Intersectoral coordination in Aedes aegypti control. A pilot project in Havana City, Cuba

SUMMARY: Background The 55th World Health Assembly declared dengue prevention and control a priority and urged Member States to develop sustainable intersectoral strategies to this end. To provide evidence for the reorientation of the dengue prevention policy in Cuba, we launched an intervention study to document the effectiveness of a local-level intersectoral approach. METHODS: We used a quasi-experimental design. Social scientists introduced participatory methods to facilitate dialogue in the biweekly meetings of the intersectoral Health Council of the intervention area. This council subsequently developed an intersectoral plan for dengue prevention, of which the core objective was to design and implement activities for communication and social mobilization. In the control area, routine dengue control activities continued without additional input. Knowledge, attitudes and perceptions of dengue, and entomological indices were compared inside and between the areas before and after the 1-year intervention period. RESULTS: In the intervention area the Health Council elaborated an intersectoral plan for dengue prevention focused on source reduction. The Aedes aegypti control methods consisted in eliminating useless containers in the houses and surroundings, covering tanks, and cleaning public and inhabited areas. It was implemented through communication and social mobilization. The Health Council in the control area occasionally discussed dengue issues but did not develop a coordinated action plan. Good knowledge about breeding sites and disease symptoms increased significantly (by 49.7% and 17.1% respectively) in the intervention area as well as the proportion of respondents eliminating containers in and around their houses (by 44%). No changes were observed in the control area. The House Index in the intervention area was 3.72% at baseline and decreased to 0.61% after 1 year. In the control area it remained stable throughout the study period (1.31% and 1.65% respectively). CONCLUSION: The introduction of a participatory approach by social scientists promotes changes in intersectoral management. This facilitates social mobilization which, in its turn, leads to significant changes in knowledge, attitudes and dengue-related practices in the population and eventually to more effective control of Ae. aegypti.     

Intersectoral coordination, community empowerment and dengue prevention: six years of controlled interventions in Playa Municipality, Havana, Cuba

Objective To document the process, outcome and effectiveness of a community‐based intervention for dengue control. Methods The primary intervention, focused on strengthening intersectoral coordination, was initiated by researchers in January 2000 in a pilot area in Playa municipality, Havana. In August 2002 health authorities extended the intervention to neighbouring areas, one of which was selected for evaluation. In August 2003 a complementary strategy, focused on community empowerment, was initiated in half of the pilot area. In our control area, routine dengue activities continued throughout the study period. Longitudinal process assessment was carried out using document analysis, interviews and group discussions. Random population surveys in 1999, 2002 and 2005 assessed levels of participation and behavioural changes. Entomological surveillance data from 1999 to 2005 were used to determine effectiveness. Results Mean scores for participation in the pilot area were 1.6, 3.4 and 4.4 at baseline, and 2 years after initiating intersectoral coordination and intersectoral coordination plus community empowerment interventions, respectively. While in the control area little behavioural change was observed over time, changes were considerable in the pilot and extension areas, with 80% of households involved in the community empowerment intervention showed adequate behavioural patterns. The pilot and extension areas attained comparable entomological effectiveness with significantly lower Breteau indices (BIs) than the control area. The pilot (sub‐) area with the community empowerment intervention reached BIs below 0.1 that continued to be significantly lower than the one in the control area until the end of the study. Conclusion The study showed a trend in the levels and quality of participation, behavioural change and effectiveness of Aedes control from the routine activities only over an intervention with intersectoral coordination to one that combined intersectoral coordination and community empowerment approach.     

