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HomeMy WebLinkAboutCOUNCIL - COMPLETE AGENDA - 03/27/2018 - COMPLETE AGENDACity of Fort Collins Page 1 Wade Troxell, Mayor Council Information Center (CIC) Gerry Horak, District 6, Mayor Pro Tem City Hall West Bob Overbeck, District 1 300 LaPorte Avenue Ray Martinez, District 2 Fort Collins, Colorado Ken Summers, District 3 Kristin Stephens, District 4 Cablecast on FCTV Channel 14 Ross Cunniff, District 5 and Channel 881 on the Comcast cable system Carrie Daggett Darin Atteberry Delynn Coldiron City Attorney City Manager City Clerk The City of Fort Collins will make reasonable accommodations for access to City services, programs, and activities and will make special communication arrangements for persons with disabilities. Please call 221-6515 (V/TDD: Dial 711 for Relay Colorado) for assistance. City Council Work Session March 27, 2018 6:00 PM • CALL TO ORDER. 1. West Nile Virus (WNV) Management Policy and Response Plan Review. (staff: Mike Calhoon, Matt Parker; 10 minute staff presentation; 50 minute discussion) The purpose of this item is to review the current West Nile Virus (WNV) program, provide an update on new findings related to WNV, provide a summary of the input provided by the WNV Technical Advisory Committee (TAC), and gauge the desire of Council to entertain a future resolution changing the thresholds for adult mosquito management actions. 2. Sign Code Update, Phase 2. (staff: Noah Beals, Tom Leeson; 10 minute staff presentation; 30 minute discussion) The purpose of this item is to check in with Council on the process of the Sign Code Update. 3. 2019/2020 Budgeting for Outcomes (BFO) Consideration Items. (staff: Mike Beckstead; Greg Yeager; Teresa Roche; Carol Webb: 5 minute staff presentation per topic; 10-15 minute discussion per topic) The purpose of this item is to inform and seek input from Council on several items that will be significant to the upcoming BFO process. City of Fort Collins Page 2 Topics to be discussed include: 1. Police staffing process 2. Compensation and Benefits 3. Process improvements to capital cost estimates 4. Potential infrastructure financing projects • OTHER BUSINESS. • ADJOURNMENT. DATE: STAFF: March 27, 2018 Mike Calhoon, Parks Supervisor Matt Parker, Crew Chief WORK SESSION ITEM City Council SUBJECT FOR DISCUSSION West Nile Virus (WNV) Management Policy and Response Plan Review. EXECUTIVE SUMMARY The purpose of this item is to review the current West Nile Virus (WNV) program, provide an update on new findings related to WNV, provide a summary of the input provided by the WNV Technical Advisory Committee (TAC), and gauge the desire of Council to entertain a future resolution changing the thresholds for adult mosquito management actions. GENERAL DIRECTION SOUGHT AND SPECIFIC QUESTIONS TO BE ANSWERED 1. Are there any further questions that Council has pertaining to the WNV Program? 2. Would Council like to consider a new resolution addressing changes to the adult mosquito control thresholds of the WNV program? • Current threshold levels are a Vector Index* of 0.75 and either (1) more than one human case per week, OR (2) more than one WNV positive blood donor per season. *The Vector Index value is a calculation of risk of WNV exposure. The index considers the population levels of WNV carrying mosquito species and the rate of infection within those species. BACKGROUND / DISCUSSION WNV has been in Colorado since 2002 and the threat of disease transmission is now an annual concern. WNV is a disease transmitted to humans by Culex mosquitoes, which are the vector (source of transmission). WNV is continually present in the avian community. When female Culex mosquitoes bite an infected bird, followed by biting previously uninfected birds, the amplification cycle of WNV begins. This amplification potentially increases throughout the summer weeks as conditions (precipitation, temperature, wind events, etc.) allow. The aim of a mitigation program is to break the amplification and transmission cycle at the appropriate time while balancing social and environmental costs. Most people infected with WNV will have no symptoms. About 1 in 5 (20-25 percent) people who are infected will develop a fever with other symptoms. Less than 1 percent of people who are infected will develop a serious neurologic illness such as encephalitis or meningitis (inflammation of the brain or surrounding tissues). However, recent research indicates there may be additional health concerns related to long-term kidney complications as well as latent neurological impacts. As new information becomes available, it is important to periodically reassess WNV program elements. In 2003, as the mosquito-borne disease first entered the community, the City of Fort Collins initiated a rapid response effort to reduce risk of people’s exposure to WNV. This response established specific elements of a WNV Program including: a larvicide program, trapping and surveillance of adult mosquitoes and, as a last resort, an adult mosquito pesticide application. As WNV became endemic in the community, the City developed an ongoing program with a mission to reduce the human impact of WNV while balancing costs, social, and environmental impacts. While other communities operate programs oriented towards mosquito nuisance 1.1 Packet Pg. 3 March 27, 2018 Page 2 reduction, or a blend of disease mitigation and nuisance reduction, the City of Fort Collins’ program works exclusively to reduce the human impact of WNV. The City uses the federal Environmental Protection Agency (EPA) and Centers for Disease Control (CDC) recommended Integrated Pest Management (IPM) approach. This is a data-driven approach to mosquito-borne disease management. The core elements include: 1. Public Education Efforts focus on building public awareness of WNV risk and personal mitigation options. WNV awareness has increased through the years, subsequently the outreach efforts are increasingly concentrated on affecting behavioral change. 2. Larval Management The bulk of program expenses relate to ongoing larvae reduction. Breeding areas are inspected on a weekly basis and treated if larvae are present. Inspection frequency increases as the mosquito reproduction rate increases with warmer weather. 3. Surveillance The City’s WNV program employs a robust trapping and surveillance system providing weekly data on the population levels and disease rates. 4. Adult Mosquito Control Industry best management practices include the establishment of pre-defined thresholds at which action steps should be taken. This idea is embedded throughout the WNV program, most importantly with the thresholds related to adult mosquito applications. 5. Continual Improvement Assessment An annual review with the TAC is an essential element of the program. Through the years, the TAC has assisted staff in developing program improvements such as: increased public outreach, expansion of the larval treatment and surveillance season and recommendations on adult mosquito control thresholds. Technical Advisory Committee Information Since the arrival of WNV in Fort Collins in 2003, the City has used community expertise to inform its WNV Management Program. In 2007, the TAC was formed at the direction of the City Manager. Volunteers are appointed by the City Manager and provide feedback on the WNV Management Program. Each year the TAC convenes to review and consider modifications to the program. TAC members include: Amy Kafka (Owner/Operator of Garden Sweet Farm), Dana Kunze (founder of No Spray Fort Collins Facebook site), Boris Kondratieff (Colorado State University), Darrick Turner (Larimer County Department of Public Health and Environment), Eric Levine (Air Quality Board - Ex Officio), Greg McMaster (Air Quality Board - Ex Officio), Chester G. Moore (Colorado State University - Retired), Dr. Roxanne Connelly (Centers for Disease Control) and Elizabeth Pruessner (Natural Resources Advisory Board - Ex Officio). While not representing their employers on the TAC, members include internationally recognized experts on vector-borne diseases, entomology and public health issues. Through the years the TAC has proved to be instrumental in identifying and promoting opportunities for continual improvement including; expansion of the larval control perimeter, development of a business opt-out program, as well as improvements to the communication of risk levels and data results. 1.1 Packet Pg. 4 March 27, 2018 Page 3 Research Updates WNV had previously been thought of as an acute disease with only those individuals experiencing the most severe symptoms showing lasting effects. The viral family (Flaviviridae), to which WNV belongs, is generally composed of viruses that the immune system clears after acute infection. Recent studies show WNV to have longer term impacts, even among those patients exhibiting less severe symptoms. In 2002, as WNV began to impact citizens of Houston, TX, researchers from the Baylor College of Medicine established a longitudinal cohort study to better understand the long-term health impacts of WNV. Multiple studies have come about via this cohort; the primary areas of investigation are the long-term renal (kidney) and neurologic impacts of WNV infection. In Attachment 1, Long-Term Neurological Outcomes in West Nile Virus-Infected Patients: An Observational Study, Weatherhead, et al conducted neurological evaluations of individuals enrolled in the Houston West Nile Virus Cohort at 1-3 years and 8-11 years post-infection. These individuals included infection at three levels; West Nile fever, West Nile meningitis, and West Nile encephalitis. Approximately 1/3 of the patients previously diagnosed with the severe forms of WNV (meningitis and encephalitis) continued to show neurological abnormalities at the 8-11 year post-infection evaluation. Additionally, patients with WNV fever showed a higher rate of neurological complication at the 8-11 year post-infection evaluation than at the 1- 3 year evaluation. In Attachment 2, Prevalence of Chronic Kidney Disease and Progression of Disease Over Time among Patients Enrolled in the Houston West Nile Virus Cohort., Nolan, et al. using the same cohort, assessed the prevalence of chronic kidney disease over a multi-year observational study. Approximately half of the subjects presented with neuroinvasive WNV (meningitis and encephalitis) and the remaining half experienced West Nile Fever. Although 8% of the study group had renal complications prior to WNV and an additional 9% developed renal issues at the time of WNV infection, 40% of the group had conditions defined as Chronic Kidney Disease when evaluated 7-9 year post-infection. Summary of 2017-2018 Off-Season TAC Discussions Staff and TAC members discussed adjustments to the thresholds at four different meetings throughout the off- season. However, the TAC could not develop a consensus position on the setting of thresholds as they relate to either the requirement of human cases, or a given vector index value. The TAC, consisting of approximately seven individuals at any given meeting held opinions, about equally split, on both elements. Human Case Consideration TAC members expressing a desire to retain a human case requirement, feel that significant risk reduction could be realized via personal protective measures and therefore the benefits of community behavior could reduce the need for introducing the potential risk presented by adult mosquito applications. This argument gives weight to the effectiveness of personal protective decisions as opposed to the inherent lack of personal control associated with broad adult mosquito applications. Members advocating for the elimination of the human case element expressed a reluctance to rely on individual behavior and feel that the potential risk brought about by adult mosquito applications are minimal. Additionally, members suggesting the elimination of human cases as a consideration expressed that the lag time associated with the requirement of human cases reduces the effectiveness of a timely application aimed at the growing side of the amplification curve. Inclusion of Human Case Requirement Pros: • Acknowledges the role of personal protection, i.e. increased use of personal protective measures allows the community to withstand a higher WNV risk with less impact to the population. 1.1 Packet Pg. 5 March 27, 2018 Page 4 Cons: • Lagging indicator (roughly two to four weeks of lag time). • May lead to adult mosquito applications conducted after critical amplification times. • Increases the onus on individuals to practice personal protection. Vector Index Value Members of the TAC held opinions that ranged from a VI of 0.33 to 0.75, with occasional comments that the VI could be 0.25 or 1.0. Those advocating for a vector index at the current level of 0.75 or higher stated that the risks associated with adult mosquito applications outweigh the risk of WNV presented to the general community, particularly when the availability of personal protective measures is considered. Members suggesting a VI lower than 0.75 cite the predictive nature of the vector index calculation; i.e. that a VI at or greater than 0.5 strongly predicts the occurrence of WNV human cases. Although the predictive quality of the vector index does not work well in the opposite direction, i.e. VI values lower than 0.5 do not indicate that human cases are unlikely. Vector Index Lower than 0.75 Pros: • Earlier intervention aimed at reducing the amplification of WNV • Potentially smaller, targeted areas of adult control application. Cons: • Potential to conduct more frequent adult mosquito applications. Vector Index at 0.75 or Higher Pros: • Acknowledges the role of personal protection, i.e. increased use of personal protective measure allows the community to withstand higher VI values with less impact to population. • Gives greater deference to property rights of those not wanting pesticide impacts. Cons: • Later interjection in the amplification process may lead to greater geographic area experiencing growing WNV risks. • Human cases accrue at a lag time of two to four weeks. Staff Recommendation If Council would like staff to present a proposed resolution addressing changes to the adult mosquito control thresholds, the staff recommendation would include lowering the Vector Index to 0.5 and removing the human case requirement. Such thresholds would more closely align with Centers for Disease Control recommendations and would allow for a timelier response to the amplification process of WNV. Staff Rationale The amplification cycle is key to managing WNV, particularly during those years wherein the environmental conditions lead to high risk. With a lower threshold, a timelier response and a smaller footprint can lead to a more effective reduction of disease amplification. Although lower thresholds will likely lead to more frequent spray events, these events will likely reduce the overall amount of pesticide use and the linear miles treated. Although environmental factors are largely beyond our control, a good measure of success would be a reduction of the linear miles treated per application, and per season. 