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Towards Climate Based Early Warning and Response Systems for Malaria
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Great strides have been made in combating malaria, however, the indicators in sub Saharan Africa still do not show promise for elimination in the near future as malaria infections still result in high morbidity and mortality among children. The abundance of the malaria-transmitting mosquito vectors in these regions are driven by climate suitability. In order to achieve malaria elimination by 2030, strengthening of surveillance systems have been advocated. Based on malaria surveillance and climate monitoring, forecasting models may be developed for early warnings. Therefore, in this thesis, we strived to illustrate the use malaria surveillance and climate data for policy and decision making by assessing the association between weather variability (from ground and remote sensing sources) and malaria mortality, and by building malaria admission forecasting models. We further propose an economic framework for integrating forecasts into operational surveillance system for evidence based decisionmaking and resource allocation. 

Methods: The studies were based in Asembo, Gem and Karemo areas of the KEMRI/CDC Health and Demographic Surveillance System in Western Kenya. Lagged association of rainfall and temperature with malaria mortality was modeled using general additive models, while distributed lag non-linear models were used to explore relationship between remote sensing variables, land surface temperature(LST), normalized difference vegetation index(NDVI) and rainfall on weekly malaria mortality. General additive models, with and without boosting, were used to develop malaria admissions forecasting models for lead times one to three months. We developed a framework for incorporating forecast output into economic evaluation of response strategies at different lead times including uncertainties. The forecast output could either be an alert based on a threshold, or absolute predicted cases. In both situations, interventions at each lead time could be evaluated by the derived net benefit function and uncertainty incorporated by simulation. 

Results: We found that the environmental factors correlated with malaria mortality with varying latencies. In the first paper, where we used ground weather data, the effect of mean temperature was significant from lag of 9 weeks, with risks higher for mean temperatures above 250C. The effect of cumulative precipitation was delayed and began from 5 weeks. Weekly total rainfall of more than 120 mm resulted in increased risk for mortality. In the second paper, using remotely sensed data, the effect of precipitation was consistent in the three areas, with increasing effect with weekly total rainfall of over 40 mm, and then declined at 80 mm of weekly rainfall. NDVI below 0.4 increased the risk of malaria mortality, while day LST above 350C increased the risk of malaria mortality with shorter lags for high LST weeks. The lag effect of precipitation was more delayed for precipitation values below 20 mm starting at week 5 while shorter lag effect for higher precipitation weeks. The effect of higher NDVI values above 0.4 were more delayed and protective while shorter lag effect for NDVI below 0.4. For all the lead times, in the malaria admissions forecasting modelling in the third paper, the boosted regression models provided better prediction accuracy. The economic framework in the fourth paper presented a probability function of the net benefit of response measures, where the best response at particular lead time corresponded to the one with the highest probability, and absolute value, of a net benefit surplus. 

Conclusion: We have shown that lagged relationship between environmental variables and malaria health outcomes follow the expected biological mechanism, where presentation of cases follow the onset of specific weather conditions and climate variability. This relationship guided the development of predictive models showcased with the malaria admissions model. Further, we developed an economic framework connecting the forecasts to response measures in situations with considerable uncertainties. Thus, the thesis work has contributed to several important components of early warning systems including risk assessment; utilizing surveillance data for prediction; and a method to identifying cost-effective response strategies. We recommend economic evaluation becomes standard in implementation of early warning system to guide long-term sustainability of such health protection programs.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2017. , 87 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1874
Keyword [en]
Malaria, Mosquito, Lead time, Early Warnings, Forecasts, Economic Evaluation, Rainfall, KEMRI/CDC HDSS, Kenya, Temperature, LST, NDVI, Climate, HDSS, GAM, GAMBOOST, DLNM, Remote Sensing, Net Benefit, Cost-Effectiveness, Boosting Regression, Weather, Public Health, Infectious Diseases
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health; Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-130169ISBN: 978-91-7601-641-1 (print)OAI: oai:DiVA.org:umu-130169DiVA: diva2:1064930
Public defence
2017-02-10, Sal 135, Byggnad 9A, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2017-01-20 Created: 2017-01-13 Last updated: 2017-01-20Bibliographically approved
List of papers
1. The Association of Weather Variability and Under Five Malaria Mortality in KEMRI/CDC HDSS in Western Kenya 2003 to 2008: A Time Series Analysis
Open this publication in new window or tab >>The Association of Weather Variability and Under Five Malaria Mortality in KEMRI/CDC HDSS in Western Kenya 2003 to 2008: A Time Series Analysis
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2015 (English)In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 12, no 2, 1983-1997 p.Article in journal (Refereed) Published
Abstract [en]