Social and environmental determinants of Aedes aegypti infestation in Central Havana: results of a case-control study nested in an integrated dengue surveillance programme in Cuba

OBJECTIVE: To characterize the social and environmental risk factors associated with the presence of Aedes aegypti in order to improve community dengue control. METHODS: A case-control study with 'cases' being households with entomologically confirmed A. aegypti infestation; personal interviews in Central Havana, a densely populated inner city area characterized by overcrowded housing and irregular water service. The participants were residents of 278 houses with infestation and 556 houses without infestation. RESULTS: Greater risk of infestation was associated with lack of preventive measures, such as no larvicide in the water tanks (OR = 2.21) and use of flower vases for religious practice (1.93), not being economically active (1.64), vulnerable populations with higher risks in households with older people (1.52) and households with children (1.94). CONCLUSIONS: Efforts to reduce infestations should continue to focus on water tank sanitation and improving housing conditions, but also engage community religious leaders to help promote safe practices. Vulnerable populations should be especially targeted by prevention activities. A surveillance programme can produce evidence to guide interventions.     

The development of predictive tools for pre‐emptive dengue vector control: a study of Aedes aegypti abundance and meteorological variables in North Queensland,Australia

Objectives To describe the meteorological influences on adult dengue vector abundance in Australia for the development of predictive models to trigger pre‐emptive control operation. Methods Multiple linear regression analyses were performed using meteorological data and female Aedes aegypti collection data from BG‐Sentinel Mosquito traps placed at 11 monitoring sites in Cairns, north Queensland. Results Considerable regression coefficients (R² = 0.64 and 0.61) for longer‐ and shorter‐term factor models respectively were derived. Longer‐term factors significantly associated with abundance of adult vectors were mean minimum temperature (lagged 6 month) and mean daily temperature (lagged 4 month), explaining the predictable increase in abundance during the wet season. Factors explaining fluctuation in abundance in the shorter term were mean relative humidity over the previous 2 week and current daily average temperature. Rainfall variables were not found to be strong predictors of A. aegypti abundance in either longer‐ or shorter‐term models. Conclusions The implications of these findings for the development of useful predictive models for vector abundance risks are discussed. Such models can be used to guide the application of pre‐emptive dengue vector control, and thereby enhance disease management.     

Geographic and temporal genetic patterns of Aedes aegypti populations in Rio de Janeiro, Brazil

Rio de Janeiro is considered as the most important entry point for dengue viruses in Brazil. Using isoenzyme markers, we investigated the genetic structure of the mosquito vector Aedes aegypti sampled at three-month intervals in 14 districts in Rio de Janeiro from December 2002 to December 2003. We detected high levels of genetic differentiation (i.e. high F(ST) values and significant P values), which tended to persist throughout the year. The species does not take advantage of routes and railways to disperse. Genetic structuring was higher in the rainy season, suggesting low dispersion of Ae. aegypti at this time of year when all dengue epidemics have been reported in the city.     

Costs of dengue prevention and incremental cost of dengue outbreak control in Guantanamo, Cuba

Objective To assess the economic cost of routine Aedes aegypti control in an at‐risk environment without dengue endemicity and the incremental costs incurred during a sporadic outbreak. Methods The study was conducted in 2006 in the city of Guantanamo, Cuba. We took a societal perspective to calculate costs in months without dengue transmission (January–July) and during an outbreak (August–December). Data sources were bookkeeping records, direct observations and interviews. Results The total economic cost per inhabitant (p.i.) per month. (p.m.) increased from 2.76 USD in months without dengue transmission to 6.05 USD during an outbreak. In months without transmission, the routine Aedes control programme cost 1.67 USD p.i. p.m. Incremental costs during the outbreak were mainly incurred by the population and the primary/secondary level of the healthcare system, hardly by the vector control programme (1.64, 1.44 and 0.21 UDS increment p.i. p.m., respectively). The total cost for managing a hospitalized suspected dengue case was 296.60 USD (62.0% direct medical, 9.0% direct non‐medical and 29.0% indirect costs). In both periods, the main cost drivers for the Aedes control programme, the healthcare system and the community were the value of personnel and volunteer time or productivity losses. Conclusions Intensive efforts to keep A. aegypti infestation low entail important economic costs for society. When a dengue outbreak does occur eventually, costs increase sharply. In‐depth studies should assess which mix of activities and actors could maximize the effectiveness and cost‐effectiveness of routine Aedes control and dengue prevention.     

From the Cover: Suppression of female fertility in Aedes aegypti with a CRISPR-targeted male-sterile mutation

Aedes aegypti spread devastating viruses such as dengue, which causes disease among 100 to 400 million people annually. A potential approach to control mosquito disease vectors is the sterile insect technique (SIT). The strategy involves repeated release of large numbers of sterile males, which reduces insect populations because the sterile males mate and thereby suppress the fertility of females that would otherwise mate with fertile males. While SIT has been successful in suppressing certain agricultural pests, it has been less effective in depressing populations of Ae. aegypti. This limitation is in part because of the fitness effects resulting from mutagenizing the mosquitoes nonspecifically. Here, we introduced and characterized the impact on female fertility of an Ae. aegypti mutation that disrupts a gene that is specifically expressed in testes. We used CRISPR/Cas9 to generate a null mutation in the Ae. aegypti β2-tubulin (B2t) gene, which eliminates male fertility. When we allowed wild-type females to first mate with B2t mutant males, most of the females did not produce progeny even after being subsequently exposed to wild-type males. We also introduced B2t mutant and wild-type males simultaneously with wild-type females and found that a larger number of B2t mutant males relative to the wild-type males was effective in significantly suppressing female fertility. These results raise the possibility of employing B2t sterile males to improve the efficacy of SIT in suppressing populations of Ae. aegypti through repeated releases and thereby reduce the transmission of viruses by these invasive mosquitoes.

Aedes aegypti transmit dengue and Zika and other viral pathogens that cause disease among many tens of millions of people each year (1). Moreover, the incidence of diseases spread by this invasive mosquito continues to be on the rise (2). Only females spread disease, and this occurs because they take a blood meal to obtain nutrients needed for egg production. One potential approach for controlling Ae. aegypti is the sterile insect technique (SIT) (3, 4). SIT involves inundating a local population with large excesses of sterile males. Sterile males are thought to cause sterility in females because the initial mating prevents successful insemination by a wild-type male (1, 3). SIT involves repeated release of large numbers of males in a defined geographical region until the number of females falls below a critical threshold necessary for sustaining the population at a high level.To create sterile males for implementation of SIT, male mosquitoes are exposed to high doses of chemicals or radiation (5). These approaches suffer from the limitation that they do not specifically target male fertility genes (5). Rather, they induce mutations in many genes. This leads to a fitness deficit, reducing the overall robustness of the mosquitoes and the ability of the sterilized males to compete with males in the wild.In addition to classical SIT, many other approaches are being pursued including the release of fertile male insects with a dominant lethal mutation that kills females (6, 7). A very exciting new technology is the use of CRISPR/Cas9 to create gene drives that suppress mosquito populations (8–12). Despite the great promise of these strategies, the release of fertile transgenic mosquitoes creates public concern due to the potential for unintended consequences resulting from these insects lingering in the environment (13).In addition to the classical SIT approach, sterility can also be induced by release of male mosquitoes infected with endosymbiotic strains of Wolbachia (14). The bacteria are present in the testis and ovaries and can disrupt reproductive capacity through multiple mechanisms including cytoplasmic incompatibility (incompatible insect technique; IIT), which occurs following mating between an infected male and a female that is not infected with the same strain of Wolbachia (15). While IIT is a very exciting approach with examples of success (16–18), Wolbachia could spread through an indigenous population, thereby interfering with its efficacy, or get introduced into areas that are not intended to be targeted.The classical SIT approach that involves release of sterile males has multiple advantages that motivate continuing interest in improving this strategy. It has been highly effective in controlling insect pests over the course of 65 y (19, 20), the strategy is environmentally sound (3), and SIT does not suffer from a high level of concern about introduction of transgenes into native insect populations since the released males are sterile. Nevertheless, due to the adverse effects of nonspecific chemical- or radiation-induced sterility, the efficacy of SIT in suppressing mosquito vectors is limited (5). Potentially, SIT could be improved by an alternative, genetic approach using sterile males with a targeted mutation in a single gene that is specifically required for male fertility. However, no male fertility gene has been defined experimentally in mosquitoes.To identify an Ae. aegypti gene likely to cause male sterility, we considered Drosophila male fertility genes that are conserved in these mosquitoes. The Ae. aegypti β2 tubulin (B2t) gene was a prime candidate for eliminating male fertility, since Drosophila B2t is required for male fertility, is specifically expressed in Drosophila sperm (21–23), and the Drosophila and Ae. aegypti proteins are 96% identical. Moreover, the Ae. aegypti B2t gene appears to be expressed specifically in testes (24). In this study, we used CRISPR/Cas9 to knock out the B2t gene. The Ae. aegypti B2t mutant males were sterile and were as robust as wild type in terms of all parameters measured, except for the sterility. Of primary importance, the B2t mutant males were effective in suppressing female fertility. These data indicate that mutation of B2t provides a targeted genetic strategy for improving SIT.     

