More than 5% of children under age 6 in nine mostly rural California counties had blood lead levels in 2015 that put them above for lead exposure — at least 4.5 micrograms of lead per deciliter of blood — according to the most detailed data from the California Department of Public Health. Across the state, 1.4% of children who were tested, or about 7,650 kids, had elevated blood lead levels that year.

By comparison, when images of discolored water flowing from Flint’s taps made national news in 2015, 3.7% of Flint children under 6 who were tested had elevated lead levels, according to a study published in the .

California’s worrisome numbers were highlighted in by the state auditor, which also found that more than 2 million children were not tested as required over a period of nine years.

The auditor faulted the state departments of Public Health and Health Care Services for failing to ensure children receive the tests, and for not taking prescribed actions to reduce childhood lead exposure in high-risk areas.

In response to the audit, the state Department of Public Health released 2018 data in early March showing that slightly fewer children were tested statewide than in 2015 and that the percentage of children with unacceptable lead levels did not decrease. The department did not release specific data for many of the rural counties that previously had high percentages of children with elevated blood lead levels.

State lawmakers also responded to the audit by introducing five bills to get more children tested as required, expand mandated testing to more children and improve follow-up care for children with elevated blood lead levels.

They “treat us like we’re a wasteland,” said Assembly member Cristina Garcia (D-Bell Gardens), author of .

Garcia represents a Los Angeles County district where the soil in and around thousands of homes was contaminated with lead and arsenic by the battery recycling plant in Vernon. A massive cleanup effort was launched after the plant closed in 2015. Despite tens of millions of dollars allocated for remediation, local officials and residents say more funding is needed because only a few hundred homes have been cleaned up, and thousands are still contaminated.

California’s top health care officials said they’re taking the auditor’s findings seriously. Dr. Sonia Angell, director of the Department of Public Health, said the department is working on a plan to improve its oversight of childhood lead testing and coordinate with local officials to reduce children’s exposure to the toxic metal.

“While it is impossible to eradicate all lead in the environment, there is more we can do to protect our children,” Angell acknowledged in a prepared statement.

Industrial emissions can cause concentrated exposure in some areas, but the most common source of lead exposure in children is lead paint in old homes, where young children ingest the neurotoxin through small flakes and paint dust. Lead paint was phased out in the 1970s but still exists in older houses and apartments, especially poorly maintained ones.

Lead can also leach into the water from old pipes. That was the case in Flint, where the local water authority didn’t properly treat water , which caused lead from old pipes to seep into the drinking water.

Exposure to lead has been linked to health and developmental problems, including learning and hearing disabilities, lower IQs, behavioral problems, hyperactivity and delayed puberty, .

“There’s a really long and extensive body of evidence that shows that any amount of exposure to lead can be harmful,” said Jill Johnston, assistant professor of preventive medicine at the University of Southern California.

that low socioeconomic status is a risk factor for lead contamination. In California, efforts to address lead exposure have focused on children enrolled in Medi-Cal, the state Medicaid program for low-income people.

Federal and state laws require children enrolled in Medi-Cal to have blood lead tests at 1 and 2 years of age. Children under 6 are supposed to receive a makeup test if they were not tested when they were 2 years old.

About half of California children are enrolled in Medi-Cal.

The auditor’s report found that about half of the eligible children enrolled in Medi-Cal from fiscal years 2009-10 through 2017-18 — about 1.4 million kids — did not receive any of the state-mandated lead tests. And about 740,000 children missed one of the mandated tests.

In addition to kids on Medi-Cal, state regulations mandate that any child with an official risk factor, such as living in a home built before 1978, get tested. Garcia said that the list of official risk factors is not up to date with current research and that her proposed legislation would update it.

The auditor’s report does not pinpoint why so many children are not getting the tests, but the auditor recommended the state Department of Public Health update the risk factors, and inform health care providers about those risk factors and the testing requirements by this month.

Angell said the department would “issue regulations for public comment on enhanced screening requirements and data reporting for lead exposure” by August.

The data the department released in early March in response to the audit did not include results at the ZIP code level. A department spokesperson said that data is expected to be released this spring.

