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Although it is widely recognized that strong program management is essential to achieving better health outcomes, this priority is not recognized in malaria programmatic practices. Increased management precision offers the opportunity to improve the effectiveness of malaria interventions, overcoming operational barriers to intervention coverage and accelerating the path to elimination. Here we propose a combined approach involving quality improvement, quality management, and participative process improvement, which we refer to as Combined Quality and Process Improvement (CQPI), to improve upon malaria program management. We draw on evidence from other areas of public health, as well as pilot implementation studies in Eswatini, Namibia and Zimbabwe to support the proposal. Summaries of the methodological approaches employed in the pilot studies, overview of activities and an outline of lessons learned from the implementation of CQPI are provided. Our findings suggest that a malaria management strategy that prioritizes quality and participative process improvements at the district-level can strengthen teamwork and communication while enabling the empowerment of subnational staff to solve service delivery challenges. Despite the promise of CQPI, however, policy makers and donors are not aware of its potential. Investments are therefore needed to allow CQPI to come to fruition.

BackgroundTo date, health-related social needs (HRSN) screening implementation efforts have reported high rates of identified social needs. However, little is known about how screening processes may fail to leverage implementation strategies to optimize reach, and thereby unintentionally target non-representative groups for screening and referral programs. MethodsElectronic medical data were abstracted from 2016-2020 for 4,731 screened patients from 7 affiliated clinics of a federally-qualified health center (FQHC). Unscreened patients were pulled first as a random sample from the study period, then matched based on clinic site and clinic visit frequency. Sociodemographic traits, comorbid conditions, and outpatient encounter type and frequency were compared between the screened and unscreened patient cohorts using descriptive statistics.ResultsScreened patients (n-4731) had a median of 3.3 (+/- 2.5) unmet HRSN. Compared to a random sample of unscreened FQHC patients, screened patients had significantly more clinic visits (26.8 vs 16.3; pConclusionsWithout an a priori plan for implementation, we have found a predisposition to screen patients who visit outpatient services more often and have a higher comorbid disease burden. HRSN screening processes will benefit from implementation strategies to improve reach and to ensure maximal uptake of screening.

Due to challenges in measuring changes in malaria in low transmission settings, serology is increasingly being used to complement clinical and parasitological surveillance. Longitudinal cohort studies have shown serological markers, such as Etramp5.Ag1, to be particularly discriminatory of spatio-temporal differences in malaria transmission. However, these markers have yet to be used as endpoints in intervention trials. This study is an extended analysis of a 2017 cluster randomised trial conducted in Zambezi Region, Namibia, evaluating the effectiveness of reactive focal mass drug administration (rfMDA) and reactive vector control (RAVC). A panel of eight serological markers of Plasmodium falciparum infection - Etramp5.Ag1, GEXP18, HSP40.Ag1, Rh2.2030, EBA175, PfMSP119, PfAMA1, and PfGLURP.R2 - was used on a multiplex immunoassay to measure population antibody responses as trial endpoints.Reductions in sero-prevalence to antigens Etramp.Ag1, PfMSP119, Rh2.2030, and PfAMA1 were observed in study arms combining rfMDA and RAVC, but only effects for Etramp5.Ag1 were statistically significant. Etramp5.Ag1 sero-prevalence was significantly lower in all intervention arms. Compared to the reference arms, adjusted Etramp5.Ag1 prevalence ratio (aPR) was 0.77 (95%CI 0.65 – 0.90, pThe use of serological endpoints to evaluate trial outcomes was comparable to qPCR and measured effect size with improved precision. Serology has clear application in cluster randomised trials, particularly in settings where measuring clinical incidence or infection is less reliable due to seasonal fluctuations, limitations in health care seeking, or incomplete testing and reporting.Key questionsWhat is already known?▪Numerous serological studies across sub-Saharan Africa have found that malaria-specific antibody responses are highly correlated with malaria transmission.▪Serology is increasingly being used to complement traditional malaria surveillance data in settings where clinical or parasitological measures of incidence or infection may be less reliable due to fluctuations in parasite densities, limitations in health care seeking, or incomplete testing and reporting.▪The identification of new serological markers associated with recent malaria exposure hold promise as measures of malaria incidence. In previous longitudinal cohort studies, Etramp5.Ag1 has been shown to be a discriminatory serological marker capable of detecting spatio-temporal differences in malaria transmission. However, these markers have never been formally used as endpoints in a malaria cluster randomised trial.What are the new findings?▪This study is the first application of serological endpoints in a malaria cluster randomised trial. Using a multiplexed immunoassay, a panel of sero-incidence markers of recent malaria exposure were used to evaluate the effectiveness of reactive focal mass drug administration (rfMDA) and reactive focal vector control (RAVC) compared to reactive case detection (standard of care) to reduce malaria transmission.▪Cluster-level antibody responses were significantly lower in all intervention arms compared to control, and effect sizes were measured with greater study power than other trial endpoints such as quantitative polymerase chain reaction (qPCR) parasite prevalence.What do the new findings imply?▪The findings from this study, together with ongoing innovations in assay design and multi-disease platforms, illustrate the potential application of serological markers as endpoints in cluster randomised trials. The use of serological endpoints can help achieve trial efficiencies, such as reduced sample size, particularly in low transmission settings or multi-intervention trials where measuring differences between study arms may be challenging with clinical or parasitological endpoints alone.

