General Knowledge of MosquitoBorne Diseases Survey Nogales AZ, 2017

Binational Infectious Disease Surveillance Program Office of Border Health Policy & Intergovernmental Affairs Arizona Department of Health Services

Nogales AZ 2017 Survey Background Arboviruses are transmitted between arthropod vectors and vertebrate hosts. Arthropod vectors of medically important viruses occur in more than 100 countries, where they transmit viral diseases that affect hundreds of millions of people every year (1, 2). Three genera of mosquitoes, Culex, Aedes, and Anopheles are among the most important arthropod vectors of public health importance (3). Seven arboviral diseases, including Zika, Dengue, Yellow Fever, and Chikungunya are transmitted by Aedes aegypti and Aedes albopictus (4-7). In the United States, Aedes aegypti was reported in 220 counties in 28 states, the District of Columbia and Puerto Rico, while Aedes albopictus was reported in 1,368 counties in 40 states, and the District of Columbia (4) Although both Aedes aegypti and Aedes albopictus are endemic in southern California, Arizona, Texas, and Florida (4, 8, 9); local transmission of viruses borne by the mosquito species is rare (5, 10). Although 12 cases of locally acquired Chikungunya infections were reported in Florida in 2014, and one was reported in 2015 in Texas, the majority of Dengue, Chikungunya, and Zika cases identified in the US from 2014 were imported into the United States, with viremic individuals returning to the United States after having contacted the infections abroad. Most of the cases identified in the United States from 2014 were imported from Mexico, Central America, and the Caribbean Islands (10-12). Travel across the US-Mexico border is common; the US Department of Transportation reported 185 million individual crossings at the US-Mexico border for the 2017calendar year, both into and out of the United States (13). The current trend is expected to continue, and travel by US citizen to Mexico is projected to increase in the next six years (14). Additionally, with the reported expansion of chikungunya, dengue, and Zika viruses into the Caribbean Islands and Latin America (6, 12, 15-17), there is an increasing risk for travelers to return to Arizona infected with one or more of these viruses (18). All three of these diseases have potential for local transmission in Arizona, and study was conducted in response to these encroaching threats. This increase in Douglas A. Ducey | Governor Cara M. Christ | MD, MS, Director Health and Wellness for all Arizonans

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cross-border travel will have a three-fold impact for the epidemiology of arboviral diseases in the United States. First, there will be a higher probability that U.S. residents visiting endemic areas could become infected while traveling, if they do not take adequate protective measures against mosquitoes and they get bitten and infected. If so, they will then transport the infection back into the United States, where they could develop symptoms and if detected, become an imported case. Second, any exposed individual with viremia of sufficient level and duration could transmit the arbovirus to the local mosquito population, which can then become effective vectors for local transmission of the arboviruses. Third the risk to set the conditions for the most important requirements to establish an endemic arbovirus transmission is having a large enough pool of viremic individuals and a highly competent vector together (7). Since Aedes mosquito populations occur in both the United States and Mexico, imported cases infecting the local mosquito populations in the United States could easily lead to become endemic cycles of arboviral diseases in the United States. Outbreaks of arboviral diseases, such as Zika, Dengue, and Chikungunya in nonendemic areas can be problematic in many ways. High rates of hospitalizations usually associated with Dengue, and outpatient care for Zika and Chikungunya patients, would constitute a heavy burden on health infrastructure; the accompanying morbidity would cause loss of livelihoods, reduced productivity, and a drain on public resources. Unfortunately, there are no therapies of proven efficacy against these viruses, and no protective vaccines are available (19). For now, experts recommend prevention using public health awareness regarding mosquito avoidance and mosquito control strategies (10). As part of these efforts, the Arizona Department of Health Services (ADHS) has conducted a mosquito-borne disease awareness campaign in the past few years, called “Fight the Bite!” (20,21). This campaign guides Arizona state efforts to prevent mosquito-borne diseases and provides a framework for county-level activities. “Fight the Bite!” provides health education and information about mosquito-borne diseases, mosquito control measures, and protection against exposure (20, 21). Since 2012, the Border Infectious Disease Surveillance Program (22) has been actively involved with vector-borne disease surveillance, with a special focus on Douglas A. Ducey | Governor Cara M. Christ | MD, MS, Director Health and Wellness for all Arizonans