“If the department was taking this more seriously, what we received today would have provided more details,” Garcia said via email in early March.

“We need to have a regularly updated map showing what the blood lead levels are geographically and in a more granular manner.”

Richard Figueroa, then-acting director of the Department of Health Care Services, said the department “will do more to ensure that required blood lead tests are occurring.” The department will implement a public outreach campaign to inform families covered by Medi-Cal how to get their children tested, he said, and by June will require managed care plans to identify children who have not been tested and remind participating health care providers about the testing requirement.

Garcia said she does not trust the state agencies to fix these problems on their own. “They’re OK with blowing through deadlines and not prioritizing these communities,” she said, “even though we have a real serious public health risk.”

It is a matter that hits close to home for her.

“My sister and I used to joke that if we didn’t grow up in the place that we did, we might be geniuses,” Garcia said.

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The number of Californians enrolled in the state’s health insurance program for low-income residents swelled by 5.5 million from 2010 to 2019. It now covers 1 in 3 Californians and 40% of children.

The program’s annual budget — a combination of state and federal money — tops $100 billion, more than the entire state budget of .

“Medi-Cal is the largest Medicaid program among all of the states,” said Dr. Andrew Bindman, a professor of medicine at the University of California-San Francisco who helped implement the Affordable Care Act as part of the Obama administration.

It’s most likely going to get bigger. On Friday, California Gov. Gavin Newsom released his 2020-21 state budget blueprint, which would boost Medi-Cal’s annual budget to and expand coverage to even more people.

Medi-Cal, California’s version of the federal Medicaid program, was transformed in the past decade by federal and state laws — especially the federal Affordable Care Act — and by the ups and downs in California’s economy.

In early 2010, Medi-Cal covered 7.2 million people. Enrollment peaked at 13.7 million in March 2016, and slowly but steadily decreased to 12.8 million people in August 2019, according to the most recent enrollment data from the state Department of Health Care Services. About 4.9 million of them were under age 19.

In 2018, half of enrollees identified as Hispanic, 18% as white, 10% as Asian or Pacific Islander and 8% as black, . Thirteen percent of enrollees did not report their race/ethnicity.

The federal Affordable Care Act spurred the most significant changes to Medi-Cal since 2010, largely because it allowed states to broaden eligibility for their Medicaid programs to low-income people who had not previously qualified. , have adopted Medicaid expansions.

In California, Medi-Cal enrollment grew 78% from January 2010 to August 2019, primarily due to the expansion, which began in 2014.

“California went all-in on that,” Bindman said, and reduced its uninsured rate from to 7.2% .

Before the change, adults usually didn’t qualify unless they were parents with dependent children, pregnant or had certain conditions or disabilities.

Under the expansion, any adult who met the income guidelines could enroll, which represented a “radical shift” in the way the program operates, said Jen Flory, a policy advocate at the Western Center on Law & Poverty.

It transformed Medi-Cal “to more general low-income coverage,” she said.

The number of adults enrolled through the expansion has hovered around 3.7 million since mid-2016, while the rest of the Medi-Cal population dropped from 10 million to 9 million during the same period. Flory credited a strong economy and low unemployment in part, as more people got jobs that offered employer-based insurance and others surpassed the income limits to qualify.

But Flory and Bindman said other factors might be contributing.

They pointed to fears within immigrant communities over increased immigration enforcement, and policies such as the Trump administration’s “” rule. The rule would allow immigration officials to more easily deny permanent residency status to those who depend on certain public benefits such as Medicaid.

Federal judges temporarily blocked the rule from taking effect in mid-October, but the Trump administration on Monday to allow it to implement the rule while the legal battles continue.

As a result of such policies and proposals, they said, some immigrants may not be enrolling in Medicaid and other government programs, even if they are eligible.

In the past decade, Medi-Cal has also changed how it delivers care. In January 2010, roughly half of Medi-Cal enrollees participated in the traditional “fee-for-service” model, in which patients can see any doctor who accepts them, and providers are reimbursed for each medical service or visit.

The other half received care from managed-care plans. Under managed care, the state contracts with health plans to deliver benefits to enrollees and pays them a fixed monthly rate to cover the expense of doing so — a payment system known as “capitation.”

