Income differences in COVID-19 incidence and severity in Finland among people with foreign and native background: A population-based cohort study of individuals nested within households

BackgroundAlthough intrahousehold transmission is a key source of Coronavirus Disease 2019 (COVID-19) infections, studies to date have not analysed socioeconomic risk factors on the household level or household clustering of severe COVID-19. We quantify household income differences and household clustering of COVID-19 incidence and severity.Methods and findingsWe used register-based cohort data with individual-level linkage across various administrative registers for the total Finnish population living in working-age private households (N = 4,315,342). Incident COVID-19 cases (N = 38,467) were identified from the National Infectious Diseases Register from 1 July 2020 to 22 February 2021. Severe cases (N = 625) were defined as having at least 3 consecutive days of inpatient care with a COVID-19 diagnosis and identified from the Care Register for Health Care between 1 July 2020 and 31 December 2020. We used 2-level logistic regression with individuals nested within households to estimate COVID-19 incidence and case severity among those infected.Adjusted for age, sex, and regional characteristics, the incidence of COVID-19 was higher (odds ratio [OR] 1.67, 95% CI 1.58 to 1.77, p < 0.001, 28.4% of infections) among individuals in the lowest household income quintile than among those in the highest quintile (18.9%). The difference attenuated (OR 1.23, 1.16 to 1.30, p < 0.001) when controlling for foreign background but not when controlling for other household-level risk factors. In fact, we found a clear income gradient in incidence only among people with foreign background but none among those with native background. The odds of severe illness among those infected were also higher in the lowest income quintile (OR 1.97, 1.52 to 2.56, p < 0.001, 28.0% versus 21.6% in the highest quintile), but this difference was fully attenuated (OR 1.08, 0.77 to 1.52, p = 0.64) when controlling for other individual-level risk factors—comorbidities, occupational status, and foreign background. Both incidence and severity were strongly clustered within households: Around 77% of the variation in incidence and 20% in severity were attributable to differences between households. The main limitation of our study was that the test uptake for COVID-19 may have differed between population subgroups.ConclusionsLow household income appears to be a strong risk factor for both COVID-19 incidence and case severity, but the income differences are largely driven by having foreign background. The strong household clustering of incidence and severity highlights the importance of household context in the prevention and mitigation of COVID-19 outcomes.

Sanni Saarinen and colleagues explore the association between income differences and COVID-19 incidence and severity among people with foreign and native background in Finland.     

Political ecology and environmental management in the Loess Plateau,China

This paper explores the changing political ecology of soil and water management—the articulation of physical and political-economic processes—in the Loess Plateau of north-central China. Market-oriented reforms and the shift from collective to household farming have created a diverse array of tenure, management, and financing arrangements. In the process relationships between farm households, the collective, and the state have been altered, with profound implications for land use and sustainability. The paper reviews the political ecology approach and its relevance to environmental management in China. An outline of the physical and economic context of soil erosion in the Loess Plateau is followed by examination of the impact of reform on rural environmental management. Local innovations in the organization of environmental management are highlighted. The conclusion comments on the utility of the regional political ecology approach and suggests some critical issues for further research.     

Household Extension and Fragmentation: Investigating the Socio-Environmental Dynamics of Mossi Domestic Transitions

Recent studies in West Africa and other parts of the world suggest that globalization and modernization make extended forms of domestic organization untenable in the face of modern economic and ecological circumstances. Unlike the large and extended domestic groups of pre-industrial and pre-colonial periods, households today tend to be small and nuclear. Thirty years ago, a series of case studies conducted on the Central Plateau of Burkina Faso documented this nucleation process among Mossi rural communities and predicted the decline and demise of Mossi extended households. This article tests the degree to which these predictions were correct based on ethnographic fieldwork in three villages in 2004. The results indicate that extended households indeed persist. Their persistence is explained by analyzing the roles of environmental and social change on the twin processes of household extension and fragmentation. Regional desiccation, off-farm income-generating opportunities, and agricultural intensification have created conditions that equally promote both household extension and fragmentation.     