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mosquito-borne diseases since 2015. BIDS is housed in the Office of Border Health (OBH), within the Office of Assistant Director, in the Division of Policy and Intergovernmental Affairs, at ADHS. As part of BIDS’ surveillance activities, the program has partnered with the Santa Cruz County Health Department and the Southeast Arizona Area Health Education Center (SEAHEC) to conduct educational activities in the community to gauge knowledge of mosquito-borne disease knowledge, attitudes and practices among residents of Santa Cruz County. SEAHEC is a non-profit organization that partners with local and state governments to support health workforce development of rural and medically underserved communities in southeast Arizona. Also, SEAHEC allows volunteers to participate in program activities, and to obtain hands-on, public health experience through participation in program activities. Nogales, Arizona and Nogales, Sonora, have strong historical, familial, and economic ties; many families bestride the border, and people cross back and forth to visit relatives, to work, or for commerce. The unique combination of historical, sociological, and economic factors makes Santa Cruz County an excellent sentinel site for monitoring infectious disease outbreaks at the U.S. Mexico border. Having a good understanding of the knowledge, attitudes, and practices regarding mosquito avoidance in Santa Cruz County will help us learn how the previous year’s “Fight the Bite!” campaign impacted the border population, and to determine which aspects of the campaign will need improvement in the future.

Methods A short survey was designed to assess the general knowledge of mosquito-borne diseases among the community. The survey was created by BIDS in cooperation with the Santa Cruz County Health Department and was administered by SEAHEC volunteers under two sponsored activities. The survey collected basic demographic information such as gender, age group, and neighborhood. Survey questions asked for general information about arboviral disease presence, transmission, risk, and exposure protection. Douglas A. Ducey | Governor Cara M. Christ | MD, MS, Director Health and Wellness for all Arizonans

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SEAHEC incorporated the survey activity into a border-region educational experience for students from the University of Arizona. Students from two groups administered the survey in selected neighborhoods and distributed materials from the “Fight the Bite!” campaign to participants. The Focusing Research on the Border Area (FRONTERA) group was active in June 2017, and the Border Latino and American Indian Summer Exposure to Research (BLAISER) group were active in August 2017. Before engaging with survey participants, student surveyors received training on border-region arbovirus epidemiology and were familiarized with the educational material they would be distributing. They were also trained on how to administer the survey. After the training, the students visited five separate neighborhoods around Nogales: Rio Rico, Las Terrazas, Loma Mariposa, Pajarito, and Royal Road Apartments; surveys were also administered at a local supermarket. To eliminate bias, participants were unable to see possible answers, and questions were read aloud by the students. Surveys were collected by the SEAHEC coordinator and delivered to the BIDS team. The program “Epi Info 7” was used to create a database and to tabulate results.

Results Both groups of students administered a total of 231 surveys in Nogales. Demographic data was collected from 221 of the 231 surveys. Age group and gender distribution of the participants are described in Table 1. Table 1. Demographics Age (23)

<15 11 (4.98%)

Gender

15-34 60 (27.15%)

34-65

>65

94 (42.53)

56 (25.34%)

Male

Female

77 (35.81%)

Female 138 (64.19)

Douglas A. Ducey | Governor Cara M. Christ | MD, MS, Director Health and Wellness for all Arizonans

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Survey Questions 3a – 6a are shown below, and answers collected are summarized in Table 2. Q3a: Do you know of any diseases that you can get from mosquitoes? Q4a: Do you think you are at risk for getting a disease from a mosquito? Q5a: Have you ever received information about protecting yourself from mosquitoes? Q6a: In the past year, have you tried to avoid getting mosquito bites or tried to get rid of mosquitoes around your home?

Table 2. Nogales 2017 Survey Results Q3a

Yes

No

154 (70.32%)

65 (29.68%)

Yes

No

I don’t know

120 (53.10%)

86 (38.05%)

20 (8.85%)

Yes

No

I don’t know

114 (50.67%)

109 (48.44%)

2 (0.89%)

Q4a

Q5a

Q6a

Yes

No

178 (79.11%)

47 (20.89%)

Question 7a reads: “Is there anything that prevents you from protecting yourself and your home from mosquitoes?” This question was unanswered in 11 surveys; consequently, 220 responses are included in Table 3 below. Table 3. Q7a Results (n = 220) Yes

No

25 (11.36%)

195 (88.64%)

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Each question had a follow-up ‘b’ section, if the answer to the ‘a’ section was ‘yes’. Question 3 had a ‘c’ section as well. A summary of five most common answers for each of the ‘b’ and ‘c’ questions are shown below. Q3

b) Diseases that can be transmitted by mosquitoes (n=231) – Zika (29.87%), Dengue (23.38%), Malaria (11.26%), Chikungunya (6.49%), West Nile Virus (5.19%). c) Where information was obtained regarding mosquito-borne diseases – Television (35.93%), Newspaper (16.02%), Family or friends (8.23%), Radio (7.79%), Internet (7.79%).

Q4

b) Which diseases they felt they were at risk of contracting (n=231) – Dengue (15.15%), Zika (14.29%), Chikungunya (3.90%), West Nile Virus (3.90%), Malaria (3.03%).

Q5

b) Where they obtained information to protect themselves from mosquitoes (n=231) – Television (18.18%), Healthcare Provider (8.66%), Newspaper (7.79%), Family or friends (5.63%), Radio (4.76%).

Q6

b) Methods used to avoid mosquitoes (n=231) –Wore repellent (56.28%), Cleaned my yard (21.65%), Avoid standing water (15.15%), Covered clothing (7.36%), Avoided outdoors (6.49%).

Q7

b) Barriers that prevent protecting themselves from mosquitoes (n=35) – Physically unable (20.0%), don’t know how (11.4%), Too expensive (5.7%), don’t have a reason (14.3%), other (45.7%).

Douglas A. Ducey | Governor Cara M. Christ | MD, MS, Director Health and Wellness for all Arizonans

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Discussion The 2017 Nogales survey is a follow up to the first one, which was done in 2016. In the current survey, we aimed at learning about the knowledge, attitudes, and practices related to mosquito-borne diseases among members of the border community. We also wanted to assess the impact of educational materials distributed in the last survey, as well as other information on mosquito borne diseases received from other sources, on the current state of knowledge, perceptions and attitudes on mosquito-borne diseases among members of the community. The major objectives of the study were to evaluate the general of knowledge about mosquito-borne diseases in the community, assess awareness of the presence of the diseases in the community, identify sources and type of information received on how to protect oneself from mosquito bites, and identify attitudes regarding mosquito-borne disease, risk perception, and practices used to avoid mosquitoes. We also wanted to evaluate any changes in the knowledge, perceptions and attitudes of community members on mosquito borne diseases between the two survey years, especially after educational materials were distributed in the community last year. Data from the Nogales 2017 survey showed that 70.3% of respondents were aware of diseases that could be transmitted by mosquitoes. However, only 53.1% thought they were at risk for contracting one. Dengue and Zika were identified as having the highest risk of being contracted (15.15% and 14.29%, respectively). The high level of risk awareness regarding Dengue was justified by reports showing 158 confirmed cases of Dengue in Sonora, Mexico as at Week 49 in 2017, with an incidence rate of 5.25/100,000 inhabitants (24). By Week 49 in 2016, Sonora had 197 confirmed native cases of Dengue (25). Therefore, compared to 2016, the current year witnessed a 19.8% decline in the prevalence of the disease during the corresponding period In the case of Zika, 14.3% of respondents identified the disease as having a high risk of being contracted by them. As at Week 49 in 2017, 55 confirmed native cases of Zika were reported in Sonora, compared to 21 cases during the corresponding period in 2016 (25). This represented an increase of 161.9% in the prevalence of the disease Douglas A. Ducey | Governor Cara M. Christ | MD, MS, Director Health and Wellness for all Arizonans

