The June 2025 issue of the Journal of Environmental Health (Volume 87, Number 10), published by the National Environmental Health Association.
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Environmental Health To build, sustain, and empower an effective environmental health workforce Volume 87, No. 10 June 2025 Journal of
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ABOUT THE COVER
Droughts directly and indirectly aect the health of communities through reduced air and water qual- ity, increased inci- dence of infectious disease, malnutri- tion, and mental
The Health-Related Consequences of Drought in the Po and Colorado River Basins................. 8
ADVANCEMENT OF THE PRACTICE
Online Teaching of Environmental Health................................................................................ 20
Special Report: Health Equity, Environmental Justice, and American Indian and Alaska Native Communities: A Short Report ......................................................................... 26
illness. The Po River Basin region in Europe and the Colorado River Basin region in the U.S. illustrate how geography and policy aect the prevalence of health-related consequences of drought. This issue’s cover article quantified the relevant health-related consequences of drought in these two regions and identified the most salient public health challenge in each region. By identifying these prominent health- related consequences, public health practitio- ners and policymakers can more strategically target interventions and policies to reduce the health burden of drought. See page 8. Cover images © iStockphoto: mauinow1, Pietro Cappa
Guest Editorial: Beyond Inspections: Using Foodborne Outbreak Data to Drive Prevention ......... 36
Direct From ATSDR: Promoting Environmental Health and Environmental Medicine Resources From ATSDR: Educator Insights ................................................................... 40
The Practitioner’s Tool Kit: The Small Talk on Dust ................................................................... 44
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President’s Message: Changing Behavior Through Understanding Values, Perceptions, and Motivations ..................................................................................................................... 6
Special Listing ........................................................................................................................... 50
NEHA 2025 AEC....................................................................................................................... 52
NEHA News .............................................................................................................................. 54
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June 2025 • Journal of Environmental Health
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PRESIDENT’S MESSAGE
Changing Behavior Through Understanding Values, Perceptions, and Motivations
CDR Anna Khan, MA, REHS/RS
T his President’s Message column is my last. It has been an honor to serve as the president of the National Envi- ronmental Health Association (NEHA). Simi- lar to the presidents who came before me, I have encountered challenges and new oppor- tunities to learn, grow, and evolve. One pub- lic health area that has continually captivated my thoughts is the power of behavior change. As I reflect on my time as NEHA president, I know change is not just about delivering facts or enforcing rules. It is about under- standing the heart of what motivates people. It is something that deeply matters to us as environmental health professionals and is at the heart of our mission to protect and improve the well-being of our communities. We want to bring about positive change dur- ing the inspection, whether we are explain- ing an observation during a food inspection or discussing a water issue. Change requires empathy, compassion, and the willingness to see things from the perspective of oth- ers. It is about inspiring others to act, to see beyond the moment, and to step toward a healthier, more sustainable future. The work we do is not easy, and change is never simple. Shifting people’s behaviors, especially when it comes to public health and environmental well-being, takes time and patience. It is easy to believe that pro- viding facts alone will drive change, but we know that true transformation happens when we understand the deeper layers of human behavior—our values, our perceptions, and our motivations. It is through understanding each other, with kindness and empathy, that we can create a better tomorrow for all.
face of industrial pollution, and in 1970, it was labeled as “our ecological crisis.” It took time for people to understand the dire consequences of pollution and to shift their perceptions. Over the years, as thousands of jobs were lost and the long-term eects on public health became clearer, the public’s view shifted. This change did not happen because people were simply told facts. It happened because people started to see and feel the con- sequences of their actions. This transforma- tion in public perception shows us that even when change seems dicult, it is possible when people are ready to confront the truth. This example serves as a reminder that, when it comes to behavior change, facts alone do not change hearts and minds. We often hear that to make a dierence, we must pro- vide the facts. But we know that facts alone do not always drive people to act. Facts can guide decisions, but they do not necessarily inspire change. People’s behavior is deeply influenced by how they interpret and relate to the facts, and by if they believe they have control over their actions. People’s values, perceptions, and motivations shape how they approach prob- lems and how they make decisions. The key to creating meaningful change lies in understanding those values. People are driven by what they care about most. For some, it could be saving money or conserving resources. For others, it could be protecting the environment or the health of their fami- lies. Take something as simple as turning o the lights when leaving a room. It is a small action, but it has been taught to generations of children as a way to save energy. In my own home, I would hear my parents jokingly say,
Change requires a deep empathy, compassion, and the willingness to see things from the perspective of others.
