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Background: Rigorous evaluations of health system interventions to strengthen hypertension and cardiovascular disease (CVD) care remain scarce in sub-Saharan Africa. This study aims to evaluate the reach, effectiveness, adoption / acceptability, implementation fidelity, cost, and sustainability of the Ghana Heart Initiative (GHI), a multicomponent supply-side intervention to improve cardiovascular health in Ghana. Methods: This study adopts a mixed- and multi-methods design comparing the effects of the GHI in 42 intervention health facilities (i.e. primary, secondary and tertiary) in the Greater Accra Region versus 56 control health facilities in the Central and Western Regions. The evaluation design is guided by the RE-AIM framework underpinned by the WHO health systems building blocks framework, integrated by the Institute of Medicine’s six dimensions of health care quality: safe, effective, patient-centered, timely, efficient, equitable. The assessment tools include: (i) a health facility survey, (ii) a healthcare provider survey assessing the knowledge, attitudes, and practices on hypertension and CVD management, (iii) a patient exit survey, (iv) an outpatient and in-patient medical record review and (v) qualitative interviews with patients and various health system stakeholders to understand the barriers and facilitators around the implementation of the GHI. In addition to primary data collection, the study also relies on secondary routine health system data, i.e., the District Health Information Management System to conduct an interrupted time series analysis using monthly counts for relevant hypertension and CVD specific indicators as outcomes. The primary outcome measures are performance of health service delivery indicators, input, process and outcome of care indicators (including screening of hypertension, newly diagnosed hypertension, prescription of guideline directed medical therapy, and satisfaction with service received and acceptability) between the intervention and control facilities. Lastly, an economic evaluation and budget impact analysis is planned to inform the nationwide scale-up of the GHI. Discussion: This study will generate policy-relevant data on the reach, effectiveness, implementation fidelity, adoption / acceptability, and sustainability of the GHI, and provide insights on the costs and budget-impacts to inform nation-wide scale-up to expand the GHI to other regions across Ghana and offer lessons to other low- and middle-income countries settings as well. RIDIE Registration Number: RIDIE-STUDY-ID-6375e5614fd49 (https://ridie.3ieimpact.org/index.php).

BACKGROUND e-Learning for health professionals in many low- and middle-income countries (LMICs) is still in its infancy, but with the advent of COVID-19, a significant expansion of digital learning has occurred. Asynchronous e-learning can be grouped into interactive (user-influenceable content) and noninteractive (static material) e-learning. Studies conducted in high-income countries suggest that interactive e-learning is more effective than noninteractive e-learning in increasing learner satisfaction and knowledge; however, there is a gap in our understanding of whether this also holds true in LMICs. OBJECTIVE This study aims to validate the hypothesis above in a resource-constrained and real-life setting to understand e-learning quality and delivery by comparing interactive and noninteractive e-learning user satisfaction, usability, and knowledge gain in a new medical university in Zambia. METHODS We conducted a web-based, mixed methods randomized controlled trial at the Levy Mwanawasa Medical University (LMMU) in Lusaka, Zambia, between April and July 2021. We recruited medical licentiate students (second, third, and fourth study years) via email. Participants were randomized to undergo asynchronous e-learning with an interactive or noninteractive module for chronic obstructive pulmonary disease and informally blinded to their group allocation. The interactive module included interactive interfaces, quizzes, and a virtual patient, whereas the noninteractive module consisted of PowerPoint slides. Both modules covered the same content scope. The primary outcome was learner satisfaction. The secondary outcomes were usability, short- and long-term knowledge gain, and barriers to e-learning. The mixed methods study followed an explanatory sequential design in which rating conferences delivered further insights into quantitative findings, which were evaluated through web-based questionnaires. RESULTS Initially, 94 participants were enrolled in the study, of whom 41 (44%; 18 intervention participants and 23 control participants) remained in the study and were analyzed. There were no significant differences in satisfaction (intervention: median 33.5, first quartile 31.3, second quartile 35; control: median 33, first quartile 30, second quartile 37.5; P=.66), usability, or knowledge gain between the intervention and control groups. Challenges in accessing both e-learning modules led to many dropouts. Qualitative data suggested that the content of the interactive module was more challenging to access because of technical difficulties and individual factors (eg, limited experience with interactive e-learning). CONCLUSIONS We did not observe an increase in user satisfaction with interactive e-learning. However, this finding may not be generalizable to other low-resource settings because the post hoc power was low, and the e-learning system at LMMU has not yet reached its full potential. Consequently, technical and individual barriers to accessing e-learning may have affected the results, mainly because the interactive module was considered more difficult to access and use. Nevertheless, qualitative data showed high motivation and interest in e-learning. Future studies should minimize technical barriers to e-learning to further evaluate interactive e-learning in LMICs. CLINICALTRIAL

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The first line of malaria vector control to date mainly relies on the use of long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS). For integrated vector management, targeting the vector larvae with biological larvicides such as Bacillus thuringiensis israelensis (Bti) can be an effective additional mainstay. This study presents data from the second intervention year of a large-scale trial on biological larviciding with Bti that was carried out in 127 rural villages and a semi-urban town in Burkina Faso. Here we present the reductions in malaria mosquitoes that were achieved by continuing the initial interventions for an additional year, important to assess sustainability and repeatability of the results from the first intervention year. Larviciding was performed applying two different larviciding choices ((a) treatment of all environmental breeding sites, and (b) selective treatment of those that were most productive for Anopheles larvae indicated by remote sensing based risk maps). Adult Anopheles spp. mosquito abundance was reduced by 77.4% (full treatment) and 63.5% (guided treatment) compared to the baseline year. The results showed that malaria vector abundance can be dramatically reduced using biological larviciding and that this effect can be achieved and maintained over several consecutive transmission seasons.

Background e-Learning for health professionals in many low- and middle-income countries (LMICs) is still in its infancy, but with the advent of COVID-19, a significant expansion of digital learning has occurred. Asynchronous e-learning can be grouped into interactive (user-influenceable content) and noninteractive (static material) e-learning. Studies conducted in high-income countries suggest that interactive e-learning is more effective than noninteractive e-learning in increasing learner satisfaction and knowledge; however, there is a gap in our understanding of whether this also holds true in LMICs. Objective This study aims to validate the hypothesis above in a resource-constrained and real-life setting to understand e-learning quality and delivery by comparing interactive and noninteractive e-learning user satisfaction, usability, and knowledge gain in a new medical university in Zambia. Methods We conducted a web-based, mixed methods randomized controlled trial at the Levy Mwanawasa Medical University (LMMU) in Lusaka, Zambia, between April and July 2021. We recruited medical licentiate students (second, third, and fourth study years) via email. Participants were randomized to undergo asynchronous e-learning with an interactive or noninteractive module for chronic obstructive pulmonary disease and informally blinded to their group allocation. The interactive module included interactive interfaces, quizzes, and a virtual patient, whereas the noninteractive module consisted of PowerPoint slides. Both modules covered the same content scope. The primary outcome was learner satisfaction. The secondary outcomes were usability, short- and long-term knowledge gain, and barriers to e-learning. The mixed methods study followed an explanatory sequential design in which rating conferences delivered further insights into quantitative findings, which were evaluated through web-based questionnaires. Results Initially, 94 participants were enrolled in the study, of whom 41 (44%; 18 intervention participants and 23 control participants) remained in the study and were analyzed. There were no significant differences in satisfaction (intervention: median 33.5, first quartile 31.3, second quartile 35; control: median 33, first quartile 30, second quartile 37.5; P=.66), usability, or knowledge gain between the intervention and control groups. Challenges in accessing both e-learning modules led to many dropouts. Qualitative data suggested that the content of the interactive module was more challenging to access because of technical difficulties and individual factors (eg, limited experience with interactive e-learning). Conclusions We did not observe an increase in user satisfaction with interactive e-learning. However, this finding may not be generalizable to other low-resource settings because the post hoc power was low, and the e-learning system at LMMU has not yet reached its full potential. Consequently, technical and individual barriers to accessing e-learning may have affected the results, mainly because the interactive module was considered more difficult to access and use. Nevertheless, qualitative data showed high motivation and interest in e-learning. Future studies should minimize technical barriers to e-learning to further evaluate interactive e-learning in LMICs.

