A total of 307 participants, 110 index cases and 197 neighbors, were included in the analysis. Ninety-three participants (54 index cases and 39 neighbors) slept exclusively in the forest and 204 participants (53 index cases and 151 neighbors) slept exclusively on farms. Ten participants slept in both forests and on farms and were excluded from forest and farm subgroup analysis. Index cases reported employment in harvesting aloe (27) or timber (5), farming cassava (24) or rice (19), trapping (2), plantation labor (16), construction (10), and other unspecified activities (7). Thirty-one (28%) index cases reported work activities at night, defined as between 6 pm and 5 am.
Location of index cases
A majority of index cases (59; 54%) originated from 14 discrete, remote area locations. The most common remote area locations were Ca Ton (13 cases; 12%) and Hon Ong (10 cases; 9%), while 51 (46%) did not specify the name of the location. Remaining cases (36; 33%) were spread across the other 10 locations. Within the 7–14 days before the onset of fever, just under half of the index cases were residing in either Ha Dan (25; 23%), Ca Ton (16; 15%), or Hon Ong (12; 11%). Figure 2 illustrates a map of index case remote area sleeping site locations and associated forest canopy cover.
Demographic comparison of index cases and neighbors
Of the 307 participants, 76% were male; among index cases, 82% were male, whereas among neighbors, 73% were male (P = 0.070). The mean age was significantly higher (Student t test t = -3.0786, P<0.001, ES Cohen d = -0.35) among neighbors (41.7 years) than among index cases (36.6 years; Table 1).
All participants belonged to either the Cham (60.3%) or Kinh (39.7%) ethnic groups. The proportion of Cham participants was significantly higher among neighbors (64.5%) than among index cases (52.7%), although small effect size (ES) indicated lack of practical significance (c2 (1; 307) = 4.06, P =0.04, ES F = 0.12). The difference in proportions of self-reported illiterate index cases (22.7%) and neighbors (30.5%) was not statistically significant (c2 (1; 307) = 2.11, P =0.147). The proportions of those who had graduated from secondary school was not significantly different between the index cases (20.9%) and neighbors (15.7%) ( c2 (1; 307) = 1.30, P =0.254) (Table 1).
Of the 93 respondents who slept in the forest only, 80.7% were of Kinh ethnicity while 74.1% of index cases were of Kinh ethnicity. All self-reported illiterate forest workers were index cases. There were significantly more neighbors with high school education or above than index cases (c2 (1; 93) = 7.60, P =0.006, ES F = 0.29) (Table 1). Those who made more than five trips a year to the forest were 7.41 times more likely to be an index case (95% CI 2.66–20.63). Index cases were also more likely to sleep in huts without walls or in hammocks without a building structure (prevalence odds ratio (POR) 44.00, 95% CI 13.05–148.33). Additionally, index cases were more likely than neighbors to work in deep forest occupations, such as aloe collecting and trapping, (POR 11.67, 95% CI 4.37–31.18) and to work after dark (POR 5.48, 95% CI 1.84–16.35) (Table 2).
Of the 204 respondents who slept on farms only, 79.4% were of Cham ethnicity. Thirty-nine percent of both index cases and neighbors self-identified as illiterate; there were no statistical differences between index cases and neighbors regarding ethnicity and education. The majority of both index cases and neighbors made four or fewer trips per year to work at a farm (POR 1.70, 95% CI 0.85–3.32), and stayed for less than 20 days at a time (POR 1.25, 95% CI 0.87–2.43). Although both groups were predominantly employed in farming activities, index cases were more likely than neighbors to be employed in non-farming activities, such as logging (POR 2.74, 95% CI 1.27–5.91). There was no significant difference in the likelihood of working after dark for farm-based index cases and neighbors (POR 1.46, 95% CI 0.78–2.74) (Table 2).
Mosquito net usage, ownership and attitudes
More than half of forest-based participants (50 cases; 54%) reported that they did not use a bed or hammock net on a regular basis, while 47% reported use of untreated bed nets and only 10% reported use of insecticide-treated nets (ITNs). There may be overlap in responses as respondents were given the option to select multiple answers for this question. Forest index cases were more likely than neighbors to sleep without any kind of net (POR 2.95, 95% CI 1.26–6.92) and less likely to use ITNs (adjusted POR 0.10, 95% CI 0.02–0.58). The difference in use of untreated bed nets between index cases and neighbors was significant in univariate analysis, but not significant after adjusting for education level (Table 2). Just under half of farm-based participants (90; 44%) reported that they did not use a bed or hammock net on a regular basis. Thirty-five percent and 34% used untreated nets and ITNs, respectively. The likelihoods of not using bed nets, using untreated nets and using treated nets were not significantly different for neighbors and index cases (POR 0.96, 95% CI 0.51–1.81, POR 1.33, 95% CI 0.69–2.53 and POR 0.55, 95% CI 0.27–1.12, respectively).
Observations and data on net ownership as well as attitudes were also captured in the study (Table 3). Approximately half (49.2%; 151) of all participants owned untreated nets and 36.8% (113) owned treated nets. Thirty-nine percent (121) of all participants indicated they were willing to use untreated nets at sleeping sites in the future when asked: 36.4% (40) of index cases and 41.1% (81) of neighbors. Participants owned 54 treated nets, of which index cases represented only 13 while neighbors accounted for 41 nets. Only 10% (19) of huts had treated nets: 6% (4) in index huts and 14% (15) in neighbors’ huts. When asked about willingness to use treated nets at sleeping sites only 13% (40) of participants indicated they were willing to use treated nets: 9% (10) index cases and 15% (30) neighbors. Only the difference in number of huts having untreated nets between index cases and neighbors was statistically significant (POR 0.40, 95% CI 0.20–0.78).
Participants lived in 180 huts, of which 21 huts had two or more cases per hut and accounted for 56% (60) of index malaria cases, 50 huts had one case, and 109 huts had no cases. Index case huts had an average of 1.6 (SD=1.1) members per hut. The 109 neighbor huts had an average of 1.8 (SD=1.2) members per hut. Significantly higher number of index huts than neighbor huts had more than three occupants (POR 4.63, 95% CI 2.74–7.81); 32% of huts slept more than one person (minimum number) and 25% of huts slept more than five people (maximum number). The minimum and maximum number of people usually sleeping in a hut was significantly higher among the index huts than the neighbor huts, POR 3.23, 95% CI 1.96–5.34 and POR 4.15, 95% CI 2.42–7.10, correspondingly (Table 4).
Two hundred and seventy-four (89%) participants lived in huts established in the last 10 years (from 2007–2016), including 92% of index cases and 88% of neighbors. Sixty-nine percent (213) of participants were able to reach their huts from their reported residence within 30 minutes by motorbike. Neighbors had huts significantly closer to their official homes than the index cases; neighbors’ huts were 3.10 times more likely to be within a 30-minute motorbike ride (95% CI 1.87–5.13) and 1.77 times more likely to be within a 15-minute of additional walking (95% CI 1.07–2.94) than index’s huts.
Seventy-three percent (223) of participants had immediate access to a cell phone network and 13% (40) had access to a cell phone network within 30 minutes by motorbike. Access to a cell phone network was significantly lower among the index huts for immediate network (POR 0.27, 95% CI 0.16–0.45), but no significant difference was observed for network coverage within 30 minutes by motorbike (POR 1.56, 95% CI 0.80–3.03). About three quarters of the participants retrieved their water from a stream and the remaining quarter from a well. The odds of index cases taking water from a stream was 2.84, 95% CI 1.54–5.26) times higher than that of neighbors (Table 4).