The Democratic Republic of the Congo adopted the strategy of using, at the community level, a dose of rectal artesunate as a pre-referral treatment for severe malaria amongst children under 5 years who could not quickly reach a health care facility and take oral medication. However, the adherence to referral advice after the integration of this strategy and the acceptability of the strategy were unknown.To assess adherence by the mothers/caretakers of children under 5 years to referral advice provided by the community health workers after pre-referral treatment of severe malaria with rectal artesunate, the authors conducted a noninferiority community trial with a pre- and post-intervention design in 63 (pre-intervention) and 51 (post-intervention) community care sites in 4 provinces  from August 2014 through June 2016. The pre- and post-intervention surveys targets 387 mothers of children under 5 years and 63 community health workers and 346 mothers and 41 community health workers, respectively. A 15% margin was considered for noninferiority analyses due to the expected decrease in adherence to referral advice after the introduction of the new intervention.The mothers acknowledged that the rectal route was often used (60.7%), and medicines given rectally were considered more effective (63.6%) and easy to administer (69.7%). The acceptability of pre-referral rectal artesunate was relatively high: 79.4% (95% CI 75.4–83.3) among mothers, 90.3% (95% CI 82.3–96.8) among community health workers, and 97.8% (95% CI 93.3–100) among nurses. Adherence to referral advice at post-intervention [84.3% (95% CI 80.6–88.1)] was non-inferior to pre-intervention adherence [94.1% (95% CI 91.7–96.4)].The integration of pre-referral rectal artesunate for severe malaria into the community care site in the DR Congo is feasible and acceptable. It positively affected adherence to referral advice. However, more health education is needed for parents of children under 5 years and community health workers. Globally, an estimated 435,000 people died of malaria in 2017. Approximately 61% of the victims were children under 5 years (CU5), and 93% of those malaria deaths occurred in the World Health Organization (WHO) African Region. Among the 17 countries that had nearly 80% of the malaria deaths globally in 2017, Nigeria accounted for the highest proportion of deaths (19%), followed by the Democratic Republic of Congo (DRC) (11%) [Severe malaria progresses in children very quickly, and once a patient can no longer be given oral medication, survival depends upon quickly being taken to the hospital, where parenteral treatment can be given. Parenteral anti-malarial treatment is sometimes available at the primary health care level. However, access to parenteral treatment is quite difficult, and the delay can have a negative impact on the progress of the disease, even leading to death. Because the disease progresses rapidly, the risk of death from severe malaria is greatest in the first 24 h of the onset of symptoms , yet in Therefore, the 2010 WHO guidelines for the treatment of malaria recommend the use of an emergency treatment for patients with suspected severe malaria before their transfer to a health facility. The WHO-recommended pre-referral treatment options include intramuscular artesunate, artemether or quinine, or rectal artesunate (RA) .Evidence from recent studies demonstrates that in situations where IV administration is not possible and intramuscular injection is impractical , the use of a single dose of RA as pre-referral treatment reduces the risk of death or permanent disability in young children . The useIn line with the WHO recommendation, the DRC adopted the strategy in 2012 but delayed its implementation because its acceptability and feasibility were still unknown. In its effort to reduce the morbidity and mortality of malaria, the DRC in 2005 launched the community-based management of malaria integrated with pneumonia and diarrhoea at community care sites (CCSs) within the framework of the Integrated Management of Childhood Illness (IMCI).The cornerstone of this strategy is the early detection and prompt treatment of clinical cases, and CHWs are given the opportunity to diagnose and treat malaria. This requires that effective and appropriate treatment with first-line oral artemisinin-based combination therapy (ACT) and guidance on referral criteria are provided at the community level through trained CHWs. Community-based management of malaria allows the coverage of health services for malaria to extend beyond the reach of health facilities. Diagnosis with a rapid diagnostic test (RDT) prior to the treatment of malaria-positive patients with ACT is currently the recommended practice. Severe cases should be referred to an appropriate facility.CCSs are well-defined geographic areas covering one or more villages that are far from a health facility (more than 5 km) and that receive health care services provided by two trained CHWs. The CHWs are trained in IMCI and are selected and appointed by the communities. They provide the following services under the supervision of the chief nurse of the health facility (primary point of care): community management of childhood diseases , including the referral of cases with danger signs; community outreach activities; and community-based surveillance of diseases. Some studies have