Background In Namibia, as in many malaria elimination settings, reactive case detection (RACD), or malaria testing and treatment around index cases, is a standard intervention. Reactive focal mass drug administration (rfMDA), or treatment without testing, and reactive focal vector control (RAVC) in the form of indoor residual spraying, are alternative or adjunctive interventions, but there are limited data regarding their community acceptability. Methods A parent trial aimed to compare the effectiveness of rfMDA versus RACD, RAVC versus no RAVC, and rfMDA + RAVC versus RACD only. To assess acceptability of these interventions, a mixed-methods study was conducted using key informant interviews (KIIs) and focus group discussions (FGDs) in three rounds (pre-trial and in years 1 and 2 of the trial), and an endline survey. Results In total, 17 KIIs, 49 FGDs were conducted with 449 people over three annual rounds of qualitative data collection. Pre-trial, community members more accurately predicted the level of community acceptability than key stakeholders. Throughout the trial, key participant motivators included: malaria risk perception, access to free community-based healthcare and IRS, and community education by respectful study teams. RACD or rfMDA were offered to 1372 and 8948 individuals in years 1 and 2, respectively, and refusal rates were low ( Conclusions Communities found both reactive focal interventions and their combination highly acceptable. Engaging communities and centering and incorporating their perspectives and experiences during design, implementation, and evaluation of this community-based intervention was critical for optimizing study engagement.

Currently ADNOC is conducting the world's largest continuous 3D seismic acquisition campaign of approximately 90 000km2 with the aim of covering the entire Abu Dhabi emirate subsurface (both onshore and offshore) with 3D seismic. The main objective of this campaign is to provide high quality seismic data to explore conventional and unconventional resources. The new 3D covers areas that were under-explored in the past and is of excellent quality to apply advanced technologies for interpretation and reservoir characterization. The new 3D seismic data has high-trace density, broadband frequency content, full-azimuth and long offsets, which provides paramount information for detailed subsurface imaging and characterization of complex reservoirs.This study is focused on a 3D land seismic survey recently acquired that is currently at the time and depth imaging stage. The early-out volumes obtained from processing consist of valuable preliminary data that can be used to infer some possible exploration prospectivity features while final processing is still ongoing.A significant benefit of the pre-stack depth migration (PSDM) method is the construction of a detailed anisotropic subsurface velocity property model. Therefore, it accounts for lateral velocity variations, which are related to geological features especially attractive to explorationists, and has a more accurate overburden representation than historical time imaging workflows. Herein, we present some examples on how the 3D PSDM volume reveals more confidence in geological features that are not so clear in a pre-stack time migrated (PSTM) volume. The preliminary results indicate how shallow hydrocarbon presence can interfere with the PSDM velocity model and how it can be solved to reveal possible exploration potential in deeper sections.