Integration of municipal state,society and university efforts for sanitary risk prevention associated with Aedes aegypti mosquito in the metropolitan area of Buenos Aires,Argentina

The sanitary problem of Aedes aegypti mosquito acquires relevance around the world because it is the vector of dengue, zika, chikungunya and yellow fever. The vector is adapting to southern regions faster, and the propagation of these diseases in urban areas is a complex problem for society. We aimed to contribute to the risk prevention of disease transmission in the Metropolitan Area of Buenos Aires, through monitoring Aedes aegypti population levels and developing education campaigns with government agencies and society participation. Monitoring activities aimed to diagnose the presence of the vector and its ecology behaviour, and to generate education and prevention politics to avoid its propagation. The results show that (1) the mosquito is in the territory and it is spreading, (2) prevention activities of the municipalities are insufficient to generate an effective sanitary response and (3) it is necessary to improve the education programmes to the population about the life cycle of the vector. The integration of university, government and society improved the work of the team because it combined knowledge about vector ecology, diseases and territory characteristics.     

Survival of Betta splendens fish (Regan, 1910) in domestic water containers and its effectiveness in controlling Aedes aegypti larvae (Linnaeus, 1762) in Northeast Brazil

Objective In Northeast Brazil, large domestic containers used to store water are important breeding sites of Aedes aegypti, the main vector of dengue fever. The objective of this study was to estimate the survival of Betta splendens (Perciformes: Osphronemidae) fish in domestic containers in Fortaleza (Ceará State), as well as its effectiveness in the control of premature A. aegypti stages. Methods The use of B. splendens was compared to Bacillus thuringiensis israelensis (Bti) in domestic containers. In a first home visit, B. splendens or Bti were applied to water containers. Two follow‐up visits were conducted after 3–4 and 5–6 months to assess the presence of viable fish in the containers and infestation by larvae. Betta splendens fish were still present in 97.6% of containers 45–60 days after application. When the fish was present, the infestation rate was significantly higher (P < 0.001) in the Bti group (IR ratio = 21.60; 95% CI: 6.46–72.28). In deposits where the fish remained, efficacy was 85% better than Bti. The permanence of fish was higher in concrete tanks (48.5%) located outside the house (47.5%) and at ground level (53.3%). We conclude that B. splendens may be suitable for biological control of A. aegypti larvae in large domestic water containers, but that appropriate measures should be taken to assure prolonged survival and the presence of fish in the containers.     

Community participation as an interactive learning process: experiences from a schistosomiasis control project in Zimbabwe

A schistosomiasis control project was undertaken from 1994 to 1998 in Guruve District, Zimbabwe, based on the active involvement of local communities in the growing and application of the molluscicidal plant Phytolacca dodecandra as a supplement to other control measures such as chemotherapy and health education. The berries of P. dodecandra are highly molluscicidal to the intermediate host snails of schistosomiasis and is rapidly degradable in water. It was observed that plant care fluctuated during the study period. Only a few households participated in snail control activities, although 97% of respondents in a baseline survey had stated a willingness to take part. This invoked an investigation to explore the reality from a user perspective. Focus group discussions, semi-structured interviews and observations were used to solicit information. In spite of a cultural inclination for collective work, many reasons for low-level involvement emerged, inter alia the low perceived value of the project, demands for tangible benefits, inaccessible fields and weak leadership. This study shows that community participation is a complex process upon which a multiplicity of social and cultural determinants have an impact. If community participation is to become successful in development programmes it ought to be viewed as a mutual learning process where obstacles are identified and discussed and solutions shared among community members and project staff.     

