To determine the incidence, clinical and laboratory characteristics, and utility of molecular diagnosis of human monocytotropic ehrlichiosis (HME) in the primary care setting, we conducted a prospective study in an outpatient primary care clinic in Cape Girardeau, Missouri. One hundred and two patients with a history of fever for 3 days (>37.7 degrees C), tick bite or exposure, and no other infectious disease diagnosis were enrolled between March 1997 and December 1999. HME was diagnosed in 29 patients by indirect immunofluorescent antibody assay and polymerase chain reaction (PCR). Clinical and laboratory manifestations included fever (100%), headache (72%), myalgia or arthralgia (69%), chills (45%), weakness (38%), nausea (38%), leukopenia (60%), thrombocytopenia (56%), and elevated aspartate aminotransferase level (52%). Hospitalization occurred in 41% of case-patients. PCR sensitivity was 56%; specificity, 100%. HME is a prevalent, potentially severe disease in southeastern Missouri that often requires hospitalization. Because clinical presentation of HME is nonspecific, PCR is useful in the diagnosis of acute HME.

Paragonimiasis is an infection caused by lung flukes of the genus Paragonimus. In Asia, P. westermani infections are relatively common because of dietary practices. However, in North America, cases of paragonimiasis, which are caused by P. kellicotti flukes, are rare. Only 7 autochthonous cases of paragonimiasis were reported during 1968-2008. In 2009, we reported 3 new case-patients with paragonimiasis who had been seen at our medical center over an 18-month period. Six additional case-patients were identified in St. Louis, Missouri, USA, and treated at Washington University-affiliated health centers in 2009-2010. We report detailed descriptions of these case-patients, which includes unusual clinical manifestations. We also describe public health interventions that were undertaken to inform the general public and physicians about the disease and its mode of transmission.

Bourbon virus (BRBV) was first isolated in 2014 from a resident of Bourbon County, Kansas, USA, who died of the infection. In 2015, an ill Payne County, Oklahoma, resident tested positive for antibodies to BRBV, before fully recovering. We retrospectively tested for BRBV in 39,096 ticks from northwestern Missouri, located 240 km from Bourbon County, Kansas. We detected BRBV in 3 pools of Amblyomma americanum (L.) ticks: 1 pool of male adults and 2 pools of nymphs. Detection of BRBV in A. americanum, a species that is aggressive, feeds on humans, and is abundant in Kansas and Oklahoma, supports the premise that A. americanum is a vector of BRBV to humans. BRBV has not been detected in nonhuman vertebrates, and its natural history remains largely unknown.

According to public health research, exposure to casinos is a risk factor for disordered gambling. Consequently, casino self-exclusion programs, which provide gamblers with the opportunity to voluntarily seek limits on their access to gambling venues, can serve as a barometer of the concentration of disordered gambling in an area. This study reports on the distribution, both temporally and geographically, of 6,599 people who applied to exclude themselves from Missouri casinos between November, 1996 and February, 2004. Analyses used Microsoft MapPoint to plot the location of casinos and self-excluders (SEs) across Missouri and its constituent counties. These regional exposure analyses showed that the Western region around Kansas City is an epicenter of disordered gambling as, to a lesser extent, is the Eastern region around St. Louis. The annual number of SE enrollments increased during the first few years of the Missouri self-exclusion program and then leveled off during the later years. These findings have important implications for public health and the development of public health interventions for disordered gamblers.

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Missouri is an agriculturally intensive state, primarily growing corn and soybeans with additional rice and cotton farming in some southeastern counties. Communities located in close proximity to pesticide-treated fields are known to have increased exposure to pesticides and may be at increased risk of adverse birth outcomes. The study aims were to assess the relationship between county-level measures of crop-specific agricultural production and adverse birth outcomes in Missouri and to evaluate the most appropriate statistical methodologies for doing so.

In the United States, rural populations comprise 60 million individuals and suffered from high COVID-19 disease burdens. Despite this, surveillance efforts are biased toward urban centers. Consequently, how rurally circulating SARS-CoV-2 viruses contribute toward emerging variants remains poorly understood. In this study, we aim to investigate the role of rural communities in the evolution and transmission of SARS-CoV-2 during the early pandemic. We collected 544 urban and 435 rural COVID-19-positive respiratory specimens from an overall vaccine-naïve population in Southwest Missouri between July and December 2020. Genomic analyses revealed 53 SARS-CoV-2 Pango lineages in our study samples, with 14 of these lineages identified only in rural samples. Phylodynamic analyses showed that frequent bi-directional diffusions occurred between rural and urban communities in Southwest Missouri, and that four out of seven Missouri rural-origin lineages spread globally. Further analyses revealed that the nucleocapsid protein (N):R203K/G204R paired substitutions, which were detected disproportionately across multiple Pango lineages, were more associated with urban than rural sequences. Positive selection was detected at N:204 among rural samples but was not evident in urban samples, suggesting that viruses may encounter distinct selection pressures in rural versus urban communities. This study demonstrates that rural communities may be a crucial source of SARS-CoV-2 evolution and transmission, highlighting the need to expand surveillance and resources to rural populations for COVID-19 mitigation.

