There is more to satellite imagery than meets the eye.

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Use of soil moisture active passive satellite data and WorldClim 2.0 data to predict the potential distribution of visceral leishmaniasis and its vector Lutzomyia longipalpis in Sao Paulo and Bahia states, Brazil.

Visceral leishmaniasis (VL) is a neglected tropical disease transmitted by Lutzomyia longipalpis, a sand fly widely distributed in Brazil. Despite efforts to strengthen national control programs reduction in incidence and geographical distribution of VL in Brazil has not yet been successful; VL is in fact expanding its range in newly urbanized areas. Ecological niche models (ENM) for use in surveillance and response systems may enable more effective operational VL control by mapping risk areas and elucidation of eco-epidemiologic risk factors. ENMs for VL and Lu. longipalpis were generated using monthly WorldClim 2.0 data (30-year climate normal, 1-km spatial resolution) and monthly soil moisture active passive (SMAP) satellite L4 soil moisture data. SMAP L4 Global 3-hourly 9-km EASE-Grid Surface and Root Zone Soil Moisture Geophysical Data V004 were obtained for the first image of day 1 and day 15 (0:00-3:00 hour) of each month. ENM were developed using MaxEnt software to generate risk maps based on an algorithm for maximum entropy. The jack-knife procedure was used to identify the contribution of each variable to model performance. The three most meaningful components were used to generate ENM distribution maps by ArcGIS 10.6. Similar patterns of VL and vector distribution were observed using SMAP as compared to WorldClim 2.0 models based on temperature and precipitation data or water budget. Results indicate that direct Earth-observing satellite measurement of soil moisture by SMAP can be used in lieu of models calculated from classical temperature and precipitation climate station data to assess VL risk.

The changing risk of vector-borne diseases: Global satellite remote sensing and geospatial surveillance at the forefront.

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Predicted distribution of sand fly (Diptera: Psychodidae) species involved in the transmission of Leishmaniasis in São Paulo state, Brazil, utilizing maximum entropy ecological niche modeling.

Leishmaniasis is a public health problem worldwide. We aimed to predict ecological niche models (ENMs) for visceral (VL) and cutaneous (CL) leishmaniasis and the sand flies involved in the transmission of leishmaniasis in São Paulo, Brazil. Phlebotomine sand flies were collected between 1985 and 2015. ENMs were created for each sand fly species using Maximum Entropy Species Distribution Modeling software, and 20 climatic variables were determined. Nyssomyia intermedia (Lutz & Neiva, 1912) and Lutzomyia longipalpis (Lutz & Neiva, 1912), the primary vectors involved in CL and VL, displayed the highest suitability across the various regions, climates, and topographies. L. longipalpis was found in the border of Paraná an area currently free of VL. The variables with the greatest impact were temperature seasonality, precipitation, and altitude. Co-presence of multiple sand fly species was observed in the cuestas and coastal areas along the border of Paraná and in the western basalt areas along the border of Mato Grosso do Sul. Human CL and VL were found in 475 of 546 (86.7%) and 106 of 645 (16.4%) of municipalities, respectively. Niche overlap between N. intermedia and L. longipalpis was found with 9208 human cases of CL and 2952 cases of VL. ENMs demonstrated that each phlebotomine sand fly species has a unique geographic distribution pattern, and the occurrence of the primary vectors of CL and VL overlapped. These data can be used by public authorities to monitor the dispersion and expansion of CL and VL vectors in São Paulo state.

Malaria in Burkina Faso (West Africa) during the twenty-first century.

Temperature and rainfall predicted for the twenty-first century by global coupled models as reported by IPCC, (2014a, and b) were obtained regionally for Burkina Faso and through the Paluclim project, 2011-2014. One of the goals of this project was to assess the upcoming evolution of malaria transmission dynamics. From an impact model on malaria risk linked to climate variability, temperature and rainfall indices were derived. Malaria transmission dynamics were then predicted using the derived temperature and rainfall for the twenty-first century. Similar to the historical evidence of rainfall being an important factor for regulating the seasonal density of malaria vectors, this study also reports a definitive link between low-frequency rainfall variability and malaria in the region under the influence of the Atlantic Multidecadal Oscillation (AMO). This finding can be used by local stakeholders involved with the geography-based population health planning. Moreover, the predicted increase in temperature during the twenty-first century suggests a reduction of larvae survival in Burkina Faso and thus the malaria risk. More generally, the temperature increase could become a new limiting factor for malaria transmission dynamics in the Sahel Region (as reported by Mordecai et al. (2013).