Let us look at a powerful example from history that oers important lessons for us today. According to Boissoneault (2019), the Civil War turned Cleveland, Ohio, into a manufacturing city “almost overnight,” and factories quickly sprouted along the Cuyahoga River, which fueled an economic boom. The river, once a vital lifeline for the community, became choked with pollution, was coated in oil, and was no longer able to be used as a source of healthy drinking water. This economic progress was viewed by some as a symbol of success. The river even caught fire at least 12 times over the years. Yet, amid this destruction and the loss of millions of dollars, some individuals still did not see the consequences of the pollution. In the 1950s, however, the factories closed and >60,000 jobs were lost, and the costs became unde- niable. By 1969, when the river caught fire again, the national response was immediate and fierce. In the wake of that fire, the coun- try began to see the true environmental crisis unfolding. The Cuyahoga River became the
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“We don’t own stock in GE, turn the lights off when you leave the room.” Others might frame it differently, saying, “We turn off the lights because we care about the environ- ment.” Regardless of the motivation, the out- come is the same—behavior changes when people understand why it matters, when they see the impact of their actions, and when they feel personally connected to the change. To create real and lasting change, we must recognize that people are emotional beings, not machines. Our emotions, experiences, and perceptions drive the choices we make. And so, if we want to influence behavior, we must first understand the emotional and psychological factors that shape decisions. Change is not just about delivering facts or enforcing rules, it is about understanding the heart of what motivates people. I will
say it again: Change requires a deep empa- thy, compassion, and the willingness to see things from the perspective of others. Understanding people’s values, percep- tions, and motivations is key to bringing about meaningful and lasting behavioral change. This approach requires empathy, patience, and an openness to seeing things from other people’s perspectives. Whether we are working to protect the environment, improve public health, or encourage more sustainable prac- tices, it is essential to recognize the emotional and psychological factors that influence deci- sion-making. By doing so, we can create more compassionate, effective strategies for change that resonate with people and ultimately lead to a better world for all. As I step down from my role as NEHA president, I am filled with gratitude for the
opportunity to contribute to our shared goals. I hope that we continue to approach our work with understanding, empathy, and a commit- ment to positive change.
Reference Boissoneault, L. (2019, June 19). The Cuyahoga River caught fire at least a dozen times, but no one cared until 1969. Smithsonian magazine. https://www.smith sonianmag.com/history/cuyahoga-river- caught-fire-least-dozen-times-no-one- cared-until-1969-180972444/ akhan@neha.org
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June 2025 • Journal of Environmental Health
ADVANCEMENT OF THE SCIENCE
Open Access
The Health-Related Consequences of Drought in the Po and Colorado River Basins
Christopher A. Carter, MPH Kansas State University Ellyn R. Mulcahy, MPH, PhD
Department of Diagnostic Medicine and Pathobiology, Kansas State University
Thomas Platt, PhD Division of Biology, Kansas State University Justin Kastner, PhD
Department of Diagnostic Medicine and Pathobiology, Kansas State University
diseases, malnutrition, migration, and mental illness. Poor air quality causes and aggravates numerous conditions including upper respiratory tract infections, asthma, and cardiovascular disease (Li et al., 2023; Lippmann, 2020). Exposure to airborne pol- lutants also increases rates of diabetes melli- tus and adverse birth outcomes (Feng et al., 2016). Drought inhibits the removal of air- borne pollutants from the air via precipita- tion, alters the generation rate of pollutants such as ozone, and extends the suspension time of airborne particulates (Wang et al., 2017). Dry conditions also favor wildfires and the resuspension of soil, both of which are common sources of airborne pollutants (Bo et al., 2020; Šmejkalová & Brzezina, 2022). These mechanisms can increase concentrations of coarse particulate matter (PM 10 ), fine particulate matter (PM 2.5 ), and nitrogen oxide despite reductions in anthro- pogenic emissions (Hu et al., 2019). Con- versely, periods of high precipitation reduce concentrations of PM 10 (Baltaci et al., 2019). Through these reductions in wet scaveng- ing and changes in pollutant dynamics, the negative health consequences of air pol- lutants worsen during drought conditions and exemplify the direct consequences of drought on health. Particulate matter often includes soil-resid- ing pathogens such as Coccidioides immitis and C. posadasii , the causative agents of coc- cidioidomycosis (Valley fever). Coccidioides mycelia reside in the soil and produce spores that, when inhaled, cause fungal pneumo- nia in a variety of hosts such as humans, dogs, and aquatic mammals (Nguyen et al., 2013). Soil moisture provided by winter pre-