Pediatric high-grade glioma (pHGG) is among the most formidable cancers occurring in childhood. Bone morphogenetic protein 4 (BMP4) reduces the number of glioma stem-like cells and induces apoptosis. Treating tumors with exogenous BMP4 could prove effective in treating gliomas. However, a short half-life limits its clinical application. Glycosylated peptide amphiphile (GlycoPA), with a design inspired by heparin’s natural ability to bind growth factors including BMP4 through non-covalent interactions, was previously characterized and found to form high-aspect ratio supramolecular nanofibers that present growth-factor binding sulfated monosaccharides on their surface. These supramolecular nanofibers could carry excessive amounts of growth factor and markedly enhance their biological function. In this study, we verified that GlycoPA is able to bind BMP4 and dramatically increase its half-life with an ELISA assay. We also show that GlycoPA-BMP4, in comparison to free BMP4, significantly decreases pHGG cells’ proliferation in vitro. Initial in vivo intracranial distribution experimental results showed that GlycoPA has a superior normal brain distribution in comparison to a control PA (E2 PA) that has the same base structure as GlycoPA except with no glycosylated group. Preliminary results show that GlycoPA-BMP4 markedly decreases pediatric glioma tumor growth in comparison to free BMP4. Our combined in vitro and in vivo results demonstrate PA supramolecular nanofibers as an innovative and promising BMP4 delivery platform for clinical application in the treatment of brain tumors. Our future directions will investigate the therapeutic efficacy of GlycoPA-BMP4 in pediatric HGG through testing large numbers of animals and introducing first-line clinical chemotherapy drugs in combination and in various consequence.

Summary Background In low malaria-endemic settings, screening and treatment of individuals in close proximity to index cases, also known as reactive case detection (RACD), is practised for surveillance and response. However, other approaches could be more effective for reducing transmission. We aimed to evaluate the effectiveness of reactive focal mass drug administration (rfMDA) and reactive focal vector control (RAVC) in the low malaria-endemic setting of Zambezi (Namibia). Methods We did a cluster-randomised controlled, open-label trial using a two-by-two factorial design of 56 enumeration area clusters in the low malaria-endemic setting of Zambezi (Namibia). We randomly assigned these clusters using restricted randomisation to four groups: RACD only, rfMDA only, RAVC plus RACD, or rfMDA plus RAVC. RACD involved rapid diagnostic testing and treatment with artemether-lumefantrine and single-dose primaquine, rfMDA involved presumptive treatment with artemether-lumefantrine, and RAVC involved indoor residual spraying with pirimiphos-methyl. Interventions were administered within 500 m of index cases. To evaluate the effectiveness of interventions targeting the parasite reservoir in humans (rfMDA vs RACD), in mosquitoes (RAVC vs no RAVC), and in both humans and mosquitoes (rfMDA plus RAVC vs RACD only), an intention-to-treat analysis was done. For each of the three comparisons, the primary outcome was the cumulative incidence of locally acquired malaria cases. This trial is registered with ClinicalTrials.gov , number NCT02610400 . Findings Between Jan 1, 2017, and Dec 31, 2017, 55 enumeration area clusters had 1118 eligible index cases that led to 342 interventions covering 8948 individuals. The cumulative incidence of locally acquired malaria was 30·8 per 1000 person-years (95% CI 12·8–48·7) in the clusters that received rfMDA versus 38·3 per 1000 person-years (23·0–53·6) in the clusters that received RACD; 30·2 per 1000 person-years (15·0–45·5) in the clusters that received RAVC versus 38·9 per 1000 person-years (20·7–57·1) in the clusters that did not receive RAVC; and 25·0 per 1000 person-years (5·2–44·7) in the clusters that received rfMDA plus RAVC versus 41·4 per 1000 person-years (21·5–61·2) in the clusters that received RACD only. After adjusting for imbalances in baseline and implementation factors, the incidence of malaria was lower in clusters receiving rfMDA than in those receiving RACD (adjusted incidence rate ratio 0·52 [95% CI 0·16–0·88], p=0·009), lower in clusters receiving RAVC than in those that did not (0·48 [0·16–0·80], p=0·002), and lower in clusters that received rfMDA plus RAVC than in those receiving RACD only (0·26 [0·10–0·68], p=0·006). No serious adverse events were reported. Interpretation In a low malaria-endemic setting, rfMDA and RAVC, implemented alone and in combination, reduced malaria transmission and should be considered as alternatives to RACD for elimination of malaria. Funding Novartis Foundation, Bill & Melinda Gates Foundation, and Horchow Family Fund.

