The Zika Airs Project (Zap) Final Report

THE ZIKA AIRS PROJECT (ZAP) FINAL REPORT

Recommended Citation: The Zika AIRS Project (ZAP). Final Report. Rockville, MD. The Zika AIRS Project, Abt Associates Inc. Contract: GHN-I-00-09-00013-00 Task Order: AID-OAA-TO-14-00035 Submitted to: United States Agency for International Development

Abt Associates Inc. 1 6130 Executive Boulevard 1 Rockville, Maryland 20852 1 T. 301.347.5000 1 F. 301.913.9061 1 www.abtassociates.com

CONTENTS

Acronyms ...... iii 1. Introduction ...... 1 2. Technical Activities by Component ...... 3 2.1 Component 1: Collaborate and coordinate national vector control aspects for Zika virus disease ...... 3 2.2 Component 2: Provision of equipment and technical expertise to build entomological capacity ...... 6 2.3 Component 3: Procurement, storage and distribution of vector control commodities, and subsequent implementation of vector control strategies ...... 12 2.4 Cross-Cutting Components: Capacity Building and Gender ...... 21 3. ZAP Country Summaries ...... 24 3.1 Dominican Republic ...... 24 3.2 El Salvador ...... 30 3.3 Guatemala ...... 35 3.4 Haiti ...... 40 3.5 Honduras ...... 45 3.6 Jamaica ...... 50 3.7 Nicaragua ...... 56 3.8 Ecuador, Paraguay and Peru ...... 57 3.9 Eastern and Southern Caribbean ...... 58 4. Communications ...... 61 4.1 Videos ...... 61 4.2 Success Stories/Zika Fighter Profiles ...... 61 4.3 Conferences ...... 61 4.4 Strategic Meetings ...... 63 5. Lessons Learned and Conclusions ...... 65 5.1 Lessons learned ...... 65 5.2 Conclusions ...... 66 ANNEX : Monitoring and Evaluation Summary ...... 69

ACRONYMS

AIRS Africa Indoor Residual Spraying BG Biogent BTI Bacillus Thuringiensis Israelensis CAZ Community Action on Zika CDC Centers for Disease Control and Prevention CECOVEZ Centro de Control y Prevención de Enfermedades Producidas por Vectores y Zoonosis (Center for Vector Control and Zoonosis, Dominican Republic) DPS Dirección Provincial de Salud (Provincial Health Directorate, Dominican Republic) DR Dominican Republic ESC Eastern and Southern Caribbean EW Epidemiological Week GAT Gravid Aedes Trap GEMS Global Environmental Management Support IEC Information, Education, and Communication IRS Indoor Residual Spraying M&E Monitoring and Evaluation MCDI Medical Care Development International MCRU Mosquito Control Research Unit (Jamaica) MINSA Ministerio de Salud de Nicaragua (Ministry of Health, Nicaragua) MOH Ministry of Health MOHW Ministry of Health and Wellness (Jamaica) MSPAS Ministry of Public Health and Social Assistance (Guatemala) MSPP Ministère de la Santé Publique et de la Population (Haiti) PAHO Pan American Health Organization PMI President’s Malaria Initiative PNCM Programme National de Lutte contre la Malaria (National Malaria Control Program, Haiti) PROEDUSA Departamento de Promoción y Educación para la Salud (Department of Health Promotion and Education, Guatemala) SBCC Social and Behavior Change Communication SEDIS Secretaria de Desarrollo e Inclusion Social (Ministry of Social Inclusion, Honduras)

iii

SENEPA Servicio Nacional de Erradicación del Paludismo (National Malaria Control Service, Paraguay) SESAL Secretaría de Salud (Ministry of Health, Honduras) SIBASI Sistemas Basicos de Salud Integral (El Salvador) UASD Universidad Autonoma de Santo Domingo (Dominican Republic) USAID United States Agency for International Development UWI University of the West Indies WHO World Health Organization ZAP Zika AIRS Project

1. INTRODUCTION

In 2015 and 2016, the Zika virus was rapidly spreading across the Americas. The virus, often asymptomatic, has been linked to serious birth defects, including microcephaly and neurological damage. In February 2016, with the number of babies born with microcephaly skyrocketing in Latin America and the Caribbean, the World Health Organization (WHO) declared the Zika virus outbreak a global health emergency. In September 2016, the United States Agency for International Development (USAID) introduced the Zika AIRS Project (ZAP), implemented by Abt Associates, as a vector control response to the emerging infectious disease, with a three year period of performance through September 2019. Working in the Dominican Republic (DR), Eastern and Southern Caribbean, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Jamaica, Nicaragua, Paraguay, and Peru, ZAP collaborated with country governments to plan and implement vector control strategies to reduce disease outbreaks and respond quickly to arboviruses. Over the life of the project, ZAP conducted more than 7.5 million household level vector control visits. See Exhibit 1 for a map of ZAP’s presence in the region. EXHIBIT 1: MAP OF ZAP IMPLEMENTATION AND TECHNICAL SUPPORT IN LATIN AMERICA AND THE CARIBBEAN

ZAP focused on three main pillars:  Entomological monitoring and surveillance—because Zika is spread to people primarily through the bite of an infected Aedes aegypti mosquito, ZAP conducted robust entomological monitoring to understand the spread and behavior of Aedes mosquitos in focus countries, and the effects of mosquito control interventions. Monitoring approaches consisted of larvae/pupae surveys, and the use of several mosquito collection methods including Prokopack aspirators, Gravid Aedes Traps (GATs), and Biogent (BG) sentinel traps for adult collection, ovitraps for egg collection, and manual collection for larvae.  Vector control activities—to tackle the spread of the virus, ZAP targeted areas with high indices of arboviruses for vector control activities that included larviciding with Bacillus thuringiensis israelensis (Bti). Bti is a biological or a naturally occurring bacteria that kills mosquito larvae once ingested. Bti can be used safely around homes and in water storage containers. ZAP also piloted other vector control methods including indoor residual spraying (IRS), wide area spraying of larviciding, and lethal ovitraps.  Environmental management—through household visits, ZAP engaged communities to reduce mosquito breeding sites through environmental management. ZAP’s environmental management activities included cleaning up areas around homes to eliminate places where mosquitoes can breed, and educating home owners on common breeding sites. Although the scale of risk has declined, risks of Zika and other arboviruses remain. Sustainability was an important area of focus for ZAP throughout implementation, particularly in its final year. With ZAP’s help, countries are now better equipped and prepared to prevent the spread of mosquito-borne diseases. In collaboration with Ministries of Health (MOHs) and local stakeholders, ZAP provided extensive institutional capacity building and infrastructure strengthening in support of robust routine entomological monitoring. For example, ZAP initiated the development, delivery, and/or refurbishment of insectaries and laboratories in Antigua, Barbados, Ecuador, El Salvador, Guatemala, Haiti, Honduras, and Jamaica. These innovative insectaries are strengthening the ability of each country to continue important entomological functions. In Jamaica, ZAP partnered with MOH and the University of the West Indies (UWI) to establish the country’s first Mosquito Control Research Unit (MCRU) with a fully- equipped laboratory and insectary. ZAP also built local capacity to conduct insecticide susceptibility tests to guide vector control decisions. Furthermore, ZAP has equipped country governments to carry forward policies, protocols, and decision-making that rely on reliable, accurate, and real-time data, ensuring they are better able to prepare for and prevent future outbreaks.

2. TECHNICAL ACTIVITIES BY COMPONENT

In response to the Zika outbreak, USAID released an Emergency Request Justification in 2016 that identified the need to “support efforts to identify, localize, and prevent continuing spread of the Zika virus throughout Central and South America and the Caribbean, and other affected areas.”1 Based on this justification, USAID designed efforts to mitigate the spread of Zika through implementing a package of vector control activities in communities affected by and at-risk of the virus. This included support for robust continuous community mobilization campaigns tailored to each community to actively reduce or eliminate standing water sources where Aedes species mosquitos breed and focal larviciding based on vector mapping and resistance data to eliminate major breeding sites at regular intervals. In addition, USAID’s investment was designed to develop and strengthen regional capacity for entomological monitoring, which faced challenges due to the dwindling numbers of qualified and experienced specialists, limited financial and technical resources, and inconsistent political support. Capacity building through targeted technical assistance, investments in laboratories, strategic donations of equipment and materials, promoting information exchange, and the development and adoption of best practices, cut across all activities. This section provides an overview of ZAP’s work in relation to these technical components, and highlights major accomplishments and results at the country and regional levels.

2.1 COMPONENT 1: COLLABORATE AND COORDINATE NATIONAL VECTOR CONTROL ASPECTS FOR ZIKA VIRUS DISEASE Upon USAID approval of ZAP in September of 2016, Abt deployed country level teams in five countries: Haiti, DR, Honduras, El Salvador, and Guatemala. In 2017, implementation was initiated in Jamaica and Nicaragua. ZAP teams conducted a rapid situational analysis in each country to confirm results from capacity assessments conducted by USAID’s Health Finance and Governance project in June and July 2016. These initial assessments informed project implementation. The MOH was the main collaborating entity in each country, therefore country teams quickly partnered with MOH representatives responsible for vector control and entomological monitoring activities. Although these activities often sat within vertical disease programs, they were implemented by decentralized units of each MOH at the regional, departmental, or provincial levels. For example, the Sistemas Basicos de Salud Integral (SIBASI) in El Salvador delivers government-funded clinical and public health services; in Guatemala, the MOH operates through departmental entities; in the DR, provincial health directorates (Direcciones Provinciales de Salud or DPS) are in charge of delivering priority public health services; and in Jamaica, the MOH runs parish-level units. ZAP coordinated and collaborated with the central level MOH, and worked directly with local MOH entities in each target area. Additionally, the Honduras team worked with the MOH in Tegucigalpa, San Pedro Sula, and the department of Choluteca; and the Haiti team worked with the MOH in the Northern Department. ZAP also occasionally collaborated with other government agencies, such as the Ministries of Agriculture and Environment in the DR to enable importation of larvicides. In Honduras, the Ministry of Social Inclusion became a strategic partner to mobilize human and financial resources.

1 Department of State (2016). Emergency Request Justification to fund the USG Zika response.

The ZAP teams also worked with several USAID implementing partners operating at regional and country levels. Examples included: the USAID Applying Science to Strengthen and Improve Systems (ASSIST) project; the Community Action on Zika (CAZ) project implemented by Save the Children and Red Cross; Population Services International responsible for communications/behavior change activities; UNICEF responsible for social protection of Zika-affected families; and Medical Care Development International (MCDI) and its Zika Community Response in Guatemala and El Salvador project. ZAP country teams collaborated with these partners to develop synergies and capitalize on one another’s capabilities, particularly in the areas of communications and community mobilization. The Pan American Health Organization (PAHO) was an important regional partner at both the headquarters (Washington, DC) and at the country level. PAHO’s Regional Plan of Action for Entomology and Vector Control served as a framework for sustainability. It also provided an opportunity for innovations and best practices developed by ZAP to be incorporated into national action plans; these should be in place between 2018 and 2023. At the country level, PAHO advisors supported ZAP’s capacity building and training activities, as well as policy dialogue, to promote the vector control agenda. In addition, PAHO’s appointment of a regional Vector Control Advisor based in El Salvador was a positive step towards collaborative technical support and coordination. The United States Centers for Disease Control and Prevention (CDC) was another regional partner. Both CDC and USAID funded Zika prevention and control activities, and undertook targeted research and dissemination activities through the Training Programs in Epidemiology and Public Health Interventions Network. Finally, the Council of Health Ministers for Central American and the Caribbean (Consejo de Ministros de Salud de Centroamerica y el Caribe) was an occasional strategic partner for vector control activities in the region, including an information exchange workshop in Belize in October 2018. ZAP pursued three streams to maximize regional and country coordination and collaboration. Additional details on each of these streams is provided below.

2.1.1 ASSIST HOST COUNTRY GOVERNMENTS TO DEVELOP VECTOR CONTROL STRATEGIES AND IMPLEMENTATION GUIDELINES ZAP provided targeted support in selected countries to improve the operational and regulatory framework for vector control and entomological monitoring in all countries. The expectation was that by having updated regulations and technical protocols for vector control and entomological monitoring, field operations would be more efficient and effective at the country level. For example:  In the DR, ZAP was invited to develop a pocket guide for field personnel—in April 2018, the DR’s MOH released updated national implementation guidelines for vector control and entomological surveillance after a seven-year hiatus. However, these were difficult to operationalize in the field due to a heavy theoretical emphasis. ZAP therefore prepared a brief summary for quick consultation in the field.  In both Guatemala and the DR, IRS campaigns were conducted to control Aedes aegypti. This required detailed operational guidelines covering all technical aspects of IRS. While IRS results fell short in terms of reducing the density of adult mosquitoes at the household level, the guidelines are available for future reference, as needed.  In El Salvador, the ZAP team formulated national guidelines for insecticide resistance testing, which have been used for training and field implementation. The team also developed technical guidelines for the operation of entomological laboratories. Both tools are available for in- country and regional use.  In Jamaica, ZAP enhanced the capacity of the MCRU insectary by developing standard operating procedures and a safety manual, and facilitating the Biosafety Level 1 certification for the

laboratory. In addition, together with the Jamaican MOH and MCRU, ZAP developed a comprehensive Vector Control Training curriculum based on the ZAP implementation model, which has been adopted by the government.  In Ecuador, the MOH requested ZAP support because existing guidelines were based on outdated malaria control material. With targeted input from ZAP’s home office, the MOH team compiled two volumes of national guidelines, one on vector control and the other on entomological monitoring. These have been formally approved and released by the MOH.

2.1.2 FACILITATE COORDINATION OF IN-COUNTRY STAKEHOLDERS RELATED TO ZIKA VECTOR CONTROL ACTIVITIES Country-level vector control requires an array of resources regardless of the scenario faced. Under a high-risk scenario with high vector density and active disease transmission (e.g., an outbreak), effective vector control requires significant mobilization of personnel, equipment, and other resources. Under conditions of low entomological risk (low vector density, limited active transmission of disease), routine vector control and entomological surveillance still requires personnel, standard operating procedures, basic equipment and supplies, and logistical support. During the acute phase of Zika transmission in the Latin American and Caribbean region in 2016, some governments mobilized massive numbers of people and deployed large quantities of equipment, supplies, and vehicles. The intention was to achieve national coverage with health promotion messages, environmental clean-up and source elimination campaigns, and in some cases, direct application of larvicide. This experience was replicated to some extent by the ZAP project. In the seven long-term presence countries, massive vector control and entomological monitoring activities were implemented. Throughout, ZAP teams worked closely with MOH entities at central and local levels, and intra- and inter-sectoral coordination was a cross-cutting factor. Interventions needed participation by local governments (i.e., municipalities), as well as community-based organizations, educational institutions, and the private sector. For example:  In El Salvador, collaboration with municipal governments was very successful. In the municipality of Mejicanos near San Salvador, the local mayor became a vector control champion who encouraged citizens to eliminate breeding sites and adopt preventive behaviors to protect against mosquitoes. ZAP established an entomology laboratory in the municipality of El Paisnal, who donated the building, helped refurbish a portion of the building, and supplied energy and water.  In the DR, close coordination with the municipality of Moca, where environmental clean-up and larviciding activities were conducted, enabled proper collection and disposal of solid waste. Local governments facilitated access to cemeteries, which were significant breeding sites and therefore needed targeted and regular vector control.  In Haiti, the ZAP team collaborated with local schools to promote knowledge and awareness about mosquitoes, their role in disease transmission, and ways to protect against them. ZAP also partnered strategically with academic institutions in El Salvador, Honduras, the DR, and Jamaica. In the first three countries, advanced entomology training programs (i.e., diplomados) were designed and implemented in close collaboration with local universities, the MOH, and PAHO. In Jamaica, the ZAP team worked with UWI to strengthen an entomological laboratory and improve local capacity.

2.1.3 PROVIDE TECHNICAL INPUT AND FACILITATE INFORMATION SHARING OF APPROPRIATE DATA OR LESSONS LEARNED TO USG AND OTHER TECHNICAL ORGANIZATIONS REGARDING ZIKA RESPONSE One of ZAP’s key tasks was to generate robust data and share project results. Country teams worked on a number of enhancements to data collection, processing, analysis, and dissemination. For example, in Guatemala, a mobile data collection system was deployed in 2017 during IRS. This system allowed efficient data collection and real-time analysis. Other countries followed suit—in 2018, as part of a larviciding campaign in the province of Espaillat, the DR team developed a mobile data collection system to facilitate prompt and accurate data collection, as well as real-time analysis and reporting. Jamaica also developed an efficient data collection system and used dashboards to visualize results—visual displays allowed two-dimensional data analysis to assess pre- and post-intervention results of larviciding. The ZAP teams also worked with the MOH to advance in-country systems. In 2019, the DR team worked with the MOH to develop an entomological monitoring module to be incorporated into the national epidemiological surveillance system. When ready, public health planners and program managers will have both epidemiological and entomological data to assess risks and determine proper interventions. In El Salvador, entomological data generated by the ZAP team was incorporated into the national health information system for broad analysis and dissemination. In most countries, ZAP results were shared with MOH stakeholders through technical meetings, working sessions, or written dissemination materials. Country and regional events also served to facilitate information sharing with USAID, PAHO, and other technical organizations. In addition, periodic meetings of Zika program partners were used to share updates and discuss opportunities for collaboration.

2.2 COMPONENT 2: PROVISION OF EQUIPMENT AND TECHNICAL EXPERTISE TO BUILD ENTOMOLOGICAL CAPACITY

2.2.1 PROCUREMENT OF ENTOMOLOGICAL SUPPLIES AND EQUIPMENT RELATED TO VECTOR SURVEILLANCE ZAP procured entomological supplies and equipment to support different forms of vector surveillance— ovitrap monitoring, which provides egg density data as an indicator of potential entomological risk; larval surveys, which are the most frequently used method for entomological surveillance in the region; and adult mosquito surveillance, a method that had not been used in the region at scale. ZAP procured and donated equipment and materials for both laboratory work (e.g. microscopes, stereoscopes, books, and other analytic tools), and for field work (e.g. sampling collectors and mosquito traps). For ovitrap surveillance, this included magnifying glasses or microscopes; for larval surveys, dippers, pipettes, and trays; and for adult mosquito surveillance, BG-sentinel traps, Prokopack aspirators, and GATs. ZAP also led efforts to update insecticide resistance data, overcoming a 20-year data gap in some countries. WHO and CDC methods were used to assess adult resistance, and WHO methods were used for larvicide resistance. ZAP purchased and donated all entomological supplies needed to conduct insecticide susceptibility bioassays for both WHO and CDC current protocols (including reagents and bioassay test materials). In addition, ZAP provided laboratory equipment, materials, and supplies to conduct entomological monitoring and research. Exhibit 2 includes lists of procured and donated inputs to most ZAP-supported countries.

EXHIBIT 2: SUMMARY OF ENTOMOLOGICAL SURVEILLANCE AND MONITORING EQUIPMENT AND SUPPLIES Entomological monitoring supplies and  DNA Oligos equipment:  Ovitrap papers  Entomological books  Ovitraps  Entomological cabinets  Larval pupal separators  Forceps  BG-sentinel mosquito traps  Pipette tips  Biogents Gravid Aedes Traps  Petri dishes  Prokopak aspirators  Sorting trays  Prokopak cups  Incubators  CDC light traps  Thermohygrometers  Mouth aspirators  Mosquito collection box Insectary/laboratory supplies and equipment:  Laboratory oven  Mosquito rearing and observation kits  Freezer  Mosquito dissection kits  Mini mosquito breeder  Compound dissection kits  Laboratory coats  Dissecting stereomicroscopes  Nitrile gloves  insecticide papers  Spatulas  WHO/CDC insecticide test kits  Reagents  WHO test tube kits  Micro-centrifuges  Beakers  Portable autoclaves  Pipettes  Commercial humidifiers

2.2.2 PROVIDE TECHNICAL INPUT AND BUILD CAPACITY OF NATIONAL OR SUB- NATIONAL ENTITIES FOR ENTOMOLOGICAL MONITORING

2.2.3 TECHNICAL SUPPORT ZAP teams provided technical support for all forms of vector surveillance across target countries. ZAP worked with partner organizations, mainly MOHs, to develop local capacity to implement ovitrap surveillance. This included training, as well as development of guidelines and data collection and analysis tools (i.e., mobile applications and dashboards). In the DR, for example, ovitrap deployment provided the opportunity to expand MOH coverage and build technical capacity at the local level to set up, manage, report, and analyze ovitrap data. ZAP collaborated with local counterparts to improve larval surveys by providing refresher trainings, helping update national guidelines, and accompanying MOH teams during field work. ZAP also helped streamline entomological surveillance tools using mobile data collection and visualization tools, and supported the systematic collection and analysis of Stegomya indices (household index, container index, and Breteau index2) across all ZAP core countries. The project also trained field technicians and supervisors in adult mosquito surveillance. Lastly, ZAP led efforts to update insecticide resistance data by strengthening technical capacity through national and regional trainings, as well as by building skills in data collection and interpretation.

2.2.4 TRAININGS ZAP provided workshops for two groups of technicians—field-based and laboratory staff. In all countries, ZAP invited MOH staff to participate in training workshops held at the local, regional, and national levels. Additionally, ZAP delivered training courses specifically targeted to MOH needs. These trainings took place on different dates, addressing local, regional, and national groups of MOH technical staff. In specific cases (e.g., the DR, Honduras, and El Salvador), ZAP organized and facilitated diploma programs with a strong focus on entomological monitoring methods and practices. ZAP also conducted workshops on entomological surveillance topics including: surveillance of different developmental phases of Aedes mosquitoes, taxonomical identification of species, best practices for sampling, packaging and transporting of biological material, and parity and gonotrophic cycle determinations. Workshops on insecticide susceptibility testing covered standard current international protocols and practices, and included hands-on surveillance practice, access to scientific literature in an electronic format, and technical discussions of best practices for Aedes monitoring.

2.2.5 LABORATORIES AND INSECTARIES In order to strengthen national capacity to carry out quality entomological monitoring in the region, ZAP helped install and/or refurbish laboratories. Key laboratory functions encompassed: insecticide resistance surveillance, egg density count for ovitrap monitoring, mosquito rearing and species identification (immature and adult forms), and adult sampling collection. Following ZAP’s overall approach, country project teams developed partnerships with local entities, including MOHs, academia, and municipal governments. For example:  In El Salvador, ZAP partnered with the MOH, the municipality of El Paisnal, and Universidad Evangelica de El Salvador to install a national entomology laboratory and two regional laboratories (in El Paisnal and San Miguel). In collaboration with the Universidad Evangelica, ZAP also organized a diploma program in entomology (see Exhibit 4).

2 Household index – (HI) percentage of houses infested with larvae and/or pupae; the Container index (CI) - percentage of water-holding containers infested with larvae and/or pupae and Bretaeu index (BI) - number of positive containers per 100 houses inspected.

 In Jamaica, ZAP collaborated with the MOH and the University of West Indies to strengthen the MCRU’s laboratory capacity to conduct entomological monitoring in seven intervention sites and to provide specialized trainings.  In the DR, ZAP collaborated with the MOH, municipal governments, and Universidad Autonoma de Santo Domingo (UASD) to strengthen laboratory capacity, deliver trainings, and conduct insecticide resistance testing in 16 sentinel sites. An innovative solution to improving laboratory capacity was the donation of insectaries-in-a-box in Guatemala, Haiti, EXHIBIT 3: HAITI INSECTARY- Jamaica, Ecuador, and Barbados. First developed by Abt in Mali IN-A-BOX under the Africa Indoor Residual Spraying (AIRS) Project, these facilities quickly enhanced local capacity to breed and maintain mosquito colonies needed for entomological operational research, training, and field surveillance. See Exhibit 3. Diploma training programs. An important aspect of ZAP’s work was the establishment of diploma training programs—see Exhibit 4.

EXHIBIT 4: STRENGTHENING TECHNICAL CAPACITY IN VECTOR CONTROL AND ENTOMOLOGICAL MONITORING: DIPLOMA TRAINING PROGRAMS IN EL SALVADOR, HONDURAS, AND THE DOMINICAN REPUBLIC Background: Rapid capacity assessments conducted in mid-2016 revealed that national vector control programs in core ZAP countries faced multiple challenges. The number and quality of trained technicians and managers was insufficient to sustain an effective response, and a generation of specialists was approaching retirement in several countries, with uncertain plans for their renewal.

Objectives: The initial objective was to support the quick mobilization of people and resources, including managers and supervisors, to implement vector control and entomological monitoring activities. However, it was necessary to develop a cadre of trained personnel to sustain the national response beyond the life of the project.

Approach and results: In addition to short-term and in-service training, ZAP helped organize longer term, quality training programs to be institutionalized within existing systems. The DR took the lead in establishing a diploma program in 2017, and El Salvador and Honduras followed quickly in 2018 and 2019. Each program was unique, including up to 300 training hours delivered over 2-6 month periods per training cohort. In the DR, for example, the diploma program trained participants through 128 contact hours delivered over an 8 week period. In all countries, MOH personnel were the target audience, and the diploma programs entailed partnerships with MOHs, academia, cooperation agencies, and USAID/ZAP. Implementation details are provided below.