shown that in some countries, it was feasible and acceptable to use rectal artesunate at the community level as a pre-referral treatment for severe malaria –9. In coAlthough the feasibility and acceptability of the strategy has been demonstrated, its effect on adherence to referral advice has not been thoroughly assessed. Vermeersch et al. noted the need to address the mother’s judgement of the severity of malaria to prevent overuse of the RA as a pre-referral treatment . MoreoveThe primary objective of this study was to assess the adherence of the mothers/caretakers of CU5 to referral advice after pre-referral treatment of severe malaria with RA at the community level. The secondary objectives were to determine the acceptability of the strategy and the knowledge of CHWs regarding danger signs of malaria to better inform scaling up. The main hypothesis was that the integration of pre-referral RA at the community level will not negatively affect the uptake of referrals of CU5 with symptoms of severe malaria, i.e., adherence to the referral advice after the introduction of the “new intervention”  will be noninferior by more than a 15% margin compared to adherence to “reference intervention” .The introduction of RA as a pre-referral treatment for severe malaria might pose the risk that the child will not be taken to a health facility because he or she will appear to get better rapidly after the treatment; however, such non-adherence runs the risk of death from resurgence and the development of drug resistance due to incomplete removal of parasites. However, pre-referral RA is more acceptable because it prevents the danger of death and disability, taking into account that every hour without treatment for severe malaria increases the risk of death . This stA noninferiority community trial with a pre- and post-intervention design was conducted from August 2014 through June 2016 to determine whether the integration of RA for the pre-referral treatment of severe malaria (hereby referred to as the new intervention) within the routine IMCI (referred to as the reference intervention) will not be worse than the reference intervention regarding adherence to referral advice. The margin of noninferiority selected was 15%, i.e., adherence to referral advice at post-intervention will not be more inferior than 15% compared to the pre-intervention adherence.It was assumed that the new intervention would decrease adherence to referral advice because the pre-referral RA, when given promptly in the community, is proven to act rapidly on the danger signs , and rapThe study was conducted at CCSs in rural areas (each with two CHWs) located far from health facilities . The study took place in 63 CCSs (pre-intervention) and 51 CCSs (post-intervention) located in seven health districts, namely, Kanda-Kanda (in the province of West Kasai); Bibanga (Lomami); Bilomba, Lubondaie and Dibaya (Kasai); Fungurume and Lualaba . At post-intervention, the two latter health districts  were excluded from the sampling frame due to budgetary constraints. All health districts were located in high malaria transmission areas, and they were supported for malaria prevention and management interventions by the Integrated Health Project in DRC (IHP) funded by the President’s Malaria Initiative (PMI) and implemented by Management Science for Health (MSH). The CCSs were randomly selected from among villages located in remote areas of the health districts and where there were some trained CHWs providing IMCI care to CU5. At each CCS, one CHW was selected to participate in the study.The primary concern with the implementation of RA at the community level is that referral completion rates will decrease, as caregivers might not realize the necessity of completing referrals because the children might improve clinically and/or because they have already received a medication from the CHW; given this operational concern, a noninferiority analysis was the most appropriate method for sample size and power calculations. This analysis permits researchers to assess whether a given outcome level  is “noninferior” to a designated outcome level  within a certain margin of error.Assuming a 50% referral completion rate to be conservative and a 15% noninferiority limit  than pre-RA roll-out completion rates), 80% power, a Type I error of 0.05, intraclass correlation of 0.05 , sample sizes of 64 CHWs and 384 caregivers were needed based on estimates that 5% of the children seen per month have danger signs (as recorded in CHW registers) and that 45% of participants will complete the follow-up referral.The eligibility criteria for CU5 to be included in the study were as follows: children aged from 12 to 59 months; with fever (or history of fever within 2 days) plus at least one of the following danger signs for malaria : (i) convulsions; (ii) inability to drink, eat or suck; (iii) vomiting all liquids and solids; (iv) altered consciousness/coma; (v) lethargy.At pre-intervention, 420 CU5 who sought consultations from September 2014 through April 2014 at 63 CCSs and who were given referral advice because of the presence of fever (or a history of fever in the last 2 days) and at least one danger sign of malaria were randomly selected and included in the study. A total of 384 mothers/caretakers (91.4%) of CU5 were successfully located and interviewed. After three unsuccessful