Comparing prioritization strategies for delivering indoor residual spray (IRS) implementation, using a network approach.

BACKGROUND: Indoor residual spraying (IRS) is an effective method to control malaria-transmitting Anopheles mosquitoes and often complements insecticide-treated mosquito nets, the predominant malaria vector control intervention. With insufficient funds to cover every household, malaria control programs must balance the malaria risk to a particular human community against the financial cost of spraying that community. This study creates a framework for modelling the distance to households for targeting IRS implementation, and applies it to potential risk prioritization strategies in four provinces (Luapula, Muchinga, Eastern, and Northern) in Zambia. METHODS: Optimal network models were used to assess the travel distance of routes between operations bases and human communities identified through remote sensing. Network travel distances were compared to Euclidean distances, to demonstrate the importance of accounting for road routes. The distance to reaching communities for different risk prioritization strategies were then compared assuming sufficient funds to spray 50% of households, using four underlying malarial risk maps: (a) predicted Plasmodium falciparum parasite rate in 2-10 years olds (PfPR), or (b) predicted probability of the presence of each of three main malaria transmitting anopheline vectors (Anopheles arabiensis, Anopheles funestus, Anopheles gambiae). RESULTS: The estimated one-way network route distance to reach communities to deliver IRS ranged from 0.05 to 115.69 km. Euclidean distance over and under-estimated these routes by - 101.21 to 41.79 km per trip, as compared to the network route method. There was little overlap between risk map prioritization strategies, both at a district-by-district scale, and across all four provinces. At both scales, agreement for inclusion or exclusion from IRS across all four prioritization strategies occurred in less than 10% of houses. The distances to reaching prioritized communities were either lower, or not statistically different from non-prioritized communities, at both scales of strategy. CONCLUSION: Variation in distance to targeted communities differed depending on risk prioritization strategy used, and higher risk prioritization did not necessarily translate into greater distances in reaching a human community. These findings from Zambia suggest that areas with higher malaria burden may not necessarily be more remote than areas with lower malaria burden.

The use of spatial and genetic tools to assess Plasmodium falciparum transmission in Lusaka, Zambia between 2011 and 2015.

BACKGROUND: Zambia has set itself the ambitious target of eliminating malaria by 2021. To continue tracking transmission to zero, new interventions, tools and approaches are required. METHODS: Urban reactive case detection (RCD) was performed in Lusaka city from 2011 to 2015 to better understand the location and drivers of malaria transmission. Briefly, index cases were followed to their home and all consenting individuals living in the index house and nine proximal houses were tested with a malaria rapid diagnostic test and treated if positive. A brief survey was performed and for certain responses, a dried blood spot sample collected for genetic analysis. Aggregate health facility data, individual RCD response data and genetic results were analysed spatially and against environmental correlates. RESULTS: Total number of malaria cases remained relatively constant, while the average age of incident cases and the proportion of incident cases reporting recent travel both increased. The estimated R0 in Lusaka was < 1 throughout the study period. RCD responses performed within 250 m of uninhabited/vacant land were associated with a higher probability of identifying additional infections. CONCLUSIONS: Evidence suggests that the majority of malaria infections are imported from outside Lusaka. However there remains some level of local transmission occurring on the periphery of urban settlements, namely in the wet season. Unfortunately, due to the higher-than-expected complexity of infections and the small number of samples tested, genetic analysis was unable to identify any meaningful trends in the data.

Accuracy and impact of spatial aids based upon satellite enumeration to improve indoor residual spraying spatial coverage.

