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Background: Brazil has the second highest case count of Hansen's disease (leprosy, HD), but factors contributing to transmission in highly endemic areas of the country remain unclear. Recent studies have shown associations of helminth infection and leprosy, supporting a biological plausibility for increased leprosy transmission in areas with helminths. However, spatial analyses of the overlap of these infections are limited. Therefore, we aimed to spatially analyze these two diseases in a co-endemic area of Minas Gerais, Brazil, in order to identify potential epidemiologic associations., Methods: An ecological study using public health surveillance records and census data was conducted to investigate whether the occurrence of HD -and specifically multibacillary (MB) disease- was associated with the presence of schistosomiasis in a community of 41 municipalities in eastern Minas Gerais, Brazil from 2011 to 2015. Multivariate logistic regression and spatial cluster analyses using geographic information systems (GIS) were performed., Results: The average annual incidence of HD in the study area was 35.3 per 100,000 while Schistosoma mansoni average annual incidence was 26 per 100,000. Both HD and schistosomiasis were spatially distributed showing significant clustering across the study area. Schistosomiasis was present in 10.4% of the tracts with HD and thirteen high-high clusters of local bivariate autocorrelation for HD and schistosomiasis cases were identified. A multivariate non-spatial analysis found that census tracts with MB disease were more likely to have schistosomiasis when adjusted for population density, household density, and household income (aOR = 1.7, 95% CI 1.0, 2.7). This remained significant when accounting for spatial correlation (aOR = 1.1, 95% CI (1.0, 1.2))., Conclusion: We found clustering of both HD and schistosomiasis in this area with some statistically significant overlap of multibacillary HD with S. mansoni infection. Not only did we provide an effective approach to study the epidemiology of two endemic neglected tropical diseases with geographic spatial analyses, we highlight the need for further clinical and translational studies to study the potential epidemiologic associations uncovered., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Stephens et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Tracking the spread of antibiotic resistant bacteria is critical to reduce global morbidity and mortality associated with human and animal infections. There is a need to understand the role that wild animals in maintenance and transfer of antibiotic resistance genes (ARGs)., Methods: This study used metagenomics to identify and compare the abundance of bacterial species and ARGs detected in the gut microbiomes from sympatric humans and wild mouse lemurs in a forest-dominated, roadless region of Madagascar near Ranomafana National Park. We examined the contribution of human geographic location toward differences in ARG abundance and compared the genomic similarity of ARGs between host source microbiomes., Results: Alpha and beta diversity of species and ARGs between host sources were distinct but maintained a similar number of detectable ARG alleles. Humans were differentially more abundant for four distinct tetracycline resistance-associated genes compared to lemurs. There was no significant difference in human ARG diversity from different locations. Human and lemur microbiomes shared 14 distinct ARGs with highly conserved in nucleotide identity. Synteny of ARG-associated assemblies revealed a distinct multidrug-resistant gene cassette carrying dfrA1 and aadA1 present in human and lemur microbiomes without evidence of geographic overlap, suggesting that these resistance genes could be widespread in this ecosystem. Further investigation into intermediary processes that maintain drug-resistant bacteria in wildlife settings is needed., Competing Interests: Timothy D. Read and Patricia C. Wright are Academic Editors for PeerJ., (©2024 Talbot et al.)

In Latin America, rabies virus has persisted in a cycle between Desmodus rotundus vampire bats and cattle, potentially enhanced by deforestation. We modeled bovine rabies virus outbreaks in Costa Rica relative to land-use indicators and found spatial-temporal relationships among rabies virus outbreaks with deforestation as a predictor.

Background: The pandemic propagation of SARS-CoV-2 led to the adoption of a myriad of non-pharmacological interventions (NPIs, e.g., social distancing, mobility restrictions, gathering restrictions) in the Americas. Using national epidemiological data, here we report the impact of the layered adoption of multiple NPIs aimed at curving SARS-CoV-2 transmission in Yucatan State, Mexico., Methods: Data from suspected and laboratory confirmed COVID-19 cases during 2020 were analyzed by age groups and sex, clinical signs, and symptoms as well as outcome. The impact of NPIs was quantified using time-varying reproduction numbers ( R t ) estimated as a time-series and by sectors of the city., Findings: A total of 69,602 suspected cases were reported, 39.3% were laboratory-confirmed. Men were hospitalized (60.2%), more severely ill (3% vs 1.9%) and more likely to die (62%) than women. Early in the outbreak, all sectors in Merida had R t estimates above unity. Once all NPÍs were in place, R t values were dramatically reduced below one, and in the last interval transmission estimates of R t remained below one in all sectors., Interpretation: In the absence of a COVID-19 vaccination program, the combination and wide adherence of NPÍs led to a low and stable trend in SARS-CoV-2 transmission that did not overwhelm the health sector. Our study reflects that a controlled and planned ease of restrictions to balance health, social and economic recovery resulted in a single wave of transmission that prolonged at low and stable levels., Funding: GVP received funding from Emory University via the MP3 Initiative., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

