONSEQUENCES OF NO ANTIBIOTIC EVER PROGRAMS When antibiotics are completely removed from food animal production systems, the health and welfare of animals produced under that restriction are at increased risk. Monthly mortality among NAE broiler chickens was 25-50% higher in 2017 compared to conventionally raised chickens in the United States. From October 2017 to May 2018, according to data from Agri Stats, mortality rates of broilers raised without antibiotics averaged 4.2%, while conventionally raised chickens had an average mortality rate of about 2.9% (more than 40% lower).8 After falling steadily from 18% mortality to below 5% between 1925 and 2013, there has been an increase in mortality rates coinciding with the corresponding increased amount of NAE production (Figure 1).11 In 2017, researchers conducted an anonymous online survey of 565 food animal producers and veterinarians working with food animals predominantly in the United States. Over half of the respondents currently worked with or had previously worked with animals being raised in NAE programs, and thus had direct experience with NAE production. Over 80% of producers and veterinarian survey respondents with NAE production experience said that they thought that NAE either slightly or significantly worsens animal health and welfare.12 A troubling finding from the survey revealed that respondents with NAE production experience somewhat or strongly agreed that maintaining an NAE label at times took priority over animal health and welfare.12 NAE producers face various pressures to not treat sick animals with antibiotics and subsequently lose the value of the NAE product. A council of scientists studied NAE production and determined that it caused and may continue to cause producers and veterinarians to withhold [antibiotic] treatment for animals intended for the consumer market. They concluded that, “negative impacts on animals’ welfare resulting from disease that could be prevented and/or that cannot be controlled and treated are significant and unacceptable.”13 Investigations into the causes of increased mortality in NAE broilers have identified increased occurrence of specific disease conditions such as necrotic enteritis and bacterial osteomyelitis, 33

Figure 1. Annually mortality of U.S. broiler chickens from 2008 -2019: Source National Chicken Council

corroborating that NAE practices are jeopardizing animal health and welfare. The increase in these conditions in NAE broilers is presumably due to the increased potential for intestinal disease, which in turn leads to more bacterial escape from the intestine to cause lesions elsewhere (such as in bones) and the associated diarrhea adds excess moisture to the poultry litter, causing ammonia levels in poultry buildings to increase. NAE flocks are at 3.5-fold greater risk of ammonia burns in the eye and have 1.4-fold greater risk of having manure burn foot lesions compared with conventionally raised flocks.14 NAE broilers have also been shown to have reduced daily weight gain and higher feed conversion ratio (pounds of feed required to produce pounds of live chicken) when compared with conventionally raised flocks, despite the reduced stocking density usually used for NAE flocks.15 The higher mortality in NAE chickens, along with the lower stocking density, higher feed conversion ratio, reduced body weights for age and increased downtime between flocks (a common practice in NAE production) results in a negative environmental impact compared to chickens raised in conventional programs. Researchers estimate that if all nine billion meat-type chickens raised annually in the United States were raised in NAE programs, an additional 680-880 million more birds per year would need to be raised to maintain the current level of chicken meat supply.16 To raise these additional chickens would require 5.4-7.2 million more tons of feed and 1.9-3.0 billion more gallons of water each year, and produce 4.6-6.1 million more tons of manure.17,18 To truly assess the environmental impact of NAE production more accurately, a full life-cycle assessment analysis, a tool used to calculate the total environmental costs attributed to animal production systems, is required. 34 Delaware Journal of Public Health – January 2021

ANTIBIOTIC USE CLAIMS ON MEAT LABELS Although some surveys indicate that a growing number of consumers say they want to know more details about how their food is produced and are worried about issues such as antibiotic use in animal agriculture, other research suggests that when it comes to buying meat, most consumers decide based only on price, taste, and freshness.9 Retail meat sales in the United States follows a “good, better, best” marketing strategy. The least expensive (good) option contains many store branded products that usually lack special antibiotic or other voluntary label claims. The intermediary options (better) are meat products from national branded companies, some of which have voluntary label claims regarding antibiotic use. For example, chicken products from national branded company Tyson, currently the largest U.S. NAE chicken producer, carry the “no antibiotics ever” label claim. The most expensive (best) meat products available may contain multiple health and welfare voluntary label claims, stating that the animals were raised in systems that differ substantially from conventional farming practices, such as USDA certified organic or privately managed programs such as Global Animal Partnership (GAP), a program featured primarily at Whole Foods Markets. The label “no antibiotics ever” is an example of what is known as an “absence claim” label. Absence labels refer to an attribute or practice that was not used in the raising of the animals so labeled. All meat labels must first be approved by FSIS Labeling, and verification of claims related to animal raising practices is required prior to their approval. The use of antibiotics in food animal production is poorly understood by consumers, who often associate antibiotic use during animal raising with the presence of harmful antibiotic residue levels remaining in the meat after

the animal is harvested, even though federal regulations prevent the sale of any meat containing antibiotic residues above safe maximum residue levels as determined by the FDA.17,18 The FDA establishes “withdrawal times,” which are times after drug treatment when milk and eggs are not allowed to be used for food and during which animals are not to be slaughtered. This allows time for the animals to eliminate the drug residues and ensures that all meat sold in the U.S. does not contain harmful drug residues, no matter what label claim is displayed on the meat package.

RAISING ANIMALS USING A MORE HOLISTIC APPROACH Narrowly focused animal raising practices such as “no antibiotics ever,” which only provide guidance about how antibiotics are used in food animals, often create unintended consequences or negative trade-offs in other attributes, such as animal health and welfare or environmental impacts. A more enlightened approach to raising animals is to follow more balanced and holistic guidelines that by design seek to avoid such unintended negative outcomes. One such program that follows this paradigm, One Health CertifiedTM (, was publicly launched in January 2020. This new consumer choice label program follows a One Health philosophy and strives to provide optimal health outcomes for animals, people, and the environment. One Health is a multidisciplinary concept that recognizes that the health of humans, animals and the environment are inseparable and that activities in one compartment of the triad directly impact the other compartments. The One Health CertifiedTM program provides public transparent guidelines outlining best responsible animal care practices for food animal producers to follow in five core areas: disease prevention, veterinary care, responsible antibiotic use, animal welfare and environmental impact. The program has several unique aspects relative to current meat label offerings. One Health CertifiedTM is a public program open to all producers, and offers participants a unique way to market their products using clearly defined, implemented and transparent process points. Program guidelines are verified through annual government audits via the USDA Process Verified Program (PVP) procedures operated by the USDA Agricultural Marketing Service (USDA-AMS). Companies that align their procedures to meet the program standards and achieve certification can label their retail and wholesale products with a simple logo that conveys that responsible animal care practices have been followed and verified. One Health CertifiedTM programs are currently available for chicken and turkey, and additional programs are being developed for the other major animal protein commodities - pork, beef, egg, and dairy. Some of the unique features of One Health CertifiedTM include aspects of veterinary care, responsible antibiotic use, environmental impact, and central oversight with annual reporting requirements. The veterinary care program requires a comprehensive animal health plan that mandates prompt treatment of sick animals. Farmers must act at defined action thresholds to quickly respond to changes in the health status of animals. If an infectious disease is suspected, a veterinary action plan that outlines actions and prescribes appropriate treatments must be completed. A treatment outcome assessment is

required if a veterinarian ordered treatment was administered. Responsible antibiotic use guidelines have restrictions on the use of antibiotics important in human medicine intended to minimize the development of AMR bacteria important in human illness originating from the farm. Human medically important antibiotics may only be used when deemed medically necessary to treat and control animal illness when prescribed by a licensed veterinarian with a valid client patient relationship with the farm owner. Antibiotics that are considered not important in human medicine may be used to maintain animal health and welfare according to FDA regulations. When used properly, these low risk or animal-only antibiotics greatly reduce the need for administration of antibiotics important in human medicine. All information related to antibiotic use must be documented and maintained. One Health CertifiedTM is the first animal raising standard to address environmental inputs of animal agriculture and to measure their impact. The program supports environmental stewardship practices related to food animal production by requiring annual measurements that calculate the carbon footprint to produce the meat and requires that waste management programs be properly maintained on each farm. One Health CertifiedTM is a dynamic program based on a continuous improvement process with standard updates planned every three years. Program participants are required to submit a detailed report annually to the One Health Certified Foundation, a non-profit organization within the National Institute of Antimicrobial Resistance Research and Education (NIAMRRE) located at Iowa State University that administers the One Health CertifiedTM program. Evaluations of submitted data and new scientific research will drive program improvements to assure that the program continues to evolve over time.

CONCLUSIONS The potential risk of AMR originating from farms raising food animals is an important concern for public health. Research and primarily governmental monitoring programs of farms, animal processing facilities and retail meat products are ongoing that attempt to determine some factors contributing to that risk. Other involved risk factors, such as environmental spread of AMR bacteria and genes from the farm and safe food handling procedures of retailers and consumers are more difficult to assess. Voluntary meat label claims related to antibiotic use programs in the animals raised is one way to provide actionable information to consumers about this topic to assist in making more informed decisions in the marketplace. Complete removal of all antibiotics from food animal systems such as in “no antibiotic ever” programs may at times unnecessarily put animal health and welfare at increased risk and raises the environmental cost of food animal production. A more enlightened approach to animal raising incorporates a more balanced and comprehensive approach and seeks to minimize the trade-offs often associated with more narrowly focused programs. An example of such a program is One Health CertifiedTM, a new consumer choice label that represents transparent program guidelines outlining best responsible animal care practices in a publicly available continuous improvement process for animal producers to follow and for consumers to understand. Correspondence: G. Donald Ritter, D.V.M.; 35

REFERENCES 1. Hoelzer, K., Wong, N., Thomas, J., Talkington, K., Jungman, E., & Coukell, A. (2017, July 4). Antimicrobial drug use in food-producing animals and associated human health risks: What, and how strong, is the evidence? BMC Veterinary Research, 13(1), 211. 2. National Chicken Council. (2015). Chicken check in 2015. Retrieved from: 3. U.S. Food and Drug Administration. (2018). Title 21: part 556 tolerances for residues of new animal drugs in food. Silver Spring, MD: FDA. Retrieved from: 2725fe73ab8&mc=true&node=pt21.6.556&rgn=div5 4. Interagency Coordination Group on Antimicrobial Resistance. (2018). Communicating antimicrobial resistance to consumers antimicrobial use and resistance IACG discussion paper. Retrieved from: communication_to_collective_action_270718.pdf 5. M’ikanatha, N. M., Yin, X., Dettinger, L., Johnston, M., Eckroth, W., Husband, B. I., . . . Tait, J. (2019, Oct). Abstract 628. Presented at: IDWeek; Oct 2-6, 2019; Washington, DC Infectious Disease Society of America. 6. Costard, S., Pouzou, J. G., Belk, K. E., Morley, P. S., Schmidt, J. W., Wheeler, T. L., . . . Zagmutt, F. J. (2020, September). No Change in risk for antibiotic-resistant salmonellosis from Beef, United States, 2002–2010. Emerging Infectious Diseases, 26(9), 2108–2117. 7. Food Safety Inspection Service. (2016). Labeling guideline on documentation needed to substantiate animal raising claims for label submissions. U.S. Department of Agriculture. 8. AgriStats. Client provided data. Retrieved from:

36 Delaware Journal of Public Health – January 2021

9. Nielsen Retail Scan Data. Retrieved from: 10. Glassman, M. (2015). Hungry for information: polling Americans on their trust in the food system. Americans prioritize affordability. The Chicago Council on Global Affairs. 11. National Chicken Council. (2020). Retrieved from: 12. Singer, R. S., Porter, L. J., Thomson, D. U., Gage, M., Beaudoin, A., & Wishnie, J. K. (2019, December 6). Raising animals without antibiotics: US producer and veterinarian experiences and opinions. Frontiers in Veterinary Science, 6, 452. 13. Council for Agricultural Science and Technology. (2018, Apr). Task force report on scientific, ethical, and economic aspects of farm animal welfare. Ames, Iowa. No. 143, 24-25. 14. Karavolias, J., Salois, M. J., Baker, K. T., & Watkins, K. (2018, August 10). Raised without antibiotics: Impact on animal welfare and implications for food policy. Translational Animal Science, 2(4), 337–348. 15. Gaucher, M. L., Quessy, S., Letellier, A., Arsenault, J., & Boulianne, M. (2015, August). Impact of a drug-free program on broiler chicken growth performances, gut health, Clostridium perfringens and Campylobacter jejuni occurrences at the farm level. Poultry Science, 94(8), 1791–1801. 16. Salois, M. J., Cady, R. A., & Heskett, E. A. (2016). The environmental and economic impact of withdrawing antibiotics from US broiler production. Journal of Food Distribution Research, 47, 79–80. 17. Foundation, I. F. I. C. (2018). Food insight 2018. Retrieved from: 18. Digital, S. W. N. S. (2018). Retrieved from:

Seeking Clinical Practice Partners

FOOD INSECURITY QUALITY MEASURE TESTING PROJECT Quality Insights is recruiting one practice with patient populations with risk factors for food insecurity to consider collaborating with us on our project that aims to screen and provide appropriate clinical support to alleviate food insecurity. Specifically, this quality improvement project will focus on improving health outcomes by facilitating the reduction of or management of food insecurity at the point of care. Below are details for this project.

Requirements to Participate: Benefits of Participation: Receive assistance with collecting or extracting data for three food insecurity quality measures that may be implemented in future reporting programs Receive a honorarium payment of $4,500 for participating Provide insight into social determinants of health in the context of food insecurity Participate in creating new quality measures intended for use at the health plan level Create a foundation for your practice’s quality improvement efforts, as well as prepare your practice for future value–based payment models

• Designate an individual to act as

the primary contact for Quality Insights

• Complete a Memorandum of

Understanding (MOU) and Business Associates Agreement (BAA)

• Work with a patient population

that could qualify for or is currently receiving food benefits such as WIC or SNAP

• Submit existing EHR data and

complete a data collection period for three new quality measures

• Willing to provide perspective

related to implementing workflow modifications to improve data collection and health outcomes related to food insecurity

Quality Insights requires completion of our MOU and BAA for participation and payment. If you are interested in participating, please email Quality Insights Measures Mailbox


COVID-19 Acutely Impacted the Delmarva Poultry Industry in Early 2020 Christopher Brosch, M.Sc. Administrator, Nutrient Management Program, Delaware Department of Agriculture Georgie Cartanza Poultry Extension Agent, University of Delaware

ABSTRACT Early community spread of COVID-19 presented a public health crisis and Delmarva’s essential workforce at the poultry processing plants. Plant workers in May 2020 were struggling to adapt to exposure risk and illness in the workforce. Furthermore, pressures of an unfamiliar marketplace strained the supply and demand linkages in poultry processing. By utilizing strategies to meaningfully slow the supply of chicken at the processing plant, farm and hatchery, supply was slowed without stopping. This ensured security in the food supply, but jeopardized farmers raising these livestock. After weeks of processing adjustments, some chicken farms were depopulated as a last resort to protect their welfare. The remains of the depopulated flocks presented a risk to public health from environmental externalities. Across the Delmarva peninsula, carcasses were composted in the housing in which they were raised along with feed, bedding and manure, and high-carbon material, and were carefully monitored to reduce environmental impacts. Compost is recycled into a resource and can be utilized safely on farms for soil conditioning, like organic fertilizer, rather than presenting an environmental disaster. In April and May of 2020, while grocery stores in the United States were being wiped of foodstuffs, public testing for COVID-19 was ramping up. This was in part because of illnesses and calls to action from workers in meat processing plants across the country who were becoming infected with and fearful of the COVID-19 illness. Industry and the Government sprang to action with additional protective equipment, paid sick leave, mandatory health screening, and implementation of the Defense Production Act to ensure American food security. Nearly all citizens were impacted by the disruption in the supply chain of food, such as milk and chicken in the grocery stores, but agribusinesses, farmers, and the environment fell under threat as well. In many places, food shortages hit before travel restrictions. It was not the inability to move food to consumers globally that impacted grocery store stocks, but the supply itself. At that time, meat processing facilities were still running at a relatively normal rate. The first disruption was the almost immediate and total decline in purchasing of food service-packaged (bulk) meat, like 40-pound boxes of fresh and frozen boneless skinless chicken breast, which would have normally been bought by restaurants for dishes such as chicken tenders, sandwiches and Alfredo. Processing plants across the region preparing nearly 1.7 million chickens per day for distribution suffered decreased speeds as factory lines were accommodating larger than intended birds.1 The companies also shifted to direct-to-consumer packaging and hosted drive-through chicken sales at large outdoor venues on Delmarva where food service packages were put on clearance to lines of eager people. Soon also, scores of workers in each shift could not or would not come to work because of the virus’ spread, further limiting the supply chain. As supply issues quickly stacked up against solutions, plants and chicken farmers utilized other means of slowing the supply of chickens without a marketplace. At the plant, rendering operations that breakdown by-products like feathers, scraps and blood were maximized to recover fat and protein for animal feed from entire birds that could not be sold. Fewer eggs were hatched 38 Delaware Journal of Public Health – January 2021

and chicks delivered to be raised by poultry farmers and those farmers with growing birds implemented strategies to slow down their chickens’ growth and draw out the supply of chickens to be processed at the plant. By the end of May 2020, these strategies had helped relieve some pressure in the system, but there were too many large chickens on farms and too few resources to bring them to any market. Compounding the crisis was the sheer scale of the issue; every chicken processing facility was strained, so cooperation of competitors (which historically solves acute issues) was not available. The final option available, like was done to millions of gallons of milk, was disposal (see Figure 1). The decision to cull birds on a farm is never an easy one, and it is even more difficult to destroy an entire 20 to 50 thousand head flock, but the alternatives are worse. As chickens are fed and grow, they have a higher demand for feed. At market age, a chicken farm only has capacity to store a few days of feed before it needs to be restocked. This increases the risk that chickens’ welfare will suffer, as feed demand across the peninsula will exceed the logistical capacity of delivery.2 Furthermore, at a certain weight, chickens become lethargic and may suffer from an unwillingness to eat or drink enough to maintain their health. Nursing large healthy chickens through a backlog in processing also strains the infrastructure and the housing is stocked for efficient use of space and heat, so delays can also lead to crowding and stress. Ultimately, if the life of a marketable chicken is extended beyond a few weeks, the welfare will quickly decline to a point where it is more humane to cull them on the farm. The implications of in-field culling of flocks, or using the industries’ term “depopulation,” are also dire for human health and the environment. Decades ago, and in other extreme cases today, pits were dug to bury mass mortalities on farms to control the decomposition and eliminate disease vectors like flies and scavengers. This disposal method will still contribute to groundwater contamination by nitrogen causing eutrophication of down-stream surface waters and perhaps drinking water well contamination.3 The preferred alternative is in-house composting, doi: 10.32481/djph.2021.01.008

where carcasses are mixed and stacked with dried manure and woody material to decompose in the poultry house as carbon rich materials. In the house, moisture, temperature and ventilation can be controlled better than underground, while maintaining the same control over scavengers (see Figure 2).

plans and plan implementation, but also the disposal of farm mortalities and was instrumental in enforcing the requirements for proper composting to protect the environment and public health. In these tragic circumstances, public officials were successful in doing both.

Monitoring of conditions around and within the pile is easy and convenient inside a poultry house as well. The conclusion of decomposition by in-house composting is a renewable resource that can be land applied for soil fertility in accordance with nutrient management plans aimed at minimizing water quality impacts of agriculture.

Correspondence: Christopher Brosch,

The Nutrient Management Program at the Delaware Department of Agriculture was established by law in 1999 to implement regulations for the land application of manure and fertilizers to protect water quality and farm profitability. The Program and the University of Delaware certify farmers and crop consultants following nutrient management training. Farmers are reimbursed for expenses related to the implementation of plans written by certified consultants. The Program enforces the regulations on

2. Lusk, J., & Croney, C. (2020, May 14). The Road from Farm to Table. Retrieved December 17, 2020, from

REFERENCES 1. Delmarva Chicken Association (Ed.). (2020). DCA Facts & Figures. Retrieved December 17, 2020, from

3. USDA-APHIS. (2016, January). Depopulation and Disposal for Birds in Your HPAI-Infected Flock. Retrieved November 19, 2020, from hpai_depopulation_disposal.pdf

Figure 1. Preparation of composting piles following euthanasia of unmarketable chickens due to COVID-19 pandemic. Illustrating high-carbon material mixed with and covering carcasses in a Delaware chicken house in May 2020. Photo courtesy C. Brosch.

Figure 2. Temperature monitoring of compost piles in Delaware following euthanasia of unmarketable chickens during COVID-19 pandemic in May 2020. Photo courtesy G. Cartanza. 39


Inside this issue Inside this issue Former Fogarty Inside thistrainee issue


By Susan Scutti

By Susan Scutti Three days in the company of scientific trailblazers at By Susan Scutti

the annual Women Leaders in Global Health Conference Three days in the company of scientific trailblazers at demonstrated, once again, that the personal is political. Three days Women in the company trailblazers at the annual Leaders of in scientific Global Health Conference Her early 30s marked the moment when Dr. Soumya the annual Women in Global Health is Conference demonstrated, onceLeaders again, that the personal political. Swaminathan, the WHO’s chief scientist, said she entered demonstrated, once again, that thewhen personal is political. Her early 30s marked the moment Dr. Soumya “the culture of the male-dominated committee room” where Her early 30s marked the moment when Dr. Swaminathan, the WHO’s chief scientist, saidSoumya she entered older, male scientists patronized her and belittled her ideas. Swaminathan, the male-dominated WHO’s chief scientist, said she entered “the culture of the committee room” where She faced this challenge with support from a male mentor “the of the male-dominated room” older,culture male scientists patronized hercommittee and belittled herwhere ideas. who advised her to speak up: “They will grow to respect older, malethis scientists patronized her and belittled ideas. She faced challenge with support from a maleher mentor you and listen to you.” Now that Swaminathan’s voice is She this challenge from a male mentor who faced advised her to speakwith up: support “They will grow to respect heard around the world, she remains committed to exposing who advised her speak up: “They will grow to respect you and listen to to you.” Now that Swaminathan’s voice is lingering biases of previous generations. “It’s still more you and listen the to you.” Now Swaminathan’s is heard around world, shethat remains committed voice to exposing difficult for women to get their grants approved than men, heard around the shegenerations. remains committed exposing lingering biases of world, previous “It’s still to more everything else being equal,” said the former Fogarty trainee, lingering biases of previous generations. “It’s still more difficult for women to get their grants approved than men, citing a recent study. “Women also have more difficulty difficult forelse women to equal,” get their grants approved than men, everything being said the former Fogarty trainee, . . . continued on p. 2 getting their research published.” everything elsestudy. being equal,” former trainee, citing a recent “Womensaid alsothe have moreFogarty difficulty citing recent study. “Women also have difficulty . more continued on page p. 2 gettingatheir research published.” . ... .continued on next . . . continued on p. 2 getting their research published.”

Photo by Photo PointImages/iStock/Thinkstock Photo by PointImages/iStock/Thinkstock by PointImages/iStock/Thinkstock

Women advocate for leadership roles in global health Women advocate for leadership roles in global health Women advocate for leadership roles in global health

Women scientists gathered recently for a virtual conference to discuss ways to nurture female leaders and achieve gender equity in global health research. Women scientists gathered recently for a virtual conference to discuss ways to nurture leaders and recently achieve for gender equity in global to health research. Women female scientists gathered a virtual conference discuss ways to

NIH helps LMIC institutions combat sexual harassment NIH helps LMIC institutions combat sexual harassment NIH helps LMIC institutions combat sexual harassment In an ongoing effort to reduce sexual harassment in science, Fogarty has awarded funds to 10 low- and middle-income In an ongoing effort to reduce sexual harassment in science, country (LMIC) institutions to shore up relevant policies, In an ongoing effort tofunds reduce in science, Fogarty has awarded to sexual 10 low-harassment and middle-income conduct training sessions and create awareness of the Fogarty awarded funds to to shore 10 lowmiddle-income country has (LMIC) institutions upand relevant policies, processes to report sexual harassment. The NIH Office of country to shore relevant policies, conduct (LMIC) traininginstitutions sessions and createup awareness of the AIDS Research provided funds for the one-year awards. conduct sessions create awareness the of processestraining to report sexual and harassment. The NIH of Office processes to report sexual harassment. The NIHawards. Office of AIDS Research provided funds for the one-year “We realize sexual harassment is a widespread and pervasive AIDS Research provided funds for the one-year awards. problem,” said Fogarty Director Dr. Roger I. Glass. “We’ve “We realize sexual harassment is a widespread and pervasive seen that many women enter the research pipeline but don’t “We realizesaid sexual harassment a widespread and“We’ve pervasive problem,” Fogarty DirectorisDr. Roger I. Glass. reach leadership positions. A number have reported having problem,” said Fogarty Roger I.pipeline Glass. “We’ve seen that many womenDirector enter theDr. research but don’t to change their careers due to harassment, which is a seen many women enter the research don’t reachthat leadership positions. A number havepipeline reportedbut having devastating experience for them and a loss for science.” reach leadership positions. A number have reported having to change their careers due to harassment, which is a to change their careers for duethem to harassment, which is a devastating experience and a loss for science.” During a recent virtual network meeting hosted by Fogarty, devastating experience for them and a loss for science.” awardees discussed how their institutions are dealing with During a recent virtual network meeting hosted by Fogarty, During a recent virtual network meeting hosted by Fogarty, awardees discussed how their institutions are dealing with awardees discussed how their institutions are dealing with

nurture female leaders and achieve gender equity in global health research.

the problem and shared strategies on how to make improvements. Although grantees reported most organizations have the problem and shared strategies on how to make improveanti-harassment policies in place, many said they were not the problem and shared strategies how to make improvements. Although grantees reportedon most organizations have well publicized, and reporting processes and follow up proments. Although grantees most said organizations anti-harassment policies inreported place, many they werehave not cedures were not clearly defined. The conversation was anti-harassment policies in place, many and said follow they were not well publicized, and reporting processes up prointended to encourage collaboration in developing models well publicized, and reporting processes and follow was up procedures were not clearly defined. The conversation to combat harassment that can be shared broadly. cedures not clearly defined. Theinconversation was intendedwere to encourage collaboration developing models intended encourage collaboration in developing to combattoharassment that can be shared broadly.models NIH grantees are all required to provide a harassment-free to combat harassment that can be shared broadly. work environment and are subject to the same terms and NIH grantees are all required to provide a harassment-free conditions wherever they are located, said NIH Associate NIH are alland required to provide harassment-free workgrantees environment are subject to thea same terms and Director for Science Policy Dr. Carrie Wolinetz. She cautioned work environment and areare subject to the terms and conditions wherever they located, saidsame NIH Associate the group that “policies can only take you so far,” and conditions they are said NIH She Associate Director forwherever Science Policy Dr.located, Carrie Wolinetz. cautioned suggested they must be combined with communication, Director Science Policy Carrie Sheand cautioned the groupfor that “policies canDr. only takeWolinetz. you so far,” training and rigorous reporting—which require a firm the group that only take so far,” and suggested they “policies must be can combined withyou communication, commitment at all levels of an organization. suggested they must be combined with communication, training and rigorous reporting—which require a firm training and rigorous reporting—which require a firm commitment at all levels of an organization. commitment at all levels of an organization.