BACKGROUND: Indoor residual spraying (IRS) is a key tool in the fight to control, eliminate and ultimately eradicate malaria. IRS protection is based on a communal effect such that an individual's protection primarily relies on the community-level coverage of IRS with limited protection being provided by household-level coverage. To ensure a communal effect is achieved through IRS, achieving high and uniform community-level coverage should be the ultimate priority of an IRS campaign. Ensuring high community-level coverage of IRS in malaria-endemic areas is challenging given the lack of information available about both the location and number of households needing IRS in any given area. A process termed 'mSpray' has been developed and implemented and involves use of satellite imagery for enumeration for planning IRS and a mobile application to guide IRS implementation. This study assessed (1) the accuracy of the satellite enumeration and (2) how various degrees of spatial aid provided through the mSpray process affected community-level IRS coverage during the 2015 spray campaign in Zambia. METHODS: A 2-stage sampling process was applied to assess accuracy of satellite enumeration to determine number and location of sprayable structures. Results indicated an overall sensitivity of 94% for satellite enumeration compared to finding structures on the ground. RESULTS: After adjusting for structure size, roof, and wall type, households in Nchelenge District where all types of satellite-based spatial aids (paper-based maps plus use of the mobile mSpray application) were used were more likely to have received IRS than Kasama district where maps used were not based on satellite enumeration. The probability of a household being sprayed in Nchelenge district where tablet-based maps were used, did not differ statistically from that of a household in Samfya District, where detailed paper-based spatial aids based on satellite enumeration were provided. CONCLUSION: IRS coverage from the 2015 spray season benefited from the use of spatial aids based upon satellite enumeration. These spatial aids can guide costly IRS planning and implementation leading to attainment of higher spatial coverage, and likely improve disease impact.

Shifting the burden or expanding access to care? Assessing malaria trends following scale-up of community health worker malaria case management and reactive case detection.

BACKGROUND: Malaria is a significant burden to health systems and is responsible for a large proportion of outpatient cases at health facilities in endemic regions. The scale-up of community management of malaria and reactive case detection likely affect both malaria cases and outpatient attendance at health facilities. Using health management information data from 2012 to 2013 this article examines health trends before and after the training of volunteer community health workers to test and treat malaria cases in Southern Province, Zambia. RESULTS: An estimated 50% increase in monthly reported malaria infections was found when community health workers were involved with malaria testing and treating in the community (incidence rate ratio 1.52, p < 0.001). Furthermore, an estimated 6% decrease in outpatient attendance at the health facility was found when community health workers were involved with malaria testing and treating in the community. CONCLUSIONS: These results suggest a large public health benefit to both community case management of malaria and reactive case detection. First, the capacity of the malaria surveillance system to identify malaria infections was increased by nearly one-third. Second, the outpatient attendance at health facilities was modestly decreased. Expanding the capacity of the malaria surveillance programme through systems such as community case management and reactive case detection is an important step toward malaria elimination.

Location, location, location: environmental factors better predict malaria-positive individuals during reactive case detection than index case demographics in Southern Province, Zambia.

BACKGROUND: Decreasing malaria transmission leads to increasing heterogeneity with increased risk in both hot spots (locations) and hot pops (certain demographics). In Southern Province, Zambia, reactive case detection has formed a part of malaria surveillance and elimination efforts since 2011. Various factors may be associated with finding malaria infections during case investigations, including the demographics of the incident case and environmental characteristics of the location of the incident case. METHODS: Community health worker registries were used to determine what factors were associated with finding a malaria infection during reactive case detection. RESULTS: Location was a more powerful predictor of finding malaria infections during case investigations than the demographics of the incident case. After accounting for environmental characteristics, no demographics around the incident case were associated with finding malaria infections during case investigations. Various time-invariant measures of the environment, such as median enhanced vegetation index, the topographic position index, the convergence index, and the topographical wetness index, were all associated as expected with increased probability of finding a malaria infection during case investigations. CONCLUSIONS: These results suggest that targeting the locations highly at risk of malaria transmission is of importance in elimination settings.

A framework for evaluating the costs of malaria elimination interventions: an application to reactive case detection in Southern Province of Zambia, 2014.