More than a year after the first domestic COVID-19 cases, the United States does not have national standards for COVID-19 surveillance data analysis and public reporting. This has led to dramatic variations in surveillance practices among public health agencies, which analyze and present newly confirmed cases by a wide variety of dates. The choice of which date to use should be guided by a balance between interpretability and epidemiological relevance. Report date is easily interpretable, generally representative of outbreak trends, and available in surveillance data sets. These features make it a preferred date for public reporting and visualization of surveillance data, although it is not appropriate for epidemiological analyses of outbreak dynamics. Symptom onset date is better suited for such analyses because of its clinical and epidemiological relevance. However, using symptom onset for public reporting of new confirmed cases can cause confusion because reporting lags result in an artificial decline in recent cases. We hope this discussion is a starting point toward a more standardized approach to date-based surveillance. Such standardization could improve public comprehension, policymaking, and outbreak response. ( Am J Public Health . 2021;111(12):2127-2132. https://doi.org/10.2105/AJPH.2021.306520).

Background: Evidence suggests that biological mechanisms involved in helminth infections and vitamin deficiencies increase susceptibility to other infections. The aim of this study was to investigate the associations of helminth co-infection and select micronutrient deficiencies with leprosy using a case-control design., Methods: From 2016 to 2018, individuals aged ≥3 years were recruited at clinics in and around Governador Valadares, Minas Gerais, Brazil in three groups: cases of leprosy, household contacts and community-matched (non-contact) controls. Helminths were diagnosed through stool Kato Katz examination and serum reactivity to anti-soluble adult worm antigen preparation IgG4. Serum ferritin, 25-OH vitamin D and retinol concentrations were measured. Multi-variate logistic regression was conducted to identify associations with active leprosy., Results: Seventy-nine cases of leprosy, 96 household contacts and 81 non-contact controls were recruited; 48.1% of participants were male with a median age of 40 years. Helminths were found in 7.1% of participants on Kato Katz test, all but one of which were Schistosoma mansoni, and 32.3% of participants were positive for S. mansoni serology. On multi-variate analysis, cases were more likely to be infected with helminths (diagnosed by stool) than household contacts [adjusted odds ratio (aOR) 8.69, 95% confidence interval (CI) 1.50-50.51]. Vitamin D deficiency was common, and was more likely in cases compared with non-contact controls (aOR 4.66, 95% CI 1.42,-15.33). Iron deficiency was not associated with leprosy, and vitamin A deficiency was not detected., Conclusion: These associations suggest that the immune consequences of schistosomiasis and vitamin D deficiency may increase the risk of active leprosy. Comorbid conditions of poverty deserve further study as addressing co-infections and nutritional deficiencies could be incorporated into programmes to improve leprosy control., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Ross River virus (RRV) is responsible for the most common vector-borne disease of humans reported in Australia. The virus circulates in enzootic cycles between multiple species of mosquitoes, wildlife reservoir hosts and humans. Public health concern about RRV is increasing due to rising incidence rates in Australian urban centres, along with increased circulation in Pacific Island countries. Australia experienced its largest recorded outbreak of 9544 cases in 2015, with the majority reported from south east Queensland (SEQ). This study examined potential links between disease patterns and transmission pathways of RRV., Methods: The spatial and temporal distribution of notified RRV cases, and associated epidemiological features in SEQ, were analysed for the period 2001-2016. This included fine-scale analysis of disease patterns across the suburbs of the capital city of Brisbane, and those of 8 adjacent Local Government Areas, and host spot analyses to identify locations with significantly high incidence., Results: The mean annual incidence rate for the region was 41/100,000 with a consistent seasonal peak in cases between February and May. The highest RRV incidence was in adults aged from 30 to 64 years (mean incidence rate: 59/100,000), and females had higher incidence rates than males (mean incidence rates: 44/100,000 and 34/100,000, respectively). Spatial patterns of disease were heterogeneous between years, and there was a wide distribution of disease across both urban and rural areas of SEQ. Overall, the highest incidence rates were reported from predominantly rural suburbs to the north of Brisbane City, with significant hot spots located in peri-urban suburbs where residential, agricultural and conserved natural land use types intersect., Conclusions: Although RRV is endemic across all of SEQ, transmission is most concentrated in areas where urban and peri-urban environments intersect. The drivers of RRV transmission across rural-urban landscapes should be prioritised for further investigation, including identification of specific vectors and hosts that mediate human spillover.