Introduction: Dengue has been endemic to Pakistan in the last two decades. There was a massive outbreak in the Swat valley in 2013. Here we demonstrate the spatio-temporal clustering and diffusion patterns of the dengue outbreak. Methods: Dengue case data were acquired from the hospital records in the Swat district of Pakistan. Ring maps visualize the distribution and diffusion of the number of cases and incidence of dengue at the level of the union council. We applied space-time scan statistics to identify spatio-temporal clusters. Ordinary least squares and geographically weighted regression models were used to evaluate the impact of elevation, population density, and distance to the river. Results: The results show that dengue distribution is not random, but clustered in space and time in the Swat district. Males constituted 68% of the cases while females accounted for about 32%. A majority of the cases (>55%) were younger than 40 years of age. The southern part was a major hotspot affected by the dengue outbreak in 2013. There are two space-time clusters in the spatio-temporal analysis. GWR and OLS show that population density is a significant explanatory variable for the dengue outbreak, while GWR exhibits better performance in terms of ‘R2 = 0.49 and AICc = 700’. Conclusion: Dengue fever is clustered in the southern part of the Swat district. This region is relatively urban in character, with most of the population of the district residing here. There is a need to strengthen the surveillance system for reporting dengue cases in order to respond to future outbreaks in a robust way. Keywords: Dengue, Swat, Pakistan, Spatio-temporal, Clusters, Diffusion

ObjectivesTo examine the knowledge, attitudes and practices (KAP) of COVID-19 of rural and urban residents in Liberia to inform the development of local social and behaviour change communication strategies.DesignCross-sectional, mixed-mode (online and telephone) survey using non-probability sampling.SettingAll 15 counties in Liberia with a focus on Maryland County.ParticipantsFrom 28 May to 28 June 2020, data were collected from a total of 431 adults aged 18 years and older (telephone 288 (66.8%); online 143 (33.2%)) out of a total of 741 contacts.Main outcome measuresKAP scores. Frequencies and proportions were calculated, followed by univariate and multivariable analyses to examine the association between KAP scores and the sociodemographic variables.ResultsAround 69% of the online survey respondents were younger than 35 years of age, compared with 56% in the telephone interviews. The majority (87%) of online respondents had completed tertiary education, compared with 77% of the telephone respondents. Male participants, on average, achieved higher knowledge (52%) and attitude scores (72%), in contrast to females (49% and 67%, respectively). Radio (71%) was the most cited source for COVID-19 information, followed by social media (63%). After controlling for sociodemographic variables, adaptive regression modelling revealed that survey mode achieved 100% importance for predicting knowledge and practice levels with regard to COVID-19.ConclusionsThe survey population demonstrated moderate COVID-19 knowledge, with significant differences between survey mode and educational level. Correct knowledge of COVID-19 was associated with appropriate practices in Maryland County. Generalisation of survey findings must be drawn carefully owing to the limitations of the sampling methods. Yet, given the differences in knowledge gaps between survey modes, sex, education, occupation and place of residence, it is recommended that information is tailored to different audiences.

Invoking health benefits to promote climate-friendly household behavior has three unique advantages: (i) health co-benefits accrue directly to the acting individual, they are "private goods" rather than public ones; (ii) the evidence base for, and magnitude of health co-benefits is well-established; and (iii) the idea of a healthy life-style is well-engrained in public discourse, much more so than that of a climate-friendly life-style. In previous research, assessing the influence of information on health effects on people’s motivation to adopt mitigation actions, health co-benefits for the individual were typically confounded with collective health co-benefits, for example from pollution reduction. The present research aims to overcome this limitation by providing information on individual health co-benefits that are unconditional on the actions of others (direct health co-benefits). We report effects of this kind of health information on stated willingness to adopt mitigation actions as well as on simulation-based carbon emission reductions in a pre-registered experimental setting among 308 households in 4 mid-size case-study cities in 4 European high-income countries: France, Germany, Norway and Sweden. For each mitigation action from the sectors food, housing, and mobility, half of the sample received the amount of CO2equivalents (CO2-eq) saved and the financial costs or savings the respective action generated. The other half additionally received information on direct health co-benefits, where applicable. For households receiving information on direct health co-benefits, we find a higher mean willingness to adopt food and housing actions, and a greater proportion very willing to adopt one or more mitigation actions (OR 1.86, 95% CI 1.1, 3.12); and a greater simulated reduction in overall carbon footprint: difference in percent reduction -2.70%, (95% CI -5.34, -0.04) overall and -4.45%, (95% CI -8.26, -0.64) for food. Our study is the first to show that providing information on strictly unconditional, individual health co-benefits can motivate households in high-income countries to adopt mitigation actions.

Background: Dengue fever persists as a major global disease burden, and may increase as a consequence of climate change. Along with other measures, research actions to improve diagnosis, surveillance, prevention, and predictive models are highly relevant. The European Commission funded the DengueTools consortium to lead a major initiative in these areas, and this review synthesises the outputs and findings of this work conducted from 2011 to 2016. Research areas: DengueTools organised its work into three research areas, namely [1] Early warning and surveillance systems; [2] Strategies to prevent dengue in children; and [3] Predictive models for the global spread of dengue. Research area 1 focused on case-studies undertaken in Sri Lanka, including developing laboratory-based sentinel surveillance, evaluating economic impact, identifying drivers of transmission intensity, evaluating outbreak prediction capacity and developing diagnostic capacity. Research area 2 addressed preventing dengue transmission in school children, with case-studies undertaken in Thailand. Insecticide-treated school uniforms represented an intriguing potential approach, with some encouraging results, but which were overshadowed by a lack of persistence of insecticide on the uniforms with repeated washing. Research area 3 evaluated potential global spread of dengue, particularly into dengue-naïve areas such as Europe. The role of international travel, changing boundaries of vectors, developing models of vectorial capacity under different climate change scenarios and strategies for vector control in outbreaks was all evaluated. Concluding remarks: DengueTools was able to make significant advances in methods for understanding and controlling dengue transmission in a range of settings. These will have implications for public health agendas to counteract dengue, including vaccination programmes. Outlook: Towards the end of the DengueTools project, Zika virus emerged as an unexpected epidemic in the central and southern America. Given the similarities between the dengue and Zika viruses, with vectors in common, some of the DengueTools thinking translated readily into the Zika situation.

RationaleGuidelines recommend pre-/post-bronchodilator spirometry for diagnosing COPD, but resource constraints limit the availability of spirometry in primary care in low- and middle-income countries. Although spirometry is the diagnostic gold standard, we shall assess alternative tools for settings without spirometry.MethodsA systematic literature review and meta-analysis was conducted, utilising Cochrane, CINAHL, Google Scholar, PubMed and Web of Science (search cut-off was May 01, 2020). Published studies comparing the accuracy of diagnostic tools for COPD with post-bronchodilator spirometry were considered. Studies without sensitivity/specificity data, without a separate validation sample and outside of primary care were excluded. Sensitivity, specificity and area under the curve (AUC) were assessed.ResultsOf 7578 studies, 24 were included (14 635 participants). Hand devices yielded a larger AUC than questionnaires. The meta-analysis included 17 studies and the overall AUC of micro-spirometers (0.84, 95% CI 0.80–0.89) was larger when compared to the COPD population screener (COPD-PS) questionnaire (0.77, 95% CI 0.63–0.85) and the COPD diagnostic questionnaire (CDQ) (0.72, 95% CI 0.64–0.78). However, only the difference between micro-spirometers and the CDQ was significant.ConclusionsThe CDQ and the COPD-PS questionnaire were approximately equally accurate tools. Questionnaires ensured testing of symptomatic patients, but micro-spirometers were more accurate. A combination could increase accuracy but was not evaluated in the meta-analysis.