The percentage of enrollees served by managed care climbed to 82% by July 2019 as California, like many other states, looked to that model to save money.

The Trump administration and Republicans in Congress have and called for on Medicaid. Such proposals may accelerate if Republicans retain the White House and regain control of the U.S. House of Representatives this year.

While the federal government moves to restrict funding and enrollment, California lawmakers continue to expand eligibility for Medi-Cal.

Starting this year, low-income young adults became eligible for full Medi-Cal benefits regardless of their immigration status, joining , who became eligible in 2016.

On Friday, Newsom proposed expanding full Medi-Cal benefits to eligible undocumented immigrant adults ages 65 and over as part of his state budget proposal.

California’s policies offer “a striking contrast to the policies of the current federal administration,” Bindman said.

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Effective Jan. 1, the Los Angeles hospital loosened the income cap for patients to qualify for free or discounted care.

Previously, the nonprofit hospital’s financial assistance policy allowed patients with household incomes up to 200% of the federal poverty level to qualify for free care, which amounts to $24,980 for an individual or $51,500 for a family of four, based on 2019 figures.

Cedars-Sinai has spent a much smaller percentage of its operating expenses on charity care: 0.19% in 2018 compared with an average of 0.9% by other California nonprofit hospitals, data from the Office of Statewide Health Planning and Development shows.

The hospital is now making its charity care policy the most generous of the state’s 10 largest nonprofit hospitals, ranked by net patient revenue from the 2017-18 fiscal year, according to a California Healthline analysis. It will expand eligibility for free medical care to patients with household incomes up to 400% of the federal poverty level: $49,960 for an individual and $103,000 for a family of four. It will also expand access to discounted care to those with incomes up to 600% of the federal poverty level.

The hospital said it is making the change because it is treating more patients who are “underinsured” because they have health insurance plans with high deductibles, copayments or other out-of-pocket costs.

“More of our patients are having financial difficulties, so we want to help them,” Cedars-Sinai said in an emailed statement. It declined to attribute its response to a specific person.

The hospital defended its low charity care percentages, saying the figures don’t account for its other charitable grants and programs, or the large number of low-income patients it serves who have publicly funded health coverage. It pointed out that it spent 16.5% of its total expenses in fiscal year 2018 on such programs and expenses.

Cedars-Sinai Medical Center is the third-largest nonprofit hospital in California, after Stanford Hospital and the University of California-San Francisco Medical Center. It had $3.15 billion in operating expenses in 2018, according to state data.

Nonprofit hospitals are exempt from paying local, state and federal taxes in exchange for providing , which can include free and discounted charity care, as well as programs like grants for homeless services and free community clinics.

The federal government does not specify an amount of charity care that nonprofit hospitals must provide, which means that policies vary from hospital to hospital, as does the amount of free care they ultimately give.

For instance, of the 10 largest nonprofit hospitals in the state, the University of California-San Diego Medical Center provided the highest share of charity care in 2018 — 5.2% of operating expenses — which is more than five times the state average for nonprofit hospitals, according to state data. However, it also has relatively low income levels for qualifying: 200% of the federal poverty level for free care and 400% for discounted care.

Kaiser Permanente, which operates 36 hospitals in California, has not been required to report facility-level financial data to the state, so its hospitals were not part of the analysis. Kaiser Permanente allows patients with income up to 350% of the federal poverty level to apply for financial aid. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

Hospitals must post their financial assistance policies online, and inform patients how to apply by posting notices and providing written notice to uninsured patients when they are admitted and billed. But not all hospitals do this, and some actively discourage people seeking financial assistance.

Federal poverty levels aren’t the only criteria hospitals consider when granting financial aid. Applications for free care are evaluated case by case, according to many of the hospitals’ policies. Whether a patient qualifies can depend on other factors such as family assets, medical debt and even where the patient lives.

Charity care rates are down statewide .

Jan Emerson-Shea, spokeswoman for the California Hospital Association, said the demand for charity care is decreasing because more people are getting insurance. At the same time, the amount hospitals spend to care for the growing number of patients with public insurance has increased, she said.