Objectives: The aim of this study was to analyze pharmacy functionality, or the volume of operational pharmacies, among areas in North Carolina and South Carolina affected by Hurricane Florence., Methods: Using geographic information system software and data from the Federal Emergency Management Agency and Healthcare Ready, we computed, mapped, and analyzed pharmacy functionality measures for the period of September 12, 2018, through September 20, 2018, among counties in North Carolina and South Carolina to examine health-care-related disaster readiness for and response to Hurricane Florence., Results: In the Hurricane Florence-impacted region, counties located along the coast had the most suboptimal pharmacy functionality, whereas counties located more centrally within North Carolina and South Carolina had more optimal pharmacy functionality throughout the disaster. Generally, functionality was high at Hurricane Florence's landfall on September 14, 2018, for which operating pharmacy capacity was reported at 85% in North Carolina and 88% in South Carolina. Both states had the lowest functionality on September 16, 2018, at 71% for North Carolina and 62% for South Carolina., Conclusions: During the Hurricane Florence event, suboptimal pharmacy functionality was detected for coastal areas and during the disaster response period. Hurricane readiness plans and infrastructure strengthening should be emphasized for community pharmacies in hurricane-prone areas.

Importance: Invasive nontypeable Haemophilus influenzae (NTHi) infection among adults is typically associated with bacteremic pneumonia. Nontypeable H influenzae is genetically diverse and clusters of infection are uncommon., Objective: To evaluate an increase in invasive NTHi infection from 2017-2018 among HIV-infected men who have sex with men in metropolitan Atlanta, Georgia., Design, Setting, and Participants: A population-based surveillance study with a cohort substudy and descriptive epidemiological analysis identified adults aged 18 years or older with invasive NTHi infection (isolation of NTHi from a normally sterile site) between January 1, 2008, and December 31, 2018 (final date of follow-up)., Exposures: Time period, HIV status, and genetic relatedness (ie, cluster status) of available NTHi isolates., Main Outcomes and Measures: The primary outcome was incidence of invasive NTHi infection (from 2008-2016 and 2017-2018) among persons with HIV and compared with NTHi infection from 2008-2018 among those without HIV. The secondary outcomes were assessed among those aged 18 to 55 years with invasive NTHi infection and included epidemiological, clinical, and geographic comparisons by cluster status., Results: Among 553 adults with invasive NTHi infection (median age, 66 years [Q1-Q3, 48-78 years]; 52% male; and 38% black), 60 cases occurred among persons with HIV. Incidence of invasive NTHi infection from 2017-2018 among persons with HIV (41.7 cases per 100 000) was significantly greater than from 2008-2016 among those with HIV (9.6 per 100 000; P < .001) and from 2008-2018 among those without HIV (1.1 per 100 000; P < .001). Among adults aged 18 to 55 years with invasive NTHi infections from 2017-2018 (n = 179), persons with HIV (n = 31) were significantly more likely than those from 2008-2018 without HIV (n = 124) to be male (94% vs 49%, respectively; P < .001), black (100% vs 53%; P < .001), and have septic arthritis (35% vs 1%; P < .001). Persons with HIV who had invasive NTHi infection from 2017-2018 (n = 31) were more likely than persons with HIV who had invasive NTHi infection from 2008-2016 (n = 24) to have septic arthritis (35% vs 4%, respectively; P = .01). Pulsed-field gel electrophoresis of 174 of 179 NTHi isolates from 18- to 55-year-olds identified 2 genetically distinct clonal groups: cluster 1 (C1; n = 24) and cluster 2 (C2; n = 23). Whole-genome sequencing confirmed 2 clonal lineages of NTHi infection and revealed all C1 isolates (but none of the C2 isolates) carried IS1016 (an insertion sequence associated with H influenzae capsule genes). Persons with HIV were significantly more likely to have C1 or C2 invasive NTHi infection from 2017-2018 (28/31 [90%]) compared with from 2008-2016 among persons with HIV (10/24 [42%]; P < .001) and compared with from 2008-2018 among those without HIV (9/119 [8%]; P < .001). Among persons with C1 or C2 invasive NTHi infection who had HIV (n = 38) (median age, 34.5 years; 100% male; 100% black; 82% men who have sex with men), 32 (84%) lived in 2 urban counties and an area of significant spatial aggregation was identified compared with those without C1 or C2 invasive NTHi infection., Conclusions and Relevance: Among persons with HIV in Atlanta, the incidence of invasive nontypeable H influenzae infection increased significantly from 2017-2018 compared with 2008-2016. Two unique but genetically related clonal strains were identified and were associated with septic arthritis among black men who have sex with men and who lived in geographic proximity.