BACKGROUND The impact of climate change on health, adaptation measures and health co-benefits of mitigation have not been taught as topics in conventional face-to-face courses, such as in stand-alone, accredited short courses or as modules in Masters or PhD-level courses. Educational technologies such as massive open online courses (MOOCs) have high potential to substantially accelerate the dissemination of knowledge on the nexus of climate change and health. We developed three MOOCs teaching on the link between climate change and health. OBJECTIVE We conducted an online survey study to evaluate instructor-to-learner interaction (ITI), instructor support (IS), instructor feedback (IF), learner-to-learner interaction (LLI), course content (CC), course structure (CS), information delivery technology (IDT), perceived effectiveness (PE), learner retention (LR), as well as self-reported learner retention (SRLR). What did participants learn? Who and how many registered from the global North and South? What was the completion rate and how does it compare to average completion rates of MOOCs? What is the impact of knowledge acquired? METHODS Participants of all three MOOCs were invited to a post online survey study or the three climate change and health MOOCs. The survey consisted mainly out of no/yes/other and free text questions, as well as five five-point Likert items. We collected demographic information about education, age, gender, country of origin and current place of living. RESULTS In total, the MOOCs had a reach of almost 7000 students worldwide. 188 students took part in the online survey, with the highest percentage of MOOC-survey participants from low-income countries. The MOOCs were seen as useful, especially with regards to their professional impact, their coverage of content and their up-to-dateness in the topic area of climate change and health. The francophone MOOC was found to have an extraordinarily high number of participants from lower-income- and low-and-middle-income countries. The primary motivation to join the MOOC was to gain knowledge and skills on the topic of climate change and health. CONCLUSIONS Health is a top priority for citizens worldwide, and our results show that (i) globally there is great interest in the topic of climate change and health and (ii) that the three MOOCs were adequate to teach a global and diverse audience in this topic, reaching even participants from resource-low countries. Therefore, MOOCs should be included in the discussion on how to disseminate knowledge and methodological expertise globally, as they are an effective mean to explain and teach about the complex links and dynamics between climate change and health.

Background Viral diseases transmitted via Aedes mosquitoes are on the rise, such as Zika, dengue, and chikungunya. Novel tools to mitigate Aedes mosquitoes-transmitted diseases are urgently needed. We tested whether commercially insecticide-impregnated school uniforms can reduce dengue incidence in school children. Methods We designed a cluster-randomised controlled trial in Thailand. The primary endpoint was laboratory-confirmed dengue infections. Secondary endpoints were school absenteeism; and impregnated uniforms’ 1-hour knock-down and 24 hour mosquito mortality as measured by standardised WHOPES bioassay cone tests at baseline and after repeated washing. Furthermore, entomological assessments inside classrooms and in outside areas of schools were conducted. Results We enrolled 1,811 pupils aged 6–17 from 5 intervention and 5 control schools. Paired serum samples were obtained from 1,655 pupils. In the control schools, 24/641 (3.7%) and in the intervention schools 33/1,014 (3.3%) students had evidence of new dengue infections during one school term (5 months). There was no significant difference in proportions of students having incident dengue infections between the intervention and control schools, with adjustment for clustering by school. WHOPES cone tests showed a 100% knock down and mortality of Aedes aegypti mosquitoes exposed to impregnated clothing at baseline and up to 4 washes, but this efficacy rapidly declined to below 20% after 20 washes, corresponding to a weekly reduction in knock-down and mosquito mortality by 4.7% and 4.4% respectively. Results of the entomological assessments showed that the mean number of Aedes aegypti mosquitoes caught inside the classrooms of the intervention schools was significantly reduced in the month following the introduction of the impregnated uniforms, compared to those collected in classrooms of the control schools (p = 0.04) Conclusions Entomological assessments showed that the intervention had some impact on the number of Aedes mosquitoes inside treatment schools immediately after impregnation and before insecticidal activity declined. However, there was no serological evidence of protection against dengue infections over the five months school term, best explained by the rapid washing-out of permethrin after 4 washes. If rapid washing-out of permethrin could be overcome by novel technological approaches, insecticide-treated clothes might become a potentially cost-effective and scalable intervention to protect against diseases transmitted by Aedes mosquitoes such as dengue, Zika, and chikungunya. Trial Registration ClinicalTrials.gov NCT01563640, Author Summary Viral diseases transmitted via Aedes mosquitoes are on the rise, such as Zika, dengue, and chikungunya. Novel tools to mitigate Aedes mosquitoes-transmitted diseases are urgently needed. We tested whether commercially available insecticide-impregnated school uniforms can reduce dengue incidence in school children. To test this hypothesis we designed a school based randomized controlled trial where we enrolled 1,811 school children aged 6–17. For study monitoring, we also measured the effect of the impregnated uniforms on the survival of Aedes mosquitoes based on a standard bioassay test called WHOPES cone test. Furthermore, we counted the number of Aedes mosquitoes in classrooms and outside areas of classrooms. In the control schools, 3.7% and in the intervention schools 3.3% of the students had evidence of new dengue infections during the 5 month long school term, which indicates that there was no protection against dengue infections despite the fact that the knockdown effect of the impregnated uniforms was very high in the laboratory. We also showed a significant reduction of Aedes mosquitoes in the classrooms of the intervention schools. So why did this not translate into clinical protection against dengue? We assume the reason was the rapid wash-out effect of permethrin. Despite the company’s claim that impregnated clothing would withstand up to 70 launderings, we found a rapid decline in permethrin efficacy already after 4 washes, with the efficacy to below 20% after 20 washes. If rapid washing-out of permethrin could be overcome by novel technological approaches, insecticide-treated clothes might become a potentially cost-effective and scalable intervention to protect against diseases transmitted by Aedes mosquitoes such as dengue, Zika, and chikungunya.

Background: It is now universally acknowledged that climate change constitutes a major threat to human health. At the same time, some of the measures to reduce greenhouse gas emissions, so-called climate change mitigation measures, have significant health co-benefits (e.g., walking or cycling more; eating less meat). The goal of limiting global warming to 1,5° Celsius set by the Conference of the Parties to the United Nations Framework Convention on Climate Change in Paris in 2015 can only be reached if all stakeholders, including households, take actions to mitigate climate change. Results on whether framing mitigation measures in terms of their health co-benefits increases the likelihood of their implementation are inconsistent. The present study protocol describes the transdisciplinary project HOPE (HOuseholds’ Preferences for reducing greenhouse gas emissions in four European high-income countries) that investigates the role of health co-benefits in households’ decision making on climate change mitigation measures in urban households in France, Germany, Norway and Sweden. Methods: HOPE employs a mixed-methods approach combining status-quo carbon footprint assessments, simulations of the reduction of households’ carbon footprints, and qualitative in-depth interviews with a subgroup of households. Furthermore, a policy analysis of current household oriented climate policies is conducted. In the simulation of the reduction of households’ carbon footprints, half of the households are provided with information on health co-benefits of climate change mitigation measures, the other half is not. Households’ willingness to implement the measures is assessed and compared in between-group analyses of variance. Discussion: This is one of the first comprehensive mixed-methods approaches to investigate which mitigation measures households are most willing to implement in order to reach the 1,5° target set by the Paris Agreement, and whether health co-benefits can serve as a motivator for households to implement these measures. The comparison of the empirical data with current climate policies will provide knowledge for tailoring effective climate change mitigation and health policies. Errata: Herrmann et al. Household preferences for reducing greenhouse gas emissions in four European high-income countries: Does health information matter? A mixed-methods study protocol, BMC Public Health (2017) 17:679 DOI 10.1186/s12889-017-4676-yErrata: Herrmann et al. Household preferences for reducing greenhouse gas emissions in four European high-income countries: Does health information matter? A mixed-methods study protocol, BMC Public Health (2017) 17:846 DOI 10.1186/s12889-017-4861-z

BACKGROUND: Dengue is an important neglected tropical disease, with more than half of the world's population living in dengue endemic areas. Good understanding of dengue transmission sites is a critical factor to implement effective vector control measures. METHODS: A cohort of 1,811 students from 10 schools in rural, semi-rural and semi-urban Thailand participated in this study. Seroconversion data and location of participants' residences and schools were recorded to determine spatial patterns of dengue infections. Blood samples were taken to confirm dengue infections in participants at the beginning and the end of school term. Entomological factors included a survey of adult mosquito density using a portable vacuum aspirator during the school term and a follow up survey of breeding sites of Aedes vectors in schools after the school term. Clustering analyses were performed to detect spatial aggregation of dengue infections among participants. RESULTS: A total of 57 dengue seroconversions were detected among the 1,655 participants who provided paired blood samples. Of the 57 confirmed dengue infections, 23 (40.0%) occurred in students from 6 (6.8%) of the 88 classrooms in 10 schools. Dengue infections did not show significant clustering by residential location in the study area. During the school term, a total of 66 Aedes aegypti mosquitoes were identified from the 278 mosquitoes caught in 50 classrooms of the 10 schools. In a follow-up survey of breeding sites, 484 out of 2,399 water containers surveyed (20.2%) were identified as active mosquito breeding sites. DISCUSSION AND CONCLUSION: Our findings suggest that dengue infections were clustered among schools and among classrooms within schools. The schools studied were found to contain a large number of different types of breeding sites. Aedes vector densities in schools were correlated with dengue infections and breeding sites in those schools. Given that only a small proportion of breeding sites in the schools were subjected to vector control measures (11%), this study emphasizes the urgent need to implement vector control strategies at schools, while maintaining efforts at the household level.

objective The objective is to investigate the effect of malaria control with insecticide-treated mosquito nets (ITNs) regarding possible higher mortality in children protected during early infancy, due to interference with immunity development, and to assess long-term effects on malaria prevalence and morbidity. methods Between 2000 and 2002, a birth cohort was enrolled in 41 villages of a malaria holoendemic area in north-western Burkina Faso. All neonates (n = 3387) were individually randomised to ITN protection from birth (group A) vs. ITN protection from age 6 months (group B). Primary outcome was all-cause mortality. In 2009, a survey took place in six sentinel villages, and in 2010, a census was conducted in all study villages. results After a median follow-up time of 8.3 years, 443 ⁄ 3387 (13.1%) children had migrated out of the area and 484 ⁄ 2944 (16.4%) had died, mostly at home. Long-term compliance with ITN protection was good. There were no differences in mortality between study groups (248 deaths in group A, 236 deaths in group B; rate ratio 1.05, 95% CI: 0.889–1.237, P = 0.574). The survey conducted briefly after the rainy season in 2009 showed that more than 80% of study children carried asexual malaria parasites and up to 20% had clinical malaria. conclusion Insecticide-treated mosquito net protection in early infancy is not a risk factor for mortality. Individual ITN protection does not sufficiently reduce malaria prevalence in high-transmission areas. Achieving universal ITN coverage remains a major challenge for malaria prevention in Africa.

Objective For measurement of progress towards the Millennium Development Goal (MDG) 1, reliable data on nutrition indicators of specific countries are essential. Malnutrition is also the main determinant for childhood mortality, which is addressed in MDG 4. Methods In the health and demographic surveillance area of Kossi Province in north-western Burkina Faso, nutritional parameters were compared in two cohorts of young children of the same age range from eight villages. Surveys took place in June and December of the year 1999 and 2009. A multivariate model was used to control for confounding variables. Results For the 1999 study, data were analysed for 179 and 197 children who took part in the June and December survey respectively. In 2009, corresponding data were analysed for 460 and 409 children. Prevalence of underweight was highest in December 1999 (42.6%) and lowest in December 2009 (34.1%). After adjustment for age, sex and village, there was a slight but not always significant improvement in the z-scores of weight-for-age, weight-for-length, length-for-age, and mid-arm circumference over time. Conclusions The findings from this study confirm the still unacceptable high prevalence of malnutrition in young children of rural sub-Saharan Africa (SSA). Progress in the reduction of malnutrition remains slow on this continent making it rather unlikely that the corresponding MDGs will be achieved. Large-scale multi-sectoral community-based interventions are urgently needed for a sustainable improvement of child health in SSA. Objectif: Pour la mesure des progres realises vers l’Objectif du Millenaire pour le Developpement (OMD) 1, des donnees fiables sur les indicateurs de nutrition specifiques des pays sont essentielles. La malnutrition est egalement le principal determinant de la mortalite infantile, qui est aborde dans l’OMD 4. Methodes: Dans la zone de surveillance demographique et de sante de la province de Kossi, dans le nord-ouest du Burkina-Faso, les parametres nutritionnels ont ete compares dans deux cohortes de jeunes enfants de la meme tranche d’âge provenant de huit villages. Les enquetes ont eu lieu en juin et decembre 1999 et 2009. Un modele multivarie a ete utilise pour controler pour les variables confusionnelles. Resultats: Pour l’etude de 1999, les donnees ont ete analysees pour 179 et 197 enfants qui ont participe respectivement a l’enquete de juin et decembre. En 2009, les donnees correspondantes ont ete analysees pour 460 et 409 enfants. La prevalence de l’insuffisance ponderale etait la plus elevee en decembre 1999 (42,6%) et la plus faible en decembre 2009 (34,1%). Apres ajustement pour l’âge, le sexe et le village, il y avait une legere amelioration, mais pas toujours significative dans les z-scores du poids pour l’âge, le poids pour la taille, la taille pour l’âge et le perimetre brachial, au cours le temps. Conclusions: Les resultats de cette etude confirment la prevalence toujours elevee et inacceptable de la malnutrition chez les jeunes enfants des regions rurales de l’Afrique subsaharienne. Les progres realises dans la reduction de la malnutrition restent lents sur ce continent, rendant plutot improbable l’atteinte des OMD correspondants. Des interventions multisectorielles a grande echelle basees sur la communaute sont urgemment necessaires pour une amelioration durable de la sante de l’enfance en Afrique subsaharienne. Objetivo: Para medir el progreso hacia el Objetivo de Desarrollo del Milenio (ODM) 1, es esencial contar con datos fiables sobre los indicadores nutricionales para paises especificos. La desnutricion es tambien el principal determinante de mortalidad infantil, del cual se ocupa el ODM 4. Metodos: En el area de seguimiento sanitario y demografico de la provincia de Kossi, al noroeste de Burkina Faso, se compararon los parametros nutricionales para dos cohortes de ninos pequenos, con el mismo rango de edad, pertenecientes a ocho poblados. Las encuestas se realizaron en Junio y Diciembre de los anos 1999 y 2009. Se utilizo un modelo multivariado para controlar variables de confusion. Resultados: Se analizaron datos del estudio de 1999 de 179 y 197 ninos, que participaron en las encuestas de Junio y Diciembre respectivamente. Para el 2009 se analizaron datos correspondientes a 460 y 409 ninos. La prevalencia de bajo peso era mayor en Diciembre de 1999 (42.6%) y menor en Diciembre del 2009 (34.1%). Despues de ajustar para edad, sexo y poblacion, habia una pequena pero no siempre significativa mejora en los z-scores de peso-por-edad, peso-por-altura, altura-por-edad, y circunferencia del brazo a lo largo del tiempo. Conclusiones: Los hallazgos de este estudio confirman que la desnutricion continua teniendo una prevalencia inaceptablemente alta entre ninos pequenos de zonas rurales del Africa subsahariana. El progreso de reduccion de la desnutricion continua siendo lento en este continente, lo cual hace que sea improbable que los ODM correspondientes puedan ser alcanzados. Se requiere urgentemente realizar intervenciones a gran escala, multisectoriales y basadas en la comunidad, para conseguir una mejora sostenible en la salud infantil en Africa subsahariana.