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from 2017. Zika virus was first reported in the Americas in 2015/16 (26), and 24 confirmed native cases were reported in Sonora, Mexico in 2016 (27). However, the incidence of Zika virus infections has significantly declined in the Americas (26, 28), including in Sonora, Mexico (27, 29). The high risk rating of Dengue and Zika in the 2017 survey cycle is similar to the trend in the 2016 survey (22). This high level of awareness is attributable to the effectiveness of educational campaigns targeting this population, and the globally discussed horrible effects associated with Zika infection during pregnancy. To learn about the effectiveness of educational materials distributed in the community in 2016 on how to avoid mosquito bites, as well as the impact of information received as part of the “Fight the Bite!” and complimentary educational campaigns done by different agencies throughout the county, we included questions that aimed to collect information about sources of information on mosquito-borne diseases. From the answers to these questions, we found that 71.4% of participants received educational information about mosquito- borne diseases from television, radio, internet, and healthcare providers. Compared to 61.9% of respondents in 2016, this year’s data showed an increase of 15.3% in the proportion of respondents who received information through these sources. We also wanted to estimate how many residents were taking action to protect their homes and families from mosquitoes. Almost all the participants indicated that they attempt to avoid mosquito bites, including taking such measures as wearing repellents when outside the house (56.3%), cleaning the yard (21.7%), getting rid of standing water (15.2%), avoiding the outdoors whenever possible (6.5%, and covering with clothing (7.4%). These protective measures outlined by the respondents also reflected information presented by the “Fight the Bite!” campaign, as well as campaigns promoted by the government of Sonora. We believe that parallel educational campaigns from Sonora and Arizona help to educate the border-region population, including Nogales, Arizona residents who participated in this survey. Unfortunately, we also discovered that some participants were not actively protecting themselves from mosquito-borne diseases. A small number of respondents Douglas A. Ducey | Governor Cara M. Christ | MD, MS, Director Health and Wellness for all Arizonans

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recognized barriers to protecting themselves, with the top impediment being physical inability (3.03%). A small number of residents (1.7%) indicated that they did not know how to protect themselves. The proportion of these individuals was small; compared to the one of those who knew how to protect themselves from mosquitoes, and were actively taking action to do so. However, there is a need to identify such individuals, and to reach them with the aim of addressing the obstacles that prevent them from taking action to protect themselves and their families from mosquitoes. Open-ended questions were added to collect more information related to general knowledge and perceptions about arbovirus diseases. Other diseases that participants named as transmitted by mosquitoes included influenza, Ebola, HIV and Bird flu. This lack of knowledge could be reflective of misinformation from the educational campaigns, or confusion about transmission of those diseases. Lack of knowledge was also reflected in responses on measures to avoid mosquito bites. For example, some respondent listed use of herbs, incense, shampoo, rubbing Vodka on the skin, and lighting candles. The results of this survey suggest that ADHS’s “Fight the Bite!” campaign could be improved by reinforcing the educational message in Santa Cruz County, and reemphasizing which mosquito-borne diseases present a public health risk to the community. The importance of refocusing the message is borne in the fact that a substantial number of participants (70.32%, n=231) were aware of mosquito-borne disease, but many (38.1%) did not think that they were at risk of being infected. It may also be beneficial to further educate residents on how they could protect themselves and their families from mosquito borne-disease, as 1.7% of respondents expressed ignorance on how to protect themselves and their families. Although a small number of participants did not feel the need to practice mosquito avoidance, most of the answers indicated that they actively avoid mosquitoes by using repellents (56.3%) and removing breeding sites around their homes (36.9). However, members of the community who fail to protect themselves from mosquito bites are left vulnerable to infection, and could aid in the introduction of arboviral diseases to this community. Once infected, and if environmental conditions are Douglas A. Ducey | Governor Cara M. Christ | MD, MS, Director Health and Wellness for all Arizonans

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conducive, these individuals could spread the viruses and establish the possibility of causing native cases to appear in non-endemic areas, as previously mentioned.