Ecological niche models for sand fly species and predicted distribution of Lutzomyia longipalpis (Diptera: Psychodidae) and visceral leishmaniasis in Bahia state, Brazil.

Visceral leishmaniasis is a public health problem in Brazil. This disease is endemic in most of Bahia state, with increasing reports of cases in new areas. Ecological niche models (ENM) can be used as a tool for predicting potential distribution for disease, vectors, and to identify risk factors associated with their distribution. In this study, ecological niche models (ENMs) were developed for visceral leishmaniasis (VL) cases and 12 sand fly species captured in Bahia state. Sand fly data was collected monthly by CDC light traps from July 2009 to December 2012. MODIS satellite imagery was used to calculate NDVI, NDMI, and NDWI vegetation indices, MODIS day and night land surface temperature (LST), enhanced vegetation index (EVI), and 19 Bioclim variables were used to develop the ENM using the maximum entropy approach (Maxent). Mean diurnal range was the variable that most contributed to all the models for sand flies, followed by precipitation in wettest month. For Lutzomyia longipalpis (L. longipalpis), annual precipitation, precipitation in wettest quarter, precipitation in wettest month, and NDVI were the most contributing variables. For the VL model, the variables that contributed most were precipitation in wettest month, annual precipitation, LST day, and temperature seasonality. L. longipalpis was the species with the widest potential distribution in the state. The identification of risk areas and factors associated with this distribution is fundamental to prioritize resource allocation and to improve the efficacy of the state's program for surveillance and control of VL.

Use of Geospatial Surveillance and Response Systems for Vector-Borne Diseases in the Elimination Phase.

The distribution of diseases caused by vector-borne viruses and parasites are restricted by the environmental requirements of their vectors, but also by the ambient temperature inside the host as it influences the speed of maturation of the infectious agent transferred. The launch of the Soil Moisture Active Passive (SMAP) satellite in 2015, and the new ECOSTRESS instrument onboard the International Space Station (ISS) in 2018, established the leadership of the National Aeronautics Space Administration (NASA) in ecology and climate research by allowing the structural and functional classification of ecosystems that govern vector sustainability. These advances, and the availability of sub-meter resolution data from commercial satellites, contribute to seamless mapping and modelling of diseases, not only at continental scales (1 km²) and local community or agricultural field scales (15⁻30 m²), but for the first time, also at the habitat⁻household scale (<1 m²). This communication presents current capabilities that are related to data collection by Earth-observing satellites, and draws attention to the usefulness of geographical information systems (GIS) and modelling for the study of important parasitic diseases.

Molecular Confirmation of Ascaris suum: Further Investigation into the Zoonotic Origin of Infection in an 8-Year-Old Boy with Loeffler Syndrome.

An 8-year-old male from south Louisiana was diagnosed with Loeffler syndrome of suspected Ascaris origin. Further investigation of the farm recovered larvated, infective Ascaris eggs from the soil in drains surrounding pens on the family's small hog farm. Molecular analysis of the recovered eggs, in conjunction with Ascaris-specific IgE, inadequate farm management and sanitation, and behavioral risk factors indicate the patient had an Ascaris suum soil-transmitted infection.

Geospatial and modeling tools for leishmaniasis studies: a review of publication between 2008-2018

Aspects of how geospatial technologies can be used on visceral leishmaniasis (VL) control programs are discussed. We reviewed a number of papers discussing the usage of those technologies, through a PubMed literature review. Additionally, we provided conceptual elements for a development of a hierarchical scale framework on VL for decision making in São Paulo State, using Geographical Information Systems. Supported by Geospatial Techniques, we developed a view of some instruments for helping communities to better manage their risk areas. We used a classification called Strengths of GIS and Spatial Analysis in Epidemiology (SGISSAE). This review identified 50 papers published in the PubMed. With respect to developing the theoretical perspective, this paper can help to identify points of deficiency in shortage in discussions and leishmaniasis control programs, which led us to recommend future to delimitation studies to at community-based level and to define local actions to identify and manage the disease. In the conceptual framework data at community-based level will allow us to understand more broadly the changing spatial distribution of the disease.(AU)