A state-of-the-art, high-density full azimuth seismic dataset was acquired over a producing field south-west Abu Dhabi to determine optimum high-resolution acquisition and processing parameters. The existing 3D seismic data was acquired in 1994-95 with low fold coverage. The central part of the new seismic volume has good well control to develop, optimize, and QC processing workflows. The new dataset utilised the system with single-sensor geophone accelerometers, point source DX80 vibrators using the Maximum Displacement sweep design with an enhancement of low frequencies as such a broadened amplitude spectrum. The key specifications for seismic acquisition include full azimuth high-density single-source / single-sensor data, long offsets and a broadband vibroseis sweep that retains low frequencies down to 3Hz. The single-sensor single-source technology and the full azimuth dense geometry (5x5m grid) was designed for an optimum subsurface imaging for this survey. The volume was processed through anisotropic prestack time and depth migration followed by poststack wavelet processing and spectral balancing.

Interest in quantitative interpretation (QI) of seismic data in the Abu Dhabi region continues to steadily increase, and the objective of creating inversion-ready seismic data is driving evolution of the surface seismic data processing workflows to focus on more detailed and thorough handling of the amplitude and phase throughout processing (pre-, during, and post-imaging). To achieve close well ties across the survey and to ensure the data is suitable for interpretation purposes, zero-phasing and wavelet stability (along with using well information during earth model building) are key stages in the depth imaging seismic processing workflow. Accurate amplitude with offset and azimuth handling is also required for inversion studies. In this paper, we propose a workflow where a geophysically and geologically credible, 3D variable Q-field is built into the earth model early in the processing flow, allowing a more complete approach to handling the Q-effects of the subsurface without increasing project turnaround time. This case study shows that a data-driven spatially variable Q-field combined with Kirchhoff Pre-Stack Depth migration compensates effectively for both amplitude and phase effects, providing a broadband image with improved event continuity and better handling of noise compared with applying a constant pre-migration Q-compensation (which was previously thought to be suitable for this low-relief region). By calibrating the variable Q-field to available well logs and near surface information, and ensuring that the different geophysical parameters in the earth model are all suitably coupled, an enhanced image is achieved which then requires minimal spectral shaping or residual phase corrections post migration. Ray-based Q-tomography workflows allow iterative 3D updates alongside coupled subsurface properties like anisotropy and velocity, within a high-resolution Earth model suitable for depth imaging. Reliable phase stability, higher resolution, broader useable bandwidth and improved amplitude preservation are key targets of this holistic approach.

Exposure assessment studies are the primary means for understanding links between exposure to chemical and physical agents and adverse health effects. Recently, researchers have proposed using wearable monitors during exposure assessment studies to obtain higher fidelity readings of exposures actually experienced by subjects. However, limited research has been conducted to link a wearer&rsquo, s actions to periods of exposure, a necessary step for estimating inhaled dosage. To aid researchers in these settings, we developed a machine learning model for identifying periods of bicycling activity using passively collected data from the RTI MicroPEM wearable exposure monitor, a lightweight device capable of continuously sampling both air pollution levels and accelerometry parameters. Our best performing model identifies biking activity with a mean leave-one-session-out (LOSO) cross-validation F1 score of 0.832 (unweighted) and 0.979 (weighted). Accelerometer derived features contributed greatly to the model performance, as well as temporal smoothing of the predicted activities. Additionally, we found competitive activity recognition can occur with even relatively low sampling rates, suggesting suitability for exposure assessment studies where continuous data collection for long periods (without recharge) are needed to capture realistic daily routines and exposures.