Background: Open drains are common methods of transporting solid waste and excreta in low-income urban neighborhoods. Open drains can overflow due to blockages with solid waste and during rainfall, posing exposure risks. The goal of this study was to evaluate whether pediatric enteric infection was associated with open drains and flooding in a dense, low-income, urban neighborhood., Methods: As part of the MAL-ED study in Vellore, India, a cohort of 230 children provided stool specimens at 14-17 scheduled home visits and during diarrheal episodes in the first two years of life. All specimens were analyzed for enteric pathogens. Caregivers in 100 households reported on flooding of drains and households and monthly frequency of contact with open drains and flood water. Household GPS points were collected. Monthly rainfall totals for the Vellore district were collected from the Indian Meteorological Department. Clustering of reported drain and house flooding were identified by Kulldorff's Bernoulli Spatial Scan. Differences in enteric infection were assessed for household responses and spatial clusters, with interactions between reported flooding and rainfall to approximate monthly drain flooding retrospectively, using multivariable, mixed-effects logistic regression models., Results: Coverage of household toilets was low (33%), and most toilets (82%) discharged directly into open drains, suggesting poor neighborhood fecal sludge management. Odds of enteric infection increased significantly with total monthly rainfall for children who lived in households that reported that the nearby drain flooded (4% increase per cm of rain: OR: 1.04, 95% CI: 1.00-1.08) and for children in households in a downstream spatial cluster of reported drain flooding (5% increase per cm of rain: OR: 1.05, 95% CI: 1.01-1.09). There was no association between odds of enteric infection and frequency of reported contact with drain or floodwater., Conclusions: Children in areas susceptible to open drain flooding had increased odds of enteric infection as rainfall increased. Results suggested that infection increased with rainfall due to neighborhood infrastructure (including poor fecal sludge management) and not frequency of contact. Thus, these exposures may not be mitigated by changes in personal behaviors alone. These results underscore the importance of improving the neighborhood environment to improve children's health in low-income, urban settings.

Exposure to fecal contamination in public areas, especially in dense, urban environments, may significantly contribute to enteric infection risk. This study examined associations between sanitation and fecal contamination in public environments in four low-income neighborhoods in Accra, Ghana. Soil (n = 72) and open drain (n = 90) samples were tested for E. coli, adenovirus, and norovirus. Sanitation facilities in surveyed households (n = 793) were categorized by onsite fecal sludge containment ("contained" vs. "uncontained") using previous Joint Monitoring Program infrastructure guidelines. Most sanitation facilities were shared by multiple households. Associations between spatial clustering of household sanitation coverage and fecal contamination were examined, controlling for neighborhood and population density (measured as enumeration areas in the 2010 census and spatially matched to sample locations). E. coli concentrations in drains within 50m of clusters of contained household sanitation were more than 3 log-units lower than those outside of clusters. Further, although results were not always statistically significant, E. coli concentrations in drains showed consistent trends with household sanitation coverage clusters: concentrations were lower in or near clusters of high coverage of household sanitation facilities-especially contained facilities-and vice versa. Virus detection in drains and E. coli concentrations in soil were not significantly associated with clustering of any type of household sanitation and did not exhibit consistent trends. Population density alone was not significantly associated with any of the fecal contamination outcomes by itself and was a significant, yet inconsistent, effect modifier of the association between sanitation clusters and E. coli concentrations. These findings suggest clustering of contained household sanitation, even when shared, may be associated with lower levels of fecal contamination within drains in the immediate public domain. Further research is needed to better quantify these relationships and examine impacts on health., Competing Interests: The authors have declared that no competing interests exist.