One Health research: a holistic approach to improving health

FOCUS FOCUS FOCUS 40 Delaware Journal of Public Health – January 2021

• Researchers study zoonotic diseases among Mongolian herders One Health research: a holistic approach to improving health • Livestock contact poses danger of human illness in Tanzania One Health research: a holistic approach to improving health • Researchers study zoonotic diseases among Mongolian herders • Efforts to boost agriculture increase risk of parasites in Senegal • Researchers studyposes zoonotic diseases among Mongolian herders Livestock contact danger of human illness in Tanzania Read on 6–9 Read More on pages 45-48 • Livestock poses danger of human illness in pages Tanzania Efforts to contact boost agriculture increase risk ofmore parasites in Senegal • Efforts to boost agriculture increase Read risk ofmore parasites in Senegal on pages 6–9 Read more on pages 6 – 9


Women Women advocate advocate for for leadership leadership roles roles in in global global health health Women Women advocate advocate for for leadership leadership roles roles in in global global health health ....... .continued from previous . continued continued from from p.1 p.1 page .. .. .. continued continued from from p.1 p.1 Hosted Hostedby byWomenLift WomenLiftHealth, Health,the thevirtual virtualsymposium symposium Hosted Hostedby byWomenLift WomenLift Health, Health,in the the virtual virtualsymposium symposium showcased showcased women womenscientists scientists in leadership leadership roles rolesin inAsia Asiaand and showcased showcased women women scientists in inleadership leadership roles roles in inof Asia Asia and and Africa. Africa. While While many manyscientists sessions sessionshighlighted highlighted the the value value of women women Africa. Africa. While While many many sessions sessions highlighted highlighted the thevalue value of ofwomen women in in global global health health efforts, efforts, panelists panelists also alsoshared shared evidence evidence of ofthe the in inglobal global health efforts, efforts, panelists panelists also also shared sharedevidence evidence of ofthe the gaps gaps and andhealth barriers barriers to togender gender equity equity in inscientific scientific institutions, institutions, gaps gapsand andbarriers barriers to gender gender equity equityin inscientific scientificinstitutions, institutions, including including unequal unequalto pay pay and andunderrepresentation. underrepresentation. Personal Personal including includingunequal unequal pay and andunderrepresentation. underrepresentation. Personal Personal experiences, experiences, expert expertpay suggestions suggestions and andhopeful hopefulruminations ruminations experiences, experiences,rapt expert expert suggestions suggestions and and hopeful hopeful ruminations ruminations entertained entertained rapt attendees attendees across across the the globe globeduring during the thethreethreeentertained entertained rapt rapt attendees attendees across across the the globe globe during during the the threethreeday dayonline onlinestream. stream. day dayonline onlinestream. stream. More Morethan thanlistening listeningis isrequired requiredto toachieve achievepay payequity equityand and More Morethan than listening listening is isrequired required to toachieve achieve pay payequity equity and and gender gender parity, parity, said saidDr. Dr. Michele MicheleBarry, Barry, director director of ofStanford Stanford gender genderHealth parity, parity,and said saidfounder Dr. Dr.Michele Michele Barry, Barry,director director of of“The Stanford Stanford Global Global Health and founder of ofWomenLift WomenLift Health. Health. “The best best Global Global Health Healthand and founder of WomenLift Health. Health.voice,” “The “Thebest best way way to toadvocate advocate for forfounder change changeof is isWomenLift through throughcollective collective voice,” way wayto toadvocate advocate for change change is isthrough through collective collective voice,” according according to tothe thefor longtime longtime Fogarty Fogarty grantee. grantee. Barry Barryvoice,” recalled recalledher her according according to tojoining the thelongtime longtime Fogarty Fogarty grantee. grantee. Barry Barry recalled her younger younger self self joining women women scientists scientists at atYale Yale who whorecalled brought broughther younger younger self self joining joining women women scientists scientists at at Yale Yale who who brought brought “our “ourpetition petitionand andbill billof ofrights rightsto tothe theinstitutional institutionalleadership leadership “our “ourthey petition petition and andbill bill of ofrights rights to the theinstitutional institutional leadership leadership and and they actually actually listened listened and andto began began to tocorrect correctsalaries salaries they theyactually actually listened listenedBecoming and andbegan beganaa to to correct correct salaries and andtrack track demographics.” demographics.” Becoming leader leader is issalaries another another and andtrack track demographics.” demographics.” Becoming Becoming aaleader leader is another another way way to toeffect effect institutional institutionalchange, change, said said Barry, Barry,is who who cited citedDr. Dr. way wayto toeffect effect institutional change, change, said saidBarry, Barry, who who cited citedDr. Dr. Glenda Glenda Gray, Gray,institutional head headof ofthe theSouth South African African Medical Medical Research Research Glenda GlendaGray, Gray, head of ofthe the South South African African Medical Research Research Council Council as asan anhead example. example. Aware Aware that that men menMedical predominated predominated in inthe the Council Councilas asan an example. example. Aware Aware that that men men predominated predominated in inthe the extramural extramural research research units, units, Gray Gray gated gated men men from fromapplying applying extramural extramural research units, units, Gray Graygated gated men menfrom fromapplying applying until until gender genderresearch parity paritywas was achieved, achieved, said saidBarry. Barry. until untilgender genderparity paritywas wasachieved, achieved,said saidBarry. Barry. No No matter matter how how it’s it’s accomplished, accomplished, real real change change often often requires requires No No matter matter how how it’s it’swhich accomplished, accomplished, real change change often often requires requires passing passing new new laws, laws, which is is aa slow slowreal process process and and “often “often aa passing passing new new laws, laws, which which is is aa slow slow process process and and “often “often aa long long fight,” fight,” said said Professor Professor Agnes Agnes Binagwaho Binagwaho of of Rwanda’s Rwanda’s long long fight,” fight,”of said said Professor Professor Agnes Agnes Binagwaho Binagwaho of Rwanda’s University University of Global Global Health Health Equity. Equity. “We “We need needof to toRwanda’s do do an an University University of of Global Global Health Health Equity. “We “We need need to to do do an annual annual gender gender equity equity audit, audit,Equity. where where men men are are part part of ofan the the annual annual gender gender equity audit, audit,provide where where men men are part part of ofshowing the the exercise.” exercise.” Such Suchequity inventories inventories provide hard hardare evidence evidence showing exercise.” exercise.” Such Such inventories inventories provide provide hard hard evidence evidence showing showing where where parity parity has has not not yet yet been been reached reached and and where where attention attention where where parity parity has has not not yet yet been been reached reached and where where attention attention needs needs to to be be paid, paid, said said Rwanda’s Rwanda’s former formerand health health minister. minister. needs needs to to be be paid, paid, said said Rwanda’s Rwanda’s former former health health minister. minister. Although Although all all scientists scientists face face adversaries adversaries who who seek seek to to “pull “pull Although Although all all scientists scientists face adversaries adversaries who whoor seek seek to to “pull “pull you you down, down, dismiss dismiss you youface in in some some way, way, shape shape or form,” form,” you you down, down,Trust dismiss dismiss you you in inDr. some some way, way, shape shape or orsaid form,” form,” Wellcome Wellcome Trust scientist scientist Dr. Gagandeep Gagandeep Kang Kang said she she Wellcome Wellcome Trust scientist scientist Dr. Gagandeep Gagandeep Kang said she she believes believes ititTrust happens happens more moreDr. to to women women than thanKang men. men.said Early Early in in her her believes believesthe itit happens happens more more to to women womenrecalled than than men. men. Early Early in her her career, career, the former former Fogarty Fogarty grantee grantee recalled doing doing her herin best best career, career, the the former former Fogarty Fogarty grantee grantee recalled recalled doing doing her her best best to to dodge dodge slights. slights. Avoidance, Avoidance, though, though, “exerts “exerts an an emotional emotional to to dodge dodge slights. slights. Avoidance, Avoidance, though, though, “exerts “exerts an an emotional emotional tax tax on on you,” you,” so so over over time, time, Kang Kang decided decided to to assert assert herself. herself. tax tax on on you,” you,” so over overup, time, time, Kang Kang decided decided to assert assert herself. herself. “You “You have have to toso speak speak up, otherwise otherwise you’re you’reto complicit complicit in in “You “You have have to to speak speak up, up, otherwise otherwise you’re you’re complicit complicit in in continuing continuing the the problem.” problem.” Acknowledging Acknowledging that that “sometimes “sometimes continuing continuing the the problem.” Acknowledging Acknowledging that that “sometimes “sometimes it’s it’s not not gone gone so soproblem.” well, well, where where I’ve I’ve become become persona persona non non grata,” grata,” it’s it’s not not gone gone so so well, well, where where I’ve I’ve become become persona persona non non grata,” grata,” Kang Kang believes believes her her true true value value remains remains visible: visible: “Ultimately, “Ultimately, Kang Kang believes believes her her true value value remains remains visible: visible: “Ultimately, “Ultimately, you’re you’re standing standing on ontrue your your science.” science.” you’re you’re standing standing on on your your science.” science.” Decision-making Decision-making is is still still very very much much the the preserve preserve of of men, men, Decision-making Decision-making is is still still very very much much the the preserve preserve of of men, men, acknowledged acknowledged African African Academy Academy of of Sciences Sciences Director Director Dr. Dr. acknowledged acknowledged African African Academy Academy500 of of Sciences Sciences Director Dr. Tom Tom Kariuki. Kariuki. Of Of the the academy’s academy’s 500 fellows, fellows,Director only only100 100Dr. are are Tom Tom Kariuki. Kariuki. Of Of the thesurvey academy’s academy’s 500 500 fellows, fellows, only only 100 100 are are women. women. In In aa recent recent survey of of women women scientists scientists across across women. women. In Inmajority amajority a recent recent survey survey of ofdifficulty women women scientists scientists across across Africa, Africa, the the reported reported difficulty advancing advancing in in their their Africa, Africa, the the majority majority reported reported difficulty difficulty advancing advancing in in their their

22 22

careers, careers, he he said. said. Conscious Conscious and and unconscious unconscious biases, biases, careers, careers, he he said. said. Conscious Conscious and and unconscious unconscious biases, biases, including including the the assumption assumption that that women women will will stop stop work work once once including including the the assumption assumption that that women women will will stop stop work work once pregnant, pregnant, play play aa role role in in disparities, disparities, said said Kariuki. Kariuki. Yet, Yet,once he he is is pregnant, pregnant, play play aa role role in in disparities, disparities, said said Kariuki. Kariuki. Yet, he he is is hopeful. hopeful. “We “We have have aa burgeoning burgeoning pipeline pipeline of of young youngYet, scientific scientific hopeful. hopeful.who “We “Weare have have aa burgeoning burgeoning pipeline pipeline of of young young scientific scientific women women who are looking looking to to join join this this new new ecosystem ecosystem that that we we women women who who are looking looking to join join this this new newTo ecosystem ecosystem that that we we are are trying trying to toare develop develop on on to the the continent.” continent.” To effect effect change, change, he he are are trying trying to to develop develop on on the the continent.” continent.” To To“very effect effectintentional change, change, he he believes believes African African institutions institutions must must become become “very intentional believes believes African African institutions must must become become “very “very intentional about about where where we weinstitutions want want to to arrive.” arrive.” For For example, example, he heintentional said said they they about aboutset where where we weof want want to to arrive.” arrive.” For For example, example, he hewhile said said they they must must set aa goal goal of “50-50 “50-50 parity parity in in recruitment” recruitment” while must must set set a a goal goal of of “50-50 “50-50 parity parity in in recruitment” recruitment” while while establishing establishing policies policies that that address address bullying bullying and and harassment. harassment. establishing establishing policies policies that that address address bullying bullying and and harassment. harassment. When When enough enough women women leaders leaders occupy occupy decision-making decision-making roles, roles, When When enough enough women women leaders leaders occupy occupy decision-making decision-making roles, roles, the the very very structure structure of of jobs jobs will will change, change, Kang Kang observed. observed. She, She, the the very veryhas structure structure of of jobs jobs will will change, change, Kang observed. observed. She, She, herself, herself, has watched watched countless countless women womenKang subordinates subordinates “get “get herself, herself, has has watched watched countless women subordinates “get “get married, married, have have babies, babies,countless take take time timewomen off, off, but butsubordinates when when their their children children married, married, have haveand babies, babies, take time time off, off, but butare when when their their children children are are in in school school and they theytake come come back, back, they they are way way more more are are in in school school and and they theymen,” come come back, back, they they“If are are way way more more productive productive than than many many men,” she she said. said. “If you you take take itit over over productive productive than than many many men,” men,” she she said. said. “If “If you you take take it it over over aa timescale timescale of of an an entire entire career, career, there there is is no no question question that that aa awoman a timescale timescale of an an entire entire career, career, there there is is no no question question that that aa woman will willof deliver.” deliver.” woman woman will will deliver.” deliver.” Supporting Supporting women women begins begins at at home, home, said said Dr. Dr. Quaraisha Quaraisha Supporting Supporting women women begins begins at at home, home, said said Dr. Dr. Quaraisha Quaraisha Abdool Abdool Karim Karim of of Columbia Columbia University. University. “Both “Both my my husband husband Abdool Abdool Karim Karim of of Columbia Columbia University. University. “Both “Both my my husband husband and and II are are scientists. scientists. ItIt is is because because we we have have shared shared parental parental and and II are are scientists. scientists. It is ishave because because we we have haveShe shared shared parental parental responsibilities responsibilities that thatIt we we have flourished.” flourished.” She acknowledged acknowledged responsibilities responsibilities that that we we have have flourished.” flourished.” She Sheadding acknowledged acknowledged the the debt debt she she owed owed her her parents parents and and teachers, teachers, adding the the debt she she owed owed her her parents parents and and teachers, teachers, adding adding that thatdebt “early “early foundational foundational work work makes makes all all the the difference” difference” that that “early “early scientists. foundational foundational work work makes all all the the difference” difference” for for women women scientists. Still Still she shemakes believes believes there there will will always always for for“more women women scientists. scientists. Still Still she she believes believes there there will will always always be be “more people people dissuading dissuading you you from from your your dreams dreams than than be be “more “moresupporting people people dissuading dissuading you youhave from fromto your your dreams dreams than actually actually supporting you, you, so so you you have to look look really reallythan hard hard actually actually supporting supporting you, you,who so so you you have to to look look really really hard hard to to find find those those few few people people who are arehave going going to to support support you you no no to to find find those those few few people peopleincluding who who are are going going to to support support you you no no ifif matter matter what.” what.” Support, Support, including mentoring, mentoring, is is necessary necessary matter matter what.” what.” Support, Support, including including mentoring, is issuccessfully, necessary necessary ifif women women scientists scientists are are going going to to use usementoring, their their talents talents successfully, women women scientists scientists are are going going to to use use their talents successfully, the the conference conference panelists panelists agreed. agreed. AAtheir good goodtalents mentor mentorsuccessfully, “helps “helps you you the the conference conference panelists panelists agreed. agreed. A A good good mentor mentor “helps “helps you you navigate navigate the the waters” waters” and and brainstorms brainstorms about about overcoming overcoming navigate navigate the the waters” waters” and and brainstorms brainstorms about about overcoming overcoming personal personal as as well well as as professional professional barriers barriers to to success, success, said said personal personal as as well well as as professional professional barriers barriers to to success, success, said said Barry. Barry. “When “When you’re you’re aa mentor mentor you you try try to to help help your your mentee mentee Barry. Barry. “When “When you’re you’re aa mentor mentor you you try try to to help help your your mentee mentee find find clarity.” clarity.” find find clarity.” clarity.” COVID-19 COVID-19has hasmade madeachieving achievinggender genderequality equalityeven evenmore more COVID-19 COVID-19 has has made madebearing achieving achieving gender gender equality even evenand more more difficult difficult with with women women bearing the the brunt bruntequality of ofthe thesocial social and difficult difficultwith with women women bearing bearing the brunt brunt of ofthe thesocial social and and economic economic fallout, fallout, noted noted Amie Amiethe Batson, Batson, executive executive director director economic economic fallout, fallout, noted noted Amie Batson, Batson, executive executive director of ofWomenLift WomenLift Health. Health. As AsAmie the theworld world rebuilds, rebuilds, she shedirector said saidthe the of ofWomenLift WomenLift Health. Health.As Asthe the world world rebuilds, rebuilds, she sheto said said the the global global health healthcommunity community needs needs to torethink rethink how how to more more global globalhealth health community community needs needs to torethink rethink how howto to more more effectively effectively deliver deliver health healthcare, care, which which will willdepend depend on on equitable equitable effectively effectivelydeliver deliver health care, which whichwill will depend dependdraw on onequitable equitable representation representation of ofhealth women womencare, in inleadership. leadership. Leaders Leaders draw on ontheir their representation representation of ofwomen women in in“When leadership. leadership. Leaders Leaders draw draw on ontheir their experiences, experiences, noted noted Batson. Batson. “When you youdon’t don’t have have diversity, diversity, experiences, experiences, noted notedBatson. Batson. “When “Whenyou you don’t don’t have havediversity, diversity, you’re you’re not notdrawing drawing on onthe thediversity diversity of oflived lived experiences experiences that that you’re you’renot not drawing drawingon onthe thediversity diversityof oflived livedexperiences experiencesthat that women women bring.” bring.” women womenbring.” bring.” WomenLift WomenLiftHealth, Health,sponsored sponsoredby bythe theBill Billand andMelinda MelindaGates Gates WomenLift WomenLiftHealth, Health, sponsored sponsored by bythe the Bill Billand andMelinda Melinda Gates Gates Foundation, Foundation, grew grewfrom from an anannual annual conference conference begun begunin in 2017. 2017. Foundation, Foundation,grew grewfrom froman anannual annualconference conferencebegun begunin in2017. 2017. RESOURCES RESOURCES RESOURCES RESOURCES



NIH NIH studies studies global-to-local global-to-local solutions solutions for for HIV HIV stigma stigma Stigma remains an enormous barrier to controlling the Stigma Stigma remains remains an an enormous enormous barrier barrier to to controlling controlling the the HIV/AIDS epidemic in many parts of Africa, as well as HIV/AIDS HIV/AIDS epidemic epidemic in in many many parts parts of of Africa, Africa, as as well well as as in underserved areas of the U.S. A number of successful in in underserved underserved areas areas of of the the U.S. U.S. A A number number of of successful successful interventions developed in Africa and tailored for use in interventions interventions developed developed in in Africa Africa and and tailored tailored for for use use in in the U.S. were discussed during a recent webinar hosted the U.S. were discussed during a recent webinar hosted the U.S. were discussed during a recent webinar hosted by Fogarty and the NIH Office of Behavioral and Social by by Fogarty Fogarty and and the the NIH NIH Office Office of of Behavioral Behavioral and and Social Social Sciences Research. Sciences Sciences Research. Research. This global-to-local approach will be explored in a series This This global-to-local global-to-local approach approach will will be be explored explored in in a a series series of webinars to share lessons learned on a variety of topics. of webinars to share lessons learned on a variety of webinars to share lessons learned on a variety of of topics. topics. “Our goal is to encourage both funders and researchers to “Our “Our goal goal is is to to encourage encourage both both funders funders and and researchers researchers to to give serious consideration into how global health research give give serious serious consideration consideration into into how how global global health health research research findings could be adapted for use in the U.S,” according to findings findings could could be be adapted adapted for for use use in in the the U.S,” U.S,” according according to to Fogarty senior scientist Dr. Linda Kupfer. “Although globalFogarty senior scientist Dr. Linda Kupfer. “Although Fogarty senior scientist Dr. Linda Kupfer. “Although globalglobalto-local research transfer is not new, we hope to investigate to-local to-local research research transfer transfer is is not not new, new, we we hope hope to to investigate investigate this topic somewhat differently by focusing on the type of this this topic topic somewhat somewhat differently differently by by focusing focusing on on the the type type of of research methods that have been used successfully.” research methods that have been used successfully.” research methods that have been used successfully.”