Self-Reported Serious Illnesses in Rural Cambodia: A Cross-Sectional Survey

Background

There is substantial evidence that ill-health is a major cause of impoverishment in developing countries. Major illnesses can have a serious economic impact on poor households through treatment costs and income loss. However, available methods for measuring the impact of ill-health on household welfare display several shortcomings and new methods are thus needed. To understand the potential complex impact of major illnesses on household livelihoods, a study on poverty and illness was conducted in rural Cambodia, as part of an international comparative research project. A cross-sectional survey was performed to identify households affected by major illness for further in-depth interviews.

Methodology and Principal Findings

5,975 households in three rural health districts were randomly selected through a two-stage cluster sampling and interviewed. 27% of the households reported at least one member with a serious illness in the year preceding the survey and 15% of the household members reported suffering from at least one serious illness. The most reported conditions include common tropical infectious diseases, chronic diseases (notably hypertension and heart diseases) and road traffic accidents. Such conditions were particularly concentrated among the poor, children under five, women, and the elderly. Poor women often reported complications related to pregnancy and delivery as serious illnesses.

Conclusions and Significance

Despite some methodological limitations, this study provides new information on the frequency of self-reported serious illnesses among the rural Cambodia''s population, which serves as a basis for further in-depth investigation on ‘major illnesses’ and their economic consequences on poor households. This can in turn help policy makers to formulate appropriate interventions to protect the poor from the financial burden associated with ill-health. Our findings suggest that every year a considerable proportion of rural population in Cambodia, especially the poor and vulnerable, are affected by serious illnesses, both communicable and non-communicable diseases.     

Child nutrition in the transition from nomadic pastoralism to settled lifestyles: individual, household, and community-level factors

The research reported here examines child nutrition in a population that is currently experiencing a transition in subsistence, shifting from nomadic pastoralism to a variety of settled lifestyles. We investigate the range of nutritional consequences of settlement both within and between communities by examining individual, household, and community-level predictors of child nutritional status. Data are drawn from the Rendille Demographic and Health Survey, which contains anthropometric data from 1,088 children ages 6 months to 10 years, as well as socioeconomic data from 640 households drawn from one nomadic and four economically and ecologically diverse settled communities. Comparisons allow us to test the widely held assumption that settlement results in nutritional improvements. The examination of individual and household-level factors highlights several important influences on child nutrition. We find a complex interaction between gender and birthorder, whereby firstborn sons have significantly higher weight-for-height scores than other children, potentially reflecting preference under a system of primogeniture. We also find a complex interaction between defacto female-headed households, where males are absent for over half of the year, and economic status. Young children from poor female-headed households have significantly lower weight-for-height than other children, possibly due to the fact that these households are amongst the poorest in the entire community. However, young children from economically sufficient female-headed households actually fare better than their counterparts in male headed households, suggesting that in households with any discretionary resources, female heads prioritize food acquisition relative to other concerns. Finally, our comparison of child nutritional status across communities, while controlling for individual and household-level variation, does not support the contention that settlement is associated with nutritional improvements. Rather, the effect of community, and its associated changes in subsistence and lifestyle, results in either no nutritional changes, or in the case of young children in the lowland desert community of Korr, diminished nutritional status. Our results underscore the importance of considering variation in sample composition and socioeconomic status when performing community comparisons, and highlight the central role of women in influencing the nutritional welfare of their families.     