1.1 Packet Pg. 6 March 27, 2018 Page 5 ATTACHMENTS 1. Long-term neurological outcomes in WNV patients (PDF) 2. Prevalence of Chronic Kidney Disease (PDF) 3. Powerpoint Presentation (PDF) 1.1 Packet Pg. 7 Am. J. Trop. Med. Hyg., 92(5), 2015, pp. 1006–1012 doi:10.4269/ajtmh.14-0616 Copyright © 2015 by The American Society of Tropical Medicine and Hygiene Long-Term Neurological Outcomes in West Nile Virus–Infected Patients: An Observational Study Jill E. Weatherhead, Vicki E. Miller, Melissa N. Garcia, Rodrigo Hasbun, Lucrecia Salazar, Mazen M. Dimachkie, and Kristy O. Murray* Baylor College of Medicine, Department of Pediatrics, Houston, Texas; The University of Texas Health Science Center at Houston, Houston, Texas; The University of Kansas Medical Center, Kansas City, Kansas Abstract. The Houston West Nile Cohort (HWNC) was founded in 2002 when West Nile virus (WNV) reached Houston, TX. The long-term outcomes following WNV infection are still mostly unknown, though neurological abnormal- ities up to 1 year postinfection have been documented. We report an observational study of neurological abnormalities at 1–3 and 8–11 years following WNV infection in the HWNC. We conducted standard neurological examinations at two separate time points to assess changes in neurological status over time. The majority of patients (86%, 30/35) with encephalitis had abnormal neurological exam findings at the time of the first assessment compared with uncomplicated fever (27%, 3/11) and meningitis (36%, 5/14) cases. At the time of the second assessment, 57% (4/7) of West Nile fever (WNF), 33% (2/6) of West Nile meningitis (WNM), and 36% (5/14) of West Nile encephalitis (WNE) had developed new neurological complications. The most common abnormalities noted were tandem gait, hearing loss, abnormal reflexes, and muscle weakness. Long-term neurological abnormalities were most commonly found in patients who experienced primary WNV encephalitis. New abnormalities may develop over time regardless of initial clinical infection. Future studies should aim to differentiate neurological consequences due to WNV neuroinvasive infection versus neurological decline related to comorbid conditions. INTRODUCTION The first outbreak of West Nile virus (WNV) in the Western Hemisphere occurred in New York City in 1999.1 Sub- sequently, the virus spread rapidly south and westward throughout the United States reaching Harris County, Texas in 2002. By the end of 2004, human infection had been docu- mented in all states except Washington, Hawaii, and Alaska.2,3 Between 1999 and 2013, more than 39,000 cases of clinical WNV were reported to Centers for Disease Control and Prevention (CDC).4 WNV infection is most commonly asymptomatic with approximately 20% infected persons found to have clinically apparent disease.5–7 The majority of people with symptoms present with fatigue, fever, and headache and less commonly with myalgia, muscle weakness, rash, difficulty concentrating, neck pain, arthralgia, vomiting, diarrhea, and sensitivity to light.8,9 West Nile neuroinvasive disease (WNND), character- ized as meningitis, encephalitis, and/or acute flaccid paralysis, occurs in as few as 1 in 150 infected persons.6 WNV meningitis is defined clinically as fever, pleocytosis in the cerebrospinal fluid (CSF), and clinical evidence of meningeal inflammation (nuchal rigidity, photophobia, and nausea/vomiting). WNV encephalitis further requires the presence of prolonged altered mental status (> 24 hours), seizures, or focal neurological abnormalities.10,11 Among the patients who meet clinical criteria for WNND, acute case fatality is approximately 10%.1 Patients presenting with clinically compatible symptoms are typically diagnosed with WNV infection by detection of anti- WNV IgM using monoclonal antibody capture enzyme-linked immunosorbent assay (MAC-ELISA) in the serum or CSF.5,12 Although short-term follow up studies have shown persis- tent neurologic deficits in patients with WNND, little is known about the long-term neurologic sequelae associated with West Nile fever (WNF), meningitis (WNM), and enceph- alitis (WNE).13 In this study, we longitudinally examined a large cohort of patients with a history of WNV infection to deter- mine long-term neurologic outcomes at 1–3 and 8–11 years post–acute WNV infection. All neurological examinations were performed by physi- cians. The examination included assessment of level of con- sciousness, cranial nerve, cerebellar function, motor and sensory functions, reflexes, and gait. Data from the neurolog- ical exams were recorded on the Neurological Examination Form at the time of the exam. A descriptive analysis of abnor- mal neurological outcomes by clinical presentation (WNF, WNM, and WNE) was performed. Univariate analysis was performed to examine the relationship between age (55 years and older), WNE, and gender with the outcome of an abnormal neurological exam. All variables with P < 0.25 on univariate analysis were entered into a multivariate logistic regression model to determine which variables were independently, statistically (P £ 0.05) associated with having an abnormal neurological exam. RESULTS Primary neurological assessment (1–3 years postinfection). Sixty of the initial 77 (78%) cohort participants who were infected between 2002 and 2004 agreed to participate and were available for primary neurological assessment. Of the 60 participants, 11 had an initial clinical presentation of WNF, 14 had WNM, and 35 had WNE (Figure 1). The demographics of the 60 patients are included in Table 1. The median age in years was older in the WNE compared with WNM and WNF groups (68 years versus 46 and 54 years, respectively). Furthermore, the population with WNE had a higher prevalence of comorbidities, particularly hypertension (65%), diabetes mellitus (31%), and history of stroke (22%). The majority of patients with WNM and WNE were male. The primary neurologic exams of the 11 patients with WNF at 1–3 years postinfection were normal with exception of three (27%) patients (Table 2). One patient was found to have abnormal hearing prior to acute infection. The second patient had ataxia with tandem walking and decreased hearing bilaterally, although onset of hearing loss after acute infection was not documented. The third patient was found to have decreased right arm strength; abnormal tandem gait, toe, and heel walking; and positive Romberg sign. Cranial nerves, mus- cle strength, sensation, cerebellar examination, and reflexes were normal in all patients. The primary neurologic exams among the 14 patients with WNM were also largely unremarkable (Table 2). Cranial nerve examinations were all normal. Sensory examination was normal in all participants with the exception of two patients. One patient with a history of diabetes mellitus and hypertension had decreased pinprick sensation in both feet and decreased vibratory sensation in the patient’s right foot, consistent with peripheral neuropathy. The second patient with a history of stroke had decreased light touch in bilateral feet and left shin, decreased vibratory sensation in left foot, and intermittent left facial numbness. This patient also had abnormal toe walking because of left foot plantar flexion weakness. All other patients had normal strength through- out. All participants had normal motor strength, absence of Figure 1. Flow chart of West Nile virus–positive participants in Houston enrolled between 2002 and 2004. LONG-TERM WEST NILE OUTCOMES 1007 1.1.1 Packet Pg. 9 Attachment: Long-term neurological outcomes in WNV patients (6605 : West Nile Virus (WNV) Management Policy and Response Plan Review) clonus, and normal Babinski reflexes. One patient had sym- metric but decreased reflexes in the lower extremities. All had normal gait and were able to perform the heel walking test. Two patients had abnormal tandem gait; however, both had significant comorbidities. One participant with abnormal tan- dem gait had a history of prior alcohol and drug abuse and the other had a history of diabetes mellitus. Coordination was also unremarkable with normal rapid alternating movements, heel/shin, and finger-to-nose tests. One patient had a slight tremor in the left hand. A total of 35 patients with WNE were evaluated at primary follow-up, and 30 (86%) were found to have abnormal neuro- logical exams (Table 2). Thirteen patients (37%) had abnormal motor strength and 9 patients (26%) had abnormal reflexes, although some reported strength and reflex abnormalities prior to WNV infection. Eleven patients (31%) had abnormal vibratory sensation. One patient with unilateral decreased vibratory sensation also had ipsilateral tongue deviation. Seven patients had tremors (20%), two of which were intention tremors. Hearing abnormalities were found in 16 (46%) patients with WNE, with 5 of these 16 patients (31%) reporting some hearing loss prior to infection. One patient who pre- sented with decreased visual acuity at the onset of WNV con- tinued to have abnormal visual acuity 3 years postinfection. Additional cranial nerve abnormalities were noted: lateral gaze palsy with nystagmus (one patient), unilaterally trapezius muscle Table 2 Neurological examination results at primary follow up (1–3 years) post–West Nile virus infection: Prevalence of abnormal findings among the Houston West Nile cohort Abnormal neurological exam findings WNF (N = 11) WNM (N = 14) WNE (N = 35) Total (N = 60) Abnormal level of consciousness 0 0 0 0 Motor weakness 1 (9%) 0 13† (37%) 14† (23%) Reflexes Tendon reflexes 0 1 (7%) 9† (26%) 10 (17%) Babinski 0 0 1 (3%) 1 (2%) Clonus 0 1 (3%) 1 (2%) Sensory Light touch 0 1 (7%) 1 (3%) 1 (2%) Pinprick 0 1 (7%) 4 (11%) 5 (8%) Vibratory 0 2 (14%) 11 (31%) 13 (22%) Cerebellum Heel/shin 0 0 2 (6%) 2 (3%) Finger to nose 0 0 0 0 Rapid alternating movements 0 0 0 0 Tremor 0 1 (7%) 7 (20%) 8 (13%) Romberg 1 (7%) 0 6 (17%) 7 (12%) Gait 0 0 4 (11%) 4 (7%) Tandem 2 (18%) 2 (14%) 21 (60%) 25 (42%) Toe walking 1 (7%) 1 (7%) 7 (20%) 9 (15%) Heel walking 1 (7%) 0 8 (23%) 9 (28%) Cranial nerves Visual acuity 0 0 1 (3%) 1 (2%) Facial asymmetry 0 0 0 0 Pupil reactivity 0 0 1* (3%) 1* (2%) Hearing 2* (18%) 2* (14%) 16† (46%) 20† (33%) Extraocular muscles 0 1* (7%) 1 (3%) 2† (3%) Palate elevation 0 0 0 0 Facial sensation 0 1 (7%) 0 1 (2%) Trapezius/sternocleidomastoid 0 0 1 (3%) 1 (2%) Jaw strength 0 0 0 0 weakness (one patient), and tongue deviation without prior history of stroke (one patient). Most notably, tandem gait abnormalities occurred in 60% WNE patients, and many of these patients had abnormal Romberg, gait, and/or toe and heel walking. Two patients had abnormal heel-to-shin exam but none of the patients had abnormal rapid alternating movements or abnormal finger-to-nose testing. Secondary neurological assessment (8–11 years postinfection). A total of 27 patients (45%) were available for the second neurological assessment (8–11 years post– WNV infection). Of the 33 patients who were unavailable, 12 (36%) patients had died before the second neurological exam, 9 (27%) had moved or were lost to follow-up, 7 (21%) could not make it to the clinic for the exam, and 4 (12%) refused further participation. A total of 7 patients from the original 11 patients (63% retention) with WNF had a neurologic exam at second follow up (Supplemental Table 1). One patient who had docu- mented abnormal tandem gait and abnormal hearing follow- ing WNF at primary follow-up was found to have severe neurological sequelae on second exam. She was non- ambulatory, and required complete assistance for activities of daily living. She was nonverbal, aphasic, and unresponsive to commands. She had severe contractures of all extremities with increased tone. A second patient with no history of comorbidities and a normal neurologic exam at the time of the first neurological assessment was found to have new bilateral lower extremity decreased sensation to pinprick. A third patient, with a history of hepatitis B virus infection, who previously was found to have decreased right arm strength and abnormal tandem gait, Romberg, toe walking, and heel walking, had improved arm strength. However, the patient continued to have difficulty with tandem gait, Romberg, toe walking, heel walking, and developed abnor- mal pinprick sensation in upper extremities. The fourth patient who was otherwise healthy and had a normal primary neurologic exam was subsequently found to have abnormal pinprick sensation, left hand weakness, and