visits to the household during the study period, the remaining 36 mothers/caretakers of CU5 were excluded. At post-intervention, 346 mothers/caretakers of CU5 who consulted at the CCSs were interviewed. In addition, 63 CHWs and 41 CHWs were included in during the pre- and post-intervention periods, respectively.This was a pilot implementation conducted in rural settings in which care-seeking at health facilities was low and was substantially delayed due to poor access. The principal intervention of interest was the addition to the IMCI package of a single pre-referral dose of RA administered by a CHW to a CU5 with suspected severe malaria and referral advice given to mothers/caretakers. As per the standardized national IMCI guidelines, all children aged 2 months to 59 months who presented at the CCS with fever (or a history of fever in the past 2 days) and at least one danger sign of malaria received one single dose of artesunate suppository corresponding to their age as a pre-referral treatment without being tested for malaria by an RDT. In addition, the CHWs advised the children’s mothers/caretakers to immediately go to the nearest health facility for comprehensive treatment for severe malaria. There was no child in the sample who experienced a side effect after receiving the pre-referral RA for severe malaria or who died.The CCSs selected for this study have been functioning for a few years and have managed uncomplicated malaria, diarrhoea and pneumonia. With the integration of severe malaria treatment  into the IMCI package, the CHWs were trained on this new topic. This training also covered how to correctly fill out various health forms, such as case record forms, to ensure the quality of the data that were collected.The intervention was implemented from May 2015 through June 2016. Specifically, it consisted of the following activities: (i) refresher trainings of CHWs and chief nurses (those in charge of overseeing CHWs) on the correct identification of the five danger signs of malaria and the correct administration of the rectal artesunate; (ii) pre-referral treatment of eligible CU5 with rectal artesunate; (iii) provision of referral advice to the mothers/caretakers of CU5 to proceed to the nearest health facility for comprehensive severe malaria treatment; (iv) post-referral home visits to check for adherence to referral advice and the status of the referred CU5; (v) following the routine health system’s supply chain management, regular supply of selected CCSs with artesunate suppositories from the chief nurse at the nearest health facility; (vi) regular supervision visits of the CCS conducted by the chief nurses and by the study team.During the training sessions, in addition to the themes developed in the context of standardized national IMCI guidelines, the focus was on identifying the danger signs and management of severe malaria with pre-referral artesunate suppository in CU5 and referral counselling. The CHW training concluded with a post-training test of their knowledge and skills. CHWs who passed this test were certified to include the prereferral RA in their tasks. Those who did not pass were given the opportunity to obtain additional training and retest. Certification was required to manage severe malaria with RA and participate as a CHW in this intervention study.As severe malaria is a relatively rare condition, it was important to understand how well-certified CHWs could use and retain their competencies. Thus, monthly evaluations and post-training sessions were provided to the selected CHWs by trained health providers, such as nurses or doctors in targeted health zones. In addition, on a quarterly basis, the trained health providers, along with the study team (supervisors), went to the targeted CCSs to review the case record forms that CHWs complete for each suspected case of severe malaria. This group specifically looked for errors related to case identification, doses given, expulsion of the suppository, referral advice provided, and referral slips given to caregivers. These supervisors also tested the CHWs’ knowledge regarding the identification of cases through scenarios involving hypothetical cases of CU5 presenting with various symptoms, administration of RA treatment, referral of patients to the hospital, and follow-up after patients returned home.Data collection was carried out in two phases: pre-intervention and post-intervention. At pre-intervention, data on perceptions of severe malaria, history of treatment via the rectal route and acceptability of the pre-referral treatment were collected through a mixed approach . The results presented in this article will be limited to the quantitative approach, which consisted of conducting interviews of the mothers/caretakers of CU5, CHWs and chief nurses with a structured questionnaire.During the two study periods, data on adherence to referral advice were assessed based on self-reports by the mothers/caretakers of CU5 that they went to the nearest health facility for a comprehensive treatment according to the referral advice they received. In addition, at post-intervention, data on adherence to referrals were double-checked with follow-up interviews (performed by CHWs 7 days after the child received RA) and interviews conducted by the study team at the end of the study period.Data collected through the quantitative approach were