“If you want to break the back of the HIV epidemic you have “If “If you you want want to to break break the the back back of of the the HIV HIV epidemic epidemic you you have have to get out into the community,” noted Tierney, a former to get out into the community,” noted Tierney, a former to get out into the community,” noted Tierney, a former Fogarty grantee and professor at the University of Texas Fogarty Fogarty grantee grantee and and professor professor at at the the University University of of Texas Texas at Austin. A successful program that conducted home at Austin. A successful program that conducted at Austin. A successful program that conducted home home visits for 2 million Kenyans—providing testing for HIV, visits visits for for 2 2 million million Kenyans—providing Kenyans—providing testing testing for for HIV, HIV, pregnancy and blood glucose levels—was adapted for use pregnancy pregnancy and and blood blood glucose glucose levels—was levels—was adapted adapted for for use use in a low-income neighborhood in Austin. The initiative also in a low-income neighborhood in Austin. The initiative in a low-income neighborhood in Austin. The initiative also also helps clients navigate the health care system and provides helps helps clients clients navigate navigate the the health health care care system system and and provides provides referrals to food banks and other community resources. referrals referrals to to food food banks banks and and other other community community resources. resources. Given that AIDS is the leading cause of death for African Given Given that that AIDS AIDS is is the the leading leading cause cause of of death death for for African African American women aged 25-34, researchers at the University American women aged 25-34, researchers at the American women aged 25-34, researchers at the University University of Washington (UW) studied how they could reduce HIV of of Washington Washington (UW) (UW) studied studied how how they they could could reduce reduce HIV HIV stigma to better meet the needs of this population. They stigma to better meet the needs of this population. stigma to better meet the needs of this population. They They found solutions in a toolkit developed by the International found found solutions solutions in in a a toolkit toolkit developed developed by by the the International International Center for Research on Women that was successfully used Center for Research on Women that was successfully Center for Research on Women that was successfully used used in Africa, according to UW’s Dr. Deepa Rao. The resource in in Africa, Africa, according according to to UW’s UW’s Dr. Dr. Deepa Deepa Rao. Rao. The The resource resource provides materials for a variety of flexible approaches provides provides materials materials for for a a variety variety of of flexible flexible approaches approaches to spur conversations including warm-up games, case to to spur spur conversations conversations including including warm-up warm-up games, games, case case studies, role playing and other exercises. In NIH-funded studies, role playing and other exercises. In studies, role playing and other exercises. In NIH-funded NIH-funded pilot testing, the program was found to be feasible and pilot pilot testing, testing, the the program program was was found found to to be be feasible feasible and and acceptable in U.S. communities. Videos designed to trigger acceptable acceptable in in U.S. U.S. communities. communities. Videos Videos designed designed to to trigger trigger difficult conversations were added and found to be effective. difficult difficult conversations conversations were were added added and and found found to to be be effective. effective. The program was also adjusted for use in men. The The program program was was also also adjusted adjusted for for use use in in men. men. Researchers at the University of Alabama at Birmingham Researchers Researchers at at the the University University of of Alabama Alabama at at Birmingham Birmingham (UAB) also used components of the Africa toolkit in their (UAB) (UAB) also also used used components components of of the the Africa Africa toolkit toolkit in in their their

A A number number of of interventions interventions to to reduce reduce HIV HIV stigma stigma in in Africa Africa have have been been adapted adapted for for A number of interventions this to reduce HIV stigma in Africa have been adapted for use use in in the the U.S., U.S., including including this health health fair fair in in Seattle Seattle that that increased increased HIV HIV testing testing in in use in the U.S., including this health fair in Seattle that increased HIV testing in an an African African immigrant immigrant community community by by 50%. 50%. an African immigrant community by 50%.

efforts to reduce HIV stigma locally. “Stigma experiences efforts efforts to to reduce reduce HIV HIV stigma stigma locally. locally. “Stigma “Stigma experiences experiences have many commonalities at their core across the globe,” have have many many commonalities commonalities at at their their core core across across the the globe,” globe,” observed UAB’s Dr. Janet Turan. She and her team added observed UAB’s Dr. Janet Turan. She and her team observed UAB’s Dr. Janet Turan. She and her team added added a module on intersectional stigma, encouraging program a a module module on on intersectional intersectional stigma, stigma, encouraging encouraging program program participants to explore identity issues related to race, participants participants to to explore explore identity identity issues issues related related to to race, race, poverty, religion and sexual orientation. “Everybody has poverty, poverty, religion religion and and sexual sexual orientation. orientation. “Everybody “Everybody has has a story to share on that and it’s a very powerful exercise,” a a story story to to share share on on that that and and it’s it’s a a very very powerful powerful exercise,” exercise,” said Turan. With proof of concept from their successful said said Turan. Turan. With With proof proof of of concept concept from from their their successful successful pilot, they are now scaling up in Alabama and Tennessee pilot, they are now scaling up in Alabama pilot, they are now scaling up in Alabama and and Tennessee Tennessee as well as using Fogarty funding to adapt the intervention as as well well as as using using Fogarty Fogarty funding funding to to adapt adapt the the intervention intervention for use in the Dominican Republic. for for use use in in the the Dominican Dominican Republic. Republic. Finally, another UW team used a community health Finally, Finally, another another UW UW team team used used a a community community health health fair approach to increase screening for HIV and other fair fair approach approach to to increase increase screening screening for for HIV HIV and and other other diseases among African immigrant communities in the diseases diseases among among African African immigrant immigrant communities communities in in the the Seattle area. African-born individuals account for 2% Seattle area. African-born individuals account for Seattle area. African-born individuals account for 2% 2% of population but receive 10% of the county’s new HIV of of population population but but receive receive 10% 10% of of the the county’s county’s new new HIV HIV diagnoses. Given immigration sensitivities, it was not diagnoses. diagnoses. Given Given immigration immigration sensitivities, sensitivities, it it was was not not feasible to go door-to-door, so mini-health fairs were feasible feasible to to go go door-to-door, door-to-door, so so mini-health mini-health fairs fairs were were held in residential complexes to provide screening for held held in in residential residential complexes complexes to to provide provide screening screening for for HIV, hypertension, diabetes, cholesterol and obesity, in HIV, HIV, hypertension, hypertension, diabetes, diabetes, cholesterol cholesterol and and obesity, obesity, in in addition to providing dental care and other services. The addition addition to to providing providing dental dental care care and and other other services. services. The The result was a 50% uptake in HIV testing, according to result result was was a a 50% 50% uptake uptake in in HIV HIV testing, testing, according according to to UW’s Dr. Rena Patel. UW’s UW’s Dr. Dr. Rena Rena Patel. Patel. Fogarty is interested in continuing to collect case Fogarty Fogarty is is interested interested in in continuing continuing to to collect collect case case studies of global-to-local transfer of innovations and studies studies of of global-to-local global-to-local transfer transfer of of innovations innovations and and interventions. Please send submissions to arianne. interventions. interventions. Please Please send send submissions submissions to to arianne. arianne. RESOURCES RESOURCES RESOURCES

42 Delaware Journal of Public Health – January 2021

Photo Photo courtesy courtesy Dr.Dr. Rena Rena Patel/project Patel/project Harambee Harambee Photo courtesy ofofof Dr. Rena Patel/project Harambee

There are similar barriers for access to health care among There There are are similar similar barriers barriers for for access access to to health health care care among among those living in Eldoret, Kenya and Austin, Texas, observed those those living living in in Eldoret, Eldoret, Kenya Kenya and and Austin, Austin, Texas, Texas, observed observed Dr. William Tierney, who has conducted research in both Dr. Dr. William William Tierney, Tierney, who who has has conducted conducted research research in in both both locations. Poverty, lack of transportation and unreliable locations. Poverty, lack of transportation and unreliable locations. Poverty, lack of transportation and unreliable cellphone communication all pose significant challenges in cellphone cellphone communication communication all all pose pose significant significant challenges challenges in in both populations, which makes combatting the HIV/AIDS both populations, which makes combatting the both populations, which makes combatting the HIV/AIDS HIV/AIDS epidemic difficult. epidemic epidemic difficult. difficult.

3 3 3

PROFILE PROFILE Fogarty Fogarty Fellow Fellow studied studied surgical surgical Fogarty studied surgical quality quality in inFellow Mozambique Mozambique By Byquality Susan SusanScutti Scutti in Mozambique By Susan Scutti

Although Althoughnon-traditional non-traditional‘surgeons’ ‘surgeons’perform perform40% 40%ofof operations operationsin inMozambique, Mozambique,the themortality mortalityrate rateisiscomparcomparAlthough non-traditional ‘surgeons’ perform 40% of able able to toother other regions regionsin inSouthern Southern Africa, Africa, according according to toaa operations in Mozambique, the mortality rate is comparstudy study conducted conducted by byFogarty FogartyFellow Fellow Dr. Dr.Matchecane Matchecane Cossa. Cossa. able to other regions in Southern Africa, according to a With Withonly onlyone onesurgeon surgeonfor forabout aboutevery everyone onemillion millionpeople people study conducted by Fogarty Fellow Dr. Matchecane Cossa. in inMozambique, Mozambique,nurse nursetechnicians techniciansare areessential. essential.“We “Wecan can With only one surgeon for about every one million people train trainaanurse nurseto toperform performsurgeries surgeriesas asaaway wayto tohelp helppeople,” people,” in Mozambique, nurse technicians are essential. “We can explained explainedCossa. Cossa.In Inthe theresearch researchproject projecthe heconducted conducted train a nurse to perform surgeries as a way to help people,” during duringhis hisfellowship, fellowship,he hemeasured measurednot notonly onlythe thevolume volume explained Cossa. In the research project he conducted but butalso alsothe thequality qualityofofsurgical surgicalcare carein inMozambique’s Mozambique’s45 45 during his fellowship, he measured not only the volume district district hospitals hospitals using using standard standard WHO WHO criteria. criteria. He He tallied tallied but also the quality of surgical care in Mozambique’s 45 the the number number of ofoperating operating rooms,operations, operations, accredited accredited district hospitals using rooms, standard WHO criteria. He tallied surgeons surgeons and and anesthesia anesthesia professionals professionals as as well well as asday dayofof the number of operating rooms, operations, accredited surgery surgery death death rates rates and and post-operative post-operative in-hospital in-hospital death death surgeons and anesthesia professionals as well as day of rates. rates. surgery death rates and post-operative in-hospital death rates. Cossa Cossahad hadrecognized recognizedthe theneed needfor forthis thiskind kindofofdata dataafter after being being appointed appointed chief chief of of surgery surgery for for his his country’s country’s health health Cossa had recognized the need for this kind of data after ministry. ministry. “When “WhenI Igot gotthere, there, someone someone asked asked me: me:How How being appointed chief of surgery for his country’s health ministry. “When got have? there, someone asked me: How many many surgeons surgeons do doIyou you have?How Howmany many procedures procedures many surgeons doyear? you have? many procedures are are performed performed each each year? What WhatHow are areyour yourstats?” stats?” Some Some are performed eachbut year? What are your the stats?” Some information information existed, existed, but Cossa Cossa suspected suspected thenumbers numbers information existed,especially but Cossafor suspected the numbers might might not notbe bereliable, reliable, especially forrural ruralareas. areas. He Hedecided, decided, notthis be reliable, especially for rural areas. decided, “If “Ifmight I Igather gather this information, information, ititwill will help help me me make makeHe decisions decisions “If I on gather this what information, it will help me make decisions based based onexactly exactly whatwe wehave.” have.” based on exactly what we have.”

While Whilemost mostsurgeons surgeonsdon’t don’tconduct conductresearch, research,Cossa’s Cossa’s While most surgeons don’t conduct research, Cossa’s mentors mentors inspired inspired him himto to break break this thistrend. trend. “I“Ialways always mentors inspired him to break this trend. “I always wanted wantedto todo doresearch researchand andI Ihad hadbeen beensearching searchingfor foran an wanted to do research and I had been searching for an opportunity,” opportunity,”said saidCossa, Cossa,who whohad hadchosen chosenthoracic thoracicsurgery surgery opportunity,” said Cossa, who had chosen thoracic surgery as ashis hisspecialty specialtybecause becauseMozamique Mozamiquehad hadno nopractitioners practitioners as his specialty because Mozamique had no practitioners in inthat thatfield. field.Given Giventhe thecountry’s country’shigh highrates ratesofoftuberculosis, tuberculosis, in that field. Given the country’s high rates of tuberculosis, which whichcan canrequire requirethoracic thoracicsurgery, surgery,he heknew knewhe hewould would which can require thoracic surgery, he knew he would be beable ableto tomake makean animpact. impact.Once Oncehe hesecured securedhis hisFogarty Fogarty be able to make an impact. Once he secured his Fogarty fellowship, fellowship, he he cobbled cobbled together together a a team team of of medical medical students fellowship, he cobbled together a team of medicalstudents students and and residents residents working working in in Maputo Maputo along along with with surgeons surgeons and residents working in Maputo along with surgeons across across the the country. country. “I“I“I convinced convinced them that this was across the country. convincedthem themthat thatthis thiswas was important important and and I I sent sent them them a a template template so so they they could could collect important and I sent them a template so they couldcollect collect data data for for me,” me,” he he said. said. data for me,” he said. The The study study has has already already influenced influenced policy decisions. The The study has already influencedpolicy policydecisions. decisions.The The findings findings showed showed the the health health ministry ministry where where operating operating rooms findings showed the health ministry where operatingrooms rooms are are needed needed and and which which provinces provinces require surgeon. “We are needed and which provincesrequire requireaaasurgeon. surgeon.“We “We have less surgeons by far thanthe thetarget targetset setby WHO have have less less surgeons surgeons by by far far than than the target set bythe theWHO WHO

44 4

Matchecane MatchecaneCossa, Cossa,M.D. M.D. Fogarty FogartyFellow: Fellow:

2015-2016 2015-2016 Matchecane Cossa, M.D.

US USInstitution: Institution: University UniversityofofCalifornia, California,San SanDiego Diego Fogarty Fellow: 2015-2016 Foreign Foreign Institution: Institution: University Universidade Universidade Eduardo EduardoSan Mondlane Mondlane US Institution: of California, Diego Research Research area: area: Evaluation Evaluationofof surgical surgical care careininMozambique Mozambique Foreign Institution: Universidade Eduardo Mondlane Research area:

Evaluation of surgical care in Mozambique

and andwe wehave havevery veryfew fewORs, ORs,very veryfew fewanesthesiologists,” anesthesiologists,” said said Cossa. Cossa. “But “But the the mortality mortality rate rate is is not notthat thathigh highand andisis and we have very few ORs, very few anesthesiologists,” similar similar to to Southern Southern African African regions.” regions.” Surgical Surgical death death rates said Cossa. “But the mortality rate is not that high andrates is of of the the trained trained nurses nurses were were similar similar to to rates rates among among actual actual similar to Southern African regions.” Surgical death rates surgeons. surgeons. “Of “Ofnurses course, course, people people would would prefer prefer to tobe beoperated operated of the trained were similar to rates among actual on on by by a a general general surgeon, surgeon, but but the the results results show show that that for for surgeons. “Of course, people would prefer to be operated our our country country the the work work of of the the trained trained nurses nurses is is laudable laudable on by a general surgeon, but the results show that for and andcountry very veryimportant,” important,” he hethe said. said. our the work of trained nurses is laudable and very important,” he said. Another Anotherresult resultofofthe thestudy: study:Cossa Cossahas hasseen seenaashift shift Another result ofyounger the study: Cossa has shift in inattitudes attitudes ofofyounger surgeons, surgeons, who whoseen now nowaexpress express in of younger surgeons, who“When now express an anattitudes interest interestin inconducting conducting research. research. “When you youthink think an interest in conducting research. “When you think about about LMICs, LMICs, you youthink thinkthat thatit’s it’squite quite difficult difficult to toget get about LMICs,but youit’s think thatfeasible,” it’s quite difficult to get information information but it’s always always feasible,” said saidCossa. Cossa. information but it’s always feasible,” said Cossa. An Animportant importantbenefit benefitofofhis hisFogarty Fogartyproject projectwas wasthe the An important benefit of week his Fogarty was the online online training. training. “Every “Every week there thereproject were wereprograms, programs, online training. “Every week there wereUnexpected programs, lessons classes, classes, all allabout about research,” research,” he hesaid. said. Unexpected lessons classes, all about research,” he said. Unexpected lessons were werelearned learnedas aswell. well.“Many “Manypeople peoplethink thinkthat, that,when whenthey they were learned as well. “Many people think that, when they gather gatherinformation informationfrom fromthe thework workthey’ve they’vedone, done,this thisdata data gather information from the work they’ve done, this data belongs belongsto tothem themand andthey theywant wantto tokeep keepititto tothemselves,” themselves,” belongs to them and they want to keep it to themselves,” said saidCossa. Cossa.“Through “ThroughFogarty, Fogarty,the themost mostimportant importantthing thingI I said Cossa. “Through Fogarty, the most important thing I learned learnedisiscollaboration collaborationand andcooperation.” cooperation.” learned is collaboration and cooperation.” Today, Today,when whenyounger youngersurgeons surgeonsask askabout aboutFogarty, Fogarty,Cossa Cossa Today, when younger surgeons ask about Fogarty, Cossa tells tells them them “go “go for for it, it, it it will will help help your your career,” career,” yet yet at at the the tells them “go for it, it will help your career,” yet at the same sametime time timehe he hecautions cautions cautionsthat that that “it “it takes takes alot lot of time.” time.” The The same “it takes a alot ofof time.” The greatest greatest benefit benefit of of all all is is the the ability ability to to improve improve yourself, yourself, greatest benefit of all is the ability to improve yourself, he hesaid: said:“You “You “Youcan can canfind find findwhat what what wrong wrong with with what what you you are are he said: isisis wrong with what you are doing doing and and change change it it because because you you have have this this collaboration collaboration doing and change it because you have this collaboration with withthe the theentire entire entireworld. world. world.Through Through Through research research you you have have with research you have the theopportunity opportunity to to develop develop your your career career as as a a health health opportunity to develop your career as a health professional.” professional.” professional.” RRESOURCES ES O U R CES RESOURCES




Dr. Admire Dube is a pharmacist by training and an associate professor of pharmaceutics at the University of the Western Cape in South Africa. His specialty is nanotechnology research. He completed postdoctoral training with Fogarty support at the University at Buffalo, where he conducted studies on the potential of nanomedicines to treat tuberculosis (TB). This work laid the foundation for his successful application to Fogarty’s Emerging Global Leader program. Subsequently, he and two collaborators received a research grant from the NIH’s National Institute of Allergy and Infectious Diseases (NIAID) to continue this work.

What did you gain from Fogarty training?

What else have you learned?

Firstly, the training helped me define the focus of my current research. I initiated research into nanomedicines for the treatment of TB at this time. I gained exposure to various types of nanoparticles, various characterization tools, as well as grant writing skills. My seminal research paper to date was generated during this training period. The training also prepared me to establish my laboratory and secure research funding. This has proved invaluable to my career trajectory, as I have been able to establish a nanomedicine for infectious diseases laboratory here in South Africa, and to secure NIH grants from Fogarty and NIAID.

We’ve already started administering these nanoparticles to mice which are infected with TB. We are putting these nanoparticles into the lungs of the mice directly because TB is a pulmonary disease. We're then going to see whether the immune system of the mice is activated. As a pharmacist, a lot of my expertise is in making nanoparticles. My new training in immunology helped me tag these nanoparticles, bringing the two aspects together so now we can develop immunotherapies.

“My Fogarty award is probably the best thing that has happened in my career because it provided me the protected time to concentrate on my research.” What is the significance of your research? In terms of research, I'm working on a project that is using nanoparticles to engineer, or control, an individual’s immune system in order to fight off TB infection. In a sense, I'm using nanoparticles to make an immunotherapy. The hope is that the host immune cells can then eradicate the TB causing pathogen without the use of drugs. We’re avoiding the use of conventional antibiotics and instead making these immunotherapies. In my lab, specifically, I'm synthesizing these nanoparticles and characterizing them. We then perform tests in cells and mice infected with TB. This is the next step. We plan to publish research next year that shows that nanoparticles can be effective in killing TB within a cell. The cell becomes hostile to this bacteria and once it's hostile, the bacteria can’t survive within that cell.

How has Fogarty impacted your career path? My Fogarty award is probably the best thing that has happened in my career because it provided me the protected time to concentrate on my research. In so doing, I've now been able to establish my research lab focused on nanoparticles and tuberculosis. I’ve been able to attract other funding as well, which has led to local and international collaborations with notable scientists where we synthesize and test various nanoparticles. Now that we have our NIAID grant we plan to look at different kinds of nanoparticles. I think the Emerging Global Leader program is an excellent funding mechanism for early career researchers. It is quite important for researchers to conduct research that is relevant to their local context, something that is afforded by this program. The personal development through mentorship has been great. Additionally, while I'm being mentored, I am mentoring others. I’ve also been promoted from senior lecturer to associate professor, so I’ve been able to progress in my career as well as receive funding to conduct this exciting science involving tuberculosis and nanotechnology, something that I’m passionate about doing. There’s nothing better than getting to spend time on what you really enjoy!

RESOURCES 44 Delaware Journal of Public Health – January 2021



One Health: a holistic approach to improving the health of people, animals and the environment


esearchers may never discover exactly how the current novel coronavirus outbreak began, but they agree that as humans have changed the way they interact with animals and the environment, emerging infectious diseases are rapidly growing in frequency. Accelerating rates of deforestation, human settlements encroaching on forests, global trade and travel, and livestock production are thought to be the underlying drivers of so-called “spillover” events, when diseases jump from animals to humans. For example, bats are one of the species suspected to be the source of the virus that causes COVID-19, while viruses in bats and other animals spurred the Ebola outbreak that began in 2014, MERS in 2012 and SARS in 2002, and others. Constant mutations jeopardize existing vaccines and treatments. With 70% of emerging infectious diseases originating in animals, there is increasing urgency to prioritize the study of zoonotic diseases. “To anticipate threats for humans, we’ve got to partner with people in other disciplines including animal and environmental health,” said Dr. Gregory Gray, a Fogarty grantee and epidemiologist at Duke University.

Photo courtesy of NIAID

The One Health movement aims to integrate the efforts of multiple disciplines to improve health for people, animals and the environment. It has become a Spillover events, where diseases jump from animals to humans, are increasing in frequency. Humans have acquired MERS coronavirus through close contact with camels.

global effort, including annual conferences that bring scientists and policymakers together to consider how to control existing and emerging infectious diseases. Since the majority of diseases that occur in humans also affect animals, it's important that the biomedical research workforce includes multidisciplinary practitioners with a broad understanding of subjects such as animal anatomy, physiology, pharmacology, epidemiology, behavior science and infectious diseases. Communication strategies and public outreach are also critical to develop interventions such as educational programs for workers to improve hygiene and increase use of personal protective equipment, development of rapid diagnostics and vaccines, and improved food safety measures.

“ To anticipate threats for humans, we’ve got to partner with people in other disciplines including animal and environmental health.

— DR. GREGORY GRAY, DUKE UNIVERSIT Y NIH’s zoonotic research is based at Rocky Mountain Laboratories in Montana. Part of the National Institute of Allergy and Infectious Diseases, it’s a state-of-theart biomedical facility designed for investigations of highly pathogenic viruses. Fogarty supports studies of emerging global threats through its Ecology and Evolution of Infectious Diseases program, a partnership with the National Science Foundation. The initiative supports efforts to understand the underlying ecological and biological mechanisms that govern relationships between environmental changes and the emergence and transmission of infectious diseases. Funded researchers explore how environmental events such as habitat alteration, biological invasion, climate change and pollution alter the risks of disease outbreaks in both animals and humans. As outbreaks of emerging infectious diseases— such as the current COVID-19 pandemic— increase in frequency and impact, scientists and policymakers are calling for an increased emphasis on global preparedness.




Prawn farming reduces disease transmission in Senegal Photo courtesy of Upstream Alliance

With one billion of the world’s people suffering from malnutrition, there is pressure to intensify agricultural production, especially in the world’s poorest countries. However, there is tension between the need to supply more food and the ecological impact that can have. Deploying herbicides, fertilizers, pesticides—as well as improving irrigation—can have unintended consequences for the spread of infectious diseases. For example, a small dam was built in the Senegal River basin in 1986 to block salt water flowing upstream from the ocean so crop cultivation could be expanded. Shortly after, the local population experienced recurring outbreaks of schistosomiasis, a debilitating disease. Scientists hypothesized that enlarging the area of freshwater in the river basin may have created the ideal habitat for the snails that host the disease-causing parasites, while reducing upriver migration of fish and other snail predators. In addition, agrochemical runoff may have increased algae growth providing a food source for snails, while insecticides might have reduced populations that would normally consume snails, such as prawns, crayfish and water bugs. A research team led by Dr. Jason Rohr at the University of Notre Dame has been using a Fogarty ecology and evolution of infectious diseases grant to investigate various aspects of the complex problem. Collaborator Dr. Susanne Sokolow has been conducting research in the region since her postdoc, which was funded in 2009 by the NIH’s National Institute of Allergy and Infectious Diseases. “Every year the government distributed praziquantel, the recommended anti-parasitic drug for schistosomiasis, to all the kids,” said Sokolow. “And yet each year they came back re-infected at almost the same rates as the previous year.” Among rural children, prevalence topped 80%. The scientists wanted to understand pre- and post-dam river ecology in order to “creatively interrupt part of the parasite’s lifecycle,” said Sokolow, who leads Stanford University's disease ecology program. Working in partnership with a local Senegalese biomedical research institute, one experiment looked at the effects of herbicides on the life stages of schistosomes. Another stocked the Senegal river with native prawns as determined by mathematical models drawn from Sokolow’s previous research. This included the observation that prawns consume snails at daily rates of up to 30% of their body weight. The intervention worked: the number of infected snails was reduced by 80% and the local population finally escaped yearly schistosomiasis reinfection. In addition to improved health, the community also gained a dietary protein source and a new cash crop.

46 Delaware Journal of Public Health – January 2021

By introducing prawns into the Senegal River basin, researchers dramatically reduced the population of snails carrying parasites that were responsible for a rise in schistosomiasis after a dam was built.

Care must be taken when considering introducing predators into the environment, Sokolow noted. Previous attempts with American crayfish successfully reduced schistosome-hosting snails in African bodies of water but they also eroded river banks, devoured crops and caused declines in native species. Her team’s most recent experiments, funded by the same Fogarty grant plus other benefactors, focus on agrichemicals and explore how run-off pesticides might kill susceptible prawns. One of Sokolow’s experiments uses drones to map river plant life to predict human reinfection rates. “Environmental diagnostics” could someday complement medical treatment and accelerate wellness, Sokolow said. She believes lessons learned in the Senegal river basin have the potential to reduce global suffering of schistosomiasis, which affects more than 240 million people worldwide and can lead to anemia, impaired growth and development, liver damage and bladder cancer. She led an analysis of schistosomiasis infection data from sub-Saharan Africa before and after construction of 14 large dams and concluded the prawn intervention should be more broadly adopted. “If this could be extended to the agricultural landscapes of Africa and the Americas where schistosomiasis transmission is highest, prawn aquaculture might offer a powerful tool in the global fight against schistosomiasis.” She also posed a question for future research: “For what other human disease systems can win–win solutions for people and nature be carried out successfully at scale, while remaining cost-effective?”



Scientists Scientists in in Tanzania Tanzania show show not not every every fever fever is is malaria malaria Fevers are often assumed to be a sign of malaria in Fevers are often assumed to be a sign of malaria in Africa—where precise tests for disease diagnosis are not Africa—where precise tests for disease diagnosis are not widely available. If left untreated, malaria can sometimes widely available. If left untreated, malaria can sometimes progress rapidly and even cause death. But if overprogress rapidly and even cause death. But if overtreated, it can contribute to proliferation of drug-resistant treated, it can contribute to proliferation of drug-resistant malaria. In Tanzania’s mountainous regions, there are few malaria. In Tanzania’s mountainous regions, there are few mosquitoes mosquitoes so so other other febrile febrile diseases diseases are are more more likely likely than than malaria. malaria.

do district veterinary offices and other livestock sector do district veterinary offices and other livestock sector communities understand about infections? communities understand about infections?

