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Eisen L, Eisen RJ. Changes in the geographic distribution of the blacklegged tick, Ixodes scapularis, in the United States. Ticks Tick Borne Dis 2023; 14:102233. [PMID: 37494882 PMCID: PMC10862374 DOI: 10.1016/j.ttbdis.2023.102233] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/29/2023] [Accepted: 07/17/2023] [Indexed: 07/28/2023]
Abstract
Ixodes scapularis (the blacklegged tick) was considered a species of no medical concern until the mid-1970s. By that time, the tick's geographic distribution was thought to be mainly in the southeastern United States (US), with additional localized populations along the Eastern Seaboard north to southern Massachusetts and in the Upper Midwest. Since 1975, I. scapularis has been implicated as a vector of seven human pathogens and is now widely distributed across the eastern US up to the border with Canada. Geographic expansion of tick-borne diseases associated with I. scapularis (e.g., Lyme disease, anaplasmosis, and babesiosis) is attributed to an expanding range of the tick. However, due to changes in tick surveillance efforts over time, it is difficult to differentiate between range expansion and increased recognition of already established tick populations. We provide a history of the documented occurrence of I. scapularis in the US from its description in 1821 to present, emphasizing studies that provide evidence of expansion of the geographic distribution of the tick. Deforestation and decimation of the white-tailed deer (Odocoileus virginianus), the primary reproductive host for I. scapularis adults, during the 1800s presumably led to the tick disappearing from large areas of the eastern US where it previously had been established. Subsequent reforestation and deer population recovery, together with recent climate warming, contributed to I. scapularis proliferating in and spreading from refugia where it had persisted into the early 1900s. From documented tick collection records, it appears I. scapularis was present in numerous locations in the southern part of the eastern US in the early 1900s, whereas in the north it likely was limited to a small number of refugia sites during that time period. There is clear evidence for established populations of I. scapularis in coastal New York and Massachusetts by 1950, and in northwestern Wisconsin by the late 1960s. While recognizing that surveillance for I. scapularis increased dramatically from the 1980s onward, we describe multiple instances of clearly documented expansion of the tick's geographic distribution in the Northeast, Upper Midwest, and Ohio Valley regions from the 1980s to present. Spread and local population increase of I. scapularis, together with documentation of Borrelia burgdorferi sensu stricto in host-seeking ticks, was universally followed by increases in Lyme disease cases in these areas. Southward expansion of northern populations of I. scapularis, for which the host questing behavior of the nymphal stage leads to substantially higher risk of human bites compared with southern populations, into Virginia and North Carolina also was followed by rising numbers of Lyme disease cases. Ongoing surveillance of ticks and tick-borne pathogens is essential to provide the data needed for studies that seek to evaluate the relative roles of land cover, tick hosts, and climate in explaining and predicting geographic expansion of ticks and tick-borne diseases.
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Affiliation(s)
- Lars Eisen
- Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 3156 Rampart Road, Fort Collins, CO 80521, United States.
| | - Rebecca J Eisen
- Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 3156 Rampart Road, Fort Collins, CO 80521, United States
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Bhadra S, Esteve-Gasent MD, Ellington AD. Analysis of macerated ticks using Boolean logic gating colorimetric isothermal nucleic acid assays for Lyme Borrelia and Ixodes scapularis ticks. Sci Rep 2023; 13:11439. [PMID: 37454160 PMCID: PMC10349842 DOI: 10.1038/s41598-023-38452-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 07/08/2023] [Indexed: 07/18/2023] Open
Abstract
Lyme disease, one of the most common tickborne diseases, has been rapidly spreading in parallel with the expansion of the range of its tick vector. Better tick surveillance efforts are needed to accurately estimate disease risk and to guide public health and clinical management. We have developed two multiplex loop-mediated isothermal amplification (LAMP) reactions coupled with oligonucleotide strand displacement (OSD) probes to identify the tick host, Ixodes scapularis, and the Lyme disease pathogen, Borrelia burgdorferi, they carry. In each multiplex LAMP-OSD assay the co-presence of two target sequences is computed at the DNA level by linking the two corresponding amplicons and detecting the co-product on colorimetric lateral flow dipsticks. In tests with synthetic DNA, the co-presence of as few as four copies of input DNA could be detected, without producing spurious signals. Most importantly, though, the LAMP-OSD assay is amenable to being carried out directly with macerated tick samples, without any sample preparation. In such field conditions, assays performed robustly and demonstrated 97-100% sensitivity and 100% specificity with both field-collected and lab-raised artificially infected ticks. Such easy-to-use, arthropod and pathogen-specific assays would be well suited to field and near patient use without relying on complex instrumentation or infrastructure.