Objective Evaluate Hexoskin performance on a stationary bike against "gold standard" laboratory equipment and develop adjustment models for future use in field settings. Methods Compared respiratory rate (RR), tidal volume (VT), minute ventilation (VE), and heart rate (HR) measured by the Hexoskin shirt to simultaneous spirometry and full 12-lead electrocardiogram during a laboratory based incremental exercise test on a stationary bicycle. Results Data from 17 participants demonstrated Hexoskin VT and VE had the best agreement in the submaximal exercise level (discrepancies less than or equal to 5.3%) with larger discrepancies observed at rest (less than or equal to 15.3%) and at maximal exercise level (less than or equal to 11.7%). The discrepancies for HR and RR were lower at all levels (less than 10%). Adjusting for sex and body weight allowed for a single VE algorithm across the entire range of effort (r = 0.89). Conclusion These discrepancies are acceptable for field use in comparison to the ranges typical of bicycle commuting.

Background: In low-endemic malaria settings, screening and treatment near index cases (reactive case detection, RACD) is practiced for surveillance and response; however, other approaches may be more effective. Methods: We conducted a cluster-randomised controlled two-by-two factorial design trial to evaluate the impact of reactive focal mass drug administration, rfMDA, and reactive focal vector control, RAVC, in the low-endemic setting of Zambezi, Namibia. Fifty-six clusters were randomised to: RACD or rfMDA, and RAVC or no RAVC (RACD: rapid diagnostic testing and treatment with artemether-lumefantrine (AL); rfMDA: presumptive treatment with AL; RAVC: indoor residual spraying using pirimiphos-methyl), with interventions administered within 500 meters of index cases. To evaluate the effectiveness of interventions targeting the parasite reservoir in humans (rfMDA vs RACD), in mosquitos (RAVC vs no RAVC), and in both humans and mosquitoes (rfMDA+RAVC vs RACD only), a modified intention-to-treat analysis was used to compare cumulative incidence of locally acquired malaria cases and cross-sectional prevalence of infection with parasites. Trial registration: ClinicalTrials.gov NCT02610400. Findings: From Jan-Nov 2017, 55 clusters had index cases triggering 342 interventions that covered 8 948 individuals. Incidence per 1 000 person-years for rfMDA, RAVC, and rfMDA+RAVC clusters vs control was: 30·8 vs 38·3 (adjusted incidence rate ratio (aIRR) 0·54 [95% CI 0·14-0·94, p=0·03]), 30·2 vs 38·9 (aIRR 0·51 [0·12-0·90, p=0·01]), and 25·0 vs 41·4 (aIRR 0·28 [0·10-0·84, p=0·02]), respectively. Compared to control, prevalence of infection (%) for rfMDA, RAVC, and rfMDA+RAVC vs control was 3·2 vs 3·8 (adjusted prevalence ratio (aPR) 0·58 [95% CI 0·18-0·98, p=0·04]), 2·9 vs 4·1 (aPR 0·34 [0·11-0·57, p

Highly resolved pollution data offers novel insights into where and when urban residents incur air pollution exposures. Armed with such data, urban planners can design infrastructure to minimize ex...

Real-time estimates of volumetric minute ventilation (MV) can now be made through wearable sensors, allowing field studies to extend the personal exposure approach to more accurately account for im...

Journals, time activity diaries, and other manual annotations of a participant’s activities can be labor intensive, particularly if a wide variety of activities are required to meet study goa...