BACKGROUND: This paper summarizes a framework for evaluating the costs of malaria elimination interventions and applies this approach to one key component of the elimination strategy-reactive case detection (RCD)-implemented through 173 health facilities across 10 districts in Southern Province of Zambia during 2014. METHODS: The primary unit of analysis is the health facility catchment area (HFCA). A five-step approach was followed to estimate implementation costs: organize preliminary information; estimate basic unit costs; estimate activity unit costs; estimate and organize final unit cost database; and create the final costing database (one row of data per HFCA). By working through a specific application, the overall logic of the analysis and details of each step are presented. An electronic annex also provides all details of the analysis. Because population varies substantially across HFCAs, all results are reported per 1000 population in HFCAs. RESULTS: During 2014, 38.9 households per HFCA were visited for RCD services; 166.8 individuals were tested and 32.3 tested positive and were treated. The mean annual cost per HFCA was $1177 (median = $923, IQR $651-$1417). Variation in costs was driven by the number of CHWs and passive cases detected. CHW-related costs and data review meetings accounted for the largest share of costs. Rapid diagnostic tests and drugs accounted for less than 10 % of total costs. CONCLUSIONS: The framework presented here follows standard methods in applied costing of public health interventions (combining ingredients- and activity-based costing approaches into one final cost analysis). Through an application to a specific programme implemented in Zambia in 2014, the details of how to apply such methods to an actual programme are presented. Such details are not typically presented in existing costing analyses but are required for applied analysts working with national malaria control programmes and other organizations to complete such analyses as part of routine programme implementation. Obtaining data and information for implementing the approach remains complicated, in part because analysts from one organization may not have easy access to information from another organization. This basic approach is transparent and easily applied to other malaria elimination interventions being implemented in sub-Saharan Africa and elsewhere.

Targeting indoor residual spraying for malaria using epidemiological data: a case study of the Zambia experience.

BACKGROUND: In Zambia and other sub-Saharan African countries affected by ongoing malaria transmission, indoor residual spraying (IRS) for malaria prevention has typically been implemented over large areas, e.g., district-wide, and targeted to peri-urban areas. However, there is a recent shift in some countries, including Zambia, towards the adoption of a more strategic and targeted IRS approach, in coordination with increased emphasis on universal coverage of long-lasting insecticidal nets (LLINs) and effective insecticide resistance management. A true targeted approach would deliver IRS to sub-district areas identified as high-risk, with the goal of maximizing the prevention of malaria cases and deaths. RESULTS: Together with the Government of the Republic of Zambia, a new methodology was developed applying geographic information systems and satellite imagery to support a targeted IRS campaign during the 2014 spray season using health management information system data. DISCUSSION/CONCLUSION: This case study focuses on the developed methodology while also highlighting the significant research gaps which must be filled to guide countries on the most effective strategy for IRS targeting in the context of universal LLIN coverage and evolving insecticide resistance.

A qualitative review of implementer perceptions of the national community-level malaria surveillance system in Southern Province, Zambia.

BACKGROUND: Parts of Zambia with very low malaria parasite prevalence and high coverage of vector control interventions are targeted for malaria elimination through a series of interventions including reactive case detection (RCD) at community level. When a symptomatic individual presenting to a community health worker (CHW) or government clinic is diagnostically confirmed as an incident malaria case an RCD response is initiated. This consists of a CHW screening the community around the incident case with rapid diagnostic tests (RDT) and treating positive cases with artemether-lumefantrine (AL, Coartem™) in accordance with national policy. Since its inception in 2011, Zambia's RCD programme has relied on anecdotal feedback from staff to identify issues and possible solutions. In 2014, a systematic qualitative programme review was conducted to determine perceptions around malaria rates, incentives, operational challenges and solutions according to CHWs, their supervisors and district-level managers. METHODS: A criterion-based sampling framework based on training regime and performance level was used to select nine rural health posts in four districts of Southern Province. Twenty-two staff interviews were completed to produce English or bilingual (CiTonga or Silozi + English) verbatim transcripts, which were then analysed using thematic framework analysis. RESULTS: CHWs, their supervisors and district-level managers strongly credited the system with improving access to malaria services and significantly reducing the number of cases in their area. The main implementation barriers included access (e.g., lack of rain gear, broken bicycles), insufficient number of CHWs for programme coverage, communication (e.g. difficulties maintaining cell phones and "talk time" to transmit data by phone), and inconsistent supply chain (e.g., inadequate numbers of RDT kits and anti-malarial drugs to test and treat uncomplicated cases). CONCLUSIONS: This review highlights the importance of a community surveillance system like RCD in shaping Zambia's malaria elimination campaign by identifying community-based infections that might otherwise remain undetected. At this stage the system must ensure it can meet growing public demand by providing CHWs the tools and materials they need to consistently carry out their work and expand programme reach to more isolated communities. Results from this review will be used to plan programme scale-up into other parts of Zambia.

Open-source satellite enumeration to map households: planning and targeting indoor residual spraying for malaria.

BACKGROUND: Defining the number and location of sprayable structures (houses) is foundational to plan and monitor indoor residual spray (IRS) implementation, a primary intervention used to control the transmission of malaria. Only by mapping the location and type of all sprayable structures can IRS operations be planned, estimates of spray coverage determined, and targeted delivery of IRS to specific locations be achieved. Previously, field-based enumeration has been used to guide IRS campaigns, however, this approach is costly, time-consuming and difficult to scale. As a result, field-based enumeration typically fails to map all structures in a given area, making estimations less reliable and reducing the enumerated coverage. METHODS: Using open source satellite imagery and Geographic Information System software, satellite enumeration was conducted to guide IRS operations in 15 districts (91,302 km(2)) in northern Zambia during the 2014 spray season. Cost of satellite enumeration was compared to standard enumeration. Enumerated households were sampled to estimate sprayable surface area and wall type from the satellite enumeration using linear and logistic regression, respectively. RESULTS: In comparison to the traditional field-based enumeration procedure, satellite-based enumeration was 22 times faster, and 10 times less costly. An estimated 98 % of the satellite enumerated buildings correctly classified roof type. Predicted surface area of each household correlated at a value of 0.91 with measured surface area of each household. CONCLUSION: For IRS campaigns, high quality and high coverage enumeration data aid in planning, through informed insecticide procurement. Through the identification of geographical areas and populations to target, enumeration data guide operations and assist monitoring and evaluation of IRS through the unbiased estimation of coverage achieved. Satellite enumeration represents a quick, cheap and accurate system to provide these data, and has potential applications beyond IRS for delivery of other targeted or non-targeted interventions (e.g. net distributions, mass drug administration, immunization campaigns, or even sampling frames for field studies).

Malaria surveillance in low-transmission areas of Zambia using reactive case detection.

BACKGROUND: Repeat national household surveys suggest highly variable malaria transmission and increasing coverage of high-impact malaria interventions throughout Zambia. Many areas of very low malaria transmission, especially across southern and central regions, are driving efforts towards sub-national elimination. CASE DESCRIPTION: Reactive case detection (RCD) is conducted in Southern Province and urban areas of Lusaka in connection with confirmed incident malaria cases presenting to a community health worker (CHW) or clinic and suspected of being the result of local transmission. CHWs travel to the household of the incident malaria case and screen individuals living in adjacent houses in urban Lusaka and within 140 m in Southern Province for malaria infection using a rapid diagnostic test, treating those testing positive with artemether-lumefantrine. DISCUSSION: Reactive case detection improves access to health care and increases the capacity for the health system to identify malaria infections. The system is useful for targeting malaria interventions, and was instrumental for guiding focal indoor residual spraying in Lusaka during the 2014/2015 spray season. Variations to maximize impact of the current RCD protocol are being considered, including the use of anti-malarials with a longer lasting, post-treatment prophylaxis. CONCLUSION: The RCD system in Zambia is one example of a malaria elimination surveillance system which has increased access to health care within rural communities while leveraging community members to build malaria surveillance capacity.

Enhanced surveillance and data feedback loop associated with improved malaria data in Lusaka, Zambia.

BACKGROUND: Accurate and timely malaria data are crucial to monitor the progress towards and attainment of elimination. Lusaka, the capital city of Zambia, has reported very low malaria prevalence in Malaria Indicator Surveys. Issues of low malaria testing rates, high numbers of unconfirmed malaria cases and over consumption of anti-malarials were common at clinics within Lusaka, however. The Government of Zambia (GRZ) and its partners sought to address these issues through an enhanced surveillance and feedback programme at clinic level. METHODS: The enhanced malaria surveillance programme began in 2011 to verify trends in reported malaria, as well as to implement a data feedback loop to improve data uptake, use, and quality. A process of monthly data collection and provision of feedback was implemented within all GRZ health clinics in Lusaka District. During clinic visits, clinic registers were accessed to record the number of reported malaria cases, malaria test positivity rate, malaria testing rate, and proportion of total suspected malaria that was confirmed with a diagnostic test. RESULTS AND DISCUSSION: Following the enhanced surveillance programme, the odds of receiving a diagnostic test for a suspected malaria case increased (OR = 1.54, 95 % CI = 0.96-2.49) followed by an upward monthly trend (OR = 1.05, 95 % CI = 1.01-1.09). The odds of a reported malaria case being diagnostically confirmed also increased monthly (1.09, 95 % CI 1.04-1.15). After an initial 140 % increase (95 % CI = 91-183 %), costs fell by 11 % each month (95 % CI = 5.7-10.9 %). Although the mean testing rate increased from 18.9 to 64.4 % over the time period, the proportion of reported malaria unconfirmed by diagnostic remained high at 76 %. CONCLUSIONS: Enhanced surveillance and implementation of a data feedback loop have substantially increased malaria testing rates and decreased the number of unconfirmed malaria cases and courses of ACT consumed in Lusaka District within just two years. Continued support of enhanced surveillance in Lusaka as well as national scale-up of the system is recommended to reinforce good case management and to ensure timely, reliable data are available to guide targeting of limited malaria prevention and control resources in Zambia.

