Study protocol: improving response to malaria in the Amazon through identification of inter-community networks and human mobility in border regions of Ecuador, Peru and Brazil

INTRODUCTION

Understanding human mobility's role in malaria transmission is critical to successful control and elimination. However, common approaches to measuring mobility are ill-equipped for remote regions such as the Amazon. This study develops a network survey to quantify the effect of community connectivity and mobility on malaria transmission.

METHODS

We measure community connectivity across the study area using a respondent driven sampling design among key informants who are at least 18 years of age. 45 initial communities will be selected: 10 in Brazil, 10 in Ecuador and 25 in Peru. Participants will be recruited in each initial node and administered a survey to obtain data on each community's mobility patterns. Survey responses will be ranked and the 2-3 most connected communities will then be selected and surveyed. This process will be repeated for a third round of data collection. Community network matrices will be linked with each country's malaria surveillance system to test the effects of mobility on disease risk.

ETHICS AND DISSEMINATION

This study protocol has been approved by the institutional review boards of Duke University (USA), Universidad San Francisco de Quito (Ecuador), Universidad Peruana Cayetano Heredia (Peru) and Universidade Federal Minas Gerais (Brazil). Results will be disseminated in communities by the end of the study.

Network Profile: Improving Response to Malaria in the Amazon through Identification of Inter-Community Networks and Human Mobility in Border Regions of Ecuador, Peru, and Brazil

Objectives

Understanding human mobility's role on malaria transmission is critical to successful control and elimination. However, common approaches to measuring mobility are ill-equipped for remote regions such as the Amazon. This study develops a network survey to quantify the effect of community connectivity and mobility on malaria transmission.

Design

A community-level network survey.

Setting

We collect data on community connectivity along three river systems in the Amazon basin: the Pastaza river corridor spanning the Ecuador-Peru border; and the Amazon and Javari river corridors spanning the Brazil-Peru border.

Participants

We interviewed key informants in Brazil, Ecuador, and Peru, including from indigenous communities: Shuar, Achuar, Shiwiar, Kichwa, Ticuna, and Yagua. Key informants are at least 18 years of age and are considered community leaders.

Primary outcome

Weekly, community-level malaria incidence during the study period.

Methods

We measure community connectivity across the study area using a respondent driven sampling design. Forty-five communities were initially selected: 10 in Brazil, 10 in Ecuador, and 25 in Peru. Participants were recruited in each initial node and administered a survey to obtain data on each community's mobility patterns. Survey responses were ranked and the 2-3 most connected communities were then selected and surveyed. This process was repeated for a third round of data collection. Community network matrices will be linked with eadch country's malaria surveillance system to test the effects of mobility on disease risk.

Findings

To date, 586 key informants were surveyed from 126 communities along the Pastaza river corridor. Data collection along the Amazon and Javari river corridors is ongoing. Initial results indicate that network sampling is a superior method to delineate migration flows between communities.

Conclusions

Our study provides measures of mobility and connectivity in rural settings where traditional approaches are insufficient, and will allow us to understand mobility's effect on malaria transmission.

The impact of sustained malaria control in the Loreto region of Peru: a retrospective, observational, spatially-varying interrupted time series analysis of the PAMAFRO program

Background

Although malaria control investments worldwide have resulted in dramatic declines in transmission since 2000, progress has stalled. In the Amazon, malaria resurgence has followed withdrawal of Global Fund support of the Project for Malaria Control in Andean Border Areas (PAMAFRO). We estimate intervention-specific and spatially-explicit effects of the PAMAFRO program on malaria incidence across the Loreto region of Peru, and consider the influence of the environmental risk factors in the presence of interventions.

Methods

We conducted a retrospective, observational, spatial interrupted time series analysis of malaria incidence rates among people reporting to health posts across Loreto, Peru between the first epidemiological week of January 2001 and the last epidemiological week of December 2016. Model inference is at the smallest administrative unit (district), where the weekly number of diagnosed cases of Plasmodium vivax and Plasmodium falciparum were determined by microscopy. Census data provided population at risk. We include as covariates weekly estimates of minimum temperature and cumulative precipitation in each district, as well as spatially- and temporally-lagged malaria incidence rates. Environmental data were derived from a hydrometeorological model designed for the Amazon. We used Bayesian spatiotemporal modeling techniques to estimate the impact of the PAMAFRO program, variability in environmental effects, and the role of climate anomalies on transmission after PAMAFRO withdrawal.

Findings

During the PAMAFRO program, incidence of P. vivax declined from 42.8 to 10.1 cases/1000 people/year. Incidence for P. falciparum declined from 14.3 to 2.5 cases/1000 people/year over this same period. The effects of PAMAFRO-supported interventions varied both by geography and species of malaria. Interventions were only effective in districts where interventions were also deployed in surrounding districts. Further, interventions diminished the effects of other prevailing demographic and environmental risk factors. Withdrawal of the program led to a resurgence in transmission. Increasing minimum temperatures and variability and intensity of rainfall events from 2011 onward and accompanying population displacements contributed to this resurgence.

Interpretation

Malaria control programs must consider the climate and environmental scope of interventions to maximize effectiveness. They must also ensure financial sustainability to maintain local progress and commitment to malaria prevention and elimination efforts, as well as to offset the effects of environmental change that increase transmission risk.

Funding

National Aeronautics and Space Administration, National Institutes of Health, Bill and Melinda Gates Foundation.