Malaria is among the leading causes of mortality in the younger under-five group of children zero to four years of age. This study aims at describing the relationship between rainfall and temperature on under-five malaria or anaemia mortality in Kenya Medical Research Institute and United States Centers for Disease Control (KEMRI/CDC) Health and Demographic Surveillance System (HDSS). This study was conducted through the ongoing KEMRI and CDC collaboration. A general additive model with a Poisson link function was fit to model the weekly association of lagged cumulative rainfall and average temperature on malaria/anemia mortality in KEMRI/CDC HDSS for the period 2003 to 2008. A trend function was included in the model to control for time trends and seasonality not explained by weather fluctuations. 95% confidence intervals was presented with estimates. Malaria or anemia mortality was found to be associated with changes in temperature and rainfall in the KEMRI HDSS, with a delay up to 16 weeks. The empirical estimates of associations describe established biological relationships well. This information, and particularly, the strength of the relationships over longer lead times can highlight the possibility of developing a predictive forecast with lead times up to 16 weeks in order to enhance preparedness to high transmission episodes.

Keyword
malaria mortality, KEMRI/CDC HDSS, general additive model, rainfall, temperature, lag, Kenya
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-99955 (URN)10.3390/ijerph120201983 (DOI)000350209800052 ()25674784 (PubMedID)
Available from: 2015-02-17 Created: 2015-02-17 Last updated: 2017-01-13Bibliographically approved
2. Remotely Sensed Environmental Conditions and Malaria Mortality in Three Malaria Endemic Regions in Western Kenya
Open this publication in new window or tab >>Remotely Sensed Environmental Conditions and Malaria Mortality in Three Malaria Endemic Regions in Western Kenya
2016 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, no 4, e0154204Article in journal (Refereed) Published
Abstract [en]

Background

Malaria is an important cause of morbidity and mortality in malaria endemic countries. The malaria mosquito vectors depend on environmental conditions, such as temperature and rainfall, for reproduction and survival. To investigate the potential for weather driven early warning systems to prevent disease occurrence, the disease relationship to weather conditions need to be carefully investigated. Where meteorological observations are scarce, satellite derived products provide new opportunities to study the disease patterns depending on remotely sensed variables. In this study, we explored the lagged association of Normalized Difference Vegetation Index (NVDI), day Land Surface Temperature (LST) and precipitation on malaria mortality in three areas in Western Kenya.

Methodology and Findings

The lagged effect of each environmental variable on weekly malaria mortality was modeled using a Distributed Lag Non Linear Modeling approach. For each variable we constructed a natural spline basis with 3 degrees of freedom for both the lag dimension and the variable. Lag periods up to 12 weeks were considered. The effect of day LST varied between the areas with longer lags. In all the three areas, malaria mortality was associated with precipitation. The risk increased with increasing weekly total precipitation above 20 mm and peaking at 80 mm. The NDVI threshold for increased mortality risk was between 0.3 and 0.4 at shorter lags.

Conclusion

This study identified lag patterns and association of remote- sensing environmental factors and malaria mortality in three malaria endemic regions in Western Kenya. Our results show that rainfall has the most consistent predictive pattern to malaria transmission in the endemic study area. Results highlight a potential for development of locally based early warning forecasts that could potentially reduce the disease burden by enabling timely control actions.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-121576 (URN)10.1371/journal.pone.0154204 (DOI)000374973600047 ()27115874 (PubMedID)
Available from: 2016-06-27 Created: 2016-06-03 Last updated: 2017-01-13Bibliographically approved
3. Using remote sensing environmental data to forecast malaria incidence at a rural district hospital in Western Kenya
Open this publication in new window or tab >>Using remote sensing environmental data to forecast malaria incidence at a rural district hospital in Western Kenya
(English)Manuscript (preprint) (Other academic)
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-129976 (URN)
Available from: 2017-01-10 Created: 2017-01-10 Last updated: 2017-01-18
4. A methodological framework for economic evaluation of operational response to vector-borne disease forecasts
Open this publication in new window or tab >>A methodological framework for economic evaluation of operational response to vector-borne disease forecasts
(English)Manuscript (preprint) (Other academic)
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-129977 (URN)
Available from: 2017-01-10 Created: 2017-01-10 Last updated: 2017-01-20

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