AbstractUrban sanitation necessitates management of fecal sludge inside and outside the household. This study examined associations between household sanitation, fecal contamination, and enteric infection in two low-income neighborhoods in Vellore, India. Surveys and spatial analysis assessed the presence and clustering of toilets and fecal sludge management (FSM) practices in 200 households. Fecal contamination was measured in environmental samples from 50 households and household drains. Enteric infection was assessed from stool specimens from children under 5 years of age in these households. The two neighborhoods differed significantly in toilet coverage (78% versus 33%) and spatial clustering. Overall, 49% of toilets discharged directly into open drains ("poor FSM"). Children in households with poor FSM had 3.78 times higher prevalence of enteric infection when compared with children in other households, even those without toilets. In the neighborhood with high coverage of household toilets, children in households with poor FSM had 10 times higher prevalence of enteric infection than other children in the neighborhood and drains in poor FSM clusters who had significantly higher concentrations of genogroup II norovirus. Conversely, children in households with a toilet that contained excreta in a tank onsite had 55% lower prevalence of enteric infection compared with the rest of the study area. Notably, households with a toilet in the neighborhood with low toilet coverage had more fecal contamination on floors where children played compared with those without a toilet. Overall, both toilet coverage levels and FSM were associated with environmental fecal contamination and, subsequently, enteric infection prevalence in this urban setting.

Buruli ulcer, caused by Mycobacterium ulcerans, is highly endemic in West Africa. While the mode of transmission is unknown, many studies associate Buruli ulcer with different types of water exposure. We present results from the largest study to date to test for M. ulcerans in aquatic sites and identify environmental attributes associated with its presence. Environmental samples from 98 aquatic sites in the Greater Accra, Ashanti, and Volta regions of Ghana were tested for the presence of M. ulcerans DNA by polymerase chain reaction. The proportion of aquatic sites positive for M. ulcerans varied by region: Ashanti 66% (N = 39), Greater Accra 34% (N = 29), and Volta 0% (N = 30). We explored the spatial distribution of M. ulcerans positive and negative water bodies and found no significant clusters. We also determined both highly localized water attributes and broad scale remotely sensed land cover and terrain environmental characteristics associated with M. ulcerans presence through logistic regression. Our results concur with published results regarding conditions suitable for M. ulcerans growth and associations with Buruli ulcer disease burden with regards to water characteristics and disturbed environments, but differ from others with regards to spatial associations and topographic effects such as elevation and wetness. While our results suggest M. ulcerans is an environmental organism existing in a specific ecological niche, they also reveal variation in the elements defining this niche across the sites considered. In addition, despite the causal association between Buruli ulcer and M. ulcerans, we observed no significant statistical association between case reports of Buruli ulcer and presence of M. ulcerans in nearby waterbodies.

The widespread transmission of dengue viruses (DENV), coupled with the alarming increase of birth defects and neurological disorders associated with Zika virus, has put the world in dire need of more efficacious tools for Aedes aegypti -borne disease mitigation. We quantitatively investigated the epidemiological value of location-based contact tracing (identifying potential out-of-home exposure locations by phone interviews) to infer transmission foci where high-quality insecticide applications can be targeted. Space-time statistical modeling of data from a large epidemic affecting Cairns, Australia, in 2008-2009 revealed a complex pattern of transmission driven primarily by human mobility (Cairns accounted for ~60% of virus transmission to and from residents of satellite towns, and 57% of all potential exposure locations were nonresidential). Targeted indoor residual spraying with insecticides in potential exposure locations reduced the probability of future DENV transmission by 86 to 96%, compared to unsprayed premises. Our findings provide strong evidence for the effectiveness of combining contact tracing with residual spraying within a developed urban center, and should be directly applicable to areas with similar characteristics (for example, southern USA, Europe, or Caribbean countries) that need to control localized Aedes -borne virus transmission or to protect pregnant women's homes in areas with active Zika transmission. Future theoretical and empirical research should focus on evaluation of the applicability and scalability of this approach to endemic areas with variable population size and force of DENV infection.