Even though hospitals are absorbing those costs, they’re not counted as charity care, she added.

Under the Affordable Care Act, some states, including California, expanded Medicaid eligibility to more low-income people. Nearly , or 1 in 3, are enrolled in California’s Medicaid program, which is called Medi-Cal.

“The reimbursement we receive from the government to care for a Medi-Cal or Medicare patient is far less than the actual cost of caring for the patient,” Cedars-Sinai said in its statement.

Gerard Anderson, a health policy and management professor at Johns Hopkins University, praised Cedars-Sinai’s decision to increase the income threshold for charity care as an example of how hospitals can adjust to the changing needs of the community.

“Because there are fewer people that don’t have health insurance coverage, you have to raise the threshold in order to get the same number of people to qualify,” he said.

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California public health officials of confirmed, suspected and probable new cases of the fungal disease as of Nov. 30, 2019, up 12% from 6,929 in the first 11 months of 2018.

The increase is part of a recent trend in the nation’s Southwest dating to 2014, with outbreaks most prevalent in California and Arizona. Nationally, public health officials reported 14,364 confirmed cases of valley fever in 2017, more than six times the number reported in 1998, according to the and Prevention.

Valley fever is caused by a that lives in the soil of California’s Central Valley, Arizona and areas of other Southwestern states prone to desert-type conditions. Animals and people can contract the infection by breathing in dust that contains the microscopic fungus spores. The infection is not transmitted from person to person.

Symptoms can include fatigue, cough, fever, headache, muscle aches or rash. While the majority of people infected experience mild flu-like symptoms or no symptoms at all, as many as 10% develop serious, sometimes long-term lung problems, including pneumonia.

Valley fever generally is treated with antifungal medications, but about 200 Americans die from the disease every year, according to the CDC. Researchers are working to develop a vaccine for both humans and animals.

Federal health officials say these infections likely are underreported because not every state requires public disease reporting for valley fever and because some infected people never develop symptoms or seek medical care.

Dr. Royce Johnson, a valley fever expert, recalls treating about 250 to 300 cases a year when he arrived in rural Kern County in the 1970s. As of Nov. 30 this year, Kern County — now a hot spot for the disease — reported more than 2,700 confirmed, suspected or probable cases, according to the California Department of Public Health.

“This is a major, major health problem, and it’s growing,” said Johnson, medical director of the Valley Fever Institute at Kern Medical in Bakersfield. “The extent of the endemic area is increasing, and the number of cases in the whole Southwest is going up.”

A University of California study examining on California estimated the direct and indirect lifetime costs of 2017 cases at about $700 million, when considering treatment expenses, lost productivity and mortality.

Researchers attribute the spike in cases to a number of factors. There’s more awareness of the disease because of media coverage and public health campaigns. California has earmarked $2 million for a public awareness campaign, and employers in regions of the state where workers are at higher risk for the disease will be required to educate them about the disease.

Population growth in the American Southwest, where the fungus is endemic, also plays a role, both because of the increased pool of patients and development that disturbs the soil. In Kern County, which reports the majority of California’s cases, the population has grown 65% since 1990.

But the most significant factor may prove to be climate change, which expands the ecosystems where the fungus can flourish. Using climate models, that by 2100 the expanse of areas with hot, dry conditions favored by the fungus could double and the number of valley fever cases could grow by 50%.

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The state Department of Managed Health Care hit Anthem Blue Cross with $9.6 million in fines from January 2014 through early November 2019, according to a California Healthline analysis of agency data. That is about 44% of the $21.7 million in penalties the department issued against full-service health plans during that period.

And yet, Anthem covered only 10% to 13% of Californians with department-regulated plans. An annual average of 3.8 million Californians were enrolled in the plan over the period analyzed.

By comparison, Kaiser Permanente covered nearly one-third of Californians in department-regulated plans in that time frame, but received 11% of the penalties. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

“One reason Blue Cross has more actions is due to the plan’s historical failures to properly identify and handle enrollee grievances and appeals,” department spokeswoman Rachel Arrezola said via email.

Anthem said it takes all enrollee grievances seriously.

