In 2006, the World Health Organization issued a position statement promoting the use of indoor residual spraying (IRS) with dichlorodiphenyltrichloroethane (DDT) for malaria vector control in epidemic and endemic areas. Other international organizations concurred because of the great burden of malaria and the relative ineffectiveness of current treatment and control strategies. Although the Stockholm Convention of 2001 targeted DDT as 1 of 12 persistent organic pollutants for phase-out and eventual elimination, it allowed a provision for its continued indoor use for disease vector control. Although DDT is a low-cost antimalarial tool, the possible adverse human health and environmental effects of exposure through IRS must be carefully weighed against the benefits to malaria control. This article discusses the controversy surrounding the use of DDT for IRS; its effective implementation in Africa; recommendations for deployment today, and training, monitoring, and research needs for effective and sustainable implementation. We consider the costs and cost effectiveness of IRS with DDT, alternative insecticides to DDT, and the importance of integrated vector control if toxicity, resistance, and other issues restrict its use.

Background Patient portals are becoming ubiquitous. Previous research has documented substantial barriers, especially among vulnerable patient subgroups such as those with lower SES or limited health literacy (LHL). We tested the effectiveness of delivering online, video-based portal training to patients in a safety net setting. Methods We created an online video curriculum about accessing the San Francisco Health Network portal, and then randomized 93 English-speaking patients with 1+ chronic diseases to receive: 1) an in-person tutorial with a research assistant or 2) link to view the videos on their own. We also examined a third, non-randomized usual care comparison group. The primary outcome was portal log-in (yes/no) 3–6 months post-training, assessed via the EHR. Secondary outcomes were self-reported attitudes and skills collected via baseline and follow-up surveys. Results Mean age was 54, 51% had LHL, 60% were non-white, 52% were female, 45% reported fair/poor health, and 76% reported daily Internet use. At follow-up, 21% logged into the portal, with no differences by arm (p=0.41), but this was higher than the overall clinic rate of 9% (p<0.01) during the same time period. We found significant pre-post improvements in self-rated portal skills (p=0.03) and eHealth literacy (p<0.01). Those with LHL were less likely to log in post-training (p<0.01). Conclusions Both modalities of online training were comparable, and neither mode enabled a majority of vulnerable patients to use portals, especially those with LHL. This suggests that portal training will need to be more intensive or portals need improved usability to meaningfully increase use among diverse patients.