Urban Household Carbon Emission and Contributing Factors in the Yangtze River Delta,China

Carbon reduction at the household level is an integral part of carbon mitigation. This study analyses the characteristics, effects, contributing factors and policies for urban household carbon emissions in the Yangtze River Delta of China. Primary data was collected through structured questionnaire surveys in three cities in the region – Nanjing, Ningbo, and Changzhou in 2011. The survey data was first used to estimate the magnitude of household carbon emissions in different urban contexts. It then examined how, and to what extent, each set of demographic, economic, behavioral/cognitive and spatial factors influence carbon emissions at the household level. The average of urban household carbon emissions in the region was estimated to be 5.96 tonnes CO₂ in 2010. Energy consumption, daily commuting, garbage disposal and long-distance travel accounted for 51.2%, 21.3%, 16.0% and 11.5% of the total emission, respectively. Regulating rapidly growing car-holdings of urban households, stabilizing population growth, and transiting residents’ low-carbon awareness to household behavior in energy saving and other spheres of consumption in the context of rapid population aging and the growing middle income class are suggested as critical measures for carbon mitigation among urban households in the Yangtze River Delta.     

Environment,livelihood and household: The ethno‐history of Rana Tharus Badaghar households

This paper focuses on the changes occurring in households in the indigenous Rana Tharus community. I discuss the household not in terms of physical structure but instead on the social aspects: how people relate to each other through the lens of the household context. I argue that the fluid nature of households makes its flexible to different ecological environments and socio‐economic scenarios. My ethnography of Rana households clearly illustrated that the formation, structure and management of Rana households was fundamentally linked to people's livelihoods. Before 1950s, abundant land resources allowed Ranas to live in joint‐type households. This particular household arrangement not only fulfilled labour needs but also secured the mutual security for every household member. Gradually, undivided and big households (known in Rana as Badaghar) became the ideal model for Ranas as soon as such establishments did not become divided or separated. This household structure also served as an important safety net for most Ranas and fundamental to other social relationships especially Mukhiya (household head system) and Kurmaa (patrilineal kin). However, since the 1950s, new socio‐economic landscapes have significantly challenged the maintenance of traditional Rana households. Within the lifetime of most Ranas, they first experienced household fission and the disappearance of the Mukhiya system. The dynamic relationships between Rana household and new ecological, social and economic landscapes are explored here. It is concluded that the household is a critical institution allowing anthropologists to better understand the long‐term social impacts caused by state policies and ecological changes. This is because people often practice their new household relations in their everyday life as a response to environmental and livelihood changes.     

Economic Impact of Maternal Death on Households in Rural China: A Prospective Cohort Study

Objective

To assess the economic impact of maternal death on rural Chinese households during the year after maternal death.

Methods

A prospective cohort study matched 183 households who had suffered a maternal death to 346 households that experienced childbirth without maternal death in rural areas of three provinces in China. Surveys were conducted at baseline (1–3 months after maternal death or childbirth) and one year after baseline using the quantitative questionnaire. We investigated household income, expenditure, accumulated debts, and self-reported household economic status. Difference-in-Difference (DID), linear regression, and logistic regression analyses were used to compare the economic status between households with and without maternal death.

Findings

The households with maternal death had a higher risk of self-reported “household economy became worse” during the follow-up period (adjusted OR = 6.04, p<0.001). During the follow-up period, at the household level, DID estimator of income and expenditure showed that households with maternal death had a significant relative reduction of US$ 869 and US$ 650, compared to those households that experienced childbirth with no adverse event (p<0.001). Converted to proportions of change, an average of 32.0% reduction of annual income and 24.9% reduction of annual expenditure were observed in households with a maternal death. The mean increase of accumulated debts in households with a maternal death was 3.2 times as high as that in households without maternal death (p = 0.024). Expenditure pattern of households with maternal death changed, with lower consumption on food (p = 0.037), clothes and commodity (p = 0.003), traffic and communication (p = 0.022) and higher consumption on cigarette or alcohol (p = 0.014).

Conclusion

Compared with childbirth, maternal death had adverse impact on household economy, including higher risk of self-reported “household economy became worse”, decreased income and expenditure, increased debts and changed expenditure pattern.     

The Economic Burden Attributable to a Child’s Inpatient Admission for Diarrheal Disease in Rwanda

Background

Diarrhea is one of the leading causes of childhood morbidity and mortality. Hospitalization for diarrhea can pose a significant burden to health systems and households. The objective of this study was to estimate the economic burden attributable to hospitalization for diarrhea among children less than five years old in Rwanda. These data can be used by decision-makers to assess the impact of interventions that reduce diarrhea morbidity, including rotavirus vaccine introduction.