Industrial activity is one of the main sources of ambient pollution in developed countries. However, research analyzing its effect on birth outcomes is inconclusive. We analyzed the association between proximity of mother's municipality of residence to industries from 24 different activity groups and risk of very (VPTB) and moderate (MPTB) preterm birth, very (VLBW) and moderate (MLBW) low birth weight, and small for gestational age (SGA) in Spain, 2004-2008. An ecological study was defined, and a "near vs. far" analysis (3.5 km threshold) was carried out using Hierarchical Bayesian models implemented via Integrated Nested Laplace Approximation. VPTB risk was higher for mothers living near pharmaceutical companies. Proximity to galvanization and hazardous waste management industries increased the risk of MPTB. Risk of VLBW was higher for mothers residing near pharmaceutical and non-hazardous or animal waste management industries. For MLBW many associations were found, being notable the proximity to mining, biocides and animal waste management plants. The strongest association for SGA was found with proximity to management animal waste plants. These results highlight the importance of further research on the relationship between proximity to industrial sites and the occurrence of adverse birth outcomes especially for the case of pharmaceutical and animal waste management activities.

Background: Malaria, caused by the parasite Plasmodium falciparum, is a significant source of morbidity and mortality in southern Zambia. In the Mapanza Chiefdom, where transmission is seasonal, Anopheles arabiensis is the dominant malaria vector. The ability to predict larval habitats can help focus control measures., Methods: A survey was conducted in March-April 2007, at the end of the rainy season, to identify and map locations of water pooling and the occurrence anopheline larval habitats; this was repeated in October 2007 at the end of the dry season and in March-April 2008 during the next rainy season. Logistic regression and generalized linear mixed modeling were applied to assess the predictive value of terrain-based landscape indices along with LandSat imagery to identify aquatic habitats and, especially, those with anopheline mosquito larvae., Results: Approximately two hundred aquatic habitat sites were identified with 69 percent positive for anopheline mosquitoes. Nine species of anopheline mosquitoes were identified, of which, 19% were An. arabiensis. Terrain-based landscape indices combined with LandSat predicted sites with water, sites with anopheline mosquitoes and sites specifically with An. arabiensis. These models were especially successful at ruling out potential locations, but had limited ability in predicting which anopheline species inhabited aquatic sites. Terrain indices derived from 90 meter Shuttle Radar Topography Mission (SRTM) digital elevation data (DEM) were better at predicting water drainage patterns and characterizing the landscape than those derived from 30 m Advanced Spaceborne Thermal Emission and Reflection Radiometer (ASTER) DEM., Conclusions: The low number of aquatic habitats available and the ability to locate the limited number of aquatic habitat locations for surveillance, especially those containing anopheline larvae, suggest that larval control maybe a cost-effective control measure in the fight against malaria in Zambia and other regions with seasonal transmission. This work shows that, in areas of seasonal malaria transmission, incorporating terrain-based landscape models to the planning stages of vector control allows for the exclusion of significant portions of landscape that would be unsuitable for water to accumulate and for mosquito larvae occupation. With increasing free availability of satellite imagery such as SRTM and LandSat, the development of satellite imagery-based prediction models is becoming more accessible to vector management coordinators.

Urinary schistosomiasis is an important source of human morbidity in Msambweni, Kenya, where the intermediate host snail, Bulinus nasutus is found in ponds and water pools. In the past, aquatic habitats in the area have been studied separately; however, recent collections of B. nasutus snails and shells indicated that many of these ponds are in fact connected during and following sufficient rains. Satellite imagery and a geographical information system (GIS) were used to survey the main water courses and potential drainage routes, to locate potential source populations of snails and to determine probable snail dispersal routes. The 2 water bodies implicated as being the most important Schistosoma haematobium transmission foci in the area were found to differ in their degree of connectivity to other B. nasutus source habitats. One pond becomes connected even after normal rains, while the other pond requires prolonged rains or flooding to become connected with source habitats. Consequently, the transmission foci differ in their susceptibility to snail population control measures. Spatially explicit dispersal models that consider the spatial and temporal patterns of connectivity between aquatic habitats will contribute to improved snail surveillance and more focused control for urinary schistosomiasis at a local level.