The current global geographic distribution of malaria results from a complex interaction between climatic and non-climatic factors. Over the past century, socio-economic development and public health measures have contributed to a marked contraction in the distribution of malaria. Previous assessments of the potential impact of global changes on malaria have not quantified the effects of non-climate factors. In this paper, we describe an empirical model of the past, present and future-potential geographic distribution of malaria which incorporates both the effects of climate change and of socio-economic development. A logistic regression model using temperature, precipitation and gross domestic product per capita (GDPpc) identifies the recent global geographic distribution of malaria with high accuracy (sensitivity 85% and specificity 95%). Empirically, climate factors have a substantial effect on malaria transmission in countries where GDPpc is currently less than US$20,000. Using projections of future climate, GDPpc and population consistent with the IPCC A1B scenario, we estimate the potential future population living in areas where malaria can be transmitted in 2030 and 2050. In 2050, the projected population at risk is approximately 5.2 billion when considering climatic effects only, 1.95 billion when considering the combined effects of GDP and climate, and 1.74 billion when considering GDP effects only. Under the A1B scenario, we project that climate change has much weaker effects on malaria than GDPpc increase. This outcome is, however, dependent on optimistic estimates of continued socioeconomic development. Even then, climate change has important effects on the projected distribution of malaria, leading to an increase of over 200 million in the projected population at risk.

Introduction The global spread and the increased frequency and magnitude of epidemic dengue in the last 50 years underscore the urgent need for effective tools for surveillance, prevention, and control. This review aims at providing a systematic overview of what predictors are critical and which spatial and spatio-temporal modeling approaches are useful in generating risk maps for dengue. Methods A systematic search was undertaken, using the PubMed, Web of Science, WHOLIS, Centers for Disease Control and Prevention (CDC) and OvidSP databases for published citations, without language or time restrictions. A manual search of the titles and abstracts was carried out using predefined criteria, notably the inclusion of dengue cases. Data were extracted for pre-identified variables, including the type of predictors and the type of modeling approach used for risk mapping. Results A wide variety of both predictors and modeling approaches was used to create dengue risk maps. No specific patterns could be identified in the combination of predictors or models across studies. The most important and commonly used predictors for the category of demographic and socio-economic variables were age, gender, education, housing conditions and level of income. Among environmental variables, precipitation and air temperature were often significant predictors. Remote sensing provided a source of varied land cover data that could act as a proxy for other predictor categories. Descriptive maps showing dengue case hotspots were useful for identifying high-risk areas. Predictive maps based on more complex methodology facilitated advanced data analysis and visualization, but their applicability in public health contexts remains to be established. Conclusions The majority of available dengue risk maps was descriptive and based on retrospective data. Availability of resources, feasibility of acquisition, quality of data, alongside available technical expertise, determines the accuracy of dengue risk maps and their applicability to the field of public health. A large number of unknowns, including effective entomological predictors, genetic diversity of circulating viruses, population serological profile, and human mobility, continue to pose challenges and to limit the ability to produce accurate and effective risk maps, and fail to support the development of early warning systems. Electronic supplementary material The online version of this article (doi:10.1186/1476-072X-13-50) contains supplementary material, which is available to authorized users.

Seawater and plankton samples were collected over a period of 17 months from November 1998 to March 2000 along the coast of Peru. Total DNA was extracted from water and from plankton grouped by size into two fractions (64 μm to 202 μm and >202 μm). All samples were assayed for Vibrio cholerae , V. cholerae O1, V. cholerae O139, and ctxA by PCR. Of 50 samples collected and tested, 33 (66.0%) were positive for V. cholerae in at least one of the three fractions. Of these, 62.5% ( n = 32) contained V. cholerae O1; ctxA was detected in 25% ( n = 20) of the V. cholerae O1-positive samples. None were positive for V. cholerae O139. Thus, PCR was successfully employed in detecting toxigenic V. cholerae directly in seawater and plankton samples and provides evidence for an environmental reservoir for this pathogen in Peruvian coastal waters.

To investigate if the first national insecticide-treated bed-net campaign in Burkina Faso, done in 2010, was followed by a decrease in childhood malaria in a district with high baseline transmission of the disease.We obtained data on the prevalence of Plasmodium falciparum parasitaemia in children aged 2 weeks to 36 months from malaria surveys in 2009 and 2011. We assessed morbidity in children younger than 5 years by comparing data from the Nouna health district's health management information system before and after the campaign in 2010. We analysed mortality data from 2008 to 2012 from Nouna's health and demographic surveillance system.The bed-net campaign was associated with an increase in the reported use of insecticide-treated nets. In 2009, 73% (630/869) of children reportedly slept under nets. In 2011, 92% (449/487) did. The campaign had no effect on the proportion of young children with P. falciparum parasitaemia after the rainy season; 52% (442/858) in 2009 and 53% (263/499) in 2011. Cases of malaria increased markedly after the campaign, as did the number of children presenting with other diseases. The campaign was not associated with any changes in child mortality.The 2010 insecticide-treated net campaign in Burkina Faso was not associated with a decrease in care-seeking for malaria or all-cause mortality in children younger than 5 years. The most likely explanation is the high coverage of nets in the study area before the campaign which could have had an effect on mosquito vectors, limiting the campaign's impact.Étudier si la première campagne nationale visant à utiliser des moustiquaires imprégnées d'insecticide au Burkina Faso, menée en 2010, a été suivie d'une baisse des cas de paludisme infantile dans un district ayant un taux élevé de transmission de la maladie.Nous nous sommes procuré des données sur la prévalence de la parasitémie deLa campagne pour l'utilisation de moustiquaires a été associée à une augmentation de l'utilisation de moustiquaires imprégnées d'insecticide. En 2009, d'après l'enquête menée, 73% des enfants (630/869) dormaient sous une moustiquaire. En 2011, ils étaient 92% (449/487). La campagne n'a pas eu d'effet sur la proportion de jeunes enfants présentant une parasitémie deLa campagne de 2010 pour l'utilisation de moustiquaires imprégnées d'insecticide au Burkina Faso n'a pas été associée à une diminution des consultations pour paludisme ou de la mortalité, toutes causes confondues, chez les enfants de moins de 5 ans. L'explication la plus probable est liée au taux élevé d'utilisation de moustiquaires dans la zone étudiée avant la campagne, qui pourrait avoir eu un effet sur les moustiques vecteurs de la maladie et avoir limité l'impact de la campagne.Investigar si la primera campaña nacional de mosquiteros tratados con insecticida en Burkina Faso, que se llevó a cabo en 2010, tuvo como resultado un descenso del paludismo infantil en un distrito con una referencia elevada de transmisión de la enfermedad.Se obtuvieron datos sobre la prevalencia de parasitemia porLa campaña de distribución de mosquiteros se relacionó con un aparente aumento del uso de redes tratadas con insecticida. En 2009, aparentemente el 73% (630/869) de los niños dormía bajo mosquiteros. En 2011, lo hacía el 92% (449/487). La campaña no tuvo efecto en la proporción de niños pequeños con parasitemia porLa campaña de distribución de mosquiteros tratados con insecticida realizada en 2010 en Burkina Faso no estuvo relacionada con un descenso en la atención médica relacionada con la malaria o la mortalidad a causa de la misma en niños menores de 5 años. La explicación más lógica es la gran cobertura de redes en el área del estudio antes de la campaña, lo que podría haber tenido un efecto en los mosquitos vectores, limitando el impacto de la campaña.استقصاء إذا ما تبع الحملة القومية الأولى لاستخدام الناموسية المعالجة بمبيد حشري في بوركينا فاصو، والتي تم تنفيذها في عام 2010، أي انخفاض في معدل الإصابة بالملاريا عند الأطفال في إحدى المناطق التي تتسم بارتفاع قاعدة انتشار المرض.حصلنا على بيانات عن انتشار التسمم الدموي بطفيلارتبطت حملة استخدام الناموسية بزيادة ما أمكن تسجيله من استخدام الناموسيات المعالجة بالمبيد الحشري. ووفقًا لما تم رصده، فقد بلغت نسبة الأطفال الذين ناموا تحت الناموسية 73% (630/869) في عام 2009، بينما بلغت 92% (449/487) في عام 2011. ولم تؤثر الحملة على نسبة الأطفال الصغار المصابين بالتسمم الدموي بطفيللم ترتبط حملة استخدام الناموسية المعالجة بالمبيد الحشري التي تم تنفيذها في عام 2010 في بوركينا فاصو بانخفاض طلب الرعاية الصحية فيما يتعلق بالملاريا أو بمعدل الوفيات لجميع الأسباب في الأطفال الذين تقل أعمارهم عن خمس سنوات. والتفسير الأرجح لذلك هو ارتفاع مستوى التغطية للناموسيات قبل الحملة في المنطقة التي خضعت للدراسة، مما أثَّر على البعوض الناقل للمرض، وأدى إلى الحد من تأثير الحملة.旨在调查布基纳法索在 2010 年展开的第一次全国经杀虫剂处理的蚊帐运动之后，高基线疾病传播地区的儿童疟疾是否减少。.我们从 2009 和 2011 年的疟疾调查中获取了两周到 36 个月大的儿童感染恶性疟原虫寄生虫血症的患病率数据。我们通过比较 2010 年开展该运动前后努纳卫生地区的卫生管理信息系统中的数据，评估了 5 岁以下儿童的死亡率。我们分析了努纳卫生和人口监测系统中 2008 年到 2012 年间的数据。.蚊帐运动与报道的经杀虫剂处理的蚊帐使用量增长相关。据报道，2009 年，73% (630/869) 的儿童睡在蚊帐中。2011 年，92% (449/487) 的儿童睡在蚊帐中。该运动对雨季后感染恶性疟原虫寄生虫血症的儿童比例没有影响；2009 年该比例为 52% (442/858)，2011 年则为 53% (263/499)。该运动开展后，疟疾病例显著增长，同时感染其它疾病的儿童数量也显著增长。该运动与儿童死亡率的变化毫无关联。.布基纳法索在 2010 年开展的经杀虫剂处理的蚊帐运动与 5 岁以下儿童的疟疾求医行为或全因死亡率的降低不相关。最合理的解释是，在该运动开展前，蚊帐在研究区域的高使用率对蚊虫媒介已产生影响，因此使该运动的影响受到限制。.Выяснить, снизилась ли частота заболевания детей малярией в регионе с высоким базовым уровнем передачи этой инфекции после того, как в 2010 году в Буркина-Фасо была проведена первая национальная кампания по обработке надкроватных сеток инсектицидами.Мы получили данные о частоте случаев паразитемии, вызваннойКампания по обработке сеток сопровождалась ростом числа сообщений об использовании надкроватных сеток, обработанных инсектицидами. По данным отчетов, в 2009 году 73% детей (630 из 869) спали под сетками. В 2011 году их доля составила 92% (449 из 487). Кампания не повлияла на долю малолетних детей, зараженных паразитомПроведенная в Буркина-Фасо в 2010 году кампания по обработке надкроватных сеток инсектицидами не привела к снижению частоты заболевания малярией с обращением родителей за медицинской помощью. Эта кампания также не ассоциировалась со снижением смертности по различным причинам среди детей в возрасте до 5 лет. Наиболее вероятной причиной такого результата может быть тот факт, что в зоне проведения исследования и до начала кампании наблюдался высокий уровень использования надкроватных сеток, что могло повлиять на векторы распространения комаров и ограничить эффект от кампании.