recorded using Epidata software ver 3.1 and analysed with SPSS version 20. Proportions with 95% confidence intervals were calculated for the primary outcome  and secondary outcomes . Comparisons of proportions between pre-intervention and post-intervention for CHWs who knew all five danger signs of malaria were performed using the paired t-test. In addition, the z test for the comparison of differences between two proportions was used for noninferiority analysis with a 15% margin (Δ).Bivariate analysis using the Pearson (or Fisher exact) Chi-square test was used to assess the association between key independent variables  and the dependent variable . Multiple logistic regression analysis was performed to identify variables  independently associated with adherence to referral advice.The sociodemographic characteristics of the mothers/caretakers and CHWs are shown in Tables The interviewed mothers stated that the rectal route was often used (60.7%), and medicines given rectally were considered more effective (63.6%) and easy to administer (69.7%). When asked about prior knowledge of the rectal artesunate, 8.7% of the mothers/caretakers reported that they had already heard about it, mainly through CHWs (75%) or family members (25%). In addition, the interviewees were asked if they could use RA for the pre-referral treatment of severe malaria in their CU5 when it was offered by the CHW. The acceptability of RA was relatively high: 79.4% (95% CI 75.4–83.3) among mothers, 90.3% (95% CI 82.3–96.8) among CHWs, and 97.8% (95% CI 93.3–100) among nurses.The main recommendations outlined by the mothers/caretakers to ensure the success of the strategy were as follows: reinforce community outreach regarding the pre-referral treatment (46.7%), ensure the regular provision of artesunate suppositories (21.1%), reinforce the training of CHWs (14%) and offer pre-referral RA free or at low cost (8.4%).The median age of the children enrolled in the study at the pre- and intervention periods was 2 years (IQR = 2) and 3 years (IQR = 2), respectively; for mothers/caretakers, it was 28 years (IQR = 13) and 31 years (IQR = 13), respectively. The adherence to referral advice at pre- and post-intervention was 94.1% (95% CI 91.7–96.4) and 84.3% (95% CI 80.6–88.1), respectively. Hence, adherence at pre-intervention was noninferior compared to adherence at post-intervention .Bivariate analysis showed that there were significant differences in adherence status according to the mothers’/caretakers’ education and marital status (p < 0.001) and whether the CU5 presented symptoms upon arrival at the CCS (p < 0.001) Table .Table 3RMultiple logistic regression analysis showed that the odds of adhering to referral advice were two times greater for educated mothers/caretakers than for mothers/caretakers with no education .In addition, at post-intervention, the study examined some characteristics that underlie adherence to referral advice, including the following factors: symptoms presented by the children under five that led mothers/caretakers to consult a CHW; mothers’/caretakers’ care-seeking behaviours when a danger sign of malaria was presented by children under five; person who made the decision to consult a CHW or visit a health care facility; CHWs’ capacity to recognize danger signs of malaria in children under five and to give pre-referral treatment and referral advice. Figure Regarding the knowledge of CHWs for identifying cases with danger signs of malaria that were tested through scenarios involving hypothetical cases of CU5 presenting with various symptoms, 41.5% of the CHWs (n = 41) could correctly identify the five danger signs of malaria at post-intervention, compared to none at pre-test (p < 0.05). The reasons for not adhering to referral advice were diverse and are shown in Fig. The study findings confirm that the integration of RA for pre-referral treatment of severe malaria into the routine IMCI strategy was feasible and acceptable; acceptability was 79.4% among mothers, 90.3% among CHWs, and 97.8% among nurses. The high acceptability rate of this innovative intervention by the community is very important from a public health point of view, as the National Malaria Control Programme is expecting to deploy the RA for pre-referral treatment of severe malaria on a large scale.The acceptability rate is similar to those observed in other studies –9. This Another explanation for the high acceptance of RA was that malaria was perceived by the community as a public health emergency and was considered to be responsible for most deaths among children. Moreover, confidence among the community in the health services provided by CHWs was observed.Results showed that adherence to referral advice after integration of the pre-referral rectal artesunate was not more than 15% inferior compared to the initial adherence. This result strongly advocates recommendations to scale up the strategy throughout the country, as the findings stressed that introduction of the pre-referral rectal artesunate, which is a life-saving strategy, did not negatively affect adherence to referrals. In fact, failure to adhere to referral advice might delay identification of the real cause of the disease, while rapid recovery may lead to caretakers to perceive that no further treatment is necessary . The higAt the time the study was conducted, information on adherence