Aspectos sobre como as tecnologias geoespaciais podem ser usadas nos programas de controle da leishmaniose visceral (LV) são discutidos. Nós confrontamos uma série de artigos discutindo o uso dessas tecnologias, através de uma revisão da literatura no PudMed. Adicionalmente, fornecemos elementos conceituais para o desenvolvimento de uma estrutura hierárquica sobre a escala na tomada de decisão sobre a leishmaniose no Estado de São Paulo, utilizando Sistemas de Informação Geográfica. Com o apoio das técnicas geoespaciais, desenvolvemos alguns instrumentos para ajudar as comunidades a gerenciar melhor suas áreas de risco. Usamos uma classificação chamada Forças do SIG e da análise espacial em Epidemiologia (SGISSAE). A revisão nos permitiu selecionar 50 artigos publicados no PubMed. Com relação ao desenvolvimento da perspectiva teórica, este artigo pode ajudar a identificar pontos de deficiência em discussões e programas de controle da leishmaniose, o que nos levou a recomendar futuros estudos de delimitação a nível comunitário e a definir ações locais para identificar e gerenciar a doença. No quadro conceptual, os dados ao nível da comunidade permitirão compreender mais amplamente a evolução da distribuição espacial da doença. (AU)

Geohealth: biology based mapping of vector borne disease in the Americas using NASA satellite data / Geosaúde: mapeamento da biologia das doenças vetoriais nas Américas utilizando dados de satélites da NASA

Implementation of a geospatial surveillance and response system data resource for vector borne disease in the Americas (GeoHealth) will be tested using NASA satellite data, geographic information systems and ecological niche modeling to characterize the environmental suitability and potential for spread of endemic and epizootic vector borne diseases. The initial focus is on developing prototype geospatial models for visceral leishmaniasis, an expanding endemic disease in Latin America, and geospatial models for dengue and other Aedes aegypti borne arboviruses (zika, chikungunya), emerging arboviruses with potential for epizootic spread from Latin America and the Caribbean and establishment in North America. Geospatial surveillance and response system open resource data bases and models will be made available, with training courses, to other investigators interested in mapping and modeling other vector borne diseases in the western hemisphere and contributing brokered data to an expanding GeoHealth data resource as part of the NASA AmeriGEOSS initiative.(AU)

A implementação de uma fonte de dados de vigilância e um sistema de resposta geoespacial para doenças transmitidas por vetores nas Américas (GeoHealth) será testada utilizando dados provenientes de satélites da NASA, sistemas de informações geográficas e modelagem do nicho ecológico, para caracterizar a suceptibilidade ambiental e o potencial de dispersão de doenças endêmicas e epizooticas transmitidas por vetores vetores. O foco inicial será o desenvolvimento de protótipos de modelos geoespaciais para a leishmaniose visceral, uma doença endêmica e em expansão na América Latina, e modelos geoespaciais para dengue e outros transmitidos pelo Aedes aegypti (zika, chikungunya), arbovírus emergentes com potencial para disseminação epizoótica pela América Latina e Caribe e estabelecimento na América do Norte. Sistemas de vigilância e resposta geoespacial e modelos de recursos em bases de dados abertas serão diponibilizados, com cursos de treinamento, para outros pesquisadores interessados em mapear e modelar outras doenças transmitidas por vetores no hemisfério ocidental e contribuir intermediando dados para uma fonte de dados GeoHealth em expansão, como parte da Iniciativa AmeriGEOSS, da NASA. (AU)

Geospatial and modeling tools for leishmaniasis studies: a review of publication between 2008-2018 / Ferramentas geoespaciais e de modelagem para estudos de leishmaniose: uma revisão de publicação entre 2008-2018

Aspects of how geospatial technologies can be used on visceral leishmaniasis (VL) control programs are discussed. We reviewed a number of papers discussing the usage of those technologies, through a PubMed literature review. Additionally, we provided conceptual elements for a development of a hierarchical scale framework on VL for decision making in São Paulo State, using Geographical Information Systems. Supported by Geospatial Techniques, we developed a view of some instruments for helping communities to better manage their risk areas. We used a classification called Strengths of GIS and Spatial Analysis in Epidemiology (SGISSAE). This review identified 50 papers published in the PubMed. With respect to developing the theoretical perspective, this paper can help to identify points of deficiency in shortage in discussions and leishmaniasis control programs, which led us to recommend future to delimitation studies to at community-based level and to define local actions to identify and manage the disease. In the conceptual framework data at community-based level will allow us to understand more broadly the changing spatial distribution of the disease.