The Impact of Household and Community Indoor Residual Spray Coverage with Fludora Fusion in a High Malaria Transmission Setting in Northern Zambia.

Zambia's National Malaria Elimination Program transitioned to Fludora Fusion in 2019 for annual indoor residual spraying (IRS) in Nchelenge District, an area with holoendemic malaria transmission. Previously, IRS was associated with reductions in parasite prevalence during the rainy season only, presumably because of insufficient residual insecticide longevity. This study assessed the impact of transitioning from Actellic 300CS to long-acting Fludora Fusion using active surveillance data from 2014 through 2021. A difference-in-differences analysis estimated changes in rainy season parasite prevalence associated with living in a sprayed house, comparing insecticides. The change in the 2020 to 2021 dry season parasite prevalence associated with living in a house sprayed with Fludora Fusion was also estimated. Indoor residual spraying with Fludora Fusion was not associated with decreased rainy season parasite prevalence compared with IRS with Actellic 300CS (ratio of prevalence ratios [PRs], 1.09; 95% CI, 0.89-1.33). Moreover, living in a house sprayed with either insecticide was not associated with decreased malaria risk (Actellic 300CS: PR, 0.97; 95% CI, 0.86-1.10; Fludora Fusion: rainy season PR, 1.06; 95% CI, 0.89-1.25; dry season PR, 1.21; 95% CI, 0.99-1.48). In contrast, each 10% increase in community IRS coverage was associated with a 4% to 5% reduction in parasite prevalence (rainy season: PR, 0.95; 95% CI, 0.92-0.97; dry season: PR, 0.96; 95% CI, 0.94-0.99), suggesting a community-level protective effect, and corroborating the importance of high-intervention coverage.

Developing High-Resolution Population and Settlement Data for Impactful Malaria Interventions in Zambia.

Foundational high-resolution geospatial data products for population, settlements, infrastructure, and boundaries may greatly enhance the efficient planning of resource allocation during health sector interventions. To ensure the relevance and sustainability of such products, government partners must be involved from the beginning in their creation, improvement, and/or management, so they can be successfully applied to public health campaigns, such as malaria control and prevention. As an example, Zambia had an ambitious strategy of reaching the entire population with malaria vector control campaigns by late 2020 or early 2021, but they lacked the requisite accurate and up-to-date data on infrastructure and population distribution. To address this gap, the Geo-Referenced Infrastructure and Demographic Data for Development (GRID3) program, Akros, and other partners developed maps and planning templates to aid Zambia's National Malaria Elimination Program (NMEP) in operationalizing its strategy.

Irrigated agriculture is an important risk factor for West Nile virus disease in the hyperendemic Larimer-Boulder-Weld area of north central Colorado.