While While studying studying HIV/AIDS HIV/AIDS coinfections coinfections in in the the east east African African country, Fogarty country, Fogarty grantee grantee Dr. Dr. John John Crump Crump came came across across patients who were admitted to hospitals with severe fever. When they were tested for malaria, only 1-to-2% were positive, said Crump, a Duke University faculty member. “When we looked at the causes of fever, we started to realize how important bacterial zoonoses were as a cause of febrile illness,” Crump said. Not only do these diseases diseases affect affect human human health health but but they they also also have have financial financial implications. If animals are sick, they may produce implications. If animals are sick, they may produce less less milk, milk, suffer suffer pregnancy pregnancy loss loss and and the the young young may may fail fail to to develop develop normally. normally.

He He and and his his team team established established a a surveillance surveillance project project to to track three track three zoonotic zoonotic diseases: diseases: leptospirosis, leptospirosis, Q Q fever fever and brucellosis. The work included estimating disease burden, studying clinical approaches, researching risk factors to determine prevention strategies and testing diagnostics. Practical tasks included literature reviews, patient surveys and statistical analyses. Crump and his team published about 30 journal articles during the the project. project. In In one one paper, paper, brucellosis brucellosis was was determined determined to be endemic in northern Tanzania, with to be endemic in northern Tanzania, with 35 35 cases cases per per 100,000 persons. Another article outlined the 100,000 persons. Another article outlined the etiology, etiology, epidemiology, epidemiology, clinical clinical presentation, presentation, diagnosis, diagnosis, treatment treatment and prevention of brucellosis, leptospirosis, and prevention of brucellosis, leptospirosis, Q Q fever fever and and rickettsioses. rickettsioses.

Dr. Jo Dr.Halliday, Jo Halliday, University University of Glasgow of Glasgow

Many Tanzanians raise small quantities of goats and Many Tanzanians raise small quantities of goats and poultry at home. “At one end of the spectrum you’ve got poultry at home. “At one end of the spectrum you’ve got pastoralists, like the Maasai, who live a nomadic lifestyle pastoralists, like the Maasai, who live a nomadic lifestyle in very close association with large mixed herds of cattle, in very close association with large mixed herds of cattle, sheep and goats. They have the most intense contact with sheep and goats. They have the most intense contact with animals and so have the highest disease risk and the animals so have on thelivestock highest disease and the greatest and dependence for theirrisk livelihoods,” greatest dependence on livestock for their livelihoods,” explained Crump. Meanwhile, smallholder farmers seen explained Meanwhile, smallholder farmers seen around theCrump. city of Moshi tend not to graze their small around the citythem of Moshi tend nottotoother grazeanimals. their small herds, keeping unexposed herds, keeping them unexposed to other animals. Crump formed a team of researchers to better understand Crump formed issues a team and of researchers to better understand the underlying answer questions including: the underlying issues answer questions What do primary care and practitioners believe toincluding: be causes of fever? do care they practitioners know of bacterial zoonoses? What What do What primary believe to be causes of fever? What do they know of bacterial zoonoses? What Fogarty funded researchers in Tanzania fevers, to reduce unnecessary treatment Fogarty funded researchers in Tanzania fevers, to reduce unnecessary treatment

studied of false studied of false

causes of diseases that produce diagnoses of malaria. causes of diseases that produce diagnoses of malaria.

“It made sense that social science was needed to shed “It made sense that social science was needed to shed light on those topics,” said Crump. “One Health is a way light on those topics,” said Crump. “One Health is a way of working with people from various disciplines in human, of working with people from various disciplines in human, animal animal and and environmental environmental health health that that fits fits perfectly perfectly with with the kinds of research questions we face in the kinds of research questions we face in Tanzania.” Tanzania.”

All told, Crump believes the project’s greatest impact All told, Crump believes the project’s greatest impact has been unmasking the concurrent problems of malaria has been unmasking the concurrent problems of malaria overdiagnosis and bacterial zoonoses underdiagnosis, overdiagnosis and bacterial zoonoses underdiagnosis, while pushing patient management toward new while pushing management toward new approaches forpatient those without malaria. “We’re seeing approaches for those without malaria. “We’re seeing less empiric treatment for malaria—more withholding less empiric treatment for malaria—more withholding of antimalarials if there’s a negative malaria diagnostic of antimalarials if there’sofaalternative negative malaria test—and consideration causesdiagnostic of severe test—and consideration of alternative causes of severe fever. Hopefully that’s resulting in better outcomes for fever. Hopefully that’s resulting in better outcomes for patients,” said Crump. patients,” said Crump. Additional results have also “flowed out of the research,” said Crump, who points to the “Not Every is Additional results have also “flowed out of Fever the research,” Malaria” campaign. “The to WHO treatment said Crump, who points the malaria “Not Every Fever is guidelines have also“The changed—I can’t say we’re entirely Malaria” campaign. WHO malaria treatment responsible for that—but the guidelines now sayentirely do a test guidelines have also changed—I can’t say we’re for malaria first and only use antimalarials if the test responsible for that—but the guidelines now say do a is test positive.” This major policy shift likely took into account for malaria first and only use antimalarials if the test is additional research others as likely well as increased testing, positive.” This majorby policy shift took into account still all of it “has confirmed that malaria overdiagnosis is additional research by others as well as increased testing, not just a problem in Tanzania, but in many places that still all of it “has confirmed that malaria overdiagnosis is were once endemic for malaria but are no longer due to not just a problem in Tanzania, but in many places that successful malaria control activities,” he said. were once endemic for malaria but are no longer due to successful malaria control activities,” he said. Crump considers improved infrastructure another significant outcome of his Fogarty work. “The training of Crump considers improved infrastructure another Tanzanians and the capacity building for the research significant outcome of his Fogarty work. “The training of platform is possibly the most important thing,” he Tanzanians and the capacity building for the research said. “It’s a long game, but ultimately the goal is for platform is possibly the most importantgarner thing,”external he our Tanzanian partners to increasingly said. “It’sfor a long but ultimately the goal is for support their game, research.” our Tanzanian partners to increasingly garner external support for their research.”


Research Research improves improves health health among among Mongolian Mongolian herders herders


ongolia’s ongolia’s economy economy has has undergone undergone rapid rapid changes changesin in the thepast pastfew fewdecades decadeswith with marked markedincreases increasesin inlivelivestock stockproduction production of of sheep, sheep, goats, goats, camels, camels, horses horses and andcattle. cattle.As Asthe thenormally normallypastoral pastoral populations populationshave have begun begunmigrating migratingto tourban urban areas, areas, humans humans and and animals animalsare are coming cominginto intocloser closer contact, contact, increasing increasing the the spread spread of ofdisease. disease. Climate Climate change change has has exacerbated exacerbatedthe thesituation, situation, requiring requiring nomadic nomadicherders herdersto tomove movemore morefrequently frequentlyin in search searchof ofwater water and andgrazing grazingland landfor fortheir theirflocks. flocks.

Then Then the thethree-person three-person teams teamsof of Mongolian Mongolianand andAmerican American scholars scholarsdesigned designedprojects, projects, moved movedthem themthrough through ethical ethical reviews, reviews,developed developedbudgets budgetsand andbought bought supplies. supplies. During During the theprocess, process,Mongolian Mongolian trainees traineesimproved improvedtheir theirEnglish English language languageproficiency proficiencyand andpresentation presentationskills. skills.Gray Grayand andDr. Dr. Battsetseg BattsetsegGonchigoo, Gonchigoo, of of Mongolia’s Mongolia’s Institute Institute of of Veterinary Veterinary Medicine Medicineand andothers othersprovided providedmentorship mentorshipthroughout, throughout,as as the theteams teamsconducted conducted their theirfield fieldwork, work, analyzed analyzedresults, results, prepared preparedpublications publicationsand andwrote wrotegrant grant applications. applications.The The research researchteams teamsstudied studiedvarious variousaspects aspectsof of animal-human animal-human interactions interactions over over six sixyears yearsand andpublished publishedmore morethan than20 20 scientific scientificarticles articleswith withtheir theirfindings. findings. Some Someof ofthe theresults results were weresurprising, surprising, Gray Graynoted. noted. “For “For instance, instance,we wefound foundthe thefirst first evidence evidencethat that strains strainsof of influenza influenzaAAvirus virusthat that commonly commonlyinfect infect horses horseswere werealso also likely likely infecting infectingcamels. camels. And And we we found found an an unusual unusual rickettsial rickettsial pathogen pathogenin inticks, ticks,which which might might explain explain some some of of their their ticktickbite bite associated associateddeaths deaths among among humans.” humans.” Mongolia Mongoliais ishome hometo toabout about33million millionpeople peoplewho whoco-exist co-exist with with 50 50million millionlivestock, livestock, on on which which they theyrely relyfor forcritical criticalrereources ourcessuch suchas asmeat meat and andmilk milkproducts, products, leather leatherand and hides, hides, wool, wool,cashmere, cashmere,and and other other goods goods needed needed for for household household sustenance, sustenance,barter barterand andsale. sale. To To better betterunderstand understandthe thetypes types of ofanimal-human animal-humancontact, contact, hygiene hygienepractices practicesand andknowledge knowledge of ofzoonotic zoonoticdiseases, diseases,one oneresearch research team teamdeveloped developedand and conducted conductedaasurvey surveyof of Mongolian Mongolian herding herding households. households. 48 Delaware Journal of Public Health – January 2021

Mongolian Mongolianand andU.S. U.S.researchers researcherswere weretrained trainedwith withFogarty Fogartysupport supporttotostudy studyanimalanimalhuman humandisease diseasetransmission transmissionamong amongnomadic nomadiclivestock livestockherders. herders.

Participants Participantsreported reported the thecontact contactthey theyhad had with withanimals, animals, for for instance instanceduring duringbirthing, birthing,milking milkingor or slaughtering. slaughtering. Other Other risks riskstallied tallied include includehandling handlingmanure manureused usedfor forfuel. fuel. While Whilethe themajority majoritysaid said they theywashed washed their their hands hands after after animal animalcontact, contact,most mostdid did not notafter after defecation defecationor orurination. urination. Less Lessthan thanhalf halfthe therespondents respondentshad had access accessto toan animproved improved drinking drinkingwater water source sourceand and about about50% 50%reported reportedpracticing practicing open opendefecation. defecation.Most Mosthouseholds householdshad had knowledge knowledge of of disease diseasetransmission transmissionfrom from animals animalsto tohumans humans but but far far fewer fewer understood understood the thereverse. reverse. Research Researchteams teamsalso alsostudied studied tick-born tick-borninfections, infections, demondemonstrating stratingthey theyare arecommon commonamong amongdomestic domesticanimals, animals, small smallwild wild mammals mammalsand and herders. herders.Others Othersfocused focusedon on mosquito-borne mosquito-borneinfections infectionsthat thatcan cancause causediseases diseases such such as asencephalitis encephalitisand and West WestNile NileVirus Virusin inboth bothanimals animals and and humans. humans.Another Another group group used used rapid rapid diagnostics diagnostics to to look lookfor for influenza influenzaAAand andB, B,suggesting suggestingthe thetests testsmay maybe bean aneffective effective tool toolfor for rural ruralpractitioners. practitioners.Other Other trainees traineesinvestigated investigatedthe the prevalence prevalenceand and risk risk factors factorsfor for intestinal intestinalparasites. parasites. Findings Findingsfrom from Gray’s Gray’steams teamshave havehelped helped shape shape Mongolian Mongolian public publichealth healthstrategies. strategies.Researchers Researchersdeveloped developedflyers, flyers, videos videosand and an aneducational educationalhandbook handbook for for herder herdersafety, safety, encouraging encouraginginfluenza influenzavaccines vaccinesand and the theuse useof of personal personal protective protectiveequipment. equipment.Text Textmessaging messagingmight mightbe be considered considered for for future futureoutreach, outreach,Gray Graynoted, noted,since sincethe thesurvey survey found found solar-power solar-power charged charged cellphones cellphoneswere werepresent presentin inall allherder herder households. households. Gray Grayhopes hopesthe thediscoveries discoveriesmade madein inMongolia Mongoliacan can help help to toreduce reducethe theburden burdenof ofzoonotic zoonoticdiseases diseases among among pastoral pastoralpeople peopleworldwide. worldwide.“If “Ifwe wecan cananticipate anticipate when when microbiological microbiologicalthreats threatsare arejumping jumpingback back and andforth forth between betweenanimals animalsand and humans humansbefore beforethey theytake take hold hold and and become becomevery verytransmittable, transmittable,then thenwe wecan candesign designmitigation mitigation strategies,” strategies,”said said Gray. Gray.“What “Whatimpacts impactspeople peoplein inthe the developing developingworld world today todaycan canbe beaaproblem problem in inour ourvery very own own back back yard yard tomorrow, tomorrow,so sothe thework work that thatFogarty Fogarty does does in in global globalhealth healthis isextremely extremelyimportant importantin inprotecting protecting U.S. U.S. citizens citizensand and their their animals.” animals.” 99

Photo courtesy courtesy of of Dr. Dr. Gregory Gregory Gray Gray Photo

With With limited limitedresearch research and and diagnostic diagnostic capacity, capacity, Mongolia Mongolia had haddifficulty difficultyresponding respondingto to zoonotic zoonoticdiseases. diseases. AAFogarty Fogarty research researchtraining traininggrant grantto toDuke DukeUniversity’s University’sDr. Dr.Gregory Gregory Gray Graysupported supportedaafive-year five-yeareffort effort to to change changethat. that. Gray Gray recruited recruitedaadozen dozenscientists scientists for for training training in in One One Health Health concepts conceptsand andinnovative innovativediagnostic, diagnostic, epidemiologic epidemiologicand and analytical analyticalresearch researchmethods. methods. Mongolian Mongolian and and U.S. U.S. scholars scholars spent spentseveral severalmonths monthsat at Duke Dukelearning learningaa multidisciplinary multidisciplinary approach approachto toresearch research that that includes includes aspects aspects of of public publichealth, health, agriculture, agriculture,environmental environmental engineering engineeringand andveteriveterinary narymedicine. medicine.Trainees Traineesalso also learned learnedabout about responsible responsible research researchconduct—including conduct—includinghuman humansubject subjectprotection protectionand and the theinformed informedconsent consent process—and process—andreceived receivedanti-sexual anti-sexual harassment harassmentinstruction. instruction.

OPINION By By Dr. Dr. Roger Roger I.I. Glass, Glass, Director, Director, Fogarty Fogarty International International Center Center

Fogarty Fogarty community community benefits benefits from from virtual virtual engagement engagement Before Before the the pandemic pandemic struck, struck, II spent spent much much time time traveling traveling the the globe globe visiting visiting grantee grantee research research sites, sites, holding holding discussions discussions with with scientists scientists and and health health officials officials and and participating participating in in conferences. conferences. II hadn’t hadn’t realized realized how how much much II thrived thrived on on making making these these personal personal connections connections until until COVID-19 COVID-19 sidelined sidelined me me at at home. home. As As much much as as II have have embraced embraced the the world world of of virtual virtual meetings, meetings, itit has has sometimes sometimes been been aa frustrating frustrating and and exhausting exhausting experience. experience. II miss miss the the serendipitous serendipitous sidebar sidebar conversations conversations at at events, events, the the ability ability to to renew renew acquaintances acquaintances and and forge forge new new ones ones in in aa free, free, unstructured unstructured way. way. Sometimes Sometimes II have have found found myself myself struggling struggling to to follow follow simultaneous simultaneous events, events, juggling juggling multiple multiple screens, screens, failing failing to to be be as as fully fully present present as as II would would have have been been in in person. person. But But in in conversations conversations with with the the Fogarty Fogarty team, team, II have have come come to to appreciate appreciate that that there there are are exciting exciting opportunities opportunities in in this this brave brave new new world world and and that that many many of of our our grantees grantees and and trainees trainees are are deriving deriving significant significant benefits benefits from from virtual virtual engagement. engagement. At At Fogarty, Fogarty, we we have have continued continued our our normal normal practice practice of of convening convening our our community community through through annual annual network network meetings meetings for for those those affiliated affiliated with with each each of of our our funding funding programs. programs. We’ve We’ve discovered discovered that that by by eliminating eliminating expensive expensive travel travel for for in-person in-person sessions, sessions, we we have have in in many many cases cases doubled doubled attendance. attendance. This This has has greatly greatly increased increased participation participation by by lowlow- and and middle-income middle-income country country (LMIC) (LMIC) scientists scientists and and enabled enabled trainees trainees to to be be able able to to join join the the conversation conversation and and provide provide their their unique unique perspectives. perspectives. We We have have also also heard heard anecdotally anecdotally that that break-out break-out sessions sessions showcasing showcasing trainees trainees have have allowed allowed them them to to share share their their findings findings with with their their peers peers and and cultivate cultivate new new research research partnerships. partnerships. Some Some have have said said they they found found itit inspirational inspirational to to have have the the opportunity opportunity to to measure measure themselves themselves against against the the high high bar bar set set by by their their fellow fellow trainees. trainees. ItIt also also allows allows Fogarty Fogarty program program officers officers to to hear hear directly directly from from trainees trainees about about how how well well our our initiatives initiatives are are meeting meeting their their needs needs and and what what we we can can do do to to improve improve their their experiences. experiences. The The reliance reliance on on virtual virtual meetings meetings has has also also prompted prompted some some LMIC LMIC institutions institutions to to strengthen strengthen online online learning learning options options and and invest invest in in improving improving internet internet connectivity, connectivity, especially especially in in rural rural areas. areas.

We We had had planned planned to to host host an an in-person in-person gathering gathering of of Africa’s Africa’s data data science science community community in in Uganda Uganda last last summer summer to to kick kick off off NIH’s NIH’s new new DS-I DS-I Africa Africa program. program. We We pivoted pivoted instead instead to to aa virtual virtual networking networking platform, platform, where where we we hosted hosted live live and and taped taped keynote keynote speakers, speakers, panel panel discussions discussions and and other other interactive interactive events. events. We We invited invited individuals individuals and and organizations organizations to to post post profiles, profiles, engage engage in in message message board board discussions discussions and and connect connect informally informally with with potential potential partners partners in in networking networking lounges. lounges. We We were were pleased pleased that that we we far far exceeded exceeded our our expected expected attendance attendance with with 2,234 2,234 registrants, registrants, about about half half joining joining from from Africa. Africa. The The original original in-person in-person gathering gathering had had been been planned planned to to accommodate accommodate only only 350 350 attendees. attendees. The The majority majority of of participants participants responding responding to to aa post-event post-event survey survey reported reported they they had had used used the the opportunity opportunity to to engage engage with with scientists scientists outside outside their their discipline discipline and and world world region. region. Many Many said said the the symposium symposium was was more more advanced advanced than than other other virtual virtual meetings meetings they’d they’d attended attended and and thought thought itit pushed pushed the the envelope envelope of of what what itit is is possible possible to to do do to to recreate recreate the the “in “in real real life” life” experience. experience. This This fall, fall, NIH NIH held held its its annual annual grants grants workshop workshop online online for for the the first first time. time. More More than than 20,000 20,000 people people signed signed up up to to participate, participate, which which was was 20 20 times times the the usual usual number. number. Fogarty Fogarty hosted hosted aa number number of of interactive interactive sessions sessions on on grantsmanship grantsmanship during during the the proceedings proceedings and and staffed staffed aa virtual virtual exhibit. exhibit. We We were were delighted delighted to to see see that that more more than than 2,000 2,000 participants participants were were from from LMICs—a LMICs—a vast vast improvement improvement from from business business as as usual! usual! Fogarty’s Fogarty’s team team of of disease disease modelers modelers also also got got on on the the virtual virtual bandwagon—offering bandwagon—offering online online genomic genomic epidemiepidemiology ology training training to to LMIC LMIC scientists. scientists. Five-day Five-day courses courses included included instruction instruction on on lab lab procedures procedures for for using using the the portable portable MinION MinION sequencing sequencing platform, platform, as as well well as as bioinformatic bioinformatic techniques techniques needed needed to to perform perform quality quality control control of of raw raw data data and and assemble assemble full full SARS-CoV-2 SARS-CoV-2 genomes. genomes. Trainees Trainees learned learned to to create create genomic genomic databases databases and and build build and and interpret interpret phylogenetic phylogenetic trees. trees. The The immediate immediate goals goals were were to to produce produce SARS-CoV-2 SARS-CoV-2 sequences sequences that that can can be be included included in in public public databases databases and and journal journal publications. publications. The The long-term long-term aim aim is is to to advance advance the the use use of of genomics genomics in in public public health health labs labs in in LMICs. LMICs. While While II look look forward forward to to the the day day when when we we can can abandon abandon social social distancing, distancing, we we at at Fogarty Fogarty will will carefully carefully consider consider how how we we can can best best balance balance the the inclusiveness inclusiveness of of virtual virtual engagement engagement with with the the benefits benefits of of in-person in-person gatherings. gatherings. II think think perhaps perhaps aa mixed-meeting mixed-meeting format format will will become become the the model model for for the the future. future. RESOURCES RESOURCES

10 10 49

PEOPLE Fauci recognized for public service Dr. Anthony Fauci, director of NIH’s National Institute of Allergy and Infectious Diseases, has received a lifetime achievement award from the U.S. Global Leadership Coalition. Fauci was also honored recently by the American Society of Tropical Medicine and Hygiene for outstanding service to the global public as a trusted voice in science.

Pinn honored as pioneer in women’s health research The Women in Medicine Legacy Foundation has recognized the achievements of Dr. Vivian Pinn with its Alma Dea Morani, MD Renaissance Woman Award. Pinn was the first director of the Office of Research on Women’s Health at the NIH where she continues to serve, most recently as a Fogarty senior scientist emerita.

Pettigrew receives NSB’s Vannevar Bush Award The National Science Board (NSB) has presented Dr. Roderic Pettigrew with its prestigious Vannevar Bush Award for his public service and scientific contributions. Pettigrew was founding director of the NIH’s National Institute of Biomedical Imaging and Bioengineering.

ASTMH awards medal to NIH grantee Happi Dr. Christian Happi, director of the African Centre for Excellence for the Genomics of Infectious Disease, has been awarded the Bailey K. Ashford Medal by the American Society of Tropical Medicine and Hygiene. Happi is a professor at Redeemer’s University in Nigeria.

HHS presents service medal to Ohene-Frempong Dr. Kwaku Ohene-Frempong has received the HHS’s Assistant Secretary of Health Exceptional Service Medal for his outstanding contributions to alleviating global suffering from sickle cell disease (SCD). A professor emeritus of pediatrics at the University of Pennsylvania, he has dedicated his 40-year career to finding a cure for SCD.

WHO Foundation names Soni inaugural CEO The WHO Foundation has appointed Anil Soni as its inaugural Chief Executive Officer, effective January 1, 2021. The Foundation, an independent grantmaking agency headquartered in Geneva, was launched in May 2020 to work alongside the WHO. Soni joins the Foundation from Viatris, a global healthcare company, where he was head of infectious diseases.

Global HEALTH Briefs NIH releases data management policy

To speed development of treatments and vaccines in response to the COVID-19 pandemic, NIH has unveiled a policy requiring researchers to plan prospectively for managing and sharing scientific data generated with NIH funds. It also establishes the baseline expectation that data sharing is a fundamental component of the research process. The new policy will go into effect in January 2023 to give the grantee community time to prepare. Statement:

Research training is available online

Free online lectures and presentations targeting early-career clinician-scientists are available from the NIH’s National Institute of Child Health and Human Development. The curriculum includes a variety of topics important for those applying for jobs, writing grants and developing independent research laboratories or programs. Website:

NAM considers COVID-19, climate change

The National Academy of Medicine has posted video and slide presentations from its recent annual meeting that examined COVID-19, climate change and other urgent threats to human health. The NIH’s Dr. Anthony Fauci and philanthropist Bill Gates delivered keynote addresses during the proceedings. Website:

Wellcome announces new funding strategy UK-based Wellcome Trust has released a new research funding strategy to tackle three of the world’s most urgent health challenges. Efforts will focus on improving the understanding and treatment of mental health, exploring the harmful effects of global warming, and working to bring infectious diseases under control and stop epidemics. Strategic plan:

TDR releases gender analysis toolkit

An intersectional gender analysis toolkit has been produced by TDR, the global organization devoted to supporting research and training in tropical diseases. The resource is intended to strengthen research capacity, address barriers to implementation of health interventions and explore solutions to improve access to quality health care. Website:

11 50 Delaware Journal of Public Health – January 2021


Funding Opportunity Announcement



Harnessing Data Science for Health Discovery and Innovation in Africa U2R Research Training Program U54 Research Hubs – AIDS applications

EXTENDED: Dec 18, 2020 Feb 8, 2021

International Bioethics Training R25 Clinical Trial Not Allowed D43 Clinical Trial Optional

Jun 4, 2021

Global Infectious Disease (GID) Research Training Program D43 Clinical Trials Optional

Aug 3, 2021

Fogarty HIV Research Training for LMIC Institutions D43 Clinical Trial Optional D71 Clinical Trial Not Allowed G11 Clinical Trial Not Allowed

Aug 20, 2021

For more information, visit

Global Health Matters November/December 2020

2019 Global Burden of Disease study highlights rising NCD risk factors

Volume 19, No. 6 ISSN: 1938-5935 Fogarty International Center National Institutes of Health Department of Health and Human Services Managing editor: Ann Puderbaugh Web manager: Anna Pruett Ellis Writer/editor: Susan Scutti Designer: Carla Conway

A worldwide crisis of chronic diseases and failure of public health to stem the rise in preventable risk factors have left populations vulnerable to acute health emergencies such as COVID-19, according to the 2019 Global Burden of Disease study. “Most of these risk factors are preventable and treatable, and tackling them will bring huge social and economic benefits. We are failing to change unhealthy behaviors, particularly those related to diet quality, caloric intake and physical activity, in part due to inadequate policy attention and funding for public health and behavioral research,” said Dr. Christopher Murray, director of the Institute for Health Metrics and Evaluation at the University of Washington, who led the research.