to referral advice after receiving RA for the pre-referral treatment of severe malaria at the community level or on factors influencing adherence after pre-referral treatment was limited. Most of studies have assessed adherence to referrals from primary health facilities to hospitals, and it ranged from 28 to 75% –19.Another study in Afghanistan assessed compliance with referrals for children with serious illness, including acute respiratory infections (ARI), diarrhoea or fever, as provided by any health workers at the community or at the health facility level (primary or secondary) and found that 76% of caregivers complied with the referral advice .One factor that significantly influenced adherence to referral advice was the level of education of the mother/caretakers. Al Fadil found similar results in Sudan . In addiConsidering that one of the key challenges in delivering health care services in the DRC is geographical accessibility, especially in remote rural areas where some villages are located more than 5 km  from the nearest health care facility, the CHWs trained in IMCI offer a good alternative that extends primary health care to communities by maintaining linkages with formal health services.CHWs are nonmedical volunteers who live in the catchment area they serve and can provide early treatment for diarrhea, pneumonia and malaria at any time of the day. However, this advantage is not always the case in other sub-Saharan African settings, as reported earlier in Malawi, where CHWs are government employees and live outside the catchment area . OverallHowever, failure for them to recognize danger signs of malaria as per the standardized IMCI case-definition would prevent expected health outcomes of the pre-referral RA strategy. That is, why Newbrander emphasized achieving successful child survival through recognition by health care providers of general danger signs of diseases that need referral . The resThe risk of misclassification of suspected cases of severe malaria was more pronounced, with the results showing that one reason mothers/caretakers did not adhere to the referral advice is that the child recovered after the RA, which is extremely unlikely if the child had severe malaria and received just one single dose of RA. Finally, although the success of this strategy depends greatly on the adherence of mothers/caretakers to referral advice, the current findings also highlight the need to reinforce CHWs’ capabilities to distinguish symptoms suggestive of severe malaria from all other serious conditions that a CU5 may present to ensure prompt pre-referral treatment and to prevent overuse of the pre-referral RA .Adherence was assessed based on the self-reporting of the mothers/caretakers. Although the effective arrival time of the CU5 at the referral health facility was not checked, the CHWs systematically conducted follow-up interviews with the mothers/caretakers of all children who were given RA and referred. These visits enabled assessment of the child’s status and the collection of self-reported information regarding the referral facilities to which the child was taken. Other studies should more thoroughly explore adherence rates before and after the administration of pre-referral treatment at the community level, for instance, by providing a referral note that will be stamped at the facility on arrival and returned to the mothers/caretakers or by reviewing hospitalization registries at the health facility level.Integration of the pre-referral strategy for severe malaria into CCSs in the DRC is feasible and acceptable, and it positively affects adherence to referral advice. However, more health education is needed for parents of CU5 to raise awareness of the danger signs of malaria and reinforce prompt care-seeking behaviours. In addition, regular provision of RA and more training is needed for CHWs and nurses to increase their performance in the management of severe malaria at the community level.


Traps were run for 12 nights in a Latin square design at Rainham Marshes, Essex, UK in September 2018. The 3D-printed trap showed equivalent catch rates to the two commercially available traps. The 3D-printed trap designs are distributed free of charge in this article with the aim of assisting entomological field studies across the world.Mosquito surveillance is a fundamental component of planning and evaluating vector control programmes. However, logistical and cost barriers can hinder the implementation of surveillance, particularly in vector-borne disease-endemic areas and in outbreak scenarios in remote areas where the need is often most urgent. The increasing availability and reduced cost of 3D printing technology offers an innovative approach to overcoming these challenges. In this study, we assessed the field performance of a novel, lightweight 3D-printed mosquito light trap baited with carbon dioxide (CO Key species include members of the genus Anopheles and, accordingly, many organizations use these traps as a core part of their vector surveillance programs4. The BG-Sentinel trap  with accompanying attractant lure (BG-lure) is also frequently used to sample a wide range of mosquito species during both the day and night, notably Aedes and Culex species5. Together with others, these traps provide effective and rapidly deployable mosquito trapping capabilities. However, for some