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1.  The impact of biases in mobile phone ownership on estimates of human mobility 
Mobile phone data are increasingly being used to quantify the movements of human populations for a wide range of social, scientific and public health research. However, making population-level inferences using these data is complicated by differential ownership of phones among different demographic groups that may exhibit variable mobility. Here, we quantify the effects of ownership bias on mobility estimates by coupling two data sources from the same country during the same time frame. We analyse mobility patterns from one of the largest mobile phone datasets studied, representing the daily movements of nearly 15 million individuals in Kenya over the course of a year. We couple this analysis with the results from a survey of socioeconomic status, mobile phone ownership and usage patterns across the country, providing regional estimates of population distributions of income, reported airtime expenditure and actual airtime expenditure across the country. We match the two data sources and show that mobility estimates are surprisingly robust to the substantial biases in phone ownership across different geographical and socioeconomic groups.
doi:10.1098/rsif.2012.0986
PMCID: PMC3627108  PMID: 23389897
mobile phone; human mobility; socio-economic status
2.  The Malaria Transition on the Arabian Peninsula: Progress toward a Malaria-Free Region between 1960–2010 
Advances in parasitology  2013;82:205-251.
The transmission of malaria across the Arabian Peninsula is governed by the diversity of dominant vectors and extreme aridity. It is likely that where malaria transmission was historically possible it was intense and led to a high disease burden. Here, we review the speed of elimination, approaches taken, define the shrinking map of risk since 1960 and discuss the threats posed to a malaria-free Arabian Peninsula using the archive material, case data and published works. From as early as the 1940s, attempts were made to eliminate malaria on the peninsula but were met with varying degrees of success through to the 1970s; however, these did result in a shrinking of the margins of malaria transmission across the peninsula. Epidemics in the 1990s galvanised national malaria control programmes to reinvigorate control efforts. Before the launch of the recent global ambition for malaria eradication, countries on the Arabian Peninsula launched a collaborative malaria-free initiative in 2005. This initiative led a further shrinking of the malaria risk map and today locally acquired clinical cases of malaria are reported only in Saudi Arabia and Yemen, with the latter contributing to over 98% of the clinical burden.
doi:10.1016/B978-0-12-407706-5.00003-4
PMCID: PMC3951717  PMID: 23548086
3.  Access and barriers to measures targeted to prevent malaria in pregnancy in rural Kenya* 
Objectives
To evaluate barriers preventing pregnant women from using insecticide-treated nets (ITN) and intermittent presumptive treatment (IPT) with sulphadoxine-pyrimethamine (SP) 5 years after the launch of the national malaria strategy promoting these measures in Kenya.
Methods
All women aged 15–49 years were interviewed during a community survey in four districts between December 2006 and January 2007. Women pregnant in the last 12 months were asked about their age, parity, education, use of nets, ITN, antenatal care (ANC) services and sulphadoxine-pyrimethamine (SP) (overall and for IPT) during pregnancy. Homestead assets were recorded and used to develop a wealth index. Travel time to ANC clinics was computed using a geographic information system algorithm. Predictors of net and IPT use were defined using multivariate logistic regression.
Results
Overall 68% of pregnant women used a net; 52% used an ITN; 84% attended an ANC clinic at least once and 74% at least twice. Fifty-three percent of women took at least one dose of IPT-SP, however only 22% took two or more doses. Women from the least poor homesteads (OR = 2.53, 1.36–4.68) and those who used IPT services (OR = 1.73, 1.24–2.42) were more likely to sleep under any net. Women who used IPT were more likely to use ITNs (OR = 1.35, 1.03–1.77), while those who lived more than an hour from an ANC clinic were less likely (OR = 0.61, 0.46–0.81) to use ITN. Women with formal education (1.47, 1.01–2.17) and those who used ITN (OR: 1.68, 1.20–2.36) were more likely to have received at least one dose of IPT-SP.