All text produced in Global Health Matters is in the public domain and may be reprinted. Please credit Fogarty International Center. Images must be cleared for use with the individual source, as indicated.


The study reveals that the rise in exposure to key risk factors— including high blood pressure, high blood sugar, high body-mass index, and elevated cholesterol—combined with rising deaths from cardiovascular disease, suggest that the world might be approaching a turning point in life expectancy gains. R ESOURCE Full report: 51

Live Bird Markets of the Northeastern United States

Jarra F. Jagne, D.V.M., D.A.C.V.P.M New York State Animal Health and Diagnostic Center, Department of Population Medicine and Diagnostic Sciences, Cornell University College of Veterinary Medicine Joy Bennett, D.V.M., M.P.H., D.A.C.V.P.M. New York State Department of Agriculture and Markets Division of Animal Industry Eireann Collins, D.V.M. New York State Department of Agriculture and Markets Division of Animal Industry

ABSTRACT The live bird marketing system (LBMS) in the Northeastern United States (US) consists of a complex system of production flocks, dealers/haulers and live bird markets (LBMs). The States of New York (NY), Pennsylvania (PA) and New Jersey (NJ) have the most active systems with New York State having the most markets presently at 87. The states of Massachusetts, Maine and Connecticut have very few markets. Live bird markets serve mainly ethnic immigrant populations in large urban centers of Northeastern states. The markets are important in the epidemiology of avian influenza viruses (AIV) especially H5 and H7 strains that have zoonotic potential and an effect on trade with United States trading partners. Massive surveillance efforts are carried out to detect and control the spread of these virus strains in the markets under a state/federal/industry program. The program, named the “Prevention and Control of H5 and H7 Avian Influenza in the Live Bird Marketing System: Uniform Standards for a State-Federal-Industry Cooperative Program” is managed mainly by the states, with the federal government assisting in the lab detection and characterization of viruses isolated from the markets. This paper will describe the Northeastern market systems with emphasis on the largest system in NY State and will give a glimpse into its structure, clientele, general regulations, risk factors and avian influenza surveillance.

INTRODUCTION The Northeastern United States has the largest number of live bird markets (LBMs) in the United States.1 These markets are located in the States of New York (NY), Pennsylvania (PA), New Jersey (NJ), Connecticut (CT), Maine (ME), Massachusetts (MA) and Rhode Island (RI). In the past two decades, the live bird markets in CT, ME, RI and MA have decreased in number and importance, while those in the metropolitan areas of NY, NJ and PA thrive with the influx of new immigrants arriving from Asia, Africa and the Middle East. The only other region in the US that has a significant amount of live bird markets is in California (CA) on the West Coast.2 Despite the fact that each state has its own unique way of running the LBMs, there are many similarities in the way the markets are structured. There is also similarity in the way poultry flows from production sites all over the Northeast, the Mid-West, Mid-Atlantic and Canada into the urban markets.3 The poultry value chain for the LBMS in the Northeast is very simple compared to what has been observed in other countries. Poultry are raised on special production farms or commercial farms (spent layers) that sell wholesale to dealers and haulers who in turn sell to LBM owners who sell retail to consumers. Depending on customer preferences, birds brought into the markets are broilers (white or brown), spent hens, game fowl, ducks, geese, pigeons, guinea fowl, quail, and specialty chickens such as Silkies. Many come from large farms but an increasing number also come from smaller farms and backyard flocks. Many markets also sell turkeys and other animals such as sheep, goats and rabbits.4 Apart from the obvious economic benefits the states get from the presence of LBMs in the form of taxes and income for owners, dealers, haulers, farmers and jobs for many people, the LBMs are also noted for having AIV isolated frequently from birds and in the environment. Avian influenza viruses of the H7 and H5 52 Delaware Journal of Public Health – January 2021

types can become highly pathogenic and change into potentially zoonotic viruses.3 To decrease circulating AIV, the whole market system revolves around surveillance, sanitation and regulatory measures through a state/federal/industry program managed by the United States Department of Agriculture’s (USDA) Animal and Plant Health Inspection Services (APHIS). The program is the aptly named “Prevention and Control of H5 and H7 Avian Influenza in the Live Bird Marketing System: Uniform Standards for a State-Federal-Industry Cooperative Program”. It is used by all states in the US, and is the standard regulatory guide. The USDA also set up an LBM advisory group, “The Live Bird Market Working Group” which meets annually with all state stakeholders, federal personnel, federal and state laboratories to provide updates on state LBMs and AIV testing of markets and flocks.5


Producers from Pennsylvania provide the majority of the birds going into the LBMS for all the Northeastern States (Table 1). The Northeast LBMs provide about 500,000 birds weekly for LBMs in NY, NJ and PA, and the numbers increase during high demand periods such as holidays. The LBMs also receive poultry from other Northeastern states, the Midwest, the Mid-Atlantic region, and Canada. All Northeastern states require LBM source birds to be from an established, healthy, AI negative flock. Registration of supply flocks with departments of agriculture is required annually. Each farm is given a unique premises ID that is used for interstate movement of birds and all business conducted at LBMs. Producers also have to keep meticulous records of the farm operations and to keep them for at least a year. Animal health officers working for the state can go to farms at any time for inspection of the farm and records.5 doi: 10.32481/djph.2021.01.009



# of LBM













Table 1. Northeast LBM system – Numbers of producers, dealers and LBMs

Producers have to participate in AIV surveillance and can choose to have their flocks either monitored or tested. Monitored flocks are tested monthly using 30 randomly selected birds and have to test negative three times before birds can be moved to LBMs. Any breaks in the monthly testing means the birds will go to tested flock status until they can go back to being a monitored flock. The tested flock program requires birds to be on a farm for 21 days without any contact with other birds. Similar to the monitored flock, 30 birds are randomly selected for testing. Birds can only be moved to the LBMs if they test negative for AIV within a ten-day window of being moved. Samples for monitored and tested flocks are swabs, blood samples and sometimes eggs.5 Producers are provided with poultry inspection certificates that specify monitored or tested flocks and contain testing information for AIV. These certificates are required for interstate movement of birds and are valid for 30 days from date of sample collection in monitored flocks and 10 days from sample collection in tested flocks. If birds test positive for H7 or H5 AIV for either monitored or tested status, the farms have to be quarantined after confirmation by the National Veterinary Service Laboratory (NVSL) and the birds depopulated. After depopulation, the USDA, in concert with the state, conducts sanitation measures such as cleaning and disinfection of the premises and observation of farm downtimes until the premises test negative again. Routine sanitation and biosecurity are required for all farms at all times. Cleaning and disinfection of premises, equipment, vehicles and crates for transporting birds are also part of the sanitation plan for production sites. Farms are not allowed to mix poultry species in one location, especially ducks and geese that are known to be natural reservoirs of AIV.3 Other biosecurity measures include housing birds properly to prevent birds being exposed to migratory waterfowl. Regulations also include training of farm personnel in biosecurity.5

Dealers and Haulers

Dealers (distributors and wholesalers) and haulers are the link between the farms and the LBMs. Dealers are companies or individuals that obtain live poultry from different farms for sale to LBM owners. Haulers are businesses or individuals that solely transport live birds for others. Wholesalers and distributors usually have permanent facilities where trucks carrying birds assemble before distribution and return to have trucks and crates cleaned and disinfected. Dealers, haulers, distributors and wholesalers also have to meet the regulatory standards set in the Uniform Standards Program. These include having a biosecurity program, registration in all states where they do business (including picking up birds and selling birds), and a premises identification number. AIV surveillance includes quarterly sampling and testing of transport crates, birds, trucks and environmental sampling. Dealers also have to clean and disinfect all trucks, crates and holding areas before returning to farms. Their facilities should have mechanical crate washers and all season wash facilities as required by

the state. Dealer premises are inspected once a month, and cleaned and disinfected quarterly. All routine inspections are unannounced except for cleaning and disinfection inspections. They are also required to have a biosecurity plan in place that is approved by the state of residence. Similar to production sites, any positive H5/H7 test results confirmed by NVSL require quarantine and depopulation of birds in the facility, followed by cleaning and disinfection. Monthly testing is done until the facility has three consecutive negative tests that will allow the dealer to return to quarterly testing.

Live Bird Markets

We will use the example of New York State to describe the LBMs. New York State has 84 markets located in or near New York City (NYC). The majority are located in the boroughs of Brooklyn, Queens and the Bronx. Outside of NYC, there is one in Schenectady, one near Buffalo and a new market in Syracuse totaling 87 markets. The LBMs in the NYC are located in separate buildings or storefronts (Figure 1). The markets are where different types of poultry are custom slaughtered and sold to the public. The City of New York will not allow any new LBMS to be constructed, but will allow existing ones to be sold and used for the same purpose. The different types of poultry are contained in metal cages (Figure 2) where patrons can easily see them and make their choice before purchase and slaughter.

Figure 1. Storefront of a Live Bird Market

As per state and federal regulations, all birds purchased at live bird markets have to be slaughtered at the market. No one is allowed to take live birds home. Broilers and other birds are weighed and sold to patrons by the pound but some, such as spent hens are sold as single birds. Market owners cater to a large immigrant population in NYC, and some of the markets may cater to a single ethnic group. In a recent poll carried out in NYC markets by the New York State Department of Agriculture and Markets (NYSDAM), patrons who frequented the markets spoke a total of eight languages including Spanish, Bengali, Arabic, Vietnamese, Chinese, Haitian Creole and Korean. The patrons tend to be new and first generation immigrants. Many types of poultry are sold in the LBMs including geese and ducks, quail, white and red broilers, pigeons, guinea fowl and spent layers. The different nationalities have their bird preferences, with red broilers prized among Dominicans and Puerto Ricans, spent hens or spent breeder fowl among West African immigrants and Silkies considered a delicacy among Asians. 53

LIVE BIRD MARKET REGULATIONS Live bird market owners are participants under the Uniform Standards Program. They register with participating states in the Northeast and are given a premises identification number. Records of all birds accepted into the facilities and sold to customers are kept and can be inspected randomly by state animal health inspectors during unannounced inspections and AIV testing that are done quarterly. All markets are also required to voluntarily sell all their poultry and clean and disinfect at least once every quarter; this has been in place since 2003 and has been found to be effective in controlling pathogens in the market.6 In addition to the Standards Program, live bird markets must also work with the different municipalities to follow local public health, environmental and sanitation laws and the Federal Poultry Products Inspection Act. Owners and workers are also required to undergo training in biosecurity and the Uniform Standards program.

Sampling and Testing Procedures for AIV Surveillance in LBMs

Inspectors that visit the markets wear appropriate personal protective equipment (PPE). PPE is changed for each market visited, and inspectors must observe biosecurity protocols and allow 48-72 hours before they can visit a farm. Live bird markets are inspected and tested at least once per quarter. Birds are examined and records are reviewed for compliance with state

Figure 2. Cages with Live Birds in New York City

54 Delaware Journal of Public Health – January 2021

regulations. Records that may be examined at inspection include poultry inspection certificates, invoices/receipts and cleaning and disinfection log books. During inspection visits that include sampling, inspectors randomly select from five to eleven birds of each type to sample. For gallinaceous species, samples are swabbed from the trachea or oropharyngeal area and pooled up to 11 birds per tube for real time reverse transcriptase polymerase chain reaction (rRT- PCR) testing. Domestic ducks and geese are swabbed in the cloaca and pooled up to five birds/tube for rRT-PCR testing. Sample pools have to be from the same species and must be taken from the same area. Environmental samples include swabs from floors, cages, drains, walls, scales, door handles, etc. and are pooled up to five swabs per tube for virus isolation testing. Following cleaning and disinfection procedures, markets are inspected and environmental samples collected prior to re-stocking. Markets are permitted to re-open pending results. All samples are shipped to state diagnostic labs for testing. Markets found to be positive for H5/H7 AIV per confirmation by NVSL will be quarantined, depopulated, cleaned, and disinfected. New birds will not be allowed until the market passes inspection and environmental samples are negative by virus isolation. In 2019, New York State surveillance figures showed 709 inspections, 24,053 birds tested and 4,678 environmental tests done. None was positive for H5/H7 AIV.7



From 1983-1984, the state of Pennsylvania experienced a catastrophic outbreak of HPAI H5N2. The strain was found to be similar to a low pathogenic strain that had been circulating in NY LBMs.3 Low pathogenic strains of avian influenza (LPAI) were not part of the minimal surveillance programs in place in the 1980s. Despite interventions in closing, cleaning, and disinfecting the markets, LPAIs were responsible for five outbreaks seen on commercial poultry farms from 1996-2002. LPAI viruses were also shown to mutate into highly pathogenic AIV after amino acid changes at the cleavage site of the virus.3 In the commercial farm outbreaks, epidemiological studies showed that vehicles taking birds to LBMs had been on farm premises in PA and RI. By the end of the 1990s, the State of New York put in the first regulations to try and eradicate low pathogenic H5/H7 viruses from the markets.3 Samples taken in Northeast LBMs in the early 2000s found 60-80% LPAI H7 strains in live bird markets.8 Additional regulations were added by NY State, forcing markets and dealers to have quarterly closings followed by cleaning and disinfection and stopping the movements of live birds out of LBMs when they were already in the facility.6

Since 2003, when strict regulations were introduced by a state, federal and industry partnership, the Northeast United States has seen a substantial decrease in the number of markets testing positive for the potentially zoonotic H5/H7 influenza viruses (Figure 3).

Risk of Avian Influenza in LBMs

The risk of Avian Influenza entering into LBMs is always high and comes from the large number of birds that are constantly present in the market and the variety of sources the birds come from.2 Delivery trucks, crates and equipment used to transport the birds and not sufficiently cleaned or disinfected can carry the virus between farms and markets. Another risk seen in LBMs occurs when market owners or their employees mix different species together in the same market and in the same cages. Spaces in LBMs are closely confined and allow cages to be in close proximity. Waterfowl are the natural reservoir for AIV; chickens and waterfowl such as ducks and geese should not be placed in the same cage, but before regulations were enacted, it was a common practice in LBMs.

The interventions of state and federal regulations covering production sources, dealers, haulers and the markets themselves have made a big difference. Quarterly cleaning and disinfection, unannounced inspections, meticulous record keeping and a strict surveillance program have all contributed to the success seen in Northeastern live bird markets. In 1997, six people out of 18 infected died in a LBM in Hong Kong. It was later determined that they died of highly pathogenic Avian Influenza H5N1. This was the first time that human deaths had been recorded for Avian Influenza viruses.3 H5N1 is a zoonotic virus and its presence in many countries all over the world is one of the reasons we must be vigilant. According to the World Health Organization, to date, 455 people in various countries out of 862 infected have died of HPAI H5N1 infections. The virus is endemic in poultry populations in Indonesia, Egypt and Vietnam. There is no evidence of humanto-human transmission and the virus has never been isolated in the United States.9 Another recent zoonotic virus, H7N9, also emerged in China in 2013 that was traced to poultry coming from live bird markets. A total of 1567 persons have been infected since then and of these 615 died. H7N9 has been described as a low pathogenic strain that does not make chickens sick but can produce illness in humans.10 In view of the present COVID-19 pandemic and the origin of the virus from an animal market, there is an even greater need to keep out zoonotic HPAI H5N1 from the United States through the strict surveillance and regulation of live bird markets.

Figure 3. Number of NY markets positive for avian influenza H5/7 by year (courtesy NYSDAM) 55

Acknowledgements: I would like to thank my co-authors Dr Joy Bennett and Dr Eireann Collins of the New York State Department of Agriculture and Markets. Thanks also to Dr Aliza Simeone of the Pennsylvania Department of Agriculture and Jennifer Niper of the New Jersey Department of Agriculture for the information provided. Correspondence: Jarra Jagne, D.V.M.,

REFERENCES 1. Garber, L., Voelker, L., Hill, G., & Rodriguez, J. (2007, March). Description of live poultry markets in the United States and factors associated with repeated presence of H5/H7 lowpathogenicity avian influenza virus. Avian Diseases, 51(s1, Suppl), 417–420. 2. Cardona, C., Yee, K., & Carpenter, T. (2008). Are live bird markets reservoirs of avian influenza? Poultry Science Association Keynote Symposium, 856-859. 3. Senne, D. A., Pedersen, J. C., & Panigrahy, B. (2003). Live-bird markets in the Northeastern United States: A source of avian influenza in commercial poultry. Avian Influenza Wageningen UR Frontis Series, 19-24. Retrieved from: download?doi= 4. Trock, S. C., Senne, D. A., Gaeta, M., Gonzalez, A., & Lucio, B. (2003). Low-pathogenicity avian influenza virus in live bird markets—What about the livestock area? Avian Diseases, 47(s3, Suppl), 1111–1113.

5. United States Department of Agriculture. (2020). Animal Disease Information. Retrieved December 19, 2020, from downloads/lbms_program_stand 6. Trock, S. C., Gaeta, M., Gonzalez, A., Pederson, J. C., & Senne, D. A. (2008, March). Evaluation of routine depopulation, cleaning, and disinfection procedures in the live bird markets, New York. Avian Dis, 52(1), 160–162. 7. Collins, E.P. (2020, Feb 19-20). New York State live bird market 2019 report (meeting presentation). USDA Live Bird Market Working Group 2020 Annual Meeting, Atlanta, GA. 8. Mullaney, R. (2003). Live-bird market closure activities in the northeastern United States. Avian Diseases, 47(s3, Suppl), 1096–1098. 9. World Health Organization. (2020). Cumulative number of human cases for avian influenza A(H5N1) reported to WHO, 2003-2020. Retrieved from: human_animal_interface/2020_DEC_tableH5N1.pdf?ua=1 10. World Health Organization. (2018, Sep 5). Human infection with avian influenza A(H7N9) virus – China: Update. Retrieved from:

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Pollinators are Essential Workers Emily Wine, M.S. State Apiarist, Delaware Department of Agriculture

Agriculture in the United States is largely a system of largescale monocultures. This means that fields requiring bee pollination are food deserts for bees when crops aren’t blooming. As a result, the landscape does not sustain enough pollinators to provide sufficient crop pollination. To meet this demand, commercial beekeepers truck hives around the country. Beekeepers move hives by loading trucks at night or in the early morning, when bees are inside the hives and not flying. In 2012, the pollination industry was valued at $15 to $29 billion per year.1 The seasonality of bloom periods for crops throughout the country has resulted in a pollination circuit for commercial beekeepers. Two-thirds of the nation’s commercial hives (roughly 2 million hives) spend the month of February in California, where they pollinate more than 1.3 million acres of almonds. Large influxes of hives also go to Florida for orange pollination; the Northeast for blueberry, cranberry, apple, and vegetable production; and West coast states for apple, cherry, and plum production. North and South Dakota, the nation’s top honey-producing states, also receive huge influxes of hives to their rangeland for summer honey production.2 In Delaware, over 300 registered beekeepers manage the approximately 2,000 bee colonies that reside in Delaware year-round. Most of these beekeepers are hobbyists with fewer than ten hives. Delaware does not have enough commercial beekeeping operations to fulfill crop pollination requirements. Approximately 1,500 hives are moved into Delaware each summer for commercial pollination contracts, largely for watermelon production. These migratory hives come from New Jersey, Maryland, Pennsylvania, Florida, and Louisiana. In 2019, Delaware had over 4,000 acres of crops requiring bee pollination, including more than 2,700 acres of watermelons (Figure 1). The remaining acreage primarily consisted of cucumbers, peaches, apples, and pumpkins.3

wheat, barley, millet, rye, sorghum, teff, and root and tuber crops), require bee pollination. Rather, bee pollination improves diet quality by adding flavor, color, and nutrients to our diets in the form of fruits, vegetables, nuts, and seeds. Some self-fertile crops, such as oranges, almonds, and blueberries, experience higher yields and larger fruits with bee pollination. Crops such as watermelons, squash, and cucumbers will not bear fruit without bee pollination. Crops that are directly dependent on pollinators require pollinators to produce a fruit. Indirectly dependent crops require pollinators to set seed, but not to produce the crop itself. Indirectly dependent crops include carrots, onions, celery, beets, cabbage, alfalfa, and others. Meat, dairy, and eggs rely indirectly on bee pollination, because livestock are fed alfalfa.

APIARY PROGRAM The Apiary Program at the Delaware Department of Agriculture provides both education and regulatory services. All apiaries in Delaware must be registered, including those of hobbyist beekeepers with just a few hives. The State Apiarist manages two teaching apiaries for hands-on beekeeping workshops, and gives presentations on best management practices to local beekeeping groups. To reduce the spread of bee pests and pathogens, hives are inspected by the Delaware Department of Agriculture Apiary Program prior to transport. Hive equipment is also surveyed for hitchhiking pests such as fire ants or spotted lantern flies. Our Apiary Program inspects all operations that sell bees to ensure that hives are free of any regulated pests or pathogens. In addition to inspecting hives for transport and sale, the Apiary Program aims to inspect apiaries managed by a third of all registered beekeepers each year.

The importance of bee pollination is often framed as a food security issue. However, none of the starchy staple crops that provide 90 percent of the world’s caloric intake (rice, corn,

During inspections, any pests or pathogens observed in hives are recorded. Delaware beekeepers contend with numerous hive pests, including Varroa mites, small hive beetles, and wax moths. Problematic pathogens include American and European Foulbrood bacteria, Nosema and chalkbrood fungi, and numerous viruses, including Deformed Wing Virus, Sacbrood Virus, and many others.

Figure 1. Acreage of crops directly dependent on bee pollination in Delaware in 20193

The Apiary Program also conducts research projects. Every year, the State Apiarist collects samples for the National Honey Bee Survey, which provides a comprehensive study of disease and pest loads. In addition to tracking endemic pests and diseases, the National Honey Bee Survey monitors hives for global threats to honey bees not currently found in the United States. These threats include the Tropilaelaps mite, which feeds on developing brood stages, Slow Bee Paralysis Virus, which paralyzes the front two legs of adult honey bees, and exotic honey bee species such as the Asian Honey Bee Apis cerana. The State of Delaware is also monitoring for invasive bees and wasps such as the Asian Giant Hornet Vespa mandarinia, which was recently detected in Washington State. Both the National Honey Bee Survey and the Bee and Wasp Survey are funded by the United States Department of Agriculture Animal and Plant Health Inspection Service (USDA-APHIS).

58 Delaware Journal of Public Health – January 2021

doi: 10.32481/djph.2021.01.010



The Varroa destructor mite is the most damaging honey bee pest in the United States. Varroa mites have a worldwide distribution and are widespread everywhere in the United States, with the exception of some of the Hawaiian Islands. Varroa mites reproduce on developing brood and feed on the fat body of developing brood and adults. Varroa mites hitch rides on foraging bees, and are transmitted to other bees while foraging on flowers. Foragers may also drift into neighboring hives or attempt to rob resources from other hives. Movement of bees into nearby hives is a major source of Varroa transmission. Part of the reason Varroa mites are so damaging is their body size. A similarly large parasite in humans would be roughly the size of a Chihuahua. In addition, Varroa mites transmit viruses such as Deformed Wing Virus, which causes shriveled wings. Bees with deformed wings are unable to fly and die when only a few days old. In addition to viruses directly transmitted by Varroa mites, mite infestation weakens hives and makes them more susceptible to other diseases, such as European Foulbrood and Sacbrood virus.

American Foulbrood (AFB) is caused by the spore-forming bacterium Paenibacillus larvae. The disease is found throughout the United States and has a worldwide distribution. Currently, American Foulbrood is the only regulated apiary pathogen in Delaware. Hives with confirmed AFB infection are required to be destroyed. Brood infected with AFB appears coffee-colored and has a ropy texture and foul odor. AFB is regulated because the disease is deadly, incurable, and has spores that can survive up to 40 years. The biggest risk factor for AFB is use of contaminated equipment. Robbing behavior, when bees steal honey from other hives, can also spread AFB. While there are antibiotics approved to treat AFB, these antibiotics do not kill the long-lived spores. If a beekeeper ceases treatment with antibiotics, the disease can recur.

Beekeepers manage Varroa mites through cultural techniques and miticides. Cultural techniques include creating breaks in the honey bee brood development cycle to prevent mites from reproducing on developing brood, selecting queens with genetic resistance to mites, and removing drone brood (Figure 2). Male honey bees develop on drone brood, and their large body size and longer developmental time favors greater mite reproduction. Since female honey bees perform all of the tasks in the hive, and males are only necessary for mating with the queen, drone brood can be removed without weakening the colony. Chemical control for Varroa mites involves using organic acid, synthetic chemical, or essential oil treatments to kill mites. These miticides must be applied in compliance with the product’s label directions, because misuse could cause damage to the hive or contamination of honey.