This study focused on two West Nile virus (WNV) disease outbreak years, 2003 and 2007, and included a three-county area (Larimer, Boulder, and Weld) in North Central Colorado that is hyperendemic for WNV disease. We used epidemiological data for reported WNV disease cases at the census tract scale to: (1) elucidate whether WNV disease incidence differs between census tracts classified as having high versus lower human population density (based on a threshold value of 580 persons/km2) and (2) determine associations between WNV disease incidence and habitat types suitable as development sites for the larval stage of Culex mosquito vectors. WNV disease incidence was significantly elevated in census tracts with lower human population density, compared with those with high density of human population, in both 2003 (median per census tract of 223 and 143 cases per 100,000 population, respectively) and 2007 (median per census tract of 46 and 19 cases per 100,000 population). This is most likely related, in large part, to greater percentages of coverage in less densely populated census tracts by habitats suitable as development sites for Culex larvae (open water, developed open space, pasture/hay, cultivated crops, woody wetlands, and emergent herbaceous wetlands) and, especially, for the subset of these habitats made up by irrigated agricultural land (pasture/hay and cultivated crops) that presumably serve as major producers of the locally most important vector of WNV to humans: Culex tarsalis. A series of analyses produced significant positive associations between greater coverage of or shorter distance to irrigated agricultural land and elevated WNV disease incidence. As an exercise to produce data with potential to inform spatial implementation schemes for prevention and control measures within the study area, we mapped the spatial patterns, by census tract, of WNV disease incidence in 2003 and 2007 as well as the locations of census tracts that had either low (<25th percentile) or high (>75th percentile) WNV disease incidence in both outbreak years (relative to the incidence for each year). This revealed substantial changes from 2003 to 2007 in the spatial pattern for census tracts within the study area with high WNV disease incidence and suggests a dynamic and evolving scenario of WNV transmission to humans that needs to be taken into account for prevention and control measures to stay current and represent the most effective use of available resources.

Leveraging risk maps of malaria vector abundance to guide control efforts reduces malaria incidence in Eastern Province, Zambia.

Although transmission of malaria and other mosquito-borne diseases is geographically heterogeneous, in sub-Saharan Africa risk maps are rarely used to determine which communities receive vector control interventions. We compared outcomes in areas receiving different indoor residual spray (IRS) strategies in Eastern Province, Zambia: (1) concentrating IRS interventions within a geographical area, (2) prioritizing communities to receive IRS based on predicted probabilities of Anopheles funestus, and (3) prioritizing communities to receive IRS based on observed malaria incidence at nearby health centers. Here we show that the use of predicted probabilities of An. funestus to guide IRS implementation saw the largest decrease in malaria incidence at health centers, a 13% reduction (95% confidence interval = 5-21%) compared to concentrating IRS geographically and a 37% reduction (95% confidence interval = 30-44%) compared to targeting IRS based on health facility incidence. These results suggest that vector control programs could produce better outcomes by prioritizing IRS according to malaria-vector risk maps.

Malaria case management in Zambia: A cross-sectional health facility survey.

Misdiagnosis of malaria could lead to the overuse of antimalarials resulting in the progression of underlying illness as well as increased risk of mortality. Misdiagnosis is an important consideration as a significant proportion of febrile illnesses in sub-Saharan Africa are attributable to conditions other than malaria. A health facility survey was carried out for a simple random sample of health facilities across 4 provinces of central Zambia in 2014. Twenty-nine facilities with at least 10 outpatients per day were included in the final sample. A modified service provision assessment questionnaire was used for data collection along with several other instruments. Primary outcomes included the quality and accuracy of diagnostic testing for malaria as well as health worker diagnostic and treatment practices. Laboratory technicians displayed 65.5% sensitivity and 86.0% specificity in performing malaria microscopy. Rapid diagnostic test results as reported by health workers were cross-checked by survey staff revealing 99.8% (95% CI: 98.0%-100.0%) concordance. Overall, 69.5% (177/286) (95% CI [58.8%-78.4%]) of patients were reported as febrile of which 37.0% (68/177) (95% CI [21.0%-56.6%]) had a malaria test requested or conducted by their health worker. Appropriate health worker adherence to recommended malaria case management practices (i.e. requesting/conducting malaria tests for febrile patients and providing appropriate antimalarial treatment for test positive cases or forgoing antimalarial treatment for test negative cases) was 30.5% (57/177) (95% CI [17.1%-48.4%]). Presence of fever (aOR = 10.6; 95% CI [3.6-31.2]) and self-reported headache (aOR = 2.2; 95% CI [1.0-4.9]) were significant factors in explaining health worker practices of requesting or performing malaria tests. Routine practice of IQA activities (aOR = 4.8; 95% CI [1.5-15.1]) and self-reported headache (aOR = 3.3; 95% CI [1.1-10.1])) were both significant predictors of antimalarial drug treatment or prescription among malaria untested patients. Prescriber adherence to malaria diagnostic test results in central Zambia is good, but the overall testing rate of febrile patients was low. Additionally, a number of patients observed during this survey were found to have received a clinical diagnosis of malaria without parasitological confirmation and many patients without test results received antimalarial treatment.

