Eva Harris, PhD and Josefina Coloma, PhD Division of Infectious Disease and Vaccinology, School of Public Health, UC Berkeley

Sustainable Sciences Institute, San Francisco & Managua, Nicaragua

Engaging Communities from Surveillance to Policy

Mandate Example: Dengue, Zika, arboviral diseases

What are effective community-based interventions & participatory approaches to prevent and control infectious disease threats in urban areas?

What elements should be considered in the planning of community-based intervention or participatory approach for it to be successful? What are common pitfalls of these interventions? How can we ensure sustainability?

To what extent are there surveillance methods that can capture accurate and precise data in real-time and distinguish different types of residence, locations, socioeconomic strata to reveal varied effects of infectious disease transmission in the urban built environment? How has this information been used to develop targeted policies and interventions? How can communities help with this?

Kraemer et al. eLife 2015;4:e08347.

GLOBAL DISTRIBUTION OF AEDES AEGYPTI

The mosquito problem

Current efforts have failed or are insufficient

Evidence that community-based dengue control programmes alone and in combination with other control activities can enhance the effectiveness of dengue control programmes is weak.

In conclusion, dengue vector control is effective in reducing vector populations, particularly when interventions use a community-based, integrated approach, which is tailored to local eco-epidemiological and sociocultural settings and combined with educational programmes to increase knowledge and understanding of best practice.

Community-based participatory research: Variations on a theme

Eco-bio-social initiative (TDR)

EGI-Dengue; COMBI (PAHO)

Community involvement in dengue vector control: the Cuban example

Camino Verde/SePA

Dengue/ZikaChat

Care group model

Andersson et al. (2015) BMJ 351:h3267

www.denguechat.org

This paper: http://bit.ly/CGPaper1 CareGroupInfo.org

Health Brigades: Brigadas SePA or Care Groups

Three Levels of Intervention

House Barrio-Neighborhood

Inter-Barrio

Engaging/Motivating community People-centered

Socializing Evidence for Participatory Action

CIET

Camino Verde

Barrio-level interventions

Reduction of key breeding sites

Discussions and games in schools

Participation in barrio fairs

Clean-up campaigns

Community solutions to the tire problem

Pilot phase: Observational study 2004-2008

Critical role of evidence for dialogue and ´reflection´ with residents Risk exists in their own home They can control the vector in their own environment Integrated neighborhood action is needed

Socialization & dialogue about the evidence (household, neighbor-hood) can generate interventions from a cost–benefit perspective

Beyond motivation, the SEPA process aims for households and communities to responsibly assume control of their own health

Prevention = empowerment

External actions are generated from the knowledge and experience of the communities themselves. There are no fixed, one-size-fits-all solutions; the practice is specific to each neighborhood (barrio)

Requires that community responsibility materializes organically. Effectiveness & sustainability depend on local management and autonomy of SEPA brigades.

Five main lessons from pilot that formed basis of CRCT

Random Selection of Barrios

Baseline Measurement

Entomological Antibodies in Saliva Costs, Social Capital

Randomization Intervention/

Reference

Interventions

Impact Measurement

Nicaragua 60 clusters 40,362 residents Managua, Nicaragua Urban

Paral lel CRCT Trials

México 90 clusters

44,820 residents Guerrero, México

Urban: Acapulco Rural: Costas Chica y Grande

30 intervention 30 control 140 homes/cluster

Primary outcomes: Serological incidence (anti-DENV antibodies in saliva) in children 3-9 y/o; Entomological indices; Report of recent dengue case

15 intervention x 3 areas: 45 15 control x 3 areas: 45 138 homes/cluster

Primary outcomes

Andersson et al, submitted

Secondary analysis: Effect of Temephos

Andersson et al, submitted

All households Adjusted odds ratio 95% CI

Intervention 0.74 0.59-0.93 Temephos found in water storage containers 1.44 1.21-1.72 Only households where no dengue case was reported

Intervention 0.75 0.59-0.94 Temephos found in water storage containers 1.44 1.19-1.73

Data on serological evidence of temephos:

238/1418 households with temephos and 613/5156 without temephos during the entomological survey had at least one child with serological evidence of DENV infection

391/3460 households in intervention clusters and 474/3238 in control clusters had at least one child with serological evidence of DENV infection Saturated models also contained water supply, purchase of household pesticide, sex of informant Random effects were country and cluster

Same results obtained over 7 years of observational “pilot” study, both for protection with SePA intervention and risk with Temephos

Real-time capture and use of data: Dengue/ZikaChat web- and cell-based platform

Report and eliminate mosquito breeding sites

Mapping communities

Household surveys

SES/dialogue about household costs

Real-time, crowd-sourced, community entomology

Game theory and practice – customized!