EUROPEAN FOULBROOD European Foulbrood (EFB) is caused by the bacterium Melissococcus plutonius. European Foulbrood is not a regulated disease in Delaware because it lacks the long-lived spore stage. EFB also has a worldwide distribution. Unlike AFB, hives can recover from EFB infection. EFB tends to be more prevalent under conditions of stress, such as locations with nectar or pollen dearths. EFB can often be managed through cultural techniques such as providing supplemental nutrition, replacing the queen, and replacing old equipment to prevent pathogen build-up. Even without a spore stage, EFB bacteria can remain on equipment for a year or more. Some more virulent strains of EFB may not resolve without antibiotics. Treatment with antibiotics requires a veterinary feed directive (VFD) from a veterinarian. A VFD is similar to a prescription, and it prevents antibiotics from being used unnecessarily or incorrectly. Overuse of antibiotics can lead to antibiotic resistance, and misuse could lead to contamination of honey.

WINTER LOSSES According to the Bee Informed Partnership’s annual management survey, hive losses in Delaware from 2010 to 2020 have ranged from 30.0 to 64.2 percent.4 These losses have tracked closely with national averages. Common causes of winter losses include high Varroa mite infestation loads and starvation due to insufficient stored honey. Educational workshops performed by the Apiary Program aim to improve the health and survival of Delaware’s bee colonies.


Figure 2. The State Apiarist demonstrates how to check for Varroa mites at a workshop at the Delaware Department of Agriculture’s teaching apiary at Blackbird State Forest.

Describing pollination services solely in terms of their importance to agriculture and the economy understates their importance. About 80 percent of the world’s flowering plants rely on pollinators to reproduce. While commercial pollination is largely performed by honey bees, there are over 4,000 species of native bees in the United States. Flies, wasps, moths, beetles, butterflies, birds, and bats also pollinate plants. While unmanaged pollinators contribute to crop pollination, their impact on the broader ecological community is far greater. Without pollinators, the structure of plant communities would change, altering ecosystems and food webs in unpredictable ways. 59


• University of Delaware Extension:

The biggest step anyone can take to help pollinators to plant flowers. Our heavily managed landscapes of grassy lawns, developed hardscapes, regularly mowed roadsides, and weed-free farm fields provide little benefit to bees. By planting flowers, you will provide nectar and pollen sources for managed honey bees, our native wild bees, and other pollinators. Even if you only have space for a few potted plants, you can have a small pollinator garden. The following resources are helpful guides on planting habitat for pollinators in the State of Delaware.

• Pollinator Partnership Ecoregional Planting Guides:

BOOKS: • Hendy, J., & Evans, A. (2014). Encyclopedia of garden plants for every location. NY, NY: Dorling Kindersley Limited. • Lee-Mäder, E. (2011). Attracting native pollinators: Protecting North America’s bees and butterflies: The Xerces Society guide. North Adams, MA: Storey Pub. • Lindtner, P. (2014). Garden Plants for Honey Bees. Kalamazoo, MI: Wicwas Press, LLC. • Sarver, M. (2007). Delaware native plants for native bees. Dover, DE: USDA NRCS and Delaware Dept. of Agriculture.

WEBSITES: • The Xerces Society: • Penn State Extension:

60 Delaware Journal of Public Health – January 2021

• Lady Bird Johnson Wildflower Center: Corresponding Author: Emily Wine,

REFERENCES 1. Calderone, N. W. (2012). Insect pollinated crops, insect pollinators and US agriculture: Trend analysis of aggregate data for the period 1992-2009. PLoS One, 7(5), e37235. 2. Jabr, F. (2013, Sep 1). The mind-boggling math of migratory beekeeping. Scientific American. Retrieved from: 3. USDA National Agricultural Statistics Service. (2019). NASS - Quick Stats. USDA National Agricultural Statistics Service. Retrieved from 4. Bee Informed Partnership. (n.d.). Retrieved from

A Basic Checklist Become familiar with pollinators in your landscape. n Watch for activity throughout the day and the seasons. n Keep a simple notebook of when and what comes to your garden. NOTE: It is not necessary to identify each species when you first get started. Simply note if it is a bee that likes the yellow flower that blooms in the fall. n Consult a local field guide or web site when you are ready to learn more details.

Add native plants to attract more native pollinators. n List the plants you currently have in your landscape. n Determine when you need additional flowers to provide nectar and pollen throughout the growing season. n Add plants that provide additional seasons of bloom, create variable heights for shelter, and attract the types of pollinators you want. n Don’t forget to include host plants that provide food and shelter for larval development. n Contact your local native plant society or extension agent for more help.

Use pollinator friendly landscape practices to support the pollinators you attract. n Use Integrated Pest Management Practices to address pest concerns. n Tolerate a little mess – leave dead snags and leaf litter, keep areas bare for ground nesting insects, and leave some weeds that provide food for pollinators. n Provide safe access to clean water.

Notice the changes that you have helped to create!

Selecting Plants for Pollinators


COVID-19 Pandemic Strengthens Human-Animal Bond Sheri L. Wood, D.V.M. Medical Director, Brandywine Valley SPCA

The human-animal bond has existed for much longer than most people realize. There is archeological evidence of domesticated wolves found in human settlements dating back at least 14,000 years ago. It is thought that as humans and animals both sought food, shelter, and safety, they found comfort in each other and cohabitated.1 That bond has only gotten stronger over the years, and pets have played increasingly more prominent roles in contemporary households. The intense daily stressors that our society has placed on individuals has led to more recognized cases of depression and anxiety, and people are turning to domestic animals for relief. Studies have actually proven that owning a pet can actually reduce blood pressure and lower cholesterol levels.2 Some pets are even being classified as “emotional support” animals. Never has there been a greater need for emotional support in recent years than the present, during the pandemic of COVID-19. Since March of 2020, people have retreated into their homes, having much less human-to-human interaction and spending most of their days alone and in confinement. As many are now working, teaching, and learning remotely, their lives are revolving around their homes and immediate family. Those who didn’t have time enough for pets before COVID-19 are now finding that they not only have the time, but also a need for some companionship from a pet. As the Medical Director of Brandywine Valley SPCA (https://, one of the largest shelter organizations in the Delaware Valley, I’ve experienced first-hand this intense shift toward increases in pet ownership in this area.

occurred. This allows those shelters to be able to provide room for the animals found during the disaster- so that they may be able to again be reunited with their families in that area. This is a win-win situation for all of the pets and people involved. Not only have we been able to place many animals into homes in our area, but we’ve also been able to assist local families who have been affected by the pandemic. By offering discounted medical care and free vaccines and pet food, many have been able to keep their current pets in their homes. Despite the trying times we’ve all been experiencing during the COVID-19 pandemic, the human-animal bond seemingly remains stronger than ever, and both the humans and the animals are benefiting. So, if you find yourself feeling as if you need some emotional support, a hobby, or just some companionship during this time, feel free to stop by a local shelter and find a new best friend!

REFERENCES 1. Serpell, J. A. (2008). In the company of animals: A study of human-animal relationships. Cambridge: Cambridge University Press 2. Allen, K., Blascovich, J., & Mendes, W. B. (2002, SeptemberOctober). Cardiovascular reactivity and the presence of pets, friends, and spouses: The truth about cats and dogs. Psychosomatic Medicine, 64(5), 727–739. fcgi?cmd=Retrieve&db=PubMed&list_uids=12271103&dopt=Abstract

The BVSPCA was founded in 1929 in Chester County, Pennsylvania and expanded to all three counties in Delaware in 2016. For the past several months, there has been an incredible increase in the number of adoptions occurring at all of Brandywine Valley’s shelters, more than we’ve historically ever seen. For example, since July, the adoption numbers have increased by an average of 381 per month- that’s a 63% increase! It is now a normal occurrence to see lines forming outside of the shelters waiting for the doors to open each day. People who were too busy prior to the pandemic are now finding the time they need to acclimate a pet to their home. Those who anticipate not having time once returning to a regular routine have signed up to foster. I believe that this huge increase in adoption and fostering has a direct correlation to the COVID-19 pandemic. Because of the large numbers of adoptions, the Brandywine Valley shelters are emptier than they’ve ever been. This has given us the opportunity to save even more animals’ lives, by transporting in animals from areas with high euthanasia rates, such as Texas, Louisiana, and Georgia. Now, dogs and cats that were destined for euthanasia are getting a second chance at a good life in a loving home. Not only that, but there is now more room in the shelters to bring in animals from areas where hurricanes or natural disasters have recently hit. The BVSPCA aids these areas by transporting in animals who were currently in the shelters where the disaster 62 Delaware Journal of Public Health – January 2021

doi: 10.32481/djph.2021.01.011

Accessible information:


• Always wash your hands—and your child's—after handling or being around animals or their waste, food, or supplies (like cages, water bowls, toys, beds, leashes, etc.). This is especially important before handling baby bottles and pacifiers or holding infants. • Choose the right pets for your household. Do some research before getting a new pet. » Children under 5 years of age, adults over 65 years of age, and anyone with a weakened immune system should not have contact with rodents, reptiles, amphibians, and poultry. • Don't kiss, snuggle, or hold rodents, reptiles, amphibians, and poultry close to your face. These animals are more likely to spread germs. • Always supervise children around pets. Don’t let them kiss their pets, hold pets close to their faces, or allow pets to lick their face or mouth. • Keep pets and their supplies out of the kitchen or other areas where you prepare, serve, or eat food. • Clean up after animals properly. » Scoop cat litter daily (especially if anyone in the home is pregnant) and change it at least twice weekly. Pregnant women should not clean cat litter.

» Always remove dog waste from private and public spaces.

» Clean cages, habitats, and supplies outside the home when possible to avoid contaminating surfaces. If that is not possible, then clean them in a laundry sink or bathtub and then disinfect that area immediately afterwards. • Avoid rough play with animals to prevent bites and scratches. Teach children to play with animals appropriately. Do not let small children near pets that are eating. • Clean bites and scratches immediately with soap and water, and seek medical care if the wound is serious or becomes red, painful, warm, or swollen; the animal appears sick; or if you don't know the vaccination status of the animal.


• Enjoy wildlife from a safe distance to avoid illness and injury.


Delaware Partnership for One Health Douglas D Riley D.V.M. Delaware Public Health Veterinarian

THE PARTNERSHIP What is One Health? One Health is a collaborative, multisectoral, and trans-disciplinary approach – working at local, regional, national, and global levels – to achieve optimal health and well-being outcomes recognizing the interconnectedness between people, animals, plants and their shared environment. Why is this important in Delaware? Planetary environmental health may affect human and animal health through contamination, pollution and changing climate conditions that may lead to increases in both non-infectious diseases (e.g. food deprivation) and infectious disease (e.g. COVID-19). Worldwide, nearly 75 percent of all emerging human infectious diseases in the past three decades originated in animals. As we push into the wild and the habitats of animals, these chance events will increase. We must remember that the global population in 2011 was 7 billion, and is expected to be 11 billion by 2050. In order to provide adequate healthcare, food and water for the growing global population, the health professions, and related disciplines and institutions, must work together. Remember, human-animal interactions/bonds can beneficially impact the health of both people and animals (Figure 1). This is One Health, One World, One Medicine and quite possibly our Last Chance.

A NEW BEGINNING COUPLED WITH AN AWAKENING TO THE TRUTH Initially conceived during the 2014 Ebola Outbreak in Africa, and formalized during the Avian Influenza outbreak and increases in Zika Virus cases, the One Health Partnership takes time to look at the issues in a new way. Instead of a decision based on a single siloed profession, we seek the input from multiple professionals in order to avoid unintended outcomes from a lack of a complete picture and understanding of potential bad outcomes to overall health. While there is no formal process for the development of a One Health movement, task force, coalition or partnership, the end results are very similar: the preservation of life and the mitigation of harm. Over the last few years, Delaware has spearheaded a coalition with our neighboring states in order to better share vital information and best practices. This is the first step in breaking down the walls that separate us, and learning what issues there are outside our own borders. We need to be able to better understand one another, and to use shared information as a tool to better inform the people and the leaders so that appropriate actions can be taken to secure a more fruitful tomorrow. Today, as we press on with our “new normal” lives, we are living in and around a One Health issue: COVID-19, a novel 64 Delaware Journal of Public Health – January 2021

Coronavirus suspected to have originated in wildlife due to a chance encounter from a human being. This encounter led to the establishment of a new human pathogen and, unfortunately, the start of a pandemic. This should not have come as a surprise, as we have been preparing for such an event for many years. What did come as a surprise was just how elegant the enemy - SARS-CoV-2 – is, and how readily it is able to mutate and adapt.

HOW CAN THE ONE HEALTH MODEL WORK NOW? Fortunately, the One Health model is working right now. Medical fields have shared information, therapies and best practices. Animals are being monitored for potential infection, disease and establishment of reservoirs. Both active and passive monitoring is now happening in many areas of the United States and across the globe, and this information is being shared with global partners.

FINAL THOUGHTS At one time, I advocated One Health as a New Beginning, here and throughout Asia. Now it is time for an Awakening. We can revert to the old normal (siloed discussions, unshared information, and a selfish demeanor) or we can shed the old ways and emerge from the COVID-19 Pandemic anew. Humanity will determine its path, and hopefully there will be an awakening where we are more apt to come alongside our neighbors and provide a hand up, and not a handout, or a gesture that is less than genuine. COVID should be a lesson that we can be defeated. As depicted in Orson Welles War of the Worlds, the aliens are killed by earthly pathogens, “slain after all man’s devices had failed, by the humblest things that God, in His wisdom, has put on the earth.”

Figure 1. Emotional support animals can bring joy and happiness to patients in long-term care facilities (source: unknown, licensed under CC BY-NC-ND).

doi: 10.32481/djph.2021.01.012

HOW TO CHECK YOUR PET FOR TICKS • Check your pet for ticks every day, especially after they spend time outdoors. • Run your fingers through your pet’s fur with gentle pressure to feel for any small bumps. • Look for ticks in the following areas:







Ticks can carry diseases that can make people and pets sick. If you find a tick, remove it as soon as possible. Ask your veterinarian about ways to keep ticks off your pets!


Lone Star Ticks (Amblyomma americanum): An Emerging Threat in Delaware Ashley C. Kennedy, Ph.D., M.S., B.C.E. Tick Biologist, Mosquito Control Section, Division of Fish & Wildlife, Delaware Department of Natural Resources and Environmental Control Emily Marshall, M.S. Enteric Disease Epidemiologist, Division of Public Health, Delaware Department of Health and Social Services

ABSTRACT Public health messaging in the eastern United States has historically underemphasized the risks posed by lone star ticks (Amblyomma americanum), focusing instead on blacklegged ticks (Ixodes scapularis). This gap persists despite mounting evidence that lone star ticks also play an important role in disease ecology as confirmed vectors for a wide variety of tick-borne pathogens. These pathogens include several distinct bacterial agents that cause ehrlichiosis and tularensis in humans and dogs, a protozoal agent that causes cytauxzoonosis in cats, and emerging viruses such as Heartland, Bourbon, and Tacaribe. Lone star ticks are additionally linked to Rocky Mountain spotted fever, southern tick-associated rash illness, and alpha-gal syndrome, a condition marked by immune reactions to ingestion of mammalian meat. Moreover, their distribution in North America is expanding due to changing climatic factors and land use patterns. Lone star ticks are the most commonly encountered tick in Delaware, especially in Sussex and Kent Counties, and make up the vast majority of ticks collected in the first two years of the state’s tick surveillance program. Given the magnitude of lone star ticks’ medical and veterinary import, it is vital for healthcare professionals and health educators to devote more attention to this emerging threat.

Lone star ticks (Amblyomma americanum) have long been noted as aggressive human biters whose bites leave irritating, itchy wounds, but their greater importance in public health has been historically under-recognized. They are the most common human-biting ticks in Delaware and in the United States as a whole.1 Lone star ticks are associated with bacterial, viral, and protozoal pathogens as well as a newly recognized allergy to mammalian products (alpha-gal syndrome). Nonetheless, they are often overshadowed by blacklegged or “deer” ticks (Ixodes scapularis) in the public health sphere. This dearth of attention has resulted in a shortage of effective control methods for this species and may contribute to incorrect diagnoses and/or substandard treatment for associated diseases.

The first lone star tick specimen collected in Delaware was reported 75 years ago.4 At that time, it was not considered established in the state (i.e., there was no documentation of populations surviving year-round), and Virginia was considered the northernmost extent of its normal range. In the intervening decades, however, they have invaded, established, and supplanted blacklegged ticks and American dog ticks (Dermacentor variabilis) as the most commonly encountered tick species in the state. This range expansion is attributed to changing climatic factors such as shorter, milder winters, as well as the increasing abundance of preferred hosts like the whitetailed deer (Odocoileus virgianus), which in turn is facilitated by reduced predation pressure and changing land use patterns (e.g., forest fragmentation, suburbanization, and increased availability of edge habitat).2

In contrast to ticks that use an ambush strategy (i.e., lying in wait for a host to move by), lone star ticks actively seek hosts, attracted by carbon dioxide and vibrations from host movement.2 To complete their life cycle, lone star ticks must take three blood meals, each from a different individual host; all three motile stages (larvae, nymphs, and adults) will readily feed on humans in addition to other vertebrate hosts. Each blood meal represents a possible exposure to pathogenic agents. Generally, the bite of a larval tick is considered less dangerous than the bite of a nymphal or adult tick because the larvae are feeding for the first time and thus have not had prior exposure to infected hosts. There is an increasingly recognized possibility, however, that some larvae may be infected by transovarial transmission of pathogens from the mother tick, irrespective of fed versus unfed status1,3; thus, all stages of lone star ticks should be considered possible threats to humans and other hosts.

Lone star ticks are abundant in the southeastern and southcentral United States, and within Delaware they are more common in the southern counties than in New Castle County. Despite their widespread presence, they are under appreciated as a threat to human and veterinary health. Much of our public health messaging (e.g., signage at state parks and other public lands, as well as in clinics and veterinary clinics) pertains to blacklegged ticks and specifically the risk of acquiring Lyme disease. This focus on blacklegged ticks has heretofore been justified by the fact that Lyme disease is the most common tick-borne infection in the country, and lone star ticks are unable to vector the Lyme diseasecausing spirochete and thus do not play an appreciable role in that disease cycle.5 Although Lyme disease remains the most common tick-associated disease in Delaware,6 this focus on one tick species and one disease suggests that other tick species and tick-borne pathogens are unimportant, when in fact they are associated with serious health outcomes.


66 Delaware Journal of Public Health – January 2021

doi: 10.32481/djph.2021.01.013


The association between ehrlichiosis and lone star ticks was discovered in 1990. Prior to this recognition, lone star ticks were considered nuisance biters but of generally low public health importance.7 Ehrlichiosis is a catch-all term for disease caused by infection with Ehrlichia bacteria. Lone star ticks are capable vectors of at least three known pathogenic species in this genus: E. chaffeensis, E. ewingii, and “Panola Mountain” Ehrlichia.8 Reported ehrlichiosis cases have steadily increased since reporting began in 1999.9 Symptoms include fever, chills, headaches, muscle aches, nausea, and vomiting. A subset of patients, particularly those who are older or immunocompromised or those who do not receive adequate antibiotic treatment in early stages, may experience more severe illness marked by neurological complications, respiratory failure, and organ failure, which can result in death.9 The non-specific presentation of ehrlichiosis can delay or complicate diagnosis. Importantly, some antibiotics that are prescribed for Lyme disease are not effective against ehrlichiosis, and prophylactic use of antibiotics is not recommended for the latter.10 Another bacterial infection associated with lone star ticks is tularemia. Along with other tick species and some mosquito and biting fly species, lone star ticks can transmit the causative agent, Francisella tularensis. This pathogen merits further scrutiny as a possible agent of bio-terrorism, and presents with a wide range of clinical signs and symptoms, from fever and enlarged lymph nodes to skin lesions, sepsis, and meningitis.11 Lone star ticks are specifically linked to Type A1, the most virulent strain, based on geographic distribution data.12 Lone star ticks are capable of transmitting Rickettsia rickettsii, the causative agent of Rocky Mountain spotted fever, in a laboratory setting.13 Whether they can do so in nature remains unconfirmed, but some recent authors consider it a strong possibility.14,15 Indeed, infection rates of lone star ticks with R. rickettsii have been recorded as higher than those in American dog ticks, long considered the major vector of this pathogen.14 Rocky Mountain spotted fever is considered among the most severe tick-associated illnesses globally because of its mortality rate.14 Clinical signs and symptoms include fever, aches, nausea, and a distinctive rash.16 Other Rickettsia species have been isolated from lone star ticks, including R. parkeri, the agent of Tidewater spotted fever, which is more typically associated with Gulf Coast ticks (Amblyomma maculatum).17 In places where both of these tick species occur (which includes Delaware), spillover of R. parkeri from Gulf Coast ticks feeding on the same hosts as lone star ticks could infect the latter and further increase the risk of transmission to humans.17 Lone star ticks have the ability to transmit R. parkeri transovarially (i.e., female ticks can lay already-infected eggs, meaning that even the bite of a larval tick could transmit the pathogen).3 Lone star ticks are also frequently infected with R. amblyommatis, another member of the spotted fever group rickettsiae. While some authors refer to this species as nonpathogenic, there are reports that it can cause clinical illness, with symptoms resembling those of other spotted fevers.18 If its pathogenic status is confirmed, an additional concern for this species is that it can be transovarially transmitted.1

Lone star ticks are the presumptive vector for a condition called southern tick-associated rash illness (STARI). This disease occurs in the southern United States and bears a resemblance to Lyme disease, especially with regard to the appearance of an erythema migrans or “bull’s-eye” rash, although STARI is noted to have milder symptoms.19 The etiologic agent has not yet been identified (although it is suspected to be a species of Borrelia, given the similarities to Lyme disease) and thus it has not been conclusively linked to a vector species, but the distribution of STARI cases closely overlaps with the geographic range of lone star ticks and case data indicate that patients reported tick bites prior to the onset of symptoms. Due to the absence of a confirmed agent, diagnosis of STARI depends on clinical signs and symptoms, geography, and exposure to tick bite.19

Viral agents

Bourbon virus and Heartland virus are emerging diseases whose causative agents are vectored by the lone star tick.20 Symptoms for both viral infections include fever, fatigue, headaches, and joint or muscle aches.21 An additional virus, Tacaribe, has also recently been isolated from lone star ticks, although its pathogenicity to humans is unknown.22 These viruses belong to three different families (Orthomyxoviridae, Phenuiviridae, and Arenaviridae, respectively), indicating that lone star ticks are capable of carrying a wide variety of viral agents. These viruses have not yet been detected in Delaware; Tacaribe was detected in Florida, whereas Heartland and Bourbon occur in the Midwest, however, ticks’ movement via wildlife hosts, especially migratory birds, means that ticks infected with novel pathogens could be introduced into a given area at virtually any time, so vigilance needs to be consistent.23 There are no specific treatments or vaccines available for these viruses; medical providers’ options are limited to treating the symptoms to make the patient more comfortable.21

Alpha-gal syndome

Alpha-gal syndrome (AGS) is distinct from other tick-associated illnesses because it does not involve an infectious agent. The clinical illness is not induced by infection with a pathogen, but by an immune reaction to the presence of alpha-gal (a sugar) in the bloodstream. Alpha-gal, or more accurately, galactose-alpha1,3-galactose, is naturally found in mammals except for humans and other catarrhine primates (i.e., apes, Old World monkeys).24 Lone star ticks that feed on a mammalian host may subsequently contain trace amounts of alpha-gal in antigens in their salivary glands, which is then injected into hosts. In AGS patients, the immune system reacts to alpha-gal in the bloodstream as though it were a foreign invader: with an IgEmediated allergic response, which varies in presentation from patient to patient. In milder cases, it may present as itching; pruritus is the most commonly reported symptom. More severe symptoms range from gastrointestinal distress to anaphylaxis. Even patients that have an extensive history of consuming and tolerating meat prior to the sensitizing event (i.e., tick bite) can develop this sensitivity.25 Some patients additionally experience allergic reactions to dairy foods and pharmaceutical products that contain gelatin and other mammalian products. A key example is the cancer-fighting drug cetuximab; patients’ adverse reactions to this drug were the initial event that launched investigations into AGS. By 2011, the link between ticks and AGS was established. Unlike some other food allergies, in which reactions occur more or less immediately, reactions to alpha-gal typically occur several 67

hours after ingestion. Not every exposure to alpha-gal results in an allergic reaction.25 Delayed diagnosis of this condition presents serious risks as this allergy can manifest as serious reactions. At this time, there is no treatment for AGS; clinical guidance includes avoiding mammalian products, carrying an epinephrine injectable device, and taking antihistamines as needed.26

