DengueChat: A Social and Software Platform for Community-based Arbovirus Vector Control.

The mosquito Aedes aegypti transmits arboviral diseases at extraordinary rates. Dengue alone afflicts 50 to 100 million people each year, with more than 3 billion at risk globally. This indicates that current approaches to prevention and control are inadequate, and that a paradigm shift from one that largely promotes vertical chemical-based control and vaccine development to one that also concentrates on eliminating the mosquito through actions by the communities it plagues is necessary. We have developed a new social and software platform, DengueChat (denguechat.org), to advance community interventions in arbovirus vector control. It is an interactive platform combining open-source digital communication technologies with face-to-face assemblies. It promotes resident participation in evidence collection, reporting, and analysis, and it incorporates pedagogic information, key messaging, and game concepts to motivate communities to implement vector reduction strategies. Using DengueChat, we conducted a 19-month pilot study in five neighborhoods of Managua, Nicaragua. The results strongly suggest that using the software produced value-added features that enhance community engagement. We measured the entomological and behavioral impacts at different time points and relative risk reduction of entomological indices at the end of the study. The entomological results showed significant risk reductions in disease transmission: Ae. aegypti larvae and pupae indices were reduced by approximately 44% in neighborhoods using DengueChat during one epidemic year, whereas control neighborhoods experienced an increase of more than 500%. A cluster permutation test determined that the probability of household positivity was significantly reduced in neighborhoods that participated in DengueChat compared with the reference neighborhoods (P = 0.0265). Therefore, DengueChat is a promising resource for vector control.

Zika virus infection in Nicaraguan households.

Zika virus (ZIKV) infection recently caused major epidemics in the Americas and is linked to congenital birth defects and Guillain-Barré Syndrome. A pilot study of ZIKV infection in Nicaraguan households was conducted from August 31 to October 21, 2016, in Managua, Nicaragua. We enrolled 33 laboratory-confirmed Zika index cases and their household members (109 contacts) and followed them on days 3-4, 6-7, 9-10, and 21, collecting serum/plasma, urine, and saliva specimens along with clinical, demographic, and socio-economic status information. Collected samples were processed by rRT-PCR to determine viral load (VL) and duration of detectable ZIKV RNA in human bodily fluids. At enrollment, 11 (10%) contacts were ZIKV rRT-PCR-positive and 23 (21%) were positive by IgM antibodies; 3 incident cases were detected during the study period. Twenty of 33 (61%) index households had contacts with ZIKV infection, with an average of 1.9 (range 1-6) positive contacts per household, and in 60% of these households, ≥50% of the members were positive for ZIKV infection. Analysis of clinical information allowed us to estimate the symptomatic to asymptomatic (S:A) ratio of 14:23 (1:1.6) among the contacts, finding 62% of the infections to be asymptomatic. The maximum number of days during which ZIKV RNA was detected was 7 days post-symptom onset in saliva and serum/plasma and 22 days in urine. Overall, VL levels in serum/plasma, saliva, and urine specimens were comparable, with means of 5.6, 5.3 and 4.5 log10 copies/ml respectively, with serum attaining the highest VL peak at 8.1 log10 copies/ml. Detecting ZIKV RNA in saliva over a similar time-period and level as in serum/plasma indicates that saliva could potentially serve as a more accessible diagnostic sample. Finding the majority of infections to be asymptomatic emphasizes the importance of silent ZIKV transmission and helps inform public health interventions in the region and globally.

Community cost-benefit discussions that launched the Camino Verde intervention in Nicaragua.