Effective program management is essential for successful elimination of malaria. In this perspective article, evidence surrounding malaria program management is reviewed by management science and malaria experts through a literature search of published and unpublished gray documents and key informant interviews. Program management in a malaria elimination setting differs from that in a malaria control setting in a number of ways, although knowledge and understanding of these distinctions are lacking. Several core features of successful health program management are critical to achieve elimination, including effective leadership and supervision at all levels, sustained political and financial commitment, reliable supply and control of physical resources, effective management of data and information, appropriate incentives, and consistent accountability. Adding to the complexity, the requirements of an elimination program may conflict with those of a control regimen. Thus, an additional challenge is successfully managing program transitions along the continuum from control to elimination to prevention of reintroduction. This article identifies potential solutions to these challenges by exploring managerial approaches that are flexible, relevant, and sustainable in various cultural and health system contexts.

Summary points Country programs and international donors are increasingly focused on regional approaches to malaria elimination; regional initiatives have been established in southern Africa, the Arabian Peninsula, Asia Pacific, Eastern Europe, and Latin America. Despite this growing attention, there is limited information and guidance on both key activities and organizational components of regional initiatives. In a review conducted for this policy forum, common characteristics across existing regional initiatives emerged: building a region-specific evidence base, leveraging expertise and resources, shifting commodities or pooling procurement, developing data-sharing systems, mobilizing resources, promoting high-level accountability, and strengthening advocacy. Regional initiatives share key structural elements: a strategic unit, technical forums, mechanisms to distribute financing, a high-level political body, and a regional champion or envoy. Monitoring and evaluating the impact of regional initiatives is weak, and reporting of funding is very limited. A suitable set of indicators to better evaluate the impact of regional initiatives is needed. Finally, the established aid architecture should adapt to improve proposal and grant management processes for regional initiatives in comparison to national and bilateral grants.

This case study demonstrates that the regularization of single-sensor, single-source (S4) seismic data along discrete azimuth directions with regular source-detector distance intervals (radial domain gathers) can provide enhanced imaging through azimuthal velocity analysis, and deliver inversion-ready datasets with improved noise attenuation. A holistic workflow is presented that is tailored both to improve the final image quality, and to enable azimuthal amplitude variation with offset and azimuth (AVO/AVOAz) analyses, leading to the derivation of intrinsic rock property attributes leading to better reservoir management decisions & drilling plans. A prestack depth migration approach provides compensation for the overburden effect and improves resolution at the zone of interest by removing the effects of heterogeneities in the velocity field, which can be misinterpreted as azimuthal anisotropy. The 2016 processing sequence of a dense, broadband 3D land seismic survey in Abu Dhabi supports the understanding that azimuth-rich S4 acquisition geometries can provide advantages over conventional techniques (such as the use of receiver arrays or narrow-azimuth surveys) for the imaging, fracture characterization, and reservoir management of very subtle low-relief structures, in particular shedding light on the complex geological environments of carbonate reservoirs in the Middle East.

Pediatric gliomas, particularly high-grade gliomas, which include diffuse intrinsic pontine gliomas (DIPGs), are among the most formidable and devastating cancers in children. These tumors remain incurable, despite many treatment approaches. We recently identified a small population of glioma cells with stem-like features in pediatric gliomas (glioma stem cells: GSCs), that may be responsible, for therapeutic resistance. Bone morphogenetic protein 4 (BMP4), essential for CNS development, increases GSC therapeutic sensitivity and is a promising adjuvant for glioma treatment. Mechanisms through which BMP4 increases therapeutic sensitivity need to be elucidated, as this can lead to identification of additional treatment targets and delivery systems for BMP4 administration in a clinical setting. Additionally, extension of BMP4 short half-life would enhance its’ clinical application. Here we show that BMP4 increases chemosensitivity by decreasing H3K4me3 at the promoter of multidrug resistant gene 1 (MDR1), resulting in decreased MDR1 expression. BMP4 appears to bring about this effect by decreasing hSETD1A, an H3K4me3 methyltransferase. Our work also demonstrates the first use of a novel sulfated glycopeptide (glyco-PA) nanostructure as a vector for BMP4 delivery. Glyco-PA markedly extended and enhanced BMP4 function, and increased chemotherapeutic anti-tumor activity against pediatric malignant glioma cells in culture. Overall, this work illuminates BMP4 effects on pediatric glioma therapeutic sensitivity through epigenetic mechanisms, and demonstrates the potential of bioactive glyco-PA nanostructures as a delivery mechanism for treating pediatric malignant gliomas and other tumors.