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Affiliation(s)
- Sanchita Bhadra
- Department of Molecular Biosciences, College of Natural Sciences, The University of Texas at Austin, Austin, TX, USA.
- Center for Systems and Synthetic Biology, The University of Texas at Austin, Austin, TX, USA.
| | - Maria D Esteve-Gasent
- Department of Veterinary Pathobiology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX, USA
| | - Andrew D Ellington
- Department of Molecular Biosciences, College of Natural Sciences, The University of Texas at Austin, Austin, TX, USA.
- Center for Systems and Synthetic Biology, The University of Texas at Austin, Austin, TX, USA.
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Fleshman AC, Graham CB, Maes SE, Foster E, Eisen RJ. Reported County-Level Distribution of Lyme Disease Spirochetes, Borrelia burgdorferi sensu stricto and Borrelia mayonii (Spirochaetales: Spirochaetaceae), in Host-Seeking Ixodes scapularis and Ixodes pacificus Ticks (Acari: Ixodidae) in the Contiguous United States. JOURNAL OF MEDICAL ENTOMOLOGY 2021; 58:1219-1233. [PMID: 33600574 PMCID: PMC8355468 DOI: 10.1093/jme/tjaa283] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Indexed: 05/12/2023]
Abstract
Lyme disease is the most common vector-borne disease in the United States. While Lyme disease vectors are widespread, high incidence states are concentrated in the Northeast, North Central and Mid-Atlantic regions. Mapping the distribution of Lyme disease spirochetes in ticks may aid in providing data-driven explanations of epidemiological trends and recommendations for targeting prevention strategies to communities at risk. We compiled data from the literature, publicly available tickborne pathogen surveillance databases, and internal CDC pathogen testing databases to map the county-level distribution of Lyme disease spirochetes reported in host-seeking Ixodes pacificus and Ixodes scapularis across the contiguous United States. We report B. burgdorferi s.s.-infected I. scapularis from 384 counties spanning 26 eastern states located primarily in the North Central, Northeastern, and Mid-Atlantic regions, and in I. pacificus from 20 counties spanning 2 western states, with most records reported from northern and north-coastal California. Borrelia mayonii was reported in I. scapularis in 10 counties in Minnesota and Wisconsin in the North Central United States, where records of B. burgdorferi s.s. were also reported. In comparison to a broad distribution of vector ticks, the resulting map shows a more limited distribution of Lyme disease spirochetes.
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Affiliation(s)
- Amy C Fleshman
- Bacterial Diseases Branch, Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Fort Collins, CO
| | - Christine B Graham
- Bacterial Diseases Branch, Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Fort Collins, CO
| | - Sarah E Maes
- Bacterial Diseases Branch, Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Fort Collins, CO
| | - Erik Foster
- Bacterial Diseases Branch, Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Fort Collins, CO
| | - Rebecca J Eisen
- Bacterial Diseases Branch, Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Fort Collins, CO
- Corresponding author, e-mail:
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Clow KM, Leighton PA, Pearl DL, Jardine CM. A framework for adaptive surveillance of emerging tick-borne zoonoses. One Health 2019; 7:100083. [PMID: 30809583 PMCID: PMC6376153 DOI: 10.1016/j.onehlt.2019.100083] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 02/07/2019] [Accepted: 02/09/2019] [Indexed: 12/19/2022] Open
Abstract
Significant global ecological changes continue to drive emergence of tick-borne zoonoses around the world. This poses an important threat to both human and animal health, and highlights the need for surveillance systems that are capable of monitoring these complex diseases effectively across different stages of the emergence process. Our objective was to develop an evidence-based framework for surveillance of emerging tick-borne zoonoses. We conducted a realist review to understand the available approaches and major challenges associated with surveillance of emerging tick-borne zoonoses. Lyme disease, with a specific focus on emergence in Canada, was used as a case study to provide real-world context, since the process of disease emergence is ongoing in this country. We synthesize the results to propose a novel framework for adaptive surveillance of emerging tick-borne zoonoses. Goals for each phase of disease emergence are highlighted and approaches are suggested. The framework emphasizes the needs for surveillance systems to be inclusive, standardized, comprehensive and sustainable. We build upon a growing body of infectious disease literature that is advocating for reform to surveillance systems. Although our framework has been developed for tick-borne zoonoses, it is flexible and has the potential to be applied to a variety of other vector-borne and zoonotic diseases.