Communication: Dialogue, blog

Data: Reports, Analysis

photo

Step 1

Step 2 Step 3

DengueChat Web App

DENGUECHAT

Earn points Brigade and barrio- level competition

Barrios participate in teams (virtual and real)

Evidence-based (or data-based) communication strategy to mobilize vector control

Data collected in a CSV

59.1

4.7 4.7 3.2

15.8 18.9

29.2

Octubre 2014 Marzo 2015 Marzo 2016 Diciembre 2016

Barrios de Intervención

Barrios de Referencia

Breteau Index

18.8

1.2 0.1 0.1

2.9

14.4

18.7

Octubre 2014 Marzo 2015 Marzo 2016 Diciembre2016

Barrios de Intervención

Barrios de Referencia

Pupae per container

DengueChat pilot study results

Brazil and Mexico Developed and tested alpha version of DengueTorpedo using two social models: 1) Redes

de Mare, a neighborhood association in the largest favela in São Paulo and 2) student groups, Grupos de Acción para la Salud, in Tepalcingo, Mexico. Violence (Rio, during pacification of favelas) and corruption (Mexico) were serious problems.

Nicaragua Pilot phase in 5 neighborhoods (barrios) and matched controls Currently implemented as part of the multi-country USAID program “Engagement of

Communities against Zika” in Care Groups that deploy information and foster practices aimed at key “behavior changes”.

DengueChat is used as a monitoring tool and a platform for return of community data to 50,000 households with 960 brigadistas as part of the MOH community health model.

New questionnaires & data visualization capabilities (ORs of interventions, spatial analysis)

Colombia Fundación Santa Fe de Bogotá (NGO) with Municipality of Armenia, Colombia, in

COVECOM programa de Comités de Vigilancia en Salud Publica Comunitarios. DengueChat implemented through students in social service year.

Paraguay Asunción slums. Collaboration with Municipality, University, NGOs and CONACYT.

Implementation with community health workers organized by NGO facilitators

DengueChat evolution and trajectory (I)

Towards policy Ministry of Health of Nicaragua is creating the policy guidelines and

protocols to incorporate the strategy into the community-based health model, MOSAFC

Working with USAID, UNICEF, CDC to incorporate key components of SePA and cyclical evidence generation into recommendations and current programs in 13 countries in Latin America

IDB: Apps for development, Open-source code release and funding for implementation (Costa Rica, Easter Island, and others)

Data- or evidence-driven policy change. Discussions with PAHO… Incorporate community into all interventions

DengueChat evolution and trajectory (II)

Towards a sustainable model

Beyond a game to community action

Community participation in research and data generation

Tension between vertical and horizontal programs

Involvement of civic organizations, not just MOH

Integrated/intersectorial: health, municipal services, community organizations in complex integrated model

Evidence-based actions and policy

Scale-up and out

Acknowledgments

CIET Jorge Arosteguí Alvaro Cárcamo Rosa Maria Reyes Carlos Hernandez Alejandro Belli Magdalena Zamora

Elizabeth Nava Arcadio Morales Jose Legorreta Sergio Paredes Ildefonso Fernandez Antonio Juan Cortez

Neil Andersson Robert Ledogar Jorge Laucirica

Nicaraguan Ministry of Health (CNDR) Angel Balmaseda Juan Carlos Mercado Andrea Nuñez Douglas Elizondo Sonia Arguello Emperatriz Lugo Sonia Valle

SILAIS Managua Carolina Davila Sonia Aragon Maritza Cuan

Univ of California, Berkeley Josefina Coloma

Social Apps Lab, UCB James Holston Dmitri Skjorshammer

Sustainable Sciences Institute Harold Suazo Laguna Mercedes Lopez Juana Rosa Ruiz Rosa Villareal Jackie Mojica Jenny Ruiz Hernandez Julia Castilllo

AMOS Health Laura Chanchien Parajon Lester Lorente Gabriela Woo Silvia Carvajal

Funding UBS-Optimus Foundation BMG/ICSS UNICEF USAID

Los Brigadistas y Residentes!

Gracias!!