Background A malaria eradication goal has been proposed, at the same time as a new global strategy and implementation framework. Countries are considering the strategies and tools that will enable progress towards malaria goals. The eliminating malaria case-study series reports were reviewed to identify successful programme management components using a cross-case study analytic approach. Methods Nine out of ten case-study reports were included in the analysis (Bhutan, Cape Verde, Malaysia, Mauritius, Namibia, Philippines, Sri Lanka, Turkey, Turkmenistan). A conceptual framework for malaria elimination programme management was developed and data were extracted and synthesized. Findings were reviewed at a consultative workshop, which led to a revision of the framework and further data extraction and synthesis. Success factors of implementation, programme choices and changes, and enabling factors were distilled. Results Decentralized programmes enhanced engagement in malaria elimination by sub-national units and communities. Integration of the malaria programme into other health services was also common. Decentralization and integration were often challenging due to the skill and experience levels of newly tasked staff. Accountability for programme impact was not clarified for most programmes. Motivation of work force was a key factor in maintaining programme quality but there were few clear, detailed strategies provided. Different incentive schemes targeted various stakeholders. Training and supervision, although not well described, were prioritized by most programmes. Multi-sectoral collaboration helped some programmes share information, build strategies and interventions and achieve a higher quality of implementation. In most cases programme action was spurred by malaria outbreaks or a new elimination goal with strong leadership. Some programmes showed high capacity for flexibility through introduction of new strategies and tools. Several case-studies described methods for monitoring implementation quality and coverage; however analysis and feedback to those implementing malaria elimination in the periphery was not well described. Political commitment and sustained financing contributed to malaria programme success. Consistency of malaria programmes depends on political commitment, human and financial resources, and leadership. Operational capacity of the programme and the overall health system structure and strength are also important aspects. Conclusions Malaria eradication will require adaptive, well-managed malaria programmes that are able to tailor implementation of evidence-based strategies, founded upon strong sub-national surveillance and response, with adequate funding and human resources. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1518-9) contains supplementary material, which is available to authorized users.

Background Significant progress has been made in reducing the malaria burden in the Asia Pacific region, which is aggressively pursuing a 2030 regional elimination goal. Moving from malaria control to elimination requires National Malaria Control Programmes (NMCPs) to target interventions at populations at higher risk, who are often not reached by health services, highly mobile and difficult to test, treat, and track with routine measures, and if undiagnosed, can maintain parasite reservoirs and contribute to ongoing transmission. Methods A qualitative, free-text questionnaire was developed and disseminated among 17 of the 18 partner countries of the Asia Pacific Malaria Elimination Network (APMEN). Results All 14 countries that responded to the survey identified key populations at higher risk of malaria in their respective countries. Thirteen countries engage in the dissemination of malaria-related Information, Education, and Communication (IEC) materials. Eight countries engage in diagnostic screening, including of mobile and migrant workers, military staff, and/or overseas workers. Ten countries reported distributing or recommending the use of long-lasting insecticide-treated nets (LLINs) among populations at higher risk with fewer countries engaging in other prevention measures such as indoor residual spraying (IRS) (two countries), spatial repellents (four countries), chemoprophylaxis (five countries), and mass drug administration (MDA) (three countries). Though not specifically tailored to populations at higher risk, 11 countries reported using mass blood surveys as a surveillance tool and ten countries map case data. Most NMCPs lack a monitoring and evaluation structure. Conclusion Countries in the Asia Pacific have identified populations at higher risk and targeted interventions to these groups but there is limited information on the effectiveness of these interventions. Platforms like APMEN offer the opportunity for the sharing of protocols and lessons learned related to finding, targeting and successfully clearing malaria from populations at higher risk. The sharing of programme data across borders may further strengthen national and regional efforts to eliminate malaria. This exchange of real-life experience is invaluable to NMCPs when scarce scientific evidence on the topic exists to aid decision-making and can further support NMCPs to develop strategies that will deliver a malaria-free Asia Pacific by 2030.

Background The most common reason for antibiotic prescribing in hospitalized patients is suspected respiratory tract infection. In many cases, however, antibiotics may be started when the diagnosis is unclear and continued for a fixed course regardless of patients’ clinical trajectories. We sought to characterize the distribution of clinical signs in patients started on antibiotics for possible pneumonia, number of days to normalization of clinical signs, and duration of antibiotics beyond when signs normalized. Methods We performed a retrospective analysis on 43,820 consecutive adults admitted to Brigham and Women’s Hospital from May 2017 to January 2018. We identified all nonventilated patients started on antibiotics for pneumonia using clinicians’ stated indications in their medication orders. We analyzed the distribution of clinical signs indicative of pneumonia (maximum temperature, maximum white blood cell count, median respiratory rate, and supplemental oxygen need) on the first day of antibiotics. We then calculated median days to normalization for each sign, total days of antibiotics for pneumonia, and duration of antibiotics beyond when all signs normalized. Results We identified 2,754 nonventilated patients started on antibiotics for pneumonia. On the first day of antibiotics, 38%had oxygen saturations ≥95% without supplemental oxygen, 78% had normal temperatures, 63% had normal white blood cell counts, and 79% had median respiratory rates Conclusion Pneumonia is a major driver of antibiotic utilization in hospitalized patients but we found 25% of cases lacked the cardinal clinical signs of pneumonia and antibiotics were continued for ≥3 days after all clinical signs normalized in a third of the 75% of patients who did have signs of pneumonia. These findings suggest substantial opportunities to improve antibiotic prescribing for suspected respiratory tract infections in hospitalized patients. Disclosures All authors: No reported disclosures.

Background Pneumonia is the most common hospital-acquired infection; most cases occur in nonventilated patients, yet the majority of hospitals do not track nonventilator hospital-acquired pneumonia (NV-HAP) given the complexity and subjectivity of CDC’s current surveillance definition and large number of patients at risk. We sought to develop objective, electronically computable surveillance definitions for NV-HAP to facilitate routine surveillance. Methods We developed ten candidate definitions based on different combinations of 6 clinical indicators and applied them to 60,725 adult admissions of ≥3 days to Brigham and Women’s Hospital between July 2015 and June 2017. Potential indicators included worsening oxygenation, new antibiotics given for ≥3 days, fever, abnormal white blood cell count, chest imaging orders, and respiratory cultures on hospital day ≥3. Worsening oxygenation was defined as ≥2 days of decreased oxygen saturation or escalation in supplemental oxygen following ≥2 days of stable oxygenation. We calculated incidence and mortality rates for each definition. We then matched each case with up to four controls on the basis of clinical service and duration of hospitalization and measured associations between each definition and increased mortality and length of stay, adjusting for patients’ demographics, comorbidities, and severity of illness. Results The incidence of NV-HAP ranged from 7.6 events per 100 admissions with the least restrictive definition (worsening oxygenation alone), to 0.7 events per 100 admissions (worsening oxygenation, fever or leukocytosis, and new antibiotics), to 0.2 events per 100 admissions (all signs present). Crude mortality rates ranged from 17% to 30%. Odds ratios for mortality in cases vs. controls ranged from 4.3 (95% CI 3.8–5.0) to 8.5 (95% CI 6.3–11.4). Odds ratios for days-until-discharge in cases vs. controls ranged from 1.7 (95% CI 1.5–1.9) to 2.1 (95% CI 2.0–2.2). Conclusion We demonstrate the feasibility of applying electronically computable objective surveillance definitions for NV-HAP. These definitions yield incidence and mortality rates comparable to existing estimates based on manual surveillance Methods. Further work is needed to better understand the clinical correlates of these events and their potential preventability. Disclosures All authors: No reported disclosures.