Background This study aims to explore the use of traditional medicines to cope with climate sensitive diseases in areas vulnerable to climate change. We assessed the extent to which traditional or alternative medicines were used for the treatment of the climate sensitive diseases by villagers as part of their health-coping strategies. Methods The study deployed a mixed-method research design to know the health-coping strategies of the people in a resource-poor setting. A cross sectional study was conducted from September 2010 to March 2011 among 450 households selected randomly in the districts of Rajshahi and Khulna, Bangladesh. The elder males or females of each household were interviewed. For qualitative methods, twelve focus group discussions (six with females and six with males) and fifteen key informant interviews were conducted by the research team, using interview guidelines on the use of traditional medicine. Results Univariate analysis showed that the use of traditional medicines has increased among community members of all socio-economic and demographic backgrounds. Due to the increased incidence of disease and sickness respondents had to increase the use of their cultural means to cope with adverse health situations. Conclusions A systematic collection of knowledge on the use of traditional medicines to cope with climate-sensitive diseases can help the adaptation of communities vulnerable to climate change. In addition it can be instrumental in creating a directory of traditional medicine components used for specific diseases and highlight the effectiveness and relevance of traditional medicines as health-coping strategies. This may be useful for policymakers, researchers, and development partners to adapt existing health care policy in resource-limited contexts. It may also encourage WHO, national and international institutions, such as pharmaceutical companies, to carry out research investigating the effectiveness of these traditional medicines and integrate them with modern medicine. Overall, it could increase the health coping capacity of people in a resource-poor setting and contribute to their adaptation capabilities.

Insecticide-treated mosquito nets (ITNs) are an essential tool of the Roll Back Malaria strategy. An increasing number of African countries have embarked on mass distribution campaigns of long-lasting insecticide-treated nets (LLINs) with the ultimate goal of universal coverage. Such a national campaign with the goal of one ITN for every two people has been conducted in Burkina Faso in 2010. Our aim was to assess the coverage and equity effect of the universal distribution campaign of LLINs in Burkina Faso and to identify determinants of ITN ownership across households after the campaign. We evaluated its effects through comparison of data from two household surveys conducted in early 2010 (before the campaign) and early 2011 (after the campaign) on a representative rural district in north-western Burkina Faso. Data were collected on household characteristics (including socio-economic status) and ITN ownership. We used concentration curves and indices to compare ITN coverage indicators before and after the campaign and multilevel multivariate logistic regression to estimate factors associated with achievement of the universal coverage target in 2011. The survey included 1106 households in 2010 and 1094 in 2011. We found that the proportion of households with at least one ITN increased from 59% before the campaign to 99% afterwards, whereas the concentration index dropped from 0.087 (standard error (SE): 0.014) to 0.002 (SE: 0.002). Fifty-two per cent of households reached the target of one ITN for every two people per household, with the relevant concentration index at -0.031 (SE: 0.016). Eighty-six per cent of households owned at least one ITN for every three people. The main characteristics significantly associated with the targeted intra-household coverage were family size and distance to the health centre but not socio-economic status. In conclusion, despite not having fully met its target, the national LLIN campaign achieved a high level of coverage and fostered equity.

Background: In Sub Saharan Africa malaria remains one of the major health problems and its control represents an important public health measure. Integrated malaria control comprises the use of impregnated mosquito nets and indoor residual spraying. The use of drugs to treat patients can create additional pressure on the equation of malaria transmission. Vector control may target the adult mosquitoes or their aquatic larval stages. Biological larvicides such as Bacillus thuringiensis israelensis (Bti) represent a promising approach to support malaria control programs by creating additional pressure on the equation of malaria transmission. Methods: In this study we examined the efficacy of a water-dispersible granule formulation (WDG) of the biological larvicide Bti (VectoBac®) against wild Anopheles spp. larvae. Different concentrations of the larvicide were tested in standardized plastic tubs in the field against untreated controls. In weekly intervals tubs were treated with fixed concentrations of larvicide and the percentage reduction of larvae and pupae was calculated. Results: All used concentrations successfully killed 100 percent of the larvae within 24 hours, while the higher concentrations showed a slightly prolonged residual effect. Natural reconolization of larvae took place after two and three days respectively, late instar larvae were not found before 5 days after treatment. For the higher concentrations, up to three days no new larvae were found, implicating that the residual effect of WDG in tropical conditions is approximately one to two days. The overall pupae reduction in treated tubs was 98.5%. Conclusions: Biological larviciding with Bti can be a promising, additional tool in the fight against malaria in Africa. Environmental particularities in tropical Africa, first and foremost the rapid development of mosquitoes from oviposition to imago have to be taken into account before implementing such counter measures in national or international vector control programs. Nonetheless biological larviciding seems to be an appropriate measure for selected conditions, offering a significant contribution to the future of malaria control.