Deep sequencing of wastewater to detect SARS-CoV-2 has been used during the COVID-19 pandemic to monitor viral variants as they appear and circulate in communities. SARS-CoV-2 lineages of an unknown source that have not been detected in clinical samples, referred to as cryptic lineages, are sometimes repeatedly detected from specific locations. We have continued to detect one such lineage previously seen in a Missouri site. This cryptic lineage has continued to evolve, indicating continued selective pressure similar to that observed in Omicron lineages.

Amyotrophic lateral sclerosis (ALS) cases diagnosed between 1998 and 2002 were identified to study ALS prevalence and spatial clustering in Jefferson County, Missouri, where an active lead smelter is located. The study used the El Escorial criteria for ALS diagnosis, the capture-recapture analysis for ALS case ascertainment, and the spatial scan statistic for cluster analysis. The estimated crude prevalence of ALS in Jefferson County was 3.9 per 100,000 population (95% CI, 1.7-7.7) at the time point on December 31, 2002. After age-adjustment to the 2002 U.S. population, the prevalence was 4.2 per 100,000 (95% CI, 1.9-6.6). This prevalence estimate was comparable to recent prevalence estimates from Western Europe. A small but significant cluster (p=0.04) was detected around the smelter area. An ALS registry utilizing outpatient, inpatient, and death certificate data is needed to provide comprehensive information for ALS case ascertainment. Etiologic studies are needed to assess whether living in proximity to a lead smelter is associated with the development of ALS.

Nontuberculous mycobacteria (NTM) infections are caused by environmental exposure. We describe spatial distribution of NTM infections and associations with sociodemographic factors and flooding in Missouri, USA. Our retrospective analysis of mycobacterial cultures reported to the Missouri Department of Health and Social Services surveillance system during January 1, 2008-December 31, 2019, detected geographic clusters of infection. Multilevel Poisson regression quantified small-area geographic variations and identified characteristics associated with risk for infection. Median county-level NTM infection rate was 66.33 (interquartile range 51-91)/100,000 persons. Risk of clustering was significantly higher in rural areas (rate ratio 2.82, 95% CI 1.90-4.19) and in counties with >5 floodings per year versus no flooding (rate ratio 1.38, 95% CI 1.26-1.52). Higher risk for NTM infection was associated with older age, rurality, and more flooding. Clinicians and public health professionals should be aware of increased risk for NTM infections, especially in similar environments.

Once ubiquitous, North American box turtles are experiencing reductions in abundance and range, but the magnitude of these losses is largely unknown. In Missouri, native box turtles (Terrapene mexicana triunguis and Terrapene ornata ornata) are declining across the state due to anthropogenic disturbances such as urbanization, habitat fragmentation, and vehicle collisions. Through radio-tracking over a period of 7 years, we documented the survival of adult three-toed box turtles at two sites in Missouri: Forest Park (urban park) and Tyson Research Center (TRC) (a protected rural forest). Estimated annual survival of adult turtles in Forest Park was 79% (95% CI: 0.68-0.87) while at TRC annual survival was 93% (95% CI: 0.83-0.97). The odds of annual survival for a turtle at TRC were 3.5 times that of a turtle living in Forest Park. "Winter kill," which refers to box turtles found dead on the surface during brumation or within 2 weeks of emergence, was the most frequently documented category of mortality in Forest Park. At TRC, winter kill was not documented; however, the reasons for most deaths were unknown. These data raise questions about the potential of large urban parks as refuges for box turtles, which we may answer by future studies that compare box turtles living in multiple urban and rural settings. Our preliminary data suggest that even the largest urban parks may not be able to sustain populations of box turtles which has severe implications as urbanization continues to degrade and eliminate box turtle habitat throughout their range.

