Francisella tularensis is disseminated in nature by biting arthropods such as mosquitoes. The relationship between mosquitoes and F. tularensis in nature is highly ambiguous, due in part to the fact that mosquitoes have caused significant tularemia outbreaks despite being classified as a mechanical vector of F. tularensis. One possible explanation for mosquitoes being a prominent, yet mechanical vector is that these insects feed on flower nectar between blood meals, allowing for transmission of F. tularensis between mosquitoes. Here, we aimed to assess whether F. tularensis could survive in flower nectar. Moreover, we examined if mosquitoes could interact with or ingest and transmit F. tularensis from one source of nectar to another. F. tularensis exhibited robust survivability in flower nectar with concentrations of viable bacteria remaining consistent with the rich growth medium. Furthermore, F. tularensis was able to survive (albeit to a lesser extent) in 30% sucrose (a nectar surrogate) over a period of time consistent with that of a typical flower bloom. Although we observed diminished bacterial survival in the nectar surrogate, mosquitoes that fed on this material became colonized with F. tularensis. Finally, colonized mosquitoes were capable of transferring F. tularensis to a sterile nectar surrogate. These data suggest that flower nectar may be capable of serving as a temporary source of F. tularensis that could contribute to the amplification of outbreaks. Mosquitoes that feed on an infected mammalian host and subsequently feed on flower nectar could deposit some F. tularensis bacteria into the nectar in the process. Mosquitoes subsequently feeding on this nectar source could potentially become colonized by F. tularensis. Thus, the possibility exists that flower nectar may allow for vector-vector transmission of F. tularensis.

Abstract-To reduce maternal and newborn morbidity and mortality, health care payers are experimenting with ways to better align incentives to promote high-quality maternal health services. This review examined 26 recent initiatives of health care payers in 16 low-and middle-income countries to pay for quality, and not solely quantity, of maternal health services. Payers measured quality by assessing availability of structural inputs (24 of 26 cases), adherence to processes (25 of 26 cases), and observation of key outputs of health facilities (14 of 26 cases). Two payers sought to also assess quality through observed patient outcomes. In 25 of the initiatives, payers used the quality assessment to adjust facility payments; in the remaining initiative, the payer used the quality assessment to adjust payments to provincial governments, which in turn pay facilities. The recent growth in such payment systems suggests more health care payers have identified ways to link quality measurement with provider payment mechanisms. Eleven impact evaluations of systems documented changes in provider behavior consistent with various elements of quality; however, only three evaluations reported effects on maternal or newborn morbidity and mortality and do not conclude whether the design or flaws in how it was implemented led to the results. Implementation fidelity-the degree to which the initiative was implemented as designed-was not widely addressed and is an area for future research. Furthermore, although payers in low-and middle-income countries have identified ways to operationalize a payment system that adjusts payments based on some measure of quality, the complexity and level of resources required to operationalize them raise concerns about sustainability.

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The Air Force Surgeon General has established the Office for Prevention and Health Care Assessment (OPHSA) to become the center of excellence for preventive services and health care assessment in the U. S. Air Force and the Department of Defense. OPHSA using the principles of total quality management and integrated teams will evaluate, compare, and modify preventive services delivery guidelines to preserve the fighting force by preventing illness and injuries in military populations. OPHSA will evaluate and formulate health care'delivery guidelines to improve health care access and delivery to military patient populations. OPHSA will develop data to determine the health status and health needs of beneficiary populations so medical managers can delivery medical care in the most cost effective manner.OPHSA is located at Brooks Air Force Base in San Antonio, Texas. OPHSA will have thirty seven active duty military, civil service, and contract employees and should be fully functional by the end of 1995. BACKGROUND:Medical policyreflects national priorities. With the end of the Cold War, the downsizing of the Department of Defense, and the concomitant national attention on costs, the Air Force medical service has faced these issues squarely, with the Surgeon General adopting the following statement as one of his goals: