Perceptions of Problems with Household Insects: Qualitative and Quantitative Findings from Peri-Urban Communities in Arequipa, Peru

Vector-borne diseases continue to impose a major health burden on Peru and neighboring countries. The challenge of addressing vector-borne disease is compounded by changing social, economic, and climatic conditions. Peri-urban Arequipa is an important region to study insect infestations because of ongoing challenges with disease vectors such as triatomines and a variety of other insects. We conducted surveys (N = 1,182) and seven focus groups (average seven participants) in peri-urban Arequipa to explore knowledge of and perception toward various insects that infest the region. Focus group participants reported the presence of a wide variety of insects in and around the home, including disease vectors such as triatomines (also identified by 27.2% of survey households), mosquitoes, spiders, and bed bugs, as well as nuisance insects. Health concerns related to insects included vector-borne diseases, spider bites, allergies, and sequelae from bed bug bites, and hygiene concerns. A majority of participants in the quantitative surveys identified triatomines as the insect they were most worried about (69.9%) and could identify Chagas disease as a health risk associated with triatomines (54.9%). Insect infestations in peri-urban Arequipa present multiple burdens to residents, including injury and illness from triatomines and other insects, as well as potential mental and economic concerns related to insects such as bed bugs. Future initiatives should continue to address triatomine infestations through educational outreach and implement a more holistic approach to address the burden of both disease and nuisance insects.

"Easy women get it": pre-existing stigma associated with HPV and cervical cancer in a low-resource setting prior to implementation of an HPV screen-and-treat program

BACKGROUND

Cervical cancer is preventable with vaccination and early detection and treatment programs. However, for these programs to work as intended, stigma related to HPV and cervical cancer must be understood and addressed. We explored pre-existing stigma associated with HPV and cervical cancer in the public healthcare system and community of a low-resource setting prior to implementation of an HPV screen-and-treat program.

METHODS

This study conducted thematic analysis of data collected during implementation of a novel HPV screen-and-treat system for cervical cancer early detection and treatment in Iquitos, Peru. We included 35 semi-structured interviews (19 health professionals, 16 women with cervical precancer or cancer), eight focus groups (70 community women), one workshop (14 health professionals), 210 counseling observations (with 20 nurse-midwives), and a document review. We used the Socio-Ecological Model to organize the analysis.

RESULTS

We identified three main themes: 1. the implication that women are to blame for their HPV infection through characterizations of being easy or promiscuous, 2. the implication that men are to blame for women's HPV infections through being considered careless or unfaithful, 3. HPV is shameful, embarrassing, and something that should be hidden from others. Consequently, in some cases, women refrained from getting screened for HPV. These themes were seen at the individual level among women, relationship level among women, men, and family members, community level among healthcare staff, and societal level within components of cervical cancer guidelines and male chauvinism.

CONCLUSIONS

Cervical cancer early detection and treatment programs in limited resource settings must address stigma entrenched throughout the entire healthcare system and community in order to sustainably and successfully implement and scale-up new programs. Interventions to tackle this stigma can incorporate messages about HPV infections and latency to lessen the focus on the influence of sexual behavior on HPV acquisition, and instead, promote screening and treatment as paramount preventative measures.

Using the Health Belief Model to Predict Pre-Travel Health Decisions among U.S.-Based Travelers

International travelers are at increased risk of infectious disease, but almost half of Americans traveling to lower- and middle-income countries seek no health information before traveling. The Health Belief Model (HBM) can help evaluate decisions by categorizing behaviors into five categories: susceptibility, severity, benefits, barriers, and self-efficacy. This study sought to use the HBM to elucidate what may influence an individual to make certain pre-travel health decisions. We surveyed 604 participants who had recently traveled to an at-risk country. Participants were subset into nested groups: full population, sought any health information, and visited a clinic or health care provider (HCP). Survey questions were categorized according to the HBM, assembled into a priori models, and analyzed in each group using logistic regression with three main outcome variables: "Sought any pre-travel health information," "Visited clinic or HCP," and "Received vaccine." Of the 604 participants, 333 (55%) sought any health information, 245 (41% of total) reported visiting an HCP, and 166 (27% of total) reported receiving a vaccine before traveling. Models containing variables from the susceptibility and benefits categories were most successful in predicting all three outcomes; susceptibility was a more relevant consideration in information seeking and seeing a provider than vaccination, whereas benefits was relevant for all outcomes. Our results emphasize the importance of an individual's perceived susceptibility to disease and perceived benefit of interventions in predicting pre-travel health behaviors. Understanding this interaction can help shape how HCPs and public health entities can encourage health care seeking and vaccine uptake in travelers.

An effective internet-based system for surveillance and elimination of triatomine insects: AlertaChirimacha

Vector-borne diseases remain a significant public health threat in many regions of the world. Traditional vector surveillance and control methods have relied on active and passive surveillance programs, which are often costly and time-consuming. New internet-based vector surveillance systems have shown promise in removing some of the cost and labor burden from health authorities. We developed and evaluated the effectiveness of a new internet-based surveillance system, "AlertaChirimacha", for detecting Triatoma infestans (known locally by its Quechua name, Chirimacha), the Chagas disease vector, in the city of Arequipa, Peru. In the first 26 months post-implementation, AlertaChirimacha received 206 reports of residents suspecting or fearing triatomines in their homes or neighborhoods, of which we confirmed, through pictures or inspections, 11 (5.3%) to be Triatoma infestans. After microscopic examination, none of the specimens collected were infected with Trypanosoma cruzi. AlertaChirimacha received 57% more confirmed reports than the traditional surveillance system and detected 10% more infested houses than active and passive surveillance approaches combined. Through in-depth interviews we evaluate the reach, bilateral engagement, and response promptness and efficiency of AlertaChirimacha. Our study highlights the potential of internet-based vector surveillance systems, such as AlertaChirimacha, to improve vector surveillance and control efforts in resource-limited settings. This approach could decrease the cost and time horizon for the elimination of vector-mediated Chagas disease in the region.

"Easy women get it": Pre-existing stigma associated with HPV and cervical cancer in a low-resource setting prior to implementation of an HPV screen-and-treat program

Background

Cervical cancer is preventable with vaccination and early detection and treatment programs. However, in order for these programs to work as intended, stigma related to HPV and cervical cancer must be understood and addressed. We explored pre-existing stigma associated with HPV and cervical cancer in the public healthcare system of a low-resource setting prior to implementation of an HPV screen-and-treat program.

Methods

This study conducted thematic analysis of data collected during implementation of a novel HPV screen-and-treat system for cervical cancer early detection and treatment in Iquitos, Peru. We included 35 semi-structured interviews (19 health professionals, 16 women with cervical precancer or cancer), eight focus groups (70 community women), one workshop (14 health professionals), 210 counseling observations (with 20 nurse-midwives), and a document review. We used the Socio-Ecological Model to organize the analysis.

Results

We identified three main themes: 1. the implication that women are to blame for their HPV infection through characterizations of being easy or promiscuous, 2. the implication that men are to blame for women's HPV infections through being considered careless or unfaithful, 3. HPV is shameful, embarrassing, and something that should be hidden from others. Consequently, in some cases, women refrained from getting screened for HPV. These themes were seen at the individual level among women, relationship level among women, men, and family members, community level among healthcare staff, and societal level within components of cervical cancer guidelines and male chauvinism.

Conclusions

Cervical cancer early detection and treatment programs in limited resource settings must address stigma entrenched throughout the entire healthcare system in order to sustainably and successfully implement and scale-up new programs. Interventions to tackle this stigma can incorporate messages about HPV infections and latency to lessen the focus on the influence of sexual behavior on HPV acquisition, and instead, promote screening and treatment as paramount preventative measures.

Direct mosquito feedings on dengue-2 virus-infected people reveal dynamics of human infectiousness

Dengue virus (DENV) transmission from humans to mosquitoes is a poorly documented, but critical component of DENV epidemiology. Magnitude of viremia is the primary determinant of successful human-to-mosquito DENV transmission. People with the same level of viremia, however, can vary in their infectiousness to mosquitoes as a function of other factors that remain to be elucidated. Here, we report on a field-based study in the city of Iquitos, Peru, where we conducted direct mosquito feedings on people naturally infected with DENV and that experienced mild illness. We also enrolled people naturally infected with Zika virus (ZIKV) after the introduction of ZIKV in Iquitos during the study period. Of the 54 study participants involved in direct mosquito feedings, 43 were infected with DENV-2, two with DENV-3, and nine with ZIKV. Our analysis excluded participants whose viremia was detectable at enrollment but undetectable at the time of mosquito feeding, which was the case for all participants with DENV-3 and ZIKV infections. We analyzed the probability of onward transmission during 50 feeding events involving 27 participants infected with DENV-2 based on the presence of infectious virus in mosquito saliva 7-16 days post blood meal. Transmission probability was positively associated with the level of viremia and duration of extrinsic incubation in the mosquito. In addition, transmission probability was influenced by the day of illness in a non-monotonic fashion; i.e., transmission probability increased until 2 days after symptom onset and decreased thereafter. We conclude that mildly ill DENV-infected humans with similar levels of viremia during the first two days after symptom onset will be most infectious to mosquitoes on the second day of their illness. Quantifying variation within and between people in their contribution to DENV transmission is essential to better understand the biological determinants of human infectiousness, parametrize epidemiological models, and improve disease surveillance and prevention strategies.

Measuring dengue illness intensity: Development and content validity of the dengue virus daily diary (DENV-DD)

BACKGROUND

Dengue is the most prevalent arboviral infection causing an estimated 50-60 million cases of febrile illness globally per year, exacting considerable disease burden. Few instruments exist to assess the patient illness experience, with most based on healthcare provider assessment, lacking standardization in timepoints and symptom assessment. This study aimed to evaluate the content validity of the novel 'Dengue Virus Daily Diary (DENV-DD)', designed to measure symptom intensity and disease burden within outpatient infant to adult populations.

METHODS

The Dengue Illness Index Report Card was used as a foundation to create the DENV-DD, consisting of patient- and observer-reported outcome (PRO/ObsRO) instruments. In two South American dengue-endemic communities, qualitative combined concept elicitation and cognitive debriefing interviews were conducted among individuals and caregivers of children with symptomatic laboratory-confirmed dengue. Interviews were conducted across two rounds allowing DENV-DD modifications. A small-scale quantitative assessment of the DENV-DD was also conducted with data from an independent Dengue Human Infection Model (DHIM) to generate early evidence of feasibility of DENV-DD completion, instrument performance and insight into the sign/symptom trajectory over the course of illness.

RESULTS

Forty-eight participants were interviewed (20 adults, 20 older children/adolescents with their caregivers, 8 caregivers of younger children). A wide spectrum of signs/symptoms lasting 3-15 days were reported with fever, headache, body ache/pain, loss of appetite, and body weakness each reported by > 70% participants. DENV-DD instructions, items and response scales were understood, and items were considered relevant across ages. DHIM data supported feasibility of DENV-DD completion.

CONCLUSIONS

Findings demonstrate content validity of the DENV-DD (PRO/ObsRO instruments) in dengue-endemic populations. Psychometric and cultural validity studies are ongoing to support use of the DENV-DD in clinical studies.

Challenges associated with follow-up care after implementation of an HPV screen-and-treat program with ablative therapy for cervical cancer prevention in Iquitos, Peru: a mixed methods study

Background

Cervical cancer is a preventable cancer; however, decreasing its prevalence requires early detection and treatment strategies that reduce rates of loss to follow-up. This study explores factors associated with loss to follow-up among HPV-positive women after implementation of a screen-and-treat approach with visual triage and ablative therapy for cervical cancer prevention in Iquitos, Peru.

Methods

We conducted semi-structured interviews with nurse-midwives (n = 15) working in cervical cancer prevention and women (n = 24) who were recorded as lost to follow-up after positive HPV results. We used the Health Care Access Barriers Model to guide analysis. We utilize manifest content analysis to describe barriers to follow-up according to the nurse-midwives and thematic analysis to report themes from the women's perspectives. We also report the steps and time taken to contact women and report discrepancies and concordances between nurse-midwives and women regarding reasons for loss to follow-up.

Results

Women in this study expressed a desire to receive treatment. Barriers, including fragmented and incomplete registry systems, made receiving follow-up care more challenging. Nurse-midwives faced structural barriers in attempting to deliver positive results to women who were challenging to contact, and women did not have clear knowledge of how to receive their HPV results. Women faced cognitive barriers including a lack of understanding about HPV results and treatment procedures, fear or anxiety about HPV or treatment, and confusion about the follow-up process. Women also reported having important work matters as a barrier. Reported financial barriers were minimal. There was agreement between women's and nurse-midwives' reported barriers to follow-up in slightly over half of the cases.

Conclusion

This study highlights the barriers to follow-up after implementation of a primary-level HPV-based screen-and-treat approach. While some barriers that have previously been associated with loss to follow-up were not observed in this study (e.g., financial), we emphasize the need for screen-and-treat programs to focus on strategies that can address incomplete registry systems, structural challenges in results delivery, cognitive barriers in understanding results and treatment, and work-related barriers.

"Day or night, no matter what, I will go": Women's perspectives on challenges with follow-up care after cervical cancer screening in Iquitos, Peru: a qualitative study

BACKGROUND

The study's objective was to explore the factors associated with loss to follow-up among women with abnormal cervical cancer screening results in Iquitos, Peru from women's perspectives.

METHODS

In-depth interviews were conducted with 20 screen-positive women who were referred for follow-up care but for whom evidence of follow-up was not found. Interview transcripts were thematically analyzed inductively, and the codes were then categorized using the Health Care Access Barriers Model for presentation of results.

RESULTS

All interviewed women were highly motivated to complete the continuum of care but faced numerous barriers along the way, including cognitive barriers such as a lack of knowledge about cervical cancer and poor communication from health professionals regarding the process, structural barriers such as challenges with scheduling appointments and unavailability of providers, and financial barriers including out-of-pocket payments and costs related to travel or missing days of work. With no information system tracking the continuum of care, we found fragmentation between primary and hospital-level care, and often, registration of women's follow-up care was missing altogether, preventing women from being able to receive proper care and providers from ensuring that women receive care and treatment as needed.

CONCLUSIONS

The challenges elucidated demonstrate the complexity of implementing a successful cervical cancer prevention program and indicate a need for any such program to consider the perspectives of women to improve follow-up after a positive screening test.

Quantifying heterogeneities in arbovirus transmission: Description of the rationale and methodology for a prospective longitudinal study of dengue and Zika virus transmission in Iquitos, Peru (2014-2019)

Current knowledge of dengue virus (DENV) transmission provides only a partial understanding of a complex and dynamic system yielding a public health track record that has more failures than successes. An important part of the problem is that the foundation for contemporary interventions includes a series of longstanding, but untested, assumptions based on a relatively small portion of the human population; i.e., people who are convenient to study because they manifest clinically apparent disease. Approaching dengue from the perspective of people with overt illness has produced an extensive body of useful literature. It has not, however, fully embraced heterogeneities in virus transmission dynamics that are increasingly recognized as key information still missing in the struggle to control the most important insect-transmitted viral infection of humans. Only in the last 20 years have there been significant efforts to carry out comprehensive longitudinal dengue studies. This manuscript provides the rationale and comprehensive, integrated description of the methodology for a five-year longitudinal cohort study based in the tropical city of Iquitos, in the heart of the Peruvian Amazon. Primary data collection for this study was completed in 2019. Although some manuscripts have been published to date, our principal objective here is to support subsequent publications by describing in detail the structure, methodology, and significance of a specific research program. Our project was designed to study people across the entire continuum of disease, with the ultimate goal of quantifying heterogeneities in human variables that affect DENV transmission dynamics and prevention. Because our study design is applicable to other Aedes transmitted viruses, we used it to gain insights into Zika virus (ZIKV) transmission when during the project period ZIKV was introduced and circulated in Iquitos. Our prospective contact cluster investigation design was initiated by detecttion of a person with a symptomatic DENV infection and then followed that person's immediate contacts. This allowed us to monitor individuals at high risk of DENV infection, including people with clinically inapparent and mild infections that are otherwise difficult to detect. We aimed to fill knowledge gaps by defining the contribution to DENV transmission dynamics of (1) the understudied majority of DENV-infected people with inapparent and mild infections and (2) epidemiological, entomological, and socio-behavioral sources of heterogeneity. By accounting for factors underlying variation in each person's contribution to transmission we sought to better determine the type and extent of effort needed to better prevent virus transmission and disease.

Planning for resilience in screening operations using discrete event simulation modeling: example of HPV testing in Peru

Background

The World Health Organization (WHO) has called for the elimination of cervical cancer. Unfortunately, the implementation of cost-effective prevention and control strategies has faced significant barriers, such as insufficient guidance on best practices for resource and operations planning. Therefore, we demonstrate the value of discrete event simulation (DES) in implementation science research and practice, particularly to support the programmatic and operational planning for sustainable and resilient delivery of healthcare interventions. Our specific example shows how DES models can inform planning for scale-up and resilient operations of a new HPV-based screen and treat program in Iquitos, an Amazonian city of Peru.

Methods

Using data from a time and motion study and cervical cancer screening registry from Iquitos, Peru, we developed a DES model to conduct virtual experimentation with “what-if” scenarios that compare different workflow and processing strategies under resource constraints and disruptions to the screening system.

Results

Our simulations show how much the screening system’s capacity can be increased at current resource levels, how much variability in service times can be tolerated, and the extent of resilience to disruptions such as curtailed resources. The simulations also identify the resources that would be required to scale up for larger target populations or increased resilience to disruptions, illustrating the key tradeoff between resilience and efficiency. Thus, our results demonstrate how DES models can inform specific resourcing decisions but can also highlight important tradeoffs and suggest general “rules” for resource and operational planning.

Conclusions

Multilevel planning and implementation challenges are not unique to sustainable adoption of cervical cancer screening programs but represent common barriers to the successful scale-up of many preventative health interventions worldwide. DES represents a broadly applicable tool to address complex implementation challenges identified at the national, regional, and local levels across settings and health interventions—how to make effective and efficient operational and resourcing decisions to support program adaptation to local constraints and demands so that they are resilient to changing demands and more likely to be maintained with fidelity over time.

Women's perspectives on the acceptability and feasibility of an HPV screen-and-treat approach to cervical cancer prevention in Iquitos, Peru: a qualitative study

BACKGROUND

The objective of this study was to explore women's experiences of a screen-and-treat approach with ablative therapy (referred to by the Spanish acronym TVT-TA) as a method of treatment following a positive HPV test in Iquitos, Peru.

METHODS

A total of 111 in-depth interviews were conducted with 47 HPV positive women who attended the TVT-TA procedure at a primary-level healthcare facility. Interviews were conducted immediately before, immediately after, and six-weeks after TVT-TA.

RESULTS

Most interviewed women reported experiencing moderate pain during ablative therapy and minimal pain immediately after and six weeks after ablative therapy. Women also stated that the pain was less intense than they had expected. The most common physical after-effects of treatment were bleeding and vaginal odor. Women experienced oscillating emotions with fear upon receiving a positive HPV result, calming after hearing about ablative therapy treatment, worry about pain from the treatment itself, relaxation with counseling about the procedure, and relief following treatment.

CONCLUSIONS

Nearly all participants emphasized that they were pleased with the TVT-TA process even if they had experienced pain during TVT-TA, recommended that TVT-TA be expanded and available to more women, and stated that TVT-TA was faster and easier than expected. This study found that TVT-TA is a feasible and acceptable means of treating HPV according to the women receiving the treatment.

Resistance to single dose albendazole and reinfection with intestinal helminths among children ages 2 to 11 years from the Peruvian Amazon region: a study protocol

BACKGROUND

Deworming programs aimed at reducing morbidity and mortality from geohelminth infections are common in many countries where these infections are endemic, but data demonstrating increasing levels of resistance to albendazole and mebendazole are causes for concern. Studies to evaluate the clinical efficacy of deworming programs are critical to maintain high infection control goals.

METHODS

We propose to assess the clinical efficacy of Peruvian national guidelines for deworming programs in a prospective observational study conducted in the Amazon River basin area near Iquitos, Peru. Major outcomes to be evaluated include (1) albendazole resistance of intestinal helminths (trichuriasis, ascariasis, hookworm), and (2) frequency of reinfection with intestinal helminths 4 months after treatment with albendazole. Children ages 2-11 years from the Belén District of Iquitos will be identified based on a community census. Following parental informed consent, demographic data, weight, and height will be recorded and a stool specimen for parasitological exam by direct observation and Kato-Katz concentration method, and helminthic egg counts will be collected prior to administration of albendazole, following Peruvian national guidelines. Follow-up stool specimens examined in the same manner will be collected at 20 days, 90 days, and 100 days following initial administration of albendazole, and based on parasites found repeat treatment will be administered in accordance with national guidelines. Real-time multiplex qPCR will be performed on helminth positive samples collected prior to initial deworming and on helminth-positive specimens detected on day 15-20. A total sample size of 380 participants was calculated based on total population in the target group and prevalence estimates of helminth infections and clinical resistance based on recent data.

DISCUSSION

Data from observational clinical efficacy studies are important to guide geohelminth infection control programs. Trial registration https://www.researchregistry.com/ . Identification number: researchregistry7736; Registered retrospectively March 13, 2022; https://www.researchregistry.com/browse-the-registry#home/registrationdetails/622e024cf06132001e3327bf/.

Determinants of food insecurity among households with children in Villa el Salvador, Lima, Peru: the role of gender and employment, a cross-sectional study

Background

From 2014–2019, Latin America and the Caribbean had the fastest growth of moderate-to-severe food insecurity than any other region, rising from 22.9% to 31.7%. While the prevalence of food insecurity is higher among women than men in every continent, Latin America has the largest food insecurity gender gap. Factors contributing to this gender inequity include underrepresentation of women in formal employment, heightened burden of dependent care on women, and unequal compensation of labor for women vs. men. The objective of this study was to investigate the association between the gender of the head of the household, employment status of household members, and food insecurity in households with children in a low-income district of Lima, Peru.

Methods

This cross-sectional study was carried out in Villa El Salvador, the fifth largest district in Metropolitan Lima, Peru, where over 20% of the population lives in poverty. Data were collected on a stratified random sample (n = 329) using a household questionnaire, including a validated food security tool (HFIAS). We ran multivariate logistic regression models predicting household food insecurity, with independent variables including gender of household head, education of household head, employment of household head, household-level employment status, age, and weekly food expenses per person.

Results

In fully adjusted models, woman-headed households had almost thrice the odds of being food insecure compared to man-headed households. Education also had a significant effect size: a household whose household head did not complete high school was 3.4 times more likely to be food insecure than if they had some post-secondary education. Woman-headed households had a significantly higher proportion of members not formally employed, compared to man-headed households, but employment status was not associated with food insecurity.

Conclusions

Gender of the household head was a major contributing factor to household food insecurity in Villa el Salvador. Gender dynamics affecting opportunities for employment, education, and non-remunerated work should inform national food security policies and interventions with the goal to not only lower food insecurity, but also reduce gender inequities in food insecurity and other nutritional outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12889-4.

Exploring perceived risk for COVID-19 and its role in protective behavior and COVID-19 vaccine hesitancy: a qualitative study after the first wave

Background

The novel coronavirus pandemic (COVID-19) has had severe impacts on morbidity and mortality globally.

Methods

This study was set in rural central Kentucky and included participants recruited from public spaces. Fifteen qualitative interviews about personal experiences during the COVID-19 pandemic were conducted by phone from July 3 to July 24, 2020. Interviews were recorded, transcribed, and coded using a grounded theory approach.

Results

Participants who perceived COVID-19 to be a severe risk tended to have personal health concerns and therefore reported taking protective measures for themselves. A slightly smaller proportion of participants reported taking measures to protect others (particularly family). A minority of participants had an ambivalent attitude towards the risk and only took measures if required. COVID-19 vaccine acceptability was low with most participants expressing concerns regarding their need for a vaccine, safety of this vaccine, the value of personal rights, or future vaccine supply.

Conclusions

Most participants perceived some risk of COVID-19 and took steps to prevent infections in themselves and others. Mandates for mask use in certain locations were additionally useful for those who had an ambivalent attitude towards the risk of illness. There was surprisingly little connection between perceiving COVID-19 risk and a desire for the COVID-19 vaccine. In this setting, vaccine acceptability was low, with vaccine concerns outweighing perceived potential benefits. In conclusion, because the risk was often constructed in terms of worries for themselves and others, the framing of health education materials for protective behaviors in these terms may be effective. Furthermore, future COVID-19 vaccine education should address vaccine knowledge and concerns, such as the need for a vaccine and its safety, and emphasize how a vaccination would reduce their chances of severe disease if they were to get sick.

The impact of dengue illness on social distancing and caregiving behavior

BACKGROUND

Human mobility among residential locations can drive dengue virus (DENV) transmission dynamics. Recently, it was shown that individuals with symptomatic DENV infection exhibit significant changes in their mobility patterns, spending more time at home during illness. This change in mobility is predicted to increase the risk of acquiring infection for those living with or visiting the ill individual. It has yet to be considered, however, whether social contacts are also changing their mobility, either by socially distancing themselves from the infectious individual or increasing contact to help care for them. Social, or physical, distancing and caregiving could have diverse yet important impacts on DENV transmission dynamics; therefore, it is necessary to better understand the nature and frequency of these behaviors including their effect on mobility.

METHODOLOGY AND PRINCIPAL FINDINGS

Through community-based febrile illness surveillance and RT-PCR infection confirmation, 67 DENV positive (DENV+) residents were identified in the city of Iquitos, Peru. Using retrospective interviews, data were collected on visitors and home-based care received during the illness. While 15% of participants lost visitors during their illness, 22% gained visitors; overall, 32% of all individuals (particularly females) received visitors while symptomatic. Caregiving was common (90%), particularly caring by housemates (91%) and caring for children (98%). Twenty-eight percent of caregivers changed their behavior enough to have their work (and, likely, mobility patterns) affected. This was significantly more likely when caring for individuals with low "health-related quality of well-being" during illness (Fisher's Exact, p = 0.01).

CONCLUSIONS/SIGNIFICANCE

Our study demonstrates that social contacts of individuals with dengue modify their patterns of visitation and caregiving. The observed mobility changes could impact a susceptible individual's exposure to virus or a presymptomatic/clinically inapparent individual's contribution to onward transmission. Accounting for changes in social contact mobility is imperative in order to get a more accurate understanding of DENV transmission.

The 9th Symposium on Global Cancer Research: Looking Back and Charting a Path Forward in Global Cancer Control

The NCI Center for Global Health convened the 9th Annual Symposium on Global Cancer Research as a virtual 2-day meeting alongside the Consortium of Universities for Global Health Annual Conference, March 10–11, 2021. The virtual format allowed for diverse and inclusive participation by over 400 attendees from 70 countries, 25+ speakers from 12 countries, and sharing of research conducted in 68 countries. The highly interactive 2-day program explored the science and complex considerations around resilience and equity in global cancer research and control. The Symposium convened individuals working in global oncology to discuss trends in global cancer research and control and map out collaborative efforts to move the field forward. The accepted scientific abstracts are published in this special supplement of AACR Cancer Epidemiology, Biomarkers, and Prevention.

Heterogeneity of Dengue Illness in Community-Based Prospective Study, Iquitos, Peru

Measuring heterogeneity of dengue illness is necessary to define suitable endpoints in dengue vaccine and therapeutic trials and will help clarify behavioral responses to illness. To quantify heterogeneity in dengue illness, including milder cases, we developed the Dengue Illness Perceptions Response (IPR) survey, which captured detailed symptom data, including intensity, duration, and character, and change in routine activities caused by illness. During 2016–2019, we collected IPR data daily during the acute phase of illness for 79 persons with a positive reverse transcription PCR result for dengue virus RNA. Most participants had mild ambulatory disease. However, we measured substantial heterogeneity in illness experience, symptom duration, and maximum reported intensity of individual symptoms. Symptom intensity was a more valuable predicter of major activity change during dengue illness than symptom presence or absence alone. These data suggest that the IPR measures clinically useful heterogeneity in dengue illness experience and its relation to altered human behavior.

Use of Formal and Informal Food Resources by Food Insecure Families in Lima, Peru: A Mixed-Methods Analysis

The goal of this study was to measure food insecurity among families with children in a low-income district of Lima, Peru and to identify the formal and informal food resources available to them that may affect their food security status. In June-July 2019, we collected data from 329 randomly selected households in Villa El Salvador (Lima, Peru). Following a mixed methods approach, we found that the percentage of households using food assistance programs (FAPs) increased with increasing levels of food insecurity, but two FAPs were heavily used by households regardless of food (in)security. The main reasons for using FAPs included financial need, already being signed up in the program, and believing that the food was of nutritional value; the main reasons for non-use were finding the program unnecessary, dislike or poor perceived quality of the food, and not being able to sign up for the program. Similarly, informal food resources, such as buying food on credit or receiving food from someone outside the household, were incrementally used with increased levels of food insecurity. Our study clarifies the relationship between level of household food insecurity and FAP use – FAPs more commonly used by food insecure households were used because of financial need, whereas the FAPs most commonly used by food secure households were those with automatic enrollment. At a programmatic level, our research highlights the need for making nutritious and preferred foods available in FAPs and standardizing the application of enrollment criteria.

Knowledge, attitudes, and practices of cervical cancer prevention and pap smears in two low-income communities in Lima, Peru

BACKGROUND

Cervical cancer is a leading cause of death among Peruvian women. Barriers at multiple levels impact effective screening and treatment, including a lack of knowledge about cervical cancer and how regular screening can reduce morbidity and mortality through earlier detection. The aim of this study is to assess knowledge, attitudes, and practices regarding cervical cancer and its prevention in the peri-urban communities of Oasis and Pampas in southern Lima, Peru that can be used to inform future campaigns about cervical cancer prevention.

METHODS

A cross-sectional survey that included several open-ended questions was administered to women in Pampas and Oasis between 2015 and 2016 to evaluate the knowledge, attitudes, and practices regarding cervical cancer and Pap smears.

RESULTS

In total, 224 women were interviewed. Knowledge about cervical cancer and Pap smears was high, and attitudes were predominantly positive among most participants. Most participants knew how often they should get Pap smears (89.7%), when to begin seeking screening (74.6%), knew the price of a Pap smear (61.9%), and felt Pap smears were important for their health (70.1%). About one third (29.5%) of premenopausal women reported receiving a Pap smear in the last year. However, open ended questions revealed some knowledge gaps around Pap smears, as well as some stigma associated to Human Papilloma Virus (HPV) infection.

CONCLUSION

Although knowledge of cervical cancer prevention was generally high and perceptions were positive among women in peri-urban Peruvian communities, our findings revealed there is a need for education on HPV infection prevalence among sexually active individuals to reduce stigma. Future research should focus on exploring experiences with follow-up and treatment associated with abnormal Pap smears, as well as perspectives from health authorities and professionals about barriers in the early detection and treatment process for cervical cancer.

Potential for community based surveillance of febrile diseases: Feasibility of self-administered rapid diagnostic tests in Iquitos, Peru and Phnom Penh, Cambodia

Rapid diagnostic tests (RDTs) have the potential to identify infectious diseases quickly, minimize disease transmission, and could complement and improve surveillance and control of infectious and vector-borne diseases during outbreaks. The U.S. Defense Threat Reduction Agency's Joint Science and Technology Office (DTRA-JSTO) program set out to develop novel point-of-need RDTs for infectious diseases and deploy them for home use with no training. The aim of this formative study was to address two questions: 1) could community members in Iquitos, Peru and Phnom Penh, Cambodia competently use RDTs of different levels of complexity at home with visually based instructions provided, and 2) if an RDT were provided at no cost, would it be used at home if family members displayed febrile symptoms? Test kits with written and video (Peru only) instructions were provided to community members (Peru [n = 202]; Cambodia [n = 50]) or community health workers (Cambodia [n = 45]), and trained observers evaluated the competency level for each of the several steps required to successfully operate one of two multiplex RDTs on themselves or other consenting participant (i.e., family member). In Iquitos, >80% of residents were able to perform 11/12 steps and 7/15 steps for the two- and five-pathogen test, respectively. Competency in Phnom Penh never reached 80% for any of the 12 or 15 steps for either test; the percentage of participants able to perform a step ranged from 26-76% and 23-72%, for the two- and five-pathogen tests, respectively. Commercially available NS1 dengue rapid tests were distributed, at no cost, to households with confirmed exposure to dengue or Zika virus; of 14 febrile cases reported, six used the provided RDT. Our findings support the need for further implementation research on the appropriate level of instructions or training needed for diverse devices in different settings, as well as how to best integrate RDTs into existing local public health and disease surveillance programs at a large scale.

Achieving equity in cervical cancer screening in low- and middle-income countries (LMICs): Strengthening health systems using a systems thinking approach

The World Health Organization (WHO) is leading a call to action to eliminate cervical cancer by the end of the century through global implementation of two effective evidence-based preventive interventions: HPV vaccination and cervical screening and management (CSM). Models estimate that without intervention, over the next 50 years 12.2 million new cases of cervical cancer will occur, nearly 60% of which are preventable only through CSM. Given that more than 80% of the cervical cancer occurs in low- and middle-income countries (LMICs), scaling up sustainable CSM programs in these countries is a top priority for achieving the global elimination goals. Multiple technologies have been developed and validated to meet this need. Now it is critical to identify strategies to implement these technologies into complex, adaptive health care delivery systems. As part of the coordinated cervical cancer elimination effort, we applied a systems thinking lens to reflect on our experiences with implementation of HPV-based CSM programs using the WHO health systems framework. While many common health system barriers were identified, the effectiveness of implementation strategies to address them was context dependent; often reflecting differences in stakeholder's belief in the quality of the evidence supporting a CSM algorithm, the appropriateness of the evidence and algorithm to context, and the 'implementability' of the algorithm under realistic assessments of resource availability and constraints. A structured planning process, with early and broad stakeholder engagement, will ensure that shared-decisions in CSM implementation are appropriately aligned with the culture, values, and resource realities of the setting.

Disease-driven reduction in human mobility influences human-mosquito contacts and dengue transmission dynamics

Heterogeneous exposure to mosquitoes determines an individual’s contribution to vector-borne pathogen transmission. Particularly for dengue virus (DENV), there is a major difficulty in quantifying human-vector contacts due to the unknown coupled effect of key heterogeneities. To test the hypothesis that the reduction of human out-of-home mobility due to dengue illness will significantly influence population-level dynamics and the structure of DENV transmission chains, we extended an existing modeling framework to include social structure, disease-driven mobility reductions, and heterogeneous transmissibility from different infectious groups. Compared to a baseline model, naïve to human pre-symptomatic infectiousness and disease-driven mobility changes, a model including both parameters predicted an increase of 37% in the probability of a DENV outbreak occurring; a model including mobility change alone predicted a 15.5% increase compared to the baseline model. At the individual level, models including mobility change led to a reduction of the importance of out-of-home onward transmission (R, the fraction of secondary cases predicted to be generated by an individual) by symptomatic individuals (up to -62%) at the expense of an increase in the relevance of their home (up to +40%). An individual’s positive contribution to R could be predicted by a GAM including a non-linear interaction between an individual’s biting suitability and the number of mosquitoes in their home (>10 mosquitoes and 0.6 individual attractiveness significantly increased R). We conclude that the complex fabric of social relationships and differential behavioral response to dengue illness cause the fraction of symptomatic DENV infections to concentrate transmission in specific locations, whereas asymptomatic carriers (including individuals in their pre-symptomatic period) move the virus throughout the landscape. Our findings point to the difficulty of focusing vector control interventions reactively on the home of symptomatic individuals, as this approach will fail to contain virus propagation by visitors to their house and asymptomatic carriers.

Human mobility patterns can play an integral role in vector-borne disease dynamics by characterizing an individual’s potential contacts with disease-transmitting vectors. Dengue virus is transmitted by a sedentary vector, but human mobility allows individuals to have contact with mosquitoes at their home and other houses they frequent (their activity space). When accounting for the decreased mobility of symptomatic dengue cases in an agent-based simulation model, however, we found a severely diminished role of the activity space in onward transmission. Those who received the majority of their mosquito contacts outside their home experienced decreases in expected bites and onward transmission when mobility changes were accounted for. Onward transmission was driven by a synergistic relationship between the number of mosquitoes in an individual’s home and their biting suitability, where even those with the highest biting suitability would have limited contribution to transmission given a low number of household mosquitoes. Reactive vector control, which often targets symptomatic cases, could be effective for slowing onward transmission from these cases, but will fail to control virus transmission due to the disproportionate contribution of asymptomatic infections.

Behavioral Insights Into Micronutrient Powder Use for Childhood Anemia in Arequipa, Peru

Health care provider-caregiver interactions and caregivers’ shifting emotional states between intention formation and use affected their adherence to a government-provided micronutrient powder intervention to prevent childhood anemia. In counseling directed to caregivers, we suggest providers offer clear messaging on MNP impact and planning for challenges during MNP use.

Childhood anemia remains a significant driver of morbidity in low- and middle-income countries, including Peru. To identify behavioral challenges to using micronutrient powder (MNP) that is given to supplement children’s diets and prevent anemia, we applied a behavioral design approach to interviews and focus groups with 129 caregivers in Arequipa, Peru. We examined 3 key points in the decision-making process: accessing MNP through the health system; forming intentions to use MNP; and MNP use at the time of child feeding. Using the NUDGE (Narrow, Understand, Discover, Generate, Evaluate) approach, we identified the following behavioral barriers and facilitators: (1) caregivers’ experiences with health care providers shaped their motivation to access MNP; (2) caregivers felt accessing MNP at clinics was inconvenient and created hassle factors; (3) caregivers’ mental models about anemia prevention shaped MNP intentions and use; (4) caregivers’ salient negative experiences could have caused them to stop giving MNP; (5) caregivers forgot to give MNP if they did not have cues to remind them but could be prompted with salient cues; and (6) caregivers were affected by emotional, cognitive, and attentional factors during feeding that were difficult to anticipate. Our results, based on a behavioral design approach, suggest opportunities to adapt current messaging, counseling, and education around MNP use. Adaptations include providing culturally relevant messages, leveraging caregivers’ emotional and cognitive states, and encouraging small but impactful changes to feeding routines to address barriers to MNP use.

Cross-sectional study of dengue-related knowledge, attitudes and practices in Villa El Salvador, Lima, Peru

OBJECTIVES

To describe and quantify the dengue-related knowledge, attitudes and practices of residents in an urban shantytown in Lima, Peru.

DESIGN/SETTING

A cross-sectional survey of adults between 18 and 80 years living in approximately 120 blocks in Oasis, an urban shantytown situated in the low-to-middle income district of Villa El Salvador in Southern Lima. The survey was adapted from an existing survey previously used in Iquitos, Peru, and included questions relating to knowledge of dengue symptoms, transmission, prevention and current mosquito control practices.

PARTICIPANTS

A total of 240 surveys were completed with 80% of respondents being female and approximately 50% of all respondents describing themselves as housewives.

RESULTS

Although 97.9% of respondents had heard of dengue, only 6.2% of people knew someone who had experienced the disease. Approximately half (54.2%) of the respondents knew dengue was transmitted by mosquitoes and 51.7% were able to identify fever and one other correct symptom of dengue. Female sex was significantly associated with greater symptom knowledge (OR 2.22, 95% CI 1.08 to 4.72) and prevention knowledge (OR 2.12, 95% CI 1.06 to 4.21). Past or current higher education attendance was significantly associated with symptom knowledge (OR 2.56, 95% CI 1.25 to 5.44) and transmission knowledge (OR 3.46, 95% CI 1.69 to 7.57). Knowledge of dengue was not significantly associated with carrying out practices to control mosquitoes (OR 1.76, 95% CI 0.87 to 3.54).

CONCLUSIONS

This population demonstrated baseline dengue knowledge. However, this was incomplete and substantially less when compared with endemic areas. Given the sporadic nature of dengue transmission in Lima, it is not surprising that knowledge of the disease was not associated with carrying out practices to reduce mosquitoes. However, as dengue transmission in Lima is likely to increase, understanding how best to improve public knowledge of the disease and how to translate this into appropriate community action will be a key public health consideration.

Integrative Systems Praxis for Implementation Research (INSPIRE): An Implementation Methodology to Facilitate the Global Elimination of Cervical Cancer

BACKGROUND

The World Health Organization (WHO) has called for a systems thinking approach to health systems strengthening to increase adoption of evidence-based interventions (EBI). The Integrative Systems Praxis for Implementation Research (INSPIRE) methodology operationalizes the WHO systems thinking framework to meet cervical cancer elimination-early detection and treatment (CC-EDT) goals.

METHODS

Using a systems thinking approach and grounded in the consolidated framework for implementation research, INSPIRE integrates multiple research methodologies and evaluation frameworks into a multilevel implementation strategy.

RESULTS

In phase I (creating a shared understanding), soft systems methodology and pathway analysis are used to create a shared visual understanding of the CC-EDT system, incorporating diverse stakeholder perspectives of the "what, how, and why" of system behavior. Phase II (finding leverage) facilitates active stakeholder engagement in knowledge transfer and decision-making using deliberative dialogues and multiple scenario analyses. Phase III (acting strategically) represents stakeholder-engaged implementation planning, using well-defined implementation strategies of education, training, and infrastructure development. In phase IV (learning and adapting), evaluation of key performance indicators via a reach, effectiveness, adoption, implementation, and maintenance framework is reviewed by stakeholder teams, who continuously adapt implementation plans to improve system effectiveness.

CONCLUSIONS

The INSPIRE methodology is a generalizable approach to context-adapted implementation of EBIs.

IMPACT

Replacing static dissemination of implementation "roadmaps" with learning health systems through the integration of systems thinking and participatory action research, INSPIRE facilitates the development of scalable and sustainable implementation strategies adapted to local contexts.

Understanding Geospatial Factors Associated With Cervical Cancer Screening Uptake in Amazonian Peruvian Women

PURPOSE

Cervical cancer (CC) is the most common and second-most deadly cancer among Peruvian women. Access to services is strongly associated with CC screening uptake. This study investigated geospatial features contributing to utilization of screening. We used geolocated data and screening information from a Knowledge, Attitudes, and Practice (KAP) survey implemented in Iquitos, Peru in 2017.

MATERIALS AND METHODS

The KAP collected cross-sectional CC screening history from 619 female interviewees age 18-65 years within 5 communities of varying urbanization levels. We used spatial statistics to determine if screened households tended to cluster together or cluster around facilities offering screening in greater numbers than expected, given the underlying population density.

RESULTS

On the basis of K-functions, screened households displayed greater clustering among each other as compared with clustering among unscreened households. Neighborhood-level factors, such as outreach, communication, or socioeconomic condition, may be functioning to generate pockets of screened households. Cross K-functions showed that screened households are generally located closer to health facilities than unscreened households. The significance of facility access is apparent and demonstrates that travel and time barriers to seeking health services must be addressed.

CONCLUSION

This study highlights the importance of considering geospatial features when determining factors associated with CC screening uptake. Given the observed clustering of screened households, neighborhood-level dynamics should be further studied to understand how they may be influencing screening rates. In addition, results demonstrate that accessibility issues must be carefully considered when designing an effective cancer screening program that includes screening, follow-up, and treatment.

Behavioral and structural barriers to accessing human post-exposure prophylaxis and other preventive practices in Arequipa, Peru, during a canine rabies epidemic

A canine rabies epidemic started in early 2015 in Arequipa, Peru and the rabies virus continues to circulate in the dog population. Some city residents who suffer dog bites do not seek care or do not complete indicated post-exposure prophylaxis (PEP) regimens, increasing the risk of human rabies. The objectives of our study are to qualitatively assess knowledge about rabies, and preventive practices, such as rabies vaccine administration, following a dog bite. We conduct eight focus group discussions in peri-urban and urban communities with 70 total participants. In our results, we observe low awareness of rabies severity and fatality, and different practices following a dog bite, depending on the community type: for example, whereas participants in the urban communities report cleaning the wound with hydrogen peroxide rather than soap and water, participants in peri-urban areas cover the wound with herbs and hair from the dog that bit them. Misconceptions about rabies vaccines and mistreatment at health centers also commonly prevent initiating or completing PEP. We identify important behavioral and structural barriers and knowledge gaps that limit evidence-based preventive strategies against rabies and may threaten successful prevention of dog-mediated human rabies in this setting.

The city of Arequipa, Peru has been experiencing an outbreak of dog rabies since 2015. The Peruvian Ministry of Health has implemented measures to prevent human infection, including no-cost rabies vaccinations for people bitten by dogs, but health posts report that many people do not utilize the service or complete treatment. We conduct focus groups in urban and peri-urban areas of Arequipa to examine community perceptions and attitudes towards PEP, and organizational and behavioral barriers to initiate and complete the PEP regimen. We observe low awareness of rabies severity, and different practices following a dog bite depending on the community type. Misconceptions about rabies vaccines and mistreatment at health centers also commonly prevent participants from initiating or completing PEP. We identify important behavioral and structural barriers and knowledge gaps that limit preventive strategies against rabies and may threaten successful prevention of dog-mediated human rabies in this setting. Finally, disparate landscapes and topography seem to have different effects on urban and peri-urban participants’ use of healthcare resources. Thus, strategies should target the specific needs of each population.

Facilitating Adoption of Evidence-Based Cervical Cancer Screening Strategies in the Peruvian Amazon Using a Novel Methodology: The Integrative Systems Praxis for Implementation Research (INSPIRE)

PURPOSE

The aim to this work was to develop an operational research methodology for context-appropriate selection, adaptation, and evaluation of the implementation of novel cervical cancer screening and treatment methods.

METHODS

We developed the Integrative Systems Practice for Implementation Research (INSPIRE) methodology, a multifaceted strategy that blends existing theoretical implementation research frameworks and defines specific research methods for use at each phase. INSPIRE is a participatory, iterative process involving 4 phases: system understanding, finding leverage, acting, and learning/adapting. Mixed methods were used to meet the objectives of each INSPIRE phase. Qualitative methods were grounded in soft systems methodology and CFIR, and quantitative methods in RE-AIM. Pathway and scenario analyses supplemented standard research methods.

RESULTS

We engaged more than 90 multilevel stakeholders in the design of a new and improved screen-and-treat system. Elaboration of system process maps through triangulation of the mixed-methods data served to create a shared reference of the current system in participatory discussions. Significant leverage opportunities were identified, including reducing fragmentation, inefficiency, and a lack of standardization to increase women’s acceptability of screening and adherence to the continuum of care. A variety of interventions were evaluated using a multiple scenario analysis tool and, ultimately, stakeholders recommended adoption of human papillomavirus testing/self-sampling to increase coverage and ablative treatment of all human papillomavirus–positive women to reduce loss to follow up. Implementation was launched in July 2019, and iterative application of INSPIRE to early implementation challenges is being used to ensure real-time adaptation to emerging system behaviors and the acceptability and sustainability of the program.

CONCLUSION

Continued success in the engagement of stakeholders in shared decision making suggests that using the INSPIRE methodology in designing implementation strategies increases a sense of ownership in the process, which may lead to more sustainable screening programs in low- and middle-income countries compared with top-down approaches.

Measuring health related quality of life for dengue patients in Iquitos, Peru

Previous studies measuring the health-related quality of life (HRQoL) of individuals with dengue focused on treatment seeking populations. However, the vast majority of global dengue cases are unlikely to be detected by health systems. Representative measurements of HRQoL should therefore include patients with disease not likely to trigger treatment-seeking behavior. This study based in Iquitos, Peru used the Quality of Wellbeing Scale-Self Administered, a survey that enquires about not only physical health, but also psychological health, self-care, mobility, and usual social activities, and rates HRQoL between 0 (death) and 1 (optimum function), to evaluate the impact of dengue on HRQoL. In order to enroll treatment and non treatment-seeking participants, three modalities of participant recruitment were used. In addition to clinic and community-based febrile surveillance, a contact-cluster methodology was also employed to identify infected individuals less likely to seek treatment. We measured changes in HRQoL and identified common areas of health impairment in 73 virologically confirmed dengue cases at 3 time points during the participant's illness; the early-acute (days 0-6 post symptom onset), late-acute (days 7-20), and convalescent illness phases (days 21 +). Participants reported HRQoL related impairments at significantly higher frequency during the early-acute versus convalescent illness phase (Fisher's exact: P<0.01). There was substantial heterogeneity in scores during each illness phase with median scores in the early-acute, late-acute and convalescent phases of 0.56 (IQR: 0.41-0.64), 0.70 (IQR: 0.57-0.94), and 1 (IQR: 0.80-1.00), respectively. In all illness phases participants recruited in clinics had on average the lowest HRQoL scores where as those recruited in the contact clusters had the highest. Only 1 individual who was recruited in the contact-clusters had no reduction in HRQoL score during their illness. These data illustrate that dengue should be considered as a disease that may have significant implications for not only physical health but also psychological health and social functioning. The impact of dengue on the HRQoL of non-treatment-seeking individuals, although lower than the impact among treatment-seeking individuals, is not necessarily trivial.

Cough dynamics in adults receiving tuberculosis treatment

Cough is a characteristic symptom of tuberculosis, is the main cause of transmission, and is used to assess treatment response. We aimed to identify the best measure of cough severity and characterize changes during initial tuberculosis therapy. We conducted a prospective cohort of recently diagnosed ambulatory adult patients with pulmonary tuberculosis in two tertiary hospitals in Lima, Peru. Pre-treatment and five times during the first two months of treatment, a vibrometer was used to capture 4-hour recordings of involuntary cough. A total of 358 recordings from 69 participants were analyzed using a computer algorithm. Total time spent coughing (seconds per hour) was a better predictor of microbiologic indicators of disease severity and treatment response than the frequency of cough episodes or cough power. Patients with prior tuberculosis tended to cough more than patients without prior tuberculosis, and patients with tuberculosis and diabetes coughed more than patients without diabetes co-morbidity. Cough characteristics were similar regardless of HIV co-infection and for drug-susceptible versus drug-resistant tuberculosis. Tuberculosis treatment response may be meaningfully assessed by objectively monitoring the time spent coughing. This measure demonstrated that cough was increased in patients with TB recurrence or co-morbid diabetes, but not because of drug resistance or HIV co-infection.

The impact of insecticide treated curtains on dengue virus transmission: A cluster randomized trial in Iquitos, Peru

Dengue is one of the most important vector-borne diseases, resulting in an estimated hundreds of millions of infections annually throughout the tropics. Control of dengue is heavily dependent upon control of its primary mosquito vector, Aedes aegypti. Innovative interventions that are effective at targeting the adult stage of the mosquito are needed to increase the options for effective control. The use of insecticide-treated curtains (ITCs) has previously been shown to significantly reduce the abundance of Ae. aegypti in and around homes, but the impact of ITCs on dengue virus (DENV) transmission has not been rigorously quantified. A parallel arm cluster-randomized controlled trial was conducted in Iquitos, Peru to quantify the impact of ITCs on DENV seroconversion as measured through plaque-reduction neutralization tests. Seroconversion data showed that individuals living in the clusters that received ITCs were at greater risk to seroconverting to DENV, with an average seroconversion rate of 50.6 per 100 person-years (PY) (CI: 29.9–71.9), while those in the control arm had an average seroconversion rate of 37.4 per 100 PY (CI: 15.2–51.7). ITCs lost their insecticidal efficacy within 6 months of deployment, necessitating re-treatment with insecticide. Entomological indicators did not show statistically significant differences between ITC and non-ITC clusters. It’s unclear how the lack of protective efficacy reported here is attributable to simple failure of the intervention to protect against Ae. aegypti bites, or the presence of a faulty intervention during much of the follow-up period. The higher risk of dengue seroconversion that was detected in the ITC clusters may have arisen due to a false sense of security that inadvertently led to less routine protective behaviors on the part of households that received the ITCs. Our study provides important lessons learned for conducting cluster randomized trials for vector control interventions against Aedes-transmitted virus infections.