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Affiliation(s)
- Katie M. Clow
- Department of Population Medicine, Ontario Veterinary College, University of Guelph, 50 Stone Road East, Guelph, Ontario N1G 2W1, Canada
| | - Patrick A. Leighton
- Department of Pathology and Microbiology, Faculty of Veterinary Medicine, University of Montréal, 3200 Rue Sicotte, Saint-Hyacinthe, Quebec J2S 2M2, Canada
| | - David L. Pearl
- Department of Population Medicine, Ontario Veterinary College, University of Guelph, 50 Stone Road East, Guelph, Ontario N1G 2W1, Canada
| | - Claire M. Jardine
- Department of Pathobiology, Ontario Veterinary College, University of Guelph, 50 Stone Road East, Guelph, Ontario N1G 2W1, Canada
- Canadian Wildlife Health Cooperative, University of Guelph, 50 Stone Road East, Guelph, Ontario N1G 2W1, Canada
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Halsey SJ, Allan BF, Miller JR. The role of Ixodes scapularis, Borrelia burgdorferi and wildlife hosts in Lyme disease prevalence: A quantitative review. Ticks Tick Borne Dis 2018; 9:1103-1114. [DOI: 10.1016/j.ttbdis.2018.04.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 04/09/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
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Levine JF, Apperson CS, Levin M, Kelly TR, Kakumanu ML, Ponnusamy L, Sutton H, Salger SA, Caldwell JM, Szempruch AJ. Stable Transmission of Borrelia burgdorferi Sensu Stricto on the Outer Banks of North Carolina. Zoonoses Public Health 2016; 64:337-354. [PMID: 27966833 DOI: 10.1111/zph.12302] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Indexed: 02/01/2023]
Abstract
The spirochaete (Borrelia burgdorferi) associated with Lyme disease was detected in questing ticks and rodents during a period of 18 years, 1991-2009, at five locations on the Outer Banks of North Carolina. The black-legged tick (Ixodes scapularis) was collected at varied intervals between 1991 and 2009 and examined for B. burgdorferi. The white-footed mouse (Peromyscus leucopus), house mouse (Mus musculus) marsh rice rat (Oryzomys palustris), marsh rabbit (Sylvilagus palustris), eastern cottontail (Sylvilagus floridanus) and six-lined racerunner (Cnemidophorus sexlineatus) were live-trapped, and their tissues cultured to isolate spirochaetes. Borrelia burgdorferi isolates were obtained from questing adult I. scapularis and engorged I. scapularis removed from P. leucopus, O. palustris and S. floridanus. The prevalence of B. burgdorferi infection was variable at different times and sites ranging from 7 to 14% of examined questing I. scapularis. Mitochondrial (16S) rRNA gene phylogenetic analysis from 65 adult I. scapularis identified 12 haplotypes in two major clades. Nine haplotypes were associated with northern/Midwestern I. scapularis populations and three with southern I. scapularis populations. Sixteen isolates obtained from tick hosts in 2005 were confirmed to be B. burgdorferi by amplifying and sequencing of 16S rRNA and 5S-23S intergenic spacer fragments. The sequences had 98-99% identity to B. burgdorferi sensu stricto strains B31, JD1 and M11p. Taken together, these studies indicate that B. burgdorferi sensu stricto is endemic in questing I. scapularis and mammalian tick hosts on the Outer Banks of North Carolina.