Abstract Global climate change will continue to expose more communities to drought, a prominent environmental health hazard. Droughts directly and indirectly aect the health of communities through reduced air and water quality, increased incidence of infectious disease, malnutrition, and mental illness. The Po River Basin region in Europe and the Colorado River Basin region in the U.S. illustrate how geography and policy aect the prevalence of health-related consequences of drought. Our study quantifies the relevant health-related consequences of drought in these two regions and identifies the most salient public health challenge in each region. The most salient risk in the Po River Basin is the heavy industry and natural geography that result in poor air quality. In the Colorado River Basin, the emerging disease coccidioidomycosis (Valley fever) poses the most salient risk. By identifying these prominent health-related consequences, public health practitioners and policymakers can more strategically target interventions and policies to reduce the health burden of drought. Keywords: drought, air quality, coccidioidomycosis (Valley fever), health consequences, Colorado River Basin (U.S.), Po River Basin (Italy)
Introduction Global climate change threatens a variety of environmental resources, including water. Rising temperatures and altered weather patterns aect the volume of existing sur- face water, groundwater, and precipitation (Intergovernmental Panel on Climate Change [IPCC], 2023). Globally, climate change is expected to increase freshwater resources due to increased precipitation, runo, river dis- charge, and flooding (Oki & Kanae, 2006). In some regions, however, weather variability
compounded with higher temperatures will lead to periods of drought interspersed with flooding (IPCC, 2023). Currently, one half of the global population experiences water scar- city for at least part of the year (IPCC, 2023). As climate change persists, water availability will continue to decline, especially for those already living in water-scarce environments (Gosling & Arnell, 2016). Water scarcity is associated with nega- tive health outcomes, including reduced air quality, waterborne and vectorborne
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associated with drought is West Nile virus (WNV) disease (Davis et al., 2018; Johnson & Sukhdeo, 2013; Paull et al., 2017; Ruiz et al., 2010). Culex pipiens —the main WNV vector in the U.S. and Italy—has a higher dehydration tolerance than most insects, including other mosquitoes; they can tol- erate up to 40% water loss. This resistance to dehydration facilitates increased Culex populations following drought (Benoit & Denlinger, 2007). Furthermore, dehydration in Culex mosquitoes increases activity and biting rates, amplifying the risk of disease transmission (Hagan et al., 2018). These behaviors differentiate Culex mosquitoes from other vectors and facilitate the amplifi- cation of diseases vectored by Culex mosqui- toes in drought conditions. Vector–pathogen dynamics also facili- tate the relationship between WNV and drought. The higher temperatures that often accompany drought increase WNV titers in mosquitoes, shorten WNV incuba- tion time, and increase the amount of virus transmitted from vectors to hosts (Reisen et al., 2006). Similarly, higher temperatures increase mosquito WNV infection rates (Kilpatrick et al., 2008). Combined with the dehydration resistance and drought- time behavior of the Culex vector, WNV dynamics during drought facilitate the amplification of WNV transmission. Drought also exacerbates poverty. Several social and economic determinants of health, including nutrition and migration, drive this complicated problem. Indeed, for already- impoverished groups living on the edge of subsistence, drought can bring additional dis- tress, even devastation (Landes, 1999). Many agricultural communities depend on locally cultivated crops and livestock for nutritional content. When drought decreases crop yields, subsistence agriculturists face food insecu- rity (Brewis et al., 2020; Lieber et al., 2020). Decreased water availability also inhibits food preparation and safety while diverting income from food acquisition to water acqui- sition (Brewis et al., 2020). Through these mechanisms, drought increases short-term effects of malnutrition such as lower body mass, especially in children (Jankowska et al., 2012; Lieber et al., 2020). Long-term effects, such as child wasting or stunting, can also increase following drought periods (Hagos et al., 2014; Jankowska et al., 2012; Yeboah et
FIGURE 1
The Po River Basin in Northern Italy
Source: Food and Agriculture Organization of the United Nations and Esri.