organisations and governments, the trap and shipping costs can be prohibitive for large-scale deployment.Mosquito surveillance is fundamental to the monitoring of vector-borne disease risk and the planning and evaluation of vector-control strategies. A wide variety of different sampling methods are used9. The 3D printer gradually stacks layers of the chosen material such as polylactic acid (PLA) filaments to build up the digitally modelled 3D objects. The biggest advantage of the 3D printer is that anybody in the world who has access to a 3D printer or 3D printing services can create uniform objects when 3D model data are provided. Although the design, creation and modification of the 3D object require a computer and specialist software, several user-friendly software programs suitable for beginners are available for free. These include, but are not limited to, Design Spark Mechanical (https://www.rs-online.com) and FreeCAD (https://www.freecadweb.org). The size and cost of 3D printers has greatly decreased in the past few years due to expired core patents related to the 3D printing technology and compact benchtop devices are now widely available. These technological developments mean that an organisation would only require a one-time purchase of a 3D printer setup and, with the availability of an appropriate digital model, could produce multiple traps at a low cost per trap.In recent years, the availability of 3D printing technology or additive manufacturing, involving the creation of a physical object from digital modelling data, has dramatically increased10. Moreover, Rainham Marshes is a site targeted as part of routine mosquito surveillance by Public Health England due to possible risk of incursion of invasive mosquito species and exotic pathogens. Here we present results of the trap comparison study and discuss the potential for wider adoption of 3D-printing into trap design and the incorporation of the 3D-printed light trap into vector surveillance programs.Here, we used 3D printing technology to design a light trap with minimal production costs using a freely-available design software. The trap was designed to have a reduced weight and size compared to most commercially available models whilst maintaining equivalent trapping efficiency. Furthermore, the trap was designed to reduce the required battery weights, often the heaviest component of a trapping setup, thus enhancing portability. In this study, we compared the sampling efficacy of our 3D-printed mosquito light trap with the CDC light trap and BG-Sentinel 2 trap in Rainham Marshes, Essex, United Kingdom (UK). This is a managed area of grazing marshland in the Thames Estuary region which supports abundant populations of wildlife and is situated close to both London and to areas of similar marshland habitat where large mosquito populations have been describedThe 3D-printed trap design was successfully produced with a reduced size and weight compared to the two commercial traps Fig. . ExcludiCuliseta (Culicella) morsitans   and Culex pipiens s.l. . The remaining six species totalled fewer than 10 samples, except for 25 samples of Anopheles (Anopheles) claviger s.s. (Meigen 1804). No statistical significance was observed between the total and species-sex stratified numbers of mosquitoes  and Ae. albopictus (Skuse 1894), for which it has repeatedly proven its high sampling efficacy14. Although these traps were designed to be lighter and less bulky than earlier mosquito trap designs15, we experienced the drawbacks of battery weight during the fieldwork , we have overcome the major weight limitations of some current trap setups. These portable battery packs are lightweight, easily recharged and of lesser or equivalent cost to the 6 V (or D cell) and 12 V traps used for the commercial traps. The AA rechargeable batteries used to power the light are also cheap and readily available. Together with the cost benefits the 3D-printed trap clearly offers significant advantages for field collectors.16. In addition, this study used a yeast mixture to generate CO2 to attract mosquitoes, which may provide a more variable or lower overall CO2 release rate than dry ice. Furthermore, the trap has not been tested for its efficacy in trapping invasive Aedes or Anopheles species, an important component of surveillance systems in many parts of the world. No invasive species are considered to be established in the UK despite recent detections18. Further studies in the UK and further afield are underway to address these data gaps but we envisage a collaborative approach to gathering further data on trap performance for collecting different species to allow for optimisation. This includes testing the trap with different attractant blends or visual cues relevant to the target mosquito species in general. The flexibility of the 3D design allows for such modifications to be made with relative ease.Despite these benefits there are important considerations to take into account prior to the wider deployment of the traps. Firstly, the trap has only been tested at a single field site and so conclusions are limited to the species complement present there and at the time of year selected for the study, which is towards the end of the peak mosquito period in the United KingdomThere are several additional practical limitations to the 3D-printed trap design at present. One issue was