Dengue is one of the most important mosquito-borne diseases affecting humans, resulting in an estimated hundreds of millions of infections annually throughout the tropics. To control dengue, most public health programs use a variety of methods to kill the primary mosquito vector, Aedes aegypti. Water holding containers that harbor larvae (and other immature stages) are treated or eliminated. During emergencies, large insecticide spray campaigns are deployed to kill infected adult mosquitoes. Innovative interventions that are effective at targeting adult mosquitoes in sustainable ways are needed to increase the options for control of dengue and other Aedes borne virus diseases. The use of insecticide-treated curtains (ITCs) has previously been shown to significantly reduce Ae. aegypti numbers in and around homes, but the impact of ITCs on dengue virus (DENV) transmission has not previously been quantified. Using a rigorous study design in which 10 clusters (~90 houses per cluster) were provided multiple ITCs to place in their homes was compared to 10 clusters of homes without ITCs. Assignment of which clusters received ITCs was randomized. Blood samples were obtained at 9-month intervals from residents living in all the clusters, so that people with serological evidence of a DENV infection could be identified by comparing paired samples. Seroconversion data showed that individuals living in the clusters that received ITCs were at greater risk to DENV seroconverting, with an average seroconversion rate of 50.6 per 100 person-years (PY) (CI: 29.9–71.9). Conversely, those in the control arm had an average seroconversion rate of 37.4 per 100 PY (CI: 15.2–51.7). ITCs lost their insecticidal efficacy within 6 months of deployment, necessitating re-treatment with insecticide. Ae. aegypti populations did not show statistically significant differences between ITC and non-ITC clusters. The reason for higher transmission in the ITC treated clusters could be attributable to failure of the curtains (loss of efficacy) and/or that the curtains were not sufficiently effective at protecting against mosquito bites. The higher risk of DENV seroconversion in ITC clusters may be due to a false sense of security that inadvertently led to less routine protective behaviors on the part of households that received the ITC.

Food Choice and Dietary Intake among People with Tuberculosis in Peru: Implications for Improving Practice

BACKGROUND

In Peru, tuberculosis (TB) is perceived as a nutritional disease. This perception, alongside factors including household food insecurity, may drive the food choices of people with TB and influence treatment outcomes.

OBJECTIVES

The objective of this qualitative study was to explore drivers of food choice among adults recently diagnosed with TB.

METHODS

The study was conducted between April and December 2016 in the Huaycán district of Lima, Peru. Structured questionnaires were administered to 39 adults with TB at the time of diagnosis and after 1 mo of treatment to characterize food security and socioeconomic status. At 1 mo of treatment, 24-h dietary recalls, enhanced by recipes obtained from local street vendors, were administered to examine patterns of food consumption and determine mean daily intake of macro- and micronutrients. Among a subset of 9 participants, in-depth interviews were used to explore dietary beliefs and food choices associated with TB.

RESULTS

Overall, 13.2% of participants were underweight at baseline, and 10.5% were overweight. At 1 mo of treatment, the mean caloric intake was 600 kcal/d over what was needed to maintain their current weight. Most of these additional kilocalories came from carbohydrates. Patients made active efforts to improve their diets during treatment, and were both receptive to, and actively sought out, nutritional advice. However, many patients reported significant unnecessary spending on questionable commercial products, such as expensive natural remedies and nutritional supplements.

CONCLUSIONS

The perceived connection between TB and diet creates both opportunities and challenges for treatment providers. Nutritional counseling provided through the national TB program should promote dietary quality through foods that are locally available, inexpensive, and aligned with cultural perceptions of health and wellness.

Potential Use of Community-Based Rapid Diagnostic Tests for Febrile Illnesses: Formative Research in Peru and Cambodia

In 2012, the U.S. Defense Threat Reduction Agency Joint Science and Technology Office initiated a program to develop novel point-of-need diagnostic devices for surveillance of emerging infectious diseases including dengue, malaria, plague, and melioidosis. Prior to distribution of devices to observe their correct use among community members in Iquitos, Peru, and Phnom Penh, Cambodia, research was conducted to: 1) assess acceptability of use, including the motivation to use a rapid diagnostic test (RDT) before or instead of seeking care at a health facility, 2) explore comprehension of RDT use instructions, and 3) examine possible strategies for large scale RDT distribution and use at each site. In February 2014, 9 focus group discussions (FGD) with community members and 5 FGD with health professionals were conducted in Iquitos, and 9 FGD with community members and 9 in-depth interviews with health professionals in Phnom Penh. In both places, participants agreed to use the device themselves (involving finger prick) or could identify someone who could do so in their home or neighborhood. The main incentive to RDT use in both sites was the ability for device results to be used for care facilitation (post confirmatory tests), specifically reduced wait times to be seen or obtain a diagnosis. Comprehension of RDT use instructions was assessed in Iquitos by asking some participants to apply the device to research team members; after watching a short video, most steps were done correctly. In Phnom Penh, participants were asked to describe each step after reading the instructions; they struggled with comprehension. Health professionals’ main concerns in both sites were their community’s ability to accurately use the test, handle complicated instructions, and safety (i.e., disposal of lancets). Health system structure and ability to use home diagnostic devices varied in the two disease endemic sites, with substantial challenges in each, suggesting the need for different strategies for RDT large scale community use, and illustrating the value of formative research before deployment of novel technologies.

Development and use of devices to diagnose infectious diseases outside of health facilities (i.e., at home or in remote areas) continues to increase, providing new options for the follow up and treatment options of individuals, depending on the diseases. In this qualitative study, researchers in Iquitos, Peru, and Phnom Penh, Cambodia explored what local people thought about the possible availability of such a device to diagnose dengue and malaria in their own houses, and what would motivate them to use such a device instead of going directly to a health facility for the diagnosis. Participants reported being willing to use device on themselves and were motivated by the possibility that, by using this diagnostic device and taking the result to their health facility, they might be able to obtain quicker and more optimized attention at the health facility; for example, by obtaining a positive result to dengue or malaria on the rapid diagnostic device, they are aware they might still need confirmatory tests, but they would be able to reduce the wait time for obtaining a definitive diagnosis and starting treatment by a full day. Questions regarding accuracy of tests, complicated instructions and safety of using these devices in the community were brought up by participants—individuals living in the communities and local health professionals. Also, in this study, it was clear that if these devices were to be made available in Peru and Cambodia, different strategies for disseminating and using these in the communities would be needed to accommodate for different health infrastructure in both sites.

"Knocking on Doors that Don't Open": experiences of caregivers of children living with disabilities in Iquitos and Lima, Peru

Background: More than one billion people worldwide live with a disability. Despite advances in recognising inequalities experienced by people with disabilities, barriers to services and stigmatisation still exist. The aims of this study were to explore: (1) perceptions and experiences of services specifically available to people with disabilities and their caregivers and (2) the perception of disability. Methods: In-depth interviews were conducted with 20 caregivers of persons with a disability and 14 key informants in two cities in Peru; Lima and Iquitos. The social-ecological model was used as a framework to analyse and present data, stratifying the key barriers and opportunities at each level. Results: At the individual level, interviewees reported a lack of support at the time of diagnosis, poor coping strategies, and communicated their desire for, and willingness to participate in support groups if they were established. On the community level, education and awareness were reportedly lacking and acts of discrimination and stigmatisation were common. Participants described opportunities for community-level campaigns to increase exposure and awareness of disability rights and inclusion. A dissatisfaction with government programmes was reported, as services were not available to everyone, in part due to geographical and socio-economic barriers. Conclusions: The main findings were the lack of emotional, informational, and tangible support available to caregivers of people with disabilities, often exacerbated by lower socio-economic status; a lack of transparency of care pathways available to people with disabilities; and a lack of visibility of people with disability in both Lima and Iquitos. Implications for Rehabilitation Support groups could offer additional support to caregivers of people with disabilities in Lima, mitigating existing gaps in services for people with disabilities, and their families. Education campaigns implemented on a community level could start to curb discrimination and stigmatisation of people with disabilities in Lima and Iquitos. A national census with inclusive language and methodology specifically designed to capture the percentage of the population currently living with a disability would give a real indication of what services are needed in Peru. The provision of clear, publically available routes of attention would assist caregivers and families to access services for people with disabilities.

Dengue illness impacts daily human mobility patterns in Iquitos, Peru

Background

Human mobility plays a central role in shaping pathogen transmission by generating spatial and/or individual variability in potential pathogen-transmitting contacts. Recent research has shown that symptomatic infection can influence human mobility and pathogen transmission dynamics. Better understanding the complex relationship between symptom severity, infectiousness, and human mobility requires quantification of movement patterns throughout infectiousness. For dengue virus (DENV), human infectiousness peaks 0–2 days after symptom onset, making it paramount to understand human movement patterns from the beginning of illness.

Methodology and principal findings

Through community-based febrile surveillance and RT-PCR assays, we identified a cohort of DENV+ residents of the city of Iquitos, Peru (n = 63). Using retrospective interviews, we measured the movements of these individuals when healthy and during each day of symptomatic illness. The most dramatic changes in mobility occurred during the first three days after symptom onset; individuals visited significantly fewer locations (Wilcoxon test, p = 0.017) and spent significantly more time at home (Wilcoxon test, p = 0.005), compared to when healthy. By 7–9 days after symptom onset, mobility measures had returned to healthy levels. Throughout an individual’s symptomatic period, the day of illness and their subjective sense of well-being were the most significant predictors for the number of locations and houses they visited.

Conclusions/Significance

Our study is one of the first to collect and analyze human mobility data at a daily scale during symptomatic infection. Accounting for the observed changes in human mobility throughout illness will improve understanding of the impact of disease on DENV transmission dynamics and the interpretation of public health-based surveillance data.