Aspectos sobre como as tecnologias geoespaciais podem ser usadas nos programas de controle da leishmaniose visceral (LV) são discutidos. Nós confrontamos uma série de artigos discutindo o uso dessas tecnologias, através de uma revisão da literatura no PudMed. Adicionalmente, fornecemos elementos conceituais para o desenvolvimento de uma estrutura hierárquica sobre a escala na tomada de decisão sobre a leishmaniose no Estado de São Paulo, utilizando Sistemas de Informação Geográfica. Com o apoio das técnicas geoespaciais, desenvolvemos alguns instrumentos para ajudar as comunidades a gerenciar melhor suas áreas de risco. Usamos uma classificação chamada Forças do SIG e da análise espacial em Epidemiologia (SGISSAE). A revisão nos permitiu selecionar 50 artigos publicados no PubMed. Com relação ao desenvolvimento da perspectiva teórica, este artigo pode ajudar a identificar pontos de deficiência em discussões e programas de controle da leishmaniose, o que nos levou a recomendar futuros estudos de delimitação a nível comunitário e a definir ações locais para identificar e gerenciar a doença. No quadro conceptual, os dados ao nível da comunidade permitirão compreender mais amplamente a evolução da distribuição espacial da doença.

Geohealth: biology based mapping of vector borne disease in the Americas using NASA satellite data / Geosaúde: mapeamento da biologia das doenças vetoriais nas Américas utilizando dados de satélites da NASA

Implementation of a geospatial surveillance and response system data resource for vector borne disease in the Americas (GeoHealth) will be tested using NASA satellite data, geographic information systems and ecological niche modeling to characterize the environmental suitability and potential for spread of endemic and epizootic vector borne diseases. The initial focus is on developing prototype geospatial models for visceral leishmaniasis, an expanding endemic disease in Latin America, and geospatial models for dengue and other Aedes aegypti borne arboviruses (zika, chikungunya), emerging arboviruses with potential for epizootic spread from Latin America and the Caribbean and establishment in North America. Geospatial surveillance and response system open resource data bases and models will be made available, with training courses, to other investigators interested in mapping and modeling other vector borne diseases in the western hemisphere and contributing brokered data to an expanding GeoHealth data resource as part of the NASA AmeriGEOSS initiative.

A implementação de uma fonte de dados de vigilância e um sistema de resposta geoespacial para doenças transmitidas por vetores nas Américas (GeoHealth) será testada utilizando dados provenientes de satélites da NASA, sistemas de informações geográficas e modelagem do nicho ecológico, para caracterizar a suceptibilidade ambiental e o potencial de dispersão de doenças endêmicas e epizooticas transmitidas por vetores vetores. O foco inicial será o desenvolvimento de protótipos de modelos geoespaciais para a leishmaniose visceral, uma doença endêmica e em expansão na América Latina, e modelos geoespaciais para dengue e outros transmitidos pelo Aedes aegypti (zika, chikungunya), arbovírus emergentes com potencial para disseminação epizoótica pela América Latina e Caribe e estabelecimento na América do Norte. Sistemas de vigilância e resposta geoespacial e modelos de recursos em bases de dados abertas serão diponibilizados, com cursos de treinamento, para outros pesquisadores interessados em mapear e modelar outras doenças transmitidas por vetores no hemisfério ocidental e contribuir intermediando dados para uma fonte de dados GeoHealth em expansão, como parte da Iniciativa AmeriGEOSS, da NASA.

Establishment of macrocyclic lactone resistant Dirofilaria immitis isolates in experimentally infected laboratory dogs.