abnormal tandem gait on secondary assessment. The remaining three patients had normal primary and secondary assessments. A total of 6 patients from the original 14 patients (43% retention) with WNM were evaluated at the secondary neuro- logical assessment (Supplemental Table 1). Two patients had normal exams on primary and secondary neurologic exams. Two patients at secondary follow-up exam originally presented with abnormal tandem gait. The first patient, who had a history of chronic alcohol use and received treatment of hepatitis C infection, was found to have continued difficulty with tandem gait. The patient also had bilateral lower extremity weakness, decreased symmetric reflexes, and abnormal pinprick sensation in bilateral lower extremities. The second patient had a history of diabetes mellitus and hypertension and also continued to have abnormal tandem gait on follow-up exam. This patient was also found to have abnormal sensation to pinprick and vibrator on primary exam, and experienced continued abnor- mal sensation at the time of the follow-up. We cannot rule out the influence of diabetic neuropathy on this patient. One patient who had decreased symmetric reflex present on pri- mary follow-up saw resolution in abnormal reflexes on sec- ondary follow-up. A fourth patient with no past medical of WNE was the only variable found to be independently asso- ciated with abnormal neurological exam findings. Comorbid conditions (hypertension, stroke, or diabetes) were not found to be statistically associated with an abnormal neurological exam. When examining differences in specific neurological findings between WNE and non-WNE cases, WNE cases were significantly more likely to have abnormal tandem gait compared with those who did not have encephalitis (OR = 1.9; 95% CI = 2.0–37.1; Fisher Exact P value = 0.001). DISCUSSION We found that patients who initially presented with acute WNE have high rates of persistent neurological abnormalities over time compared with those who presented with acute WNF or WNM. Even when controlling for age, having a clin- ical presentation of WNE remained statistically associated with having abnormal neurological exam findings. Some of the persistent abnormalities were found to be severe, includ- ing motor strength deficits, abnormal reflexes, hearing loss, and tandem gait abnormalities. Interestingly, 4/7 (57%) WNF, 2/6 (33%) WNM, and 5/14 (36%) WNE had new neurological abnormalities evident at the time of the second assessment. This is the largest report of neurological assessments among patients with clinical WNV infection and the first to system- atically examine patients at 1–3 and 8–11 years after their acute infection. Other studies have also evaluated the neurological out- comes in patients with WNND. Sejvar and others prospec- tively followed 16 patients with severe WNV infections. At 8 months postinfection, the five meningitis patients were fully recovered, and among the eight encephalitis patients, five recovered, two did not recover to preinfection neurologic status but survived, and one remained comatose and ventilator dependant.10 In a second study, Klee and others evaluated the recovery of patients affected by the 1999 outbreak of WNV in New York City through telephone surveys of patients at 12 months postinfection. By 12 months postinfection, only 37% had fully recovered, 49% had difficulty walking, and 44% had muscle weakness. Patients with a history of menin- gitis or milder infections had fewer long-term neurologic sequelae as compared with those patients with encephalitis,14 similar to the findings in our study. Our study demonstrated that older age and a diagnosis of WNE were associated with persistent neurological abnormal- ities, which is consistent with the previous literature.14–16 Fur- thermore, our data showed that patients who died prior to the secondary neurologic assessment were more likely to have a history of WNE and were more likely to have comorbidities including hypertension. In a study by Klee and others, at 12 months follow-up from initial infection, age was a positive predictor of recovery, with younger persons more likely to achieve physical, cognitive, and functional recovery.14 Murray and others also described advanced age, male gender, and history of hypertension as significant risk factors for develop- ing WNE and for death.16 Although the exact mechanisms for the association between age and comorbidities and severity of neuroinvasive disease is currently unknown, the data repre- sent a reduced neurologic recovery potential in older patients and/or patients with comorbidities infected with WNV infec- tion when compared with younger, healthier patients. Of our WNE patients, approximately 37% at primary assess- comorbidities, particularly diabetes, the data are difficult to interpret in this study population. Similarly, while hearing loss was found in a number of our patients, it is impossible to determine if these auditory defects were due to WNV injury alone or secondary to previous hearing loss or age-related hearing loss. Further studies are needed to determine the impact of invasive WNV on vestibular function. We did not observe any cases of viral relapse as has been described in other encephalitis. Herpes simplex encephalitis, for example, has been shown to have a relapse rate of approximately 10%.18 As a result of decreased potential for relapse and evidence of persistent neurologic deficits at 1–3 and 8–11 years postinfection documented in our study, we feel that recovery from WNV occurs mostly in the first year after infection with minimal recovery thereafter. It may be helpful to advise the WNE patients that the neurological deficits that persist at 1 year and beyond may not dissipate. There are many limitations to our study. First, many of our findings could be attributable to the small number of patients when we examine subgroups. Because of the follow-up nature of the study, we had two different clinicians performing the study potentially resulting in interobserver reliability. This is thought be minimal, however, considering both clinicians received training on the proper examination techniques. Another inherent limitation is that the participants did not have a baseline neurological examination prior to their WNV infection, since infection could obviously not be predicted. Although the patient and family members were able to pro- vide us with historical information about the patients’ neuro- logical status before their WNV infection, inaccuracies are possible due to recall bias. In addition, we are unable to delineate whether some of these abnormal neurological find- ings could be secondary to other causes such as diabetic neu- ropathy, stroke, or due to aging-related sensorineural hearing loss. Conducting a case–control study using age-matched normal controls could help establish a baseline group for comparison, but this could be cost-prohibitive and challenging. Larger scale multicenter studies would be of great benefit but may be impossible due to the waning of the epidemic. Finally, it is possible that a subset of WNF cases were misclassified because they did not have a lumbar puncture procedure at the time of acute illness, and therefore did not have a CSF analy- sis or brain imaging to determine if there was any evidence of meningitis or encephalitis. In conclusion, we found that WNE, compared with WNF and WNM, is commonly associated with an abnormal neuro- logical examination at both 1–3 and 8–11 years post-WNV infection, and we found that regardless of initial clinical pre- sentation following WNV infection, new neurological abnor- malities might develop over time. These abnormalities are chiefly abnormal reflexes, muscle weakness, gait impairment, and hearing and limb sensory loss. At present, there are no clear lines of prevention and treatment of WNV infection out- side avoidance of mosquitoes and use of repellants. Through this observational study, the cohort has highlighted what may be unique neurologic characteristics associated with neuro- invasive West Nile virus disease and should prompt further assessment through prospective case–control studies. Our data will nevertheless be helpful to clinicians and patients to provide a prediction of long-term neurological complications 14. Klee AL, Maldin B, Edwin B, Poshni I, Motashari F, Fine A, Layton M, Nash D, 2004. Long-term prognosis for clinical West Nile virus infection. Emerg Infect Dis 10: 1405–1411. 15. Tyler KL, 2004. West Nile virus infection in the United States. Arch Neurol 61: 1190–1195. 16. Murray K, Baraniuk S, Resnick M, Arafat R, Kilborn C, Cain K, Shallenberger R, York TL, Martinez D, Hellums JS, Hellums D, Malkoff M, Elgawley N, McNeely W, Khuwaja SA, Tesh RB, 2006. Risk factors for encephalitis and death from West Nile virus infection. Epidemiol Infect 134: 1325–1332. 17. Anastasiadou A, Kakoulidis I, Butel D, Kehagia E, Papa A, 2013. Follow-up study of Greek patients with West Nile virus neuroinvasive disease. Int J Infect Dis 17: e494–e497. 18. Skoldenberg B, Aurelius E, Hjalmarsson A, Sabri F, Forsgren M, Andersson B, Linde A, Strannega˚rd O, Studahl M, Hagberg L, Rosengren L, 2006. Incidence and pathogenesis of clinical relapse after herpes simplex encephalitis in adults. J Neurol 253: 163–170. 1012 WEATHERHEAD AND OTHERS 1.1.1 Packet Pg. 14 Attachment: Long-term neurological outcomes in WNV patients (6605 : West Nile Virus (WNV) Management Policy and Response Plan Review) Prevalence of Chronic Kidney Disease and Progression of Disease Over Time among Patients Enrolled in the Houston West Nile Virus Cohort Melissa S. Nolan1, Amber S. Podoll2, Anne M. Hause3, Katherine M. Akers2, Kevin W. Finkel2, Kristy O. Murray1* 1 Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America, 2 Department of Internal Medicine, Medical School, University of Texas Health Science Center at Houston, Houston, Texas, United States of America, 3 Department of Epidemiology, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, United States of America Abstract Introduction: In experimental models of West Nile virus (WNV) infection, animals develop chronic kidney infection with histopathological changes in the kidney up to 8-months post-infection. However, the long term pathologic effects of acute infection in humans are largely unknown. The purpose of this study was to assess renal outcomes following WNV infection, specifically the development of chronic kidney disease (CKD). Methods: In a cohort of 139 study participants with a previous diagnosis of WNV infection, we investigated the prevalence of CKD using the Kidney Disease Outcomes Quality Initiative (KDOQI) criteria based on the Modification of Diet in Renal Disease (MDRD) formula and urinary abnormalities, and assessed various risk factors and biomarkers. Results: Study participants were primarily male (60%) and non-Hispanic white (86%) with a mean age of 57 years. Most (83%) were four to nine years post-infection at the time of this study. Based on the KDOQI definition, 40% of participants had evidence of CKD, with 10% having Stage III or greater and 30% having Stage I–II. By urinary dipstick testing, 26% of patients had proteinuria and 23% had hematuria. Plasma NGAL levels were elevated in 14% of participants while MCP-1 levels were increased in 12%. Over 1.5 years, the average change in eGFR was 23.71 mL/min/1.73 m2. Only a history of Neuroinvasive WNV disease was independently associated with CKD following multivariate analysis. Discussion: We found a high prevalence of CKD after long term follow-up in a cohort of participants previously infected with WNV. The majority of those with CKD are in Stage I-II indicating early stages of renal disease. Traditional risk factors were not associated with the presence of CKD in this population. Therefore, clinicians should regularly evaluate all patients with a history of WNV for evidence of CKD. Citation: Nolan MS, Podoll AS, Hause AM, Akers KM, Finkel KW, et al. (2012) Prevalence of Chronic Kidney Disease and Progression of Disease Over Time among Patients Enrolled in the Houston West Nile Virus Cohort. PLoS ONE 7(7): e40374. doi:10.1371/journal.pone.0040374 Editor: Tian Wang, University of Texas Medical Branch, United States of America Received April 25, 2012; Accepted June 5, 2012; Published July 6, 2012 Copyright:  2012 Nolan et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This project was generously funded by the Gillson Longenbaugh Foundation and the NIH/NIAID (5R01AI091816-01, K23AI057341, N01 AI 50027-03, and U19AI089992-01). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: KMurray@bcm.edu Introduction West Nile virus (WNV), a member of the Flaviviridae family, has become endemic in the United States, with more than 1.7 million persons estimated to have been infected [1]. The long- term effects of acute infection with this disease are largely unknown. Several animal models have been developed to understand the chronic pathologic effects of WNV infection. One model indicates that renal disease can result from acute experimental infection with WNV [2]. Importantly, after clinical recovery from WNV infection, animals develop chronic kidney infection with histopathological changes in renal tissue and viuria detectable for up to 8 months after acute infection. Similar to the animal models, three studies have found evidence of virus in the urine of human WNV patients; however, these studies did not assess the renal impact of WNV infection [3,4,5]. In Houston, we previously reported that 9% of hospitalized WNV patients developed acute renal failure at the time of initial infection [6]. In this same cohort, only 8% of patients had a history of renal insufficiency prior to infection [7]. In Colorado a recent study assessing delayed mortality several years post infection, found that 21% of deceased WNV patients had documented renal failure as a contributory cause or underlying condition [8]. Thus far, the relationship between WNV infection and possible development of CKD in humans has not been thoroughly Methods In 2003, a cohort of WNV patients was established in Houston, Texas and followed prospectively from the time of acute infection to up to nine years post-infection. To date, 217 patients have been enrolled into the study. Over time, 45 participants were withdrawn from the study either due to death, lost-to-follow-up, or voluntary withdrawal. Of the remaining eligible study participants, 139 had complete information to analyze for CKD prevalence. All study activities were approved by the University’s Institutional Review Board (HSC-SPH-03-039) prior to subject enrollment. For the purposes of this study, participants were assessed during April 2010-November 2011 and were evaluated every six months from the initial start date. Evaluation included a questionnaire and sample collections, including blood and urine. The questionnaire obtained the following demographic data: age, race, ethnicity, and height and weight for body mass index calculation. In addition subjects self-reported a diagnosis of diabetes mellitus, hyperten- sion, or a family history of CKD, which are known risk factors for CKD. Blood was analyzed by Quest Diagnostic Laboratories Inc. for complete metabolic profiles and complete blood counts [9]. Serum creatinine levels were obtained and estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) study formula [10]. Chronic kidney disease was defined according to Kidney Disease Outcomes Quality Initiative (KDOQI) criteria for stages of CKD [11]. Participants were considered to have proteinuria and hematuria if urinalysis indicated greater than trace levels. Urinalysis was performed using Siemens MultistixH 10 SG reagent strips. Two potential biomarkers for renal dysfunction were also analyzed on a sub-set of fifty randomly selected participants. Neutrophil gelatinase associated lipocalin (NGAL) and monocyte chemotactic protein- 1 (MCP-1) were measured in both plasma and urine using Quantikine Immunoassays (R&D Systems: Minneapolis, MN). We recorded the presence of common complications of CKD including anemia, elevated serum blood urea nitrogen (BUN), and hyperkalemia. Descriptive statistics were used to describe the cohort and CKD risk factors, indicators and biomarkers. Univariate logistic regression analysis was performed to assess potential associations between stages of CKD with CKD risk factors. A cumulative grouping of all stages of CKD with CKD risk factors was subjected to multivariate logistic regression analysis to identify independent risk factors and test for potential confounding. All risk factors on univariate analysis with p#0.25 were included in multivariate analysis. A backwards step elimination of the highest non- significant value method was used. Only those factors with p#0.10 were considered significant in the multivariate analysis. All calculations were run using STATAH v12.0 software (College Station, TX). Results A descriptive summary of the 139 participants is provided in Table 1. Timing of WNV infection in study participants ranged from recent (within the year) to up to 9 years, with the majority (83%) being more than four years post-infection. The population was predominately composed of non-Hispanic white males with a mean age of 57. Approximately one-half of the patients presented with an initial WNV diagnosis of acute Neuroinvasive WNV disease (meningitis and/or encephalitis). Mild (febrile) and infection in a substantial percent of WNV infected persons, including up to eight years post-infection [3,13–15]. A previous study within this cohort found 20% (5/25) positive for viuria [19]. Viuria testing was not a main focus of this article since the authors are in the process of optimizing the viuria detection technique, and not all participants were tested for viuria due to logistic challenges. However, preliminary data does infer viuria testing as a possible diagnostic tool for WNV-related CKD. Of those who met the clinical definition for CKD, 50% (25/50) tested positive for viral RNA in the urine. In fact, more pronounced kidney decline was even more associated with viruira, with 83% (10/12) of those with moderate to severe CKD testing positive for viuria. While these findings are preliminary, we do intend to further investigate the possibility of viuria serving as a diagnostic marker for WNV-related renal disease. Our data also suggest that WNV patients who are hypertensive or are 65 years or older are more likely to progress into stage III– V advanced renal disease. Since hypertension and older age are significant risk factors for severe WNV disease, it is unclear what their direct association is with the progression of CKD in this particular population. It is possible that these comorbidities serve a surrogate indicator of neuroinvasive disease’s effect on renal decline. Current studies are underway aiming to evaluate long- term neurologic effects of WNV years post-infection and any correlation to renal decline among this population. Evaluation of renal tubular injury biomarkers, NGAL and MCP-1, were not prevalent among our cohort. Increased NGAL levels have been demonstrated in several studies of kidney injury and we were not able to reproduce those findings [16–19]. MCP-1 is an indicator of interstitial inflammation among lupus patients [16]. Its low prevalence and lack of statistical significance suggests that MCP-1 is not relevant among our cohort and interstitial inflammation is not a dominant factor among our cohort. A larger sample size is needed to validate our findings. We found a significant decline of eGFR values in our study population. Healthy populations have an average eGFR value decline of 21 mL/min/1.73 m2 per year [9,10]. Our study population had an average eGFR value decline of 23.71 mL/ min/1.73 m2 over 1.5 years. Even after adjusting for diabetes a known cause of eGFR decline [12], we still found the decline to be greater than expected. Additionally we found 15% of the study population had eGFR declines consistent with progression of CKD from milder to more severe stages over the 1.5 year period of observation. The lack of diabetes as an associated risk factor for Table 1. Descriptive summary of cohort demographics, CKD risk factors, CKD indicators, and CKD biomarkers. All WNV participants n=139 (%) Neuroinvasive WNV n=67 (%) Mild WNV n =44 (%) Asymptomatic WNV n=28 (%) Years Post-Acute WNV Infection Zero to Three 23 (17) 8 (12) 7 (16) 8 (33) Four to Six 56 (40) 19 (28) 22 (50) 15 (26) Seven to Nine 60 (43) 40 (60) 15 (34) 5 (8) Demographics Male 84(60) 45(67) 22(50) 17(61) Anglo 119(86) 52(78) 43(98) 24(86) eGFR decline suggests an alternate cause of progression. Therefore WNV may play a role in chronic renal dysfunction as noted by declining eGFR values. We found a high prevalence of CKD among the cohort. While an alternative equation has been indicated as a more accurate estimator of eGFR values in the ,90 range [20], we used the standard discipline for calculating our eGFR values. It is possible that using the standard equation could lead to inaccuracy and thereby misclassification. We ultimately decided to use the MDRD equation since it is believed to be the most commonly used equation by clinicians at this time. Additionally, since we used the KDOQI definition for stages of CKD which incorporates both eGFR values and evidence of kidney damage, we feel the specific equation used has minimal influence on the overall rates of CKD. When calculating the stages of CKD, we defined kidney damage as having proteinuria and/or hematuria. Proteinuria is known to be accurately measured by dipstick, although studies are inconclusive regarding the accuracy of dipstick measurement of hematuria [21]. Due to the observational nature of this study, we found dipstick measurements to be appropriate. Based on all the measurements we used to define CKD, we feel confident that our estimation that 40% of participants with CKD is accurate. Based on our observational findings, it is evident that more extensive research is needed to understand the exact association between WNV and the development of CKD. We are in the process of developing an age-, gender-, and race/ethnicity- matched case control study with two control populations (CKD non-WNV patients and general medicine patients) to better understand the potential role of WNV infection and development of CKD. The main goals of this case-control study are to first Figure 1. Change in eGFR values over time among 112 study participants, April 2010 to November 2011. doi:10.1371/journal.pone.0040374.g001 Table 2. Univariate logistic regression analysis between presence of CKD and CKD risk factors and indicators. CKD, All Stages No. (%) p-value; OR (95%CI) CKD, Stages 3–5 No. (%) p-value; OR (95%CI) CKD, Stages 1–2 No. (%) p-value; OR (95%CI) CKD Risk Factors African American Race 6/55 (11%) 0.101 3.31 (0.79–13.82) 1/13 (8%) 0.852 1.23 (0.14–10.68) 5/42 (12%) 0.086 3.31 (0.84–13.00) Hispanic Ethnicity 4/55 (7%) 0.757 1.24 (0.32–4.83) 1/13 (8%) 0.852 1.23 (0.14–10.68) 3/42 (7%) 0.952 1.04 (0.26–4.25) Aged 65 and older 18/55 (33%) 0.602 1.22 (0.58–2.54) 9/13 (69%) 0.004 6.34 (1.83–21.97) 9/42 (21%) 0.131 0.52 (0.22–1.21) Obesity 12/54 (22%) 0.594 0.80 (0.35–1.82) 5/12 (42%) 0.160 2.41 (0.71–8.20) 7/42 (17%) 0.153 0.51 (0.20–1.29) Diabetes mellitus 6/54 (11%) 0.672 0.80 (0.28–2.30) 2/13 (15%) 0.750 1.30 (0.26–6.43) 4/41 (10%) 0.579 0.72 (0.22–2.34) Hypertension 22/55 (40%) 0.273 1.49 (0.73–3.06) 9/13 (69%) 0.011 5.03 (1.46–17.36) 13/42 (31%) 0.402 0.72 (0.33–1.55) Neuroinvasive WNV Disease 32/55 (58%) 0.058 1.95 (0.98–3.88) 9/13 (69%) 0.122 2.64 (0.77–9.01) 23/42 (55%) 0.401 1.36 (0.66–2.80) Family History of Chronic Kidney Disease was excluded from the table since there were insufficient numbers to calculate statistical values. OR =Odds Ratio, CI = Confidence Interval. doi:10.1371/journal.pone.0040374.t002 CKD Prevalence among WNV Cohort PLoS ONE | www.plosone.org 4 July 2012 | Volume 7 | Issue 7 | e40374 1.1.2 Packet Pg. 18 Attachment: Prevalence of Chronic Kidney Disease (6605 : West Nile Virus (WNV) Management Policy and Response Plan Review) identify if neuroinvasive WNV is serving as a surrogate marker for immunosuppression leading to renal decline. While our data does not suggest this is the case, we cannot rule it out without a proper control group. We anticipate to find that WNV is indeed a factor in renal decline, at which point we aim to then differentiate between factors associated with persistent WNV related renal decline and other causes of renal decline. We found a high prevalence of CKD in long term follow-up of patients with a history of acute WNV infection. Over 1.5 years of follow-up, the average decline in eGFR was 23.71 mL/min/ 1.73 m2. The majority of those with CKD were found to be classified as Stage I–II, indicating mild disease. Those in this range are likely to be unaware that they are in the early stages of CKD and therefore at higher risk for disease progression. Traditional risk factors, such as diabetes, hypertension, obesity, and family history of CKD, were not found to be significantly associated with CKD among this population. However, there was an association with Neuroinvasive WNV infection at initial presentation. In light of our findings, we cannot rule out the influence of WNV with declining renal functioning. Physicians should monitor the kidney health of patients with a history of WNV infection. Acknowledgments We would like to thank Charuta Kale and Kyle McCauley for their assistance with data collection. We would also like to thank the participants of the cohort for their continued support. Author Contributions Conceived and designed the experiments: MSN ASP AMH KMA KOM. Analyzed the data: MSN AMH. Contributed reagents/materials/analysis tools: KWF KOM. Wrote the paper: MSN KWF KOM. References 1. Lindsey NP, Staples JE, Lehman JA, Fischer M (2010) Surveillance for human West Nile virus disease–United States, 1999–2008. Morb Mort Weekly Report 59:1– 17. 2. Tesh RB, Siirin M, Guzman H, Travassos da Rosa APA, Wu X, et al. (2010) Persistent west nile virus infection in the gold hamster: Studies on its mechanism and possible implications for other flavivirus infections. J Infect Dis. 192:287–295. 3. Murray K, Walker C, Herrington E, Lewis JA, McCormick J, et al. (2010) Persistent infection with West Nile virus years after initial infection. J Infect Dis. 201(1):2–4. 4. Tonry JH, Brown CB, Cropp CB, Co JK, Bennett SN, et al (2005) West Nile virus detection in urine. Emerg Infect Dis. 11(8):1294–1296. 5. Baty SA, Gibney KB, Staples JE, Patterson AB, Levy C, et al. (2012) Evaluation for West Nile Virus (WNV) RNA in Urine of Patients Within 5 Months of WNV Infection. J Infect Dis205(9):1476–1477. 6. Murray KO, Baraniuk S, Resnick M, Arafat R, Kilborn C, et al. (2008) Clinical Investigation of Hospitalized West Nile Virus Cases in Houston, 2002–2004. Vector Borne Zoonotic Dis 8:167–174. 7. Murray K, Baraniuk S, Resnick M, Arafat R, Kilborn C, et al. (2006) Risk factors for encephalitis and death from west nile virus infection. Epidemiol Infect. 12;134(6):1325–1332. 8. Lindsey NP, Sejvar JJ, Bode AV, Pape WJ, Campbell GL (2012) Delayed mortality in a cohort of persons hospitalized with West Nile virus disease in Colorado in 2003. VectorBorne Zoonotic Dis12(3): 230–235. 9. directory of services. Quest Diagnostics Incorporated; 2010. 10. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, et al. (1999) A more accurate method to estimate glomerular filtration rate from serum creatinine: A new prediction equation. Ann Inter Med 130(6):461–470. 11. KDOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification [Internet].: Kidney Disease Outcomes Quality Initiative; 2002. Available: http://www.kidney.org/professionals/KDOQI/ 1 West Nile Virus Management Policy Review Mike Calhoon, Director of Parks 3-27-18 ATTACHMENT 3 1.1.3 Packet Pg. 20 Attachment: Powerpoint Presentation (6605 : West Nile Virus (WNV) Management Policy and Response West Nile Virus Policy 2 “Reduce the risk of human WNV infection while limiting adverse human health and environmental impacts.” -- West Nile Virus Management Policy Adopted July 1, 2008 ATTACHMENT 3 1.1.3 Packet Pg. 21 Attachment: Powerpoint Presentation (6605 : West Nile Virus (WNV) Management Policy and Response Questions for Council • Does Council have any questions concerning the current WNV Program? • Would Council like to consider changes to the current thresholds for adult mosquito control? 3 ATTACHMENT 3 1.1.3 Packet Pg. 22 Attachment: Powerpoint Presentation (6605 : West Nile Virus (WNV) Management Policy and Response West Nile Virus Program Overview • Began in 2003 as WNV became endemic to the region • Reduce human impact of WNV while balancing costs and social and environmental impacts • Based on Center of Disease Control’s (CDC) model – Integrated Mosquito Management • Public education, larval management, surveillance, adult mosquito control, continual improvement assessment 4 ATTACHMENT 3 1.1.3 Packet Pg. 23 Attachment: Powerpoint Presentation (6605 : West Nile Virus (WNV) Management Policy and Response Public Education and Outreach • Print materials e.g., bus benches, banners, newspaper, etc. • Social media e.g., Nextdoor, Facebook, Twitter, etc. • Webpage – fcgov.com/westnile • Areas of focus e.g., softball players, runners, homeless, non-English speaking, river recreators etc. • Trailhead “Skeeter Meter” kiosk • Adulticiding outreach package 5 ATTACHMENT 3 1.1.3 Packet Pg. 24 Attachment: Powerpoint Presentation (6605 : West Nile Virus (WNV) Management Policy and Response Larval Management 2017 Preventative Management Actions • Source reduction preferred option • 5,963 larval site inspections; 54% producing larva • 249 backyard and storm drain inspections; 19% producing larva • Main product utilized is a naturally occurring bacteria 6 ATTACHMENT 3 1.1.3 Packet Pg. 25 Attachment: Powerpoint Presentation (6605 : West Nile Virus (WNV) Management Policy and Response Surveillance Program Developing the Weekly Data • 53 traps – set weekly from mid-June thru mid-Sept • Typically about 15 species of mosquito in the area • 2 species transmit WNV; only females mosquitoes bite • Colorado State University tests for WNV and calculates Vector Index 7 ATTACHMENT 3 1.1.3 Packet Pg. 26 Attachment: Powerpoint Presentation (6605 : West Nile Virus (WNV) Management Policy and Response Adult Mosquito Control Last Tool in the Toolbox • Larimer County Department of Public Health and Environment (DPHE) recommends application and defines perimeter based on surveillance data • Thresholds for Action: Vector Index of 0.75 AND More than 1 human case per week OR More than 1 WNV+ blood donor 8 ATTACHMENT 3 1.1.3 Packet Pg. 27 Attachment: Powerpoint Presentation (6605 : West Nile Virus (WNV) Management Policy and Response Continual Improvement Assessment Technical Advisory Committee (TAC) consists of: • Vector-borne disease experts (CDC, CSU) • Ex-officio members of Air Quality and Natural Resources Boards • No Spray Fort Collins • Organic farming business owner • Larimer County DPHE 9 ATTACHMENT 3 1.1.3 Packet Pg. 28 Attachment: Powerpoint Presentation (6605 : West Nile Virus (WNV) Management Policy and Response Continual Improvement Assessment • Annual off-season review process • Implemented TAC recommended enhancements: • Enlarged larval control perimeter • Modifications to surveillance season • Public outreach enhancements 10 ATTACHMENT 3 1.1.3 Packet Pg. 29 Attachment: Powerpoint Presentation (6605 : West Nile Virus (WNV) Management Policy and Response Continual Improvement Assessment 2017 Review-Research (2012 Epidemic – Houston Cohort): • Increased prevalence of chronic kidney disease • 4 – 9 yrs. post-infection. Nolan, et al. • Long-term neurological impacts of WNV observed • Evaluations showing abnormalities 1-3 yrs. and 8-11 yrs. post-infection. Weatherhead, et al. 11 ATTACHMENT 3 1.1.3 Packet Pg. 30 Attachment: Powerpoint Presentation (6605 : West Nile Virus (WNV) Management Policy and Response WNV Technical Advisory Committee • 2017 Review-Adult Mosquito Control Thresholds • No consensus on appropriate Vector Index threshold levels • Vector Index thoughts range from 0.33 to 1.0 and higher • No consensus on appropriate human case consideration • Including human cases accounts for personal responsibility • Inclusion creates a lagging indicator 12 ATTACHMENT 3 1.1.3 Packet Pg. 31 Attachment: Powerpoint Presentation (6605 : West Nile Virus (WNV) Management Policy and Response WNV Staff Recommendation • Staff recommends decreasing the VI threshold to 0.50 and removing the human case requirement. • Rationale: • When required, smaller, more targeted application areas may better reduce the amplification of WNV • Requiring human cases extends the lagging nature of the indicator • Recent studies show the latent effect of WNV. 13 ATTACHMENT 3 1.1.3 Packet Pg. 32 Attachment: Powerpoint Presentation (6605 : West Nile Virus (WNV) Management Policy and Response Questions for Council Does Council have any questions concerning the current WNV Program? Would Council like to consider changes to the current thresholds for adult mosquito control? Current threshold is: Vector Index of 0.75 AND More than 1 human case per week OR More than 1 WNV+ blood donor 14 ATTACHMENT 3 1.1.3 Packet Pg. 33 Attachment: Powerpoint Presentation (6605 : West Nile Virus (WNV) Management Policy and Response DATE: STAFF: March 27, 2018 Noah Beals, Senior City Planner/Zoning Tom Leeson, Director, Comm Dev & Neighborhood Svrs WORK SESSION ITEM City Council SUBJECT FOR DISCUSSION Sign Code Update, Phase 2. EXECUTIVE SUMMARY The purpose of this item is to check in with Council on the process of the Sign Code Update. GENERAL DIRECTION SOUGHT AND SPECIFIC QUESTIONS TO BE ANSWERED 1. Is the process of the Sign Code Update on track? 2. What feedback does Council have on a Digital Billboard option? BACKGROUND / DISCUSSION Phase 2 of the Sign Code Update started the end of 2017 in brainstorming meetings with City staff and the consultant. In these meetings the key purposes of the Phase 2 and the approach on how to engage residents, business owners and other stakeholders were discussed. The purposes identified in these initial meetings were: • Improve overall legibility of the Sign Code Section • Implement action items from the adopted Downtown Plan o Restore existing historic signs and allow for the reconstruction of historically significant signs that previously existed o Develop Land Use Code regulations that identify performance standards for design elements that activate buildings and private outdoor spaces along public streets. Amend the Sign Code to require pedestrian-oriented signs. • Discuss sign standards for new technology • Provide an option for consideration of Digital Billboards From these meetings a timeline and outreach approach were created. The process began with two public meetings on general topics and sign types. These meetings were advertised through the City’s website, press release and emails to stakeholders involved in Phase 1 of the Sign Code. The first meeting was attended by approximately 20-25 people. At both meetings staff conducted a power point presentation and had boards displayed on the general topics for participants to read at their own pace. After these meetings public outreach continued through an online questioner on and walk-in chat sessions (coffee talks). Staff increased the advertisement with an email blast to those who signed up for notifications on the Downtown Plan and sent out a flyer to 1,000 individuals. Both have generated additional feedback. Outreach efforts have continued through presentations at other organizations. In February staff attended the Downtown Business Association’s (DBA) board meeting and membership meeting. This month staff presented to the Chamber of Commerce Local Legislative Affairs Committee and returned to the DBA membership meeting. Discussions were held with members of the Downtown Development Authority (DDA) to review the Sign Code update. Also, staff presented at the Planning and Zoning Board and Landmark Preservation Commission to get any initial input before returning to the Boards for a recommendation. 1.2 Packet Pg. 34 March 27, 2018 Page 2 After the Council work session, staff plans to start drafting Code language. With the drafted Code language, staff will schedule an additional public meeting and present the draft Code. After this meeting the language will be refined and will move forward to the Planning and Zoning Board and Landmark Preservation Commission for a recommendation. With these recommendations, the proposed Code changes will then be presented for consideration to Council. Digital Billboards Currently, staff has outlined an approach for allowing for a new sign type: the Digital Billboard. This option addresses the removal of existing static billboards through an exchange for a Digital Billboard. With this new sign type, it is anticipated that standards that would address the following: • Location = Commercial/industrial areas on I-25 and South College Avenue • Design = Size, height and setback • Brightness & Glare = Similar to current Electronic Message Center standards and exploring shut-off times • Exchange Rate = Certain amount of square footage of static billboards would need to be removed for square footage of a digital billboard. • Message Duration = The length of time a single message required to be displayed, shorter for location along the interstate and longer for other locations ATTACHMENTS 1. Powerpoint presentation (PDF) 1.2 Packet Pg. 35 March 27, 2018 Phase 2 of Sign Code Update Noah Beals Senior City Planner - Zoning ATTACHMENT 1 1.2.1 Packet Pg. 36 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Objective 2 1. Is the process of the Sign Code Update on track? 2. What feedback does Council have on a Digital Billboard option? 1.2.1 Packet Pg. 37 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Phase 2 Sign Code Update 3 1.2.1 Packet Pg. 38 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Goals of Phase 2 4 1. Improve the overall legibility of the Sign Code Section 2. Implement action items for the adopted Downtown Plan 3. Discuss sign standards for new technology 4. Provide an option for consideration of Digital Billboards 1.2.1 Packet Pg. 39 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Public Meetings 5 Two Meetings at the Museum of Discovery and at the Drake Centre 1.2.1 Packet Pg. 40 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Online Outreach 6 • Sign Code Website • Questionnaire • Social Media • City Website 1.2.1 Packet Pg. 41 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Email Notification 7 At the end of February an email Went out to those that signed up for updates on the Downtown Plan Over recipients 1.2.1 Packet Pg. 42 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Flyer 8 Beginning of March A Flyer was mailed to over 1,000 individuals 1.2.1 Packet Pg. 43 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Walk-in Chats (Coffee Talks) 9 In March three times for walk-in chats 1.2.1 Packet Pg. 44 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Work Sessions 10 In March presented at three Work Sessions • March 09th Planning and Zoning Board • March 17th Landmark Preservation Commission • March 27th City Council 1.2.1 Packet Pg. 45 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Other Meetings 11 Other organizations that requested a presentation • March 15th , 2018 Downtown Business Association, Member meeting • March 9th , 2018 Chamber of Commerce Local Legislative Affairs Committee • February 15th , 2018 Downtown Business Association, Member meeting • February 14th , 2018 Downtown Business Association, Board Meeting 1.2.1 Packet Pg. 46 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Summary of Presentations 12 1.2.1 Packet Pg. 47 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Summary of Presentations 13 1.2.1 Packet Pg. 48 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Next Steps 14 Anticipated next steps • Begin drafting code language • Schedule a public meeting to present drafted code language • Refine the drafted language • Proceed to Planning and Zoning Board and Landmark Preservation Committee for recommendation • Present to Council with recommendations for consideration 1.2.1 Packet Pg. 49 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Digital Billboards 15 1.2.1 Packet Pg. 50 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Digital Billboards 16 1.2.1 Packet Pg. 51 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Digital Billboards 17 1.2.1 Packet Pg. 52 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Digital Billboards 18 1.2.1 Packet Pg. 53 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Digital Billboards 19 1.2.1 Packet Pg. 54 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Digital Billboards 20 1.2.1 Packet Pg. 55 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) Objective 21 1. Is the process of the Sign Code Update on track? 2. What feedback does Council have on a Digital Billboard option? 