Methods

This was a prospective costing study where medical records and hospital bills for children admitted with diarrhea at three hospitals were collected to estimate resource use and costs. Hospital length of stay was calculated from medical records. Costs incurred during the hospitalization were abstracted from the hospital bills. Interviews with the child’s caregivers provided data to estimate household costs which included transport costs and lost income. The portion of medical costs borne by insurance and household were reported separately. Annual economic burden before and after rotavirus vaccine introduction was estimated by multiplying the reported number of diarrhea hospitalizations in public health centers and district hospitals by the estimated economic burden per hospitalization. All costs are presented in 2014 US$.

Results

Costs for 203 children were analyzed. Approximately 93% of the children had health insurance coverage. Average hospital length of stay was 5.3 ± 3.9 days. Average medical costs for each child for the illness resulting in a hospitalization were $44.22 ± $23.74 and the total economic burden was $101, of which 65% was borne by the household. For households in the lowest income quintile, the household costs were 110% of their monthly income. The annual economic burden to Rwanda attributable to diarrhea hospitalizations ranged from $1.3 million to $1.7 million before rotavirus vaccine introduction.

Conclusion

Households often bear the largest share of the economic burden attributable to diarrhea hospitalization and the burden can be substantial, especially for households in the lowest income quintile.     

A Temporal Dimension of Household Vulnerability in Three Rural Communities in Lijiang,China

We examine the dynamics of household vulnerability during the past 30 years within three different social-ecological upland systems in Lijiang, Yunnan. Interviews were conducted to construct coupled human-environmental timelines to facilitate the understanding of livelihood dynamics in the context of more general changes that constitute both constraints and opportunities. The results indicate that significant livelihood changes including specialization, diversification and migration have been primarily driven by socio-political influences. Overall vulnerability of households has decreased differently across villages. Nevertheless, climate change is a concern as households perceive increasing temperature, declining precipitation and unpredictable extreme events. In the future, households’ vulnerability might increase since important components of current livelihoods remain climate sensitive. Moreover, environmentally destructive practices such as illegal logging might reinforce the negative impacts of climate change and thus undermine sustainable adaptation.     

Effect of Health Expenses on Household Capabilities and Resource Allocation in a Rural Commune in Vietnam

Background

Significant health expenses can force households to reduce consumption of items required for daily living and long-term well-being, depriving them of the capability to lead economically stable and healthy lives. Previous studies of out-of-pocket (OOP) and other health expenses have typically characterized them as “catastrophic” in terms of a threshold level or percentage of household income. We aim to re-conceptualize the impact of health expenses on household “flourishing” in terms of “basic capabilities.”

Methods and Findings

We conducted a 2008 survey covering 697 households, on consumption patterns and health treatments for the previous 12 months. We compare consumption patterns between households with and without inpatient treatment, and between households with different levels of outpatient treatment, for the entire study sample as well as among different income quartiles. We find that compared to households without inpatient treatment and with lower levels of outpatient treatment, households with inpatient treatment and higher levels of outpatient treatment reduced investments in basic capabilities, as evidenced by decreased consumption of food, education and production means. The lowest income quartile showed the most significant decrease. No quartile with inpatient or high-level outpatient treatment was immune to reductions.

Conclusions

The effects of health expenses on consumption patterns might well create or exacerbate poverty and poor health, particularly for low income households. We define health expenditures as catastrophic by their reductions of basic capabilities. Health policy should reform the OOP system that causes this economic and social burden.     