Background: Providing public access to exercise and play is vital for health promotion across populations. We evaluated the use of and satisfaction at Trojan Park, a multigenerational playground with multiple activity areas and fitness zones in the city of Wellston in St. Louis County, MO. Methods: We used video footage and the System for Observing Play and Recreation in Communities (SOPARC), which is a valid and reliable system for collecting data on physical activity in parks. We then performed intercept interviews to gather user information and measure overall satisfaction with the park. Results: The park received a variety of attendees across age groups, with children and middle-aged adults representing 41.1% and 50.3% of total park users, respectively. During the time observed, 47% of attendees were engaged in moderate to vigorous physical activity (MVPA), 22% were engaged in light physical activity (walking), and 30% were sedentary. We also observed participants spending the most time on the basketball court (38%), playground (28%), and picnic (17%) areas. Park users traveled a wide range of distances to access the park and the overwhelming majority reported a high level of satisfaction. Conclusions: Our findings demonstrate that multigenerational playgrounds with access to various activities and fitness zones may provide social and physical health benefits.

Wolbachia are endosymbionts of numerous arthropod and some nematode species, are important for their development and if present can cause distinct phenotypes of their hosts. Prophage DNA has been frequently detected in Wolbachia, but particles of Wolbachia bacteriophages (phage WO) have been only occasionally isolated. Here, we report the characterization and isolation of a phage WO of the southern ground cricket, Allonemobius socius, and provided the first whole-genome sequence of phage WO from this arthropod family outside of Asia. We screened A. socius abdomen DNA extracts from a cricket population in eastern Missouri by quantitative PCR for Wolbachia surface protein and phage WO capsid protein and found a prevalence of 55% and 50%, respectively, with many crickets positive for both. Immunohistochemistry using antibodies against Wolbachia surface protein showed many Wolbachia clusters in the reproductive system of female crickets. Whole-genome sequencing using Oxford Nanopore MinION and Illumina technology allowed for the assembly of a high-quality, 55 kb phage genome containing 63 open reading frames (ORF) encoding for phage WO structural proteins and host lysis and transcriptional manipulation. Taxonomically important regions of the assembled phage genome were validated by Sanger sequencing of PCR amplicons. Analysis of the nucleotides sequences of the ORFs encoding the large terminase subunit (ORF2) and minor capsid (ORF7) frequently used for phage WO phylogenetics showed highest homology to phage WOAu of Drosophila simulans (94.46% identity) and WOCin2USA1 of the cherry fruit fly, Rhagoletis cingulata (99.33% identity), respectively. Transmission electron microscopy examination of cricket ovaries showed a high density of phage particles within Wolbachia cells. Isolation of phage WO revealed particles characterized by 40-62 nm diameter heads and up to 190 nm long tails. This study provides the first detailed description and genomic characterization of phage WO from North America that is easily accessible in a widely distributed cricket species.

Bourbon virus (BRBV) was first discovered in 2014 in a fatal human case. Since then it has been detected in the tick Amblyomma americanum in the states of Missouri and Kansas in the United States. Despite the high prevalence of BRBV in ticks in these states, very few human cases have been reported, and the true infection burden of BRBV in the community is unknown. Here, we developed two virus neutralization assays, a vesicular stomatitis virus (VSV)-BRBV pseudotyped rapid assay and a BRBV focus reduction neutralization assay, to assess the seroprevalence of BRBV neutralizing antibodies in human sera collected in 2020 in St. Louis, MO. Of 440 human serum samples tested, three (0.7%) were able to potently neutralize both VSV-BRBV and wild-type BRBV. These findings suggest that human infections with BRBV are more common than previously recognized. IMPORTANCE Since the discovery of the Bourbon virus (BRBV) in 2014, a total of five human cases have been identified, including two fatal cases. BRBV is thought to be transmitted by the lone star tick, which is prevalent in the eastern, southeastern, and midwestern United States. BRBV has been detected in ticks in Missouri and Kansas, and serological evidence suggests that it is also present in North Carolina. However, the true infection burden of BRBV in humans is not known. In the present study, we developed two virus neutralization assays to assess the seroprevalence of BRBV-specific antibodies in human sera collected in 2020 in St. Louis, MO. We found that a small subset of individuals are seropositive for neutralizing antibodies against BRBV. Our data suggest that BRBV infection in humans is more common than previously thought.

Enterovirus D68 (EV-D68) causes severe respiratory illness outbreaks among children, particularly those with asthma. We previously detected neutralizing antibodies against the predominant EV-D68 B1 clade in the 2014 outbreak in serum collected before the outbreak (2012–2013) from persons 24 months to 85 years of age. We recently detected neutralizing antibodies to the 2014 B1, B2, and D clade viruses in serum collected after the 2014 outbreak (April–May 2017) from 300 children 6 months to 18 years of age. B1 virus neutralizing antibodies were found in 100% of patients, even children born after 2014; B2 in 84.6%, and D in 99.6%. In 2017, titers increased with patient age and were higher than titers in 2012–2013 from comparably aged children. Rate of seronegativity was highest (15.3%) for B2 virus. Multivariate analysis revealed an association between asthma and higher titers against B2 and D viruses. EV-D68 seems to have circulated during 2014–2017.