Application of the pupal/demographic-survey methodology in an area of Havana, Cuba, with low densities of Aedes aegypti (L.)

Between the April and December of 2004, an Aedes aegypti (L.) pupal/demographic survey was conducted in the Playa municipality of Havana. The aims were to identify the key types of container in the production of the adult mosquitoes (and so provide a basis for targeted control) and assess transmission risk in terms of the number of pupae/person. Pupal abundance, as measured in the survey, was compared with traditional Stegomyia indices. The immature stages of Ae. aegypti were only found in 70 of the 15,153 containers that were investigated and the pupae of this species were only seen in 52 of the containers. Ground-level water-storage tanks yielded 74.1% of all the pupae, with a further 19.0% found in miscellaneous small containers. The utility of the pupal/demographic-survey methodology in the evaluation of dengue risk in the study area, and other areas of Cuba with low densities of Ae. aegypti, is discussed.     

Cost-effectiveness of annual targeted larviciding campaigns in Cambodia against the dengue vector Aedes aegypti

OBJECTIVE: To assess the cost-effectiveness (CE) of annual targeted larviciding campaigns from 2001 to 2005 against the dengue vector Aedes aegypti in two urban areas of Cambodia with a population of 2.9 million people. METHODS: The intervention under analysis consisted of annual larviciding campaigns targeting medium to large water storage containers in households and other premises. The CE compared the intervention against the hypothetical alternative of no intervention. The CE was calculated as the ratio of disability adjusted life years (DALYs) saved to the net cost of the intervention (in 2005 US dollars) by year. A sensitivity analysis explored the range of study parameters. RESULTS: The intervention reduced the number of dengue cases and deaths by 53%. It averted an annual average of 2980 dengue hospitalizations, 11,921 dengue ambulatory cases and 23 dengue deaths, resulting in a saving of 997 DALYs per year. The gross cost of the intervention was US $567,800 per year, or US $0.20 per person covered. As the intervention averted considerable medical care, the annual net cost of the intervention was US $312,214 (US $0.11 per person covered) from a public sector perspective and US $37,137 (US $0.01 per person covered) from a societal perspective. The resulting CE ratios were: US $313/DALY gained from the public perspective and US $37/DALY gained from the societal perspective. Even under the most conservative assumption, the intervention remained cost effective from both perspectives. CONCLUSIONS: Annual, targeted larviciding campaigns appear to have been effective and cost-effective medium-term interventions to reduce the epidemiologic and economic burden of dengue in urban areas of Cambodia.     

Evidence on impact of community-based environmental management on dengue transmission in Santiago de Cuba

During the dengue outbreak that struck Santiago de Cuba in 2006-2007, we conducted an observational study in the Mariana Grajales district, the former setting of a community trial for Aedes aegypti control. In the trial, community working groups (CWG) had been created in 29 randomly selected intervention house blocks, and routine vector control activities alone were conducted in the remaining 30 control blocks. The CWG elaborated and implemented with the population plans and activities to reduce Aedes infestation. They were still functional in 2006 and continued organizing community-based environmental management activities. The attack rate of dengue fever during the outbreak was 8.5 per 1000 inhabitants in the former intervention blocks and 38.1 per 1000 inhabitants in the control blocks, which corresponds to a relative risk of 4.5 (95% CI 3.1-6.5). There was a significantly higher proportion of unaffected intervention blocks, and affected blocks had on average substantially less cases than affected control blocks. This study indicates that community-based environmental management inserted in the routine A. aegypti control programme can not only sustainably curb vector infestation but also have an impact on dengue transmission.     