BACKGROUND: Recent literature on community intervention research stresses system change as a condition for durable impact. This involves highly participatory social processes leading to behavioural change. METHODS: Before launching the intervention in the Nicaraguan arm of Camino Verde, a cluster-randomised controlled trial to show that pesticide-free community mobilisation adds effectiveness to conventional dengue controls, we held structured discussions with leaders of intervention communities on costs of dengue illness and dengue control measures taken by both government and households. These discussions were the first step in an effort at Socialising Evidence for Participatory Action (SEPA), a community mobilisation method used successfully in other contexts. Theoretical grounding came from community psychology and behavioural economics. RESULTS: The leaders expressed surprise at how large and unexpected an economic burden dengue places on households. They also acknowledged that large investments of household and government resources to combat dengue have not had the expected results. Many were not ready to see community preventive measures as a substitute for chemical controls but all the leaders approved the formation of "brigades" to promote chemical-free household control efforts in their own communities. CONCLUSIONS: Discussions centred on household budget decisions provide a good entry point for researchers to engage with communities, especially when the evidence showed that current expenditures were providing a poor return. People became motivated not only to search for ways to reduce their costs but also to question the current response to the problem in question. This in turn helped create conditions favourable to community mobilisation for change. TRIAL REGISTRATION: ISRCTN27581154 .

The Camino Verde intervention in Nicaragua, 2004-2012.

Camino Verde (the Green Way) is an evidence-based community mobilisation tool for prevention of dengue and other mosquito-borne viral diseases. Its effectiveness was demonstrated in a cluster-randomised controlled trial conducted in 2010-2013 in Nicaragua and Mexico. The Nicaraguan arm of the trial was preceded, from 2004 to 2008, by a feasibility study that provided valuable lessons and trained facilitators for the trial itself. Here, guided by the Template for Intervention Description and Replication (TIDieR), we describe the Camino Verde intervention in Nicaragua, presenting its rationale, its time and location, activities, materials used, the main actors, modes of delivery, how it was tailored to encourage community engagement, modifications made from the feasibility study to the trial itself, and how fidelity to the process originally designed was maintained. We also present information on costs and discuss the place of this study within the literature on implementation science. TRIAL REGISTRATION: ISRCTN27581154 .

Beyond efficacy in water containers: Temephos and household entomological indices in six studies between 2005 and 2013 in Managua, Nicaragua.

BACKGROUND: A cluster-randomized controlled trial of community mobilisation for dengue prevention in Mexico and Nicaragua reported, as a secondary finding, a higher risk of dengue virus infection in households where inspectors found temephos in water containers. Data from control sites in the preceding pilot study and the Nicaragua trial arm provided six time points (2005, 2006, 2007 and 2011, 2012, 2013) to examine potentially protective effects of temephos on entomological indices under every day conditions of the national vector control programme. METHODS: Three household entomological indicators for Aedes aegypti breeding were Household Index, Households with pupae, and Pupae per Person. The primary exposure indicator at the six time points was temephos identified physically during the entomological inspection. A stricter criterion for exposure at four time points included households reporting temephos application during the last 30 days and temephos found on inspection. Using generalized linear mixed modelling with cluster as a random effect and temephos as a potential fixed effect, at each time point we examined possible determinants of lower entomological indicators. RESULTS: Between 2005 and 2013, temephos exposure was not significantly associated with a reduction in any of the three entomological indices, whether or not the exposure indicator included timing of temephos application. In six of 18 multivariate models at the six time points, temephos exposure was associated with higher entomological indices; in these models, we could exclude any protective effect of temephos with 95% confidence. CONCLUSION: Our failure to demonstrate a significant protective association between temephos and entomological indices might be explained by several factors. These include ecological adaptability of the vector, resistance of Aedes to the pesticide, operational deficiencies of vector control programme, or a decrease in preventive actions by households resulting from a false sense of protection fostered by the centralized government programme using chemical agents. Whatever the explanation, the implication is that temephos affords less protection under routine field conditions than expected from its efficacy under experimental conditions. TRIAL REGISTRATION: ISRCTN 27581154 .

Mobilising communities for Aedes aegypti control: the SEPA approach.