Dengue is the most important mosquito-borne viral disease of humans worldwide. Due to the limited mobility of the mosquitoes that transmit dengue virus, human mobility can be a key to both understanding an individual’s exposure to the virus and explaining the spread of dengue throughout a population. Accurate disease models should include human mobility; however, changes in human movement patterns due to the presence of symptoms need to be taken into account. We quantified the impact of symptom presence on human mobility throughout the infectious period by analyzing a dataset on the daily movements of dengue virus infected individuals. Accounting for these changing patterns of mobility will improve understanding of the complex relationship between symptom severity, human movement, and dengue virus transmission. Furthermore, dengue transmission models that incorporate symptom-driven mobility changes can be used to evaluate scenarios and strategies for disease prevention.

A behavioral design approach to improving a Chagas disease vector control campaign in Peru

BACKGROUND

Individual behavior change is a critical ingredient in efforts to improve global health. Central to the focus on behavior has been a growing understanding of how the human brain makes decisions, from motivations and mindsets to unconscious biases and cognitive shortcuts. Recent work in the field of behavioral economics and related fields has contributed to a rich menu of insights and principles that can be engineered into global health programs to increase impact and reach. However, there is little research on the process of designing and testing interventions informed by behavioral insights.

METHODS

In a study focused on increasing household participation in a Chagas disease vector control campaign in Arequipa, Peru, we applied Datta and Mullainathan's "behavioral design" approach to formulate and test specific interventions. In this Technical Advance article we describe the behavioral design approach in detail, including the Define, Diagnosis, Design, and Test phases. We also show how the interventions designed through the behavioral design process were adapted for a pragmatic randomized controlled field trial.

RESULTS

The behavioral design framework provided a systematic methodology for defining the behavior of interest, diagnosing reasons for household reluctance or refusal to participate, designing interventions to address actionable bottlenecks, and then testing those interventions in a rigorous counterfactual context. Behavioral design offered us a broader range of strategies and approaches than are typically used in vector control campaigns.

CONCLUSIONS

Careful attention to how behavioral design may affect internal and external validity of evaluations and the scalability of interventions is needed going forward. We recommend behavioral design as a useful complement to other intervention design and evaluation approaches in global health programs.

Socio-spatial heterogeneity in participation in mass dog rabies vaccination campaigns, Arequipa, Peru

To control and prevent rabies in Latin America, mass dog vaccination campaigns (MDVC) are implemented mainly through fixed-location vaccination points: owners have to bring their dogs to the vaccination points where they receive the vaccination free of charge. Dog rabies is still endemic in some Latin-American countries and high overall dog vaccination coverage and even distribution of vaccinated dogs are desired attributes of MDVC to halt rabies virus transmission. In Arequipa, Peru, we conducted a door-to-door post-campaign survey on >6,000 houses to assess the placement of vaccination points on these two attributes. We found that the odds of participating in the campaign decreased by 16% for every 100 m from the owner’s house to the nearest vaccination point (p = 0.041) after controlling for potential covariates. We found social determinants associated with participating in the MDVC: for each child under 5 in the household, the odds of participating in the MDVC decreased by 13% (p = 0.032), and for each decade less lived in the area, the odds of participating in the MDVC decreased by 8% (p<0.001), after controlling for distance and other covariates. We also found significant spatial clustering of unvaccinated dogs over 500 m from the vaccination points, which created pockets of unvaccinated dogs that may sustain rabies virus transmission. Understanding the barriers to dog owners’ participation in community-based dog-vaccination programs will be crucial to implementing effective zoonotic disease preventive activities. Spatial and social elements of urbanization play an important role in coverage of MDVC and should be considered during their planning and evaluation.

In Peru and other dog rabies-affected countries, mass dog vaccination campaigns (MDVC) are implemented primarily through fixed-location vaccination points: owners have to bring their dogs to the vaccination points where they receive the vaccination. To stop rabies virus transmission, a high and even dog vaccination coverage is desired. In Arequipa, Peru, following a MDVC, we conducted a door-to-door survey of >6,000 houses to assess how the placement of vaccination points affected coverage of the campaign. When comparing dog owners with similar characteristics, we found that the odds of participating in the MDVC was reduced by 16% for every 100 m distance from the nearest vaccination point. Some social conditions were also associated with participating in the MDVC: for each child under 5 in the household, odds of participating in the MDVC decreased by 13%, and for each decade less lived in the area, the odds of participating in the MDVC decreased by 8%. Distance to the vaccination point and variation in social conditions across the city play important roles in achieving coverage of MDVC and should be considered during campaign planning and evaluation.

An agent-based model of dengue virus transmission shows how uncertainty about breakthrough infections influences vaccination impact projections

Prophylactic vaccination is a powerful tool for reducing the burden of infectious diseases, due to a combination of direct protection of vaccinees and indirect protection of others via herd immunity. Computational models play an important role in devising strategies for vaccination by making projections of its impacts on public health. Such projections are subject to uncertainty about numerous factors, however. For example, many vaccine efficacy trials focus on measuring protection against disease rather than protection against infection, leaving the extent of breakthrough infections (i.e., disease ameliorated but infection unimpeded) among vaccinees unknown. Our goal in this study was to quantify the extent to which uncertainty about breakthrough infections results in uncertainty about vaccination impact, with a focus on vaccines for dengue. To realistically account for the many forms of heterogeneity in dengue virus (DENV) transmission, which could have implications for the dynamics of indirect protection, we used a stochastic, agent-based model for DENV transmission informed by more than a decade of empirical studies in the city of Iquitos, Peru. Following 20 years of routine vaccination of nine-year-old children at 80% coverage, projections of the proportion of disease episodes averted varied by a factor of 1.76 (95% CI: 1.54-2.06) across the range of uncertainty about breakthrough infections. This was equivalent to the range of vaccination impact projected across a range of uncertainty about vaccine efficacy of 0.268 (95% CI: 0.210-0.329). Until uncertainty about breakthrough infections can be addressed empirically, our results demonstrate the importance of accounting for it in models of vaccination impact.

Feasibility of feeding Aedes aegypti mosquitoes on dengue virus-infected human volunteers for vector competence studies in Iquitos, Peru

BACKGROUND

Transmission of dengue virus (DENV) from humans to mosquitoes represents a critical component of dengue epidemiology. Examinations of this process have generally been hampered by a lack of methods that adequately represent natural acquisition of DENV by mosquitoes from humans. In this study, we assessed artificial and natural blood feeding methods based on rates of DENV infection and dissemination within mosquitoes for use in a field-based epidemiological cohort study in Iquitos, Peru.

METHODOLOGY/PRINCIPAL FINDINGS

Our study was implemented, stepwise, between 2011 and 2015. Participants who were 5 years and older with 5 or fewer days of fever were enrolled from ongoing clinic- and neighborhood-based studies on dengue in Iquitos. Wild type, laboratory-reared Aedes aegypti were fed directly on febrile individuals or on blood collected from participants that was either untreated or treated with EDTA. Mosquitoes were tested after approximately 14 days of extrinsic incubation for DENV infection and dissemination. A total of 58 participants, with viremias ranging from 1.3 × 10(2) to 2.9 × 10(6) focus-forming units per mL of serum, participated in one or more feeding methods. DENV infection and dissemination rates were not significantly different following direct and indirect-EDTA feeding; however, they were significantly lower for mosquitoes that fed indirectly on blood with no additive. Relative to direct feeding, infection rates showed greater variation following indirect-EDTA than indirect-no additive feeding. Dissemination rates were similar across all feeding methods. No differences were detected in DENV infection or dissemination rates in mosquitoes fed directly on participants with different dengue illness severity.

CONCLUSIONS/SIGNIFICANCE

Our study demonstrates the feasibility of using direct and indirect feeding methods for field-based studies on vector competence. Direct mosquito feeding is preferable in terms of logistical ease, biosecurity, and reliability.

"Zika is everywhere": A qualitative exploration of knowledge, attitudes and practices towards Zika virus among women of reproductive age in Iquitos, Peru

Zika virus was reported in the rainforest city of Iquitos, Peru in 2016. The potential associations between Zika and fetal neurological disorders were reported extensively in the media regarding neighboring Brazil, and led to great concern about the impact Zika could have on people's health in Iquitos when it arrived. The aim of this study was to explore the knowledge, attitudes, and preventative practices related to Zika virus and its transmission among women of childbearing age in Iquitos, Peru. Six focus group discussions with 46 women of ages 20-35 from an Iquitos district with confirmed Zika cases were conducted to explore: 1) knowledge of Zika transmission, its symptoms, and treatment, 2) attitudes regarding Zika, including perceptions of risk for and severity of Zika, and 3) preventative practices, including awareness of health promotion activities. Participants were knowledgeable about Zika symptoms and knew it was transmitted by mosquitoes, and about half had heard about the association between Zika and microcephaly, but most lacked knowledge about the associated neurological disorders in adults, its sexual transmission, and ways to prevent infection. They expressed concern for pregnant women exposed to the virus and the impact on the fetus. Participants felt at risk of contracting the Zika virus, yet had not changed preventive practices, possibly in part because their perception of the severity of this disease was low. This study reveals knowledge gaps that could be addressed via health promotion messages that might improve prevention practices to help community members protect themselves from Zika virus during this outbreak.

The Impact of Road Construction on Subjective Well-Being in Communities in Madre de Dios, Peru

The interoceanic highway (IOH) in Madre de Dios, Peru has driven dramatic change in the Peruvian Amazon basin. We conducted a mixed methods study to examine the impact of these changes on the subjective well-being (SWB) of four communities on the IOH. Themes that emerged qualitatively included changing health threats, environmental degradation, and the impact of increased migration. To achieve a higher level of SWB, respondents emphasized the need for higher incomes, opportunities to learn new skills, and a better education for their children. Potential threats to SWB included marital problems and poorer health. Quantitative analyses suggested that social support and a sense of security impacted reported SWB scores based on life satisfaction, and the impact of income on life satisfaction was mediated by food security. Although long-term residents felt that specific determinants of SWB had both increased (food variety, transport and access to work) and decreased (access to natural resources and hunting), the majority reported that their lives had improved overall. Health had been affected by the IOH in both negative ways (increased dengue and road accidents) and positive ways (improved access to health services). Our results suggest that the rapidly-changing communities near the IOH link well-being to health, income, community, and the environment.

Delays in seeking and receiving health care services for pneumonia in children under five in the Peruvian Amazon: a mixed-methods study on caregivers' perceptions

Background

Delays in receiving adequate care for children suffering from pneumonia can be life threatening and have been described associated with parents’ limited education and their difficulties in recognizing the severity of the illness. The “three delays” was a model originally proposed to describe the most common determinants of maternal mortality, but has been adapted to describe delays in the health seeking process for caregivers of children under five. This study aims to explore the caregivers’ perceived barriers for seeking and receiving health care services in children under five years old admitted to a referral hospital for community-acquired pneumonia in the Peruvian Amazon Region using the three-delays model framework.