Acknowledgements We are grateful to SEAHEC and the FRONTERA and BLAISER programs of the University of Arizona for helping to administer the surveys, and for allowing BIDS to collect the data used in this study. We are thankful to the Santa Cruz County Health Department for helping BIDS to reach the population of interest, and for their cooperation that made this study possible. BIDS processed the information used for this report as an internship project for a Master in Public Health student, who made the analysis and report.

Douglas A. Ducey | Governor Cara M. Christ | MD, MS, Director Health and Wellness for all Arizonans

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11. Felner C. Zika in America: The Year in Review. Pharmacy and Therapeutics 2016;41(12):778-791. 12. van Dodewaard CA, Richards SL. Trends in Dengue Cases Imported into the United States from Pan America 2001-2012. Environ Health Insights 2015;9:33-40. 13. BTS UDoT. Border Crossing/Entry Data: Query Detailed Statistics. Transborder.bts.gov. 2017. In; 2017. 14. Commerce USDo. U.S. Commerce Department six-year forecast for international travel to the United States. In: Commerce UDo, editor. Washington D.C., USA; 2016. p. 3. 15. Liang G, Gao X, Gould EA. Factors responsible for the emergence of arboviruses; strategies, challenges and limitations for their control. Emerg Microbes Infect 2015;4(3):e18. 16. Musso D, Nilles EJ, Cao-Lormeau VM. Rapid spread of emerging Zika virus in the Pacific area. Clin Microbiol Infect 2014;20(10):O595-6. 17. Patterson J, Sammon M, Garg M. Dengue, Zika and Chikungunya: Emerging Arboviruses in the New World. West J Emerg Med 2016;17(6):671-679. 18. AZDHS. Arizona Arboviral Handbook for Chikungunya, Dengue, and Zika viruses. Phoenix, AZ: Arizona Department of Health Services; 2017. 19. Pastula DM, Smith DE, Beckham JD, Tyler KL. Four emerging arboviral diseases in North America: Jamestown Canyon, Powassan, chikungunya, and Zika virus diseases. J Neurovirol 2016;22(3):257-60. 20. Casal MG, Dent N, Arriola J, Dominguez V, Lueck E, Gentzsch G, et al. Enhanced Aedes spp. surveillance across jurisdictions in Arizona’s border region. In: ISDS 2016 Conference Abstracts; 2016. 21. Gouge DH, Li S, Walker K, Sumner C, Nair S, Olson C. Mosquitoes: Biology and Integrated Mosquito Management: The University of Arizona Cooperative Extension, College of Agriculture & Life Sciences; 2016. 22. BIDS. General Knowledge of Mosquito-Borne Diseases Survey Nogales AZ, 2016. Tucson, AZ: Arizona Department of Health Services; 2016.

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23. Bai L, Morton LC, Liu Q. Climate change and mosquito-borne diseases in China: a review. Global Health 2013;9(9):10. 24. AZDHS. 2017 Wk 49 BIDS Zika YTD location map. Phoenix: Arizona Department of Health Services; 2017. 25. AZDHS. 2016-w49-BIDS-Arboviral-report. Phoenix: Arizona Department of Health Services; 2016. 26. Oduyebo T, Polen KD, Walke HT, Reagan-Steiner S, Lathrop E, Rabe IB, et al. Update: Interim Guidance for Health Care Providers Caring for Pregnant Women with Possible Zika Virus Exposure - United States (Including U.S. Territories), July 2017. MMWR Morb Mortal Wkly Rep 2017;66(29):781-793. 27. AZDHS. 2016 W52 BIDS Arboviral Report. Phoenix AZ: Arizona Department of Health Services; 2016. 28. Cohen J. Zika has all but disappeared in the Americas. Why? Science 2017. 29. AZDHS. 2017 W37 BIDS Arboviral Report. Phoenix, AZ: Arizona Department of Health Services; 2017 Arizona Sonora Border Region Arbovirus Summary.

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Annex 1.

Douglas A. Ducey | Governor Cara M. Christ | MD, MS, Director Health and Wellness for all Arizonans

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