cipitation and El Niño–Southern Oscillations facilitates the growth of Coccidioides myce- lia (Tobin et al., 2022; Weaver & Kolivras, 2018). Subsequent periods of high tempera- tures and drought then dry the soil, increas- ing the risk of soil disturbance and transmis- sion (Head et al., 2022). Thus, within-year variability of precipitation increases the transmission of Valley fever, contributing to the public health burden of drought-related air pollution (Shriber et al., 2017). In addition to reducing soil moisture, drought alters surface water availability, increasing the risk of chemical contamina- tion. Drought-associated floods introduce nonpoint source nitrogen and phosphorus
pollution via runoff (Bi et al., 2019). Simi- larly, groundwater depletion during droughts increases nitrate concentrations in private wells, which are a critical water infrastruc- ture in rural communities (Levy et al., 2021). This nitrate contamination can result in inad- equate blood oxygenation levels in infants and occasionally fatal methemoglobinemia (Maxwell, 2013). Drought-associated chemi- cal contamination of surface and groundwa- ter thus presents a severe public health threat, especially in rural areas. Drought-driven declines in surface water availability also impact the ecology and epidemiology of mosquito-borne diseases. The most well-evidenced zoonotic disease
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June 2025 • Journal of Environmental Health
ADVANCEMENT OF THE SCIENCE
al., 2022). While drought is often not the sole contributor to food insecurity and poverty, it does amplify existing challenges. Drought poses numerous health-related and economic challenges that often induce internal (within-country) and external (between-country) migration. Typically, drought-related migration consists of men from rural, agricultural communities seek- ing alternative income sources in urban areas—areas that might also be experienc- ing drought-related health impacts (Defrance et al., 2023; Gray & Mueller, 2012). Migra- tion as an adaptive strategy, however, is often a temporary last resort (Jülich, 2011). Drought-related migration is a contributor to global migration and accounted for 10% of the global increase in migration between 1970 and 2000 (Zaveri et al., 2021). Some subpopulations—notably women and the poor—are unable to migrate due to finan- cial or other barriers and instead face other health-related challenges of drought (Bor- gomeo et al., 2021; Defrance et al., 2023; Gray & Mueller, 2012). Individuals who do migrate also experience a variety of negative health outcomes. Migrants, when not appro- priately supported by the nation-state gov- ernments receiving them, face an increased risk of infectious diseases—notably, tubercu- losis, AIDS, and waterborne and foodborne illnesses (Gushulak & MacPherson, 2007). Mental health challenges, including but not limited to depression, also persist in migrant communities (Bhugra, 2004). Drought also affects the mental health of nonmigrant communities. Again, drought increases food insecurity, a risk factor for men- tal distress (Friel et al., 2014). Other stressors, including financial distress and social isola- tion, pose challenges (Sartore et al., 2008; Vins et al., 2015). Farmers and their families thus report increased stress and depression dur- ing droughts (Dean & Stain, 2010; Sartore et al., 2008; Vins et al., 2015). Drought-related mental health challenges can be so severe as to increase suicides, especially in rural men (Hanigan & Chaston, 2022). The culminat- ing economic and health-related challenges of drought have severe consequences on rural mental health, compounding the public health burden of drought. Our study examines the health-related consequences of drought in two regions, the Po River Basin (PRB) in Northern Italy and
FIGURE 2
The Colorado River Basin (CRB) in the Southwestern United States
Source: Lincoln Institute of Land Policy.