Methods

There were two parts to this mixed-method, cross-sectional, hospital-based study. First, medical charts of 61 children (1 to 60 months old) admitted for pneumonia were reviewed, and clinical characteristics were noted. Second, to examine health care-seeking decisions and actions, as well as associated delays in the process of obtaining health care services, we interviewed 10 of the children’s caregivers.

Results

Half of the children in our study were 9 months old or less. Main reasons for seeking care at the hospital were cough (93%) and fever (92%). Difficulty breathing and fast breathing were also reported in more than 60% of cases. In the interviews, caregivers reported delays of 1 to 14 days to go to the closest health facility. Factors perceived as causes for delays in deciding to seek care were apparent lack of skills to recognize signs and symptoms and of confidence in the health system, and practicing self-medication. No delays in reaching a health facility were reported. Once the caregivers reached a health facility, they perceived lack of competence of medical staff and inadequate treatment provided by the primary care physicians.

Conclusion

According to caregivers, the main delays to get health care services for pneumonia among young children were identified in the initial decision of caregivers to seek healthcare and in the health system to provide it. Specific interventions targeted to main barriers may be useful for reducing delays in providing appropriate health care for children with pneumonia.

Small scale migration along the interoceanic highway in Madre de Dios, Peru: an exploration of community perceptions and dynamics due to migration

Background

Madre de Dios, a southern state in the Peruvian Amazon basin, has experienced rapid development as well as an influx of migrants since the construction of the Interoceanic Highway (IOH) connecting Brazil, Bolivia, and the Peruvian coast. We explored perceptions of migration and development in up to eight communities along the IOH in Madre de Dios following construction of the highway.

Methods

We conducted a multiple methods study involving focus group (FG) discussions and interviews with key informants (KIs) in eight communities in Madre de Dios. The data was used to develop and apply a survey on demographics, financial, personal, social, human, and physical capital in four communities between February 2014 and March 2015.

Results

We conducted 12 FGs and 34 KI interviews. A total of 522 people participated in the survey. Comparing migrants (those who had moved to the area after construction of the IOH) and non-migrants, we found no difference in food security or access to health services. The majority (67.6%) of respondents from both groups reported that illness was their primary threat to well-being. Non-migrants owned more land than migrants (p < 0.001), were more likely to have piped water directly in their home (p = 0.046), and were more likely to participate in community groups (p = 0.012). Looking at perceptions about migrants, KIs and FGs discussed both positive perceptions of migrants (increased cultural exchange and new technology) and negative perceptions (increased drugs and alcohol in their communities and a lack of investment in the community). Both migrants and non-migrants reported trusting the local government more than the national government.

Conclusions

Although we hypothesized that migrants would have decreased access to food, water, health services, and land relative to non-migrants, our results show that the only significant differences were in land ownership and water access. Efforts to improve community infrastructure should be carried out at the local level and focus on improving issues reported by both groups, such as potable water, sewage, and increased access to health services. Furthermore, an emphasis on community cohesion, ensuring land rights, and increasing long-term job opportunities should help ease tensions between migrants and non-migrants.

Electronic supplementary material

The online version of this article (10.1186/s12914-018-0152-8) contains supplementary material, which is available to authorized users.

Calling in sick: impacts of fever on intra-urban human mobility

Pathogens inflict a wide variety of disease manifestations on their hosts, yet the impacts of disease on the behaviour of infected hosts are rarely studied empirically and are seldom accounted for in mathematical models of transmission dynamics. We explored the potential impacts of one of the most common disease manifestations, fever, on a key determinant of pathogen transmission, host mobility, in residents of the Amazonian city of Iquitos, Peru. We did so by comparing two groups of febrile individuals (dengue-positive and dengue-negative) with an afebrile control group. A retrospective, semi-structured interview allowed us to quantify multiple aspects of mobility during the two-week period preceding each interview. We fitted nested models of each aspect of mobility to data from interviews and compared models using likelihood ratio tests to determine whether there were statistically distinguishable differences in mobility attributable to fever or its aetiology. Compared with afebrile individuals, febrile study participants spent more time at home, visited fewer locations, and, in some cases, visited locations closer to home and spent less time at certain types of locations. These multifaceted impacts are consistent with the possibility that disease-mediated changes in host mobility generate dynamic and complex changes in host contact network structure.

Spatial Association of Canine Rabies Outbreak and Ecological Urban Corridors, Arequipa, Peru

In the city of Arequipa, Peru, a rabid dog was detected in March 2015, marking the reintroduction of the rabies virus in the area; more rabid dogs have been detected since then. The presence of free-roaming dogs in Arequipa seems to be higher in dry water channels, which are widespread in the city. We created a geographic information system (GIS) with surveillance data on the location of rabid dogs detected during the first year of the outbreak, as well as the water channels. We conducted a spatial analysis using Monte Carlo simulations to determine if detected rabid dogs were closer to the water channels than expected. Thirty rabid dogs were detected during the first year of the outbreak, and they were statistically associated with the water channels (average distance to closest water channel = 334 m; p-value = 0.027). Water channels might play a role in the ecology of free-roaming dog populations, functioning as ecological corridors. Landscape ecology could assist in understanding the impact of these urban structures on control activities and the persistence of transmission.

Barriers to dog rabies vaccination during an urban rabies outbreak: Qualitative findings from Arequipa, Peru

Background

Canine rabies was reintroduced to the city of Arequipa, Peru in March 2015. The Ministry of Health has conducted a series of mass dog vaccination campaigns to contain the outbreak, but canine rabies virus transmission continues in Arequipa’s complex urban environment, putting the city’s 1 million inhabitants at risk of infection. The proximate driver of canine rabies in Arequipa is low dog vaccination coverage. Our objectives were to qualitatively assess barriers to and facilitators of rabies vaccination during mass campaigns, and to explore strategies to increase participation in future efforts.

Methodology/Principal findings

We conducted 8 focus groups (FG) in urban and peri-urban communities of Mariano Melgar district; each FG included both sexes, and campaign participants and non-participants. All FG were transcribed and then coded independently by two coders. Results were summarized using the Social Ecological Model. At the individual level, participants described not knowing enough about rabies and vaccination campaigns, mistrusting the campaign, and being unable to handle their dogs, particularly in peri-urban vs. urban areas. At the interpersonal level, we detected some social pressure to vaccinate dogs, as well as some disparaging of those who invest time and money in pet dogs. At the organizational level, participants found the campaign information to be insufficient and ill-timed, and campaign locations and personnel inadequate. At the community level, the influence of landscape and topography on accessibility to vaccination points was reported differently between participants from the urban and peri-urban areas. Poor security and impermanent housing materials in the peri-urban areas also drives higher prevalence of guard dog ownership for home protection; these dogs usually roam freely on the streets and are more difficult to handle and bring to the vaccination points.

Conclusions

A well-designed communication campaign could improve knowledge about canine rabies. Timely messages on where and when vaccination is occurring could increase dog owners’ perception of their own ability to bring their dogs to the vaccination points and be part of the campaign. Small changes in the implementation of the campaign at the vaccination points could increase the public’s trust and motivation. Location of vaccination points should take into account landscape and community concerns.

Canine rabies was reintroduced in Arequipa, Peru in March 2015, a rare event in an area previously declared free of transmission. In Arequipa, annual mass dog vaccination is practiced as a preventive strategy, with additional campaigns being implemented since the recent detection of the virus. However, these additional efforts have not quelled the outbreak and low dog vaccination coverage is driving ongoing transmission. We conducted focus groups in urban and peri-urban areas of Arequipa to identify barriers to and facilitators of canine vaccination during mass campaigns. Based on our findings, communication campaigns should seek to increase knowledge about canine rabies and the vaccination campaign, and provide timely messages on where and when vaccination is occurring. Small changes at the campaign’s vaccination points could increase public’s trust. Finally, there are differences between urban and peri-urban areas, such as landscape and topography that affect participation in mass vaccination campaigns and that should be considered when selecting locations for vaccination points.

Interdisciplinary Postdoctoral Training in Global Health Through a Novel Joint Project for Trainees from Diverse Disciplines: Benefits, Risks, and Observations

Postdoctoral training programs are usually highly individualized arrangements between trainees and a limited number of senior mentors in their field, an approach that contrasts with current trends in public health education that promote interdisciplinary training to spur innovation. Herein, we describe an alternative model for postdoctoral training for a group of fellows from distinct disciplines. Fellows work with mentors from diverse fields to create a joint research project or a group of complementary projects, with the goal of developing a new device, intervention, or innovation to address a global health problem. The perceived benefits, challenges, and limitations of this team approach to interdisciplinary postdoctoral training are presented.

Design and Testing of Novel Lethal Ovitrap to Reduce Populations of Aedes Mosquitoes: Community-Based Participatory Research between Industry, Academia and Communities in Peru and Thailand

Background

Dengue virus (and Chikungunya and Zika viruses) is transmitted by Aedes aegypti and Aedes albopictus mosquitoes and causes considerable human morbidity and mortality. As there is currently no vaccine or chemoprophylaxis to protect people from dengue virus infection, vector control is the only viable option for disease prevention. The purpose of this paper is to illustrate the design and placement process for an attractive lethal ovitrap to reduce vector populations and to describe lessons learned in the development of the trap.

Methods

This study was conducted in 2010 in Iquitos, Peru and Lopburi Province, Thailand and used an iterative community-based participatory approach to adjust design specifications of the trap, based on community members’ perceptions and feedback, entomological findings in the lab, and design and research team observations. Multiple focus group discussions (FGD) were held over a 6 month period, stratified by age, sex and motherhood status, to inform the design process. Trap testing transitioned from the lab to within households.

Results

Through an iterative process of working with specifications from the research team, findings from the laboratory testing, and feedback from FGD, the design team narrowed trap design options from 22 to 6. Comments from the FGD centered on safety for children and pets interacting with traps, durability, maintenance issues, and aesthetics. Testing in the laboratory involved releasing groups of 50 gravid Ae. aegypti in walk-in rooms and assessing what percentage were caught in traps of different colors, with different trap cover sizes, and placed under lighter or darker locations. Two final trap models were mocked up and tested in homes for a week; one model was the top choice in both Iquitos and Lopburi.

Discussion

The community-based participatory process was essential for the development of novel traps that provided effective vector control, but also met the needs and concerns of community members.