“Anthem has been making significant changes in its grievance and appeals process, as well as investments in system improvements to help ensure we are simplifying the healthcare experience for consumers,” said spokesman Michael Bowman via email.

The fines against Anthem are related to many of the 553 enforcement actions that the department has taken against the health plan for violations such as taking too long to respond to enrollee grievances, inappropriately denying claims and not covering the cost of out-of-network care that should have been covered.

The sanctions against Anthem make up more than one-third of the 1,432 enforcement actions the department issued. They can include settlement agreements requiring plans to change bad practices, cease-and-desist orders, judicial rulings and civil complaints.

“The primary purpose of an enforcement action is to change the health plan’s behavior to comply with the law,” Arrezola said.

The dates of the enforcement actions don’t always coincide with when the violations occurred. The department can take years to process some enforcement actions and also processes some in batches, making year-over-year comparisons misleading.

In 2017, the department issued a $5 million for repeatedly failing to resolve consumer grievances in a timely manner. But after lengthy negotiations, the department and the health plan on a $2.8 million fine along with an agreement that Anthem would invest $8.4 million to make improvements.

The Department of Managed Health Care, which oversees health plans that cover about 26 million Californians, is the state’s largest health insurance regulator. Since 2000, when the agency was created, it has levied $73 million in fines to licensed health plans.

Anthony Wright, executive director of the advocacy group Health Access California, said fines are an important way to protect consumers, but he has advocated for even larger penalties.

“We don’t want these transgressions to be the cost of doing business when [insurers] have not met the standards and consumer protections that we expect of them,” he said.

Wright said it’s important for consumers to check health plan enforcement records before they enroll, which can be accessed through .

But Wright acknowledged that many people don’t have a choice, making the department’s oversight role even more important.

“The most important thing is the fines and the corrective actions,” Wright said, “to make sure these practices end.”

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“Most days you could not see the mountains” said Avol, now a professor of clinical preventive medicine at the University of Southern California’s Keck School of Medicine and chief of its environmental health division. “I was amazed that there were even mountains there.”

The effects of the smog weren’t just visual; they were felt by residents living in that polluted air. Persistent headaches. Watering eyes. Labored breath. Avol recalls how he and other members of his high school cross-country team sometimes coughed for days after competing in the smoggy air.

Over the decades, Avol has continued to make his home in Los Angeles, and has had a front-row seat to dramatic improvements in air quality. Much of that improvement stems from the ever-tightening standards California has enacted for auto and truck tailpipe emissions, starting in the 1960s. Avol is among the environmental researchers whose work has helped propel that steady progress.

“There’s a significant air pollution problem in California,” Avol said. “There’s also a success story to tell for pollution mitigation and reduction in California.”

California is now engaged in a high-stakes legal battle with President Donald Trump and his administration over the state’s longstanding authority to set its own emissions standards for cars and trucks sold in California. The administration has moved to revoke a waiver, in place since the federal Clean Air Act of 1970, that enables the state to set stricter emissions standards than the federal government because its pollution problems are so unique and severe.

In its initial efforts, California’s stricter standards targeted the emissions that fed the cloak of smog Avol knew growing up, including ozone and carbon monoxide. More recently, the state has expanded its target to include greenhouse gas emissions that contribute to climate change and global warming.

When it comes to smog, the standards have made a difference. Over the past three decades, counties across the state have made steady progress in reducing days that registered hazardous levels of ozone and particulate matter.

The improved air quality led to improved health indicators. For example, that tracked Southern California children over 20 years found that the reduction in smog translated to roughly 20% fewer new asthma cases in children.

Even with progress, the state’s pollution problems are far from solved. California’s large population combined with its fanatic car culture, warm climate, wind patterns and towering mountain-to-deep-valley geology have made continued improvement challenging. The state also bears a disproportionate burden of the country’s economic trade via high-emission trains, planes and ships.

California still has the five metropolitan areas that routinely register in the nation: Los Angeles, Visalia, Bakersfield, Fresno and Sacramento.

Avol is among those who say the Trump administration’s efforts to roll back emissions standards are likely to impede further progress. Still, he finds a silver lining. The standoff has focused a spotlight on how far California has come because it implemented strict standards and the difference that has made for the people who live here.

“In terms of protecting public health,” Avol said, “improving air quality is a big deal.”

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Pharmaceutical companies raised the “wholesale acquisition cost” of their drugs — the list price for wholesalers without discounts or rebates — by a median of 25.8% from 2017 through the first quarter of 2019, according to the Office of Statewide Health Planning and Development. (The median is a value at the midpoint of data distribution.)

Generic drugs saw the largest median increase of 37.6% during that time. By comparison, the annual inflation rate during the period was 2%.

Several drugs stood out for far heftier price increases: The cost of a generic liquid version of Prozac, for example, rose from $9 to $69 in just the first quarter of 2019, an increase of 667%. Guanfacine, a generic medication for attention deficit hyperactivity disorder (ADHD), on the market since 2010, rose more than 200% in the first quarter of 2019 to $87 for 100 2-milligram pills. Amneal Pharmaceuticals, which makes Guanfacine, cited “manufacturing costs” and “market conditions” as reasons for the price hike.

“Even at a time when there is a microscope on this industry, they’re going ahead with drug price increases for hundreds of drugs well above the rate of inflation,” said Anthony Wright, executive director of the California advocacy group Health Access.

The national debate over exorbitant prescription drug prices — and how to relieve them — was supposed to take center stage in recent weeks, as House Speaker Nancy Pelosi released a to negotiate prices for as many as 250 name-brand drugs, including high-priced insulin, for Medicare beneficiaries. Another under consideration in the Senate would set a maximum out-of-pocket cost for prescription drugs for Medicare patients and penalize drug companies if prices rose faster than inflation.

President Donald Trump has highlighted drug prices as an issue in his reelection campaign. But lawmakers’ efforts to hammer out legislation are likely to be overshadowed, for now, by presidential impeachment proceedings. In Nevada, health officials in early October for failing to comply with the state’s two-year-old transparency law requiring diabetes drug manufacturers to disclose detailed financial and pricing information.

California’s new drug law requires companies to report drug price increases quarterly. Only companies that met certain standards — they raised the price of a drug within the first quarter and the price had risen by at least 16% since January 2017 — had to submit data. The companies that met the standards were required to provide pricing data for the previous five years. In its initial report, the state focused its analysis on drug-pricing trends for about 1,000 products from January 2017 through March 2019.

California’s transparency law also requires drugmakers to state why they are raising prices. Over time, that information, in addition to cost disclosures, could create “one of the more comprehensive and official drug databases on prices that we have nationwide,” Wright said. “That, in itself, is progress, so that we can get better information on the rationale for drug price increases.”

But the data does not reflect discounts and rebates for insurers and pharmacy benefit managers and bears little resemblance to what consumers actually pay, said Priscilla VanderVeer, a spokeswoman for the trade group Pharmaceutical Research and Manufacturers of America. The group filed a seeking to overturn the California legislation that has not yet been resolved.

“If transparency legislation only looks at one part of the pharmaceutical supply chain, without getting into the various middlemen like insurers and pharmacy benefit managers that ultimately determine what patients have to pay at the pharmacy counter, it won’t help patients access or afford their medicines,” VanderVeer said in an email.

State Sen. Richard Pan (D-Sacramento), a pediatrician who chairs the Senate health committee, agrees — up to a point.

“Transparency always has value,” Pan said. But policymakers need more data on how much insurers and consumers are spending on prescription drugs, he said.

And he wonders why the price of generic drugs, including those with plenty of competition, rose at higher rates.

His concerns were echoed by University of Southern California policy researchers, who recently published a that concluded most state-level drug-transparency laws are “insufficient” to reveal the true transaction prices for prescription drugs, or where in the distribution system excessive profits lie.

“The question is, why are these prices going up? Typically, there are competing stories for that,” said Neeraj Sood, vice dean of the University of Southern California’s School of Public Policy and an author of the study. “Maybe cost of production is going up,” he said. “Maybe there’s a drug shortage, or some competitors got eliminated. This reporting of [wholesale acquisition cost] data doesn’t really tell us which of these stories is true.”

For now, California’s new data is not likely to be of much help to consumers, Pan said. But he said it might help state officials in their bid to overhaul the way the state purchases drugs for 13 million people served by Medi-Cal, the state’s Medicaid program for low-income residents. Gov. Gavin Newsom’s to have the state, rather than individual Medi-Cal managed-care plans, negotiate directly with drugmakers would save the state an estimated $393 million a year by 2023, according to the administration.

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There are now 16 counties where , commonly known as the yellow fever mosquito, has been detected, according to the state Department of Public Health. Five of those counties have also detected Aedes albopictus, the Asian tiger mosquito.

These mosquitoes, distinguished from other species because they primarily sip human blood during the day instead of at night, can spread the Zika virus, which infected more than 1 million people during that began in 2015 in Brazil. The virus also can spread during sex.

babies were born with in Brazil during the epidemic. Microcephaly is a condition in which a baby’s head is much smaller than expected, and can occur because the baby’s brain has not developed properly.

In California, these invasive mosquitoes were detected in 2011 in Los Angeles County, and since have spread northward into the Central Valley.

Although the invasive mosquitoes now inhabit a large swath of the state, authorities have recorded no cases of “” of the dangerous viruses, which means there’s no evidence these Aedes mosquitoes in California are carriers. The California residents who have fallen ill with the dangerous viruses became infected during international travel to areas where the viruses are endemic.

But the potential for in-state transmission remains.

“We do have people in California traveling abroad and bringing back those viruses every year, and now that the mosquito is spreading across the state, the risk has increased, but it’s still very low,” said Jeremy Wittie, president of the Mosquito and Vector Control Association of California.

The number of reported travel-associated cases of Zika has dropped from 509 in 2015 and 2016 combined to 25 so far this year, according to the California Department of Public Health.

Public health officials work with people who were infected overseas to minimize the risk that they will spread the virus in the state.

While state and local vector control agencies keep a close eye on these species of Aedes mosquitoes, their biggest concerns are still West Nile virus and St. Louis encephalitis, which are spread by different species of mosquitoes, more common in California. This year, there have been 89 human cases of West Nile virus reported in 15 counties, including two deaths, .

Vector control officials also stress the need for public awareness about how Californians can protect themselves and prevent mosquitoes from proliferating. “It’s simple for people to make a few changes to their lifestyle that would limit the spread of these mosquitoes,” Wittie said.

Wittie recommends people check their properties weekly and drain any standing water to limit the places where mosquitoes can reproduce.

Though these mosquitoes can travel only short distances on their own, they can be transported via international and local trade, or even in a car. They thrive in urban and residential areas, unlike other species, because their eggs can survive in dry conditions for months and require just a tiny amount of standing water to hatch.

“These mosquitoes are adept at living in tight spaces with humans,” Wittie said.

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Hasta el martes 10 de septiembre, funcionarios federales de salud estaban investigando al menos 450 posibles casos de este misterioso mal que afecta los pulmones en 33 estados, incluidos seis fatales. California ha reportado cerca de 60 casos desde finales de junio, en pacientes con antecedentes de “vapeo”; uno de ellos, en el condado de Los Ángeles, ha muerto.

El “vapeo” ha aumentado en los últimos dos años, particularmente entre adolescentes y adultos jóvenes. Más del 20% de los estudiantes de secundaria informaron haber “vapeado” en 2018, casi el doble de la tasa de 2017, según los Centros para el Control y Prevención de Enfermedades (CDC). Eso se traduce en 3 millones de estudiantes de secundaria que usaron cigarrillos electrónicos en 2018, más del doble del número que informó consumir cigarrillos tradicionales.

“Vapear” es la forma popular de definir el hábito de usar cigarrillos electrónicos para “vaporizar” la nicotina o una serie de concentrados líquidos. Al principio, estos dispositivos se comercializaron como una forma de inhalar nicotina sin los riesgos asociados con la combustión de tabaco. Pero evolucionaron rápidamente para consumirse con cientos de combinaciones de saborizantes y compuestos químicos, incluido el THC, el ingrediente psicoactivo de la marihuana, y otros extractos del cannabis.