BACKGROUND: Strains of Dirofilaria immitis suspected of lack of efficacy (LOE) to macrocyclic lactone (ML) preventive drugs have been increasingly reported in dogs by practicing veterinarians since 2005 in the Lower Mississippi Delta region. If proven, and not controlled in the early stages, the emergence of ML drug resistance threatens to become a widespread problem in the US that may limit the effectiveness of current preventive drug treatment methods. METHODS: To validate practice reports, a statewide survey of Louisiana veterinarians was done to define the extent of the problem and identify focal 'hotspots' of reported ML LOEs using Geographic Information Systems (GIS) methods. The present study then utilized microfilariae (Mf) from two canine field cases from different state locations that fit criteria for a high index of suspicion of LOE against heartworms by ML drugs. Blood containing Mf from the canine field cases was used to infect and produce L3 in Aedes aegypti for experimental infection of two groups of dogs, each of which contained two laboratory dogs, one treated with prophylactic ivermectin (12 µg/kg) monthly for 6 months at twice the label dose (6 µg/kg), and one untreated control. RESULTS: Both treated and untreated dogs from Group I and Group II developed patent D. immitis infections by 218 DPI and 189 DPI, respectively, as evidenced by a positive occult heartworm antigen test and microfilaremia by the Knott's test. Mf counts gradually increased post-patency in test and control dogs. Infective larvae raised from microfilariae from the treated Group I dog were used to successfully establish a second generation isolate, confirming heritability of resistance in the face of a monthly ivermectin challenge dose of 24 µg/kg, given monthly for 3 months. CONCLUSIONS: These experimental infection studies provide in vivo evidence of the existence of ML drug resistance in dogs infected by D. immitis L3 from suspect field LOE cases in the Lower Mississippi Delta. Results encourage further work on mechanisms underlying the emergence of ML resistance in D. immitis and development of evidence-based resistance management strategies for heartworm preventives in order to extend the useful life of current drugs.

Predictive risk mapping of schistosomiasis in Brazil using Bayesian geostatistical models.

Schistosomiasis is one of the most common parasitic diseases in tropical and subtropical areas, including Brazil. A national control programme was initiated in Brazil in the mid-1970s and proved successful in terms of morbidity control, as the number of cases with hepato-splenic involvement was reduced significantly. To consolidate control and move towards elimination, there is a need for reliable maps on the spatial distribution of schistosomiasis, so that interventions can target communities at highest risk. The purpose of this study was to map the distribution of Schistosoma mansoni in Brazil. We utilized readily available prevalence data from the national schistosomiasis control programme for the years 2005-2009, derived remotely sensed climatic and environmental data and obtained socioeconomic data from various sources. Data were collated into a geographical information system and Bayesian geostatistical models were developed. Model-based maps identified important risk factors related to the transmission of S. mansoni and confirmed that environmental variables are closely associated with indices of poverty. Our smoothed predictive risk map, including uncertainty, highlights priority areas for intervention, namely the northern parts of North and Southeast regions and the eastern part of Northeast region. Our predictive risk map provides a useful tool for to strengthen existing surveillance-response mechanisms.

Modelling the geographical distribution of soil-transmitted helminth infections in Bolivia.

BACKGROUND: The prevalence of infection with the three common soil-transmitted helminths (i.e. Ascaris lumbricoides, Trichuris trichiura, and hookworm) in Bolivia is among the highest in Latin America. However, the spatial distribution and burden of soil-transmitted helminthiasis are poorly documented. METHODS: We analysed historical survey data using Bayesian geostatistical models to identify determinants of the distribution of soil-transmitted helminth infections, predict the geographical distribution of infection risk, and assess treatment needs and costs in the frame of preventive chemotherapy. Rigorous geostatistical variable selection identified the most important predictors of A. lumbricoides, T. trichiura, and hookworm transmission. RESULTS: Results show that precipitation during the wettest quarter above 400 mm favours the distribution of A. lumbricoides. Altitude has a negative effect on T. trichiura. Hookworm is sensitive to temperature during the coldest month. We estimate that 38.0%, 19.3%, and 11.4% of the Bolivian population is infected with A. lumbricoides, T. trichiura, and hookworm, respectively. Assuming independence of the three infections, 48.4% of the population is infected with any soil-transmitted helminth. Empirical-based estimates, according to treatment recommendations by the World Health Organization, suggest a total of 2.9 million annualised treatments for the control of soil-transmitted helminthiasis in Bolivia. CONCLUSIONS: We provide estimates of soil-transmitted helminth infections in Bolivia based on high-resolution spatial prediction and an innovative variable selection approach. However, the scarcity of the data suggests that a national survey is required for more accurate mapping that will govern spatial targeting of soil-transmitted helminthiasis control.

Malaria surveillance-response strategies in different transmission zones of the People's Republic of China: preparing for climate change.

BACKGROUND: A sound understanding of malaria transmission patterns in the People's Republic of China (P.R. China) is crucial for designing effective surveillance-response strategies that can guide the national malaria elimination programme (NMEP). Using an established biology-driven model, it is expected that one may design and refine appropriate surveillance-response strategies for different transmission zones, which, in turn, assist the NMEP in the ongoing implementation period (2010-2020) and, potentially, in the post-elimination stage (2020-2050). METHODS: Environmental data obtained from 676 locations across P.R. China, such as monthly temperature and yearly relative humidity (YRH), for the period 1961-2000 were prepared. Smoothed surface maps of the number of months suitable for parasite survival derived from monthly mean temperature and YRH were generated. For each decade, the final malaria prediction map was overlaid by two masked maps, one showing the number of months suitable for parasite survival and the other the length of YRH map in excess of 60%. RESULTS: Considering multiple environmental factors simultaneously, the environmental variables suitable for malaria transmission were found to have shifted northwards, which was especially pronounced in northern P.R. China. The unstable suitable regions (transmission periods between five and six months) showed increased transmission intensity due to prolonged suitable periods, especially in the central part of the country. CONCLUSION: Adequate and effective surveillance-response strategies for NMEP should be designed to achieve the goal of malaria elimination in P.R. China by 2020, especially in the zones predicted to be the most vulnerable for climate change.

Mapping and modelling neglected tropical diseases and poverty in Latin America and the Caribbean.

The prospects and opportunities for application of risk mapping and modelling of the neglected tropical diseases (NTDs) in Latin America are examined with the aim to broaden the interest in geospatial research there. Special reference is made to the potential use of geospatial tools in health planning and implementation of national disease control programmes.

Modelling the ecological niche of hookworm in Brazil based on climate.

The distribution of hookworm in schistosomiasis-endemic areas in Brazil was mapped based on climate suitability. Known biological requirements of hookworm were fitted to data in a monthly long-term normal climate grid (18 x 18 km) using geographical information systems. Hookworm risk models were produced using the growing degree day (GDD) water budget (WB) concept. A moisture-adjusted model (MA-GDD) was developed based on accumulation of monthly temperatures above a base temperature of 15 °C (below which there is no lifecycle progression of Necator americanus) conditional on concurrent monthly values (rain/potential, evapotranspiration) of over 0.4. A second model, designated the gradient index, was calculated based on the monthly accumulation of the product of GDD and monthly WB values (GDD x WB). Both parameters had a significant positive correlation to hookworm prevalence. In the northeastern part of Brazil (the Caatinga), low hookworm prevalence was due to low soil moisture content, while the low prevalence in southern Brazil was related to low mean monthly temperatures. Both environmental temperature and soil moisture content were found to be important parameters for predicting the prevalence of N. americanus.

Environmental and socio-economic risk modelling for Chagas disease in Bolivia.

Accurately defining disease distributions and calculating disease risk is an important step in the control and prevention of diseases. Geographical information systems (GIS) and remote sensing technologies, with maximum entropy (Maxent) ecological niche modelling computer software, were used to create predictive risk maps for Chagas disease in Bolivia. Prevalence rates were calculated from 2007 to 2009 household infection survey data for Bolivia, while environmental data were compiled from the Worldclim database and MODIS satellite imagery. Socio-economic data were obtained from the Bolivian National Institute of Statistics. Disease models identified altitudes at 500-3,500 m above the mean sea level (MSL), low annual precipitation (45-250 mm), and higher diurnal range of temperature (10-19 °C; peak 16 °C) as compatible with the biological requirements of the insect vectors. Socio-economic analyses demonstrated the importance of improved housing materials and water source. Home adobe wall materials and having to fetch drinking water from rivers or wells without pump were found to be highly related to distribution of the disease by the receiver operator characteristic (ROC) area under the curve (AUC) (0.69 AUC, 0.67 AUC and 0.62 AUC, respectively), while areas with hardwood floors demonstrated a direct negative relationship (-0.71 AUC). This study demonstrates that Maxent modelling can be used in disease prevalence and incidence studies to provide governmental agencies with an easily learned, understandable method to define areas as either high, moderate or low risk for the disease. This information may be used in resource planning, targeting and implementation. However, access to high-resolution, sub-municipality socio-economic data (e.g. census tracts) would facilitate elucidation of the relative influence of poverty-related factors on regional disease dynamics.