Surveillance of dengue fever cases using a novel Aedes aegypti population sampling method in Trinidad, West Indies: the cardinal points approach

A novel dengue surveillance method is described and used to evaluate 100 suspected dengue fever (DF) cases in county St. Patrick, Trinidad, West Indies. From the 30 confirmed DF cases fully investigated within 48 h of diagnosis, 63% (19/30 houses) of their homes were found harboring Aedes aegypti immature stages. Only houses at the four cardinal points of the index case rather than the entire neighborhood were investigated. The results showed significantly (P<0.001) more Ae. aegypti positive houses were observed to the east (P<0.04) and west (P<0.01) than to the north and south (P>0.9). In addition, from the 150 houses inspected a total of 474 artificial containers were inspected and treated, of which 20.8% (99) were infested with Ae. aegypti immature stages. More than 49% of the containers inspected were small miscellaneous containers, but they only produced 4.0% of the Ae. aegypti immatures, of which only 0.4% were pupae. Water tanks (41.7%), drums (40.4%) and buckets (24.2%) produced over 98% of the pupae. The results of this study imply that dengue vector control programs in Trinidad could increase their efficiency by applying the cardinal points surveillance approach during DF case investigations and concentrating their vector control measures on the most productive containers located at the east and west of the index cases.     

Impact of vector control on a dengue fever outbreak in Trinidad, West Indies, in 1998

In 1998, Trinidad experienced its first major outbreak of dengue haemorrhagic fever. Data from the Trinidad Public Health Laboratory, the National Surveillance Unit and Insect Vector Control Division, Ministry of Health, Trinidad and Tobago were analysed to determine the impact of vector control measures on the dengue outbreak. Geographical Information Systems (GIS)/Global Positioning Systems (GPS) were used to map cases and to distinguish epidemiological clusters. The Aedes aegypti population densities were higher than the 5% transmission threshold in all counties. The spatial distribution of dengue fever cases was significantly correlated with the heavily populated east-west corridor in the north and several distinctly separate clusters in the western part of the island. The temporal distribution patterns showed significantly more dengue fever cases occurring during the rainy season than during the dry season. This study documents the importance of vector control in the prevention of dengue transmission since no vaccine is currently available, and emphasizes the urgent need to understand better the environmental factors which contribute to the proliferation of this disease vector Ae. aegypti.     

Efficacy of a spatial repellent for control of Aedes-borne virus transmission: A cluster-randomized trial in Iquitos,Peru

Over half the world’s population is at risk for viruses transmitted by Aedes mosquitoes, such as dengue and Zika. The primary vector, Aedes aegypti, thrives in urban environments. Despite decades of effort, cases and geographic range of Aedes-borne viruses (ABVs) continue to expand. Rigorously proven vector control interventions that measure protective efficacy against ABV diseases are limited to Wolbachia in a single trial in Indonesia and do not include any chemical intervention. Spatial repellents, a new option for efficient deployment, are designed to decrease human exposure to ABVs by releasing active ingredients into the air that disrupt mosquito–human contact. A parallel, cluster-randomized controlled trial was conducted in Iquitos, Peru, to quantify the impact of a transfluthrin-based spatial repellent on human ABV infection. From 2,907 households across 26 clusters (13 per arm), 1,578 participants were assessed for seroconversion (primary endpoint) by survival analysis. Incidence of acute disease was calculated among 16,683 participants (secondary endpoint). Adult mosquito collections were conducted to compare Ae. aegypti abundance, blood-fed rate, and parity status through mixed-effect difference-in-difference analyses. The spatial repellent significantly reduced ABV infection by 34.1% (one-sided 95% CI lower limit, 6.9%; one-sided P value = 0.0236, z = 1.98). Aedes aegypti abundance and blood-fed rates were significantly reduced by 28.6 (95% CI 24.1%, ∞); z = −9.11) and 12.4% (95% CI 4.2%, ∞); z = −2.43), respectively. Our trial provides conclusive statistical evidence from an appropriately powered, preplanned cluster-randomized controlled clinical trial of the impact of a chemical intervention, in this case a spatial repellent, to reduce the risk of ABV transmission compared to a placebo.