Investigadores federales y estatales dicen que muchas de las personas que se enfermaron dijeron que habían “vapeado” THC, y las autoridades se están centrando en contaminantes en productos del mercado negro, que contienen THC, como posibles culpables. Otros pacientes informaron que usaban cartuchos de nicotina, y las autoridades enfatizan que todavía tienen que identificar al dispositivo o químico específico en juego. Por ahora, advierten a las personas de todas las edades que eviten los cigarrillos electrónicos, especialmente los que se compran en la calle.

Ahora, el “vapeo” está tan generalizado entre los estudiantes de secundaria que funcionarios federales de salud dicen que su uso ha impulsado un cambio radical en lo que había sido un popular descenso de dos décadas en el consumo general de tabaco en la adolescencia. A 2018, la National Youth Tobacco Survey de los CDC mostraba que el consumo general de tabaco entre los estudiantes de secundaria había vuelto a niveles no vistos desde 2004. Aunque se comercializan como una alternativa saludable a los cigarrillos tradicionales, las versiones electrónicas pueden contener niveles sustanciales de nicotina, lo cual es altamente adictivo.

Juul, la compañía con sede en San Francisco que domina el mercado de los cigarrillos electrónicos, y otros fabricantes, promocionan sus dispositivos como una herramienta para ayudar a los adultos a dejar de fumar. Pero las encuestas del gobierno muestran que estos dispositivos elegantes, y la gran cantidad de productos que los imitan, son mucho más populares entre los estudiantes de secundaria que entre los adultos. Si bien la edad legal para comprar cigarrillos electrónicos es de 18 años en la mayoría de los estados, y 21 en California, los productos están ampliamente disponibles en línea y no todos los vendedores requieren comprobante de edad. Además, los kits de “vapeo” ahora vienen en forma de bolígrafos, unidades flash, llaveros e incluso relojes, lo que los hace modernos y fáciles de ocultar.

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The explosive rise in a serious lung illness linked to vaping spotlights the popularity of e-cigarettes among teens and young adults — and how little is known about the devices’ safety and use.

As of Sept. 12, federal health officials were investigating at least 380 possible cases of the mysterious pulmonary illness across 36 states, including six cases that resulted in death. California has reported 70 cases of lung illness since late June in patients with a history of vaping; one of those patients, in Los Angeles County, has died.

Vaping has surged in the past two years, particularly among teenagers and young adults. More than 20% of high school students reported vaping in 2018 — almost twice the 2017 rate — according to the federal Centers for Disease Control and Prevention. That translates to 3 million high school students using e-cigarettes in 2018 — well more than double the number who reported using traditional cigarettes.

Vaping is the popular shorthand for using electronic cigarettes to “vaporize” nicotine or an array of liquid concentrates. The devices initially were marketed as a way to inhale nicotine without the risks associated with burning tobacco. But they quickly evolved for use with hundreds of combinations of flavorings and chemical compounds, including THC, the psychoactive ingredient in marijuana, and other marijuana extracts.

Federal and state investigators say many of the people who have fallen ill said they had vaped THC, and officials are focusing on contaminants in black-market products containing THC as possible culprits. Other patients reported using nicotine cartridges, and authorities stress that they have yet to identify a specific device or chemical at play. For now, officials are warning people of all ages to avoid e-cigarettes, particularly products purchased on the street.

Vaping is now so pervasive among high school students that federal health officials say its use has fueled a sharp reversal in what had been a celebrated two-decade decline in overall tobacco use by teenagers. As of 2018, the CDC’s National Youth Tobacco Survey showed overall tobacco usage among high schoolers had reverted to levels not seen since 2004. Though marketed as a healthy alternative to traditional cigarettes, e-cigarettes can contain substantial levels of nicotine, which is highly addictive.

Juul, the San Francisco-based company that dominates the e-cigarette trade, and other manufacturers publicly market their devices as a tool to help adults quit smoking. But government surveys show the sleek devices — and multitude of copycat products — are far more popular among high school students than adults. While the legal age to buy e-cigarettes is 18 in most states — and 21 in California — the products are widely available online and not all sellers require proof of age. And vaping kits now come in the form of pens, flash drives, key fobs, even watches — making them both stylish and easy to disguise.

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