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Affiliation(s)
- J F Levine
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
| | - C S Apperson
- Department of Entomology, College of Agriculture and Life Sciences, North Carolina State University, Raleigh, NC, USA
| | - M Levin
- National Center for Emerging and Zoonotic Infectious Diseases, The Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - T R Kelly
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
| | - M L Kakumanu
- Department of Entomology, College of Agriculture and Life Sciences, North Carolina State University, Raleigh, NC, USA
| | - L Ponnusamy
- Department of Entomology, College of Agriculture and Life Sciences, North Carolina State University, Raleigh, NC, USA
| | - H Sutton
- Department of Entomology, College of Agriculture and Life Sciences, North Carolina State University, Raleigh, NC, USA
| | - S A Salger
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
| | - J M Caldwell
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
| | - A J Szempruch
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA
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Nelder MP, Russell CB, Sheehan NJ, Sander B, Moore S, Li Y, Johnson S, Patel SN, Sider D. Human pathogens associated with the blacklegged tick Ixodes scapularis: a systematic review. Parasit Vectors 2016; 9:265. [PMID: 27151067 PMCID: PMC4857413 DOI: 10.1186/s13071-016-1529-y] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 04/21/2016] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The blacklegged tick Ixodes scapularis transmits Borrelia burgdorferi (sensu stricto) in eastern North America; however, the agent of Lyme disease is not the sole pathogen harbored by the blacklegged tick. The blacklegged tick is expanding its range into areas of southern Canada such as Ontario, an area where exposure to blacklegged tick bites and tick-borne pathogens is increasing. We performed a systematic review to evaluate the public health risks posed by expanding blacklegged tick populations and their associated pathogens. METHODS We followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for conducting our systematic review. We searched Ovid MEDLINE, Embase, BIOSIS, Scopus and Environment Complete databases for studies published from 2000 through 2015, using subject headings and keywords that included "Ixodes scapularis", "Rickettsia", "Borrelia", "Anaplasma", "Babesia" and "pathogen." Two reviewers screened titles and abstracts against eligibility criteria (i.e. studies that included field-collected blacklegged ticks and studies that did not focus solely on B. burgdorferi) and performed quality assessments on eligible studies. RESULTS Seventy-eight studies were included in the final review, 72 were from the US and eight were from Canada (two studies included blacklegged ticks from both countries). Sixty-four (82%) studies met ≥ 75% of the quality assessment criteria. Blacklegged ticks harbored 91 distinct taxa, 16 of these are tick-transmitted human pathogens, including species of Anaplasma, Babesia, Bartonella, Borrelia, Ehrlichia, Rickettsia, Theileria and Flavivirus. Organism richness was highest in the Northeast (Connecticut, New York) and Upper Midwest US (Wisconsin); however, organism richness was dependent on sampling effort. The primary tick-borne pathogens of public health concern in Ontario, due to the geographic proximity or historical detection in Ontario, are Anaplasma phagocytophilum, Babesia microti, B. burgdorferi, Borrelia miyamotoi, deer tick virus and Ehrlichia muris-like sp. Aside from B. burgdorferi and to a much lesser concern A. phagocytophilum, these pathogens are not immediate concerns to public health in Ontario; rather they represent future threats as the distribution of vectors and pathogens continue to proliferate. CONCLUSIONS Our review is the first systematic assessment of the literature on the human pathogens associated with the blacklegged tick. As Lyme disease awareness continues to increase, it is an opportune time to document the full spectrum of human pathogens transmittable by blacklegged ticks.
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Affiliation(s)
- Mark P Nelder
- Enteric, Zoonotic and Vector-borne Diseases; Communicable Diseases, Emergency Preparedness and Response; Public Health Ontario, Toronto, Ontario, Canada.