Conclusion
Although the use of ITN had increased 10-fold and the use of IPT fourfold since last measured in 2001, coverage remains low. Provider practices in the delivery of protective measures against malaria must change, supported by community awareness campaigns on the importance of mothers’ use of IPT.
doi:10.1111/j.1365-3156.2007.01992.x
PMCID: PMC2607535  PMID: 18304267
malaria; pregnancy; antenatal care; intermittent presumptive treatment; sulphadoxine-pyrimethamine; insecticide-treated nets; Kenya
4.  Estimation of malaria incidence in northern Namibia in 2009 using Bayesian conditional-autoregressive spatial–temporal models☆ 
Highlights
•Incidence is modelled using HMIS data in Namibia.•Assembled data include parasitological and clinical diagnosed case. The clinical cases are adjusted using slide positivity rates at each facility.•Denominator catchment population adjusted for probability for seeking treatment when sick with fever.•Bayesian spatio-temporal model was implemented at facility level, adjusting for missing data using INLA.•Spatio-temporal monthly maps of incidence are produced and a mean prediction for 2009 for Namibia.
As malaria transmission declines, it becomes increasingly important to monitor changes in malaria incidence rather than prevalence. Here, a spatio-temporal model was used to identify constituencies with high malaria incidence to guide malaria control. Malaria cases were assembled across all age groups along with several environmental covariates. A Bayesian conditional-autoregressive model was used to model the spatial and temporal variation of incidence after adjusting for test positivity rates and health facility utilisation. Of the 144,744 malaria cases recorded in Namibia in 2009, 134,851 were suspected and 9893 were parasitologically confirmed. The mean annual incidence based on the Bayesian model predictions was 13 cases per 1000 population with the highest incidence predicted for constituencies bordering Angola and Zambia. The smoothed maps of incidence highlight trends in disease incidence. For Namibia, the 2009 maps provide a baseline for monitoring the targets of pre-elimination.
doi:10.1016/j.sste.2013.09.001
PMCID: PMC3839406  PMID: 24238079
ACD, active case detection; CAR, conditional auto-regressive; CPO, conditional predictive ordinate; DIC, deviance information criterion; ESRI, Environmental System Research Institute; EVI, enhanced vegetation index; GF, Gaussian field; GIS, geographic information system; GMRF, Gaussian markov random field; GPS, global positioning system; GRUMP, Global Rural and Urban Mapping Project; HMIS, Health Management Information System; INLA, Integrated Nested Laplace Approximation; JAXA, Japan Aerospace Exploration Agency; MAUP, Modifiable Areal Unit Problem; MCMC, Markov Chain Monte Carlo; MODIS, MODerate-resolution Imaging Spectro-radiometer; MoHSS, Ministry of Health and Social Services; NASA, National Aeronautics and Space Administration; NVBDCP, National Vector-Borne and Disease Control Programme; PCD, passive case detection; PHS, public health sector; RDT, Rapid Diagnostic Test; SPA, Service Provision Assessments; TRMM, Tropical Rainfall Measuring Mission; TSI, temperature suitability index; WHO, World Health Organisation; ZIP, Zero-Inflated Poisson; Namibia; Malaria; Spatio-temporal; Conditional-autoregressive
5.  Mapping Malaria Transmission Intensity in Malawi, 2000–2010 
Substantial development assistance has been directed towards reducing the high malaria burden in Malawi over the past decade. We assessed changes in transmission over this period of malaria control scale-up by compiling community Plasmodium falciparum rate (PfPR) data during 2000–2011 and used model-based geostatistical methods to predict mean PfPR2–10 in 2000, 2005, and 2010. In addition, we calculated population-adjusted prevalences and populations at risk by district to inform malaria control program priority setting. The national population-adjusted PfPR2–10 was 37% in 2010, and we found no evidence of change over this period of scale-up. The entire population of Malawi is under meso-endemic transmission risk, with those in districts along the shore of Lake Malawi and Shire River Valley under highest risk. The lack of change in prevalence confirms modeling predictions that when compared with lower transmission, prevalence reductions in high transmission settings require greater investment and longer time scales.
doi:10.4269/ajtmh.13-0028
PMCID: PMC3820324  PMID: 24062477
6.  The demographics of human and malaria movement and migration patterns in East Africa 
Malaria Journal  2013;12:397.
Introduction
The quantification of parasite movements can provide valuable information for control strategy planning across all transmission intensities. Mobile parasite carrying individuals can instigate transmission in receptive areas, spread drug resistant strains and reduce the effectiveness of control strategies. The identification of mobile demographic groups, their routes of travel and how these movements connect differing transmission zones, potentially enables limited resources for interventions to be efficiently targeted over space, time and populations.