DR: Diploma in entomology in public health and vector control  Partnership with UASD and supported by PAHO and CDC  ZAP provided financial and material support, including establishment of an entomology laboratory  MOH selected and supervised participants  Three cohorts: 78 participants  168 contact hours (140 practice hours)

El Salvador: Diploma in entomology for the prevention and control of vector-borne diseases  Partnership with MOH and Universidad Evangelica de El Salvador  Financial support from the Global Fund for AIDS, Tuberculosis, and Malaria  ZAP provided equipment and materials  Target audience: central, regional, and local level MOH personnel

 Two cohorts: 147 participants  Five modules, 188 contact hours

Honduras: Diploma in vector control and entomology  Partnership with the Catholic University of Honduras  MOH selected participants and provided oversight and follow-up  PAHO contributed international trainers  ZAP provided financial and logistical support  Duration: 6 weeks (1 week per month for 6 months); 300 hours total, combining theoretical and practical training  21 participants

Conclusion: Through diploma training programs in three countries, ZAP strengthened and expanded national capacity to support vector control and entomological monitoring activities. There is now a cadre of MOH specialists with the necessary technical skills and motivation to sustain effective programs.

2.2.6 FACILITATE ENTOMOLOGICAL MONITORING TO SUPPORT VECTOR CONTROL RESPONSE TO ZIKA Exhibit 5 summarizes ZAP’s entomological monitoring approach. As noted above, ZAP used three main methodologies for entomological surveillance—ovitraps, larvae/pupae surveys, and adult mosquito trapping. Ovitraps with infusion were deployed in a sample of 100 EXHIBIT 5: ZAP ENTOMOLOGICAL MONITORING households, and surveillance APPROACH conducted approximately every five days. Larvae/pupae surveys were conducted in a sample of 200 households approximately every 10 days. In all countries, ZAP conducted adult mosquito sampling using a variety of traps—GATs, BG-sentinel traps, and Prokopack aspirators. All entomological surveillance was conducted in designated sentinel sites where ZAP teams had previously obtained permission from residents, and in accordance with written protocols tailored to local resources and needs for field and laboratory activities. Sentinel sites selected for entomological surveillance included municipalities with high incidence of Zika cases during the 2016 epidemic. Consideration was also given to accessibility and safety. See Annex 1 for a breakdown of country and implementation activities.

Exhibit 6 summarizes the insecticide resistance tests conducted within the region. Results were discussed at the country level and in regional meetings, and will be shared formally to update regional maps and inform insecticide-based vector control decisions. EXHIBIT 6: SUMMARY OF INSECTICIDE RESISTANCE TESTS CONDUCTED BY ZAP

2.3 COMPONENT 3: PROCUREMENT, STORAGE AND DISTRIBUTION OF VECTOR CONTROL COMMODITIES, AND SUBSEQUENT IMPLEMENTATION OF VECTOR CONTROL STRATEGIES

2.3.1 PROCUREMENT, STORAGE AND DISTRIBUTION OF INSECTICIDE BASED VECTOR CONTROL PRODUCTS AND RELATED PERSONAL PROTECTIVE EQUIPMENT ZAP followed Abt and USAID procurement principles, guidelines, and regulations, as well as the U.S. President’s Malaria Initiative (PMI) Best Management Practices3 for the procurement, storage, and distribution of vector control commodities and products. Over the life of the project, ZAP ensured:  Chemical products and other stock items met quality specifications in accordance with WHO Pre-Qualification recommendations, and were transported and stored in compliance with WHO guidelines and host country policies;

3 https://www.pmi.gov/docs/default-source/default-document-library/tools-curricula/best-practices-indoor-residual- spraying-feb-2015.pdf?sfvrsn=4

 Inventory, management, and storage controls were in place and implemented effectively to prevent pilferage, misuse, or loss;  Effective use by all ZAP country teams of project standardized supply chain management tools and approaches, with improvements as needed;  The timely and accurate quantification of all required materials, equipment, and supplies by each ZAP country office, including through advanced planning;  All countries maintained a detailed inventory of internationally and locally procured equipment and consumables; and  ZAP commodities followed the approved USAID/ZAP branding and marking guidelines. Exhibit 7 summarizes the supplies and equipment used for vector control activities by ZAP. EXHIBIT 7: ILLUSTRATIVE ZAP SUPPLIES AND EQUIPMENT PROCURED TO SUPPORT VECTOR CONTROL

 Insecticide (for IRS campaigns) and/or larvicide (Bti)  Personal protective equipment: long sleeved shirts and pants  Calibrated scoops/spoons  Enamel or plastic dippers  Measuring tapes  Pocket flashlights  Writing paper and pens  First aid kits  Hand tally counters  Monitoring and evaluation tools

ZAP paid special attention to the health and personal protection of field personnel. Procurement of personal protective equipment and adequate safety practices were important considerations in planning field interventions. ZAP had a rigorous incident reporting system to monitor and respond to adverse events.

2.3.2 ENSURE COMPLIANCE WITH ALL USG ENVIRONMENTAL REGULATIONS, INCLUDING PREPARATION OF SUPPLEMENTAL INITIAL ENVIRONMENTAL EXAMINATIONS AND ENVIRONMENTAL MITIGATION AND MONITORING PLANS Abt’s environmental team developed Supplemental Environmental Assessments for Guatemala and the DR to authorize indoor residual spraying (IRS) pilots, and Supplemental Initial Environmental Examinations for the DR, El Salvador, Guatemala, Haiti, Honduras, Jamaica, and Nicaragua to authorize larviciding and entomological activities. A Request for Categorical Exclusion for Paraguay was prepared to authorize entomological laboratory work using small amounts of insecticides. To further support IRS pilots in the DR and Guatemala, ZAP translated the PMI Best Management Practices Manual into Spanish, including the checklists for site environmental compliance assessment, vehicle inspections, and various supervisory functions (e.g., monitoring of morning mobilization, spray operator performance, home owner preparation, end-of-day clean-up, and storekeeper performance). In addition, the

Environmental Compliance Team prepared the relevant section of the ZAP Larviciding and Source Reduction Guidelines, and developed an Environmental Mitigation and Monitoring Plan for the project. The ZAP Environmental Compliance Manager made two short-term technical assistance trips each to the DR and Guatemala to assist with the IRS pilots. During the ZAP workshop in El Salvador, the team of Environmental Compliance Officers assembled and held meetings to exchange knowledge and facilitate on-going communication. In addition, the Environmental Compliance Team played a prominent role in developing and administering the USAID Incident Reporting system, which covered thefts, vehicle accidents, attacks by dogs and other animals, and other qualifying incidents. Finally, the Jamaica Environmental Compliance Officer and the Director of Environmental Compliance and Safety jointly prepared a Supplemental Initial Environmental Examination to cover larvicide donations and training to countries, including Anguilla, Antigua, British Virgin Islands, Dominica, Guyana, and St. Kitts and Nevis.

2.3.3 PLAN AND IMPLEMENT APPROPRIATE MOSQUITO-VECTOR CONTROL METHODS TO COMBAT ZIKA Community-level larvicide campaigns was the key ZAP vector control intervention in the context of an overall vector control program for vector-borne diseases. ZAP country teams coordinated closely with key partners, such as the MOH and other implementing partners at the national level. Basic epidemiological information was needed to show variation in disease burden across the country, and where available, entomology information to help support decisions for activity planning. In order to manage adult mosquito populations and thus reduce the risk of Zika, ZAP focused on reducing mosquito breeding sources through larviciding, environmental cleanup, and educating households on effective prevention measures. ZAP also conducted rigorous entomological monitoring and surveillance to measure mosquito population and density over time to evaluate the impact of the project. The ZAP vector control activities focused on controlling Aedes aegypti in its immature phase through elimination of temporary container breeding sites (using environmental control and source reduction); application of larvicides in all non-removable breeding sites including large containers with water for human use; and messaging the targeted population about behavior change. Exhibit 8 provides an overview of ZAP’s vector control model. EXHIBIT 8: ZAP VECTOR CONTROL MODEL

ZAP supported resistance testing with the MOHs and together selected the water-dispersible granule formulation of Bacillus thuringiensis israelensis (Bti) for all countries. Bti, commercially available as Vectobac, is a WHO and United States Environmental Protection Agency approved larvicide. Bti is a biological or naturally occurring element found in soils; larviciding with Bti prevents the development of mosquito larvae. Bti is applied to breeding sources such as water tanks, outdoor sinks (“pilas”), or barrels to kill larvae or interrupt their development into adult mosquitoes. Bti particles work only when mosquito larvae ingest them, preventing the larvae from developing fully into adult mosquitoes. Bti remains effective in water for up to three months. However, the residual effect can be shorter if a portion of the water is replaced every three to four days, if the water contains other biological material, or if a large number of larvae are present. The selection of Bti determined the frequency of larviciding treatments based on its residual life and water usage patterns. This directly informed ZAP’s implementation methodology for Bti application at the household level. On a monthly basis, ZAP technicians visited each household to apply Bti, to search for potential breeding sites for Aedes mosquitoes, and to demonstrate to household owners how to eliminate and treat breeding sources to prevent vector-borne transmission. Additionally, technicians collected data by conducting surveys and counting pupae and larvae.4 This allowed the project to measure the impact and effectiveness of home visits. In preparation for activity implementation, ZAP defined mosquito breeding sites and how they would be treated. ZAP defined mosquito breeding sites as accumulations of water, temporary or permanent, where female mosquitoes could lay eggs that would later develop into larvae, pupae, and adult mosquitoes. According to entomological surveillance reports, breeding sites in each ZAP country were characterized and classified into various types of containers—either containers that held water for drinking and household use, and/or containers that caught rainwater (e.g., tanks, vases, cans, buckets, rubber tires, cisterns, pools, bottles, and jars). Tanks and buckets most frequently tested positive for mosquito larvae in ZAP countries. Exhibit 9 summarizes the different types of controllable breeding sites, and how these could be identified as permanent or temporary.

EXHIBIT 9:TYPES OF CONTROLLABLE MOSQUITO BREEDING SITES Controllable breeding sites—a mosquito breeding site in which a physical, chemical, or biological action could be used to eliminate any immature phase of mosquitoes, and/or the site prevented from retaining water and infestation (e.g., containers for domestic use and waste items that can hold water). The presence of these types of sites motivated educational effort, so that people and communities could learn how to control them. ZAP identified two types of controllable breeding sites:  Permanent breeding sites—cannot be moved or removed, and contains water throughout the year. These sites were always treated.  Seasonal or temporary breeding sites—only contain water in a given period of the year and can be positive for the presence of vector mosquito larvae (e.g., pottery vases in house courtyards, or temporary water storage during the dry season). Where possible, water was removed from these containers (even small amounts) and receptacles were treated. If containers were no longer in use and the homeowner agreed, they were overturned and/or disposed of to prevent future breeding.

4 Larval surveys are an imperfect measurement for Bti effectiveness, as Bti is not a contact killer of larvae. Bti must be ingested by larvae, which then dies several days later. This means it may be possible to have visible larvae in a treated container on the date of an entomological survey, and interpretation of larval indices is complex.

Exhibit 10 is a basic schematic of the ZAP approach to reducing mosquito breeding sites at the household level.

EXHIBIT 10: ZAP VECTOR CONTROL—LARVICIDING AND SOURCE REDUCTION APPROACH AT THE HOUSEHOLD LEVEL5

5 Although all ZAP work adhered to WHO and manufacturer guidelines, specific dosing for Bti treatments differed slightly in some ZAP countries.

During household visits, technicians introduced themselves, showed identification to gain entry, and EXHIBIT 11: SAMPLE ZAP systematically identified and assessed possible breeding sites FACT SHEET within the household. In many countries, the ZAP teams left resources or flyers with household members (see Exhibit 11), providing a reminder to eliminate temporary breeding sites and the date of the next visit. ZAP technicians found and registered breeding sites inside and outside the house, and deposited the correct amount of Bti for the volume of water (technicians had job aids for easy reference). Many countries used basic measuring spoons to quantify and apply Bti directly on the surface of the water. Larvae typically died within 72 hours. Technicians also worked with household members to identify breeding sites that could be eliminated, and provided information about environmental cleanup.

Anecdotal evidence suggests that household visits built a close rapport between field technicians and household members. This enabled easier communication, including effective delivery of behavior change messages and information about preventive practices. Vector Control Pilots EXHIBIT 12: LARVICIDING WITH BTI IN In addition to routine larviciding, source reduction, EL SALVADOR and community engagement, ZAP supported the following strategic pilots in the region:  IRS for Aedes control o ZAP conducted three IRS pilots. Two separate campaigns were conducted in Guatemala, and one pilot in the DR. See Country Summaries for details. o Based on the IRS results and contextual limitations of IRS feasibility in the region, ZAP concluded that IRS is not recommended as a routine vector control intervention for Aedes in urban settings in the region.  Wide area larvicide spraying with Bti o ZAP conducted a pilot of wide area larvicide spraying with Bti in El Salvador in 2018 to evaluate its efficacy using Bti as a complementary measure to routine ZAP vector control methods, and to determine the feasibility and acceptability of this approach in El Salvador. o Although acceptance was high at the household level, the results were inconclusive, with no significant difference in changes to traditional indices between

intervention and control sites. Further research is required to determine if this is an effective complementary vector control approach.  Lethal ovitraps o ZAP conducted a pilot of lethal ovitraps in the DR. o Lethal hay infused ovitraps served as an effective attractant for Aedes oviposition. In addition, the application of Bti in these traps prevents mosquito larvae from further developing, suggesting that lethal ovitraps could serve as a complementary measure for integrated vector management. Several other approaches were piloted over the life of the project, including mobile data collection in several countries, and the use of blast mobile messages to notify households in advance of home visits in Jamaica. All pilots and other operational learning efforts were used to inform programming decisions and appropriate adaptations to maximize ZAP results.

2.3.4 MONITOR THE IMPLEMENTATION OF VECTOR CONTROL ACTIVITIES Monitoring and evaluation (M&E) was a critical element of the ZAP program. Data was collected across six countries with country level vector control activities (El Salvador, the DR, Guatemala, Haiti, Honduras, and Jamaica). Two main types of data were collected: vector control data and entomological data. See Exhibit 13 for an overview of the key indicators by data type. EXHIBIT 13: ZAP M&E—SUMMARY OF KEY INDICATORS

Data was collected on a monthly basis from all households included in vector control sites— approximately 476,230 households per month across all six countries. Entomological data was collected in a much smaller subset of households (approximately 300 households per surveillance site or 6,500 households across all six countries). The number of surveillance sites varied in each country, but ranged from 2 to 7. In addition, there was at least one control site in each country where entomological data was collected, but no ZAP interventions occurred. See Exhibit 14 for an example of the scale of data collection to monitor ZAP implementation and results. M&E was of critical importance as it enabled ZAP to monitor performance against planned results, to support efficient and effective implementation, and to ensure the successful achievement of expected results. M&E data also supported ongoing learning and management decisions, enabled mid-course adjustments and correction, and provided data and lessons for the broader community.

EXHIBIT 14: SCALE OF DATA COLLECTION—HONDURAS EXAMPLE

The following data from Honduras reflects the scale of ZAP data collection and data management needs.

Vector control  An average of 205,000 households were visited per month by 450 field staff  Approximately 160,000 households were treated per month  More than 3 million homes were visited and 2.35 million households treated in a two-year period  Twenty-seven data entry staff entered data on approximately 10,640 households per day recorded on 706 forms (14 households per form)

Entomological monitoring  Entomological surveillance in four sentinel sites and one control site covered an average of 4,058 households per month by 49 technicians  In one year (2018), technicians captured 39,017 visits, producing 7,898 forms of data  Two people per laboratory conduct species identification and insecticide resistance testing

Although data collection methodologies differed by country, by the last year, all data was entered into an online database platform, such as ONA. In countries using paper forms for data collection, data was entered into ONA in data entry centers. See Exhibit 15 for examples of ONA. EXHIBIT 15: EXAMPLE OF ZAP ONA PLATFORM SCREENS

In several countries, ZAP developed robust dashboards in Tableau to support the visualization and use of real-time data to support decision-making processes. See Exhibit 16 and 17 for example dashboards.

EXHIBIT 16: SAMPLE ZAP DASHBOARDS - GUATEMALA IRS

EXHIBIT 17: SAMPLE ZAP DASHBOARDS – DOMINICAN REPUBLIC VECTOR CONTROL

2.4 CROSS-CUTTING COMPONENTS: CAPACITY BUILDING AND GENDER

2.4.1 INSTITUTIONAL AND HUMAN CAPACITY BUILDING Capacity building was one of ZAP’s key cross-cutting components. Capacity assessments conducted by the Health Finance and Governance project in mid-2016 revealed a number of challenges among selected countries. This included the limited number of skilled staff involved in vector control and entomological monitoring; lack of equipment and supplies; and weak management and logistics systems. These findings were not surprising in a context where national vector control programs had seldom been considered health sector priorities. Strengthening institutional and individual capacity was a critical first step for ZAP to operate as an emergency response initiative where high numbers of field personnel had to be recruited, trained, and mobilized to implement vector control and entomological activities at scale. ZAP strengthened country institutional capacity to conduct vector control and entomological monitoring. In El Salvador, for example, the project supported the establishment of two local entomological laboratories in San Miguel and El Paisnal. ZAP Guatemala also supported the donation of an insectary-in-a-box to operate in the area of Chiquimula. ZAP Haiti contributed to strengthening laboratory capacity in Port-au-Prince and in the Northern Health Department in Cap-Haitian. In the DR, ZAP refurbished an entomological laboratory at UASD, a facility that is being used for training and research. During its final year, ZAP DR also implemented a provincial health directorate strengthening strategy to improve the organization and performance of local health teams. The project also provided technical support to develop an entomological surveillance module that will be incorporated into the MOH’s epidemiological surveillance system to support decision-making. In Jamaica, the ZAP team contributed to strengthening the MOH’s MCRU and improved laboratory capacity in the parishes of Kingston and St. Andrew. In addition, the project developed a full training curriculum for MOH vector control technicians. Honduras ZAP focused at the community level by engaging with local partners or “guias de familia” for vector control implementation.

Across all countries, ZAP donated equipment, supplies, and products (i.e. larvicide) as part of an effort to strengthen country capacity to conduct vector control and entomology. As the project ended, ZAP country teams donated office equipment, furniture, and vehicles to local counterparts, as approved by USAID. Finally, ZAP helped develop a number of resources:  National entomology and vector control training curricula;  Larvae and pupae surveillance protocols;  Ovitrap surveillance protocols;  Adult mosquito sampling protocols;  Insecticide/larvicide resistance guidelines; and  Larvicide guidelines Synthesis of country level training Exhibit 18 summarizes data on country-level trainings. ZAP trained nearly 6,000 field technicians and other health professionals in vector control, entomology, and insecticide resistance testing across the region. Training included short courses, in-service refreshers, and the diploma program. EXHIBIT 18: NUMBER OF PEOPLE TRAINED BY TECHNICAL AREA, 2016-2019

Country Vector control Entomology Insecticide resistance Total DR 119 231 8 358 El Salvador 779 259 148 1186 Guatemala 247 192 18 457 Haiti 404 44 55 503 Honduras 2,450 183 48 2,681 Jamaica 341 137 103 581 Total 4,340 1046 380 5,766

The diploma program took place in Honduras, El Salvador, and the DR, and was implemented in partnership with local universities with PAHO’s support. The programs targeted MOH employees, and ranged from 168 to 300 contact hours with a major focus on hands-on training. A total of 246 MOH officials completed this advanced training. Additional training programs were also designed. For instance, in Jamaica, a Vector Control Worker Training Curriculum was developed to support ongoing MOH programs. These competency-based guidelines aimed to strengthen the availability and quality of field personnel that collaborated in annual vector control activities led by the MOH.

Synthesis of regional trainings Regional trainings were special events that served to gather ZAP project staff with MOH representatives. Exhibit 19 below shows a summary of regional trainings. EXHIBIT 19: REGIONAL TRAININGS, 2016-2019

Location Theme Timing El Salvador ZAP Strategic Planning November 2017 Jamaica Gender March 2018 Honduras Vector Control September 2018 DR Entomological Monitoring May 2018 Barbados Entomological Monitoring July 2019

Two additional regional trainings were conducted with a focus on capacity strengthening and standardization of operational processes for ZAP technical and administrative staff. These were a finance and administration training held in Guatemala in May 2018, and an M&E training in the DR in September 2018.

2.4.2 GENDER During startup, ZAP appointed a home office Gender Advisor to integrate gender considerations throughout program operations. Additionally, each implementing country designated a gender focal point whose main role was to ensure that gender was taken into account when making hiring or other operational decisions. For example, when ZAP started conducting household visits in crime-prone areas, pairing two field technicians, either two female or a male and a female, was more acceptable to households than male-only technicians. ZAP’s Gender Advisor trained the gender focal points to cascade training to their country teams and seasonal workers on diverse topics. These included Abt and USAID gender policies, reporting mechanisms for gender-related issues, non-discrimination in hiring, and promoting gender equality in the workplace. ZAP promoted gender equality by aiming to hire an equivalent number of males and females in all positions, ranging from administrative to managerial roles at the ZAP headquarters, within country teams, and among field workers. For example, out of 344 seasonal workers in El Salvador, 56% were female; in Haiti, 53% of entomology technicians were female; and in the DR, 60% of vector control technicians were female. Offering equal job opportunities raised some challenges. For example, some MOH officials did not want to hire women as spray operators, or to hire pregnant women, even in positions free from possible insecticide exposure. To address this, ZAP shared Abt and USAID policies on equal job opportunities. As a result, some female spray operators were hired in countries where IRS was conducted (Guatemala and the DR). Additional gender-related highlights include the following:  The Gender Advisor and Junior Technical Program Manager/Project Assistant co-facilitated a regional training for gender focal points in March 2018. During the training, focal points were introduced to basic gender concepts (e.g., the difference between sex and gender), and the gender continuum as a tool to promote integration and fair treatment in the workplace. Participants also analyzed the gender context in each country to understand social norms, and built strong relationships with other gender focal points.  Each gender focal point created an action plan to promote gender knowledge in the workplace. By September 2018, gender focal points from Guatemala, El Salvador, Honduras, Jamaica, and the DR had trained 1,861 male and female technicians in 27 trainings.  ZAP’s Gender Advisor liaised with gender focal points to ensure a comprehensive, survivor- centered response to incidents of sexual assault and harassment. Gender focal points identified and made available safe communication channels for victims of sexual harassment or assault.  Gender focal points created several posters to promote gender considerations in the workplace, which were tailored to each local context. The posters included titles such as, “Freedom from Harassment”, and “Zika and Gender”. The posters were translated and shared with all seasonal workers or placed in satellite offices.

3. ZAP COUNTRY SUMMARIES

Following initiation of ZAP in September 2016, the team focused on quick start up in El Salvador, Guatemala and Honduras, shortly followed by the DR, Haiti, and Jamaica. While efforts for start-up in Nicaragua were initiated, ZAP was unable to start implementing activities due to political instability in the country. ZAP subsequently supported technical assistance efforts in Paraguay, Ecuador, and Peru, and in 2018, initiated technical support in the Eastern and Southern Caribbean (ESC). This section describes each country’s achievements in relation to ZAP’s core components, and highlights partnerships, impact, and sustainability.

3.1 DOMINICAN REPUBLIC

3.1.1 PROGRAM HIGHLIGHTS  Vector control for Aedes—completed an IRS campaign in San Cristobal province; provided technical support and training for the CAZ project to conduct community-based vector control activities; conducted a limited larviciding campaign in Espaillat province using Bti combined with source reduction and social and behavior change communication (SBCC); and pilot tested a lethal ovitrap intervention in the province of Monte Plata.  Undertook entomological monitoring and surveillance—monitored adult mosquito density in San Cristobal before, during, and after IRS by deploying BG-sentinel traps in 540 randomly selected houses; deployed 600 ovitraps in six provinces; conducted routine monitoring of larviciding campaign; and completed insecticide resistance bioassays in 16 sentinel sites.  Strengthened country capacity—conducted in-service trainings on vector control and entomology monitoring EXHIBIT 20: DR IMPLEMENTATION MAP for Direcciones Provinciales de Salud (Provincial Health Directorates, DPS) staff and community volunteers; transitioned responsibility for continued monitoring of ovitraps to DPS teams; supported establishment of a diploma-level training program in vector control and entomological surveillance; designed and deployed a comprehensive DPS Strengthening Strategy in five provinces with potential to reach 16 provinces (50% of all provinces in the country); and developed an

entomological surveillance module that will be incorporated into the National Epidemiological Surveillance System. Key ZAP DR partners:  MOH at central and local levels;  Center for the Control of Diseases Transmitted by Vectors and Zoonosis’ (CECOVEZ);  Office of Coordination of Decentralized Management for Health Stewardship;  Municipal governments;  UASD; and  PAHO.

3.1.2 COMMUNITY MOBILIZATION, SOCIAL AND BEHAVIOR CHANGE COMMUNICATION ZAP used several community mobilization and SBCC strategies to achieve its objectives in the DR for vector control, entomological monitoring, and field implementation of insecticide resistance testing. ZAP teams worked with community groups, including neighborhood councils, community leaders, heads of school districts, and churches. The project also mobilized other partners, such as daycare centers, nursing homes, and cemetery keepers. ZAP DR and collaborating community mobilizers initiated field visits one week prior to starting household visits. This consisted of visiting targeted homes across different municipalities to hand out fliers with information about the type of intervention, start date, duration, potential benefits, and a point of contact for questions or concerns. During implementation, field technicians visited households to solicit their participation in project activities and their informed consent. Activities emphasized preventive behaviors, environmental clean-up measures, and vector control practices. During ZAP’s initial phase, ZAP collaborated closely with Save the Children’s CAZ project, a community-based USAID-funded vector control activity. ZAP helped train CAZ field staff on the basics of vector control and entomology. In addition, ZAP accompanied CAZ field staff during field visits and provided feedback to improve practices. Later, CAZ provided field staff to participate in ovitrap deployment activities. As part of ZAP’s sustainability strategy best performers were recommended as volunteers to support provincial health directorate vector control activities.