Aedes-borne viral diseases (ABVDs) [e.g., dengue (DENV), chikungunya, Zika (ZIKV), and yellow fever] are devastating, expanding global public health threats that disproportionally affect low- and middle-income countries. DENV, one of the most rapidly increasing vector-borne infectious diseases, results in ∼400 million infections each year (1, 2), with 4 billion people at risk for infection annually (3). Currently, the primary means for ABVD prevention is controlling the primary mosquito vector, Aedes aegypti. Existing vector control interventions, however, have failed to prevent ABV transmission and epidemics (4–6).There is an urgent need to develop evidence-based guidance for the use of new and existing ABV vector control tools. The evidence base for vector control against ABVs is weak, despite considerable government investments in World Health Organization (WHO)-recommended control of larval habitats (larviciding, container removal) and ultra-low-volume insecticide spraying (4, 5, 7–9). These strategies continue to be implemented despite the lack of rigorously generated data from controlled clinical trials demonstrating they reduce ABV infection or disease (6). The only ABV intervention with a proven epidemiological impact in a cluster-randomized control trial (cRCT) assessed community mobilization to reduce mosquito larval habitats (10). A recent test-negative trial with Wolbachia-infected mosquitoes reported a significant reduction of DENV illness in Indonesia (11).Spatial repellents (SRs) are devices that contain volatile active ingredients that disperse in air. The active ingredients can repel mosquitoes from entering a treated space, inhibit attraction to human host cues, or disrupt mosquito biting and blood-feeding behavior and, thus, interfere with mosquito–human contact (12–14). Any of these outcomes reduce the probability of pathogen transmission. Pyrethroid-based SRs have shown efficacy in reducing malaria infections in China (15) and Indonesia (16). There have, however, been no clinical trials evaluating the protective efficacy (PE) of SRs against ABV infection or disease.To generate evidence for public health consideration, we conducted a double-blinded, parallel cRCT to demonstrate and quantify the PE of a transfluthrin-based SR to reduce ABV infection incidence over 2 y in a human cohort in Iquitos, Peru.     

Disease control in primary health care: a historical perspective

The effectiveness of disease control by mobile teams decreased when countries became independent. Early case-finding and continuity of care require permanently accessible health care facilities where rationalization by professionals and participation of the users are well balanced. The Primary Health Care concept, a plea for this equilibrium, has been discredited by different types of misapplication. Correctly functioning and accessible first line health services, completed by a referral level, are a precondition for effective participation of the users. Where 'ideal health districts' cannot be realized, a form of steady exchanges between generalists and the specialists of the referral level has lead to diverse 'functional districts'.     

Occurrence, productivity and spatial distribution of key-premises in two dengue-endemic areas of Rio de Janeiro and their role in adult Aedes aegypti spatial infestation pattern

Objectives To evaluate: (1) the occurrence, maintenance, productivity, spatial distribution and premise condition index score of Adese aegypti‐infested houses and key‐premises in a suburban district (Tubiacanga) and a slum (Favela do Amorim) of Rio de Janeiro and (2) the role of these factors in adult Ae. aegypti female spatial distribution. Methods and Results A total of 2456 premises were inspected for immature and 1100 for adult collection. Key‐premises corresponded to 16.08% and 17.86% of infested houses in Tubiacanga, and 13.5% and 11.1% in Favela do Amorim, during the dry and wet seasons, respectively. Key‐premises held significantly more immature Ae. aegypti, pupae and larvae than infested houses in Favela do Amorim and Tubiacanga during the dry and wet seasons. In Favela do Amorim, key‐premises had a significantly higher PCI score than infested but non‐key houses. Conclusion The spatial distribution of key‐premises and adult Ae. aegypti females was often congruent, indicating that key‐premises influence the infestation pattern observed in the study areas.