LONE STAR TICK ACTIVITY IN DELAWARE The newly established statewide tick program within the Delaware Department of Natural Resources and Environmental Control, Division of Fish and Wildlife, Mosquito Control Section has collected lone star ticks at each of the 20 sites that were surveilled in 2019-2020. Lone star ticks were collected in each month from April-November, with an adult activity peak in June, a nymphal activity peak in July, and a larval activity peak in August. This species made up 94.7% of total ticks collected in 2020 as of early December. Of those, 92.1% were in the larval stage. Larvae typically cluster in dense aggregations, colloquially called “tick bombs.” During the months lone star ticks were active, the mean densities of questing lone star ticks were numerically higher in Sussex and Kent Counties (552.9 ticks/km and 450.1 ticks/km, respectively) than in New Castle County (97.4 ticks/km). Between 1998 and 2019, 430 ticks from Delaware were submitted to the Army Public Health Center’s Tick-Borne Disease Laboratory (TDBL) in Aberdeen Proving Grounds, Maryland for pathogen testing.27 Lone star ticks were the most common species submitted, making up 62.3% of total ticks. Four (1.5%) ticks tested positive for pathogens; two were positive for Ehrlichia ewingii, one for Ehrlichia chaffeensis, and one for Borrelia sp. They were submitted each month between March and October, with a peak in June (32% of lone star ticks submitted that month). The majority (75.3%) were submitted from Kent County, where Delaware’s only military base, Dover Air Force Base, is located; the TDBL serves Department of Defense personnel and their dependents.27 Most (51.3%) were in the nymphal stage. Nymphs are noticeably smaller than adults and thus harder to detect; adults are more likely to be seen or felt and removed before they bite or before they transmit pathogens. Larvae, in turn, are even smaller than nymphs; they are small enough to avoid detection even after engorging with blood, and additionally present the lowest risk of pathogen transmission, thus explaining why nymphs comprise the majority of submitted ticks. Lone star ticks were also the most frequently-submitted tick species from Delaware at the University of Massachusetts tick-testing lab (69.7% of total ticks submitted from January 2008-September 2020).28 Lone star ticks were submitted in each month from March to October; June was the peak month for submission, followed by July and September. Most (73%) were submitted from Sussex County, and most (85.9%) were in the nymphal stage. Relatively few (2.17%) of submitted ticks were infected; 2 of 126 ticks tested positive for Borrelia lonestari, a spirochete in the relapsing fever group, and 1 of 110 ticks tested positive for Ehrlichia ewingii.28 Although overall incidence of infection is low in submitted ticks thus far, their sheer abundance and proclivity to bite humans renders them a significant threat as a vector. The most common attachment sites for human-biting lone star ticks submitted from Delaware include the upper leg (19.2%), groin (19.2%), lower leg (11.5%), back (11.5%), and armpit (6.2%).28 68 Delaware Journal of Public Health – January 2021

VETERINARY SIGNIFICANCE OF LONE STAR TICKS Some of the pathogens of medical concern listed above are also of veterinary importance. Francisella tularensis causes tularemia or “rabbit fever” in dogs. Ehrlichia chaffeensis and E. ewingii cause ehrlichiosis in dogs (canine ehrlichiosis), as does E. canis.29 Ehrlichiosis is reportedly more severe in certain breeds (e.g., German Shepherds) and can be marked by lethargy, weakness, bleeding disorders, nervous system involvement, and bone marrow damage.29 Lone star ticks also carry the protozoan parasite Hepatozoon americanum, causing hepatozoonosis; dogs become infected not when bitten by the tick, but if they ingest the tick (i.e., while grooming). Hepatozoonosis is characterized by muscle weakness, muscle atrophy, and nerve damage.29 Lone star ticks usually attach to dogs ventrally, on the abdomen, axillary, or inguinal regions. They made up 19.1% of total ticks collected from dogs in the U.S.,30 however, in Delaware they appear to be a greater threat. These ticks comprised 40% of the ticks submitted to the state surveillance program collected from dogs in 2019 and 55% in 2020, as of early December. In cats, lone star ticks usually attach ventrally at the tail and perianal region.30 An agent of feline disease vectored by lone star ticks is the protozoan parasite Cytauxzoon felis, which causes cytauxzoonosis. Clinical signs of this disease include lethargy, loss of appetite, dehydration, fever, enlarged spleen, and enlarged liver; the mortality rate is high but treatment with antimalarial drugs can be effective.31 Lone star ticks comprised 38.5% of ticks collected from U.S. cats30; they made up 42.5% of the ticks collected from cats in Delaware in 2019 and 80% in 2020, as of early December.

LONE STAR TICK ECOLOGY AND CONTROL OPTIONS Lone star ticks are thriving in the southern and Mid-Atlantic states partly because of their host and habitat preferences. Their preferred hosts (white-tailed deer, wild turkeys, red foxes, gray foxes, coyotes, raccoons, and opossums) all occur in Delaware, and most are species that have benefited from increased suburbanization and forest fragmentation. Lone star ticks prefer second-growth forest, which is abundant throughout their reported range. Although they are currently more common in Sussex and Kent Counties, it is likely that they will become more established in New Castle County as well in the coming decades. They have a broader habitat range than blacklegged ticks and are more tolerant of lower humidity. Modeling indicates they will continue spreading northward and westward.32 Many of the best-known tick control methodologies were developed to control blacklegged ticks and are not effective in controlling lone star ticks. For example, interventions that target rodents, such as acaricide-treated “tick tubes” and rodent bait boxes, are ill-suited to control lone star ticks because these ticks do not preferentially feed on rodents.33 An additional challenge is posed by lone star ticks developing resistance to acaricides.33 An alternative method that may be better suited to control this species is the use of traps baited with carbon dioxide as an attractant. Although these traps have typically been used for surveillance and research purposes rather than control and thus are not commercially available, a homemade version can be

assembled using coolers, dry ice, and double-sided carpet tape.34 Some of the personal protective measures initially developed for other tick species or other arthropods are effective against lone star ticks. Permethrin-treated clothing and application of sprays containing DEET as an active ingredient provide protection against lone star ticks in the field.35,36 Removing leaf litter from yards, particularly in the areas most frequented by people and pets, can also reduce lone star ticks’ survival rates over winter, as they rely on humid microclimates, although impacts on nontarget, beneficial arthropods should be considered.33

OUTREACH FOR TICKBORNE DISEASES IN DELAWARE During 2017-2019, Delaware Division of Public Health (DPH) received federal grant funding dedicated to education and prevention outreach for tickborne diseases. Modeled after a program in Connecticut,37 the Delaware BLAST Lyme Disease Campaign officially kicked off in May 2018. The intention of the BLAST Lyme Disease Campaign was to increase awareness of ticks and tickborne diseases while also promoting prevention strategies to keep Delawareans healthy. A health educator traveled throughout all three Delaware counties to schools, kids camps, libraries, community centers, and health fairs to promote the BLAST campaign (Bathing after coming indoors, Looking for ticks on your body by doing frequent tick checks, Applying repellent, Safeguarding your yard against ticks to help reduce tick habitats, and Treating your pets against tickborne diseases). As noted above, these personal protective measures are effective against lone star ticks as well as other common human-biting tick species. During the two years the outreach was implemented, the program reached over 3,000 Delawareans ranging in age from kindergartners to residents of senior living facilities. “BLAST” received positive feedback from local and state media. Requests for outreach and presentations far exceeded available capacity. One of the most frequently asked questions during presentations pertained to lone star ticks and rumors of a “red meat allergy” (i.e., alpha-gal syndrome), indicating that the public is concerned about the risks associated with this tick species. “BLAST” provided a forum to explain the serious health complications of tickborne illnesses, such as alpha-gal syndrome. All around, recipients of the educational services reported substantial increase in knowledge and a greater likelihood to practice prevention strategies, according to program surveys. Unfortunately, due to competing interests, federal grant funding was not received after 2019.

IMPACT OF COVID-19 AND CONCLUSIONS Tick-borne infections in general are an ever-increasing threat in the United States, and the COVID-19 pandemic has indirectly contributed to this threat, making 2020 an especially challenging year in this regard. Delays in diagnosis and treatment of tick-borne infections have resulted from COVID19-related issues,38 and stay-at-home orders and reduced access to indoor recreational outlets have likely contributed to more people spending time outdoors compared to past years.39 Additionally, public health agencies that typically help to control and manage ticks and tick-associated illnesses have seen a diversion of personnel and funding to cope with the COVID-19 crisis instead.40 It is important to find ways to respond to the

coronavirus pandemic without diminishing vigilance for tick-borne infections and our preparedness to handle them as they arise. The apparent attitude towards lone star ticks among the public and within the medical community often borders on nonchalance. Tick bite victims and/or their healthcare providers may be more concerned about blacklegged/“deer” ticks and feel relatively unconcerned about other species. Unfortunately, this dismissive stance is not supported by evidence. A growing body of research, summarized above, indicates that lone star ticks are associated with a wide range of health threats, some with possibly severe outcomes. As lone star ticks become further established in Delaware and more people and pets come into contact with them, it is imperative that we raise awareness of the serious risks they pose.

ACKNOWLEDGEMENTS We are grateful to the Delaware Department of Natural Resources and Environmental Control and the U.S. Fish and Wildlife Service for access to state and federal lands for collection. We thank Robyn Nadolny of the Army Public Health Center and Stephen Rich of Tick Report for providing data, and Erin Hassett for assistance with field work. Lastly, we thank William Meredith, Karen Lopez, and anonymous reviewers for improving this manuscript. Correspondence: Dr. Ashley Kennedy,

REFERENCES 1. Mixson, T. R., Campbell, S. R., Gill, J. S., Ginsberg, H. S., Reichard, M. V., Schulze, T. L., & Dasch, G. A. (2006, November). Prevalence of Ehrlichia, Borrelia, and Rickettsial agents in Amblyomma americanum (Acari: Ixodidae) collected from nine states. Journal of Medical Entomology, 43(6), 1261–1268.[1261:POEBAR]2.0.CO;2 2. Linske, M. A., Williams, S. C., Stafford, K. C., III, Lubelczyk, C. B., Henderson, E. F., Welch, M., & Teel, P. D. (2019, December 21). Determining effects of winter weather conditions on adult Amblyomma americanum (Acari: Ixodidae) survival in Connecticut and Maine, USA. Insects, 11(1), 13. 3. Goddard, J. (2003, September). Experimental infection of lone star ticks, Amblyomma americanum (L.), with Rickettsia parkeri and exposure of guinea pigs to the agent. Journal of Medical Entomology, 40(5), 686–689. 4. MacCreary, D. (1945). Ticks of Delaware with special reference to Dermacentor variabilis (Say) vector of Rocky Mountain Spotted Fever. Bulletin of the Delaware University Agricultural Experiment Station (252). 5. Stromdahl, E. Y., Nadolny, R. M., Hickling, G. J., Hamer, S. A., Ogden, N. H., Casal, C., . . . Pilgard, M. A. (2018, May 4). Amblyomma americanum (Acari: Ixodidae) ticks are not vectors of the Lyme disease agent, Borrelia burgdorferi (Spirocheatales: Spirochaetaceae): a review of the evidence. Journal of Medical Entomology, 55(3), 501–514. 69

6. Delaware Health and Social Services. (2012, July 24). Delaware Health Alert Network #271: Tick-Borne diseases – prevention is key. Retrieved from: 7. Eisen, R. J., & Paddock, C. D. (2020, May 22). Tick and tickborne pathogen surveillance as a public health tool in the United States. Journal of Medical Entomology, tjaa087. 8. Reeves, W. K., Loftis, A. D., Nicholson, W. L., & Czarkowski, A. G. (2008, April 30). The first report of human illness associated with the Panola Mountain Ehrlichia species: A case report. Journal of Medical Case Reports, 2(1), 139. 9. Centers for Disease Control and Prevention. (2019, January 17). Ehrlichiosis. Retrieved from: 10. Dumler, J. S., & Bakken, J. S. (1995, May). Ehrlichial diseases of humans: Emerging tick-borne infections. Clin Infect Dis, 20(5), 1102–1110. 11. Yeni, D. K., Büyük, F., Ashraf, A., & Shah, M. S. U. D. (2020, September 28). Tularemia: A re-emerging tick-borne infectious disease. Folia Microbiologica, 1–14. 12. Petersen, J. M., Mead, P. S., & Schriefer, M. E. (2009, MarchApril). Francisella tularensis: An arthropod-borne pathogen. Veterinary Research, 40(2), 7. 13. Parker, R. R., Philip, C. B., & Jellison, W. L. (1933). Rocky Mountain spotted fever. Potentialities of tick transmission in relation to geographical occurrence in the United States. American Journal of Tropical Medicine, 13(4). 14. Berrada, Z. L., Goethert, H. K., Cunningham, J., & Telford, S. R., III. (2011, March). Rickettsia rickettsii (Rickettsiales: Rickettsiaceae) in Amblyomma americanum (Acari: Ixodidae) from Kansas. Journal of Medical Entomology, 48(2), 461–467. 15. Egizi, A., Gable, S., & Jordan, R. A. (2020, May 4). Rickettsia spp. infecting lone star ticks (Amblyomma americanum) (Acari: Ixodidae) in Monmouth County, New Jersey. Journal of Medical Entomology, 57(3), 974–978. 16. Centers for Disease Control and Prevention. (2019, May 7). Rocky Mountain spotted fever (RMSF). Retrieved from: 17. Wright, C. L., Sonenshine, D. E., Gaff, H. D., & Hynes, W. L. (2015, September). Rickettsia parkeri transmission to Amblyomma americanum by cofeeding with Amblyomma maculatum (Acari: Ixodidae) and potential for spillover. Journal of Medical Entomology, 52(5), 1090–1095. 18. Apperson, C. S., Engber, B., Nicholson, W. L., Mead, D. G., Engel, J., Yabsley, M. J., . . . Watson, D. W. (2008, October). Tick-borne diseases in North Carolina: Is “Rickettsia amblyommii” a possible cause of rickettsiosis reported as Rocky Mountain spotted fever? Vector Borne and Zoonotic Diseases (Larchmont, N.Y.), 8(5), 597–606. 70 Delaware Journal of Public Health – January 2021

19. Molins, C. R., Ashton, L. V., Wormser, G. P., Andre, B. G., Hess, A. M., Delorey, M. J., . . . Belisle, J. T. (2017, August 16). Metabolic differentiation of early Lyme disease from southern tick-associated rash illness (STARI). Science Translational Medicine, 9(403), eaal2717. 20. Savage, H. M., Godsey, M. S., Jr., Panella, N. A., Burkhalter, K. L., Manford, J., Trevino-Garrison, I. C., . . . Raghavan, R. K. (2018, May 4). Surveillance for tick-borne viruses near the location of a fatal human case of bourbon virus (Family Orthomyxoviridae: Genus Thogotovirus) in Eastern Kansas, 2015. Journal of Medical Entomology, 55(3), 701–705. 21. Muehlenbachs, A., Fata, C. R., Lambert, A. J., Paddock, C. D., Velez, J. O., Blau, D. M., . . . Zaki, S. R. (2014, September 15). Heartland virus-associated death in tennessee. Clin Infect Dis, 59(6), 845–850. 22. Sayler, K. A., Barbet, A. F., Chamberlain, C., Clapp, W. L., Alleman, R., Loeb, J. C., & Lednicky, J. A. (2014, December 23). Isolation of Tacaribe virus, a Caribbean arenavirus, from hostseeking Amblyomma americanum ticks in Florida. PLoS One, 9(12), e115769. 23. Ogden, N. H., Lindsay, L. R., Hanincová, K., Barker, I. K., Bigras-Poulin, M., Charron, D. F., . . . Thompson, R. A. (2008, March). Role of migratory birds in introduction and range expansion of Ixodes scapularis ticks and of Borrelia burgdorferi and Anaplasma phagocytophilum in Canada. Applied and Environmental Microbiology, 74(6), 1780–1790. 24. Crispell, G., Commins, S. P., Archer-Hartman, S. A., Choudhary, S., Dharmarajan, G., Azadi, P., & Karim, S. (2019, May 17). Discovery of alpha-gal-containing antigens in North American tick species believed to induce red meat allergy. Frontiers in Immunology, 10, 1056. 25. Commins, S. P., Jerath, M. R., Cox, K., Erickson, L. D., & PlattsMills, T. (2016, January). Delayed anaphylaxis to alpha-gal, an oligosaccharide in mammalian meat. Allergol Int, 65(1), 16–20. 26. Jackson, W. L. (2018, February 21). Mammalian meat allergy following a tick bite: A case report. Oxford Medical Case Reports, 2018(2), omx098. 27. Nadolny, R. Army Public Health Center Tick-Borne Disease Laboratory. Personal communication, December 9, 2020. 28. TickReport. (2020). University of Massachusetts Amherst. Retrieved from: 29. Shaw, S. E., Day, M. J., Birtles, R. J., & Breitschwerdt, E. B. (2001, February). Tick-borne infectious diseases of dogs. Trends in Parasitology, 17(2), 74–80. 30. Saleh, M. N., Sundstrom, K. D., Duncan, K. T., Ientile, M. M., Jordy, J., Ghosh, P., & Little, S. E. (2019, December 19). Show us your ticks: A survey of ticks infesting dogs and cats across the USA. Parasites & Vectors, 12(1), 595.

31. Meinkoth, J. H., & Kocan, A. A. (2005, January). Feline cytauxzoonosis. Vet Clin North Am Small Anim Pract, 35(1), 89–101, vi. 32. Raghavan, R. K., Peterson, A. T., Cobos, M. E., Ganta, R., & Foley, D. (2019, January 2). Current and future distribution of the lone star tick, Amblyomma americanum (L.)(Acari: Ixodidae) in North America. PLoS One, 14(1), e0209082. 33. White, A., & Gaff, H. (2018). Application of tick control technologies for blacklegged, lone star, and American dog ticks. Journal of Integrated Pest Management, 9(1), 12. 34. Kensinger, B. J., & Allan, B. F. (2011, May). Efficacy of dry ice-baited traps for sampling Amblyomma americanum (Acari: Ixodidae) varies with life stage but not habitat. Journal of Medical Entomology, 48(3), 708–711. 35. Mitchell, C., Dyer, M., Lin, F. C., Bowman, N., Mather, T., & Meshnick, S. (2020, September 7). Protective effectiveness of long-lasting permethrin impregnated clothing against tick bites in an endemic Lyme disease setting: A randomized control trial among outdoor workers. Journal of Medical Entomology, 57(5), 1532–1538.

36. Solberg, V. B., Klein, T. A., McPherson, K. R., Bradford, B. A., Burge, J. R., & Wirtz, R. A. (1995, November). Field evaluation of deet and a piperidine repellent (AI3-37220) against Amblyomma americanum (Acari: Ixodidae). Journal of Medical Entomology, 32(6), 870–875. 37. BLAST Lyme & Tick-Borne Disease Prevention Program (2020). Town of Ridgefield, CT. Retrieved from: 38. Wormser, G. P., Jacobson, E., & Shanker, E. M. (2021, January). Negative impact of the COVID-19 pandemic on the timely diagnosis of tick-borne infections. Diagnostic Microbiology and Infectious Disease, 99(1), 115226. 39. Miller, H. (2020, April 10). Spending more time outside during the pandemic? Scientists say beware of ticks. HuffPost. Retrieved from: 0a98c5b6b371812caabd 40. Crans, S. (2020, October 8). How Covid has changed our jobs [Webinar]. Pennsylvania Vector Control Association Virtual Conference.


Sentinel Chickens and Their Role in Mosquito-Borne Virus Surveillance in Delaware Shaun McIntire, Matt Esposito, and John Badger Environmental Scientists, Mosquito Control Section, Division of Fish and Wildlife, Delaware Department of Natural Resources and Environmental Control

The Delaware Mosquito Control Section (part of the Division of Fish and Wildlife in the Delaware Department of Natural Resources and Environmental Control) provides statewide services to maintain quality-of-life and protect public health by reducing mosquito population densities, and reducing the possibility of mosquito-borne illness to over 900,000 residents and nearly seven million annual visitors.1 With 90 miles of coastline and over 320,000 acres of wetland habitat, Delaware is home to approximately 57 species of mosquitoes, 19 of which are considered to be pestiferous towards humans and 17 of which are potential disease vectors.2 With an abundance of potential breeding habitat, Delaware also has the eighth-highest human population density in the United States.3 Whether it be from a nuisance standpoint (affecting quality of life, tourism, recreation, animal husbandry, property values) or the potential risk to public health, our staff focuses on controlling mosquito populations through an integrated pest management approach. Our integrated pest management includes mosquito population monitoring (both adult and larval), water management/source reduction, judicial insecticide use, and mosquito-borne virus surveillance. The Mosquito Control Section’s and the Delaware Division of Public Health’s mosquito-borne virus surveillance programs provide pertinent data to the medical and veterinary professionals throughout Delaware, alerting them to the active presence of Eastern Equine Encephalitis (EEE) and West Nile Virus (WNV) circulating in adult mosquito populations. The Mosquito Control Section conducts mosquito-borne virus surveillance and monitoring of EEE and WNV through its statewide sentinel chicken program.

Through a working partnership with the University of Delaware, our sentinel chicken flock is raised in an indoor laboratory setting at the University’s College of Agriculture. Following the Centers for Disease Control and Prevention (CDC) guidelines, at 12 weeks old the chickens are banded and pretested to ensure each individual is not infected before deployment into the field.7 Four chickens are deployed at each of the 20 monitoring sites around the state in Figure 1. Beginning in the first week of July and continuing for an eighteen-week period through the end of October, blood samples are taken weekly from a pair of chickens from each monitoring site (and thus an individual chicken is tested bi-weekly). Sampling occurs in the field by a pair of trained staffers drawing blood from the wing vein of the chicken. Collected samples are then processed by the Delaware Division of Public Health’s Delaware Public Health Laboratory (DPHL). The DPHL tests the blood samples for WNV and EEE antibodies (seen as seroconversions) using an ELISA assay method.8 When a blood sample seroconverts for either WNV or EEE, the DPHL initiates a sequence of emails notifying the Department of Health and Social Services‘ (DHSS) Division of Public Health Office of Infectious Disease Epidemiology, the Delaware Department of Agriculture (DDA), and the Mosquito Control Section.

The transmission cycle of both WNV and EEE is maintained between vector mosquito species and susceptible avian hosts. Mosquitoes become infected when feeding on infected birds, and when taking their next blood meal, the now infected mosquito can then transmit virus to humans and horses (dead-end hosts).4 The amplification of virus occurs when the infected mosquito feeds again on another susceptible avian host. One of the more common ways around the country for conducting mosquito-borne virus surveillance is through the use of sentinel chicken flocks. Chicken flocks are placed in secured pens in mosquito prevalent areas where they are exposed to biting adult mosquitoes. Weekly blood samples are taken in the field from the chickens and are then processed by a qualified health lab. When a chicken tests positive for EEE or WNV, this means local active transmission is occurring and medical, veterinary, and mosquito control professionals can respond accordingly. Once a chicken tests positive, it is removed from further testing and replaced with another non-infected chicken (i.e., no virus antibodies present). Chickens serve as valuable sentinel animals since they are not effective amplifying hosts,5 and they develop a short and relatively low viremia compared to other bird species when infected by WNV or EEE.6 72 Delaware Journal of Public Health – January 2021

Figure 1. Sentinel Chicken Locations in Delaware

doi: 10.32481/djph.2021.01.014

Positive detects of sampled chickens are shared amongst key state entities so that local response can be enacted. From the public health lab, alerts are subsequently reported to the Epidemiology Office within DHSS, the DDA’s state veterinarians, as well as the Mosquito Control Section. Each plays a pivotal role in the One Health Initiative of Delaware. Upon receiving the positive results of either WNV or EEE in a sentinel chicken, the Epidemiology Office then enters these data into ArboNET, which is the national arboviral surveillance system managed by CDC and state public health departments. In addition, the Epidemiology Office then uses the information internally as an early indicator of what may be happening to the human population within the geographic area represented by a sentinel chicken monitoring location. If trends start to show a particularly elevated or concerning level of activity, the Epidemiology Office will send a Delaware Health Alert Notification (DHAN) to the local medical and health care community with updated information regarding rising transmission rates within the specified area. Relative to concerns about mosquito-borne diseases and horses, the DDA also enacts a chain of events upon receiving analysis results from DPHL. This includes notifying state and regional stakeholders via a mailing list that consists of clinical equine veterinarians and regulatory animal health personnel at the federal and state levels. Ultimately, the Mosquito Control Section’s involvement is a response to monitor and actively reduce, as warranted, the population density of virally infected adult mosquitoes within the geographic region of a positive sentinel chicken surveillance location. This is accomplished through either ground applications of adulticides via truck mounted ULV (Ultra Low Volume) ‘fog’ sprayers for more localized treatment, or via an aerial fixed wing application of adulticides for more widespread areas. The level of response taken by each agency can depend on the timing and frequency at which the detections are occurring. Figure 2 totals the monthly WNV and EEE seroconverted chickens over the past ten years. While EEE positives remain

relatively low and follow no notable trend, WNV positive detections typically begin in July and increase through August before peaking in the month of September. Cooler fall temperatures in October and November bring an end to the mosquito and virus season; however, the virus is able to remain in the environment through overwintering vector mosquito species and in avian hosts populations.9 Figure 3 displays the yearly totals of WNV and EEE seroconverted chickens from 2000-2020. Delaware sees an average of 19.5 WNV seroconverted chickens per season, with the highest totals occurring in 2017 and 2018. Using historic data trends helps the Mosquito Control Section prepare for the current arboviral season response. By analyzing monthly data trends, Mosquito Control can gain insight into resource allocation needed for mosquito-borne virus transmission suppression. The mosquito-borne virus surveillance data obtained through the Mosquito Control Section’s sentinel chicken program serves as a vital tool in Delaware’s One Health initiative. This program increases the ability to predict when and where mosquito-borne virus transmission to humans is likely to occur in Delaware, while also encompassing the ideology of the One Health goal of protecting human, animal, and environmental health through collaboration, coordination, and communication.10 Through scientific collaboration, state agencies including the Delaware Department of Health and Social Services and the Delaware Department of Agriculture, along with the Delaware Department of Natural Resources and Environmental Control, are able to inform medical and veterinary professionals and the public of active mosquito-borne viral transmission occurring within the state. The Mosquito Control Section is able to provide an appropriate, timely insecticidal response to help avoid or suppress mosquito-borne disease outbreaks, and through press releases is able to promptly notify Delaware residents and visitors alike to take the necessary precautions to protect themselves from mosquito bites while still enjoying Delaware’s great outdoors.