3.1.3 VECTOR CONTROL EXHIBIT 21: SUMMARY OF VECTOR CONTROL INTERVENTIONS IN DR

Life of Project Country: Dominican Republic October 2017-March 2019 No. of household visits 148,407 No. of household visits with inspections 139,359 No. of household visits with treatments 95,181 No. of deposits treated with Bti 207,117 Average no. of household visits per month 29,681 No. of people residing in households visited by vector By Year control technicians  2018 108,833

ZAP completed an IRS campaign between June 12 and July 4, 2017 in San Cristobal province covering 54 clusters (27 intervention and 27 control). In consultation with the MOH, the project selected San Cristobal province due to high Zika virus prevalence in 2016, high population density, overall lower socio-economic conditions, and easy accessibility to the pilot site. Based on susceptibility studies and discussion with the MOH, ZAP used deltamethrin, a pyrethroid, for the campaign. The campaign mobilized 281 people (58% males) in different capacities, including 103 spray operators. Out of 11,790 households found, 11,739 households were sprayed (99.6% coverage), reaching 38,591 persons (614 pregnant women and 5,426 children under five years of age). Fifty-one homes were not sprayed due to refusals or locked premises. A total of 5,126 sachets of insecticide were used during the campaign (2.3 sachets per household). In 2017, the project also supported vector control activities in the provinces of Santo Domingo, Santiago, San Cristobal, and La Altagracia where Save the Children and its partners under the CAZ project were conducting community-based control and prevention interventions. ZAP DR first trained CAZ field staff, who then implemented a cascade training down to community volunteers. In addition, ZAP DR hired four monitors to accompany CAZ field personnel as they conducted vector control activities at the community level, and provided recommendations on improving field work, specifically recognition and elimination of active breeding sites and proper messaging. In 2018, ZAP DR conducted a limited community larviciding campaign in Espaillat province using Bti combined with source reduction, environmental clean-up, and SBCC. Moca, San Victor and Cayetano Germosen municipalities participated as intervention sites encompassing approximately 30,000 households; the control site was Gaspar Hernandez municipality. The purpose of the campaign was two- fold: to develop local capacity for Bti use, and to demonstrate its effectiveness against Aedes aegypti larvae found in breeding sites. The project trained two assistants, two DPS supervisors, 11 team leaders, 76 technicians, 13 mobilizers, and one security guard. ZAP led a field assessment in collaboration with the DPS to identify potential intervention areas, and project technicians visited households to explain the purpose of the activity and to elicit their consent. ZAP’s vector control technicians subsequently made monthly visits for source reduction and to apply Bti. The project covered 95% of households in Espaillat, with an 84% pupae reduction in positive containers. The project also applied larvicide in 10 selected municipal cemeteries, 25 churches, 65 schools, six day care centers, three health centers, one nursing home, and one correctional center. All vector control data was collected via mobile data collection methods. A client satisfaction survey among a random sample of 300 households showed that 82% of respondents reported fewer mosquitoes at the household level.

3.1.4 ENTOMOLOGY Impact of IRS in San Cristobal. ZAP DR monitored adult mosquito density by deploying BG-sentinel traps in 540 randomly selected houses. A smaller number of houses were also monitored using Prokopack aspirators. Monthly evaluations of insecticide residual efficacy were performed using WHO cone bioassays in nine different households. A total of 8,399 mosquitoes were collected prior to IRS, and 73,477 were collected two months after the IRS campaign. Adult mosquito density did not decline as expected, and residual efficacy of deltamethrin declined below the susceptibility threshold (80% mortality) 10 weeks after spraying. This was possibly due to: 1) not including outdoor source reduction; 2) heavy rains during and after the spray season, which contributed to proliferation of breeding sites; 3) inadequate household preparation due to the amount of furniture and other objects; 4) the common practice of ‘house washing’, and 5) the type of paint used on walls. ZAP DR also assessed spray quality and insecticide residual efficacy with cone bioassays. Immediately after the IRS campaign, there was an adequate level of effectiveness but residual efficacy was inconsistent across testing sites.

Impact of Bti in Espaillat Province. ZAP DR conducted surveillance of egg density (ovitraps), larvae and pupae surveys, and adult mosquito collection using BG-sentinel traps and Prokopack aspirators in households in the intervention sites and control site (see Exhibit 22).

There was a EXHIBIT 22: ENTOMOLOGICAL MONITORING IN THE DR considerable reduction in Aedes aegypti egg density (between 49.7% and 53.4% per quarter), and mosquito infestation (between 55% and 71.1%). Larvae and pupae surveys showed that predominant potential breeding sites were 55-gallon water tanks (44-59% of all breeding sites). The Breteau index declined in intervention areas. Three mosquito species were collected in pupae stage: Aedes aegypti (predominant in all collections), Aedes albopictus, and Culex quinquefasciatus. BG-sentinel traps and Prokopacks inside dwellings captured the largest number of adult mosquitoes. ZAP DR concluded entomological surveillance activities over a period of approximately eight weeks; the results suggest that successful application of Bti combined with physical elimination of breeding sites reduces all forms of mosquitoes. Ovitrap monitoring. ZAP DR deployed ovitraps in six provinces (Azua, La Altagracia, San Cristobal, Santiago, and Santo Domingo Oeste) over an 18 week period. The purpose was three-fold: to expand CECOVEZ coverage, develop local capacity, and demonstrate the effectiveness of ovitraps with attractant. The project managed 600 ovitraps, helping to expand CECOVEZ coverage to approximately 1,000 ovitraps nationwide. Ovitraps with hay infusion attracted greater numbers of Aedes aegypti than plain water ovitraps. ZAP DR also supported the transition of routine ovitrap monitoring to DPS teams. This was achieved by training ovitrap facilitators, who then held workshops for volunteer staff in targeted provinces to continue deploying and monitoring ovitraps. In collaboration with the CAZ project, ZAP identified community technicians who could work as facilitators and volunteers to continue activities. Five of the above provinces (Azua, La Altagracia, San Cristobal, Santiago, and Santo Domingo Oeste) deployed ovitraps with limited project support. A total of 25 ovitraps were used in each site, with collections occurring every three to five weeks. Trained personnel and local volunteers continued to work on this method, but local logistics were a major challenge due to conflicting demands on DPS staff time. Larvicide and insecticide resistance testing. ZAP DR performed tests in 16 sentinel sites. Deltamethrin resistance tested using the WHO method was registered in 15 sites, and susceptibility using the CDC test was registered in 10 sites. There was resistance at 10 sites to the other pyrethroids (permethrin and etofenprox). Suggested resistance to lambdacyalothrin using the CDC method requires confirmation at six sites, while resistance was registered at four sites. Using the WHO method, malathion and lambda-cyhalothrin registered resistance in 15 sites, and pirimiphos-methyl registered resistance in 13 sites. With the CDC method, there was malathion susceptibility in 10 sites. Suggested resistance to pirimiphos-methyl using the CDC method needs to be confirmed in San Cristobal, Higuey, Manoguayabo, Santiago, Dajabon and Villa Duarte; the other four sites registered susceptibility. Bendiocarb, representing the carbamate group, registered resistance in 10 sites using the WHO method. Suggested resistance in six sites using the WHO method requires confirmation; there was susceptibility in 10 sites with the CDC method.

3.1.5 RESEARCH/PILOTS/LEARNING In 2018, ZAP DR piloted the use of lethal ovitraps as a vector control method in Monte Plata Province. The pilot included four sentinel sites (three intervention and one control), covering 1,200 households (900 intervention and 300 control). Baseline entomologic surveillance was initiated in August 2018, with collection of larvae and pupae, as well as capture of adult mosquitoes with Prokopacks. Vector control activities started in September 2018 with deployment of lethal ovitraps along with environmental clean- up and source reduction in all intervention sites. Entomological data from the pilot showed a reduction of mosquito breeding sites, but this could not be attributed only to lethal ovitraps. Other activities, such as follow-up visits, environmental cleanup, and elimination of outdoor waste influenced breeding sites and behavioral changes among families, including in the control area. The study provided observations on the preference of ovipositing mosquitoes to the lethal ovitraps. Lethal hay-infused ovitraps served as an effective attractant for Aedes oviposition; as the application of Bti in these traps prevents mosquito larvae from further developing, this suggests that lethal ovitraps could serve as a complementary measure for integrated vector management.

3.1.6 SUSTAINABILITY HIGHLIGHTS ZAP DR provided in-service training, coaching, and “learning by doing” for local health teams. In addition, the project carried out multiple short, in-service trainings on vector control and entomology monitoring for field staff from CAZ partners and their volunteers. Exhibit 23 summarizes the number of people trained in the DR. EXHIBIT 23: SUMMARY OF PEOPLE TRAINED BY ZAP DR, 2017-2019

Year Female Male Total 2017 235 239 474 2018 225 162 387 2019 8 16 24 Total 468 417 885 DPS strengthening strategy. Throughout 2018, the ZAP DR team held several discussions with the home office team, USAID/DR, the MOH Office of Coordination of Decentralized Management for Health Stewardship, CECOVEZ, and PAHO/DR on the scope and content of a DPS Strengthening Strategy. The strategy was informed by WHO’s Global Integrated Vector Control Strengthening Initiative and PAHO’s Regional Action Plan on Entomology and Vector Control 2018-2023. It was also consistent with MOH efforts to improve DPS performance through a sustainable quality improvement approach. Implementation of the strategy started in 2019. The strategy first assessed eight parameters of local capability (see Exhibit 24) to implement integrated vector management and entomological monitoring activities among five DPS (Azua, Espaillat, Monte Plata, La Altagracia, and Sanchez Ramirez). These DPS were selected as demonstration sites for further dissemination among other provinces. Baseline capability scores ranged between 25% and 46%. With ZAP support, each DPS team designed and implemented intensive improvement plans over a period of four weeks, including establishment of basic entomological units. This process consolidated ZAP efforts, including the diploma program and the entomological surveillance module described below. The five DPS teams achieved greater understanding and adopted effective program management practices. Follow-up data showed capability scores improved to 87-93%. The central MOH has indicated its intention to issue a regulation to institutionalize ZAP’s approach for broader dissemination.

EXHIBIT 24: IMPROVING DPS CAPACITY FOR INTEGRATED VECTOR CONTROL AND ENTOMOLOGICAL MONITORING IN THE DR Background: The DPS is a decentralized unit of the MOH, responsible for the provision of disease control and health promotion services at the local level. There are 40 DPS’ in the DR, eight of which are located in large urban areas and also known as Area Health Directorates. These units are in charge of implementing epidemiological surveillance, vector control, and entomological monitoring. In early 2018, USAID/DR asked ZAP to develop and implement a DPS Strengthening Strategy as part of its transition towards project closeout. The rationale was that the DPS teams faced multiple institutional weaknesses (e.g., deficient training and laboratory capacity lack of personnel, equipment and supplies; poor managerial capacity) that hindered their important roles.

Approach: The ZAP-supported strategy was implemented fully in five DPS, followed by a light-touch version in an additional 11 DPS; this covered 16 DPS teams or 50% of all teams in the country. Key activities were supported from January to July 2019. The full implementation model required: a baseline capacity assessment; analysis and scoring of weak areas; development of technical support plans; and a follow-on assessment. The light-touch model comprised a quick baseline assessment, limited technical support and training, donations, and support to incorporate an entomological monitoring module developed by MOH and ZAP. The assessment considered eight institutional capacity dimensions: planning, control and follow-up; organization and availability of resources; social mobilization and community engagement; human resources; infrastructure and equipment; operational capacity; data collection and information management; and management of hazardous and regular waste. DAS teams led technical support plans tailored to their specific needs, and built upon field activities implemented during ZAP’s life of project (i.e., ovitraps, larviciding, training, and surveillance/M&E tools). ZAP provided technical guidance and follow-up.

Key results and conclusions: In the five DPS’ where the strategy was implemented fully, capacity scores improved from a baseline range of 25-45 points to follow-up scores of over 85 points. These teams strengthened internal managerial practices; improved inter-sectoral coordination and community participation; defined the roles and responsibilities of vector control and entomology personnel; refurbished space for vector control and mini entomological laboratories, and received basic equipment and supplies; and learned how to use the entomological surveillance module. Personnel felt empowered and engaged.

This approach demonstrates that improved institutional capacity can lead to greater responsiveness and sustainable performance by DPS teams. The five full model teams will serve as demonstration sites for other DPS teams in the country. This approach is especially relevant in the DR at a time when it is dealing with a severe outbreak of dengue and it is important to strengthen the national response with its own capabilities and resources.

In addition to the above, ZAP DR:  Helped renovate an Entomology Laboratory at UASD, which will complement the government’s efforts to generate useful evidence for program and policy decision-making, including ongoing insecticide resistance testing.  Provided technical and financial support to a diploma-level training program in vector control and entomological monitoring—the aim was to give provincial MOH technical staff practical knowledge and basic skills to organize, manage, and sustain vector

control operations; by the end of August 2019, 77 MOH participants had been trained from 31 provinces.  Provided technical support to develop an entomological monitoring module for MOH—this digital platform collects, stores, and analyzes data, and generates reports. It will help MOH collect entomological risk data (ovitrap egg density, larvae and pupae concentration, adult mosquito infestation, and insecticide resistance patterns), as well as vector control operational data (interventions, coverage, and number of people protected). The platform is housed within the National Epidemiological Surveillance System. Both entomological and epidemiological data will contribute to national and local decision-making on vector control priorities and effective disease prevention.  Developed a digital tool for costing vector control and entomological monitoring— this tool will assist DPS teams with budgeting, resource management, and operational planning. Sixteen DPS teams participated in a workshop and eight completed a practical exercise. The MOH is already encouraging each DPS to use the tool in annual operational planning and budgeting.

3.2 EL SALVADOR

3.2.1 PROGRAM HIGHLIGHTS  Vector control for Aedes—implemented larviciding and environmental clean-up activities in nine municipalities; and introduced Bti to evaluate its efficacy in controlling Aedes aegypti populations, especially in breeding sites that could not be treated using existing vector control methods.  Entomological monitoring and surveillance—undertook entomological surveillance in four municipalities; conducted a series of insecticide resistance tests in five municipalities; and monitored adult mosquito density to identify biting patterns of Aedes aegypti in San Sebastian and Verapaz.  Capacity strengthening—helped EXHIBIT 25: ZAP EL SALVADOR IMPLEMENTATION MAP establish the first national entomology laboratory in El Salvador in the municipality of El Paisnal, and two additional insectaries in San Miguel and Sonsonate; strengthened MOH capacity through trainings in entomological surveillance, vector control, and environmental compliance; helped establish the country’s first Medical Entomology Diplomado program at the

Universidad Evangelica de El Salvador; and co-developed with the MOH: 1) standard procedures for insecticide susceptibility surveillance testing, and 2) guidelines on how to manage and maintain an entomology laboratory and insectary. Key ZAP ES partners:  MOH through the Dirección de Vigilancia Sanitaria and Unidad de Vigilancia de Enfermedades transmitidas por Vectores at the central level, and regional health directors  SIBASI  Municipalities of Mejicanos and El Paisnal  Save the Children  Breakthrough Action  MCDI

3.2.2 COMMUNITY MOBILIZATION, SOCIAL AND BEHAVIOR CHANGE COMMUNICATION During 2017, ZAP El Salvador coordinated several activities with MOH and municipality staff, teachers and students at schools, and the wider community to raise awareness about the project, Zika prevention, and environmental cleanup. MCDI donated community materials from its Zika Community Response in Guatemala and El Salvador project to be used during ZAP household visits. In 2018, ZAP El Salvador modified its strategy to more actively involve community members. The project organized 47 clean-up campaigns with support from schools, community organizations, and community leaders. ZAP also enhanced messaging using public announcements created in coordination with the MOH. In addition, ZAP vector control technicians delivered 16 speeches in schools, churches, and community organizations to mobilize involvement in cleaning campaigns and adoption of preventive measures in communities. Technicians also participated in activities organized directly by government, including visits to schools, cemeteries, and households to raise awareness about Zika prevention, conduct larviciding with Bti, and remove mosquito breeding sources. In 2018, the number of closed houses found by vector control technicians dropped by 7% compared to 2017.

3.2.3 VECTOR CONTROL EXHIBIT 26: SUMMARY OF VECTOR CONTROL INTERVENTIONS IN EL SALVADOR

Life of Project Country: El Salvador June 2017 – June 2019 No. of household visits 2,129,386 No. of household visits with inspections 1,478,722 No. of household visits with treatments 1,098,801 Average no. of household visits per month 77,024 No. of people residing in households visited by vector control technicians6 By year  2017 n/a  2018 (estimate) 560,210  2019 n/a

6 El Salvador did not collect household population information, so their number for 2018 is an estimate from MEP indicators.

In 2017 and 2018, ZAP implemented larviciding and environmental clean-up activities in nine municipalities: Chalatenango, Ilobasco, Sensuntepeque, San Sebastian, San Rafael Cedros, San Cristobal, Cojutepeque, Mejicanos, and El Paisnal. These were all located within the five departments most affected by Zika. During 2017, 96,480 households were targeted, and activities reduced the larvae/pupae indexes (household, container, and Breteau indices) by up to 50%. The number of targeted households increased by 14%, from 98,325 per month in 2017 to 114,882 per month in 2018. Technicians were able to visit more households because they were more accustomed to activities and could decrease the duration of each household visit. During the visits, technicians encouraged the elimination of removable containers and treated containers that could not be removed. Overall larval indices decreased between 2017 and 2018. The household index decreased in seven of the nine target municipalities with the greatest declines in Cojutepeque, Mejicanos, and Sensuntepeque. The Breteau index showed a marked reduction in Cojutepeque, El Paisnal, and Sensuntepeque. Aedic larvae indices decreased in seven municipalities. In early 2018, larvae/pupae indices increased in certain locations of Chalatenango, El Paisnal, Ilobasco and San Sebastian where routine vector control and/or entomological monitoring activities were implemented. ZAP therefore reinforced supervision, conducted refresher trainings, promoted clean-up campaigns, and increased the dosage of Bti from 3mg to 5mg in priority locations. Indices subsequently dropped in the areas where the Bti dosage was increased, suggesting fluctuations in these indices were linked to environmental conditions and/or preventive practices by household owners. Save the Children supported ZAP in a one-day training for six supervisors and 32 team leaders on Zika prevention and symptoms. This was followed by a cascade training for vector control and entomology technicians. Save the Children also donated educational material for use by technicians during home visits.

3.2.4 ENTOMOLOGY In 2017, ZAP El Salvador conducted entomological surveillance in four municipalities: Chalatenango, Mejicanos, San Sebastian, and Santa Rita (control site). (See Exhibit 27). The locations for entomological monitoring were selected in coordination with MOH and USAID/El Salvador. In each of the sentinel sites, the project selected 200 houses for larvae surveys to stratify the most productive mosquito breeding sites: 100 houses also hosted ovitraps. ZAP also used adult mosquito traps for the first time in El Salvador.

EXHIBIT 27: ENTOMOLOGICAL MONITORING IN EL SALVADOR

The project used three methodologies to capture distinct mosquito populations: BG-sentinel traps (gravid mosquitoes), Prokopack aspirators (for resting mosquitoes), and GATs (for female mosquitoes in oviposition). The teams conducted surveillance between August and November for ten consecutive days per month in two sites—Chalatenango (intervention) and Santa Rita (control). Results showed a drastic

reduction in all Aedes indexes in all houses. BG-sentinel traps collected more mosquitoes during the day than at night, and Prokopack aspirators collected the most mosquitoes. In 2018, the project conducted entomological monitoring in four sites: Chalatenango, Mejicanos, San Sebastian, and Verapaz (control site). Entomological surveillance included monitoring egg, larvae, and pupae densities to inform project operations. Again, 200 households completed larvae and pupae surveys in each municipality, and 100 households also had ovitraps. Pupae and larvae surveys were conducted three times per month and ovitraps monitored on a weekly basis. Results showed a clear decreasing trend for all entomological indicators (household index, container index, and Breteau index), except in the control site, as expected. In 2017 and 2018, ZAP conducted a series of insecticide resistance tests with strains from five municipalities: Chalatenango, Mejicanos, Santa Rita, San Sebastian, and Verapaz. The project used two standard methodologies: WHO (from April to December 2018) and CDC (from August to December 2018). The 2017 results, which were shared with the MOH, showed high resistance of Ae. aegypti populations to temephos, the most commonly used larvicide in El Salvador. The results also showed that mosquitoes from four entomological sentinel sites were resistant to deltamethrin, permethrin, lambdacyhalothrin, and etofenprox, but susceptible to malathion and bendiocarb. ZAP completed insecticide resistance tests at the Regional Entomological Laboratory in El Paisnal using diagnostic and intensity (5x, 10x) concentrations for different insecticides following WHO protocols in 2018 and 2019. The results of susceptibility tests showed that mosquitos were resistant to all the insecticides and larvicides tested.

3.2.5 RESEARCH/PILOTS/LEARNING Wide area spraying of Bti in El Paisnal. ZAP designed this pilot to evaluate the efficacy of Bti in controlling Aedes aegypti populations, especially in breeding sites that could not be treated using existing vector control methods (e.g., accumulations of rubbish, outdoor collections of recyclables, piles of vegetation, auto parts and tires, and abandoned home appliances). ZAP El Salvador collected baseline data prior to spraying in epidemiological week. The team subsequently conducted larviciding, source reduction, and targeted messaging in 600 households (300 intervention and 300 control) following the regular vector control protocol, and sprayed Bti in intervention households. The team targeted 1,291 structures (including homes, junkyards, auto part lots, and public spaces), and sprayed targeted structures once per week during the first three weeks followed by every 2-3 weeks for the remainder of the pilot. Approximately 80% of all household and communal areas visited were sprayed (3% refused to participate due to fatigue from multiple visits, or uncertainty/suspicion about the reasons for spraying). ZAP ES monitored ovitraps every five days and conducted pupae and larvae surveys every 10 days. Aedic indices dropped more in the intervention sites compared to control sites, as expected. To monitor spray efficacy, ZAP ES randomly selected 15 junkyards and 12 households to perform jar bioassays. The results demonstrated that the mortality rate was under 100% in epidemiological week (EW) 33 to 39 in the auto part lots/junkyards, but increased to 100% in EW 46 to 48. The mortality rate was 100% in the 12 households studied with jar bioassay, except in EW 39, which decreased to 75%. Based on initial analysis, the addition of wide area spraying of Bti to routine vector control activities did not have a significant impact on larvae/pupae indices and egg density, and was therefore not recommended for inclusion. Mobile data entry pilot. From April 2018 onwards, ZAP piloted the use of mobile phones to collect vector control and entomological data in six municipalities: Chalatenango, El Paisnal, San Cristóbal, San Rafael Cedros, San Sebastian, and Verapaz. A total of 118 supervisors, team leaders, and technicians were trained to use the platform. Mobile data entry offers the benefits of: improved data quality through built-in validations; improved timeliness of reporting with daily data entry; direct communication between M&E, supervisors, team leaders, and technicians; and rapid analysis of monitoring data. The

pilot achieved its intended purpose with routine and daily data entry across all participating vector control and entomology technicians. Behavioral study on adult Aedes aegypti. During 2018, ZAP monitored adult mosquito density to identify biting patterns of Aedes aegypti in San Sebastian and Verapaz. The project used three different traps: BG-sentinel traps (for gravid mosquitoes), Prokopack aspirators (for resting mosquitoes), and GATs (for female mosquitoes in oviposition). Mosquito collection using BG-sentinel traps was conducted from May to September 2018 on ten consecutive days per month to evaluate mosquito feeding behavior. Preliminary results showed that BG-sentinel traps collected more mosquitoes during the day than at night. The largest number of mosquitoes was collected with Prokopack aspirators and the least with GATs. The mosquitoes collected with all traps included Aedes aegypti, Aedes albopictus, and Culex spp.

3.2.6 SUSTAINABILITY HIGHLIGHTS Established entomology laboratories: In 2018, ZAP inaugurated the first national entomology laboratory in El Salvador, which was established by the MOH in the municipality of El Paisnal. The laboratory was co-funded by USAID (70%), the MOH (10%), and El Paisnal (20%), and contained a designated space for all tasks related to entomological surveillance of Aedes mosquitoes. It allowed the MOH, for the first time, to support routine entomological surveillance activities and to evaluate the efficacy of insecticides used in the country. The laboratory will also serve as a learning center to train MOH officials and enable practical sessions for the Diplomado program (see below). USAID approved the second entomology laboratory to be located at the Región Oriental de Salud in San Mgiuel (to support four SIBASI in the country) and the third entomology lab to be located at SIBASI Sonsonate (to support three SIBASI). Summary of training and long-term capacity strengthening:  Number of people trained to conduct vector control visits = 799  Number of people trained to conduct entomological surveillance = 259  Insecticide susceptibility testing training = 14 events, 148 people trained During 2017 and 2018, ZAP strengthened MOH capacity through several trainings in entomological surveillance, vector control, and environmental compliance. ZAP conducted four national workshops with participants from different locations (health regions, SIBASI, and health centers). ZAP also held ad- hoc trainings for three national health regions to improve knowledge about Aedes vectors and best practices in monitoring mosquito populations. In addition, the project strengthened the practical skills of MOH personnel by designing a two-week course and training 4-5 government health officials per month at the entomological laboratory in El Paisnal. In 2018, ZAP also trained five groups (three from Metropolitana health region and two from Central) in taxonomy identification, insectary maintenance, and insecticide resistance testing. To strengthen longer-term capacity, the Universidad Evangelica de El Salvador, MOH, and ZAP launched the country’s first and second Medical Entomology Diplomado program in September 2018. ZAP supported curriculum development and provided materials and equipment to conduct practical sessions on insecticide resistance testing. In addition, the ZAP El Salvador Entomology Manager and regional entomologists facilitated several lectures. This was the first entomological course offered by a university in El Salvador, leading to the first cadre of MOH personnel formally trained in entomology. The University will continue to implement the Diplomado for a third cohort using ZAP training materials. Developed guidelines: ZAP co-developed with MOH two national guidelines: 1) detailed and standard procedures for insecticide susceptibility surveillance testing, including all technical procedures dictated

by WHO and CDC; and 2) instructions on how to manage and maintain an entomology laboratory and insectary (such guidelines had not previously existed in El Salvador).

3.3 GUATEMALA

3.3.1 PROGRAM HIGHLIGHTS  Vector control for Aedes—developed and implemented SBCC activities to increase acceptance of vector control activities; implemented two IRS campaigns; and conducted larvicide and source reduction in at-risk municipalities.  Entomological monitoring and surveillance—tested insecticide susceptibility; conducted weekly monitoring of ovitraps; undertook larvae and pupae surveys in potential breeding areas; recorded the density of adult mosquitoes using EXHIBIT 28: ZAP GUATEMALA IMPLEMENTATION MAP BG-sentinel traps, GATs, and Prokopack aspirators; and conducted insecticide susceptibility bioassays using WHO and CDC methodologies.  Capacity strengthening—built the individual and institutional capacity of Ministry of Public Health and Social Assistance (MSPAS) and its staff to plan, manage, and monitor vector control and entomological monitoring programs through various training programs, as well as secondment of MSPAS staff to the project as supervisors; and transferred SBCC materials to MSPAS for ongoing use. Key ZAP Guatemala partners:  MSPAS  MSPAS Health Area Chiquimula, El Progreso and Zacapa  Municipal governments

3.3.2 COMMUNITY MOBILIZATION, SOCIAL AND BEHAVIOR CHANGE COMMUNICATION Over the life of the project, community mobilization activities promoted the application of larvicides in households and encouraged elimination of breeding sites in household yards—this included a poster calendar for homeowners to monitor the status of breeding sites. ZAP Guatemala also met community leaders and community/municipality level associations. In 2018, ZAP Guatemala expanded its strategy in coordination with the MSPAS Department of Health Promotion and Education (Departamento de Promoción y Educación para la Salud, PROEDUSA) to address lack of awareness and low risk perception

of Zika. This was achieved by developing a strategic communication approach based on children as at- home change agents. ZAP Guatemala designed, tested, and validated materials with MSPAS, which included board games, puppet shows, and songs to educate children on how to eliminate breeding sites and to raise awareness about health risks of mosquito bites. The project also participated in health fairs and church events, and used high-visibility media opportunities (e.g., TV reports, public service announcements, and press conferences involving senior local authorities). ZAP Guatemala also conducted intensive community mobilization. For example, to ensure successful implementation of the IRS campaign and related entomological monitoring activities, ZAP Guatemala devised “Beto El Rociador” (Beto the Sprayer). The character was designed to create an identity that was easily remembered by and culturally appropriate for target communities. The project promoted Beto primarily through a song about mosquitoes and the sprayer’s visit to households, which was used in radio spots and free TV messages, as well as during school talks and meetings with community leaders. In addition, songs featuring the character were broadcast on loudspeakers before and during community visits. The character became so familiar that spray operators were referred to as “Betos.”

3.3.3 VECTOR CONTROL EXHIBIT 29: SUMMARY OF VECTOR CONTROL INVERVENTIONS IN GUATEMALA

Summary of Vector Control Activities (larviciding only) Life of Project Country: Guatemala Oct 2017- June 2019 No. of total household visits 1,053,346 No. of households visited 88,508 No. of households visited with treatment 78,089 Total number of deposits inspected 3,876,032 Average no. of household visits per month 52,437 No. of people residing in households visited by vector control technicians By year  2017 98,420  2018 285,261  2019 278,971

ZAP Guatemala worked with departmental MSPAS authorities to develop and implement a larvicide and source reduction campaign in 22 at-risk municipalities in three departments. Interventions started in the department of Chiquimula in October 2017 in five municipalities (Esquipulas, Olopa, Quezaltpeque, San Jacinto and Concepcion las Minas) and expanded in November 2017 and February 2018 to six additional municipalities (Camotan, Jocotan, Chiquimula, San Jose la Arada, Ipala and San Juan Ermita). By February 2018, ZAP Guatemala’s monthly larvicide visits had expanded to four additional municipalities in El Progreso department (Sanarate, Sansare, El Jícaro and San Antonio La Paz). Between August and October 2018, visits had expanded to seven more municipalities in Zacapa department (Estanzuela, Huité, Cabañas, Usumatlán, Rio Hondo, San Jorge and Teculután). Altogether, the project hired 181 seasonal workers who were supervised by 19 supervisors seconded from MSPAS and managed by the project. Activities consisted of broad community engagement, household-level source reduction through environmental management, and larviciding with Bti.

Additionally, ZAP Guatemala conducted two pilot IRS campaigns—see Section 3.3.5 for details. The first took place in July and August 2017 in five municipalities: (El Jícaro, Morazán, San Agustín Acasaguastlán, San Cristobal Acasaguastlán, and Cabañas). The campaign covered 8,578 households, protecting 30,010 people, including 226 pregnant women and 3,272 children under five years old. The second IRS campaign was in June and July 2018 in the city of Zacapa, with a control site in Teculután. ZAP Guatemala sprayed 4,404 households, protecting 14,026 people, including 110 pregnant women and 1,179 children under five years old. After the entomology surveillance activities for IRS in ended Teculután, ZAP Guatemala transitioned it to a vector control (Bti) application site.

3.3.4 RESEARCH/PILOTS/LEARNING IRS, El Progreso. As mentioned, ZAP Guatemala piloted the use of IRS to test its effectiveness on Aedes aegypti in 2017. The activity was coordinated with the Health Area in El Progreso. An operation center was established in San Agustin, and the pilot was conducted in July and August 2017 in five municipalities. The campaign targeted 12,000 structures using 54 clusters (27 intervention and 27 control clusters), with150 to 500 houses per cluster. ZAP Guatemala hired 80 spray operators who worked in teams of two (40 teams) and were supervised by ten MSPAS supervisors. The campaign achieved 89% coverage, and was followed by entomological monitoring in both intervention and control households using BG-sentinel traps, insect aspirators (Prokopack), and GATs. Additionally, cone bioassays were used to test insecticide residuality during monthly visits to selected houses. IRS, Zacapa. In 2018, ZAP Guatemala implemented a second pilot to test the effectiveness of IRS on Aedes in an urban setting. ZAP and the MOH selected Zacapa City because it was large enough to generate a sufficient sample, and free from other vector control interventions. Additionally, the project received strong support from key local authorities and the local MSPAS Health Area. The spray campaign was implemented in June and July 2018 and targeted 6,375 structures. The control site was established in Teculután, also in Zacapa Department, which was comparable to Zacapa City (e.g., in population size, climate, business/household ratios, and culture). The results from BG-sentinel and Prokopack collections showed that clusters of shops and businesses located in commercial areas greatly added to overall mosquito density, and had higher mosquito abundance compared to residential areas. These locations were not included in the IRS pilot due to the operational challenge of closing a business mid-day for several hours to be sprayed. Monitoring concluded in October 2018, when residuality tests showed a drop in mortality to under 80%. Both residential and commercial areas in Zacapa (intervention site) represented an important source of mosquito populations, and indoor spraying contributed to a reduction in mosquito densities for a limited time. However, the pilot highlighted the difficulty of IRS for Aedes control in urban areas—close proximity of homes and large amounts of personal effects made it difficult to spray the walls safely as instructed by protocol, as well as resistance to IRS among households due to mistrust and competing priorities. ZAP Guatemala therefore did not recommend the intervention for Aedes control in urban settings.

3.3.5 ENTOMOLOGY EXHIBIT 30: ENTOMOLOGICAL MONITORING IN GUATEMALA

ZAP Guatemala conducted a series of insecticide susceptibility tests on three local mosquito populations (Chiquimula, Zacapa and San Agustín Acasaguastlán), using standard methodologies: CDC bottle bioassay and WHO’s impregnated papers for testing adults and WHO bioassay for testing larvae. Resistant samples of Aedes aegypti mosquitoes from Zacapa and San Agustin were sent to Notre Dame University in the United States for molecular analyses of kdr genes involved in insecticide resistance.

ENTOMOLOGICAL SURVEILLANCE FOR LARVICIDE APPLICATION In the three departments with monthly Bti application, Chiquimula, El Progreso and Zacapa, ZAP conducted entomological monitoring in four sentinel sites: two control (Chiquimula City and Guastatoya City) and two intervention (Chiquimula City and Teculutan) covering 1,131 households in total. During the entomological surveillance in Chiquimula City (control and intervention site) and Guastatoya City, monitoring included: 1) ovitraps with hay infusion in 100 households per sentinel site and 2) larval and pupal surveys in 200 households per sentinel site. Monitoring in Teculutan included adult surveillance in addition to larvae and pupae surveys. The number of eggs collected fluctuated in the three sentinel sites, showing peaks in July and August 2018, which could be attributed to the rainy season. All the municipalities showed a marked decrease in house and pupae indices. The effects of the larvicide application was stratified into low, medium, and high by dividing the reduction percentage (initial house index/pupae index minus the average of house index/pupae index of the three last rounds of application in 2019) into tertiles. For house index, 15 municipalities showed a reduction ranging from 62.8% to 97.9%, which was categorized as medium to high impact. For the pupae index, 14 municipalities showed a reduction ranging from 80.1% to 100%, which was categorized as medium to high impact. Based on the house index and the MSPAS of Guatemala risk stratification, 14 of the 22 municipalities was classified as high risk in the first round of visits (HI > 25 %) and 8 in a medium risk (HI = 10.1% - 25%). In the last trimester of the campaign 15 municipalities decreased to a low risk (HI = 0% - 10%) and 7 to a medium risk. In Teculutan the entomological information for larvae and pupae as well as adult surveillance showed a sustained reduction after the larvicide application.

ENTOMOLOGICAL SURVEILLANCE FOR INDOOR RESIDUAL SPRAYING ZAP Guatemala conducted entomological monitoring and testing for: 1) insecticide resistance and susceptibility; 2) vector populations, and; 3) residuality. The project conducted the 2017 IRS pilot in 54 clusters (27 intervention and 27 control clusters) located in six municipalities (Morazán, El Jícaro, San Agustín Acasaguastlan, San Cristobal Acasagustlán, Cabañas and Usumatlán) in El Progreso and Zacapa departments, covering a total of 582 households with entomological surveillance. The project conducted

the 2018 IRS campaign in two municipalities located in the department of Zacapa: Zacapa City (intervention) and Teculután (control) for a total of 462 households. ZAP Guatemala used standard CDC bottle bioassays to determine insecticide susceptibility of Aedes aegypti populations for the 2017 IRS and 2018 IRS campaign. Such tests were conducted prior to the start of each IRS campaign. The teams used female mosquitoes of a known age reared from field larval collections (F0 and F1), and a susceptible strain of Ae. aegypti (2017 MSPAS strain and 2018 Rockefeller strain) for the bioassays. Deltamethrin (10 µg/ml) and bendiocarb (12.5 µg/ml) were tested because the vector control interventions regularly conducted by the MSPAS are carried out mainly using pyrethroids, such as deltamethrin and alpha-cypermethrin. As expected the MSPAS and Rockefeller strains were susceptible to both insecticides. The local strains from El Progreso (2017) showed susceptibility to both insecticides; while the 2018 strain from Zacapa showed susceptibility to bendiocarb and resistance to deltamethrin. After IRS in 2017, ZAP Guatemala recorded the density of adult mosquitoes using three sampling methods in 582 households: BG-sentinel traps (540 households), GATs (12 households), and Prokopack aspirators (30 households). The collected mosquitoes were classified according to the different traps utilized and types of clusters sampled comparing indoors and outdoors. About 60% of the mosquitoes collected during the entomologicial surveillance period corresponded to Aedes spp. (Ae. aegypti and Ae. albopictus), of which 57.3% were collected indoors. Before, during and after the 2018 IRS campaign entomological monitoring activities recorded presence/density of larvae, pupae and adults in 462 households using Prokopack aspirators (210 households), larvae and pupae survey (210 households) and BG-sentinel (42 households). The number of Aedes spp. collected was more or less stable in Zacapa, though the number decreased indoors one week after the beginning of the IRS campaign. In Teculutan, the results were less stable; initially the number of mosquitoes increased but during the last week of IRS, the number began to decrease both indoors and outdoors. In both sites (Zacapa and Teculutan) there is an evident rise of adult densities at the end of August 2018. This trend can be related to the rainfall fluctuation. The decrease observed in Zacapa during IRS could be attributed in part to IRS since the number of mosquitoes in Teculután increased during the same period. This trend may have been more evident if IRS coverage was higher or if a different insecticide was selected. To monitor insecticide residual effectiveness, ZAP Guatemala used standard WHO cone bioassays. Tests were conducted 24 hours after spraying, and then monthly in a sample of houses. A mortality rate above the cut-off point (80% mortality) indicated strong insecticide efficacy. Bendiocarb lasted for only one month in the intervention site, with a drop in average mortality to less than 80% in the second month. ZAP considered various factors influencing the result. In both the intervention and control sites, there were extensive collections of household belongings in sprayed areas, which may have resulted in accidental removal of insecticide, or influenced the indoor resting locations of mosquitos.

3.3.6 SUSTAINABILITY HIGHLIGHTS Established entomology laboratories: ZAP Guatemala trained MSPAS staff on entomological techniques and readiness procedures for the establishment of an insectary in a box in Chiquimula, with a delivery date of August 2019. The insectary will receive equipment and supplies from the ZAP Guatemala field laboratory and will function as the first regional insectary for the MSPAS in Guatemala’s eastern region. The insectary will be used by a local university and the MSPAS for entomology purposes.

Training and long-term capacity strengthening:  Number of people trained to conduct vector control visits = 247 (46% female)  Number of people trained to conduct entomological surveillance = 192 (40% female)  Insecticide susceptibility testing training = 3 events, 18 people trained ZAP Guatemala prioritized capacity building of MSPAS staff as IRS was new to the country. This included training vector control technicians in spray techniques, entomological monitoring, and safety and security, and training for MSPAS supervisors on the use of a Goizper pump (training was delivered by the manufacturer). The project also built the institutional capacity of MSPAS to plan, manage, and monitor vector control. MSPAS-specific trainings focused on interventions and approaches not previously used by MSPAS at the departmental level, such as Prokopack aspirators, BG-sentinel traps, spatial placement of ovitraps, and cone bioassay testing for residual effect. Training topics related to vector control and entomology, as well as safety, environmental compliance, communications skills, M&E, and supervision. Throughout 2018, ZAP decentralized entomological training opportunities to the departmental level. The project also trained four MSPAS technicians from Chiquimula in insectary management techniques and in conducting susceptibility tests with WHO and CDC methodologies. Additionally, three technicians from MSPAS Zacapa and two from MSPAS El Progreso were trained in WHO and CDC bio assay tests with local strains from their corresponding regions. An important element of the project’s ongoing capacity strengthening was its collaborative approach to supervision. MSPAS seconded staff to the project to supervise vector control and entomology field teams. The project provided hands-on skills building, leaving a team of MSPAS staff ready to supervise and manage activities after the end of the project. Developed SBCC tools and resources:  Community Prevention Plan Manual  Pre and Post IRS visit household plans  The Zika Risk – Children’s board game As mentioned earlier, MSPAS’s PROEDUSA participated in the design, validation, and approval of ZAP’s SBCC tools, including a children’s board game. All materials were transferred to PROEDUSA, specifically the MSPAS office for health education, which intends to reproduce the materials in other risk areas and to continue using materials, including for its malaria program.

3.4 HAITI

3.4.1 PROGRAM HIGHLIGHTS  Vector control for Aedes--Provided high-quality house-to-house vector control management including larviciding, Zika education, and environmental clean-up to protect vulnerable populations from Zika transmission in the North Department communes of Acul du Nord, Milot, Plaine du Nord, and Quartier Morin, and the West Department commune of Leogane.  Entomological monitoring and surveillance--Conducted entomological surveillance in the communes of Limbe and Milot in the North, and Dessources and Petite Riviere in the West; included vector bionomic studies and insecticide resistance management; conducted entomological monitoring (ovitrap egg collection, larvae and pupae surveillance, adult mosquito collection/surveillance), and susceptibility tests for larvae and adult mosquitoes in Milot (intervention site) and Limbe (control site).

 Capacity strengthening—strengthened the Government of Haiti’s capacity through Zika coordination meetings, trainings, and involvement in ZAP activities; refurbished the insectary at the National Public Health laboratory in Port au Prince; installed a new insectary at EXHIBIT 31: ZAP HAITI the North Health Department in Cap IMPLEMENTATION MAP Haitian; established community health committees in Leogane in the West Department (Département de l’Ouest) to continue vector control activities; and trained 27 MSPP technicians from all 10 departments in entomology. Key ZAP Haiti partners include:  Ministry of Public Health and Population (Ministère de la Santé Publique et de la Population, MSPP)  National Malaria Control Program (Programme National de Lutte Contre la Malaria, PNCM)  Mayor’s Office/Town Hall  CDC Foundation  Carter Center

3.4.2 COMMUNITY MOBILIZATION, SOCIAL AND BEHAVIOR CHANGE

COMMUNICATION In 2017, ZAP Haiti undertook a census of community-based organizations at the commune level, and conducted a survey of knowledge and environmental hygiene behaviors in 966 households in four target communes where vector control activities were planned. Using targeted messages, the project conducted educational sessions at the household level and in schools, and participated in inter- neighborhood competitions (e.g., poetry and painting) throughout 2017 and 2018. ZAP Haiti also mobilized community participation through “town criers” who communicated general Zika sensitization messages within communities. Sensitization efforts increased for the commune of Leogane, a newly added intervention zone during 2018. The team held several meetings with community leaders and delivered messages in churches and schools. ZAP Haiti observed a decrease in household refusal rates in the area after community engagement activities.

3.4.3 VECTOR CONTROL EXHIBIT 32: SUMMARY OF VECTOR CONTROL ACTIVITIES IN HAITI

Summary of Vector Control Activities Life of Project Country: Haiti May 2017-June 2019 No. of household visits 620,701 No. of household visits with inspections 537,103 No. of household visits with treatments 525,822 Average no. of household visits per month 29,839 No. of people residing in households visited by vector control technicians By year  2017 276,722  2018 264,373  2019 264,373

During 2017, ZAP Haiti implemented vector control activities in the North Department in the communes of Quartier Morin, Plaine du Nord, Acul du Nord and Milot. The team targeted all households in the intervention areas for larviciding and elimination of breeding sites, and shared information about Zika. In total, the project treated 44,525 households, covering a population of 276,722 of whom 6,452 were pregnant women. To support PNCM, ZAP Haiti hired 123 technicians and two coordinators, who together completed 16 rounds of larviciding. Technicians conducted 20 house- to-house visits per day with each household visited once per month for the duration of the project. In addition, technicians sensitized households about environmental clean-up during their larviciding visits and helped clean-up houses to prevent or eliminate any potential breeding sites. In 2018, ZAP Haiti continued implementing vector control activities in the North Department in the same communes (Quartier Morin, Plaine du Nord, Acul du Nord, and Milot), with the addition of Leogane (Dessources communal section). In total, the project treated 57,461 households and reached 264,373 people of whom 8,683 were pregnant women. In December 2018, communities in some localities in the North cleared several canals and ZAP Haiti technicians then treated the canals with Bti. The activity was conducted at the request of the communities because the canals were close to households and considered breeding sites for mosquitoes. Nearby residents observed a decrease in mosquitoes in and around their houses following the intervention.

3.4.4 ENTOMOLOGY ZAP Haiti selected Milot (intervention site) and Limbe (control site) for entomological monitoring. During 2017, project conducted:  Surveillance of larvae and pupae every 10 days in 400 households, with a total of 17 rounds in Limbe and 19 rounds in Milot;  Installation of double ovitraps (one with water and the other with hay infusion) in 100 households each in Milot and in Limbe—ovitraps were recovered and reinstalled every five days over a period of 33 and 36 consecutive weeks in Limbe and Milot respectively;  Adult surveillance using Prokopack and BG-sentinel traps in 20 households per commune for 10 consecutive days; and

 Installation of a small insectary in the Department du Nord/Cap Haitian Office and training of insectary technicians.

EXHIBIT 33: ENTOMOLOGICAL MONITORING IN HAITI

Aedes aegypti was the predominant vector in Limbe and Milot, although Limbe had more Aedes albopictus than Milot. Differences in population densities might reflect the availability/suitability of habitats in each area. For example, tires and ground-level barrels contributed 67% to the overall pupae population in Limbe compared to 49% in Milot. Limbe consistently had more households with positive ovitraps than Milot regardless of location of ovitraps (indoor or outdoor) or of attractant used (water or infusion). However, oviposition activity overall was much higher in ovitraps with infusion located outdoors. There were high numbers of potential breeding sites in both Limbe and Milot—high numbers of plastic containers reflected inadequate garbage disposal, and the high number of drinking troughs reflected a lack of water infrastructure in both communes. Plastic containers were the most commonly found type of container with larvae. In both locations, four container types (plastic containers, ground-level barrels, tires and ground-level cisterns) contributed more than 80% of pupae in the respective areas. ZAP Haiti continued entomological monitoring in 2018 using routine ovitrap egg collection, larvae and pupae surveillance, adult mosquito collection/surveillance, and susceptibility tests for larvae and adult mosquitoes in the North and West departments. Bti application was conducted once a month at the household level. Initially, the average number of eggs collected per house in the intervention site was higher than in the control site, but there was an overlapping trend between sites. Given that Milot’s historically higher mosquito density decreased to an overlapping density with the control site, this could be considered an indicator of vector control effectiveness. In the West Department, the average number of eggs collected per house in the intervention site was initially lower than the control site. However, the average number of eggs collected per house in both sites was relatively similar in August, which may have been due to the rains. In Dessources, puape/larvae (Breteau Index, Container Index, and Household Index) were lower than in Limbe (control site). A similar trend was observed in Dessources compared with the control site of Petite Riviere (West Department). During entomological surveys in the North, the majority of containers that tested positive for larvae in Limbe were plastic containers (28.1%), tires (18%), and coconut shells (17.2%). In Milot, the majority of containers that tested positive were drums (28.9%), tires (21.1%), and buckets (9.9%). Overall, the same types of positive containers were also found in the West Department. The data confirmed the different types of breeding sites within households, allowing the team to focus on community clean-up sensitization efforts to reduce breeding sites. Pupae density ranged between 0.09 and 0.3 pupae/house in the intervention site of Milot before Bti application, and increased to 0.6 pupae/house before falling gradually to low densities ranging between 0 and 0.01. In Limbe (control), the pupae density was higher at baseline (1.6 and 1.98 pupae/house), and afterwards showed peaks at specific periods. In Dessources (West), pupae density was low before (0.06

pupae/house) and after (0.08 pupae/house) Bti application. In Petite Riviere (control site, West), there was a pupae density increase (0.21 to 0.55 pupae/house). These results suggest a reduction in pupal density in the ZAP program intervention sites. The species composition of the pupae collected in Milot and Limbe sites were mainly represented by Aedes aegypti. A similar trend was observed in Dessources and Petite Riviere. Dynamics of adult mosquito density were measured with BG-sentinel traps and Prokopack aspirators. Numbers of mosquitoes collected ranged between 0 and 29 mosquitoes per day inside and outside households. Initially, mosquito density was higher in the Milot intervention site than in the Limbe control site, but then reduced. This could indicate program effectiveness.

3.4.5 SUSTAINABILITY HIGHLIGHTS  Number of people trained to conduct vector control visits = 440 (55% female)  Number of people trained to conduct entomological surveillance = 44 (53% female)  Insecticide susceptibility testing training = 8 events, 55 people trained In 2017, ZAP Haiti hired and trained nine entomology technicians and one supervisor who established entomological surveillance in three sentinel intervention sites (Milot) and one control site (Limbe) in the North Department. ZAP/Haiti also hired, trained and deployed 175 local vector control technicians. ZAP Haiti subsequently provided five vector control training sessions (four refresher trainings in the North Department and one training-of-trainers in Leogane), one entomology training, and two M&E training sessions to a total of 150 technicians (77 women and 73 men) In 2018, ZAP Haiti trained MSPP entomology technicians from the National Entomology Laboratory in Port au Prince to build their capacity in conducting entomological activities. A total of 32 entomology agents/technicians were trained in April 2018, including 11 from MSPP and 21 agents trained for adult mosquito collection. Six technicians from MSPP also received advanced training in insecticide susceptibility tests in mosquitoes. ZAP Haiti helped to create community health committees in the intervention communes, and trained selected committee members to conduct daily vector control activities in collaboration with MSPP at communal and departmental levels. In July 2019, three (3) health committees with eleven (11) members each, were created in Département Sanitaire de l’Ouest (Western Health Department in three (3) communal sections of Leogane commune. They were trained along with three (3) MoH health managers from the three (3) communal sections. In Département Sanitaire du Nord (Northern Health Department, seventeen (17) health technicians were trained to use BTI and conduct households visits. Due to delays arising from political turmoil in Haiti, establishment of the committees was only completed during the close-out of ZAP. Training was conducted in collaboration with MSPP and included household visits and application of Bti. The intention is that committee members will work as volunteers and continue MSPP vector control activities after ZAP’s withdrawal from Haiti. Activities will include education, daily visits in households, and larviciding. Joint teams of ZAP’s vector control technicians and elected community health committee members carried out routine vector control activities under the supervision of ZAP Haiti and the MSPP. Tools and resources developed during the life of the project to be used by MSPP included:  Training entomology module  Vector control guide  Job aid for dosage of Bti  Zika education brochure for household visits, in Creole.