Self-Reported Household Impacts of Large-Scale Chemical Contamination of the Public Water Supply,Charleston, West Virginia,USA

A January 2014 industrial accident contaminated the public water supply of approximately 300,000 homes in and near Charleston, West Virginia (USA) with low levels of a strongly-smelling substance consisting principally of 4-methylcyclohexane methanol (MCHM). The ensuing state of emergency closed schools and businesses. Hundreds of people sought medical care for symptoms they related to the incident. We surveyed 498 households by telephone to assess the episode’s health and economic impact as well as public perception of risk communication by responsible officials. Thirty two percent of households (159/498) reported someone with illness believed to be related to the chemical spill, chiefly dermatological or gastrointestinal symptoms. Respondents experienced more frequent symptoms of psychological distress during and within 30 days of the emergency than 90 days later. Sixty-seven respondent households (13%) had someone miss work because of the crisis, missing a median of 3 days of work. Of 443 households reporting extra expenses due to the crisis, 46% spent less than $100, while 10% spent over $500 (estimated average about $206). More than 80% (401/485) households learned of the spill the same day it occurred. More than 2/3 of households complied fully with “do not use” orders that were issued; only 8% reported drinking water against advice. Household assessments of official communications varied by source, with local officials receiving an average “B” rating, whereas some federal and water company communication received a “D” grade. More than 90% of households obtained safe water from distribution centers or stores during the emergency. We conclude that the spill had major economic impact with substantial numbers of individuals reporting incident-related illnesses and psychological distress. Authorities were successful supplying emergency drinking water, but less so with risk communication.     

2001: A Household Analysis of Huastec Maya Agriculture and Land Use at the Height of the Coffee Crisis

Over the last decade, historically low market prices for Coffea arabica have affected smallholder shade coffee-growing households throughout northern Latin America. In an effort to better understand household response to the coffee crisis and associated landscape changes, this paper examines agricultural production choices and land use patterns among Huastec Maya coffee-growing households. Using data compiled from 47 household interviews, I describe the cultural-geographical landscape in which the Huastec Maya land use system is embedded. In addition, I examine the economics of household production through a financial cost-benefit analysis and through an exploration of the relationship between land availability and land use patterns. Results show that economic inputs and returns from agriculture are highly variable, and that, in 2001, coffee cultivation was not a viable cash-generating strategy for most households. Land availability was found to have a significant effect on land use decisions, especially the proportion of land area devoted to fallow. Most importantly, however, the case study suggests that a purely economic approach does not suffice in explaining why the Huastec Maya continued to grow coffee in 2001, after years of low prices. Household production choices and livelihood strategies must also be viewed within a cultural context.     

Enteric Pathogens in Stored Drinking Water and on Caregiver’s Hands in Tanzanian Households with and without Reported Cases of Child Diarrhea

Background

Diarrhea is one of the leading causes of mortality in young children. Diarrheal pathogens are transmitted via the fecal-oral route, and for children the majority of this transmission is thought to occur within the home. However, very few studies have documented enteric pathogens within households of low-income countries.

Methods and Findings

The presence of molecular markers for three enteric viruses (enterovirus, adenovirus, and rotavirus), seven Escherichia coli virulence genes (ECVG), and human-specific Bacteroidales was assessed in hand rinses and household stored drinking water in Bagamoyo, Tanzania. Using a matched case-control study design, we examined the relationship between contamination of hands and water with these markers and child diarrhea. We found that the presence of ECVG in household stored water was associated with a significant decrease in the odds of a child within the home having diarrhea (OR = 0.51; 95% confidence interval 0.27–0.93). We also evaluated water management and hygiene behaviors. Recent hand contact with water or food was positively associated with detection of enteric pathogen markers on hands, as was relatively lower volumes of water reportedly used for daily hand washing. Enteropathogen markers in stored drinking water were more likely found among households in which the markers were also detected on hands, as well as in households with unimproved water supply and sanitation infrastructure.

Conclusions

The prevalence of enteric pathogen genes and the human-specific Bacteroidales fecal marker in stored water and on hands suggests extensive environmental contamination within homes both with and without reported child diarrhea. Better stored water quality among households with diarrhea indicates caregivers with sick children may be more likely to ensure safe drinking water in the home. Interventions to increase the quantity of water available for hand washing, and to improve food hygiene, may reduce exposure to enteric pathogens in the domestic environment.     