that the aluminium tape comprising the battery contact points of the electronic circuit wore out on occasion. To mitigate this, aluminium foil sheets were used to fill the gaps to complete the circuit. Selecting a more robust, but equally low-cost material may be one way of overcoming this issue. A wide range of materials suitable for various applications are available from many sources at a reasonable price. In the future, we believe that 3D printers will be able to create a trap with integrated printed electronic circuits which would preclude such issues.Secondly, the quality of 3D-printed objects is highly dependent on printer settings and filament materials. Some budget-range 3D printers and filaments may not be able to produce each piece of the trap with full precision as modelled in the CAD software or with enough durability for fieldwork. On occasion the surfaces of the printed pieces had to be sanded down to allow for an exact fit. As the quality of 3D printers and filament materials continues to improve we envisage this issue rapidly disappearing.Culicoides19. By openly disseminating the method of trap design and the designs themselves we believe that researchers working in different settings will be able to modify the trap designs to suit their aims  for collecting different vector groups such as We have demonstrated that a 3D-printed trap provides comparable mosquito trapping efficacy in a temperate marshland habitat to two commercially available traps. The significant cost savings and flexibility afforded by the 3D-printed trap could accelerate the gathering of important entomological data worldwide.The study was conducted at RSPB Rainham Marshes Nature Reserve, Essex, UK . The experiment was conducted for two replicates of the Latin squire design  from the 5th to 26th of September 2018. All traps had a setup of a yeast-sugar-mixture  to produce CO2 gas21, and only BG-Sentinel 2 traps had the attractant lure of artificial human skin scent . Approximately 1 hour prior to setting up the traps the yeast mixture was prepared in a 1.5 L PET bottle. To keep the bottle warm, one adhesive-backed disposable heat pad  was attached onto the side of each bottle. A 1.8 m vinyl tube was run from the bottle to each trap, and the outlet of the tube was fixed using a hook and tape either on the top of light trap rain shield or beside the intake funnel of the BG-Sentinel 2 , and BG-Sentinel 2 trap  at six sampling points  was used. We installed electronic circuits using aluminium tape  to power a miniature light bulb  with two 1.2 V AA rechargeable Nickel-Metal Hydride Batteries  connected in parallel. At the bottom of the body-piece, we attached short stockings  and used a transparent cup  as the collection cup. The material costs for the three parts printed in the UK was $3.78 USD (£2.9 GBP), and electronic parts were $6.84 USD (£5.27 GBP) for a total cost of $12.49 USD (£9.61 GBP) for the trap. In general, the battery for 25 hours operation  costs around $43 USD (£33 GBP).A 3D model of the trap was designed and underwent preliminary testing in Nagasaki, Japan. To design the trap, 3D computer-aided design (CAD) software Design Spark Mechanical 2.0 was used . A 3D printer was used to fabricate the trap components , using a black filament . The trap consisted of three 3D-printed pieces: a body-piece to hold a computer fan and two AA batteries to power the light bulb; a light-piece to hold a miniature light bulb; and a rain shield-piece for preventing any materials from entering the collection bag and to facilitate the attachment of a string to hang the trap Fig. . An 8 × 23. The voucher specimens are maintained in the National History Museum in London.Sampled mosquitoes were pinned and morphologically identified to species level under a binocular microscope based on published keysTo test sampling efficacy between three kinds of traps, total and species-sex stratified numbers of mosquitoes were compared. Specifically, a Kruskal-Wallis rank sum test was performed after confirming the data was not normally distributed using the Shapiro–Wilk test. All statistical analyses  were performed using RStudio  with R  backend. The statistical significance level was set to be less or equal to 0.05. In addition, QGIS  was used to create the study site map.We created map using data from Natural Earth and Google Maps. Those allow free use of their maps for research purposes with acknowledgement.Supplementary FiguresSupplementary Data 1Supplementary Data 2Supplementary Data 3Supplementary Dataset S1


In the present paper, experimental and numerical investigations were conducted on concrete bridge barriers utilizing glass fiber reinforced polymer (GFRP) bars with a hook at their ends. Implementation of these hooked bars instead of the bent bars or headed-end bars in the bridge barriers presented in the Canadian Highway Bridge Design Code (CHBDC) was investigated on American Association for State Highway and Transportation Officials (AASHTO) test level 5 (TL-5) concrete bridge barriers. This research aimed to reach a cost effective and safe anchorage method for GFRP bars at the barrier–deck junction, compared to the conventional bend bars or headed-end bars. Therefore, an experimental program was developed and performed to qualify the use of the recently-developed, small radius hooked bars at the barrier–deck junction. The