1.2.1 Packet Pg. 56 Attachment: Powerpoint presentation (6606 : Sign Code Update, Phase 2) DATE: STAFF: March 27, 2018 Lawrence Pollack, Budget Director Mike Beckstead, Chief Financial Officer Carol Webb, Water Resources/Treatmnt Opns Mgr Teresa Roche, Chief Human Resources Officer Greg Yeager, Police Deputy Chief WORK SESSION ITEM City Council SUBJECT FOR DISCUSSION 2019/2020 Budgeting for Outcomes (BFO) Consideration Items. EXECUTIVE SUMMARY The purpose of this item is to inform and seek input from Council on several items that will be significant to the upcoming BFO process. Topics to be discussed include: 1. Police staffing process 2. Compensation and Benefits 3. Process improvements to capital cost estimates 4. Potential infrastructure financing projects GENERAL DIRECTION SOUGHT AND SPECIFIC QUESTIONS TO BE ANSWERED Staff is seeking to: • Review significant factors and inputs to the 2019/20 BFO Process • Understand Council thinking and guidance prior to engaging in budget discussion • Share high-level process improvements to capital cost estimate BACKGROUND / DISCUSSION 1. Police Staffing In June of 2016, the City Council generally accepted a staffing methodology presented by Fort Collins Police Services (FCPS). The projection for future staffing was 123 additional officers over a 12-20 year period (6- 10/year) leading up to a City build-out and top population of 255,200. The model provides 30 minutes of Reactive Time and 30 minutes of Proactive Time per Patrol officer, per hour. In 2017, City Staff and the Futures Committee updated the Police Priority 1 (emergency call) response time target to arrival within 5 minutes and 30 seconds. Current FCPS staffing is preventing the Agency from meeting either target. Staff will work to align methodology assumptions with current planning estimates for population at build out and the date build out is expected to occur. Staff will also incorporate outcome goals for both Reactive & Proactive time and the new Police Priority 1 response time target to develop staffing targets to be utilized within the 2019/20 BFO process. Staff anticipates offers in two groups, one that keeps staffing aligned with population growth and one that support improvement in achieving outcome target. FCPS has a recruitment, hiring, and training plan to incorporate additional police officers into its workforce. The hiring and training of sworn officers requires a 12-18 month process. Staffing plans will include other Agency personnel to include Community Service Officers, Dispatchers, and support personnel that must be 1.3 Packet Pg. 57 March 27, 2018 Page 2 added in the same time frame. Due to the hiring and training timeline, updating the staffing methodology and supporting new positions now will allow FCPS to recruit, hire, and train the best personnel in time to meet community needs. 2. Compensation and Benefits Total Compensation costs make up 25% of the City’s operating budget and as such, careful and thoughtful attention is paid on how to attract, retain and reward our workforce within a sustainable financial model. Staff will provide a high-level overview of the compensation forecast methodology used to determine the merit increase budget and share preliminary assumptions for 2019-2020. Additionally, information will be shared on 2016- 2017 benefits costs, the status of our benefit fund reserve balance, how we define market for our health care plans and where the City is compared to market. 2019-2020 considerations and preliminary assumptions will be reviewed. A deeper dive is scheduled for the May Council Finance Committee. 3. Improvements to Capital Project Cost Estimates Utilities Capital Project Cost Estimates Estimating budgets for Capital Projects is critical to City’s budget process. These budgets need to be accurate for: 1) transparency on what the project will cost and 2) appropriating sufficient funds to deliver the project. There are a variety of factors that influence a Capital Project budget offer such as: level of design, permitting, construction cost escalations, ROW, and contingency. The level of understanding of these factors can greatly improve the accuracy of the budget. Staff is considering some improvements to better inform the budget process for certain Capital Projects. Capital Projects are generally identified during the master planning process. The master plans evaluate current and future needs and recommend capital projects to address those needs. Conceptual level costs are identified with limited design and high contingencies. Projects are incorporated into capital improvement plans and prioritized based on levels of service. Individual projects are then identified to be carried forward as a budget offer in the Budgeting for Outcomes process. Currently, budget offers include funds for design and construction. The budget amount is usually based on the conceptual level cost estimate from the master plan. This process can lead to challenges for the project such as: identifying design and permitting constraints after appropriation which may require additional funds to complete the project. Also, the design and permitting process can take up to 12-18 months leading to a time lag from when funds are appropriated to when construction costs are incurred. An improvement to the Capital Project budgeting process is to appropriate design and construction funds in sequential budget cycles. The process would allow the design to begin ahead of appropriating funds for construction. The project team can then identify project constraints and develop a more informed construction budget and schedule for the next budget cycle leading to greater accuracy and transparency. Other Capital Project Cost Estimate Improvements Additional review and verification of costs associated with facility construction, remodeling, large IT systems projects and programs that require significant CPIO and/or HR resources will also be incorporated into the BFO process. In summary: (1) Staff initiating a project will work with the appropriate support organization to review and verify assumptions and cost estimates as part of the offer development (2) After the first round of offer submittal, the budget office will pull any offers per above and share with the appropriate support organization to ensure all have been reviewed. 1.3 Packet Pg. 58 March 27, 2018 Page 3 4. Potential infrastructure financing projects Several projects are currently in discussion with Council that will requires external borrowing to complete. The projects include: (1) I-25/Prospect Interchange - estimated at $17.1M with financing needed April 2019. With the I25 expansion, an opportunity to upgrade a failing intersection with shared funding from Colorado Department of Transportation (CDOT), property owners, Timnath and the City was identified. Council has approved an intergovernmental agreement with CDOT outlining the City’s commitments to fund this project. (2) Police Training Facility - estimated at $8.5M. This project is being worked jointly with Loveland. Council has previously approved $0.8M for design work with an understanding that staff will return to Council with final scope and costs seeking a decision to move forward or not. Total costs are estimated at $18.5M and the scope will include indoor firing range, classrooms, high speed driving track and skid pad. The project will be reviewed with Council at the August 28 Work Session. A decision to proceed would need funding in early 2019. (3) Vine/Lemay Grade Separated Crossing - estimated at $10.0M. Timing on funding of this project is flexible. This project will be reviewed at Council Finance Committee on March 19. A high-level overview of each project is provided in the presentation as well as a summarization of debt service requirements if all three projects were selected. ATTACHMENTS 1. Powerpoint presentation (PDF) 1.3 Packet Pg. 59 1 2019/20 BFO Considerations March 27, 2018 ATTACHMENT 1 1.3.1 Packet Pg. 60 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Agenda 2 • Introduction • Police Staffing Process • Compensation & Benefits • Improvements to Capital Cost Estimate • Potential Infrastructure Projects ATTACHMENT 1 1.3.1 Packet Pg. 61 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Introduction 3 Objectives: 1. Review significant factors and inputs to the 2019/20 BFO Process 2. Understand Council thinking & guidance prior to engaging in budget discussion 3. Share high level process improvements to capital cost estimate Note: a detailed review of budget assumptions is schedule for the May Council Finance Committee meeting and will also be included in the August 14th Budget Review work session ATTACHMENT 1 1.3.1 Packet Pg. 62 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Police Staffing 4 ATTACHMENT 1 1.3.1 Packet Pg. 63 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Currently Budgeted Police Staffing Status 5 FCPS was authorized new personnel in the 2017-2018 budget: •(9) Officers •(1) Detective • (1) Dispatcher • (2) Police Services Technicians • (1) Property and Evidence Technician All have been hired. Civilians working at full capacity, but some officers remain in various training phases: • (8) officers at police academy • (7) officers in mini-academy & field training • (5) of these officers will fill existing attrition spots ATTACHMENT 1 1.3.1 Packet Pg. 64 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) 6 Police Hiring & Training Timelines Recruitment and Hiring • FCPS diversified hiring practices and increased hiring incentives in 2017 • Resulted in 6-year record of police officer applicants (333) • Hiring and training takes 12 to 18 months • Hiring process: 24 weeks (approx.) • Training: • 22 week academy for non-certified officers • 9 week mini-academy at FCPS for all new officers • 15 week field training program for all new officers • Steady increases in authorized strength can meet City growth demands ATTACHMENT 1 1.3.1 Packet Pg. 65 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Police Staffing Needs 7 Growth Personnel: • Align staff requirements to Community build-out population and date of build-out • Utilize 30/30 methodology to model staffing requirements Meet Outcome Targets: • To achieve desired service levels Outcome Targets Drive Staffing: • 5 minute 30 second response time to Priority 1 calls • Patrol officer 30/30 time split • 50% reactive • 50% proactive ATTACHMENT 1 1.3.1 Packet Pg. 66 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Police Staffing Council Discussion 8 Council Questions & Discussion on Police Staffing ATTACHMENT 1 1.3.1 Packet Pg. 67 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Compensation & Benefits 9 ATTACHMENT 1 1.3.1 Packet Pg. 68 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) 10 Total Compensation = 25% of City Operating Budget • 2018 Budget Allocation and Pay Increases • Budget for 2018 = 2.5% of projected base salaries • Average Pay Increase: 2.42% • 2018 Medical Employer Premium per Employee Per Year (PEPY) = $11,364 Total Compensation 2018 Highlights ATTACHMENT 1 1.3.1 Packet Pg. 69 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Compensation Forecast Methodology 11 Quantitative Analysis • Review economic factors • Review actual salary to market data Qualitative Analysis • Outreach to peer cities to gather salary budget data Indexes and Source Data Analyzed • Employers Council (EC) • Consumer Price Index (CPI) – Local and National • Real GDP Growth Rate • Employment Cost Index (ECI) Salaries and Wages • Fort Collins Unemployment Rate ATTACHMENT 1 1.3.1 Packet Pg. 70 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) 12 2015 2016 2017 2018 National1 3.0% 3.0% 3.0% 3.1% Colorado2 3.0% 3.0% 3.0% 3.2% Colorado Peer Cities 2.8% 3.0% 3.0% 3.5% City of Fort Collins 2.0% 2.0% 2.5% 2.5% 1 Source: WorldatWork Salary Budget Surveys 2 Source: Employers Council Average Salary & Range Projections Surveys 2015 – 2018 Salary Budget Comparison 2019 – 2020 Preliminary Assumptions: 3.0% – 3.5% Based on forecasted economic indicators and concern regarding competitive position relative to peers ATTACHMENT 1 1.3.1 Packet Pg. 71 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) 13 2016 - 2017 Medical & Rx Summary • 2016 Total Plan Costs: $21.9M; Per Employee Per Month: $1,076 • 2017 Total Plan Costs: $21.0M; Per Employee Per Month: $1,006 • 6.5% Decrease due to: • Membership • Large Claimants Reduced • Rx Savings ~$700K - $1M • Increase in Generic Utilization • Overall Good Year • Benefits’ Fund Balance above Policy Minimum ATTACHMENT 1 1.3.1 Packet Pg. 72 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) What Does ‘Market’ Mean? 14 Public v. Private Health Plans Premiums Budget Plan Design •HMO • PPO •POS • HDHP Employer Employee Industry Population Location Full or Self Insured Revenue v. Expense ATTACHMENT 1 1.3.1 Packet Pg. 73 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) 15 Are We Market Competitive? Fort Collins Plan Design Premium Single (13%) Premium Spouse (29%) Premium Children (29%) Premium Family (29%) Cost/ Claim Share Consumer Choice Public + In Market - 6% - 5% - 4% In Market - Private + + 8% - 12% + 5% + 4% + 4% In Market - ATTACHMENT 1 1.3.1 Packet Pg. 74 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) 16 2019 – 2020 Proposed Budget Medical – Increase Employer Cost • 2019: 2.5% • 2020: 5% Dental – Increase Employer Cost • 2019: No increase • 2020: 3% Increase to City Budget: • 2019: $650K • 2020: $1.2M Assumes 3.5% Annual Enrollment ATTACHMENT 1 1.3.1 Packet Pg. 75 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) 17 2019 – 2020 Considerations CBU Commitments • Total Compensation Committee • RFP for pre-65 Retiree Heath Coverage Model High Deductible Health Plan w/ Health Savings Account • Align with Total Rewards Philosophy – Choice • Model with UMR PPO Plan Affordable Health Premium • Premium subsidy for low income employees <$40K ATTACHMENT 1 1.3.1 Packet Pg. 76 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Compensation & Benefits Council Discussion 18 Feedback from Council • Questions regarding our compensation methodology? • Initial