Community Management of Endemic Scabies in Remote Aboriginal Communities of Northern Australia: Low Treatment Uptake and High Ongoing Acquisition

Background

Scabies and skin infections are endemic in many Australian Aboriginal communities. There is limited evidence for effective models of scabies treatment in high prevalence settings. We aimed to assess the level of treatment uptake amongst clinically diagnosed scabies cases and amongst their household contacts. In addition, we aimed to determine the likelihood of scabies acquisition within these households over the 4 weeks following treatment provision.

Methods and Findings

We conducted an observational study of households in two scabies-endemic Aboriginal communities in northern Australia in which a community-based skin health program was operating. Permethrin treatment was provided for all householders upon identification of scabies within a household during home visit. Households were visited the following day to assess treatment uptake and at 2 and 4 weeks to assess scabies acquisition among susceptible individuals. All 40 households in which a child with scabies was identified agreed to participate in the study. Very low levels of treatment uptake were reported among household contacts of these children (193/440, 44%). Household contacts who themselves had scabies were more likely to use the treatment than those contacts who did not have scabies (OR 2.4, 95%CI 1.1, 5.4), whilst males (OR 0.6, 95%CI 0.42, 0.95) and individuals from high-scabies-burden households (OR 0.2, 95%CI 0.08, 0.77) were less likely to use the treatment. Among 185 susceptible individuals, there were 17 confirmed or probable new diagnoses of scabies recorded in the subsequent 4 weeks (9.2%). The odds of remaining scabies-free was almost 6 times greater among individuals belonging to a household where all people reported treatment uptake (OR 5.9, 95%CI 1.3, 27.2, p = 0.02).

Conclusion

There is an urgent need for a more practical and feasible treatment for community management of endemic scabies. The effectiveness and sustainability of the current scabies program was compromised by poor treatment uptake by household contacts of infested children and high ongoing disease transmission.     

The Importance of Bushmeat in the Livelihoods of West African Cash-Crop Farmers Living in a Faunally-Depleted Landscape

Bushmeat is an important resource in the livelihoods of many rural communities in sub-Saharan Africa and may be a crucial safety-net for the most vulnerable households, especially during times of economic hardship. However, little is known about the impacts of wildlife depletion on these functions. This study quantifies the role of bushmeat in diversified rural household economies in a wildlife depleted forest-farm landscape in Ghana, assessing its importance overall, as well as differentiated by the relative vulnerability of households. Using repeat socioeconomic questionnaires (N=787) among 63 households over a one-year period, the following hypotheses were tested: (a) vulnerable households harvest more bushmeat; (b) bushmeat contributes a greater proportion of household production in vulnerable households; (c) bushmeat is more important for cash income than consumption in vulnerable households; and (d) bushmeat sales are more important for vulnerable households. The bushmeat harvest value averaged less than US$1.0 per day for 89% of households and comprised less than 7% of household production value. Household wealth and gender of the household head had little effect on the importance of bushmeat. However, bushmeat harvest and sales were highest during the agricultural lean season. Overall, most harvested bushmeat (64%) was consumed, enabling households to spend 30% less on meat/fish purchases. These findings suggest that, despite heavily depleted wildlife and diversified livelihoods, bushmeat continues to have an important role in rural livelihoods by acting as a safety net for income smoothing and reducing household expenditure during times of economic hardship.     

Geospatial analysis of the associations between environmental contamination with livestock feces and children with chronic fascioliasis in the Anta province of Cusco,Peru