Laboratory refurbishments:  Département Sanitaire du Nord, Cap Haitian. In 2018, ZAP Haiti held discussions with MSPP about installing an insectary-in-a-box in the North Department. The team identified the Northern Health Department facility to house the insectary and serve all northern department regions. ZAP and MSPP finally agreed to install the insectary at the North Health Department (Département Sanitaire du Nord) facility in Cap Haitian. The insectary was completed in July 2019. A handing over ceremony was organized on July 31st, 2019 during a closeout event, for the two insectaries.  Laboratoire National de Santé Publique et de la Population-National Laboratory, Port-au-Prince. ZAP Haiti worked closely with MSPP to refurbish the Port-au-Prince insectary. Soon after work started, the government had turned the initial insectary site at the national laboratory into a to-be-built regional blood bank, which caused some delays in completing rehabilitation work. A new site was found in the premises of the National Laboratory where a new container was installed by ZAP Haiti as an extension of the existing insectary. By the end of ZAP project, the blood bank had not yet been installed. EXHIBIT 34: STRENGTHENING ENTOMOLOGICAL CAPACITY IN HAITI

View of entomology trainees in Leogane MOH entomology technician at the ZAP insectary

3.5 HONDURAS

3.5.1 PROGRAM HIGHLIGHTS  Vector control for Aedes—conducted vector control interventions in Tegucigalpa, San Pedro Sula, Danlí (including Jacaleapa, San Matías, and El Paraíso), Choluteca and Marcovia from 2017- 2019; in addition, conducted vector control in Villanueva to support the Government of Honduras respond to a dengue outbreak in 2018-2019.  Entomological monitoring and surveillance—monitored entomology in five areas: Choluteca, Danlí, Tegucigalpa, San Pedro Sula, and Comayagua (control site) using ovitraps, surveyed potential breeding sites for larvae, studied pupal density, and monitored the population density of adult mosquitos using BG-sentinel traps, GATs, and Prokopack aspirators.  Capacity strengthening—ZAP Honduras prepared a comprehensive plan for gradual transition of responsibilities for vector control to the Secretaria de Desarrollo e Inclusion Social (Ministry of Social Inclusion, SEDIS) during 2018-2019; the project also improved six entomological laboratories and insectaries (San Pedro Sula, Comayagua, Choluteca, Danlí, and Tegucigalpa—metropolitan and national).

Key ZAP Honduras partners: EXHIBIT 35: ZAP HONDURAS  SEDIS IMPLEMENTATION MAP  Secretaría de Salud (Ministry of Health, SESAL)  PAHO

3.5.2 COMMUNITY MOBILIZATION, SOCIAL AND BEHAVIOR CHANGE COMMUNICATION The project’s SBCC strategy in Honduras focused primarily on interpersonal, face-to-face communication during household visits for vector control. Each visit included the ZAP technicians and home owners jointly inspecting the interior and exterior of the home for water containers, checking for the presence of mosquitos, and applying Bti to non-removable water sources. ZAP Honduras field technicians engaged household members in discussions about how to prevent breeding sites, reduce mosquito populations, and avoid bites. ZAP Honduras hired field technicians from the targeted communities in which they worked, and the technicians conducted repeated visits to establish rapport and reinforce messages about household practices (as well as to conduct activities). The project trained and retrained staff to ensure high-quality interpersonal skills. The training included attitudes such as courtesy, respect, freedom from prejudice, honesty, and humility. By combining positive attitudes, technical knowledge, and repeated visits, the team was able to achieve positive impact in terms of behavior change, as well as to mobilize communities to support vector control and entomological monitoring activities. Some households were unwilling initially to open their homes but subsequently allowed ZAP teams to conduct inspections and apply Bti. Monthly reflection and analysis meetings in each city with all technicians served to review results, identify limitations and obstacles, share lessons and identify opportunities for program improvements, thus helping to improve the quality of household visits overall.

3.5.3 VECTOR CONTROL EXHIBIT 36: SUMMARY OF VECTOR CONTROL INTERVENTIONS IN HONDURAS

Summary of Vector Control Activities Life of Project Country: Honduras April 2017 – June 2019 No. of household visits 3,432,237

No. of household visits with inspections 2,641,451 No. of household visits with treatments 2,641,451 Average no. of household visits per month 171,988 No. of people residing in households visited by vector control By year technicians

 2017 759,985  2018 813,940  2019 673,245

ZAP Honduras began vector control interventions in Tegucigalpa, San Pedro Sula, Danlí (including Jacaleapa, San Matías, and el Paraíso) and Choluteca in 2017. ZAP Honduras hired 966 seasonal workers in 2017, 443 in 2018, and 570 in 2019. Bti was applied to all large/immovable containers (e.g., outdoor sinks and large plastic water containers), while smaller containers were overturned if they had standing water. Aedes aegypti larval infestation levels were reduced in 2017 and 2018. In Choluteca, vector control efforts contributed to a decline in average larval infestation levels to below 5% (WHO/MOH threshold levels). In Danlí, larval infestation levels were at their highest in June 2017 (24%), dropping steadily to 3-10% between 2017 and 2018. In 2018, Choluteca had the lowest Breteau Index (3.96%), followed by Danlí (7.8%), Tegucigalpa (27%), and San Pedro Sula (43%). High levels of success with vector control in Choluteca were attributed to: 1) engagement and collaboration between ZAP Honduras and MOH teams, including through monthly reflection meetings where monitoring and epidemiological data were analyzed to inform program improvements; and 2) outside, ground-level immobile sinks, called pilas, represented the highest percentage (87%) of all water containers, which facilitated inspection and simplified treatment with Bti. In comparison, Tegucigalpa had a lower percentage of pilas (less than 80%), and interventions were further impeded by sprawling, mountainous geography, crime and insecurity, and over one million people living in an urban setting. San Pedro Sula had a larger presence of temporary breeding sites and much greater variety of water containers, including pilas, as well as barrels, tires, and small plastic containers. This resulted in a more complex vector control operation. In addition, higher rainfall and temperatures in San Pedro Sula compared to Danlí or Tegucigalpa, as well as a large urban, highly concentrated population, resulted in a higher number of potential mosquito breeding sites. In continuation of our efforts in San Pedro Sula, the cities in the surrounding Cores Department areas showed a significant increase in dengue cases during September and October 2018, which rose to epidemic levels. During this period, ZAP Honduras created vector control mobile teams that conducted vector control in hot spots, which changed each week and were identified in consultation with the MOH and Intersectoral Working Group. In late 2018, government authorities requested ZAP Honduras technical assistance to address the outbreak by keeping the Aedes population at a manageable level. In agreement with MOH, ZAP Honduras continued vector control work in the four areas of San Pedro Sula with the highest levels of mosquito infestation. Using all available seasonal workers, ZAP used temporary mobile vector control brigades to deploy into higher-risk neighborhoods. During this period, San Pedro Sula was able to maintain its mosquito control results while surrounding localities experienced unprecedented cases of dengue. Additional vector control activities were conducted in 2019 in San Marcos de Colón to evaluate the efficacy and residuality of commercial formulations of Bti and Spinosad, and in Villanueva to support the MOH response to the dengue epidemic. The project trained over 1,000 temporary field personnel from January to July 2019.

3.5.4 ENTOMOLOGY ZAP Honduras monitored entomology in five areas in 2017 and 2018: Choluteca, Danlí, Tegucigalpa, San Pedro Sula, and Comayagua (control site). The project:  Monitored egg deposition behavior and dynamics of Aedes aegypti at least one per week using ovitraps with and without the standard infusion of an attractant (King Grass);

 Surveyed potential breeding sites at least twice a month for the presence of Aedes aegypti larvae;  Studied pupal density and the presence of Aedes aegypti at least twice a month;  Monitored the population density of adult mosquitos using BG-sentinel traps, GAT traps, and Prokopack aspirators during at least ten consecutive days per month in Danlí (intervention site) and Comayagua (control site).

EXHIBIT 37: ENTOMOLOGICAL MONITORING IN HONDURAS

Ovitrap monitoring. In 2017, over one million Aedes spp. eggs were collected and counted (38% from ovitraps with water and 62% from ovitraps with an attractant). Of the four sites where Bti was applied, the largest number of eggs (322,599) was collected in San Pedro Sula. After several weeks of variable peaks of egg density, a decreasing tendency was noted in intervention sites. Of all the mosquito larvae identified, 86% were Aedes aegypti and 14% were Aedes albopictus. In 2018, egg density in all five intervention sites decreased. Danlí had the highest levels, and Choluteca the lowest levels. Choluteca oviposition data for 2017 and 2018 were similar, with peaks observed in May, June and July (the beginning of the rainy season). In Comayagua (control site), an increase in egg deposition resulted in SESAL intervention with Bti application and insecticide fogging. Larvicides and adulticides were applied throughout 2018. Larval surveys. At each surveillance site, the project selected 175-224 households for larval surveys, of which 50% were also used for ovitrap monitoring, and the other 50% were "paired" households (selected at least 100m from ovitrap households). Of 76,903 water containers inspected, 4,006 (5.2%) tested positive for Aedes spp. larvae. Ground level tanks, pilas, larger barrels, small drums, and tires tested positive most frequently. After initiation of vector control activities, only ground level tanks tested positive for Aedes larvae. The percentage of larval infestation declined to less than 5% in Choluteca, Danlí, and Tegucigalpa. Indices remained high in San Pedro Sula, however as previously noted, it is a large, commercial city located on the north Atlantic coastal, with annual rainfall totals higher than the other intervention cities. Pupal density. The control site showed a higher pupal density than Choluteca, Danlí or Tegucigalpa, while the highest levels were observed in San Pedro Sula in 2017. In 2018, San Pedro Sula showed high levels of pupae from the beginning of year (indicative of difficulties with larval control) until August, when numbers began to resemble those of Comayagua and Tegucigalpa. Adult mosquito surveillance. In 2017, ZAP Honduras piloted Prokopack aspirators to collect data on resting habits of mosquitoes. The team randomly selected 20 houses from Comayagua (control) and Danlí (intervention), and deployed 10 BG-sentinel traps and 10 GATs in each of the sites. In Danlí, BG- sentinel traps captured 134 adult mosquitos, of which 43% were Aedes aegypti, 6% Aedes albopictus, and 50% were Culex spp. Laboratory analysis revealed that the predominant digestive state was gravid. In

Comayagua, 300 adult mosquitos were collected before SESAL applied pesticides, of which 45% were A. aegypti, 2% A. albopictus, and 53% Culex spp. The general digestive state was unfed. Using GATs in Danlí, 62 adult mosquitos were collected before spraying, of which 58% were A. aegypti, 11% were A. albopictus, and 31% were Culex spp. The predominant digestive state was fed during the first sampling cycle and unfed during the second. In Comayagua, 55 adult mosquitos were collected, of which 69% were A. aegypti, 7% A. albopictus, and 24% Culex spp. The predominant digestive state was unfed. In 2018, BG- sentinel traps collected 2-9 times more adult mosquitoes than either Prokopacks or GATs. BG-sentinel traps consistently caught unfed female mosquitos, whereas the other two traps caught a mixture. The low number of fed/gravid adult female mosquitos caught by the Prokopack aspirator in Choluteca reflects the very low incidence of mosquitos of all life stages. Insecticide Resistance. From 2017 to 2019, ZAP Honduras worked in close collaboration with SESAL to conduct larvicide and adulticide insecticide resistance tests. The purpose was to provide SESAL with up-to-date information for planning and decision-making on insecticide resistance management. Resistance to temephos and all pyrethroids was widespread, while there was susceptibility to the organophosphate, malathion and Bti.

3.5.5 RESEARCH/PILOTS/LEARNING ZAP Honduras compared the results from Bti applications in all households In the Department of El Paraíso to only those that tested positive for mosquito larvae or pupae during the current inspection. The project initiated Bti applications in February 2018, concluding in July 2018. There was no increase in larval infestation levels where Bti was applied on a monthly basis to all households, whereas larval infestation levels increased by 17% where Bti was only applied to households that tested positive for mosquito larvae in the survey. This confirmed that best results are obtained when Bti is applied to all households in a community, neighborhood, or city. In the Department of Choluteca, ZAP Honduras compared the use of 5gms of Bti per 1,000 liters of water to 3gms. There was minimal difference in percentage infestation of larvae and pupae between the concentration of water treatments between February and July 2018. In 2019, ZAP HN conducted a pilot of Spinosad to compare its efficacy with Bti as a biological larvicide for Aedes aegypti. The main objectives were to: 1) evaluate the efficacy of two larvicides, Spinosad (Natular® DT) and Bti (Vectobac® 37WG) under controlled field and laboratory conditions; 2) determine the residual effect of Spinosad and Bti under a systematic replacement of water (to simulate household water use and practices); and, 3) evaluate the lethality of Spinosad tablets applied directly to the water compared to inside perforated plastic bags. Findings showed that Spinosad applied in perforated plastic bags effectively controls populations of Aedes for longer periods than applying equivalent doses of Bti. The community acceptance of the tablets applied in perforated plastic bags was high, since it is a method of larvicide application that the population is familiar with. Bti showed high mortality (90-100%) up to the tenth water replacement, while Spinosad showed the same mortality up to the fifteenth water replacement. And, there were no significant differences in mortality rates between Spinosad applied directly and Spinosad applied through perforated plastic bags.

3.5.6 SUSTAINABILITY HIGHLIGHTS  Number of people trained to conduct vector control visits = 3,548 (66% female)  Number of people trained to conduct entomological surveillance = 276 (45% female)  Insecticide susceptibility testing training = 3 events, 48 people trained In 2018, ZAP Honduras prepared a comprehensive Sustainability, Transfer, and Local Institutional Empowerment Plan for the project’s gradual exit. While the original plan focused on SESAL to sustain

activities, recognizing overall capacities, SEDIS was also engaged to assume such roles. Discussions took place during the first few months of 2018 with SEDIS directors and departmental governors in Tegucigalpa and San Pedro Sula. SEDIS had the necessary funding, political support, and personnel (Guias de Familia) to implement vector control interventions in different neighborhoods in both cities. Between January and December 2018, the project reduced the number of communities receiving direct ZAP Honduras interventions by 42% (from 1,271 to 734 communities), with a concurrent increase in the number of SEDIS Guias de Familia and neighborhoods covered. In total, ZAP Honduras trained 1,197 new ZAP seasonal workers, SESAL Environmental Health Technicians (Técnicos de Salud Ambiental), Guias de Familia, and others during 2019. Topics included entomological training, the mosquito life cycle, first aid, basic security, how to avoid dog attacks, safe driving, data entry, and steps for successful household visits and inspections. At SESAL’s request, ZAP trained over 720 people in vector control in June 2019. This included coordinators of Guias de Familia (Family Guides) from SEDIS for the departments of Comayagua, Intibucá, La Paz, Lempira, Ocotepeque, Copán, Olancho, Santa Bárbara, Yoro, El Paraíso Choluteca, Atlántida, Metropolitan of SPS, and Cortés. Those trained are responsible for cascading the training to their field personnel (over 10,000 persons). Between June and December 2018, ZAP Honduras trained 1,007 SEDIS vector control Guias de Familia in Tegucigalpa and San Pedro Sula, of whom 76% were female. The project also trained Choluteca government personnel in 2018, and San Pedro Sula and Danlí government personnel in 2019, on safe pesticide management in warehouses. In February 2018, ZAP Honduras conducted a one-week training workshop for over 20 SESAL field entomology technicians from all over the country in how to prepare, implement, and analyze insecticide resistance laboratory and field trials. In 2019, 93 people were trained in the five entomological monitoring ZAP cities in entomological monitoring within the framework of transition and sustainability. Additional sustainability highlights:  Vector Control and Entomology Diploma Training program. ZAP Honduras faced challenges with the planning and launch of a Diplomado program to train future vector control experts. Despite active engagement of PAHO in the program’s design, it was difficult to find a home to take ownership of the program. The National Catholic University of Honduras was eventually selected as the host institution. Some external factors delayed enrollment of the initial cohort from July 2018 to January 2019, however despite these challenges, 17 students from different departments started and successfully completed their 6 month diploma.  Vector Control Tools. The project developed handouts and a short video of the 10 key steps for household visits in 2018, and a new video for future vector control training with details of the key steps for a household visit and application of larvicide in 2019.  Improvement to six entomological laboratories and insectaries (San Pedro Sula, Comayagua, Choluteca, Danlí, and Tegucigalpa—metropolitan and national). In 2017, ZAP Honduras worked closely with SESAL to assess the needs for infrastructure improvements, as well as for equipment and supplies for insectaries and laboratories. By the end of 2018, the project completed all renovations and provided equipment the five cities.

3.6 JAMAICA

3.6.1 PROGRAM HIGHLIGHTS  Vector control for Aedes—in collaboration with the Ministry of Health and Wellness (MOHW), ZAP visited 500,001 households in over 100 communities as part of vector control and entomology field campaigns between January 2018 and April 2019. By the end of the last

campaign, ZAP vector control teams were able to access 80% of premises, demonstrating successful community engagement approaches.  Entomological monitoring and surveillance—ZAP established and monitored five sentinel sites to measure entomological indicators (egg density and larvae/pupae indices) to monitor Aedes aegypti in areas where ZAP operated. Overall, ZAP documented a 45% decrease in each of the three larvae/pupae indices following vector control interventions. To determine the efficacy of insecticides used in vector control, ZAP worked with the MOHW to collect samples in all 14 parishes of Jamaica and then conducted insecticide resistance testing on both adults and larvae Aedes aegypti mosquitoes. Only the larvicide Bti at concentrations ≥ 6 ppm produced a high mortality (98 – 100%) of all Aedes aegypti populations exposed; bendiocarb at 12.5 µg/ bottle using the CDC bioassay, was the only insecticide to which adult mosquitoes showed susceptibility.  Capacity strengthening—ZAP trained 599 people to conduct vector control activities, 137 people to conduct entomological surveillance, 103 people to conduct insecticide susceptibility testing, and over 30 people on advanced data analytics for vector management. ZAP intentionally targeted youth for many of its capacity building activities to empower this population to contribute to EXHIBIT 38: ZAP JAMAICA IMPLEMENTATION MAP their communities over the long term. With an eye on sustainability, ZAP adapted its vector surveillance and control training materials for future use by the MOHW. ZAP strengthened the MCRU by developing standard operating procedures for the insectary and facilitating the acquisition of a Biosafety Level 1 (BSL-1) certification. To strengthen the academic foundation for vector control in Jamaica, ZAP integrated MCRU with coursework at the University of the West Indies (UWI) and collaborated with other mosquito researchers. Finally, ZAP strengthened entomology capacity through refurbishment of the MOHW and MCRU insectaries and procurement of laboratory equipment and materials. Key ZAP Jamaica partners:  MOHW  UWI

3.6.2 COMMUNITY MOBILIZATION, SOCIAL AND BEHAVIOR CHANGE COMMUNICATION ZAP Jamaica initially faced challenges in gaining access to households due to a lack of community awareness about the project. Working with the MOHW, ZAP engaged communities through churches and community groups, as well as by advertising on radio and in newspapers and using flyers, pamphlets, and a calendar distributed directly to householders during visits. As a result, overall access increased from 18.1% in February 2018 to 48.1% in March 2018. Building on this success, ZAP Jamaica increased community mobilization activities through the use of “town criers”, as well as social media (Instagram and Twitter). ZAP also piloted the use of community-specific text-message “blast” campaigns— notifications sent to householders in advance of technician visits. These activities contributed to a continued increase in overall household acceptance of interventions from 55% in September 2018 to 80% in April 2019. In many communities, field technicians worked closely with key community actors on a variety of mobilization and SBCC activities. These included: creation and performance of the “Zappy” dance and song in schools; technician-led volunteer “service days” with community groups to clean-up and remove breeding sources; presentations at town halls and forums; and school reading initiatives. ZAP Jamaica also participated in partner-led community engagement activities in collaboration with Police Youth Clubs, local Red Cross branches, and sports clubs.

3.6.3 VECTOR CONTROL EXHIBIT 39: SUMMARY OF VECTOR CONTROL INTERVENTIONS IN JAMAICA

Summary of Vector Control Activities Life of Project Country: Jamaica February 2018 – April 2019 No. of households visited 500.001 No. of households visited with inspections 384, 952 No. of households visited with treatments 76, 511 No. of containers treated 123,516 Average no. of household visits per month 41,667 No. of people residing in households visited by vector control technicians By year  2017 38,758  2018 313,013  2019 292,542

ZAP Jamaica implemented the following vector control interventions: larviciding with Bti, environmental management through source reduction, and informing householders of the importance of keeping premises free of mosquito breeding sites. ZAP worked closely with MOHW to coordinate field activities and ensure efforts were synchronized across geographic areas. In particular, ZAP mirrored the MOHW’s seasonal vector control model, in which vector control workers were deployed prior to the hurricane/fall season of rains. During the first year of implementation, ZAP targeted four parishes—Kingston/St. Andrew, St. Thomas, and St. Catherine, which together constitute the Southeast Regional Health Authority. Kingston/St. Andrew is a densely populated urban area, whereas St. Catherine and St. Thomas are rural by comparison. The parishes were selected due to: a large number of reported or suspected Zika cases per

capita; high population mobility; MOHW recommendations; geographic proximity to each other; and accessibility to insectaries. The project trained and deployed 84 field technicians led by 10 supervisors in 71 communities across the four parishes. In its first year, the teams inspected 93,769 containers, of which 17,094 were positive for larvae/pupae. Water was commonly stored in drums and barrels, which accounted for the majority of containers that tested positive. However, unintentional storage of water also accounted for a large number of breeding sites. From September 2018 to April 2019, ZAP completed two additional vector control campaigns. In addition to the existing parishes, activities extended into the Northeast Regional Health Authority (NERHA). During this phase, ZAP deployed 12 field technician teams and five entomological surveillance teams, covering 94 communities with a population of over 110,000 people. ZAP introduced a regional management approach to facilitate coordination between vector control and entomology, enhance communication and collaboration with parish-level MOHW and partners, and increase oversight and supervision of field-level activities. During the first campaign (September to December 2018), ZAP Jamaica visited over 169,854 premises each month, with an average access rate of 74%. Technicians identified over 142,000 containers, 15% of which were positive breeding sites. The remaining 85% had the potential to breed or were properly stored water containers. Bti was applied to 15% of the total containers that were permanent, whether positive or negative for larvae and/or pupae, and had the potential for breeding. From January 2019 to April 2019, ZAP visited a further 236,465 premises, of which 82% allowed entry— this increase was in part due to alternative implementation hours (from 7am to 7pm). Field technicians identified over 276,000 containers, of which 6% were positive for larvae and/or pupae. Source reduction was conducted for 14% of the inspected containers, whether positive or negative for larvae and/or pupae. Bti was applied to 19% of the total permanent containers inspected that were permanent, whether positive or negative for larvae and/or pupae, and had the potential for breeding. Bti application increased due to the dengue outbreak (see below). Support to Dengue Response. During the first dengue outbreak in Portmore in March 2018, ZAP worked with the regional MOHW to expand operations. ZAP rapidly hired and trained 16 additional vector control technicians to work with the MOHW as part of this effort. In December 2018, the MOHW again requested ZAP assistance to respond to another dengue outbreak. ZAP contributed 650 bottles of Bti and application tools to the MOHW and trained personnel on its use. ZAP also restarted field activities in 94 communities two months ahead of schedule to bolster MOHW’s response and geographic coverage. During the dengue response, ZAP treated both wet and dry containers (as opposed to only wet containers) in an effort to drastically reduce the mosquito population during the outbreak period.

3.6.4 ENTOMOLOGY ZAP worked with the MOHW to identify and establish four sentinel sites at the parish level during year one: Yallahs, Linstead, Havendale, and Harbour View (control). In year two, ZAP established and monitored an additional site. Entomological surveillance teams were trained in January 2018, and baseline data was collected over an eight-week period. Technicians then visited 260 households in each sentinel site fortnightly. Ovitraps were placed in 100 households, and technicians collected egg papers every five days. Technicians also conducted larvae and pupae surveys every 10 days in 200 households per sentinel site, followed by adult specimen collection using Biogents sentinel traps, Prokopack aspirators, and GAT traps in each sentinel site for10 days per month. Technicians also assessed field- collected specimens at the MCRU insectary to identify species as Aedes compared to others, and to assess ovary status as parous or nulliparous.