Background: Dengue-related illness is a leading cause of hospitalization and death, particularly among children. Practical, acceptable and affordable measures are urgently needed to protect this age group. Schools where children spend most of their day is proposed as an ideal setting to implement preventive strategies against day-biting Aedes mosquitoes. The use of insecticide-treated school uniforms is a promising strategy currently under investigation. Methods: Using a decision-analytic model, we evaluated the cost-effectiveness of the use of insecticide-treated school uniforms for prevention of dengue, compared with a ‘‘do-nothing’’ alternative, in schoolchildren from the societal perspective. We explored how the potential economic value of the intervention varied under various scenarios of intervention effectiveness and cost, as well as dengue infection risk in school-aged children, using data specific to Thailand. Results: At an average dengue incidence rate of 5.8% per year in school-aged children, the intervention was cost-effective (ICER#$16,440) in a variety of scenarios when the intervention cost per child was $5.3 or less and the intervention effectiveness was 50% or higher. In fact, the intervention was cost saving (ICER,0) in all scenarios in which the intervention cost per child was $2.9 or less per year and the intervention effectiveness was 50% or higher. The results suggested that this intervention would be of no interest to Thai policy makers when the intervention cost per child was $10.6 or higher per year regardless of intervention effectiveness (ICER.$16,440). Conclusions: Our results present the potential economic value of the use of insecticide-treated uniforms for prevention of dengue in schoolchildren in a typical dengue endemic setting and highlight the urgent need for additional research on this intervention. Published version

Background Among the many challenges faced by the people of Bangladesh, the effects of climate change are discernibly threatening, impacting on human settlement, agricultural production, economic development, and human health. Bangladesh is a low-income country with limited resources; its vulnerability to climate change has influenced individuals to seek out health coping strategies. The objectives of the study were to explore the different strategies/measures people employ to cope with climate sensitive diseases and sickness. Methods A cross-sectional study was conducted among 450 households from Rajshahi and Khulna districts of Bangladesh selected through multi-stage sampling techniques, using a semi-structured questionnaire supplemented by 12 focus group discussions and 15 key informant interviews. Results Respondents applied 22 types of primary health coping strategies to prevent climate related diseases and sickness. To cope with health problems, 80.8% used personal treatment experiences and 99.3% sought any treatments available at village level. The percentage of respondents that visited unqualified health providers to cope with climate induced health problems was quite high, namely 92.7% visited village doctors, 75.9% drug stores, and 67.3% self-medicated. Ninety per cent of the respondents took treatment from unqualified providers as their first choice. Public health facilities were the first choice of treatment for only 11.0% of respondents. On average, every household spent Bangladesh Currency Taka 9,323 per year for the treatment of climate sensitive diseases and sickness. Only 46% of health expenditure was managed from their savings. The rest, 54% expenditure, was supported by using 24 different sources, such as social capital and the selling of family assets. The rate of out-of-pocket payment was almost 100%. Conclusion People are concerned about climate induced diseases and sickness and sought preventive as well as curative measures to cope with health problems. The most common and widely used climate health coping strategies among the respondents included self-medicating and seeking the health service of unqualified private health care providers. Per family spending to cope with such health problems is expensive and completely based on out of pocket payment. There is no fund pooling, community funding or health insurance program in rural areas to support the health coping of the people. Policies are needed to reduce out-of-pocket payment, to improve the quality of the unqualified providers and to extend public health services at rural areas and support climate related health coping. Collection of such knowledge on climate related health coping strategies can allow researchers to study any specific issue on health coping, and policy makers to initiate effective climate related health coping strategies for climate vulnerable people.

We conducted the first population-based impact assessment of a financing policy introduced in Burkina Faso in 2007 on women's access to delivery services. The policy offers an 80 per cent subsidy for facility-based delivery. We collected information on delivery in five repeated cross-sectional surveys carried out from 2006 to 2010 on a representative sample of 1050 households in rural Nouna Health District. Over the 5 years, the proportion of facility-based deliveries increased from 49 to 84 per cent (P

Dengue fever is the most important viral vector-borne disease with ~50 million cases per year globally. Previous estimates of the potential effect of global climate change on the distribution of vector-borne disease have not incorporated the effect of socioeconomic factors, which may have biased the results. We describe an empirical model of the current geographic distribution of dengue, based on the independent effects of climate and gross domestic product per capita (GDPpc, a proxy for socioeconomic development). We use the model, along with scenario-based projections of future climate, economic development, and population, to estimate populations at risk of dengue in the year 2050. We find that both climate and GDPpc influence the distribution of dengue. If the global climate changes as projected but GDPpc remained constant, the population at risk of dengue is estimated to increase by about 0.28 billion in 2050. However, if both climate and GDPpc change as projected, we estimate a decrease of 0.12 billion in the population at risk of dengue in 2050. Empirically, the geographic distribution of dengue is strongly dependent on both climatic and socioeconomic variables. Under a scenario of constant GDPpc, global climate change results in a modest but important increase in the global population at risk of dengue. Under scenarios of high GDPpc, this adverse effect of climate change is counteracted by the beneficial effect of socioeconomic development.

The objective is to investigate the effect of malaria control with insecticide-treated mosquito nets (ITNs) regarding possible higher mortality in children protected during early infancy, due to interference with immunity development, and to assess long-term effects on malaria prevalence and morbidity.Between 2000 and 2002, a birth cohort was enrolled in 41 villages of a malaria holoendemic area in north-western Burkina Faso. All neonates (n = 3387) were individually randomised to ITN protection from birth (group A) vs. ITN protection from age 6 months (group B). Primary outcome was all-cause mortality. In 2009, a survey took place in six sentinel villages, and in 2010, a census was conducted in all study villages.After a median follow-up time of 8.3 years, 443/3387 (13.1%) children had migrated out of the area and 484/2944 (16.4%) had died, mostly at home. Long-term compliance with ITN protection was good. There were no differences in mortality between study groups (248 deaths in group A, 236 deaths in group B; rate ratio 1.05, 95% CI: 0.889-1.237, P = 0.574). The survey conducted briefly after the rainy season in 2009 showed that more than 80% of study children carried asexual malaria parasites and up to 20% had clinical malaria.Insecticide-treated mosquito net protection in early infancy is not a risk factor for mortality. Individual ITN protection does not sufficiently reduce malaria prevalence in high-transmission areas. Achieving universal ITN coverage remains a major challenge for malaria prevention in Africa.

Dengue fever is a mosquito-borne viral disease estimated to cause about 230 million infectionsworldwide every year, of which 25,000 are fatal. Global incidence has risen rapidly in recent decades with some 3.6 billion people, over half of the world’s population, now at risk, mainly in urban centres of the tropics and subtropics. Demographic and societal changes, in particular urbanization, globalization, and increased international travel, are major contributors to the rise in incidence and geographic expansion of dengue infections. Major research gaps continue to hamper the control of dengue. The European Commission launched a call under the 7th Framework Programme with the title of ‘Comprehensive control of Dengue fever under changing climatic conditions’. Fourteen partners from several countries in Europe, Asia, and South America formed a consortium named ‘DengueTools’ to respond to the call to achieve better diagnosis, surveillance, prevention, and predictive models and improve our understanding of the spread of dengue to previously uninfected regions (including Europe) in the context of globalization and climate change. The consortium comprises 12 work packages to address a set of research questions in three areas: Research area 1: Develop a comprehensive early warning and surveillance system that has predictive capability for epidemic dengue and benefits from novel tools for laboratory diagnosis and vector monitoring. Research area 2: Develop novel strategies to prevent dengue in children. Research area 3: Understand and predict the risk of global spread of dengue, in particular the risk of introduction and establishment in Europe, within the context of parameters of vectorial capacity, global mobility, and climate change. In this paper, we report on the rationale and specific study objectives of ‘DengueTools’. DengueTools is funded under the Health theme of the Seventh Framework Programme of the European Community, Grant Agreement Number: 282589 Dengue Tools.Keywords: dengue; dengue control; dengue diagnostics; economic evaluation; entomology; climate change; early warning systems; risk mapping; surveillance; globalization(Published: 22 March 2012)Citation: Glob Health Action 2012, 5: 17273 - DOI: 10.3402/gha.v5i0.17273

Background Roll Back Malaria (RBM) interventions such as insecticide-treated mosquito nets (ITN) and artemisinin-based combination therapy (ACT) have become implemented with different velocities in the endemic countries of sub-Saharan Africa (SSA) in recent years. There is conflicting evidence on how much can be achieved under real life conditions with the current interventions in the highly endemic savannah areas of SSA. Methods The study took place in a rural area of north-western Burkina Faso, which was defined as holoendemic in 1999. Clinical and parasitological data were compared in two cohorts of young children of the same age range from eight villages. Surveys took place in June and December of the year 1999 and 2009 respectively. Results Prevalence of mosquito net use increased from 22% in 1999 to 73% in 2009, with the majority of nets being ITNs in 2009. In 2009, P. falciparum prevalence was significantly lower compared to 1999 (overall reduction of 22.8%). Conclusions The reduction in malaria prevalence in young children observed between 1999 and 2009 in a rural and formerly malaria holoendemic area of Burkina Faso is likely attributable to the increase in ITN availability and utilization over time.