Assessing the Impact of Leveraging Traditional Leadership on Access to Sanitation in Rural Zambia.

Open defecation is practiced by more than one billion people throughout the world and leads to significant public health issues including infectious disease transmission and stunted growth in children. Zambia implemented community-led total sanitation (CLTS) as an intervention to eliminate open defecation in rural areas. To support CLTS and the attainment of open defecation free communities, chiefs were considered key agents of change and were empowered to drive CLTS and improve sanitation for their chiefdom. Chiefs were provided with data on access to sanitation in the chiefdom during chiefdom orientations prior to the initiation of CLTS within each community and encouraged to make goals of universal sanitation access within the community. Using a survival regression, we found that where chiefs were orientated and mobilized in CLTS, the probability that a village would achieve 100% coverage of adequate sanitation increased by 23% (hazard ratio = 1.263, 95% confidence interval = 1.080-1.478, P = 0.003). Using an interrupted time series, we found a 30% increase in the number of individuals with access to adequate sanitation following chiefdom orientations (95% confidence interval = 28.8-32.0%). The mobilization and support of chiefs greatly improved the uptake of CLTS, and empowering them with increased CLTS knowledge and authority of the program in their chiefdom allowed chiefs to closely monitor village sanitation progress and follow-up with their headmen/headwomen. These key agents of change are important facilitators of public health goals such as the elimination of open defecation in Zambia by 2020.

Modular laboratories--cost-effective and sustainable infrastructure for resource-limited settings.

High-quality laboratory space to support basic science, clinical research projects, or health services is often severely lacking in the developing world. Moreover, the construction of suitable facilities using traditional methods is time-consuming, expensive, and challenging to implement. Three real world examples showing how shipping containers can be converted into modern laboratories are highlighted. These include use as an insectary, a molecular laboratory, and a BSL-3 containment laboratory. These modular conversions have a number of advantages over brick and mortar construction and provide a cost-effective and timely solution to offer high-quality, user-friendly laboratory space applicable within the developing world.

Malaria elimination: surveillance and response.

In the last decade, substantial progress has been made in reducing malaria-associated morbidity and mortality across the globe. Nevertheless, sustained malaria control is essential to continue this downward trend. In some countries, where aggressive malaria control has reduced malaria to a low burden level, elimination, either nationally or subnationally, is now the aim. As countries or areas with a low malaria burden move towards elimination, there is a transition away from programs of universal coverage towards a strategy of localized detection and response to individual malaria cases. To do so and succeed, it is imperative that a strong surveillance and response system is supported, that community cadres are trained to provide appropriate diagnostics and treatment, and that field diagnostics are further developed such that their sensitivity allows for the detection and subsequent treatment of malaria reservoirs in low prevalence environments. To be certain, there are big challenges on the road to elimination, notably the development of drug and insecticide resistance. Nevertheless, countries like Zambia are making great strides towards implementing systems that support malaria elimination in target areas. Continued development of new diagnostics and antimalarial therapies is needed to support progress in malaria control and elimination.

Spatial risk assessments based on vector-borne disease epidemiologic data: importance of scale for West Nile virus disease in Colorado.

We used epidemiologic data for human West Nile virus (WNV) disease in Colorado from 2003 and 2007 to determine 1) the degree to which estimates of vector-borne disease occurrence is influenced by spatial scale of data aggregation (county versus census tract), and 2) the extent of concordance between spatial risk patterns based on case counts versus incidence. Statistical analyses showed that county, compared with census tract, accounted for approximately 50% of the overall variance in WNV disease incidence, and approximately 33% for the subset of cases classified as West Nile neuroinvasive disease. These findings indicate that sub-county scale presentation provides valuable risk information for stakeholders. There was high concordance between spatial patterns of WNV disease incidence and case counts for census tract (83%) but not for county (50%) or zip code (31%). We discuss how these findings impact on practices to develop spatial epidemiologic data for vector-borne diseases and present data to stakeholders.