experimental findings were compared with the design factored applied transverse load specified in CHBDC for the design of the barrier–deck junction as well as factored applied bending moment obtained at the barrier–deck junction using a recently-conducted finite-element modeling. Satisfactory behavior for the developed hooked GFRP bars as well as their anchorage resistance was established and a reasonable factor of safety in design of barrier–deck joint was achieved. Bending of glass fiber reinforced polymer (GFRP) bars at construction sites is not possible, and bent bars do not have the same strength as straight bars. This problem results in an increase in the number of GFRP bars used in construction. Alternatively, headed-end GFRP bars can address this problem. A vehicle crash test was conducted using a AASHTO test level 5 (TL-5) bridge barrier reinforced with headed-end, sand-coated GFRP bars, and resulted in a new structural design for bridge barriers . AnotherA design for precast ultra-high performance fiber-reinforced concrete (UHPFRC) TL-4 barriers, including investigation into their mechanical behavior under quasi-static transverse loading up to failure, was done both experimentally and using finite element modeling . ExperimTo qualify the revised barrier design in Five TL-5 barrier specimens of 900 mm length were constructed and tested by the authors to collapse at Ryerson University’s Structures laboratory to determine their failure patterns and load carrying capacities. Based on tested concrete cylinders on the day of casting, the average compressive strengths of concrete were 43, 40, 39, 49 and 52 MPa for Specimens # 1 to # 5, respectively, while the characteristic concrete strengths were 37, 35, 38, 45 and 44 MPa, respectively [In The photos of crack patterns at failure and test setups for Specimens # 1 to # 5 are shown in The load–displacement relationship for Specimen # 2 shown in  is depicThe load–displacement relationship for Specimen # 3 shown in  is depicThe load–displacement relationship for Specimen # 4 shown in , with a The load–displacement relationship for Specimen # 5 shown in  is depicAzimi et al.  conducteWhen an errant vehicle collides with a bridge barrier, the lateral impact force is distributed in the barrier wall and the deck slab with dispersal angles, leading to the design forces at the barrier–deck junction specified in CHBDC commentaries . Figure s, cantilever overhang length, Lc, and the barrier length, Lb, were considered in the parametric study by Azimi et al. [s; 0, 0.5, 1.0, 1.5, and 2.0 m for Lc; and 3, 4, 6, 8, 10, and 12 m for Lb. Linear elastic FEA was performed on the TL-5 barrier of c, of 0 represented a fixed base of the barrier wall, for a non-deformable deck slab. Barrier lengths were considered between 3 and 12 m, as this study showed that greater length does not have considerable effect on the results. The reason to choose these length is that the minimum barrier length, Lb, is usually considered to be 3 m in practice, and the maximum barrier length of 12 m was taken into consideration in this study because analysis showed that greater lengths would have insignificant effect on the distribution of forces in the inner portions of the barriers, and no effect at the end portions of the barrier. Transverse loads were applied at the middle of the barrier for interior locations and at the end of barrier for the exterior locations, and were distributed over specified lengths. An equation for factored design moments at the barrier–deck interface was developed based on the statistical package of curve fitting (Slab thickness, ti et al. . The ass fitting , to deteComparisons between experimental and numerical results for the interior and end locations are shown in It was observed that using the proposed reinforcement arrangement presented in Regarding embedment length for the vertical bars, it was observed that 185 mm vertical embedment length for the GFRP bars in the deck slab was sufficient and satisfied the required barrier–deck anchorage capacity. The same GFRP bar arrangement can be used in solid slab and voided-slab bridge cross-sections with a minimum deck slab thickness of 500 mm.The barrier–deck anchorage capacity increased by 20% only when the 180° hooks were oriented towards the outer face of the barrier, compared to the arrangement in which these hooks faced toward the traffic side of the barrier wall.Tensile strains in the diagonal GFRP bars at the front face in the hooked bars and the adjacent middle bars at failure were far below the ultimate strain of the GFRP bars. Additionally, the concrete compressive strain at failure in the outer face of the barrier was also far below the ultimate concrete strain at failure. Moreover, the tensile strain at failure in the steel bars at the fixed end of the cantilever deck slab was below the steel yield strain. These observations support the observed failure mode at the barrier–deck region.Failure of the barrier specimen with deck slab cantilever was due to diagonal tension cracking in the deck slab cantilever just under the barrier wall. On the other hand, failure in the barrier specimen supported over the 500 mm thick deck slab was due to sudden concrete breakout at the location of the embedded GFRP bars in the deck.Based on the experimental findings in this research, the following conclusions can be made: