Fine scale mapping of malaria infection clusters by using routinely collected health facility data in urban Dar es Salaam, Tanzania.

This study investigated whether passively collected routine health facility data can be used for mapping spatial heterogeneities in malaria transmission at the level of local government housing cluster administrative units in Dar es Salaam, Tanzania. From June 2012 to January 2013, residential locations of patients tested for malaria at a public health facility were traced based on their local leaders' names and geo-referencing the point locations of these leaders' houses. Geographic information systems (GIS) were used to visualise the spatial distribution of malaria infection rates. Spatial scan statistics was deployed to detect spatial clustering of high infection rates. Among 2407 patients tested for malaria, 46.6% (1121) could be traced to their 411 different residential housing clusters. One small spatially aggregated cluster of neighbourhoods with high prevalence was identified. While the home residence housing cluster leader was unambiguously identified for 73.8% (240/325) of malaria-positive patients, only 42.3% (881/2082) of those with negative test results were successfully traced. It was concluded that recording simple points of reference during routine health facility visits can be used for mapping malaria infection burden on very fine geographic scales, potentially offering a feasible approach to rational geographic targeting of malaria control interventions. However, in order to tap the full potential of this approach, it would be necessary to optimise patient tracing success and eliminate biases by blinding personnel to test results.

Spatially aggregated clusters and scattered smaller loci of elevated malaria vector density and human infection prevalence in urban Dar es Salaam, Tanzania.

BACKGROUND: Malaria transmission, primarily mediated by Anopheles gambiae, persists in Dar es Salaam (DSM) despite high coverage with bed nets, mosquito-proofed housing and larviciding. New or improved vector control strategies are required to eliminate malaria from DSM, but these will only succeed if they are delivered to the minority of locations where residual transmission actually persists. Hotspots of spatially clustered locations with elevated malaria infection prevalence or vector densities were, therefore, mapped across the city in an attempt to provide a basis for targeting supplementary interventions. METHODS: Two phases of a city-wide population-weighted random sample of cross-sectional household surveys of malaria infections were complemented by two matching phases of geographically overlapping, high-resolution, longitudinal vector density surveys; spanning 2010-2013. Spatial autocorrelations were explored using Moran's I and hotspots were detected using flexible spatial scan statistics. RESULTS: Seven hotspots of spatially clustered elevated vector density and eight of malaria infection prevalence were detected over both phases. Only a third of vectors were collected in hotspots in phase 1 (30 %) and phase 2 (33 %). Malaria prevalence hotspots accounted for only half of malaria infections detected in phase 1 (55 %) and phase 2 (47 %). Three quarters (76 % in phase 1 and 74 % in phase 2) of survey locations with detectable vector populations were outside of hotspots. Similarly, more than half of locations with higher infection prevalence (>10 %) occurred outside of hotspots (51 % in phase 1 and 54 % in phase 2). Vector proliferation hazard (exposure to An. gambiae) and malaria infection risk were only very loosely associated with each other (Odds ratio (OR) [95 % Confidence Interval (CI)] = 1.56 [0.89, 1.78], P = 0.52)). CONCLUSION: Many small, scattered loci of local malaria transmission were haphazardly scattered across the city, so interventions targeting only currently identifiable spatially aggregated hotspots will have limited impact. Routine, spatially comprehensive, longitudinal entomological and parasitological surveillance systems, with sufficient sensitivity and spatial resolution to detect these scattered loci, are required to eliminate transmission from this typical African city. Intervention packages targeted to both loci and hotspots of transmission will need to suppress local vector proliferation, treat infected residents and provide vulnerable residents with supplementary protective measures against exposure.

Impregnating hessian strips with the volatile pyrethroid transfluthrin prevents outdoor exposure to vectors of malaria and lymphatic filariasis in urban Dar es Salaam, Tanzania.

BACKGROUND: Semi-field trials using laboratory-reared Anopheles arabiensis have shown that, delivering the volatile pyrethroid transfluthrin by absorption into hessian strips, consistently provided > 99% human protective efficacy against bites for 6 months without retreating. Here the impact of this approach upon human exposure to wild populations of vectors for both malaria and filariasis under full field conditions is assessed for the first time. METHODS: Transfluthrin-treated and untreated strips were placed around human volunteers conducting human landing catch in an outdoor environment in urban Dar es Salaam, where much human exposure to malaria and filariasis transmission occurs outdoors. The experiment was replicated 9 times at 16 outdoor catching stations in 4 distinct locations over 72 working nights between May and August 2012. RESULTS: Overall, the treated hessian strips conferred 99% protection against An. gambiae (1 bite versus 159) and 92% protection against Culex spp. (1478 bites versus 18,602). No decline in efficacy over the course of the study could be detected for the very sparse populations of An. gambiae (P = 0.32) and only a slow efficacy decline was observed for Culex spp. (P < 0.001), with protection remaining satisfactory over 3 months after strip treatment. Diversion of mosquitoes to unprotected humans in nearby houses was neither detected for An. gambiae (P = 0.152) nor for Culex spp. (Relative rate, [95% CI] = 1.03, [0.95, 1.11], P = 0.499). CONCLUSION: While this study raises more questions than it answers, the presented evidence of high protection over long periods suggest this technology may have potential for preventing outdoor transmission of malaria, lymphatic filariasis and other vector-borne pathogens.