As part of an extensive study of the eco-epidemiology of urinary schistosomiasis along the southern coast of Kenya, spatial and temporal transmission patterns were associated with various ponds infested with Bulinus snails. The household-level spatial pattern of infection for children of various age groups in 2000 was contrasted with historical data from 1984. Significant local clustering of high and low infection levels among school age children was detected, and the spatial extent of clusters and their direction from specific water sources were measured. High infection levels were clustered around ponds known to contain Bulinus nasutus snails that shed Schistosoma haematobium cercariae, and low infection levels were concentrated near a river where intermediate host snails were rarely found. The spatial patterns of infection varied between 2000 and 1984 and between age groups. High levels of infection were clustered around different transmission foci in the two study periods, and, for younger children in 2000, were clustered nearer to the transmission foci than for the older children. Simultaneous consideration of the effects of different foci on transmission will allow for targeted application of control measures aimed at interrupting S. haematobium transmission at a local level.

Depending on the research question or the public health application, the appropriate resolution of the data varies temporally, spatially, and, for satellite data, spectrally and radiometrically. Regardless of the scale used to address a research or public health question, the temptation is always there to extrapolate from fine-resolution data or to interpolate from coarse resolution studies. In both cases, the relevance of data and analyses conducted on one spatial level to other levels cannot be taken for granted. Spatial heterogeneity on the micro-scale may not be detected using coarse spatial resolution, and conversely, general patterns on the macro-scale may not be detected using fine spatial resolution. Two studies are described where the transmission dynamics and risk of infection was assessed on the micro-scale starting with household level studies in one community, and the study area was extended gradually to consider several communities and sources for vectors or intermediate hosts. In a study of Chagas disease in northwest Argentina, the reinfestation process of communities by the main domestic vector was analyzed using spatial statistics; sources within and outside communities as well as the distance of reinfestation were identified. In a study of urinary schistosomiasis in coastal Kenya, age dependent and directional focal clustering of infections was detected around some aquatic habitats, and a hydrological model was developed to detect least cost dispersal routes that allow snails to reinfest dried-up habitats. Some general aspects of focal statistics are discussed. Several general questions need to be considered in geospatial health studies, including the following: (i) what are the best criteria for selecting the spatial (and temporal) unit of intervention and analysis? (ii) how do the key measures of risk and transmission dynamics vary with scale? (iii) how do we integrate processes occurring at diverse spatial and temporal scales? All of these questions can only be addressed through solid biological, epidemiological and socio-economic understanding of the system in time and space.

Urinary schistosomiasis remains a major contributor to the disease burden along the southern coast of Kenya. Selective identification of transmission hot spots offers the potential for more effective, highly-focal snail control and human chemotherapy to reduce Schistosoma haematobium transmission. In the present study, a geographic information system was used to integrate demographic, parasitologic, and household location data for an endemic village and neighboring households with the biotic, abiotic, and location data for snail collection/water contact sites. A global spatial statistic was used to detect area-wide trends of clustering for human infection at the household level. Local spatial statistics were then applied to detect specific household clusters of infection, and, as a focal spatial statistic, to evaluate clustering of infection around a putative transmission site. High infection intensities were clustered significantly around a water contact site with high numbers of snails shedding S. haematobium cercariae. When age was considered, clustering was found to be significant at different distances for different age groups.

In the Msambweni area of the Kwale District in Kenya, an area endemic for Schistosoma haematobium, potential intermediate-host snails were systematically surveyed in water bodies associated with human contact that were previously surveyed in the 1980s. Bulinus (africanus) nasutus, which accounted for 67% of the snails collected, was the only snail shedding S. haematobium cercariae. Lanistes purpureus was the second most common snail (25%); lower numbers of Bulinus forskalii and Melanoides tuberculata were also recovered. Infection with non-S. haematobium trematodes was found among all snail species. Rainfall was significantly associated with the temporal distribution of all snail species: high numbers of Bulinus nasutus developed after extensive rainfall, followed, in turn, by increased S. haematobium shedding. Spatial distribution of snails was significantly clustered over a range of up to 1 km, with peak clustering observed at a distance of 400 meters. Water lily (Nymphaea spp.) and several aquatic grass species appeared necessary for local colonization by B. nasutus or L. purpureus.