Camino Verde (the Green Way) is an evidence-based community mobilisation tool for prevention of dengue and other mosquito-borne viral diseases. Its effectiveness was demonstrated in a cluster-randomised controlled trial conducted in 2010-2013 in Nicaragua and Mexico. The common approach that brought functional consistency to the Camino Verde intervention in both Mexico and Nicaragua is Socialisation of Evidence for Participatory Action (SEPA). In this article, we explain the SEPA concept and its theoretical origins, giving examples of its previous application in different countries and contexts. We describe how the approach was used in the Camino Verde intervention, with details that show commonalities and differences in the application of the approach in Mexico and Nicaragua. We discuss issues of cost, replicability and sustainability, and comment on which components of the intervention were most important to its success. In complex interventions, multiple components act in synergy to produce change. Among key factors in the success of Camino Verde were the use of community volunteers called brigadistas, the house-to-house visits they conducted, the use of evidence derived from the communities themselves, and community ownership of the undertaking. Communities received the intervention by random assignment; dengue was not necessarily their greatest concern. The very nature of the dengue threat dictated many of the actions that needed to be taken at household and neighbourhood levels to control it. But within these parameters, communities exercised a large degree of control over the intervention and displayed considerable ingenuity in the process. TRIAL REGISTRATION: ISRCTN27581154 .

Evidence based community mobilization for dengue prevention in Nicaragua and Mexico (Camino Verde, the Green Way): cluster randomized controlled trial.

OBJECTIVE: To test whether community mobilization adds effectiveness to conventional dengue control. DESIGN: Pragmatic open label parallel group cluster randomized controlled trial. Those assessing the outcomes and analyzing the data were blinded to group assignment. Centralized computerized randomization after the baseline study allocated half the sites to intervention, stratified by country, evidence of recent dengue virus infection in children aged 3-9, and vector indices. SETTING: Random sample of communities in Managua, capital of Nicaragua, and three coastal regions in Guerrero State in the south of Mexico. PARTICIPANTS: Residents in a random sample of census enumeration areas across both countries: 75 intervention and 75 control clusters (about 140 households each) were randomized and analyzed (60 clusters in Nicaragua and 90 in Mexico), including 85,182 residents in 18,838 households. INTERVENTIONS: A community mobilization protocol began with community discussion of baseline results. Each intervention cluster adapted the basic intervention-chemical-free prevention of mosquito reproduction-to its own circumstances. All clusters continued the government run dengue control program. MAIN OUTCOME MEASURES: Primary outcomes per protocol were self reported cases of dengue, serological evidence of recent dengue virus infection, and conventional entomological indices (house index: households with larvae or pupae/households examined; container index: containers with larvae or pupae/containers examined; Breteau index: containers with larvae or pupae/households examined; and pupae per person: pupae found/number of residents). Per protocol secondary analysis examined the effect of Camino Verde in the context of temephos use. RESULTS: With cluster as the unit of analysis, serological evidence from intervention sites showed a lower risk of infection with dengue virus in children (relative risk reduction 29.5%, 95% confidence interval 3.8% to 55.3%), fewer reports of dengue illness (24.7%, 1.8% to 51.2%), fewer houses with larvae or pupae among houses visited (house index) (44.1%, 13.6% to 74.7%), fewer containers with larvae or pupae among containers examined (container index) (36.7%, 24.5% to 44.8%), fewer containers with larvae or pupae among houses visited (Breteau index) (35.1%, 16.7% to 55.5%), and fewer pupae per person (51.7%, 36.2% to 76.1%). The numbers needed to treat were 30 (95% confidence interval 20 to 59) for a lower risk of infection in children, 71 (48 to 143) for fewer reports of dengue illness, 17 (14 to 20) for the house index, 37 (35 to 67) for the container index, 10 (6 to 29) for the Breteau index, and 12 (7 to 31) for fewer pupae per person. Secondary per protocol analysis showed no serological evidence of a protective effect of temephos. CONCLUSIONS: Evidence based community mobilization can add effectiveness to dengue vector control. Each site implementing the intervention in its own way has the advantage of local customization and strong community engagement. TRIAL REGISTRATION: ISRCTN27581154.