The Nouna Health and Demographic Surveillance System (HDSS) is located in rural Burkina Faso and has existed since 1992. Currently, it has about 78,000 inhabitants. It is a member of the International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH), a global network of memberswho conducts longitudinal health and demographic evaluation of populations in low- and middle-income countries. The health facilities consist of one hospital and 13 basic health centres (locally known as CSPS). The Nouna HDSS has been used as a sampling frame for numerous studies in the fields of clinical research, epidemiology, health economics, and health systems research. In this paper we review some of the main findings, and we describe the effects that almost 20 years of health research activities have shown in the population in general and in terms of the perception, economic implications, and other indicators. Longitudinal data analyses show that childhood, as well as overall mortality, has significantly decreased over the observation period 1993-2007. The under-five mortality rate dropped from about 40 per 1,000 person-years in the mid- 1990s to below 30 per 1,000 in 2007. Further efforts are needed to meet goal four of the Millennium Development Goals, which is to reduce the under-five mortality rate by two-thirds between 1990 and 2015. Keywords: epidemiology; Burkina Faso; Africa; INDEPTH network; public health; under-five mortality; malaria; malnutrition; health seeking behavior (Published: 14 September 2010) Citation: Global Health Action 2010, 3: 5284 - DOI: 10.3402/gha.v3i0.5284

Background The overall incidence of tuberculosis (TB) in Western Europe has been declining since the 19th Century. However, immigrant sub-groups from high-prevalence countries are slowing down this trend. The aim of this study was to describe how immigration influences TB transmission in Germany. For that we prospectively investigated the dynamics of TB transmission between TB high-prevalence immigrant and TB low-prevalence local populations with molecular epidemiological methods and conventional contact investigations. Besides, we assessed transmission in relation to social mixing using an innovative tool that measures the integration of immigrants into the local social environment. Methods A prospective study of confirmed culture positive cases of pulmonary TB and their contacts was carried out in a German federal state from 2003 to 2005. Data for the study included: 1) case data routinely collected by the local public health staff and transmitted to the state health office and the national surveillance centre, 2) a study questionnaire designed to capture social interactions of relevance for TB transmission and 3) molecular genotyping data (IS6110 DNA fingerprint and spoligotyping). The proportion of German cases caused by foreign-born cases, and vice versa, was estimated and an integration index was computed using a selected set of questions from the study questionnaire. Results A total of 749 cases of culture-positive pulmonary tuberculosis voluntarily enrolled in the study, representing 57.8% of all registered cases diagnosed over the study period. Data that included study questionnaire and DNA fingerprinting were available for 41% (n = 308) of the study participants. Forty-seven clusters, defined as a least two cases infected by the same TB strains, were identified by molecular methods and included 132 (17%) of the study participants. Epidemiological links were identified for 28% of the clusters by conventional epidemiological data. In mixed clusters, defined as clusters including German and foreign-born individuals, the probability of cases to be caused by foreign-born cases was estimated at 18.3%. We observed a trend to mixed clusters with increasing time spent by immigrants in the host country. This group also presented comparatively higher integration indexes than immigrants in immigrant-only clusters. Conclusion Our results confirm the findings of other studies that there is no significant TB transmission from TB high-prevalence immigrant to TB low-prevalence autochthonous population. This may be explained by the good performance of tuberculosis screening programmes for certain groups arriving in Germany from high- prevalence countries, by a low degree of mixing of immigrants with the local population or by a combination of both.

Background Effective and timely treatment is an essential aspect of malaria control, but remains a challenge in many parts of sub-Saharan Africa. The objective of this study was to describe young children's access to malaria treatment in Nouna Health District, Burkina Faso. Methods In February/March 2006, a survey was conducted in a representative sample of 1,052 households. Results Overall 149/1052 (14%) households reported the current possession of anti-malarial medicine, which was significantly associated with urban area, literacy of household head, having young children, and high socio-economic status. Out of a total of 802 children under five years, at least one malaria episode was reported for 239 (30%) within the last month. Overall 95% of children received treatment, either modern (72%), traditional (18%) or mixed (5%). Most of the medicines were provided as home treatment by the caregiver and half of children received some type of modern treatment within 24 hours of the occurrence of first symptoms. Despite a recent policy change to artemisinin-based combination therapy, modern anti-malarials consisted mainly of chloroquine (93%). Modern drugs were obtained more often from a health facility in localities with a health facility compared to those without (60% vs. 25.6%, p < 0.001). In contrast, beside informal providers, volunteer community health workers (CHW) were the main source of modern medicine in localities without a health centre (28% vs. 3%, p < 0.001). Conclusion Access to modern health services providing quality controlled effective combination therapies against malaria needs to be strengthened in rural Africa, which should include a re-investigation of the role of CHW 30 years after Alma Ata.

Background: To support malaria control strategies, prior knowledge of disease risk is necessary. Developing a model to explain the transmission of malaria, in endemic and epidemic regions, is of high priority in developing health system interventions. We develop, fit and validate a non-spatial dynamic model driven by meteorological conditions that can capture seasonal malaria transmission dynamics at the village level in a malaria holoendemic area of north-western Burkina Faso. Methods: A total of 676 children aged 6-59 months took part in this study. Trained interviewers visited children at home weekly from December 2003 to November 2004 for Plasmodium falciparum malaria infection detection. Anopheles daily biting rate, mortality rate and growth rate were evaluated. Digital meteorological stations measured ambient temperature, humidity and rainfall in each site. Results: The overall P. falciparum malaria infection incidence was 1.1 episodes per person year. There was strong seasonal variation in P. falciparum malaria infection incidence with a peak observed in August and September, corresponding to the rainy season and a high number of mosquitoes. The model estimates of monthly mosquito abundance and the incidence of malaria infection correlated well with observed values. The fit was sensitive to daily mosquito survival and daily human parasite clearance. Conclusion: The model has demonstrated potential for local scale seasonal prediction of P. falciparum malaria infection. It could therefore be used to understand malaria transmission dynamics using meteorological parameters as the driving force and to help district health managers in identifying high-risk periods for more focused interventions. Keywords: local scale; modelling; prediction; Plasmodium falciparum malaria; under five years; endemic region (Published: 11 November 2009) Citation: Global Health Action 2009. DOI: 10.3402/gha.v2i0.1923

Background Temperature, rainfall and humidity have been widely associated with the dynamics of malaria vector population and, therefore, with spread of the disease. However, at the local scale, there is a lack of a systematic quantification of the effect of these factors on malaria transmission. Further, most attempts to quantify this effect are based on proxy meteorological data acquired from satellites or interpolated from a different scale. This has led to controversies about the contribution of climate change to malaria transmission risk among others. Our study addresses the original question of relating meteorological factors measured at the local scale with malaria infection, using data collected at the same time and scale. Methods 676 children (6–59 months) were selected randomly from three ecologically different sites (urban and rural). During weekly home visits between December 1, 2003, and November 30, 2004, fieldworkers tested children with fever for clinical malaria. They also collected data on possible confounders monthly. Digital meteorological stations measured ambient temperature, humidity, and rainfall in each site. Logistic regression was used to estimate the risk of clinical malaria given the previous month's meteorological conditions. Results The overall incidence of clinical malaria over the study period was 1.07 episodes per child. Meteorological factors were associated with clinical malaria with mean temperature having the largest effect. Conclusion Temperature was the best predictor for clinical malaria among children under five. A systematic measurement of local temperature through ground stations and integration of such data in the routine health information system could support assessment of malaria transmission risk at the district level for well-targeted control efforts.