The amphibian chytrid fungus, Batrachochytrium dendrobatidis (Bd), is a globally emerging pathogen that has caused widespread amphibian population declines, extirpations, and extinctions. However, Bd does not occur in all apparently suitable amphibian populations, even within regions where it is widespread, and it is often unclear why Bd occurs in some habitats but not others. In this study, we rigorously surveyed the amphibian and invertebrate biodiversity of 29 ponds in Missouri, screened resident amphibian larvae (Rana (Lithobates) sp.) for Bd infection, and characterized the aquatic physiochemical environment of each pond (temperature pH, conductivity, nitrogen, phosphorus, and chlorophyll-a). Our goal was to generate hypotheses toward answering the question, "Why does Bd not occur in all apparently suitable habitats?" Bd occurred in assayed amphibians in 11 of the 29 ponds in our study area (38% of ponds). We found no significant relationship between any single biotic or abiotic variable and presence of Bd. However, multivariate analyses (nonmetric multidimensional scaling and permutational tests of dispersion) revealed that ponds in which Bd occurred were a restricted subset of all ponds in terms of amphibian community structure, macroinvertebrate community structure, and pond physiochemistry. In other words, Bd ponds from 6 different conservation areas were more similar to each other than would be expected based on chance. The results of a structural equation model suggest that patterns in the occurrence of Bd among ponds are primarily attributable to variation in macroinvertebrate community structure. When combined with recent results showing that Bd can infect invertebrates as well as amphibians, we suggest that additional research should focus on the role played by non-amphibian biota in determining the presence, prevalence, and pathogenicity of Bd in amphibian populations.

Reported coronavirus disease 2019 (COVID-19) case counts likely underestimate the true prevalence because mild or asymptomatic cases often go untested. Here, we use a sero-survey to estimate the seroprevalence of IgG antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the St. Louis, MO, metropolitan area in a symptom-independent manner. Five hundred three adult and 555 pediatric serum/plasma samples were collected from patients presenting to Barnes-Jewish Hospital or St. Louis Children's Hospital between 14 April 2020 and 12 May 2020. We developed protocols for in-house enzyme-linked immunosorbent assays (ELISAs) using spike and nucleoprotein and used the assays to estimate a seroprevalence rate based on our samples. Overall IgG seropositivity was estimated to be 1.71% (95% credible interval [CI], 0.04% to 3.38%) in pediatric samples and 3.11% (95% CI, 0.92% to 5.32%) in adult samples. Seropositivity was significantly lower in children under 5 years of age than in adults, but rates between adults and children aged 5 or older were similar. Of the 176 samples tested from children under 4 years of age, none were positive.IMPORTANCE This study determined the percentages of both children and adult samples from the greater St. Louis metropolitan area who had antibodies to SARS-CoV-2 in late April to early May 2020. Approximately 1.7 to 3.1% of the tested individuals had antibodies, indicating that they had previously been infected by SARS-CoV-2. These results demonstrate that the extent of infection was about 10 times greater than the number of confirmed cases at that time. Furthermore, it demonstrated that by 5 years of age, children were infected to an extent similar to that of adults.

Despite well-known adverse health effects of maternal smoking during pregnancy (MSP), it is still unclear if MSP varies geographically and if neighborhood socioeconomic deprivation (SED) plays an important role in MSP. This study aims to investigate small-area geographic variation in MSP and examine the association of SED with MSP.

Influenza B viruses (IBVs) are causing an increasing burden of morbidity and mortality, yet the prevalence of culture-adapted mutations in human seasonal IBVs are unclear. We collected 368 clinical samples from patients with influenza-like illness in Missouri during the 2019-2020 influenza season and recovered 146 influenza isolates including 38 IBV isolates. Of MDCK-CCL34, MDCK-Siat1, and humanized MDCK (hCK), hCK showed the highest virus recovery efficiency. All Missourian IBVs belonged to the Victoria V1A.3 lineage, all of which contained a three-amino acid deletion on the HA protein and were antigenically distant from the Victoria lineage IBV vaccine strain used during that season. By comparing genomic sequences of these IBVs in 31 paired samples, eight cell-adapted nonsynonymous mutations were identified, with the majority in the RNA polymerase. Analyses of IBV clinical sample-isolate pairs from public databases further showed that cell- and egg-adapted mutations occurred more widely in viral proteins, including the receptor and antibody binding sites on HA. Our study suggests that hCK is an effective platform for IBV isolation and that culture-adapted mutations may occur during IBV isolation. As culture-adapted mutations may affect subsequent virus studies and vaccine development, the knowledge from this study may help optimize strategies for influenza surveillance, vaccine strain selection, and vaccine development.