Fasciola hepatica is a neglected parasitic infection with significant human health and livestock industry impact. The Andean Altiplano harbors an estimated 50% of the Fasciola’s world infection burden. There is scarce data regarding the spatial associations between different Fasciola hosts. In this project, we aimed to determine the geospatial relationships between Fasciola eggs passed in feces of different livestock species and the risk of infection among each household as a unit. We used data from a cross-sectional study evaluating children and livestock feces for Fasciola infection around households in three districts of Anta province, in the Cusco region of Peru. Each sample was geographically tagged and evaluated for fascioliasis using microscopy methods. A total of 2070 households were included, the median age was 9.1 years (6.7–11.8), 49.5% were female, and 7.2% of the households had at least one infected child. A total of 2420 livestock feces samples were evaluated. The infection rate in livestock samples was 30.9%. The highest infection rate was found in sheep with 40.8%, followed by cattle (33.8%), and swine (26.4%). The median distance between a household with an infected child to a positive animal sample was 44.6 meters (IQR 14.7–112.8) and the distance between a household with no infected children to a positive animal sample was 62.2 meters (IQR 18.3–158.6) (p = 0.025). The multivariable logistic regression adjusted by presence of poor sanitation, unsafe water consumption, altitude, and presence of multiple infected children per household demonstrated an association between household infection and any cattle feces at a 50 meters radius (Uninfected: OR 1.42 (95%CI 1.07–1.89), p = 0.017. Infected: OR 1.89 (95%CI 1.31–2.73), p = 0.001), positive cattle feces at a 100 meters radius (OR 1.35 (95% CI 1.08–1.69), p = 0.008), and negative cattle feces at a 200 meters radius (OR 1.08 (95% CI 1.01–1.15), p = 0.022). We identified potential hot and cold spots for fascioliasis in the Anta province. An association between environmental contamination with feces from different livestock species and infected children in rural households was found in our study. Local health authorities may apply this strategy to estimate the risk of infection in human populations and apply targeted interventions.     

Endless Urban Growth? On the Mismatch of Population,Household and Urban Land Area Growth and Its Effects on the Urban Debate

In European cities, the rate of population growth has declined significantly, while the number of households has increased. This increase in the number of households is associated with an increase in space for housing. To date, the effects of both a declining population and decreasing household numbers remain unclear. In this paper, we analyse the relationship between population and household number development in 188 European cities from 1990–2000 and 2000–2006 to the growth of urban land area and per capita living space. Our results support a trend toward decreasing population with simultaneously increasing household number. However, we also found cites facing both a declining population and a decreasing household number. Nevertheless, the urban land area of these “double-declining” cities has continued to spread because the increasing per capita living space counteracts a reduction in land consumption. We conclude that neither a decline in population nor in household number “automatically” solve the global problem of land consumption.     

Malaria Prevalence,Spatial Clustering and Risk Factors in a Low Endemic Area of Eastern Rwanda: A Cross Sectional Study

Background

Rwanda reported significant reductions in malaria burden following scale up of control intervention from 2005 to 2010. This study sought to; measure malaria prevalence, describe spatial malaria clustering and investigate for malaria risk factors among health-centre-presumed malaria cases and their household members in Eastern Rwanda.

Methods

A two-stage health centre and household-based survey was conducted in Ruhuha sector, Eastern Rwanda from April to October 2011. At the health centre, data, including malaria diagnosis and individual level malaria risk factors, was collected. At households of these Index cases, a follow-up survey, including malaria screening for all household members and collecting household level malaria risk factor data, was conducted.

Results

Malaria prevalence among health centre attendees was 22.8%. At the household level, 90 households (out of 520) had at least one malaria-infected member and the overall malaria prevalence for the 2634 household members screened was 5.1%. Among health centre attendees, the age group 5–15 years was significantly associated with an increased malaria risk and a reported ownership of ≥4 bednets was significantly associated with a reduced malaria risk. At the household level, age groups 5–15 and >15 years and being associated with a malaria positive index case were associated with an increased malaria risk, while an observed ownership of ≥4 bednets was associated with a malaria risk-protective effect. Significant spatial malaria clustering among household cases with clusters located close to water- based agro-ecosystems was observed.

Conclusions

Malaria prevalence was significantly higher among health centre attendees and their household members in an area with significant household spatial malaria clustering. Circle surveillance involving passive case finding at health centres and proactive case detection in households can be a powerful tool for identifying household level malaria burden, risk factors and clustering.