EXHIBIT 40: ENTOMOLOGICAL MONITORING IN JAMAICA

Ovitrap monitoring. In year one, the project collected 3,669 ovitrap papers and counted 408,870 eggs. The number of eggs per ovitrap per day ranged from 3 to 49.2 across all sites. Egg numbers increased post-intervention, which may be attributed to the reduction of all other breeding sites on the premises, leaving the ovitrap as the only available breeding container. In year 2 (April 2018 to April 2019), the number of eggs per ovitrap per day ranged from less than 1 to 68 eggs across all sentinel sites. Again, the increase in egg density in the ovitraps was expected given the reduction in the number of water containers available for oviposition, which left the ovitraps as the most attractive breeding location for mosquitoes. During this period, the number of eggs per ovitrap per day in the control site was higher than all the intervention sites over the period of this report. Poor Man’s Corner/South Haven had the highest average egg density (but lower than the control site), and contributing factors are a high population, inconsistent access to piped water, low precipitation, and local residents store water around the domestic perimeters. Larvae/pupae surveys. In years one and two, all parishes showed a general decline in the indices in all areas. This was expected, as households were visited regularly and homeowners encouraged to reduce sources and cover water-holding containers. The one exception was the Bretaeu Index for Yallahs, which showed no change. This may be explained by the unique context in Yallahs, which is a hot and dry area where residents tend to harvest a lot of water in containers. Insecticide resistance testing. ZAP conducted insecticide susceptibility bioassays using the WHO or CDC methodologies on Aedes aegypti populations collected from each of the thirteen parishes across Jamaica. With the exception of St. Elizabeth, ZAP completed larvicide testing on Aedes aegypti larvae populations across Jamaica by July 2019 (all insecticide tests should be completed by August 2019). The results on the eastern side of the island, parishes where ZAP was most active (St. Catherine, KSA, St. Thomas, Portland, St. Mary and St. Ann), did not always mirror the susceptibility results of those parishes on the western side of the island (Clarendon, Manchester, St. Elizabeth, Westmoreland, Hanover, St. James and Trelawny). All susceptibility tests were compared to the laboratory control Rockefeller strain. The larvicides tested were temephos, Bti, diflubenzuron, and methoprene. Temephos, even at its highest concentration of 0.625 ppm (31 times greater than the WHO recommended diagnostic dose), was ineffective at causing 98 – 100% mortality in all tested populations. The results suggest that Aedes aegypti larvae are highly resistant to the larvicide temephos, which is not surprising considering that temephos has been used in the country for a long time. Bti, a novel larvicide to the country, showed efficacy at concentrations of ≥ 6 ppm. The mortality ranged 98 – 100% among all exposed Aedes aegypti

populations. Populations collected from Portland, Westmoreland, Hanover, and St. James were all affected by Bti at concentration of 2 ppm over a 24-hour period. The growth inhibitors diflubenzuron and methoprene had little to no effect on the populations tested, even at their highest tested concentration of 0.08 ppm. The results were interesting considering that these regulators had no known history of use as larvicides in Jamaican vector management. From the combined results, ZAP Jamaica recommended the incorporation of Bti at concentrations of 6 ppm into the vector management program of Jamaica, with regular susceptibility testing to detect development of resistance. ZAP tested seven adulticides—permethrin 0.25%, deltamethrin 0.03%, lamdacyhalothrin 0.03%, etofrenprox 0.5%, malathion 0.8%, pirimiphos methyl 0.21%, using the WHO method and bendiocarb 12.5 μg using the CDC method on adult mosquito populations across the island. The results showed evidence that mosquitoes from Jamaica were strongly resistant to pyrethroids (permethrin, deltamethrin, lambdacyhalothrin, and etofenprox). At the concentrations tested, mortality ranged from 0 – 70%. ZAP recommended that pyrethroids used for Aedes mosquito control strategies should be limited, including the possibility of enforcing regulations to minimize the use of pyrethroid-based products, especially because pyrethroid use for mosquito management strategies in Jamaica is relatively new. In addition, continued pyrethroid susceptibility tests should be conducted in the Aedes mosquito populations in Jamaica to assess possible reversal in resistance. Bendiocarb, on the other hand, was the only insecticide that showed favorable results as an adulticide and, thus, may be a viable alternative for the control of adult stages of Aedes aegypti populations in Jamaica.

3.6.5 RESEARCH/PILOTS/LEARNING In June 2018, ZAP Jamaica conducted field testing of VectoBac water dispersible granules (Bti) in three parishes to determine its efficacy at various concentrations. The results revealed that an increased concentration of VectoBac was required for water with high content of organic matter, such as leaf litter, soil, or contaminants like oils. Based on these results, the project adjusted the field operational dose of VectoBac from 3mg of product per liter of water (mg/l) to 6mg/l in clean water sources and 8mg/l in polluted water sources. These adjustments were in keeping with what is observed under laboratory larvicide testing for Jamaican Aedes mosquitoes. The MOHW requested timely, community-specific data to monitor the dengue outbreak and guide its dengue response in 2019. As a solution, ZAP developed a simple yet comprehensive dashboard to share real-time data with MOHW to help guide decisions made at the Emergency Operations Center. The read-only dashboard pulled real-time data from ZAP’s database (updated daily) and included the following community-specific information: number of household visits conducted, household access rates, and the three larvae/pupae indices. The dashboard was accessible by authorized MOHW representatives through the use of a password-protected web browser link.

3.6.6 SUSTAINABILITY HIGHLIGHTS  Number of people trained to conduct vector control visits = 599 (60% female)  Number of people trained to conduct entomological surveillance = 137 (64% female)  Insecticide susceptibility testing training = 5 events, 103 people trained  Number of people trained in advanced data analytics for vector management = 39 people trained As part of an integrated approach to vector control and entomological monitoring, ZAP trained each field technician in vector control, entomological surveillance, data collection, communication, and behavior change. This proved to be effective in helping field workers understand the importance of each element of field operation, to change roles as needed, and to explain to residents the importance of

surveillance and control of the Aedes vector. A similar approach was used to train MOHW personnel at the national, regional, and parish levels. Highlights of Tools and Resources Developed  Vector Control Worker Training Curriculum  Real-Time Vector Control Dashboards and M&E System  Field Worker Job Aids (BTI Dosage Card, Species Identification Card)  Logistics, Deployment and Packing Plans for Field Workers  Framework for the MCRU In June 2019, ZAP Jamaica adapted its integrated vector control training materials to: 1) create a package of materials for MOHW, which included a trainer’s guide, PowerPoint presentations, activity forms, and participant materials; 2) realign the sequence, flow, and content for the target workforce hired by MOHW; 3) update content where appropriate to capture a standardized approach to vector control using a competency-based model; 4) incorporate behavior change as a focal point of the approach; and 5) revise the M&E and data collection materials for MOHW (rather than project) use. The training materials will enable the MOHW to continue to train its vector control workforce after ZAP ends using a state-of-the-art curriculum. Insectary-in-a-box laboratory. MCRU was established to advance and coordinate mosquito research and control in Jamaica, and to improve the country’s response to and control of arboviruses. At the request of MOHW, ZAP supported a variety of efforts to establish and formalize the MCRU. This included working with MOHW and UWI to develop terms of reference and an organizational structure, as well as a Memorandum of Understanding. ZAP also built the capacity of MCRU to serve the greater academic community at UWI. This included support to MOHW and UWI to formalize MCRU and strengthen the capacity of the MCRU insectary, achieving BSL-1 Certification of the insectary, establishing polices and protocols, and procuring additional equipment and supplies. As a result, the MCRU insectary saw increased use by the broader academic community, including graduate level studies and undergraduate practical training. In addition, the MCRU insectary provides research material including eggs, larvae, and adult mosquitos to researchers and faculty across the University. The MCRU insectary is staffed by young professionals, mostly UWI graduates, who received technical training in several topics pertaining to medical entomology (mosquito collection, processing, identification, and insectary management). Local business people who supply insecticides or repellents against mosquitoes also expressed interest in the insectary and requested use of the facility to conduct assays to determine product efficacy.

3.7 NICARAGUA After opening the office in the fall of 2017, ZAP Nicaragua was put on an indefinite hold by the USAID mission in April of 2018 due to the political situation in country. At that time all communication and interactions with Ministerio de Salud de Nicaragua (Ministry of Health Nicaragua, MINSA) were paused. While the project had intended to implement larvicide and entomological monitoring activities in the five departments with high reported and suspected incidences of Zika (Nueva Segovia, Masaya, Chontales, Matagalpa, parts of RACS and three identified neighborhoods within Managua), these activities were never started. The ZAP Nicaragua office closed on December 15, 2018, after being unable to initiate any activities due to the ongoing uncertainty. However, the ZAP Nicaragua team was able to develop some resources to leave with stakeholders to facilitate future entomological and vector control efforts in-country. These included:  Guide to Vector Control  A two-page brief on the management and use of Bti

 Entomology Training Participant’s Guide  M&E templates and data collection forms for larviciding campaigns. Additionally, ZAP Nicaragua provided training support to strengthen the technical capabilities of entomological staff of the Amos Foundation and the International Citizen Service (both USAID partners), including community actors involved in USAID’s Zika portfolio. The ZAP Nicaragua Entomology Manager joined four workshops with Amos Foundation to support training in the mosquito life cycle and taxonomic identification of Aedes aegypti and other urban mosquito species. In addition, ZAP Nicaragua collected and reared local populations of Aedes aegypti from two departments (Managua and Masaya) to conduct insecticide resistance tests, using different adulticides and larvicides.

3.8 ECUADOR, PARAGUAY AND PERU MOH representatives from Peru, Paraguay, and Ecuador participated on the ZAP Regional Vector Control Workshop held in Honduras in September 2018, the Regional Entomology Training held in the DR in May 2018 and the ZAP Strategic Decisions Forum held in Jamaica in June 2019.

3.8.1 ECUADOR ZAP enhanced the capacity of the MOH in Ecuador by donating the first insectary in a box in the country. The insectary has three different areas, one for mosquito rearing and colonies, the second for classification and identification of immature vectors, and an area for reception and processing of field samples and data collection. The insectary is located at the Centro de Referencia Nacional de Vectores, a division from the MOH, which is in charge of designing and implementing national vector control and surveillance programs. The insectary enabled the division to identify mosquitos through dissection and to conduct taxonomical studies. ZAP also donated specialized entomology equipment to strengthen the MOH’s network of entomology laboratories and insectaries across the country. ZAP technical experts developed a national manual of entomological surveillance and vector control with Centro de Referencia Nacional de Vectores and other MOH personnel. ZAP provided feedback and guidance to the local technical team responsible for drafting the document. The manual was formally approved by the MOH and will be used as the national guidelines for vector control and surveillance operations in Ecuador. With the objective of strengthening technical capacity at all levels, ZAP invited Ecuadoran MOH personnel to participate in the following regional trainings conducted by ZAP:  ZAP Regional Entomology Training - DR 2018  ZAP Vector Control Regional Training - San Pedro Sula 2018  ZAP Forum on Strategic Decisions for Aedes Management in Latin America and the Caribbean- Jamaica 2019

3.8.2 PARAGUAY In 2017, ZAP conducted a national insecticide resistance training at the Servicio Nacional de Erradicación del Paludismo (SENEPA) headquarters in Asunción, with 15 laboratory technicians and field entomologists from SENEPA. The goal of the National Insecticide Resistance Training was to support SENEPA’s efforts in determining Ae. aegypti susceptibility to insecticides. Topics covered included: biology of Ae. aegypti, identification of larvae and adult mosquitos, general theory on insecticide resistance, theoretical discussion of CDC and WHO bioassays (including pros and cons), analysis and troubleshooting of test results, and manipulation of insecticides.

n March 2018, SENEPA requested the support of a ZAP Entomologist to provide additional support to Paraguay to reinforce training conducted in 2017. In addition, SENEPA requested support for the development of a pyriproxyfen pilot led by SENEPA in response to their transition away from temephos due to local resistance. ZAP supported the design and logistics for the pilot, which was conducted in 2018.

3.8.3 PERU After an initial visit from ZAP’s Regional Entomologist, MOH representatives developed a scope of work for a retrospective and prospective case study on the transition from temephos to pyriproxyfen. ZAP contracted with a local research firm to conduct interviews for the retrospective study on the shift from temephos to pyriproxyfen. The study tools and protocol were finalized so that the field team could start in March 2019; at the time of this report (Sept 2019) a final report had been submitted and is under final review.

3.9 EASTERN AND SOUTHERN CARIBBEAN

3.9.1 PROGRAM HIGHLIGHTS In Eastern and Southern Caribbean (ESC), ZAP’s main focus has been capacity building in entomology and distribution of entomological supplies to build capacity of the Ministry of Health and Environment departments of the region. ZAP launched these efforts in ESC beginning in October 2017. To date, ZAP has conducted three 5-day trainings in St. Lucia, Guyana, and Antigua, for Vector Control Officers and Environmental Health Officers concentrating on entomology. Additional trainings are planned for the period following development of this report. See Exhibit 41 for a summary of trainings. ZAP also distributed a mass quantity of entomological supplies to over seven countries. This included insecticide susceptibility test kits to Barbados and Guyana, and some basic entomological supplies to countries on completion of the entomological trainings. Distribution of broader entomological supplies will continue throughout the region. Key Partners  MOH Barbados  Caribbean Public Health Agency (CARPHA)  Barbados Community College  MOH Guyana

EXHIBIT 41: SUMMARY OF ZAP TRAININGS IN THE EASTERN AND SOUTHERN CARIBBEAN Name and Description of Total Total Dates Total Men Training Participants Women Medical Entomology Surveillance 29 January- 14 10 4 in Castries, St. Lucia 1 February 2019 Medical Entomology Surveillance 24 February - 24 18 6 in Georgetown, Guyana 1 March 2019 Medical Entomology Surveillance 9 -15 April 2019 24 17 7 for St. John’s, Antigua and Barbuda, British Virgin Island, Anguilla

Name and Description of Total Total Dates Total Men Training Participants Women Regional Medical Entomology 27 - 31 July 2019 15 7 8 Surveillance for Montserrat, Anguilla, St. Vincent, Dominica, Barbados, St. Kitts Nevis *Training not yet conducted at the time of writing. Insectary-in-a-Box The ZAP team supported the retrofitting of an insectary-in-a-box in Barbados, located at the MOH. The team worked closely with the MOH to identify an appropriate location for the insectary, coordinate efforts for the final installation of materials, and held an insectary launch ceremony in July 2019. In addition, retrofitting for an insectary in Antigua is underway with a completion date of September 6th.

3.1.1 SUSTAINABILITY HIGHLIGHTS ZAP conducted and analyzed a training needs assessment in 2018 of selected entomology staff in ESC countries to ascertain needs and guide trainings. ZAP coordinated closely with PAHO and the CARPHA. PAHO confirmed it will provide technical support to ESC countries to complete pilot studies with use of Bti and the diploma programs at the Barbados Community College, which are scheduled to occur in 2020. PAHO Guyana committed to financially support diploma programs at the University of Guyana, slated to begin in 2020.

3.9.2 RESEARCH/PILOTS/LEARNING The ZAP Regional Entomologist for ESC provided technical inputs to a locally-led vector control pilot in Antigua. This pilot focused on the use of Bti in a community near an active port/docking yard for cruise ships. The ZAP ESC Entomologist provided technical guidance on the methodologies for collection of baseline entomological data. The aim of the pilot is to establish a baseline for the mosquito population using mosquito traps and to evaluate the efficacy of using Bti to control mosquitoes in a field trial in St. John’s, Antigua.

4. COMMUNICATIONS

ZAP shared results and lessons learned through multiple communications channels, conferences, and participation in strategic meetings. Additionally, selected ZAP resources were added to USAID’s K4Health project website and will be added to the Global Vector Control hub site in September 2019.

4.1 VIDEOS ZAP produced two videos, a legacy video and a video focused on vector control in Honduras. The videos were pushed out on social media (Facebook, Twitter, Instagram, LinkedIn, YouTube) and sent through e-alerts to a list of more than 3,000 subscribers. The videos can be found here:  Zeroing in on Zika  ZAP Honduras Tackles Zika

4.2 SUCCESS STORIES/ZIKA FIGHTER PROFILES Fourteen success stories and two Zika Fighter profiles were posted on www.africairs.net, www.abtassociates.com and social media, and shared with USAID. A series of six ZAP success stories were also featured on the Zika Communication Network in October and November 2018: www.zikacommunicationnetwork.org/news. A success story book was created for the ZAP Regional Forum in Jamaica. The following success stories were included:  Entomologists trained in vector control techniques to prevent the spread of Zika  ZAP Helps Households To Take Action Against Mosquitoes  ZAP Conducts IRS Program in the DR  ZAP Uses Music to Move the Message  The Fruits of ZAP Jamaica  More than Mosquitoes  The Art of Awareness  ZAP Helps Dominican Republic Outsmart Mosquitoes  Mapping for Zika  The Brain Gain in Guatemala  Fighting the Bite to Prevent Zika  Children Champion for Change  Skills for Success  Overcoming cultural barriers to fight Zika  Zika Fighter: Kerri-Ann Guyah  Zika Fighter: Lastenia Doris Borjas

4.3 CONFERENCES ZAP presented at several important conferences and public events:

 Annual Conference of the American Mosquito Control Association February 25 – March 1, 2019, with the following oral and poster presentations: o Field evaluation of three different traps collecting Aedes aegypti in four parishes of Jamaica (Oral) o Preferences of breeding containers for Aedes mosquitos: a case study from Jamaica (Poster) o IRS for Aedes aegypti control in the DR: challenges and lessons learned (Oral) o Developing local capacity for Aedes aegypti surveillance using ovitraps in the DR (Poster) o Mobile technology applications for entomological surveillance and vector control in the Dominican Republic: Achievements and challenges (Oral) o Use of real time monitoring to improve implementation of vector control and entomological surveillance in Guatemala (Oral)

 Annual Meeting of the American Society of Tropical Medicine and Hygiene from October 28-November 1, 2018, including poster presentations: o Update on the insecticide resistance profile of Aedes aegypti from Central America and the Caribbean. o The Zika AIRS Project (ZAP): First year of entomological surveillance and vector control using a biolarvicide in countries of Latin America and the Caribbean.

 The Second International Conference of the Worldwide Insecticide Resistance Network in Singapore in October 2018, with the theme “Integrated approaches and innovative tools for combating insecticide resistance in arbovirus vectors”, including the oral presentation: o Systematizing Insecticide Resistance Testing for Aedes spp. in Latin America: What will it take?  2018 USAID Global Health Mini University on October 22, 2018 in Washington DC, including two sessions: o Zika: Emergency Response to Sustainable Intervention o Not All Mosquitos are Created Equal  Women Deliver, Vancouver, Canada, June 2019. o Kerri-Ann Guyah presented the Power Talk: Empowering Women and Youth as Agents of Change in Vector Control.  “Stories from the Frontline: Fighting Zika”, in August 2018 in Washington, DC. o Kerri-Ann Guyah, Vector Control and Environmental Compliance Manager for ZAP Jamaica, was one of six public health care workers to present at Smithsonian’s National Museum of Natural History’s event “Stories from the Frontline: Fighting Zika”. Read about the event here: Overcoming cultural barriers to fight Zika.  62th National Medical Conference, San Pedro Sula, Honduras in July 2019, including four oral presentations and one poster: o Oral presentations: . Effective management of Aedes aegypti with 3g vs 5g of Bacillus Thuringiensis Israelensis: Technical and financial implications. . First report of replacement of Aedes aegypti for Aedes albopictus in egg forms in Honduras. (Special award) . Effective management of Aedes aegypti in Honduras: Broader control and greater coverage with Bacillus Thuringiensis Israelensis . Assessment of larvicide Spinosad in tablets for control of Aedes aegypti in Honduras.

o Poster: . Experience in integrated management of Aedes aegypti in Choluteca, 2014-2019: Ups and downs. (Special award)

4.4 STRATEGIC MEETINGS In June/July, 2019, ZAP held two regional fora near the completion of the project with a particular emphasis on sharing lessons and exploring priorities for the future. The main objectives of these meetings were to: . Present an update on evidence to guide long-term Aedes management in the region, based on sharing new evidence and lessons from ZAP and other partners (with current scientific literature as background) . Discuss strategic decision points for integrated Aedes management, and the importance of generating, analyzing and using data at local, national and regional levels to inform actions . Share recommendations for longer-term Aedes control strategies to improve prevention and response to current or future Aedes-borne disease outbreaks. Strategic Decisions for Integrated Aedes Management in Latin America and the Caribbean Forum (June 17-19, 2019 in Jamaica): Fifty-five participants from MOH, PAHO, USAID, and ZAP country and home office teams shared information; discussed the need for evidence-based decision making, community engagement, capacity building, and inter-sectoral coordination and collaboration; and defined strategic actions towards sustainable vector control at the country- and regional levels. Strategic Decisions for Integrated Aedes Management in Eastern/Southern Caribbean (July 24-26, 2019 in Barbados): 31 participants from MOH, PAHO, CARPHA, USAID and ZAP country and home office teams joined to share information, lessons learned, and brainstorm future priorities for integrated management of Aedes. In addition, hands-on practical sessions were included on vector control interventions that ZAP supported in its core countries, including community engagement and household level larviciding with Bti. This forum also included a formal launch and handover of the Barbados insectary-in-a-box with nearly 60 participants, including the Minister of Health and Wellness. These regional forums brought together key Ministry and regional partners serving as critical opportunities for country and regional stakeholders to prioritize near term actions to both maximize momentum, maintain recently improved capacity, and continue to fill capacity gaps. Regional partners, such as PAHO and CARPHA, have been important players in these discussions, and identified priorities are in alignment with global and regional strategies, including the PAHO Regional Plan of Action for Entomology and Vector Control. ZAP held a Leadership Conference in El Salvador November 15-17, 2017, bringing together specialists on Zika prevention and control based in the United States, Guatemala, El Salvador, Honduras, Nicaragua, Jamaica, Haiti, and the DR. Country teams shared best practices, common challenges, lessons learned, and planned project activities based on ZAP experiences during the first year of implementation.

5. LESSONS AND CONCLUSIONS

5.1 LESSONS LEARNED ZAP was a three-year activity designed to strengthen national capacity among select countries in the Latin America and Caribbean to address the threat of Zika. Initially conceived as an emergency response, ZAP teams deployed in Haiti, Jamaica, the DR, Honduras, El Salvador, and Guatemala in late 2016 or early 2017 found that the Zika epidemic had peaked. The decline in Zika cases was attributed to a significant reduction in the number of susceptible individuals and other epidemiological and social factors. However, a reduction in the number of cases did not mean that the threat was over. High density of Aedes aegypti in the region remained a major risk for the spread of other arbovirosis, as evidenced by recent outbreaks of dengue fever after a period of low incidence. In this context, it was clear that ZAP’s efforts had to focus on supporting mosquito control and entomological surveillance through direct delivery of interventions, community mobilization and empowerment, reinforced technical and human capacity, and documentation of processes and results. Capacity building was an important cross-cutting element in the transition from an emergency response to a sustainable approach that would persist even after the project’s end. ZAP’s implementation across the region provided a number of lessons learned:  Defining the project’s vision and scope in light of the local context was critical to the project’s success. For example, understanding local needs and learning about each country’s capacity enabled country teams to elaborate relevant but flexible workplans. Flexibility was necessary since a “one-size-fits-all” approach was neither realistic nor desirable. It was therefore important to recognize a number of contextual factors, including: health policies and regulations; technical and institutional capacity in the health system; cultural and social conditions; and local organization and engagement. Coordination with local stakeholders, most importantly MOH’s, at the national and local levels, was critical for legitimacy, feasibility and sustainability purposes.  Not all countries had favorable conditions to accept ZAP’s support quickly. Setting up local offices required dealing with rules and regulations that often slowed down start up and implementation. International procurement or acceptance of ZAP supplies and equipment was a significant challenge in some countries. Generally, there was limited availability of qualified human resources, along with weak infrastructure and technical capacity. Gender issues became visible, as illustrated by official reluctance to support women’s involvement in activities that required physical work, for example. In some countries (e.g., Honduras), ZAP was able to second MOH officers; in others (e.g., Guatemala and El Salvador), MOH officers were embedded as supervisors and managers. In the DR, former MOH officers were enticed out of retirement to support project activities.  Strong partnerships were essential for project implementation. Partners included government agencies (namely MOH and local governments); international cooperation agencies; resource partners; and community partners. Collaborative efforts were useful to capitalize on each other’s capacities, develop synergies, and achieve common goals. Given ZAP’s evolution from an emergency response to supporting sustainable vector control programs, ministries of health were critical partners given their role in health promotion and disease prevention. MOHs were

the main beneficiaries for ZAP’s capacity building efforts. Other partners played important roles, such as academia (through support of the diploma program), local governments, and community-based organizations (such as neighborhood committees, volunteer groups, and local non-government organizations).  During its implementation phase, ZAP project teams operated within ambitious timelines, constraints in human resource management, and budget management, among others. As noted earlier, operational plans allowed for some flexibility which alleviated field implementation, especially when constraints were beyond ZAP’s control. These constraints included burdensome government rules over importation of products and commodities needed for vector control. Implementation of ZAP’s technical components, vector control and entomological monitoring, required training and capacity building; streamlined management of operations; efficient logistics and transportation systems; supportive supervision; and sound security and safety procedures.  An important contribution by the ZAP project was to introduce and adapt M&E systems and tools to meet country needs for strategic information and programmatic decision-making. Transitioning from paper-and-pencil data collection methods to mobile phone applications, for example, was a welcomed, albeit overdue, development. In the same vein, helping countries become acquainted with and develop dynamic data visualization tools (e.g. dashboards) was a necessary step to strengthen evidence-based decision making. For example, the design of an entomological surveillance module housed within the National Epidemiological Surveillance System in the DR lays the groundwork for data integration that will lead to more effective vector control and positive health outcomes. Similar efforts have shown promise in Jamaica and Guatemala.