the Colorado River Basin (CRB) in the West- ern U.S. The 661-km (410-mi) Po River forms the 71,000 km 2 (27,000 mi 2 ) PRB, providing water for 17 million people in Italy and Swit- zerland (Figure 1). The 2,220-km (1,400- mi) Colorado River forms the 630,000 km 2 (240,000 mi 2 ) CRB, providing water for 40 million people across 7 states (Arizona, California, Colorado, Nevada, New Mexico, Utah, and Wyoming), 30 federally recognized tribes, and Mexico (Figure 2). Both rivers are sourced largely from snowmelt, and as such are threatened by rising temperatures due to climate change. In the PRB, decreased precip- itation and snowmelt, along with increased evapotranspiration (likely due to higher temperatures), have led to periodic drought conditions. Similarly, warming trends in the CRB have decreased snowpack, leading to a sustained drought since 2000. To prioritize avenues for public health and other policy interventions, we explore the
severity of the potential health-related conse- quences of drought in both the PRB and the CRB. Additionally, we compare the severity of each consequence between both regions to demonstrate how geography and exist- ing policies influence the degree to which droughts impact communities. Methods Our study examined the severity of PM 10 , PM 2.5 , coccidioidomycosis, groundwater nitrate infiltration, WNV, and relative pov- erty in the PRB and CRB. To assess these health-related consequences of drought, we used publicly available data sets. The 2013–2021 PM 10 and PM 2.5 data from Italy originated from the European Environ- ment Agency (2025a, 2025b), while the U.S. Environmental Protection Agency (2023) sourced the 2013–2022 U.S. data. The Ari- zona and California 2013–2022 county- level coccidioidomycosis data originated
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Average A) PM 10 and B) PM 2.5 Concentrations in the Po River Basin (PRB) From 2013–2021 FIGURE 3
A
B
from the California Department of Public Health (2024) and the Arizona Department of Health Services (2025), and state-level data for Nevada, New Mexico, Utah, and Wyoming were obtained from the Centers for Disease Control and Prevention (CDC, n.d.). The 2013–2021 groundwater nitrate concentrations from Italy are available from the European Environment Agency (2024), and the 2013–2022 U.S. data were sourced through the U.S. Water Quality Portal (National Water Quality Monitoring Coun- cil et al., 2021). Additionally, the European Center for Dis- ease Control (2024) and CDC (2025) pro- vided the 2013–2022 WNV data. The rela- tive poverty data for Italy originated from the Italian National Institute of Statistics (2023), while the U.S. Census Bureau (2023) sourced
the CRB data. Once sourced, the data were cleaned, reformatted, analyzed, and visual- ized using RStudio (version 2024.04.0) and ArcGIS Pro (version 3.2.1, Esri Inc.). Figures were generated in RStudio using the ggplot2 package (Wickham, 2009). Maps generated in ArcGIS Pro used shapefiles from Esri, the Food and Agriculture Organization of the United Nations, and the Lincoln Institute of Land Policy. Results From 2013–2021, the PRB experienced an average PM 10 concentration of 19.72 μg/m 3 and an average PM 2.5 concentration of 13.81 μg/m 3 . Average PM 10 concentrations ranged from 0 μg/m 3 to 47.3 μg/m 3 with an average minimum value of 7.5 μg/m 3 and an average maximum value of 33.7 μg/m 3 . Average PM 2.5
concentrations ranged from 0 μg/m 3 to 35.6 μg/m 3 with an average minimum value of 4.4 μg/m 3 and an average maximum value of 24.6 μg/m 3 . Figures 3 and 4 show the average pollutant concentrations in the PRB for the study period. From 2013–2022, the CRB experienced an average PM 10 concentration of 19.33 μg/ m 3 and an average PM 2.5 concentration of 6.4 μg/m 3 . Average PM 10 concentrations ranged from 6.4 μg/m 3 to 120.3 μg/m 3 with an average minimum value of 12.3 μg/m 3 and an average maximum value of 29.6 μg/m 3 . Average PM 2.5 concentrations ranged from 0.9 μg/m 3 to 30.5 μg/m 3 with an average minimum value of 4.3 μg/m 3 and an average maximum value of 8.7 μg/m 3 . Figures 5 and 6 show the average pollutant concentrations in the CRB for the study period.