| | - Curtis B Russell
- Enteric, Zoonotic and Vector-borne Diseases; Communicable Diseases, Emergency Preparedness and Response; Public Health Ontario, Toronto, Ontario, Canada
| | - Nina Jain Sheehan
- Enteric, Zoonotic and Vector-borne Diseases; Communicable Diseases, Emergency Preparedness and Response; Public Health Ontario, Toronto, Ontario, Canada
| | - Beate Sander
- Enteric, Zoonotic and Vector-borne Diseases; Communicable Diseases, Emergency Preparedness and Response; Public Health Ontario, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Stephen Moore
- Enteric, Zoonotic and Vector-borne Diseases; Communicable Diseases, Emergency Preparedness and Response; Public Health Ontario, Toronto, Ontario, Canada
| | - Ye Li
- Analytic Services, Knowledge Services, Public Health Ontario, Toronto, ON, Canada
| | - Steven Johnson
- Analytic Services, Knowledge Services, Public Health Ontario, Toronto, ON, Canada
| | - Samir N Patel
- Public Health Ontario Laboratories, Public Health Ontario, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Doug Sider
- Enteric, Zoonotic and Vector-borne Diseases; Communicable Diseases, Emergency Preparedness and Response; Public Health Ontario, Toronto, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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Gonçalves DD, Moura RA, Nunes M, Carreira T, Vidotto O, Freitas JC, Vieira ML. Borrelia burgdorferi sensu lato in humans in a rural area of Paraná State, Brazil. Braz J Microbiol 2015; 46:571-5. [PMID: 26273276 PMCID: PMC4507553 DOI: 10.1590/s1517-838246220140097] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 08/07/2014] [Indexed: 05/28/2023] Open
Abstract
This study describes the detection of Borrelia garinii and Borrelia
burgdorferi sensu stricto (s.s.) in Brazilian individuals using PCR
and DNA sequencing. Our results suggest that these species are emerging
pathogens in this country, and additional studies are necessary to determine the
epidemiological characteristics of this disease in Brazil.
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Affiliation(s)
- Daniela Dib Gonçalves
- Universidade Estadual de Londrina, Programa de Pós-gradução em Ciência Animal, Universidade Estadual de Londrina, Londrina, PR, Brasil, Programa de Pós-gradução em Ciência Animal, Universidade Estadual de Londrina, Londrina, PR, Brazil. ; Universidade Paranaense, Medicina Veterinária Preventiva, Universidade Paranaense, Umuarama, PR, Brasil, Medicina Veterinária Preventiva, Universidade Paranaense, Umuarama, PR, Brazil
| | - Rodrigo Assunção Moura
- Universidade Paranaense, Medicina Veterinária Preventiva, Universidade Paranaense, Umuarama, PR, Brasil, Medicina Veterinária Preventiva, Universidade Paranaense, Umuarama, PR, Brazil
| | - Mônica Nunes
- Universidade Nova de Lisboa, Medical Microbiology Unit, Institute of Hygiene and Tropical Medicine, Universidade Nova de Lisboa, Lisbon, Portugal, Leptospirosis and Lyme Borreliosis Group, Medical Microbiology Unit, Institute of Hygiene and Tropical Medicine, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Teresa Carreira
- Universidade Nova de Lisboa, Medical Microbiology Unit, Institute of Hygiene and Tropical Medicine, Universidade Nova de Lisboa, Lisbon, Portugal, Leptospirosis and Lyme Borreliosis Group, Medical Microbiology Unit, Institute of Hygiene and Tropical Medicine, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Odilon Vidotto
- Universidade Estadual de Londrina, Departamento de Medicina Veterinária Preventiva, Universidade Estadual de Londrina, Londrina, PR, Brasil, Departamento de Medicina Veterinária Preventiva, Universidade Estadual de Londrina, Londrina, PR, Brazil
| | - Julio Cesar Freitas
- Universidade Estadual de Londrina, Departamento de Medicina Veterinária Preventiva, Universidade Estadual de Londrina, Londrina, PR, Brasil, Departamento de Medicina Veterinária Preventiva, Universidade Estadual de Londrina, Londrina, PR, Brazil
| | - Maria Luísa Vieira
- Universidade Nova de Lisboa, Medical Microbiology Unit, Institute of Hygiene and Tropical Medicine, Universidade Nova de Lisboa, Lisbon, Portugal, Leptospirosis and Lyme Borreliosis Group, Medical Microbiology Unit, Institute of Hygiene and Tropical Medicine, Universidade Nova de Lisboa, Lisbon, Portugal
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Herman-Giddens ME. Erythema Migrans-Like Lesions in the South Require Treatment Given the Current State of Knowledge. Vector Borne Zoonotic Dis 2014; 14:461-3. [DOI: 10.1089/vbz.2013.1545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Marcia E. Herman-Giddens
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
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