Methods
National population censuses and household surveys provide individual-level migration, travel, and other data relevant for understanding malaria movement patterns. Together with existing spatially referenced malaria data and mathematical models, network analysis techniques were used to quantify the demographics of human and malaria movement patterns in Kenya, Uganda and Tanzania. Movement networks were developed based on connectivity and magnitudes of flow within each country and compared to assess relative differences between regions and demographic groups. Additional malaria-relevant characteristics, such as short-term travel and bed net use, were also examined.
Results
Patterns of human and malaria movements varied between demographic groups, within country regions and between countries. Migration rates were highest in 20–30 year olds in all three countries, but when accounting for malaria prevalence, movements in the 10–20 year age group became more important. Different age and sex groups also exhibited substantial variations in terms of the most likely sources, sinks and routes of migration and malaria movement, as well as risk factors for infection, such as short-term travel and bed net use.
Conclusion
Census and survey data, together with spatially referenced malaria data, GIS and network analysis tools, can be valuable for identifying, mapping and quantifying regional connectivities and the mobility of different demographic groups. Demographically-stratified HPM and malaria movement estimates can provide quantitative evidence to inform the design of more efficient intervention and surveillance strategies that are targeted to specific regions and population groups.
doi:10.1186/1475-2875-12-397
PMCID: PMC3829999  PMID: 24191976
7.  Quantifying the impact of human mobility on malaria 
Science (New York, N.Y.)  2012;338(6104):267-270.
Human movements contribute to the transmission of malaria on spatial scales that exceed the limits of mosquito dispersal. Identifying the sources and sinks of imported infections due to human travel and locating high-risk sites of parasite importation could greatly improve malaria control programs. Here we use spatially explicit mobile phone data and malaria prevalence information from Kenya to identify the dynamics of human carriers that drive parasite importation between regions. Our analysis identifies specific importation routes that contribute to malaria epidemiology on regional spatial scales.
doi:10.1126/science.1223467
PMCID: PMC3675794  PMID: 23066082
8.  Millennium development health metrics: where do Africa’s children and women of childbearing age live? 
The Millennium Development Goals (MDGs) have prompted an expansion in approaches to deriving health metrics to measure progress toward their achievement. Accurate measurements should take into account the high degrees of spatial heterogeneity in health risks across countries, and this has prompted the development of sophisticated cartographic techniques for mapping and modeling risks. Conversion of these risks to relevant population-based metrics requires equally detailed information on the spatial distribution and attributes of the denominator populations. However, spatial information on age and sex composition over large areas is lacking, prompting many influential studies that have rigorously accounted for health risk heterogeneities to overlook the substantial demographic variations that exist subnationally and merely apply national-level adjustments.
Here we outline the development of high resolution age- and sex-structured spatial population datasets for Africa in 2000-2015 built from over a million measurements from more than 20,000 subnational units, increasing input data detail from previous studies by over 400-fold. We analyze the large spatial variations seen within countries and across the continent for key MDG indicator groups, focusing on children under 5 and women of childbearing age, and find that substantial differences in health and development indicators can result through using only national level statistics, compared to accounting for subnational variation.
Progress toward meeting the MDGs will be measured through national-level indicators that mask substantial inequalities and heterogeneities across nations. Cartographic approaches are providing opportunities for quantitative assessments of these inequalities and the targeting of interventions, but demographic spatial datasets to support such efforts remain reliant on coarse and outdated input data for accurately locating risk groups. We have shown here that sufficient data exist to map the distribution of key vulnerable groups, and that doing so has substantial impacts on derived metrics through accounting for spatial demographic heterogeneities that exist within nations across Africa.
doi:10.1186/1478-7954-11-11
PMCID: PMC3724578  PMID: 23875684
Population; Demography; Mapping; Millenium development goals
9.  Malaria Control and the Intensity of Plasmodium falciparum Transmission in Namibia 1969–1992 
PLoS ONE  2013;8(5):e63350.
Background
Historical evidence of the levels of intervention scale up and its relationships to changing malaria risks provides important contextual information for current ambitions to eliminate malaria in various regions of Africa today.