Figure 2. Total number of seroconverted chickens by month over the last ten years in Delaware. 73

Figure 3. WNV and EEE seroconversions of sentinel chickens from 2000-2020; WNV seroconversions average 19.5 per year.

REFERENCES: 1. Delaware Fish and Wildlife. (2020, January). Mosquito control. Retrieved from: 2. Meredith, W. H. (n.d.). Delaware’s bad actor mosquitoes. Delaware Mosquito Control Section. Retrieved from: http:// BAD-ACTOR%20MOSQUITOES%20_2_.pdf 3. United States Census Bureau. (2020, August 26). 2010 census: population density data (Text Version). Retrieved from: density-data-text.html 4. Centers for Disease Control and Prevention. (2020, August 18). Eastern equine encephalitis. Retrieved from: html 5. Florida Health Department. (2020, June 5). Florida mosquitoborne disease guide chapter 10. Mosquito-Borne Disease Guidebook. Retrieved from: 74 Delaware Journal of Public Health – January 2021

6. University of Florida. (2019). Sentinel chicken surveillance programs: pay attention to safety. Florida Medical Entomology Laboratory. Retrieved from: sentinel-chicken-surveillance-programs/ 7. Moore, C. G. (1993, April). Guidelines for arbovirus surveillance programs in the United States. Retrieved from: 8. Delaware Health and Social Services. (n.d.). Arboviruses. Retrieved from: 9. Reisen, W. K., & Wheeler, S. S. (2019, September 2). Overwintering of West Nile Virus in the United States. Retrieved from: 10. CDC. (2018, November 5). One health basics. Centers for Disease Control and Prevention. Retrieved from:


STUDENT SPOTLIGHT Starting in 2021, a new recurring section will be included in DJPH issues. This new “student spotlight” section will be a forum to highlight the research and work of students - both undergraduate and graduate - residents, fellows, trainees, and interns. This new section aims to promote student work and engagement with the public health community, as well as provide an opportunity for students to publish original work and become more familiar with the journal submission, peer review, and editorial processes. For more information, to suggest a student or trainee, or to submit piece to this section, please contact

Emergency Patient Voting Initiative in a Community Hospital During a Global Pandemic: Lessons and a Call-To-Action for Expanded Voter Access Carly Chamberlain, D.O.; Henrique Jaime, M.D.; Diana Wohler, M.D. ChristianaCare Family Medicine Residency Program

ABSTRACT The 2020 United States general election remained extremely polarized despite occurring during the midst of a global coronavirus pandemic. Acutely hospitalized persons in the days to weeks leading up to the general election are exceptionally vulnerable to voter disenfranchisement and not among the population typically discussed during election seasons. As residents in the ChristianaCare Family Medicine Residency Program in Wilmington, Delaware, we organized an emergency ballot registration and absentee voting project for hospitalized patients in our community hospital during the days to weeks leading up to the 2020 general election. We experienced multiple challenges to registering and aiding patients with ballot applications, including but not limited to communication with an overworked New Castle County elections office and coordination of receiving and returning completed ballots. However, we did notice a positive trend in the number of patients acutely hospitalized in the days-weeks leading up to Election Day who had already cast their vote through the expanded mail-in voting campaign in the setting of the COVID-19 pandemic. As physicians, we have a unique position and opportunity to not only educate patients and potential voters on voter registration, but also assist these members of our community in the registration process first-hand. In addition to these physician responsibilities, we feel strongly that the state of Delaware should continue the expansion of mail-in/absentee voting for all residents in addition to new initiatives such as extended voter registration period and early in-person voting.


These are just a few of the slogans used throughout the 2020 United States election; an historic election with the highest recorded voter turnout since 1900, despite a global pandemic.1 Perhaps more than in any prior election, the emphasis on individual voting rights and reducing voter suppression jointly accompanied election coverage. From outdated voter identification requirements, to exceedingly early registration deadlines, many Americans still face unnecessary barriers. Unfortunately, acutely hospitalized persons in the days to weeks leading up to the general election are exceptionally vulnerable to disenfranchisement and not among those typically discussed. In the year of a novel coronavirus pandemic, this population of hospitalized Americans is even more evident. 76 Delaware Journal of Public Health – January 2021

As family medicine physicians, we focus much of our medical career on patient advocacy. Perhaps one of the most basic ways we can advocate for patients is by aiding them in their fundamental right to vote. Because politics and legislation affect healthcare, healthcare cannot be apolitical. As residents in the ChristianaCare Family Medicine Residency Program in Wilmington, Delaware, we organized an emergency ballot registration and absentee voting project for hospitalized patients in our community hospital during the days to weeks leading up to the 2020 general election. This included: • Surveying patients to determine voter registration status and eligibility, • Aiding in registration, and • Submitting emergency absentee ballots for the general election. To respect patients’ personal values, we created and used flyers from official and apartisan websites including and official state voting websites only. doi: 10.32481/djph.2021.01.015

This project, set in the middle of a global pandemic, opened our eyes to how easily voters can be disenfranchised. Our community hospital serves patients predominantly from the State of Delaware, but also from neighboring states such as Pennsylvania, Maryland, and New Jersey. While we aim to treat all patients equally, many patients faced different obstacles to voting simply due to different state rules. Not only did deadlines for both voter registration and emergency absentee ballot requests differ, but the methods for requesting ballots varied between states as well. Focusing on Delaware specifically, the voter registration deadline was nearly one month prior to the general election.2 In our experience, most patients expressed interest in the few weeks prior to the election, only to discover they were not registered appropriately. While emergency absentee ballots could be requested up until 12 pm on the day prior to the general election,2 our local election officials appeared overworked and understaffed as we repeatedly tried to contact them inquiring about ballots yet to be received. After requesting and successfully receiving an absentee ballot, the ballot must then be returned, which we were able to do, but could prove another obstacle in different locations. Perhaps one positive adaptation forced by the pandemic was the expansion of mail-in voting. While surveying patients in the hospital in the weeks prior to the general elections, we were surprised to discover that many patients had already voted by mail without the insight to know they would have been unexpectedly hospitalized prior to or on Election Day. Unfortunately, increasing voter access through expansion of mailin-ballots was a polarizing debate in the nation preceding Election Day. Exaggerated claims of rampant voter fraud and the evidence against this accusation continue to flood the news media, despite previous study statistics showing cases of potential fraud ranging from only 0.0003-0.0025% of total ballots cast.3,4 Multiple studies analyzing claims and evidence of potential voter fraud confirm that the occurrence remains exceedingly rare.3,4 While we call upon all physicians, especially primary care physicians, to advocate for patient voting rights, this is not enough. A mail-in voting option available to all Delaware residents needs to be available in subsequent elections, and this concept should be consistently enhanced. Regardless of a pandemic, acutely ill persons who are hospitalized or still recovering from a hospitalization, should not feel cornered to go into a public and crowded space to vote and stand in line for hours. We argue that the availability to vote by mail/absentee for all Delaware residents should be a continued practice for upcoming state and federal elections that promotes both protection of those most vulnerable in health and, arguably, voter disenfranchisement.

Medicine teaching service, but also interested patients from other services, we unfortunately discovered many who were unable to vote because they were not registered by the Delaware deadline. Allowing for the availability of same-day voter registration would increase turnout and representation in our elections. As physicians, we have a unique position and opportunity to not only educate patients and potential voters on voter registration, but also assist these members of our community in the registration process first-hand. Through our experience, even with education and assistance, many persons will be unable to vote if mail-in voting is not expanded and registration deadlines remain nearly one month preceding the actual Election Day.

REFERENCES 1. Park, A. (2020, Nov 6). 2020 Voter turnout was the highest the U.S. has seen in over a century. Marie Claire. Retrieved from: 2. Office of the State Election Commissioner. (n.d.). Absentee voting in Delaware. State of Delaware, Department of Elections. Retrieved from: 3. The Brennan Center for Justice at NYU Law. (2017, Jun 26). Resources on voter fraud claims. Retrieved from: 4. Levitt, J. (2007, Nov 9). The truth about voter fraud. Brennan Center for Justice at New York University School of Law. Retrieved from: Truth-About-Voter-Fraud.pdf 5. Duffin, E. (2020, Dec 7). 2020 Presidential election: Voter turnout rate U.S. 2020. Retrieved from: 6. Department of Elections, Office of the State Election Commissioner. (2020, Sep 15). Election results archive. State of Delaware - election results presidential primary 2020. Retrieved from: 7. (2020). Voter registration deadlines. Retrieved from:

Delaware should also allow for same-day voter registration. While voter turnout in Delaware increased to 70% during this general election from 65% in the 2016 election, this was almost 10% less than states such as Minnesota, where same-day registration is available.5,6 Despite so much news coverage and focus on voter registration, from our experience, this was the biggest barrier to persons hospitalized. As previously mentioned, the deadline to register to vote in Delaware was the 4th Saturday before Election Day. The average deadline to register to vote among the United States is between 15-30 days prior to Election Day, with the State of Delaware being at the upper end of this range.7 After surveying not only patients admitted to our inpatient Family 77

From the history and archives collection

Anthrax Sharon Folkenroth Hess, M.A. Collections Manager, Delaware Academy of Medicine/Delaware Public Health Association

The Delaware Academy of Medicine Archives contain hundreds of rare and valuable texts, many of which were printed in Philadelphia and Wilmington. While the information and knowledge found on these pages have saved countless lives, the books themselves have left a deadly legacy in Delaware. Despite the introduction of clothbound books in the nineteenth century, leather remained a popular material for book covers and spines. Morocco leather (see Figure 1) is made from goatskin and has a highly visible ‘birdseye’ grain that looks particularly lovely when gilt. This type of leather easily absorbs dyes, allowing for bright blues, greens, and reds. Because of these qualities, morocco was the most popular leather for bookbinding. By the late nineteenth century, Philadelphia and Wilmington produced four-fifths of the country’s morocco leather output. The twenty-five shops in Philadelphia and the fourteen in Wilmington processed an astounding 125,000 goatskins per day. Importation was essential to supply this industry. Raw or untanned skins came from China, India, Mexico, Russia, Brazil, the Middle East, and North Africa packed in clay, salt, or cured in arsenic.1 Heavy metals were not the only danger present in these shipments; anthrax lay dormant in the dirt, blood, and excrement on these raw materials. Despite seeing scores of lung infections (“Woolsorters’ Disease”) among people who worked with animal skins and fur throughout the nineteenth century, 1892 stands out as an important year in Delaware’s anthrax history. That spring marked the first time anthrax was “officially recognized as existing in Delaware” and the start of an epidemic.2 This time, the bacteria killed livestock instead of people. Approximately fifty cows and horses died in the first year across nine farms located within a one mile radius near Newport, Delaware.1 The cause of the deaths was identified by the Agricultural Experiment Station (AES) in Newark, though this diagnosis initially was met with resistance. Dr. George M. Sternberg, the first U.S. bacteriologist, insisted in his 1892 Manual of Bacteriology that anthrax did “not prevail in the United States” (see Figure 2). Anthrax outbreaks on farms were not uncommon in the rest of the world, let alone the United States. By the mid century, German scientist Robert Koch identified the link between specific microorganisms (Bacillus anthracis) and specific diseases (anthrax). In the early 1880s, Louis Pasteur created a successful two-dose vaccine for animals. European nations had protocols for quarantine and disposal of remains that proved highly effective at restricting the spread. 78 Delaware Journal of Public Health – January 2021

Working with state veterinarians, AES campaigned to get farmers to follow similar protocols for cremation of the remains and isolating infected animals. Large amounts of fuel were provided free of charge by a local railroad company for this purpose. Still, the carcasses of these unfortunate beasts were either left to rot where they fell, dragged out to a body of water to float away, or buried in a shallow pit. The deaths continued until the autumn chill ended ‘anthrax season.’1 By 1893, the origin of the outbreak was traced to the sale of tannery waste to farmers for use as fertilizer, a practice that began just a few years prior to the outbreak.1 Spores of anthrax lay dormant in the fields in roots and soil. Once animals grazed on the contaminated meadows, death came swiftly. Bodily fluids from the dead or dying spread the infection to others in the herd. The practice of throwing the bodies in the rivers passed the disease to surrounding farms. Unlike the year before, only a few cases were reported in early 1893. In August there were zero. Later in the year, however, it was clear that self-interest led affected farmers to suffer losses in silence. On one farm, thirty cows out of a herd of forty died. The disease was not recognized by local veterinarians, and so the farmer pulled the bodies to the nearby river for burial. Ten infected carcasses floated and were scattered along twelve miles of riverfront. After national assistance was denied, AES secured state aid to retrieve and burn the cows. All but one were found.1 By 1910, AES reported that approximately two hundred farms, comprising a third of the total area of the state of Delaware, were “permanently infected with anthrax.”3 Wash water from local tanneries was still dumped into streams, and scraps continued to be sold for fertilizer. Nevertheless, the epidemic officially ended in the fall of 1893. Vaccines, public education, and effective legislation put a quick end to the deadly ordeal. Doctors from AES prepared a two-dose bullion vaccine based on Pasteur’s, and developed methods for production and monitoring. Livestock vaccinations were made compulsory at the State’s expense. The failure to report or attempts to conceal outbreaks resulted in hefty fines. More importantly, the State offered reparations to farmers for losses, provided they received a documented diagnosis of anthrax. Cremation of the carcasses was mandatory.1 Although the anthrax epidemic of 1892-1893 had a happy ending for farmers, tannery workers had to wait until the 1950s for a human anthrax vaccine. In the meantime, those with suspected infections were treated with mercury chloride and forbidden from entering hospitals. doi: 10.32481/djph.2021.01.016

The land under the tanneries is still contaminated with arsenic. The Department of Primary Industries and Regional Development’s Agriculture and Food Division reports that, while anthrax spores remain viable in soil for 50 years, it will take 200 years for the spores to die out in bones of buried animals. As for the books in our collection? The Smithsonian recommends wearing gloves and a mask while handling these precious tomes.

REFERENCES 1. Neale, A. T. (1896). Combating anthrax in Delaware. Delaware College Agricultural Experiment Station Bulletin, (32). 2. Andrews, J. B. (1917). Anthrax as an occupational disease. U.S. Bureau of Labor Statistics Bulletin, (205): 27. 3. Dawson, C. F. (1910). Anthrax, Synonyms: Splenic Fever, Malignant Pustule, Woolsorters’ Disease, Milzbrand (German), Charbon (French). Delaware College Agricultural Experiment Station Bulletin, (90): 17.

Figure 1. Blue morocco leather

Figure 2. Sternberg’s opening statement on anthrax 79

Delaware Journal of

Public Health

Submission Guidelines

updated April, 2020

About the Journal Established in 2015, The Delaware Journal of Public Health is a bi-monthly, peer-reviewed electronic publication, created by the Delaware Academy of Medicine/Delaware Public Health Association. The publication acts as a repository of news for the medical, dental, and public health communities, and is comprised of upcoming event announcements, past conference synopses, local resources, peer-reviewed content ranging from manuscripts and research papers to opinion editorials and personal interest pieces, relating to the public health sector. Each issue is largely devoted to an overarching theme or current issue in public health. The content in the Journal is informed by the interest of our readers and contributors. If you have an event coming up, would like to contribute an Op-Ed, would like to share a job posting, or have a topic in public health you would like to see covered in an upcoming issue, please let us know. If you are interested in submitting an article to the Delaware Journal of Public Health, or have any additional inquiries regarding the publication, please contact DJPH Deputy Editor Elizabeth Healy at, or the Executive Director of The Delaware Academy of Medicine and Delaware Public Health Association, Timothy Gibbs, at

Information for Authors Submission Requirements The DJPH accepts a wide variety of submission formats including brief essays, opinion editorials pieces, research articles and findings, analytic essays, news pieces, historical pieces, images, advertisements pertaining to relevant, upcoming public health events, and presentation reviews. If there is an additional type of submission not previously mentioned that you would like to submit, please contact a staff member.

Cover Letters must address the following four article requirements: 1. A description of what the paper adds to current knowledge, in particular with respect to material previously published in DJPH, and if systematic reviews exist on the topic. 2. The public health importance of the paper. 3. One sentence summarizing the main message(s) of the paper, which may be used to disseminate the paper on social media.

The initial submission should be clean and complete, without edits or markups, and contain both the title and author(s) fulls name(s). Submissions should be 1.5 or 4. For individual or group randomized trials, provide the double spaced with a font size of 12. Initial submissions date of trial registration and the NCT number from must also contain a cover letter with concise text or other approved registry. (maximum 150 words). Once completed, articles In the cover letter only, not in the paper. Do NOT should be submitted via email to Elizabeth Healy at include the trial registration or NCT number in the as an attachment. Graphics, images, abstract or the body of the manuscript during the info-graphics, tables, and charts, are welcome and initial submission. encouraged to be included in articles. Please ensure that all pieces are in their final format, and all edits and track All manuscripts must be submitted via email to Elizabeth Healy at changes have been implemented prior to submission. 80 Delaware Journal of Public Health – January 2021

To view additional information for online submission requirements, please refer to the website for the Delaware Journal of Public Health: Submission Length While there is no prescribed word length, full articles will generally be in the 2500-4000-word range, and editorials or brief reports will be in the 1500-2500-word range. If you have any questions regarding the length of a submission, or APA guidelines, please contact a staff member. Copyright Opinions expressed by contributors and authors do not necessarily reflect the opinions of the DJPH or affiliated institutions of authors. Copying for uses other than personal reference or interest without the consent of the DJPH is prohibited. All material submitted alongside written work, including graphics, charts, tables, diagrams, etc., must be referenced properly in accordance with APA formatting. Conflicts of Interest Any conflicts of interest, including political, financial, personal, or academic conflicts, must be declared prior to the submission of the article, or in conjunction with a submission. Conflicts of interest are any competing interests that may leave readers feeling misled or deceived, and/or alter their perception of subject matter. Declared conflicts of interest may be published alongside articles in the final electronic publication.

Additional Documents and Information for Authors Please Note: All authors and contributors are asked to submit a brief personal biography (3 sentences maximum) and a headshot along submissions. These will be published alongside final submissions in the final electronic publication. For pieces with multiple authors, these additional documents are requested for all contributors. Abstracts Authors must submit a structured or unstructured abstract along with their article. The word limit is 200 words, including headings. A title page should be submitted with this abstract as well. Structured abstracts should employ 4-5 headings: Objectives (begins with “To…”) Methods Results Conclusions A fifth heading, Policy Implications, may be used if relevant to the article. Trial Registration information is required for clinical trials and must be included in the final version abstract All abstracts should provide the dates(s) and location(s) of the study is applicable. Note: There is no Background heading.

Nondiscriminatory Language Use of nondiscriminatory language is required in all DJPH submissions. The DJPH reserves the right to reject any submission found to be using sexist, racist, or heterosexist language, as well as unethical or defamatory statements.


ONE HEALTH – RESOURCES Centers for Disease Control and Prevention (CDC) One Health One Health is a collaborative, multisectoral, and transdisciplinary approach—working at the local, regional, national, and global levels—with the goal of achieving optimal health outcomes recognizing the interconnection between people, animals, plants, and their shared environment. CDC’s One Health Office leads the agency’s One Health efforts in the United States and abroad.

Delaware Department of Agriculture (DDA) The Department of Agriculture’s mission is to sustain and promote the viability of food, fiber, and agricultural industries in Delaware through quality services that protect and enhance the environment, health, and welfare of the general public.

Delaware Department of Natural Resources and Environmental Control (DNREC) DNREC seeks to engage stakeholders to ensure the management, conservation, and enhancement of the State’s natural resources; protect public health and the environment; provide quality outdoor recreation; improve the quality of life; lead energy policy and climate preparedness; and educate the public on resource use. Its divisions include Air Quality, Water, Climate, Fish and Wildlife, and Watershed Stewardship, among others.

Delaware Department of Health and Social Services (DHSS) The mission of DHSS is to improve the quality of life for Delaware’s citizens by promoting health and well-being, fostering self-sufficiency, and protecting vulnerable populations.

Delaware Managed Pollinator Protection Plan Best management practices that beekeepers, fruit and vegetable growers, and pesticide applicators can use to help pollinators thrive. It also includes strategies to increase the quantity and quality of pollinator forage on private and public lands.

Delaware Veterinary Medical Association (DVMA) Offering legal and legislative advocacy, practical help, networking with other local and national professionals, continuing education and resources, and valuable information applicable to today’s veterinary professional in Delaware.

Delmarva Chicken Association The trade association working for the common good of the meat chicken industry in Delaware, the Eastern Shore of Maryland, and Virginia’s Eastern Shore.

One Health Commission The One Health Commission is a globally focused organization dedicated to implementing One Health and One Health actions around the world. As a 501(c)(3) organization, chartered in Washington, D.C. in 2009, it is dedicated to raising awareness and educating all audiences about the importance of transcending institutional and disciplinary boundaries to transform the way that human, animal, plant, and ecosystem health professionals work together. The Commission seeks to ‘Connect’ One Health Advocates and Stakeholders, to ‘Create’ networks and teams that work together across disciplines to ‘Educate’ about One Health and One Health issues.

One Health Delaware Details about the Community One Health Veterinary Clinic held in Wilmington. 82 Delaware Journal of Public Health – January 2021

ONE HEALTH – LEXICON Acaricide A substance poisonous to mites or ticks.

Amplifying Hosts An organism in which an infectious agent (such as a virus or bacterium) that is pathogenic for some other species is able to replicate rapidly and to high concentrations.

Axillary Region Armpit or underarm.

Dead-End Hosts Hosts that do not develop high levels of virus in their bloodstream, and cannot pass the virus on to other vectors.

Debridement The medical removal of dead, damaged, or infected tissue to improve the healing of the remaining healthy tissue. Removal may be through surgical, non-surgical, chemical, natural, or other methods (including maggot therapy).

Depopulation In-field culling of flocks

ELISA Assay Enzyme-linked immunosorbent assay. A plate-based assay technique designed for detecting and quantifying peptides, proteins, antibodies, and hormones.

Flagellated A cell or organism with one or more whip- or tail-like appendages.

Inguinal Region The groin.

Necrotic Affected with, characterized by, or producing death of a usually localized area of living tissue.

Pathogenic Causing disease.

Sample pooling Samples from several individuals are pooled and tested together in a single tube. Only if the pool result is positive do the samples need to be tested individually. This can expand testing capacity and decrease costs.

Septicemia AKA: Blood poisoning. A serious bloodstream infection that occurs after bacteria or a virus from elsewhere in the body (i.e. the lungs) enters the bloodstream and spreads.

Seroconversion The time period during which an antibody develops and becomes detectable in the blood.

Spirochete Any of a group of spiral shaped bacteria.

Vector A carrier of disease or medication.

Ventral Region Of the belly (in four-legged creatures) or front (in humans) of a body.

Viremia The presence of viruses in the blood. 83

Index of Advertisers Adopt These Healthy Pet Habits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Center for Disease Control and Prevention VacciNATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Partnership to Fight Infectious Disease The DPH Bulletin - December 2020. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Delaware Division of Public Health Food Insecurity Quality Measure Testing Project. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Quality Insights Continuing Medical Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 ChristianaCare The Nation's Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 American Public Health Association How To Stay Healthy Around Pets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Center for Disease Control and Prevention How To Check Your Pet For Ticks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Center for Disease Control and Prevention Hypertension Control Champion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Quality Insights Submission Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Delaware Journal of Public Health

84 Delaware Journal of Public Health – January 2021

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Delaware Academy of Medicine / DPHA 4765 Ogletown-Stanton Road Suite L10 Newark, DE 19713 | Follow Us:

The Delaware Academy of Medicine is a private, nonprofit organization founded in 1930. Our mission is to enhance the well being of our community through medical education and the promotion ofpublic health. Our educational initiatives span the spectrum from consumer health education tocontinuing medical education conferences and symposia. The Delaware Public Health Association was officially reborn at the 141st Annual Meeting of the American Public Health Association (AHPA) held in Boston, MA in November, 2013. At this meeting, affiliation of the DPHA was transferred to the Delaware Academy of Medicine officially on November 5, 2013 by action of the APHA Governing Council. The Delaware Academy of Medicine, who’s mission statement is “to promote the well-being of our community through education and the promotion of public health,” is honored to take on this responsibility in the First State.

ISSN 2639-6378