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The CRB reported 90,861 cases of coc- cidioidomycosis with an average annual incidence of 43.47 cases per 100,000 resi- dents. Pinal County, Arizona, reported the highest average incidence of 162.5 cases per 100,000 residents. Valley fever cases peaked in the CRB in 2021 with 12,901 cases and an incidence of 59.9 cases per 100,000 residents. Additionally, Valley fever case incidences ranged annually from 0 cases to 258.3 cases per 100,000 residents, with an average minimum incidence of 26.8 cases per 100,000 residents and an average maxi- mum incidence of 68.2 cases per 100,000 residents. Figures 7 and 8 show the average incidence of Valley fever in the CRB during the study period. From 2013–2021, PRB groundwater nitrate concentration averaged 24.2 mg/L. Nitrate concentrations ranged from 0.92 mg/L to 435.9 mg/L with an average minimum value of 14.9 mg/L and an average maximum value of 55.8 mg/L. PRB nitrate concentrations peaked in 2020, with an average concentra- tion of 53.5 mg/L. Figure 9 shows the average nitrate concentrations in the PRB during the study period. In the seven CRB states, groundwater nitrate concentrations averaged 88.2 mg/L. Nitrate concentrations ranged from 0.2 mg/L to 1,845.5 mg/L with an average minimum concentration of 85.6 mg/L and an average maximum concentration of 91.3 mg/L. CRB nitrate concentrations peaked in 2018, with an average concentration of 311.5 mg/L. Fig- ure 10 shows the average nitrate concentra- tions in the CRB during the study period. From 2013–2022, the PRB reported 1,182 cases of WNV for an average cumulative incidence of 8.3 cases per 100,000 residents, with Rovigo Province in Italy having the highest cumulative incidence of 40.5 cases per 100,000 residents. WNV cases peaked in 2018 and 2022 as the PRB reported 403 and 389 cases, respectively, corresponding to an average incidence of 3.1 cases per 100,000 residents in 2018 and 2022. The CRB reported 4,155 cases of WNV between 2013 and 2022 for an average cumu- lative incidence of 33.4 cases per 100,000 residents. Delta County, Colorado, had the highest cumulative incidence with 368 cases per 100,000 residents over the study period. WNV cases peaked in 2021 as CRB counties reported 1,934 cases.
Annual Average A) PM 2.5 and B) PM 10 Concentrations in the Po River Basin From 2013–2021 FIGURE 4 A
B
The PRB experienced an average relative poverty incidence of 5.6% (of households) from 2014–2022. The poverty incidence ranged from 3.2% to 11.7% with an average minimum incidence of 4.3% and an average maximum incidence of 7.6%. Poverty inci- dence peaked in 2016 with an average inci- dence of 6.4%. The CRB experienced an average poverty rate of 14.42% (of individuals) from 2013– 2022. The poverty rate ranged from 3.6% to 38.7% with an average minimum rate of 10.7% and an average maximum rate of 19.4%. Poverty rates peaked in 2014 with an average rate of 15.9%. Discussion Prioritizing the salient health-related conse- quences of drought is a critical step for pub- lic health practitioners and policymakers, because identifying the most salient conse-
quences allows for a targeted, actionable, and feasible mitigation strategy (Bardach, 2000). We identified the most salient consequence based on the following criteria: number of people at risk, number of people affected, severity of the hazard, trend (increasing or decreasing) during the study period, and availability of mitigation systems or policies. Based on the above considerations, the most salient health-related consequence of drought in the PRB is poor air quality. Despite existing regulations, the PRB’s aver- age annual particulate matter concentrations remain well above those recommended by the World Health Organization (WHO, 2025). Although particulate matter concentrations declined slightly over the study period, these reductions are insufficient to protect the health of PRB residents. Furthermore, air quality exposes all PRB residents to a variety of severe health hazards. Because poor air
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FIGURE 5
Average A) PM 10 and B) PM 2.5 Concentrations in the Colorado River Basin (CRB) From 2013–2022
A
B
quality affects all PRB residents and pollut- ant concentrations remain elevated despite mitigation efforts, public health practitioners and policymakers in Italy should prioritize further interventions to improve air quality in the PRB. Even though the European Union and Italy regulate the emission of common air pollutants, further collaboration between industry regulators and public health practi- tioners is indicated. During the study period, the annual average PM 2.5 concentration remained below the threshold regulated by the European Union; however, some moni- tors reported a daily average concentration much higher than that recommended by WHO ( Directive 2008/50/EC of the European Parliament , 2008). Therefore, Italian public health practitio- ners must have systems in place to educate residents and mitigate potential health effects during times of high particulate matter con- centrations. The Italian government should implement an air quality warning system (such as those used to communicate severe weather) to alert PRB residents to the health risks posed by periods of poor air quality. In addition to triggering messaging, the alert system should indicate masking recommen- dations. Public health practitioners could
FIGURE 6
Annual Average A) PM 2.5 and B) PM 10 Concentrations in the Colorado River Basin From 2013–2022
A
B
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then reduce the burden of poor air quality days by pairing masking recommendations with increased availability of free, quality masks or respirators (e.g., via free mask vend- ing machines). The most salient health-related conse- quence of drought in the CRB is coccidi- oidomycosis. Valley fever poses a health risk to all CRB residents, and those who are infected can experience severe, chronic symptoms. Alarmingly, Valley fever cases in the CRB doubled over the study period (Figure 8), and no large-scale mitigation efforts exist. Furthermore, the geographic spread of coccidioidomycosis could fur- ther increase the burden of Valley fever in the CRB. Thus, public health practitioners and policymakers should enact solutions to curtail the transmission and spread of Val- ley fever. Control of coccidioidomycosis transmis- sion, however, presents a unique challenge for policymakers and is hindered by the absence of a consistent, unified reporting system in the CRB. While there are national mandates for reporting Valley fever, not every state is required to report it, and some health departments do not notify the CDC of Valley fever cases. Thus, Valley fever data are avail- able for most of the CRB; however, no data are available for Colorado and granular data (i.e., county-level) are available only for Ari- zona and California. In this way, Valley fever is not unlike other emerging or zoonotic public health challenges such as toxoplasmosis. This lack of consistent reporting creates knowl- edge gaps in Valley fever transmission and geographic distribution. To improve understanding of Valley fever distribution and transmission in the CRB, the states of Colorado, Nevada, New Mexico, Utah, and Wyoming should report county-level Valley fever data to CDC. Even with a unified, consistent report- ing system, many coccidioidomycosis cases, especially asymptomatic ones, will remain unreported; however, a joint, One Health reporting system could facilitate robust sur- veillance. Dogs are more susceptible to coc- cidioidomycosis than humans and, therefore, can serve as sentinels for human disease. Thus, an integrated human–animal report- ing system will more accurately detect Valley fever transmission. Creating an integrated,
FIGURE 7
Average Valley Fever Incidence per 100,000 Residents in the Colorado River Basin From 2013–2022
FIGURE 8
Total Valley Fever Cases and Median Valley Fever Incidence in the Colorado River Basin From 2013–2022
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One Health reporting system will allow pub- lic health practitioners and policymakers to better understand coccidioidomycosis trans- mission and then design interventions. Conclusion Based on publicly available data about drought-related public health concerns of air quality, water safety, WNV, and relative poverty, public health practitioners and policymakers in Northern Italy must further mitigate particulate matter pollution in the PRB. Similarly, public health practitioners and policymakers in the Western U.S. must mitigate the transmission and geographic spread of coccidioidomycosis in the CRB. Acknowledgments: The authors are grateful to Dr. Jane Sykes, Dr. Jason Ackleson, and Ethan Kloster for lending their expertise and advice during this project. Corresponding Author: Justin Kastner, PhD, Professor, Department of Diagnostic Medi- cine and Pathobiology, Kansas State Univer- sity, 1800 Denison Avenue, P-216 Mosier
FIGURE 9
Average Nitrate Concentrations in the Po River Basin From 2013–2021
FIGURE 10
Average Nitrate Concentrations in the Colorado River Basin From 2013–2021
Hall, Manhattan, KS 66506. Email: jkastner@k-state.edu
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