comments to preliminary assumptions for 2018-2019 merit increase budget? • Questions about the definition of market for benefits? • Initial comments about the potential benefit options for 2019-2020? ATTACHMENT 1 1.3.1 Packet Pg. 77 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Improvements to Capital Cost Estimates 19 ATTACHMENT 1 1.3.1 Packet Pg. 78 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Capital Project Budgets 20 • Construction cost • Design cost • Construction services • Permitting & ROW • Project management • Contingency ATTACHMENT 1 1.3.1 Packet Pg. 79 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Capital Project Budgets 21 • Cost Verification (estimate) • Escalation (when it will be built) • Contingencies (address what we don’t know) • Level of Design (the more complete, the less risk) ATTACHMENT 1 1.3.1 Packet Pg. 80 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Current Capital Project Budgets MASTER PLANS Project ID Conceptual Costs CAPITAL IMPROVEMENT PLAN Prioritization Levels of Service BUDGET OFFER Design Construction 22 ATTACHMENT 1 1.3.1 Packet Pg. 81 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) ADVANTAGES • Total budget appropriated • Shorter duration between design and construction CHALLENGES • Based on limited design • Permitting unknowns • Ties up capital during design and permitting phase • Potential for additional appropriations needed 23 Current Capital Project Budgets ATTACHMENT 1 1.3.1 Packet Pg. 82 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Improved Capital Project Budgets 24 MASTER PLANS Project ID Conceptual Costs CAPITAL IMPROVEMENT PLAN Prioritization Levels of Service BUDGET OFFER Design FUTURE BUDGET OFFER Construction ATTACHMENT 1 1.3.1 Packet Pg. 83 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Improved Capital Project Budgets ADVANTAGES • Higher level design means fewer unknowns • More informed budgets/ schedules • Construction costs incurred within appropriation year CHALLENGES • Longer duration between design and construction • Spans multiple budget cycles • Shifting priorities 25 ATTACHMENT 1 1.3.1 Packet Pg. 84 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Improvements to Capital Cost Estimates 26 Improvements to Other Large Project Estimates • Facility / vertical construction… Facilities • New space, equipment or vehicles… Facilities & Fleet • IT equipment, software, outside vendor support, web design… IT • Training programs, internal / external outreach and education… CPIO/HR Prior to offer submittal, seller will work with support organization in developing offer costs, timelines and details After first round inputs, budget will pull all offers related to above and share with support organizations to ensure input and review has occurred ATTACHMENT 1 1.3.1 Packet Pg. 85 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Capital Cost Estimates Council Discussion 27 Council Questions & Discussion on Capital Cost Estimate Improvements ATTACHMENT 1 1.3.1 Packet Pg. 86 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Infrastructure Projects 28 ATTACHMENT 1 1.3.1 Packet Pg. 87 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Potential Infrastructure Projects 29 Several infrastructure projects are under discussion that will required debt service in 2019/2020 if approved • I25/Prospect Interchange – approximately $17M • Police Training Facility – approximately $8.5M • Vine/Lemay grade separated crossing $10M ATTACHMENT 1 1.3.1 Packet Pg. 88 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) 30 • January 2018 IGA with CDOT commits City to $19 million project • Structuring, collateral, and project options presented to Finance Committee 10/2017 • Finance via Certificates of Participation (COPs) • $1.3 million new debt service from General Fund • Coincides with maturity of existing debt, freeing $433K • Total Cost $31M • Includes $7M for Urban Design • CDOT $12M - 50% of base design • City/Property Owners/Timnath $19M • FC = $8.25M • Property Owners = $8.25M • Timnath = $2.5M • Current Estimate - Borrow $17.1M • $19M less ROW & TCEF contribution Project Costs Financing Infrastructure Projects I25/Prospect Interchange ATTACHMENT 1 1.3.1 Packet Pg. 89 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Training Facility Features and Capital Cost $18.5M concept facility includes: • 50 yard, 20 lane indoor Pistol Range • 100 yard, 10 lane indoor Rifle Range • 3 classrooms • Office Space • Driving Skid Pad • 1 mile Driving pursuit/speed track • Room to add on/grow in future ATTACHMENT 1 1.3.1 Packet Pg. 90 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) • Facility is jointly owned and operated and costs split 50/50 • Loveland will lead on contracts – Fort Collins reimburses • First IGA & Appropriation focused on design - $1.6M • Second IGA & Appropriation will focus on governance, operations & construction - $16.9M 50% Share Fort Collins $ 9,259 Loveland 9,259 Total $ 18,519 Anticipated Capital Need ($000's) • FC Financing for Construction - $8.5M Project Details Financing Infrastructure Projects Police Training Facility ATTACHMENT 1 1.3.1 Packet Pg. 91 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) 33 • Increasing Congestion and Delay (Train Switching and Vehicle Traffic) • Historic Neighborhood Livability: Pedestrian Safety, Air Quality, and Connectivity Issues • Reduce Traffic Along Ninth Street Infrastructure Projects Vine/Lemay Crossing ATTACHMENT 1 1.3.1 Packet Pg. 92 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) 34 1. “Pay as We Go” Option – (Save up and Build the Project in the Future) 2. Debt Financing Option – Similar to Police Training 3. Debt Financing Option – Proposed Tolling System Total Project Cost $22M* BFO Offers (already appropriated in the 15/16 and 17/18 budgets) $ 2.0M Transportation Capital Expansion Fee (TCEF) Contribution $ 10.0M** Additional Funding Needed $10M * Denotes 2017 Dollars (Will Inflate yearly with Material Cost Escalation starting in late 2018) ** $10.0M (TCEF) includes $1.4M of Phase 1 Construction Infrastructure Financing Vine/Lemay Crossing ATTACHMENT 1 1.3.1 Packet Pg. 93 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Cumulative Debt Potential 35 Debt Srvc Capacity freed in 2019 ($.4) Capacity needed with I25/Prospect* 1.3 Less Timnath share (.2) Capacity needed with Training Facility .7 Capacity needed with Vine/Lemay .8 Capacity freed with Police HQ Refinance - Capacity needed for all potential projects $2.2 Options to Explore • Longer maturities • Partial cash funding from Reserves • Interest Rates • Assumptions • New 20 year financing for each Project • 4.5% interest rate ($ million’s) Capacity needed for I25 & Police Training only $1.4 ATTACHMENT 1 1.3.1 Packet Pg. 94 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) Infrastructure Projects Council Discussion 36 Council Questions & Discussion on Infrastructure Projects & Financing ATTACHMENT 1 1.3.1 Packet Pg. 95 Attachment: Powerpoint presentation (6601 : 2019/2020 BFO Consideration Items) guidelines_ckd/toc.htm. 12. Altemtam N, Russell J, El Nahas M (2012) A study of the natural history of diabetic kidney disease (DKD). Nephrol Dial Transpl27(5):1847–1854. 13. Murray KO, Nolan MS, Yan C Persistence of Immunoglobulin-M antibodies up to 8 years following infection with West Nile virus. Clin Vaccine Immunol Submitted. 14. Prince HE, Tobler LH, Lape-Nixon M, Foster GA, Stramer SL, et al. (2005) Development and persistence of West Nile virus-specific immunoglobulin M (IgM), IgA, and IgG in viremic blood donors. J Clin Microbiol. 43(9):4316–4320. 15. Papa A, Danis K, Athanasiasdou A, Delianidou M, Panagiotopoulos T (2011) Persistence of West Nile virus immunoglobulin M antibodies, Greece. J Med Virol. 83(10):1857–1860. 16. Zhang X, Nagaraja HN, Nadasdy T, Song H, McKinley A, et al. (2012) A composite urine biomarker reflects interstitial inflammation in lupus nephritis kidney biopsies. Kidney Int 81(4):401–406. 17. Damman K, van Veldhuisen DJ, Navis G, Voors AA, Hillege HL (2008) Urinary neutrophil gelatinase associated lipocalin (NGAL), a marker of tubular damage, is increased in patients with chronic heart failure. Eur J Heart Fail 10:997–1000. 18. Devarajan P(2010) Review: Neutrophil gelatinase-associated lipocalin: A troponin-like biomarker for human acute kidney injury. J Nephrol 15:419–428. 19. Haase-Fielitz A, Bellomo R, Devarajan P, Bennett M, Story D, et al. (2009) The predictive performance of plasma neutrophil gelatinase-associated lipocalin (NGAL) increases with grade of acute kidney injury. Nephrol Dial Transpl24:3349–3354. 20. Levey AS, Stevens LA, Schmid CH, Zhang Y, Castro AF, et al. (2009) A new equation to estimate glomerular filtration rate. Ann Inter Med 150(9): 604–612. 21. Clark WF, Macnab JJ, Sontrop JM, Jain AK, Moist L, et al. (2011) Dipstick proteinuria as a screening strategy to identify rapid renal decline. Clin JAm SoNephro. 22(9):1729–1736. CKD Prevalence among WNV Cohort PLoS ONE | www.plosone.org 5 July 2012 | Volume 7 | Issue 7 | e40374 1.1.2 Packet Pg. 19 Attachment: Prevalence of Chronic Kidney Disease (6605 : West Nile Virus (WNV) Management Policy and Response Plan Review) Black 9(6) 6(9) 1(2) 2(7) Asian 2(1) 1(1) 0(0) 1(4) Hispanic 9(6) 8(12) 0(0) 1(4) CKD Risk Factors Aged 65 and older 42(30) 30(45) 9(20) 3(11) Obesity 32(25) 18(28) 7(17) 7(25) Diabetes mellitus 17(13) 14(22) 3(7) 0(0) Hypertension 47(35) 29(44) 14(33) 4(14) Family History of CKD 2(2) 1(2) 1(3) 0(0) CKD Prevalence CKD, All Stages 55 (40) 32 (48) 12 (27) 11 (39) CKD Stages 3–5 13 (10) 9 (13) 3 (7) 1 (4) CKD Stage 1–2 42 (30) 23 (34) 9 (20) 10 (36) CKD Indicators Proteinuria 36(26) 21(31) 9(20) 6(21) Hematuria 32(23) 18(27) 7(16) 7(24) Anemia 80(60) 40(60) 23(58) 17(63) Elevated serum BUN 46(33) 30(45) 12(27) 5(18) Hyperkalemia 16(12) 8(12) 7(16) 1(4) Elevated plasma NGAL 7/50 (14) 5/24 (21) 2/16 (13) 0/10 (0) Elevated plasma MCP-1 6/50 (12) 3/24 (13) 1/16 (6) 2/10 (20) doi:10.1371/journal.pone.0040374.t001 CKD Prevalence among WNV Cohort PLoS ONE | www.plosone.org 3 July 2012 | Volume 7 | Issue 7 | e40374 1.1.2 Packet Pg. 17 Attachment: Prevalence of Chronic Kidney Disease (6605 : West Nile Virus (WNV) Management Policy and Response Plan Review) asymptomatic infection comprised the other half of the population. Hypertension and advanced age were prevalent among the population. We found 40% of study participants met the KDOQI definition of CKD with 10% having Stage III or greater and 30% having Stage I–II. The prevalence of proteinuria and hematuria was 26% and 23%, respectively. Plasma NGAL levels were elevated in 14% of participants while MCP-1 levels were increased in 12%. Urinary levels NGAL and MCP-1 were elevated in 0% and 10%, respectively. The prevalence of anemia, elevated BUN, and hyperkalemia were 60%, 33%, and 12%, respectively. We analyzed the eGFR values and their change over the course of the study period (Figure 1). Follow-up data for analyzing the change in eGFR was available for 112 participants. The average change in eGFR was 23.71 mL/min/1.73 m2 over the 1.5 year study period. After adjusting for a leading cause of eGFR decline, non-diabetics had a significantly (p#0.00) different decline in eGFR values than diabetics [12]. Results of the univariate logistic regression are provided in Table 2. Univariate analysis found Stage III or greater CKD was significantly associated with being age 65 or older (p#0.01) and having hypertension (p = 0.01) at time of evaluation. No significant associations were found between Stage I–II CKD and CKD risk factors. Multivariate logistic regression was performed on the cumulative category of all stages of CKD with CKD risk factors. Based on univariate analysis, the following risk factors were included in the multivariate model: African American race (p = 0.10, OR=3.31) and history of Neuroinvasive WNV disease (p = 0.06, OR=1.95). After multivariate analysis, only Neuroin- vasive WNV disease (p = 0.058, OR=1.95) was found to be significantly associated with any stage of CKD. Discussion The goal of this study was to assess the long-term renal outcomes among a cohort of study participants with a history of WNV infection. In a previous study of WNV patients in Houston, we found 8% of participants had a history of renal insufficiency at the time of initial infection [7], and an additional 9% developed acute renal failure as a result of their illness [6]. In this follow-up study, we found 40% of our study population met the KDOQI definition for CKD when assessed up to nine years post-WNV infection. The majority of patients had CKD Stages I–II (30%) with CKD Stages III or greater being less frequent (10%). In multivariate analysis, traditional risk factors for CKD including age, and the presence of hypertension or diabetes mellitus were not associated with the presence of CKD. In fact, the analysis found history of Neuroinvasive WNV disease as the only significant risk factor associated with CKD. We cannot exclude severe infection with WNV as a factor in the development of CKD, especially considering the data from animal studies and the presence of persistent viuria in some human subjects. Since CKD is a slowly progressive disease, we looked for any potential associations between years post-acute infection (PAI) and CKD. Due to sample size restraints, we grouped years into categories. We found an overall trend of increasing odds of CKD Stage progression as the years PAI increased. Those participants who were nine to seven years PAI had 1.61 greater odds than those with zero to six years PAI of having CKD Stages III–V, while those zero to three years PAI were more likely to have CKD Stages I–II. While a larger sample size is needed to confirm this finding, our data suggests that CKD progresses in the years following acute WNV infection. Chronic renal decline is also supported by findings of extended IgM titers several years post- CKD Prevalence among WNV Cohort PLoS ONE | www.plosone.org 2 July 2012 | Volume 7 | Issue 7 | e40374 1.1.2 Packet Pg. 16 Attachment: Prevalence of Chronic Kidney Disease (6605 : West Nile Virus (WNV) Management Policy and Response Plan Review) examined. We performed an observational study to determine the prevalence of CKD and examine biomarkers for renal dysfunction in a cohort of WNV study participants years past their initial infection. PLoS ONE | www.plosone.org 1 July 2012 | Volume 7 | Issue 7 | e40374 ATTACHMENT 2 1.1.2 Packet Pg. 15 Attachment: Prevalence of Chronic Kidney Disease (6605 : West Nile Virus (WNV) Management Policy and Response Plan Review) following WNV infection, allowing for active case manage- ment to be planned and instituted. ReceivedOctober2,2014. Accepted for publicationDecember19,2014. Published online March 23, 2015. Note: Supplemental tables appear at www.ajtmh.org. Acknowledgments: We thank the participants in this study who were so gracious to offer their time and cooperation. We also thank Drs. Melissa Resnick and Jennifer Woodward for their assistance with data collection. Financial support: This research was supported by a grant from the National Institutes of Health, National Institute of Allergy and Infec- tious Diseases (NIAID grant no. K23 AI057341-01A2 and 5R01AI091816-01). Authors’ addresses: Jill E. Weatherhead, Melissa N. Garcia, and Kristy O. Murray, Department of Pediatrics, Baylor College of Med- icine, Houston, TX, E-mails: weatherh@bcm.edu, mnolan@bcm.edu, and kmurray@bcm.edu. Vicki E. Miller, Rodrigo Hasbun, and Lucrecia Salazar, University of Texas, Health Science Center, Houston, TX, E-mails: vicki.miller@uth.edu, rodrigo.hasbun@uth .tmc.edu, and Lucrecia.Salazar@uth.tmc.edu. Mazen M. Dimachkie, University of Kansas Medical Center, Lawrence, KS, E-mail: mdimachkie@kumc.edu. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. REFERENCES 1. Nash D, Mostashari F, Fine A, Miller J, O’Leary D, Murray K, Huang A, 2001. Outbreak of West Nile virus infection in the New York City area in 1999. N Engl J Med 344: 1807–1814. 2. Centers for Disease Control and Prevention, 2006. Assessing the capacity for surveillance, prevention, and control of West Nile virus infection—United States, 1999–2004. MMWR 55: 150–153. 3. Lillibridge K, Parsons R, Randle Y, Travassos da Rosa AP, Guzman H, Siirin M, Wuithiranyagool T, Hailey C, Higgs S, Bala AA, Pascua R, Meyer T, Vanlandingham DL, Tesh RB, 2004. The 2002 introduction of West Nile virus into Harris County, Texas, an area historically endemic for St. Louis encephalitis. Am J Trop Med Hyg 70: 676–681. 4. Centers for Disease Control and Prevention, 2013. West Nile virus and other arboviral diseases—United States, 2012. MMWR 62: 513–517. 5. CravenRB,Roehrig JT, 2001. West Nile virus. JAMA 286: 651–653. 6. Mostashari F, Bunning ML, Kitsutani PT, Singer DA, Nash D, Cooper MJ, Katz N, Liljebjelke KA, Biggerstaff BJ, Fine AD, Layton MC, Mullin SM, Johnson AJ, Martin DA, Hayes EB, Campbell GL, 2001. Epidemic West Nile encephalitis, New York, 1999: results of a household-based seroepide- miological survey. Lancet 358: 261–264. 7. Hayes EB, 2005. Virology, pathology, and clinical manifestations of West Nile virus disease. Emerg Infect Dis 11: 1174–1179. 8. Racsa L, Gander R, Chung W, Southern P, Le J, Beal S, Lee F, Cavuoti D, Reisch J, Alatoom A, 2014. Clinical features of West Nile virus epidemic in Dallas, Texas, 2012. Diagn Microbiol Infect Dis 78: 132–136. 9. Watson JT, Pertel PE, Jones RC, Siston AM, Paul WS, Austin CC, Gerber SI, 2004. Clinical characteristics and functional out- comes of West Nile Fever. Ann Intern Med 141: 360–365. 10. Sejvar JJ, Haddad MB, Tierney BC, Campbell GL, Marfin AA, Van Gerpen JA, Fleischauer A, Leis AA, Stokic DS, Petersen LR, 2003. Neurologic manifestations and outcome of West Nile virus infection. JAMA 290: 511–515. 11. Granwehr BP, Lillibridge KM, Higgs S, Mason PW, Aronson JF, Campbell GA, Barrett AD, 2004. West Nile virus: where are we now? Lancet Infect Dis 4: 547–556. 12. Roehrig JT, 2013. West Nile virus in the United States—ahistorical perspective. Viruses 10: 3088–3108. 13. Sejvar JJ, 2007. The long-term outcomes of human West Nile virus infection. Clin Infect Dis 44: 1617–1624. LONG-TERM WEST NILE OUTCOMES 1011 1.1.1 Packet Pg. 13 Attachment: Long-term neurological outcomes in WNV patients (6605 : West Nile Virus (WNV) Management Policy and Response Plan Review) ment and 21% at secondary assessment had evidence of neu- romuscular weakness. Other studies have consistently found muscle weakness to be a common complication of WNND infections. In one study, motor deficits were found in 4 (50%) of 8 patients with WNE patients during acute infection.10,15 Sejvar and others found that muscle weakness persisted for at least 8 months in patients with WNND presenting as poliomyelitis-like syndrome. Follow-up electromyography (EMG) revealed chronic denervation and motor axon loss in these patients.10 In a recent study from Greece, Anastasiadou and others showed that 73% of the 22 patients with WNND had muscle weakness 16 months after the onset of symptoms.17 Abnormal deep tendon reflexes were also prevalent in our WNE patients at both the 1–3 and the 8–11 years follow-up. WNV has been reported to cause acute flaccid paralysis or WNV poliomyelitis-like syndrome, which is described as areflexia and focal flaccid weakness.10 Although decreased reflexes have been reported in studies evaluating WNND, these patients have also been diagnosed with acute flaccid paralysis. No patients in this cohort had symptoms consistent with WNV poliomyelitis-like syndrome; however several patients had isolated decreased reflexes. Published data regarding isolated decreased reflexes in WNE are sparse. Poor balance was found to be the most common and persis- tent problem in patients with a history of WNV. Overall, 60% with WNE, 14% with WNM, and 18% with WNF had impaired tandem gait at 1–3 years follow-up. In the majority of patients, these findings persisted at 8–11 years follow-up. The etiology of this deficit is unknown and possibly multi- factorial including deficits in motor function, neurosensory function, and vestibular function. Interestingly, out of the 60 patients only two patients had abnormal heel-to-shin testing and no patients had abnormal finger-to-nose or rapid alternat- ing movements indicating all patients had intact coordination. Several of our patients had tremors, including postural and intention (action) tremors. Sejvar and others reported Parkinson-like action tremors at the 8-month follow-up of WNE patients.10 In our Houston cohort, there were no patients with obvious signs of parkinsonism such as cogwheeling, rest- ing tremor, or festinating gait. This is an interesting inconsis- tency between the two studies. The discrepancy may be related to the follow-up time interval as patients in the Houston cohort had their first evaluation at a later date after acute infection. This discrepancy in neurologic exam findings may suggest that Parkinson-like symptoms resolve with time. Sensory deficits were also observed in high frequency in this study. However, given the high number of patients with Figure 3. Kaplan Meier curve of all deaths in patients with diabetes vs. patients without diabetes. 1010 WEATHERHEAD AND OTHERS 1.1.1 Packet Pg. 12 Attachment: Long-term neurological outcomes in WNV patients (6605 : West Nile Virus (WNV) Management Policy and Response Plan Review) history had new abnormal pinprick sensation in bilateral lower extremities. A total of 14 patients of the original 35 patients with WNE (40% retention) were evaluated at secondary follow-up (Sup- plemental Table 2); 11 (31%) patients had died before the time of the second exam (Supplemental Table 1). Out of the 14 WNE patients who had a second exam, six had abnormal tandem walking and six had abnormal hearing exam at the primary follow-up neurologic exam. Of the six patients who had abnormal tandem gait at primary examination, all contin- ued to have abnormal tandem gait. Of the six patients who had abnormal hearing, all continued to have hearing difficul- ties. Four patients who had abnormal reflexes documented at primary neurologic follow-up were evaluated at secondary follow-up, and had persistent reflex abnormalities. Two patients who had previously had normal reflexes developed abnormal reflexes on secondary exam. The first patient had a history of a stroke, and developed decreased reflexes in upper extremi- ties on secondary exam. The second patient had a history of hypertension and developed decreased symmetric reflexes in upper and lower extremities. Three of the 14 patients had documented muscle weakness during the primary neurologic exam, and two of these patients continued to have significant muscle weakness on secondary follow-up. One patient with a history of hypertension developed symmetric decreased strength in upper and lower extremities on secondary follow-up. Of the two patients who previously had a tremor, one patient experienced resolution of the tremor and one patient had a continued tremor on the second exam. Further- more, one patient developed a new tremor that had previ- ously been absent. A total of 12 of the original 60 patients (20%) died after the primary neurologic examination. Death occurred between 1 and 10 years after initial WNV infection. Of the deceased patients, all but one patient (92%) had WNE (Figure 2), and of the original 35 patients with WNE, 11 (31%) patients died. Ten of the patients who died had hypertension (83%) and 4 had diabetes mellitus (33%) (Figure 3). Factors associated with an abnormal neurological exam. At the time of the primary assessment, abnormal neurological exams (excluding hearing loss) were found in 2/10 (20%) WNF cases, 3/12 (25%) WNM cases, and 30/35 (86%) WNE cases. On univariate logistic regression analysis, an abnormal neurologic exam findings was significantly associated with having a history of WNE (Odds Ratio [OR] = 24.0, 95% confidence interval [CI] = 6.1–93.8; P < 0.0001) and with age 60 years and older (OR = 5.4, 95% CI = 1.7–16.9; P = 0.004). On multivariate logistic regression analysis, having a history Figure 2. Kaplan Meier curve of deaths among all acute clinical presentations. LONG-TERM WEST NILE OUTCOMES 1009 1.1.1 Packet Pg. 11 Attachment: Long-term neurological outcomes in WNV patients (6605 : West Nile Virus (WNV) Management Policy and Response Plan Review) Hypoglossal/tongue 0 0 1 (3%) 1 (2%) WNF = West Nile fever; WNE = West Nile encephalitis; WNM = West Nile meningitis. *Abnormality prior to the WNV infection in all patients in cell. †Abnormality prior to the WNV infection in some patients in the cell. Table 1 Demographic characteristics and prevalence of comorbid conditions in the Houston West Nile virus cohort at the time of acute West Nile infection as assessed during the primary neurological assessment Demographic and comorbidity variables WNF (N = 11) WNM (N = 14) WNE (N = 35) Median age (range) in years 54 (17–76) 46 (22–65) 68 (9–86) Male gender (%) 3 (27%) 9 (64%) 26 (74%) Race/ethnicity (%) Caucasian 10 (91%) 12 (86%) 29 (83%) African American 1 (9%) 2 (14%) 2 (6%) Hispanic 0 0 4 (11%) Diabetes mellitus 1 (9%) 2 (14%) 11 (31%) History of stroke prior to WNV 0 1 (7%) 8 (22%) Chronic alcohol use (> 15 drinks/week) 0 2 (14%) 4 (11%) Hypertension 2 (14%) 3 (21%) 23 (65%) WNF = West Nile fever; WNE = West Nile encephalitis; WNM = West Nile meningitis. 1008 WEATHERHEAD AND OTHERS 1.1.1 Packet Pg. 10 Attachment: Long-term neurological outcomes in WNV patients (6605 : West Nile Virus (WNV) Management Policy and Response Plan Review) METHODS Beginning in 2002, Houston metropolitan area residents with suspected WNV infection who tested positive for anti- WNV IgM antibodies by ELISA were reported to local public health officials. Depending on clinical presentation, cases were classified as follows: encephalitis/meningoencephalitis/ encephalomyelitis (WNE) diagnosed by positive anti-WNV IgM antibody, CSF pleocytosis, and global cerebral dysfunc- tion with altered mental status with or without focal neurolog- ical signs and symptoms or seizures; WNM diagnosed by positive anti-WNV IgM antibody, CSF pleocytosis, and menin- geal signs and symptoms including headache and neck stiffness, and non-neuroinvasive viral syndrome with fever diagnosed by positive anti-WNV IgM antibody; and WNF with no neurolog- ical abnormalities identified. Cases identified through public health surveillance were invited to participate in the Houston West Nile Cohort (HWNC). Those available and interested were consented prior to study enrollment. The primary objec- tives of the longitudinal cohort study were to identify risk fac- tors for WNND and to follow long-term clinical outcomes. No one was denied participation based on age, gender, race, or ethnicity. This study was reviewed and approved by the Com- mittee for the Protection of Human Subjects at the University of Texas Health Science Center at Houston (HSC-SPH-03-039) and Baylor College of Medicine’s IRB (H-30533). As a com- ponent of this study, cohort participants were invited to have a complete neurological examination at two different time points following infection, with the first assessment occurring between 2005 and 2006 (1–3 years postinfection) and the second assessment occurring between 2012 and 2013 (8– 11 years postinfection). *Address correspondence to Kristy O. Murray, Baylor College of Medicine, Texas Children’s Hospital Feigin Center, BCM 320, Houston, TX 77030. E-mail: kmurray@bcm.edu 1006 ATTACHMENT 1 1.1.1 Packet Pg. 8 Attachment: Long-term neurological outcomes in WNV patients (6605 : West Nile Virus (WNV) Management Policy and Response Plan Review)