Methods
Community-based Plasmodium falciparum prevalence data from 3,260 geo-coded time-space locations between 1969 and 1992 were assembled from archives covering an examination of 230,174 individuals located in northern Namibia. These data were standardized the age-range 2 to less than 10 years and used within a Bayesian model-based geo-statistical framework to examine the changes of malaria risk in the years 1969, 1974, 1979, 1984 and 1989 at 5×5 km spatial resolution. This changing risk was described against rainfall seasons and the wide-scale use of indoor-residual house-spraying and mass drug administration.
Results
Most areas of Northern Namibia experienced low intensity transmission during a ten-year period of wide-scale control activities between 1969 and 1979. As control efforts waned, flooding occurred, drug resistance emerged and the war for independence intensified the spatial extent of moderate-to-high malaria transmission expanded reaching a peak in the late 1980s.
Conclusions
Targeting vectors and parasite in northern Namibia was likely to have successfully sustained a situation of low intensity transmission, but unraveled quickly to a peak of transmission intensity following a sequence of events by the early 1990s.
doi:10.1371/journal.pone.0063350
PMCID: PMC3646760  PMID: 23667604
10.  The effect of an anti-malarial subsidy programme on the quality of service provision of artemisinin-based combination therapy in Kenya: a cluster-randomized, controlled trial 
Malaria Journal  2013;12:81.
Background
Many patients with suspected malaria in sub-Saharan Africa seek treatment from private providers, but this sector suffers from sub-standard medicine dispensing practices. To improve the quality of care received for presumptive malaria from the highly accessed private retail sector in western Kenya, subsidized pre-packaged artemether-lumefantrine (AL) was provided to private retailers, together with a one day training for retail staff on malaria diagnosis and treatment, job aids and community engagement activities.
Methods
The intervention was assessed using a cluster-randomized, controlled design. Provider and mystery-shopper cross-sectional surveys were conducted at baseline and eight months post-intervention to assess provider practices. Data were analysed based on cluster-level summaries, comparing control and intervention arms.
Results
On average, 564 retail outlets were interviewed per year. At follow-up, 43% of respondents reported that at least one staff member had attended the training in the intervention arm. The intervention significantly increased the percentage of providers knowing the first line treatment for uncomplicated malaria by 24.2% points (confidence interval (CI): 14.8%, 33.6%; adjusted p=0.0001); the percentage of outlets stocking AL by 31.7% points (CI: 22.0%, 41.3%; adjusted p=0.0001); and the percentage of providers prescribing AL for presumptive malaria by 23.6% points (CI: 18.7%, 28.6%; adjusted p=0.0001). Generally outlets that received training and job aids performed better than those receiving one or none of these intervention components.
Conclusion
Overall, subsidizing ACT and retailer training can significantly increase the percentage of outlets stocking and selling AL for the presumptive treatment of malaria, but further research is needed on strategies to improve the provision of counselling advice to retail customers.
doi:10.1186/1475-2875-12-81
PMCID: PMC3614520  PMID: 23452547
Community case-management of malaria; Artemisinin-based combination therapy; Antimalarial subsidy programme; Drug retailers
11.  How Well Are Malaria Maps Used to Design and Finance Malaria Control in Africa? 
PLoS ONE  2013;8(1):e53198.
Introduction
Rational decision making on malaria control depends on an understanding of the epidemiological risks and control measures. National Malaria Control Programmes across Africa have access to a range of state-of-the-art malaria risk mapping products that might serve their decision-making needs. The use of cartography in planning malaria control has never been methodically reviewed.
Materials and Methods
An audit of the risk maps used by NMCPs in 47 malaria endemic countries in Africa was undertaken by examining the most recent national malaria strategies, monitoring and evaluation plans, malaria programme reviews and applications submitted to the Global Fund. The types of maps presented and how they have been used to define priorities for investment and control was investigated.
Results
91% of endemic countries in Africa have defined malaria risk at sub-national levels using at least one risk map. The range of risk maps varies from maps based on suitability of climate for transmission; predicted malaria seasons and temperature/altitude limitations, to representations of clinical data and modelled parasite prevalence. The choice of maps is influenced by the source of the information. Maps developed using national data through in-country research partnerships have greater utility than more readily accessible web-based options developed without inputs from national control programmes. Although almost all countries have stratification maps, only a few use them to guide decisions on the selection of interventions allocation of resources for malaria control.
Conclusion
The way information on the epidemiology of malaria is presented and used needs to be addressed to ensure evidence-based added value in planning control. The science on modelled impact of interventions must be integrated into new mapping products to allow a translation of risk into rational decision making for malaria control. As overseas and domestic funding diminishes, strategic planning will be necessary to guide appropriate financing for malaria control.
doi:10.1371/journal.pone.0053198
PMCID: PMC3543450  PMID: 23326398
12.  Use of Rapid Diagnostic Tests in Malaria School Surveys in Kenya: Does their Under-performance Matter for Planning Malaria Control? 
Malaria rapid diagnostic tests (RDTs) are known to yield false-positive results, and their use in epidemiologic surveys will overestimate infection prevalence and potentially hinder efficient targeting of interventions. To examine the consequences of using RDTs in school surveys, we compared three RDT brands used during a nationwide school survey in Kenya with expert microscopy and investigated the cost implications of using alternative diagnostic approaches in identifying localities with differing levels of infection. Overall, RDT sensitivity was 96.1% and specificity was 70.8%. In terms of classifying districts and schools according to prevalence categories, RDTs were most reliable for the < 1% and > 40% categories and least reliable in the 1–4.9% category. In low-prevalence settings, microscopy was the most expensive approach, and RDT results corrected by either microscopy or polymerase chain reaction were the cheapest. Use of polymerase chain reaction-corrected RDT results is recommended in school malaria surveys, especially in settings with low-to-moderate malaria transmission.
doi:10.4269/ajtmh.2012.12-0215
PMCID: PMC3516067  PMID: 23091194
13.  Malaria Risk Mapping for Control in the Republic of Sudan 
Evidence shows that malaria risk maps are rarely tailored to address national control program ambitions. Here, we generate a malaria risk map adapted for malaria control in Sudan. Community Plasmodium falciparum parasite rate (PfPR) data from 2000 to 2010 were assembled and were standardized to 2–10 years of age (PfPR2–10). Space-time Bayesian geostatistical methods were used to generate a map of malaria risk for 2010. Surfaces of aridity, urbanization, irrigation schemes, and refugee camps were combined with the PfPR2–10 map to tailor the epidemiological stratification for appropriate intervention design. In 2010, a majority of the geographical area of the Sudan had risk of < 1% PfPR2–10. Areas of meso- and hyperendemic risk were located in the south. About 80% of Sudan’s population in 2011 was in the areas in the desert, urban centers, or where risk was < 1% PfPR2–10. Aggregated data suggest reducing risks in some high transmission areas since the 1960s.
doi:10.4269/ajtmh.2012.12-0390
PMCID: PMC3516068  PMID: 23033400
14.  The Changing Limits and Incidence of Malaria in Africa: 1939–2009 
Advances in parasitology  2012;78:169-262.
Understanding the historical, temporal changes of malaria risk following control efforts in Africa provides a unique insight into what has been and might be archived towards a long-term ambition of elimination on the continent. Here, we use archived published and unpublished material combined with biological constraints on transmission accompanied by a narrative on malaria control to document the changing incidence of malaria in Africa since earliest reports pre-second World War. One result is a more informed mapped definition of the changing margins of transmission in 1939, 1959, 1979, 1999 and 2009.
doi:10.1016/B978-0-12-394303-3.00010-4
PMCID: PMC3521063  PMID: 22520443
15.  Use of Rapid Diagnostic Tests in Malaria School Surveys in Kenya: Does their Under-performance Matter for Planning Malaria Control? 
Malaria rapid diagnostic tests (RDTs) are known to yield false-positive results, and their use in epidemiologic surveys will overestimate infection prevalence and potentially hinder efficient targeting of interventions. To examine the consequences of using RDTs in school surveys, we compared three RDT brands used during a nationwide school survey in Kenya with expert microscopy and investigated the cost implications of using alternative diagnostic approaches in identifying localities with differing levels of infection. Overall, RDT sensitivity was 96.1% and specificity was 70.8%. In terms of classifying districts and schools according to prevalence categories, RDTs were most reliable for the < 1% and > 40% categories and least reliable in the 1–4.9% category. In low-prevalence settings, microscopy was the most expensive approach, and RDT results corrected by either microscopy or polymerase chain reaction were the cheapest. Use of polymerase chain reaction–corrected RDT results is recommended in school malaria surveys, especially in settings with low-to-moderate malaria transmission.
doi:10.4269/ajtmh.2012.12-0215
PMCID: PMC3516067  PMID: 23091194
16.  Malaria Risk Mapping for Control in the Republic of Sudan 
Evidence shows that malaria risk maps are rarely tailored to address national control program ambitions. Here, we generate a malaria risk map adapted for malaria control in Sudan. Community Plasmodium falciparum parasite rate (PfPR) data from 2000 to 2010 were assembled and were standardized to 2–10 years of age (PfPR2–10). Space-time Bayesian geostatistical methods were used to generate a map of malaria risk for 2010. Surfaces of aridity, urbanization, irrigation schemes, and refugee camps were combined with the PfPR2–10 map to tailor the epidemiological stratification for appropriate intervention design. In 2010, a majority of the geographical area of the Sudan had risk of < 1% PfPR2–10. Areas of meso- and hyperendemic risk were located in the south. About 80% of Sudan's population in 2011 was in the areas in the desert, urban centers, or where risk was < 1% PfPR2–10. Aggregated data suggest reducing risks in some high transmission areas since the 1960s.
doi:10.4269/ajtmh.2012.12-0390
PMCID: PMC3516068  PMID: 23033400
17.  Human movement data for malaria control and elimination strategic planning 
Malaria Journal  2012;11:205.
Recent increases in funding for malaria control have led to the reduction in transmission in many malaria endemic countries, prompting the national control programmes of 36 malaria endemic countries to set elimination targets. Accounting for human population movement (HPM) in planning for control, elimination and post-elimination surveillance is important, as evidenced by previous elimination attempts that were undermined by the reintroduction of malaria through HPM. Strategic control and elimination planning, therefore, requires quantitative information on HPM patterns and the translation of these into parasite dispersion. HPM patterns and the risk of malaria vary substantially across spatial and temporal scales, demographic and socioeconomic sub-groups, and motivation for travel, so multiple data sets are likely required for quantification of movement. While existing studies based on mobile phone call record data combined with malaria transmission maps have begun to address within-country HPM patterns, other aspects remain poorly quantified despite their importance in accurately gauging malaria movement patterns and building control and detection strategies, such as cross-border HPM, demographic and socioeconomic stratification of HPM patterns, forms of transport, personal malaria protection and other factors that modify malaria risk. A wealth of data exist to aid filling these gaps, which, when combined with spatial data on transport infrastructure, traffic and malaria transmission, can answer relevant questions to guide strategic planning. This review aims to (i) discuss relevant types of HPM across spatial and temporal scales, (ii) document where datasets exist to quantify HPM, (iii) highlight where data gaps remain and (iv) briefly put forward methods for integrating these datasets in a Geographic Information System (GIS) framework for analysing and modelling human population and Plasmodium falciparum malaria infection movements.
doi:10.1186/1475-2875-11-205
PMCID: PMC3464668  PMID: 22703541
18.  Defining approaches to settlement mapping for public health management in Kenya using medium spatial resolution satellite imagery 
Remote sensing of environment  2004;93(1-2):42-52.
This paper presents an appraisal of satellite imagery types and texture measures for identifying and delineating settlements in four Districts of Kenya chosen to represent the variation in human ecology across the country. Landsat Thematic Mapper (TM) and Japanese Earth Resources Satellite-1 (JERS-1) synthetic aperture radar (SAR) imagery of the four districts were obtained and supervised per-pixel classifications of image combinations tested for their efficacy at settlement delineation. Additional data layers including human population census data, land cover, and locations of medical facilities, villages, schools and market centres were used for training site identification and validation. For each district, the most accurate approach was determined through the best correspondence with known settlement and non-settlement pixels. The resulting settlement maps will be used in combination with census data to produce medium spatial resolution population maps for improved public health planning in Kenya.
doi:10.1016/j.rse.2004.06.014
PMCID: PMC3350067  PMID: 22581984
Landsat TM; JERS-1 SAR; texture; settlement mapping; Kenya; public health
19.  Population Distribution, Settlement Patterns and Accessibility across Africa in 2010 
PLoS ONE  2012;7(2):e31743.
The spatial distribution of populations and settlements across a country and their interconnectivity and accessibility from urban areas are important for delivering healthcare, distributing resources and economic development. However, existing spatially explicit population data across Africa are generally based on outdated, low resolution input demographic data, and provide insufficient detail to quantify rural settlement patterns and, thus, accurately measure population concentration and accessibility. Here we outline approaches to developing a new high resolution population distribution dataset for Africa and analyse rural accessibility to population centers. Contemporary population count data were combined with detailed satellite-derived settlement extents to map population distributions across Africa at a finer spatial resolution than ever before. Substantial heterogeneity in settlement patterns, population concentration and spatial accessibility to major population centres is exhibited across the continent. In Africa, 90% of the population is concentrated in less than 21% of the land surface and the average per-person travel time to settlements of more than 50,000 inhabitants is around 3.5 hours, with Central and East Africa displaying the longest average travel times. The analyses highlight large inequities in access, the isolation of many rural populations and the challenges that exist between countries and regions in providing access to services. The datasets presented are freely available as part of the AfriPop project, providing an evidence base for guiding strategic decisions.
doi:10.1371/journal.pone.0031743
PMCID: PMC3283664  PMID: 22363717
20.  Spatial modelling of healthcare utilisation for treatment of fever in Namibia 
Background
Health care utilization is affected by several factors including geographic accessibility. Empirical data on utilization of health facilities is important to understanding geographic accessibility and defining health facility catchments at a national level. Accurately defining catchment population improves the analysis of gaps in access, commodity needs and interpretation of disease incidence. Here, empirical household survey data on treatment seeking for fever were used to model the utilisation of public health facilities and define their catchment areas and populations in northern Namibia.
Method
This study uses data from the Malaria Indicator Survey (MIS) of 2009 on treatment seeking for fever among children under the age of five years to characterize facility utilisation. Probability of attendance of public health facilities for fever treatment was modelled against a theoretical surface of travel times using a three parameter logistic model. The fitted model was then applied to a population surface to predict the number of children likely to use a public health facility during an episode of fever in northern Namibia.
Results
Overall, from the MIS survey, the prevalence of fever among children was 17.6% CI [16.0-19.1] (401 of 2,283 children) while public health facility attendance for fever was 51.1%, [95%CI: 46.2-56.0]. The coefficients of the logistic model of travel time against fever treatment at public health facilities were all significant (p < 0.001). From this model, probability of facility attendance remained relatively high up to 180 minutes (3 hours) and thereafter decreased steadily. Total public health facility catchment population of children under the age five was estimated to be 162,286 in northern Namibia with an estimated fever burden of 24,830 children. Of the estimated fevers, 8,021 (32.3%) were within 30 minutes of travel time to the nearest health facility while 14,902 (60.0%) were within 1 hour.
Conclusion
This study demonstrates the potential of routine household surveys to empirically model health care utilisation for the treatment of childhood fever and define catchment populations enhancing the possibilities of accurate commodity needs assessment and calculation of disease incidence. These methods could be extended to other African countries where detailed mapping of health facilities exists.
doi:10.1186/1476-072X-11-6
PMCID: PMC3292929  PMID: 22336441
Namibia; Fevers; Treatment; Spatial; Utilisation; Malaria
21.  Performance of forecasting, warning and detection of malaria epidemics in the highlands of western Kenya 
Trends in parasitology  2003;19(9):394-399.
On the 4th July 2002 a leading national newspaper in Kenya, the Daily Nation, ran the headline ‘Minister sounds alert on malaria’ in an article declaring the onset of epidemics in the highlands of western Kenya. There followed frequent media coverage with quotes from district leaders on the numbers of deaths, and editorials on the failure of the national malaria control strategy. The Ministry of Health made immediate and radical changes to national policy on treatment costs in the highlands by suspending cost-sharing. Development partners and non-governmental organisations also responded with a large increase in the distribution of commodities (approximately US$ 500 000) to support preventative strategies across the western highland region. What was conspicuous by its absence was any obvious effort to predict the epidemics in advance of press coverage.
PMCID: PMC3173865  PMID: 12957515
22.  Temperature and Malaria Trends in Highland East Africa 
PLoS ONE  2011;6(9):e24524.
There has been considerable debate on the existence of trends in climate in the highlands of East Africa and hypotheses about their potential effect on the trends in malaria in the region. We apply a new robust trend test to mean temperature time series data from three editions of the University of East Anglia's Climatic Research Unit database (CRU TS) for several relevant locations. We find significant trends in the data extracted from newer editions of the database but not in the older version for periods ending in 1996. The trends in the newer data are even more significant when post-1996 data are added to the samples. We also test for trends in the data from the Kericho meteorological station prepared by Omumbo et al. We find no significant trend in the 1979-1995 period but a highly significant trend in the full 1979-2009 sample. However, although the malaria cases observed at Kericho, Kenya rose during a period of resurgent epidemics (1994-2002) they have since returned to a low level. A large assembly of parasite rate surveys from the region, stratified by altitude, show that this decrease in malaria prevalence is not limited to Kericho.
doi:10.1371/journal.pone.0024524
PMCID: PMC3174181  PMID: 21935416
23.  Empirical modelling of government health service use by children with fevers in Kenya 
Acta tropica  2004;91(3):227-237.
An understanding of spatial patterns of health facility use allows a more informed approach to the modelling of catchment populations. In the absence of patient use data, an intuitive and commonly used approach to the delineation of facility catchment areas is Thiessen polygons. This study presents a series of methods by which the validity of these assumptions can be tested directly and hence the suitability of a Thiessen polygon catchment model explicitly assessed. These methods are applied to paediatric out-patient origin data from a sample of 81 government health facilities in four districts of Kenya. A geographical information system was used to predict the location of the catchment boundary along a transect between each pair of neighbouring facilities based on patient choice patterns. The mean location of boundaries between facilities of different type was found to be significantly displaced from the Thiessen boundary towards the lower-order facility. The affect of distance on within-catchment utilization rate was assessed by using exclusion buffers to remove the effect of neighbouring facilities. Utilization rate was found to exhibit a slight but steady decrease with distance up to 6 km from a facility. The accuracy of the future modelling of unsampled facility catchments can be increased by the incorporation of these trends.
doi:10.1016/j.actatropica.2004.05.002
PMCID: PMC3166847  PMID: 15246929
Health services; Fevers; Thiessen polygons; Utilization rate; Kenya
24.  Forecasting, warning, and detection of malaria epidemics: a case study 
Lancet  2003;361(9370):1705-1706.
Our aim was to assess whether a combination of seasonal climate forecasts, monitoring of meteorological conditions, and early detection of cases could have helped to prevent the 2002 malaria emergency in the highlands of western Kenya. Seasonal climate forecasts did not anticipate the heavy rainfall. Rainfall data gave timely and reliable early warnings; but monthly surveillance of malaria out-patients gave no effective alarm, though it did help to confirm that normal rainfall conditions in Kisii Central and Gucha led to typical resurgent outbreaks whereas exceptional rainfall in Nandi and Kericho led to true malaria epidemics. Management of malaria in the highlands, including improved planning for the annual resurgent outbreak, augmented by simple central nationwide early warning, represents a feasible strategy for increasing epidemic preparedness in Kenya.
doi:10.1016/S0140-6736(03)13366-1
PMCID: PMC3164796  PMID: 12767739
25.  The global distribution and population at risk of malaria: past, present, and future 
The Lancet infectious diseases  2004;4(6):327-336.
The aim of this review was to use geographic information systems in combination with historical maps to quantify the anthropogenic impact on the distribution of malaria in the 20th century. The nature of the cartographic record enabled global and regional patterns in the spatial limits of malaria to be investigated at six intervals between 1900 and 2002. Contemporaneous population surfaces also allowed changes in the numbers of people living in areas of malaria risk to be quantified. These data showed that during the past century, despite human activities reducing by half the land area supporting malaria, demographic changes resulted in a 2 billion increase in the total population exposed to malaria risk. Furthermore, stratifying the present day malaria extent by endemicity class and examining regional differences highlighted that nearly 1 billion people are exposed to hypoendemic and mesoendemic malaria in southeast Asia. We further concluded that some distortion in estimates of the regional distribution of malaria burden could have resulted from different methods used to calculate burden in Africa. Crude estimates of the national prevalence of Plasmodium falciparum infection based on endemicity maps corroborate these assertions. Finally, population projections for 2010 were used to investigate the potential effect of future demographic changes. These indicated that although population growth will not substantially change the regional distribution of people at malaria risk, around 400 million births will occur within the boundary of current distribution of malaria by 2010: the date by which the Roll Back Malaria initiative is challenged to halve the world’s malaria burden.
doi:10.1016/S1473-3099(04)01043-6
PMCID: PMC3145123  PMID: 15172341

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