Evolving Drivers of Brazilian SARS-CoV-2 Transmission: A Spatiotemporally Disaggregated Time Series Analysis of Meteorology, Policy, and Human Mobility

Brazil has been severely affected by the COVID-19 pandemic. Temperature and humidity have been purported as drivers of SARS-CoV-2 transmission, but no consensus has been reached in the literature regarding the relative roles of meteorology, governmental policy, and mobility on transmission in Brazil. We compiled data on meteorology, governmental policy, and mobility in Brazil's 26 states and one federal district from June 2020 to August 2021. Associations between these variables and the time-varying reproductive number (R _t ) of SARS-CoV-2 were examined using generalized additive models fit to data from the entire 15-month period and several shorter, 3-month periods. Accumulated local effects and variable importance metrics were calculated to analyze the relationship between input variables and R _t . We found that transmission is strongly influenced by unmeasured sources of between-state heterogeneity and the near-recent trajectory of the pandemic. Increased temperature generally was associated with decreased transmission and increased specific humidity with increased transmission. However, the impacts of meteorology, policy, and mobility on R _t varied in direction, magnitude, and significance across our study period. This time variance could explain inconsistencies in the published literature to date. While meteorology weakly modulates SARS-CoV-2 transmission, daily or seasonal weather variations alone will not stave off future surges in COVID-19 cases in Brazil. Investigating how the roles of environmental factors and disease control interventions may vary with time should be a deliberate consideration of future research on the drivers of SARS-CoV-2 transmission.

Poverty dynamics, ecological endowments, and land use among smallholders in the Brazilian Amazon

Rural settlement in previously sparsely occupied areas of the Brazilian Amazon has been associated with high levels of forest loss and unclear long-term social outcomes. We focus here on the micro-level processes in one settlement area to answer the question of how settler and farm endowments affect household poverty. We analyze the extent to which poverty is sensitive to changes in natural capital, land use strategies, and biophysical characteristics of properties (particularly soil quality). Cumulative time spent in poverty is simulated using Markovian processes, which show that accessibility to markets and land use system are especially important for decreasing poverty among households in our sample. Wealtheir households are selected into commercial production of perennials before our initial observation, and are therefore in poverty a lower proportion of the time. Land in pasture, in contrast, has an independent effect on reducing the proportion of time spent in poverty. Taken together, these results show that investments in roads and the institutional structures needed to make commercial agriculture or ranching viable in existing and new settlement areas can improve human well-being in frontiers.

Poverty and Inequality in the Rural Brazilian Amazon: A Multidimensional Approach

This paper analyses poverty and inequality dynamics among smallholders along the Transamazon High-way. We measure changes in poverty and inequality for original settlers and new owners, contrasting income-based with multidimensional indices of well-being. Our results show an overall reduction in both poverty and inequality among smallholders, although poverty decline was more pronounced among new owners, while inequality reduction was larger among original settlers. This trend suggests that families have an initial improvement in livelihood and well-being which tends to reach a limit later-a sign of structural limitations common to rural areas and maybe a replication of boom and bust trends in local economies among Amazonian municipalities. In addition, our multidimensional estimates of well-being reveal that some economically viable land use strategies of smallholders (e.g., pasture) may have important ecological implications for the regional landscape. These findings highlight the public policy challenges for fostering sustainable development among rural populations.

Gender-specific out-migration, deforestation and urbanization in the Ecuadorian Amazon

The Ecuadorian Amazon, one of the richest reserves of biodiversity in the world, has faced one of the highest rates of deforestation of any Amazonian nation. Most of this forest elimination has been caused by agricultural colonization that followed the discovery of oil fields in 1967. Since the 1990s, an increasing process of urbanization has also engendered new patterns of population mobility within the Amazon, along with traditional ways by which rural settlers make their living. However, while very significant in its effects on deforestation, urbanization and regional development, population mobility within the Amazon has hardly been studied at all, as well as the distinct migration patterns between men and women. This paper uses a longitudinal dataset of 250 farm households in the Northern Ecuadorian Amazon to understand differentials between men and women migrants to urban and rural destinations and between men and women non-migrants. First, we use hazard analysis based on the Kaplan-Meier (KM) estimator to obtain the cumulative probability that an individual living in the study area in 1990 or at time t, will out-migrated at some time, t+n, before 1999. Results indicate that out-migration to other rural areas in the Amazon, especially pristine areas is considerably greater than out-migration to the growing, but still incipient, Amazonian urban areas. Furthermore, men are more likely to out-migrate to rural areas than women, while the reverse occurs for urban areas. Difference-of-means tests were employed to examine potential factors accounting for differentials between male and female out-migration to urban and rural areas. Among the key results, relative to men younger women are more likely to out-migrate to urban areas; more difficult access from farms to towns and roads constrains women's migration; and access to new lands in the Amazon-an important cause of further deforestation-is more associated with male out-migration. Economic factors such as engagement in on-farm work, increasing resource scarcity-measured by higher population density at the farm and reduction in farm land on forest and crops-and increase in pasture land are more associated with male out-migration to rural areas. On the other hand, increasing resource scarcity, higher population density and weaker migration networks are more associated with female out-migration to urban areas. Thus, a "vicious cycle" is created: Pressure over land leads to deforestation in most or all farm forest areas and reduces the possibilities for further agricultural extensification (deforestation); out-migration, especially male out-migration, occurs to other rural or forest areas in the Amazon (with women being more likely to choose urban destinations); and, giving continuing population growth and pressures in the new settled areas, new pressures promote further out-migration to rural destinations and unabated deforestation.