5.2 CONCLUSIONS ZAP’s objective as USAID’s selected Zika response vector control partner was to decrease the Aedes mosquito population sufficiently to reduce Zika transmission. Here we summarize some of the major achievements and lessons from across the regional portfolio. Vector Control. The project teams conducted more than 7.5 million household level vector control visits in five core countries. Vector control visits was comprised of monthly household visits to eliminate mosquito breeding sources through larviciding with Bti and environmental cleanup, complemented by household education on effective prevention measures. This large scale use of Bti offered important lessons for the region and considerations for larvicide options for the future. The vector control work required supervision and independent verification by both project and Ministry of Health supervisory teams. Teams have helped ministries to think outside of the box to identify alternative approaches to mobilizing and maintaining comprehensive integrated vector management programs. For example, in Honduras, ZAP trained over 1000 “guias de familia” to conduct vector control activities once ZAP ends, and in Jamaica the Ministry of Heath has formally adopted the ZAP vector control implementation model. Monitoring and Evaluation. ZAP utilized rigorous monitoring and evaluation tools to monitor the efficiency, effectiveness and quality of interventions. ZAP teams demonstrated the importance of using data to make operational decisions and improve programming over the life of the project; a commitment to learning was critical to maximizing impact. Significant advancements were made in elevating the awareness and adoption of rigorous data collection methodologies and systems by MOH counterparts in several countries.

Entomological Surveillance. A critical element of ZAPs approach to integrated management of Aedes in the region was entomological surveillance and monitoring. Entomology teams played two critical roles. The first was to inform the work performed by ZAP vector control teams by researching the distribution, composition, and behavior of mosquito populations in each country, as well as resistance to insecticides. Secondly, entomology teams verified the effectiveness of vector control approaches by monitoring egg, larval, pupal and adult mosquito populations before, during, and after ZAP interventions. Community Engagement. A unique area of success for ZAP stemmed from the project’s model of engaging households on a monthly basis, thus developing relationships of trust with targeted household beneficiaries. Anecdotal evidence shows that these recurring collaborative visits improved the success of vector control messages, acceptance of vector control interventions, and increased the likelihood that they would be implemented by household members and adopted going forward. Changing behavior at the household and community level is an important ZAP legacy. Sustainability through Capacity Building and Systems Strengthening. To meet the technical and human resources requirements, capacity building became one of the largest components of the project. Over the life of the project, ZAP trained more than 4300 vector control technicians and more than 930 entomology technicians. In addition, more than 400 individuals were trained to conduct insecticide resistance testing. ZAP strengthened nearly 20 insectaries, through refurbishment and provision of supplies and materials to support routine needs. These human and institutional resources will remain in-country and in some cases have been retained by the government to continue the work started with ZAP support. While ZAP was launched as an emergency response, it represented a unique opportunity to improve the region and country’s ability to respond to arboviruses in the future. With a one- year extension of the project in 2018, this opportunity became an expectation. Although systems strengthening was core to the project’s overall approach from the beginning, as shown by an focus on building underlying systems and local capacities, in the final year ZAP elevated its focus on institutionalization, development of best practices, guidelines and tools, and sharing of successes and lessons across the region. For instance, the Diplomat program started in the Dominican Republic to systematize entomological training was used as a regional model and subsequently rolled out in El Salvador and Honduras, and models planned for Eastern and Southern Caribbean. While arboviruses remain a persistent threat in the region, USAID’s Zika investment through ZAP has provided resources and strengthened capacity to ensure that the region is in a better position to design, implement, manage and monitor effective evidence-based vector control in the future.

ANNEXES

ANNEX 1. Country Implementation Snapshot

Country Dominican El Salvador Guatemala Haiti Honduras Jamaica Republic

Vector Control Larviciding X X X X X X IRS X X Spinosad X Lethal X Ovitraps WALS X Entomology Intervention 2 2 3 1 4 7 Sentinel Sites (# of houses) (660) (400) (305) (460) (878) (1820)

Control 1 1 3 1 1 1 (# of houses) (330) (200) (505) (460) (233) (520) Entomological GAT X X X X X X Monitoring BG Traps X X X X X X Prokopak X X X X X X Ovitraps X X X X X X

ANNEX 2. Monitoring and Evaluation Summary Dominican Republic

Indicator Indicator FY 2017 FY 2018 FY 2019 Cumulative results number Year End Q1 Q2 Q3 Q4 Q1 Q2

1a Percent (%) of N/A N/A N/A 75.00% 100.00% N/A N/A 87.50% communities where physical vector control activities are being implemented 1b Percent (%) of 42.9% 42.9% 57.1% 92.9% 88.9% 216.7% N/A 90.2% communities in which vector monitoring activities are being implemented 1c Number of 474 94 156 34 62 N/A 24 525 people trained in vector control 1d Percent (%) N/A N/A N/A 53.4% 49.7% 43.0% N/A change in mosquito egg density, from baseline, in targeted geographic areas (Baseline- Current/Baseline) % 1e % change in N/A N/A N/A 55.0% 71.1% 63.3% N/A mosquito frequency, from baseline, in targeted geographic areas

5a # communities 6 6 6 14 8 14 N/A with members actively participating in Zika monitoring, prevention, and/or support activities Additional information Definition of community in the country: Community is defined at the cluster level (subdivisions of barrios within San Cristobal) in the Dominican Republic for 2017, and at the municipality level for FY 2018 and 2019 Approximate number of people in each community: Moca - 158,820, Cayetano Germosen - 6911, Gaspar Herandez 37,378, San Victor - 21,009 Type of Index for Indicator 1e: Breteau Index

El Salvador

Indicator Indicator FY 2017 FY 2018 FY 2019 Cumulative results number Year End Q1 Q2 Q3 Q4 Q1 Q2

1a Percent (%) of 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% communities where physical vector control activities are being implemented 1b Percent (%) of 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% communities in which vector monitoring activities are being implemented 1c Number of 398 34 71 64 37 22 18 281 people trained in vector control 1d Percent (%) -4.6% 48.1% -46.2% -105.6% -130.3% 7.2% -66.4% change in mosquito egg density, from baseline, in targeted geographic areas (Baseline- Current/Baseline) % 1e % change in 32.0% 49.6% 52.0% 39.6% 52.0% 70.4% 70.7% mosquito frequency, from baseline, in targeted geographic areas

5a # communities 10 9 9 10 10 10 10 with members actively participating in Zika monitoring, prevention, and/or support activities Definition of community in the country: Municipality

Approximate number of people in each community: Chalatenango = 58,820, El Paisnal = 29,135, Mejicanos = 189,390, Cojutepeque = 65,730, San Cristobal = 11,240, San Rafael Cedros = 24,555, Ilobasco = 94,585, Sensuntepeque = 62,160, San Sebastian = 24,595

Type of Index for Indicator 1e: Household index

Honduras

Indicator Indicator FY 2017 FY 2018 FY 2019 Cumulative results number Year End Q1 Q2 Q3 Q4 Q1 Q2

1a Percent (%) of 93.0% 93.0% 100.0% 94.4% 91.3% 93.2% 100.0% 95.0% communities where physical vector control activities are being implemented 1b Percent (%) of 100.0% 100.0% 100.0% 91.9% 93.5% 87.0% 100.0% 96.1% communities in which vector monitoring activities are being implemented 1c Number of 1759 86 68 419 618 235 485 2173 people trained in vector control 1d Percent (%) 71.5% 69.1% 22.3% 10.0% 34.7% 58.5% 56.6% change in mosquito egg density, from baseline, in targeted geographic areas (Baseline- Current/Baselin e)% 1e % change in 28.0% 23.5% 8.4% -119.9% -77.7% 68.0% 46.4% mosquito frequency, from baseline, in targeted geographic areas

5a # communities 1271 1271 804 804 804 804 600 with members actively participating in Zika monitoring, prevention, and/or support activities Additional information Definition of community in the country: Barrio Approximate number of people in each community: Choluteca = 1020 (147 barrios), El Paraiso (148 barrios)= 1013, Francisco Morazan (261) = 3831, Cortes (203)= 4926. Type of Index for Indicator 1e: Pupal Index

Haiti

Indicator Indicator FY 2017 FY 2018 FY 2019 Cumulative number results Year End Q1 Q2 Q3 Q4 Q1 Q2

1a Percent (%) of 100.0% 80.0% 80.0% 100.0% 100.0% 100.0% 100.0% 94.3% communities where physical vector control activities are being implemented 1b Percent (%) of 100.0% 100.0% 66.7% 100.0% 100.0% 100.0% 100.0% 95.2% communities in which vector monitoring activities are being implemented 1c Number of 549 0 108 43 82 - - 273 people trained in vector control 1d Percent (%) 10.5% 12.5% -0.3% 34.5% -82.0% N/A -19.8% change in mosquito egg density, from baseline, in targeted geographic areas (Baseline- Current/Baseline) % 1e % change in N/A N/A 75.6% 93.0% 89.4% N/A 95.5% mosquito frequency, from baseline, in targeted geographic areas

5a # communities 5 6 5 5 5 5 5 with members actively participating in Zika monitoring, prevention, and/or support activities Additional information Definition of community in the country: Commune Approximate number of people in each community: Type of Index for Indicator 1e: Breteau Index

Jamaica

Indicator Indicator FY 2017 FY 2018 FY 2019 Cumulative number results Year End Q1 Q2 Q3 Q4 Q1 Q2

1a Percent (%) of 92.2% 100.0% 98.6% 100.0% 100.0% 100.0% 98.5% 92.2% communities where physical vector control activities are being implemented 1b Percent (%) of N/A 100.0% 100.0% 75.0% 100.0% 100.0% 100.0% 95.8% communities in which vector monitoring activities are being implemented 1c Number of 25 151 24 38 193 163 5 599 people trained in vector control 1d Percent (%) N/A N/A -56.8% -87.0% -9.3% 20.2% 52.1% change in mosquito egg density, from baseline, in targeted geographic areas (Baseline- Current/Baseline) % 1e % change in N/A N/A 26.6% 74.7% 22.9% 73.8% 99.9% mosquito frequency, from baseline, in targeted geographic areas

5a # communities N/A 47 71 70 95 95 95 with members actively participating in Zika monitoring, prevention, and/or support activities Additional information Definition of community in the country: Neighborhood Approximate number of people in each community: 101,408 Type of Index for Indicator 1e: Household Index

Guatemala

Indicator Indicator FY 2017 FY 2018 FY 2019 Cumulative results number Year End Q1 Q2 Q3 Q4 Q1 Q2

1a Percent (%) of 59.1% 87.0% 95.7% 96.4% 100.0% 100.0% 83.3% 88.8% communities where physical vector control activities are being implemented 1b Percent (%) of 100.0% 75.0% 100.0% 100.0% 100.0% 100.0% 100.0% 96.4% communities in which vector monitoring activities are being implemented 1c Number of 236 79 77 35 21 13 1 311 people trained in vector control 1d Percent (%) N/A 39.3% 5.6% -48.8% 13.7% 41.5% 51.0% change in mosquito egg density, from baseline, in targeted geographic areas (Baseline- Current/Baseline) % 1e % change in N/A 58.2% 59.8% 20.0% 37.3% 70.8% 69.4% mosquito frequency, from baseline, in targeted geographic areas

5a # communities 13 20 22 27 30 30 25 with members actively participating in Zika monitoring, prevention, and/or support activities Additional information Definition of community in the country: Municipality Approximate number of people in each community: Type of Index for Indicator 1e: Breteau Index

MEP Indicators - DR

Performance Indicator Data Source(s) and Disaggregate YEAR 1: Target Year 1: Results YEAR 2: Target Year 2: Results Year 3: Results Reporting Frequency

October 26 - January 1 2018- January 1 2019- December 21, December 31 June 30 2019 2017 2018 Component 1: Implement safe and high-quality VC programs and provide operational management support 1.1.1 Percentage reduction of Data source: Vector Control Total (All N/A N/A 85% 84% N/A breeding sites testing positive for technician data collection Department/ region/ pupae in permanent water sources form municipality combined) Reporting frequency: Moca N/A N/A N/A 79% N/A Monthly San Víctor N/A N/A N/A 92% N/A

Cayetano Germosén N/A N/A N/A 91% N/A

1.1.2 Number of people residing in Data source: Vector Control Total (All N/A N/A 92,934 108,833 N/A households visited by vector technician data collection Department/ region/ control technicians form municipality combined) Reporting frequency: By Gender Male N/A N/A N/A 54,549 N/A Annually By Gender Female N/A N/A N/A 54,284 N/A

By Pregnant Women N/A N/A N/A 1,223 N/A

By Women of N/A N/A N/A 27,548 N/A Reproductive Age

By Children <5 N/A N/A N/A 9,090 N/A

1.1.3 Number and percentage of Data source: Vector Control Total (All N/A N/A N/A 29,479; 95% N/A households receiving one vector technician data collection Department/ region/ control visit per intervention form municipality cycle7 combined)

7The “intervention cycle” is defined as the frequency with which one household is visited. Typically for vector control activities this is once per month

Collection frequency: Moca N/A N/A N/A 22,345; 76% N/A Monthly San Víctor N/A N/A N/A 5,193; 18% N/A Quarterly Cayetano Germosén N/A N/A N/A 1,941; 6% N/A 1.2.1 Number of structures Data source: Previous spray By Spray Campaign 15,000 11,790 N/A N/A N/A targeted for spraying8 campaign data, enumeration data (targets); Daily Spray Operator Forms (results)

Reporting frequency: Daily per spray campaign 1.2.2 Number of structures Data source: Daily Spray By Spray Campaign 15,000 11,739 N/A N/A N/A sprayed with IRS Operator Forms

Reporting frequency: Daily per spray campaign 1.2.3 Percentage of total Data source: Daily Spray By Spray Campaign 85% 99.6% N/A N/A N/A structures targeted for spraying Operator Forms that were sprayed with a residual insecticide (Spray Coverage) Reporting frequency: Daily per spray campaign 1.2.4 Number of people residing Data source: Daily Spray By Spray Campaign N/A 38,591 N/A N/A N/A in structures sprayed (Number of Operator Forms people protected by IRS) Reporting frequency: Daily By Gender N/A 18,866 Males N/A N/A N/A per spray campaign 19,725 Females

By Pregnant Women N/A 614 N/A N/A N/A

By Women of N/A N/A N/A N/A N/A Reproductive Age By children <5 years N/A 5,426 N/A N/A N/A old 1.2.5 Number and percentage of Data source: Project records By Spray Campaign 4 sites; 100% 4 sites; 100% N/A N/A N/A soak pits and storehouses – Reports submitted by inspected and approved prior to spraying

8 Only for countries with IRS

district environmental By Soak Pit 3 Soak Pits; 100% 3 Soak Pits; 100% N/A N/A N/A officers By Storehouse 1 Warehouse ; 1 Warehouse; N/A N/A N/A Reporting frequency: 100% 100% Each spray season Component 2: Contribute to the collection and analysis of routine entomological data 2.1 Number of entomological Data source: Entomological N/A 54 52 9 9 N/A sentinel sites supported by ZAP reports and ZAP country ES monitoring species work plan composition Reporting frequency: Annually 2.2 Number of entomological Data source: Entomological N/A N/A N/A 9 8 N/A sentinel sites supported by ZAP reports ES monitoring egg density, larvae density, and pupae density Reporting frequency: Annually

2.3 Number of entomological Data source: Entomological N/A 54 52 4 4 N/A sentinel sites supported by ZAP reports ES established to monitor adult density Reporting frequency: Annually

2.4 Number and percentage of Data source: Entomological N/A N/A N/A TBD; TBD% 1: 7% N/A entomological monitoring sentinel reports sites measuring all seven entomological indicators Reporting frequency: Annually

2.5 Number and percentage of Data source: Entomological By Type of 10; 100% 4; 40% 5: 100% 10: 71% 6:100% sentinel sites that tested at least reports Insecticide - Deltamethrin - Deltamethrin - Deltamethrin one insecticide from each of the - Permethrin - Permethrin - Permethrin three classes of insecticides Reporting frequency: Annually - Lambdacyhalothri - Lambdacyhalothri - Lambdacyhalothri recommended for vector control - Etofenprox - Etofenprox - Etofenprox - Malathion - Malathion - Malathion - Pirimiphos-Methyl - Pirimiphos-Methyl - Pirimiphos-Methyl - Bendiocarb - Bendiocarb - Bendiocarb

2.6 Number and percentage of Data source: Entomological By Type of Larvicide 10; 100% 4; 40% 5: 100% 4: 29% N/A sentinel sites that tested at least reports - Temephos - Temefos one larvicide from each of the - BTI - BTI three classes of larvicides Reporting frequency: Annually - Metopreno recommended for vector control - Diflubenzuron

2.7 Number and percent of Data source: Entomological By Spray Campaign 9; 100%10 9; 100% N/A N/A N/A homes receiving wall bioassays reports conducted after the completion of spraying at monthly intervals to Reporting frequency: Monthly evaluate insecticide decay9

By Type of N/A N/A N/A N/A N/A Insecticide

Component 3: Capacity Building and Human Resources

3.1 Number of people trained to Data source: Project records – By Campaign 72 135 N/A N/A N/A deliver IRS in target departments Training reports

Reporting frequency: Annually By Gender Male N/A 121 N/A N/A N/A

By Gender Female N/A 14 N/A N/A N/A

Percentage of N/A 10.3% N/A N/A N/A Women Trained

3.2 Total number of people Data source: Project records – Total (All N/A N/A 118 119 N/A trained to conduct vector control Training reports Department/ region/ in target departments municipality combined)

9 The wall bioassays were conducted with deltamethrin only.

Reporting frequency: Annually By Gender Male N/A N/A N/A 47 N/A

By Gender Female N/A N/A N/A 72 N/A

By Type of Vector N/A N/A N/A BTI: 93; lethal N/A Control Activity ovitraps: 26 3.3 Total number of people Data source: Project records – By Year 116 99 80 132 N/A trained to conduct Entomological Training reports Surveillance in target departments By Gender Male N/A 11 N/A 49 N/A Reporting frequency: Semi- annually By Gender Female N/A 88 N/A 83 N/A

By Position N/A Entomological N/A Entomological N/A Team Leaders: 10 Team Leaders: 5 Entomological Entomological Technicians: 89 Technicians: 124 Supervisors:3 By Department/ N/A N/A N/A N/A N/A region/ municipality 3.4 Number and percentage of Data source: Project records – Total (All N/A 7; 10% 8; TBD% 10; 42% N/A women hired in supervisory roles Contracts signed Department/ region/ in non-IRS target departments municipality Reporting frequency: combined) Annually Moca N/A N/A N/A 3; 30% N/A

San Víctor N/A N/A N/A 2; 20% N/A Gaspar Hernández N/A N/A N/A 1; 10% N/A Cayetano Germosén N/A N/A N/A 1; 10% N/A

Monte Plata N/A N/A N/A 3; 30% N/A

3.5 Number and percentage of Data source: Project records – Total (All N/A 9; 37.5% N/A N/A N/A women hired in supervisory roles Contracts signed Department/ region/ in IRS target departments municipality Reporting frequency: combined) Annually

MEP Indicators – El Salvador

YEAR 1: Target Year 1: Results YEAR 2: Target Year 2: Results Year 3: Results

Data Source(s) and Performance Indicator Disaggregate Reporting Frequency October 26 - January 1 2018- January 1 2019- December 21, December 31 June 30 2019 2017 2018 Component 1: Implement safe and high-quality VC programs and provide operational management support 1.1.1 Percentage reduction of Data source: Vector Control Total (All N/A 89.7% 10% 97.1% 96.8% breeding sites testing positive for technician data collection Department/ region/ pupae in permanent water sources form municipality combined) Reporting frequency: N/A Chalatenango N/A Chalatenango Chalatenango Monthly By Department/ 89.5% 97.9% 97.0% region/ municipality El Paisnal 92.9% El Paisnal 95.5% El Paisnal 97.9% Mejicanos 69.6% Mejicanos 96.2% Mejicanos 95.5% Cojutepeque 95.5% Cojutepeque 99.3% Cojutepeque 98.9% San Cristobal San Cristobal San Cristobal 97.3% 99.9% 99.0% San Rafael Cedros San Rafael Cedros San Rafael Cedros 96.0% 98.89% 99.8% Ilobasco 94.9% Ilobasco 95.6% Sensuntepeque Sensuntepeque Sensuntepeque 95.4% 93.2% 96.0% Ilobasco 95.5% San Sebastian San Sebastian San Sebastian 93.8% 98.9% 99.8% 1.1.2 Number of people residing in Data source: Vector Control Total (All N/A N/A N/A N/A N/A households visited by vector technician data collection Department/ region/ control technicians form municipality combined) Reporting frequency: Annually

1.1.3 Number and percentage of Data source: Vector Control Total (All 96,480 98,325 108,419 114,882 113,437 households receiving one vector technician data collection Department/ region/ 100% 102% 100% 106% 98.74% control visit per intervention form municipality cycle combined)

Collection frequency: By Department/ Chalatenango 9,366 Chalatenango Chalatenango 9,702 Chalatenango Chalatenango Monthly region/ municipality El Paisnal 4,005 10,723 (114%) El Paisnal 4,912 11,969 (123%) 11,570 (96%) Quarterly Mejicanos 33,168 El Paisnal 5,466 Mejicanos 37,793 El Paisnal 6,020 El Paisnal 7,732 Cojutepeque (136%) Cojutepeque (123%) (128%) 11,889 Mejicanos 32669 13,612 Mejicanos 39,275 Mejicanos 40,869 San Cristóbal 2,053 (98%) San Cristóbal 2,121 (104%) (104%) San Rafael Cedros Cojutepeque San Rafael Cedros Cojutepeque Cojutepeque 4,329 11,259 (95%) 4,887 13,211 (97%) 10,918 (82%) Ilobasco 14,628 San Cristobal 2,076 Ilobasco 19,170 San Cristóbal 2,301 San Cristóbal 2,236 Sensuntepeque (101%) Sensuntepeque (108%) (97%) 13,457 San Rafael Cedros 12,426 San Rafael Cedros San Rafael Cedros San Sebastián 3,585 4,337 (100%) San Sebastián 3,796 4,933 (101%) 4,621 (93%) Ilobasco 16,948 Ilobasco 19,625 Ilobasco 18,440 (116%) (102%) (93%) Sensuntepeque Sensuntepeque Sensuntepeque 10,608 (79%) 12,620 (102%) 12,445 (98%) San Sebastián 4,239 San Sebastián 4,928 San Sebastián 4,606 (118%) (130%) (93%) Component 2: Contribute to the collection and analysis of routine entomological data 2.1 Number of entomological Data source: Entomological N/A 4 4 3 4 4 sentinel sites supported by ZAP reports and ZAP country ES monitoring species work plan composition Reporting frequency: Annually 2.2 Number of entomological Data source: Entomological N/A 4 4 3 4 4 sentinel sites supported by ZAP reports ES monitoring egg density, larvae density, and pupae density Reporting frequency: Annually

2.3 Number of entomological Data source: Entomological N/A 2 2 2 2 1 sentinel sites supported by ZAP reports ES established to monitor adult density Reporting frequency: Annually

2.4 Number and percentage of Data source: Entomological N/A 4 100% 4 100% 3 100% 4 100% 4 100% entomological monitoring sentinel reports sites measuring all seven entomological indicators Reporting frequency: Annually

2.5 Number and percentage of Data source: Entomological N/A 4 100% 4 100% 4 100% 5 100% 5 100% sentinel sites that tested at least reports one insecticide from each of the three classes of insecticides Reporting frequency: Annually recommended for vector control

2.6 Number and percentage of Data source: Entomological N/A 4 100% 4 100% 4 100% 5 100% 5 100% sentinel sites that tested at least reports one larvicide from each of the three classes of larvicides Reporting frequency: Annually recommended for vector control

Component 3: Capacity Building and Human Resources

3.2 Total number of people Data source: Project records – Total (All 350 392 trained per 332 407 people trained 394 trained to conduct vector control Training reports Department/ region/ municipality: to conduct vector in target departments municipality Chalatenango 43 control activities; Reporting frequency: Annually combined) El Paisnal 24 347 were ZAP Mejicanos 105 personnel, 57 San Cristóbal 10 MOH personnel, 1 San Rafael Cedros USAID and 2 URC. 18 By target Cojutepeque 39 municipality Ilobasco 57 (excluding National Sensuntepeque 47 VC workshop): San Sebastian 42 Chalatenango 43 and 7 people from El Paisnal 21 the MOH who Mejicanos 90 participated in the San Cristobal Ento Regional 10 Workshop San Rafael Cedros 17 Cojutepeque 34 Ilobasco 60 Sensuntepeque 44 San Sebastian 52 In the National VC workshop participated 36 people of which 33 are MOH

personnel, USAID 1 and URC 2

By Gender Male N/A N/A N/A 194 males (48%) 152

By Gender Female N/A N/A N/A 213 females (52%) 242

3.3 Total number of people Data source: Project records – By Year 35 trainees for N/A 110 189 people were 58 people were trained to conduct Entomological Training reports National trained to conduct trained to conduct Surveillance in target departments Entomology Entomological Entomological Reporting frequency: Semi- Workshop and 75 Surveillance; 150 Surveillance annually trainees from the MOH personnel MOH and 39 people ZAP personnel. By Gender Male N/A N/A N/A 150 36

By Gender Female N/A N/A N/A 39 22

By Position11 N/A N/A N/A Only including ZAP 39 project personnel: 3 19 MoH supervisors, 4 team leaders (TLs) and 33 Ento techs By Department/ N/A N/A N/A San Sebastian: 10 13 Chalatenango region/ municipality Verapaz: 9 8 Mejicanos Mejiccanos: 10 10 San Sebatian Chalatenango: 10 8 Verapaz 19 MoH (11 Paracentral Region 4 Oriental Region 4 Ocidental Region)

3.4 Number and percentage of Data source: Project records – Total (All 30% of supervisors N/A 11 17 women hired in 38 people are hired women hired in supervisory roles Contracts signed Department/ region/ and team leaders supervisory roles in supervisory roles in non-IRS target departments municipality (46%) and includes of which 17 are Reporting frequency: combined) supervisors and Women (44.74%) Annually TLs for VC and Ento (3 supervisors, 12 VC TLs and 2 Ento TLs) N/A N/A N/A Chaltenango 1 Chalatenango 1, By Department/ El Paisnal 1 Cojutepeque 2, region/ municipality Mejicanos 5 El Paisnal 1, Cojutepeque 2 Ilobasco 5, San Sebastian 1 Mejicanos 5, Ilobasco 5 San Sebastian 1, Sensuntepeque 1 Sensuntepeque 1, Verapaz 1 Verapaz 1.

MEP Indicators - Honduras

Performance Indicator Data Source(s) and Disaggregate YEAR 1: Target Year 1: Results YEAR 2: Target Year 2: Results Year 3: Results Reporting Frequency

October 26 - January 1 2018- January 1 2019- December 21, December 31 June 30 2019 2017 2018 Component 1: Implement safe and high-quality VC programs and provide operational management support 1.1.1 Percentage reduction of Data source: Vector Control Total (All N/A 2.40%12 N/A 16.67%13 -16.2%14 breeding sites testing positive for technician data collection Department/ region/ pupae in permanent water sources form municipality combined) Reporting frequency: Monthly

1.1.2 Number of people residing in Data source: Vector Control Total (All 951,34015 759,98516 1,049,985 813,94017 673,24518 households visited by vector technician data collection Department/ region/ control technicians form municipality combined) Reporting frequency: By Gender Male N/A 364,793 N/A 390,691 323,158 Annually

By Gender Female N/A 395,192 N/A 423,249 350,087

12 Absolute percentage of breeding sites testing positive for pupae in October 2017 (ONA database). Same goes for regional percentages. 13 Actual percentage reduction between VC data from October 2017 (as a baseline) and December 2018. 14 Actual percentage reduction between VC data from October 2017 (as a baseline) and January 2019. 15 The difference between Targets and Results are as follows: Targets are planned house visits, they include closed households, households who rejected the visit, uninhabited households and treated households (successful visits); Results include treated households alone (where the technician entered a household and carried out an intervention). 16 Exact population data was difficult to obtain due to security concerns, therefore it was calculated based on the average number of residents per household in urban areas in Honduras, which is 5 according to the National Statistics Institute. Therefore, the number of houses (see household data in 1.1.3) was multiplied by 5. Thus, the average national number of houses treated in 2017 is 151,997 x 5 = 759,985 17 Similarly to 2017, 2018 population data was calculated based on the average of number of residents per household (5), using the number of households targeted and treated households during the month of August 2018. Based on the number of households visited in 2018 (see 1.1.3) the national number of people visited is 162,788 x 5 = 813,940 18 Similarly to 2017, 2018 population data was calculated based on the average of number of residents per household (5), using the number of households targeted and treated households during the month of January 2019. Based on the number of households visited in 2019 (see 1.1.3) the national number of people visited is 134,649 x 5 = 673,245

By Pregnant Women N/A N/A N/A N/A N/A

By Women of N/A 257,635 N/A 275,926 228,230 Reproductive Age

By Children <5 N/A 113,542 N/A 121,603 100,583

By Men (18 years and N/A 199,578 N/A 213,747 176,800 older) 1.1.3 Number and percentage of Data source: Vector Control Total (All 190,268 HH20 151,997 HH 209,997 HH22 162,788 HH 134,649 HH households receiving one vector technician data collection Department/ region/ control visit per intervention form municipality 79.89%21 77.52% 77.12% cycle19 combined) average per month average per month Average per month Collection frequency: Monthly Quarterly

By Department/ Dan. 14,809 Dan. 12,445 Dan. 30,534 Dan. 27,522 Cho 19,679 region/ municipality Cho. 23,187 Cho. 19,612 Cho. 33,185 Cho. 28,998 Tgu 55,011 SPS 78,661 SPS 73,226 SPS 58,513 SPS 45,472 Dan 19,194 Tgu. 73,611 Tgu. 46,714 Tgu. 87,765 Tgu. 60,796 SPS 40,785

Component 2: Contribute to the collection and analysis of routine entomological data 2.1 Number of entomological Data source: Entomological N/A 5 5 5 5 523 sentinel sites supported by ZAP reports and ZAP country Honduras monitoring species work plan composition Reporting frequency: Annually

20 Number of houses targeted during the month of October 2017. 21 Target visits include closed households, households who rejected the visit, uninhabited households and treated households (successful visits); Result visits include treated households alone (where the technician entered and carried out an intervention).Thus, the percentage of households receiving a vector control visit (151,997/190,268 x100) reflects the success rate of treating a house over the number of households that were approached. 22 Number of houses targeted during the month of August 2018. 23 All 5 sites were supported by ZAP entomological surveillance activities until January. Choluteca and Comayagua closed at the end of January 2019, and Danlí, Tegucigalpa, and San Pedro Sula closed at the end of April.

2.2 Number of entomological Data source: Entomological N/A 5 5 5 5 524 sentinel sites supported by ZAP reports Honduras monitoring egg density, larval density, and pupal density Reporting frequency: Annually

2.3 Number of entomological Data source: Entomological N/A 2 2 4 4 425 sentinel sites supported by ZAP reports Honduras established to monitor adult density Reporting frequency: Annually a Danli, Comayagua, San Pedro Sula and Choluteca 2.4 Number and percentage of Data source: Entomological N/A 4 4 4 4 426 entomological monitoring sentinel reports 100% 100% 100% 100% 100% sites measuring all seven entomological indicators Reporting frequency: Annually

2.5 Number and percentage of Data source: Entomological N/A 5 3 5 5 5 sentinel sites that tested at least reports 100% 60% 100% 100% 100% one insecticide from each of the three classes of insecticides Reporting frequency: Annually recommended for vector control

2.6 Number and percentage of Data source: Entomological N/A 5 5 5 1 128 sentinel sites that tested at least reports 100% 100% 100% 20% 20% one larvicide from each of the three27 classes of larvicides Reporting frequency: Annually recommended for vector control

24 Ibid. 25 Ibid. 26 Ibid. 27 These three classes include: organophosphates, insect growth regulators, and biopesticides 28 All 5 sites carried out Bti and temephos bioassays, but only Danlí carried out diflubenzuron bioassays.

Component 3: Capacity Building and Human Resources

3.2 Total number of people Data source: Project records – Total (All N/A N/A N/A 2,45029 1,098 trained to conduct vector control Training reports Department/ region/ in target departments municipality 100% Reporting frequency: Annually combined) By Gender Male N/A N/A N/A 729 477

29.8% By Gender Female N/A N/A N/A 1,721 621

70.2% By Type of Vector N/A N/A N/A N/A 1,098 Control Activity 3.3 Total number of people Data source: Project records – By Year N/A N/A N/A 64 99 trained to conduct Entomological Training reports Surveillance in target departments By Gender Male N/A N/A N/A 40 51 Reporting frequency: Semi- annually By Gender Female N/A N/A N/A 24 48

By Department/ N/A N/A N/A SPS, 56 N/A region/ municipality COM, 3 CHO, 2 DAN, 3 3.4 Number and percentage of Data source: Project records – Total (All N/A N/A N/A 33 N/A 30 women hired in supervisory roles Contracts signed Department/ region/ in non-IRS target departments municipality 62% Reporting frequency: combined) Annually

29 This represents the total number of people trained in Vector Control activities. 30 No staff were hired during the period of January to June 2019.

N/A N/A N/A SPS, 9 N/A By Department/ TGU, 15 region/ municipality CHO, 5 DAN, 4

MEP Indicators - Haiti

Performance Indicator Data Source(s) and Disaggregate YEAR 1: Target Year 1: Results YEAR 2: Target Year 2: Results Year 3: Results Reporting Frequency

October 26 - January 1 2018- January 1 2019- December 21, December 31 June 30 2019 2017 2018 Component 1: Implement safe and high-quality VC programs and provide operational management support 1.1.1 Percentage reduction of Data source: Vector Control Total (All 10% 45.5% 20% North: 89% 65.1% breeding sites testing positive for technician data collection Department/ region/ West (Leogane North: 77.76% pupae in permanent water sources form municipality commune): 5.7% West (Leogane): combined) 46.9% Reporting frequency: Monthly

1.1.2 Number of people residing in Data source: Vector Control Total (All N/A 276,722 N/A 264,373 264,373 households visited by vector technician data collection Department/ region/ control technicians form municipality combined) Reporting frequency: Male 132,827 126,903 126,903 Annually Female 143,895 137,477 137,477 Pregnant women 6,452 8,683 8,683

Women of 77,482 74,026 74,026 Reproductive age Children <5 27,672 26,438 26,438

1.1.3 Number and percentage of Data source: Vector Control Total (All 100% 102% 100% 94% 36,4381 households receiving one vector technician data collection Department/ region/ 43,824 44,525 172,821 162,707 control visit per intervention form municipality cycle combined) Collection frequency: Monthly Quarterly

Component 2: Contribute to the collection and analysis of routine entomological data 2.1 Number of entomological Data source: Entomological N/A 2 2 4 4 4 sentinel sites supported by ZAP reports and ZAP country ES monitoring species work plan composition Reporting frequency: Annually 2.2 Number of entomological Data source: Entomological N/A 2 2 4 4 4 sentinel sites supported by ZAP reports ES monitoring egg density, larvae density, and pupae density Reporting frequency: Annually

2.3 Number of entomological Data source: Entomological N/A 2 2 4 4 4 sentinel sites supported by ZAP reports ES established to monitor adult density Reporting frequency: Annually

2.4 Number and percentage of Data source: Entomological N/A 2; 100% 2; 100% 4;100% 4;100% 4 (100%) entomological monitoring sentinel reports sites measuring all seven entomological indicators Reporting frequency: Annually

2.5 Number and percentage of Data source: Entomological N/A 2; 100% 4; 100% 4; 100% 2; 100% 4 (100%) sentinel sites that tested at least reports one insecticide from each of the three classes of insecticides Reporting frequency: Annually recommended for vector control

1 Visits were limited in 2019 because of protests

100

2.6 Number and percentage of Data source: Entomological N/A 3; 100% 2; 66.6% 3; 100% 3; 100% 4 (100%) sentinel sites that tested at least reports one larvicide from each of the Diflubenzuron Diflubenzuron Diflubenzuron Diflubenzuron Diflubenzuron three classes of larvicides Reporting frequency: Annually Methoprene Methoprene Methoprene Methoprene Methoprene recommended for vector control

Component 3: Capacity Building and Human Resources

3.2 Total number of people Data source: Project records – Total (All 200 269 73 135 70 trained to conduct vector control Training reports Department/ region/ in target departments municipality Reporting frequency: Annually combined) By Gender Male N/A 123 N/A 59 39

By Gender Female N/A 146 N/A 76 31

By Type of Vector Larviciding 269 Larviciding 87 VC Tech: 70 Control Activity (does not include (does not include refresher trainings) refresher trainings) Women: 121 Women: 52 Men:118 Men: 35

Entomology Women: 10 Entomology Women: 13 Men: 2 Men: 19

M&E Women: 14 M&E Women: 11 Men:4 Men: 5

3.3 Total number of people Data source: Project records – By Year 10 12 10 32 27 trained to conduct Entomological Training reports Surveillance in target departments By Gender Male N/A 2 N/A 19 20 Reporting frequency: Semi- annually By Gender Female N/A 10 N/A 13 7

By Position2 N/A N/A N/A Entomology Ento Technicians: Technicians: 27

101

Women: 13 Men: 19

By Department/ N/A N/A N/A West West: 27 region/ municipality 22 technicians (11 North: 0 women, 11 men) North 10 technicians (2 women, 8 men) 3.4 Number and percentage of Data source: Project records – Total (All 63% 63% 63% 63% 28 (79.4%) women hired in supervisory roles Contracts signed Department/ region/ in non-IRS target departments municipality Reporting frequency: combined) Annually

63% 63% 63% 63% North: 21 (71.4%) By Department/ West: 7 (87.5%) region/ municipality

102

MEP Indicators - Jamaica

Performance Indicator Data Source(s) and Disaggregate YEAR 1: Target Year 1: Results YEAR 2: Target Year 2: Results Year 3: Results Reporting Frequency

October 26 - January 1 2018- January 1 2019- December 21, December 31 June 30 2019 20171 2018 Component 1: Implement safe and high-quality VC programs and provide operational management support 1.1.1 Percentage reduction of Data source: Vector Control Total (All N/A 2.5% 20% 20% 66% breeding sites testing positive for technician data collection Department/ region/ pupae in permanent water sources form municipality combined) Reporting frequency: By Parish N/A N/A N/A Monthly Kingston and St. 91% 81% Andrew Portland 46% 85% St. Ann 50% 61% St. Catherine 80% 87% St. Mary 71% 51% St. Thomas 80% 57% 1.1.2 Number of people residing in Data source: Vector Control Total (All N/A 38,758 N/A 313,013 292,542 households visited by vector technician data collection Department/ region/ control technicians form municipality combined) Reporting frequency: By Male N/A N/A N/A 147,299 139,505 Annually By Female 163,913 153037 By Pregnant Women N/A N/A By Women of 79,651 68,690 Reproductive Age By Children <5 21,886 19,788 1.1.3 Number and percentage of Data source: Vector Control Total (All N/A N/A 55,000; 93,793 62,899 households receiving one vector technician data collection Department/ region/ 100% 171% 180% control visit per intervention form municipality cycle combined)

1 Phase I: January - July 2018*; Phase II Cycle I: September - December 2018; Phase II Cycle II: January- April 2019.

103

Collection frequency: By Parish N/A N/A Monthly Kingston and St. 14,400 24,430 6,542 Quarterly Andrew Portland St. Ann 2,400 2,796 2,949 St. Catherine 7,200 11,639 11,049 St. Mary 14,400 26,028 6,609 St. Thomas 2,400 3,491 3,708 12,000 25,409 11,085

Component 2: Contribute to the collection and analysis of routine entomological data 2.1 Number of entomological Data source: Entomological N/A N/A N/A 8 8 5 sentinel sites supported by ZAP reports and ZAP country ES monitoring species work plan composition Reporting frequency: Annually 2.2 Number of entomological Data source: Entomological N/A N/A N/A 8 8 5 sentinel sites supported by ZAP reports ES monitoring egg density, larvae density, and pupae density Reporting frequency: Annually

2.3 Number of entomological Data source: Entomological N/A N/A N/A 8 8 5 sentinel sites supported by ZAP reports ES established to monitor adult density Reporting frequency: Annually

2.4 Number and percentage of Data source: Entomological N/A N/A N/A 8 8 5 entomological monitoring sentinel reports sites measuring all seven entomological indicators Reporting frequency: Annually

2.5 Number and percentage of Data source: Entomological N/A N/A N/A 8 8 5 sentinel sites that tested at least reports one insecticide from each of the three classes of insecticides Reporting frequency: Annually recommended for vector control

104

2.6 Number and percentage of Data source: Entomological N/A N/A N/A 7; 100% 7; 100% 4;100% sentinel sites that tested at least reports one larvicide from each of the three classes of larvicides Reporting frequency: Annually recommended for vector control

Component 3: Capacity Building and Human Resources

3.2 Total number of people Data source: Project records – Total (All N/A N/A 189 220 121 trained to conduct vector control Training reports Department/ region/ in target departments municipality Reporting frequency: Annually combined) By Gender Male N/A N/A 94 73 53

By Gender Female N/A N/A 94 147 68

By Type of Vector N/A N/A 189 220 121 Control Activity 3.3 Total number of people Data source: Project records – By Year N/A N/A 81 86 51 trained to conduct Entomological Training reports Surveillance in target departments By Gender Male N/A N/A 40 31 19 Reporting frequency: Semi- annually By Gender Female N/A N/A 41 55 32

By Position2 N/A N/A 9 9 8 77 77 43 Supervisor Technicians By Parish N/A N/A Kingston and St. 18 18 9 Andrew Portland N/A N/A N/A St. Ann 9 9 9 St. Catherine 18 18 9 St. Mary 9 9 9 St. Thomas 9 9 9

105

18 18 9

3.4 Number and percentage of Data source: Project records – Total (All N/A N/A 27 37 18 women hired in supervisory roles Contracts signed Department/ region/ 50% 74% 69% in non-IRS target departments municipality Reporting frequency: combined) Annually

N/A N/A N/A N/A N/A By Department/ region/ municipality

106

MEP Indicators - Guatemala

Performance Indicator Data Source(s) and Disaggregate YEAR 1: Target Year 1: Results YEAR 2: Target Year 2: Results Year 3: Results Reporting Frequency

October 26 - January 1 2018- January 1 2019- December 21, December 31 June 30 2019 2017 2018 Component 1: Implement safe and high-quality VC programs and provide operational management support 1.1.1 Percentage reduction of Data source: Vector Control Total (All N/A 63% N/A 75.25% 91.5% breeding sites testing positive for technician data collection Department/ region/ pupae in permanent water sources form municipality combined) Reporting frequency: N/A N/A N/A Chiquimula Chiquimula 92.45% Monthly By Department/ 74.79% 92.45% region/ municipality Zacapa Zacapa 70.70% 94.95% El Progreso 88.56%

1.1.2 Number of people residing Data source: Vector Total (All N/A 98,420 N/A 285,261 278,971 in households visited by vector Control technician data Department/ control technicians collection form region/ municipality combined) Reporting frequency: By Gender Male N/A 49,906 N/A 145,206 2,833 Annually

By Gender Female N/A 48,514 N/A 140,055 1,334 By Pregnant Women N/A 1,488 N/A 3,553 29 By Women of N/A 32,894 N/A 91,784 822 Reproductive Age By Children <5 N/A 10,873 N/A 30,146 261 1.1.3 Number and percentage of Data source: Vector Control Total (All N/A 26.82% N/A 44.99% 77,023 (93.05%) households receiving one vector technician data collection Department/ region/ control visit per intervention form municipality cycle combined)

107

Collection frequency: By Department/ N/A Chiquimula N/A Chiquimula Chiquimula Monthly region/ municipality 7,614 (26.82%) 13,899 (32.32%) 38,560 (94.63%) Quarterly Zacapa Zacapa 17,326 (74.58%) 20,924 (93.48%) El Progreso El Progresso 94.63% 8,093 (38.26%) 17,539 (91.04%)

1.2.1 Number of structures Data source: Previous spray By Spray Campaign 12,000 10,947 6,375 5,500 N/A targeted for spraying35 campaign data, enumeration data (targets); Daily Spray Operator Forms (results)

Reporting frequency: Daily per spray campaign 1.2.2 Number of structures Data source: Daily Spray By Spray Campaign 12,000 10,947 6,375 5,500 N/A sprayed with IRS Operator Forms

Reporting frequency: Daily per spray campaign 1.2.3 Percentage of total Data source: Daily Spray By Spray Campaign 100% 89% 100% 66% N/A structures targeted for spraying Operator Forms that was sprayed with a residual insecticide (Spray Coverage) Reporting frequency: Daily per spray campaign 1.2.4 Number of people residing Data source: Daily Spray By Spray Campaign N/D 30,010 N/D 14,026 N/A in structures sprayed (Number of Operator Forms people protected by IRS) Reporting frequency: Daily By Gender Male N/D 14,778 N/D 7,171 N/A per spray campaign

By Gender Female N/A 15,232 N/A 6,876 N/A

By Pregnant Women N/A 226 N/A 110 N/A

35 Only for countries implementing IRS

108

Women of N/A N/A N/A 3,763 N/A Reproductive Age

By children <5 years N/A 3,272 N/A 1,181 N/A old

1.2.5 Number and percentage of Data source: Project records By Spray Campaign N/A 1, 100% N/A 1, 100% N/A soak pits and storehouses – Reports submitted by By Soak Pit inspected and approved prior to district environmental By Storehouse spraying officers

Reporting frequency: Each spray season Component 2: Contribute to the collection and analysis of routine entomological data 2.1 Number of entomological Data source: Entomological N/A 54 clusters for IRS 54 clusters for IRS 5 clusters in 3 5 4 sentinel sites supported by ZAP reports and ZAP country and 3 sentinel sites and 2 sentinel sites sentinel sites (Chiquimula control (Chiquimula ES monitoring species work plan and intervention, control/interventio composition Guastatoya, n, Teculutan, Reporting frequency: Annually Zacapa,Teculutan) Guastatoya) 2.2 Number of entomological Data source: Entomological N/A 54 clusters for IRS 54 clusters for IRS 5 clusters in 3 5 4 sentinel sites supported by ZAP reports and 3 sentinel sites and 2 sentinel sites sentinel sites (Chiquimula control (Chiquimula ES monitoring egg density, larvae and intervention, control/interventio density, and pupae density Reporting frequency: Annually Guastatoya, n, Teculutan, Zacapa,Teculutan) Guastatoya)

2.3 Number of entomological Data source: Entomological N/A 54 clusters for IRS 54 clusters for IRS 2 clusters in 2 2 1 sentinel sites supported by ZAP reports sentinel sites (Teculuan and Teculutan ES established to monitor adult Zacapa) density Reporting frequency: Annually

2.4 Number and percentage of Data source: Entomological N/A 54 clusters for IRS 54 clusters for IRS 5 clusters in 3 5 4 entomological monitoring sentinel reports and 3 sentinel sites and 2 sentinel sites sentinel sites (Chiquimula control (Chiquimula sites measuring all seven and intervention, control/interventio entomological indicators Reporting frequency: Annually Guastatoya, n, Teculutan, Zacapa,Teculutan)) Guastatoya)

109

2.5 Number and percentage of Data source: Entomological N/A 3 6 sentinel sites 3 3 sentinel sites 3 sentinel sites sentinel sites that tested at least reports were included for were consistently were consistently one insecticide from each of the all insecticide included for all included for all three classes of insecticides Reporting frequency: Annually testing (five from El insecticide testing insecticide testing recommended for vector control Progreso and one (El Progreso, (El progreso, from Chiquimula) Zacapa, Zacapa, Additional sites Chiquimula) Chiquimula) 100% were considered Additional sites for specific tests. were for specific tests. 2.6 Number and percentage of Data source: Entomological N/A 3 3 sites (2 from El 3 3 sentinel sites 3 sentinel sites sentinel sites that tested at least reports Progreso and 1 were consistently were consistently one larvicide from each of the from Chiquimula); included for all included for all three classes of larvicides Reporting frequency: Annually percentages of insecticide testing insecticide testing recommended for vector control mortality were (El Progreso, (El progreso, variable Zacapa, Zacapa, Chiquimula) Chiquimula) 100% 2.7 Number and percent of Data source: Entomological By Spray Campaign 44 households 24 hours post IRS 30 households 24 hours post IRS N/A homes receiving wall bioassays reports (HHs) (58 HH= 100%) (HHs) (53 HH= 100%) conducted after the completion of 1 month post IRS 1 month post IRS spraying at monthly intervals to Reporting frequency: Monthly (44 HH= 100%) (47 HH= 100%) evaluate insecticide decay 2 months post IRS 2 months post IRS (39 HH= 88.64%) (44 HH= 100%) 3 months post IRS 3 months post IRS (25 HH=56.82%) (42 HH= 100%) (42 HH= 100% percentages were received variable continuous wall bioassays) Component 3: Capacity Building and Human Resources

3.2 Total number of people Data source: Project records – Total (All 156 157 168 197 13 trained to conduct vector control Training reports Department/ region/ in target departments municipality Reporting frequency: Annually combined) By Gender Male N/A 122 N/A 121 7

By Gender Female N/A 35 N/A 76 6

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By Type of Vector Larviciding Larviciding Larviciding Larviciding Larviciding Control Activity 79 trainees 77 persons 90 trainees 116 persons 68 technicians 113 persons 26 persons (38 male, 30 (72 male, 41 female) female) 9 technicians from 3 technicians from MoH (9 male) MoH (3 male) IRS IRS IRS IRS 86 89 78 84 (84 male, 5 female) (49 male, 35 10 technicians from Female) MoH (10 male) 12 technicians from MoH (12 male) 3.3 Total number of people Data source: Project records – By Year N/A Total 114 persons N/A Total 78 persons 15 persons trained to conduct Entomological Training reports 5 technicians from 9 Trainers Surveillance in target departments MoH for 45 for ento Reporting frequency: Semi- susceptibility tests surveillance for IRS annually 56 for ento 15 for ento surveillance for IRS surveillance for 5 technicians for larviciding residuality tests 9 from MoH for 10 technicians for susceptibility and laboratory residuality tests 4 technicians for insectary 34 technicians for ento surveillance for larviciding By Gender Male N/A 70 N/A 45 15

By Gender Female N/A 44 N/A 33 0

By Position36 N/A 5 N/A 9 Coordinator 1 technicians/supervis Trainers/supervisor Supervisor 4 ors from MoH s Technicians 10 109 technicians for 60 field and lab field and lab for technicians ento surveillance 9 technicians and supervisors from MoH

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By Department/ N/A 80 from El N/A Zacapa 58 El Progreso 2 region/ municipality Progreso El Progreso15 Chiquimula 4 34 from Chiquimula5 Zacapa 9 Chiquimula 3.4 Number and percentage of Data source: Project records – Total (All N/A 3 N/A 8 0 women hired in supervisory roles Contracts signed Department/ region/ in non-IRS target departments municipality Reporting frequency: combined) Annually

N/A Chiquimula 3 N/A Chiquimula 4 0 By Department/ El Progreso1 region/ municipality Zacapa 3

3.5 Number and percentage of Data source: Project records – Total (All N/A 1 N/A 3 N/A women hired in supervisory roles Contracts signed Department/ region/ in IRS target departments municipality Reporting frequency: combined) Annually

N/A El Progreso 1 N/A Zacapa 3 N/A By Department/ region/ municipality

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