Table 2. Overall assessment of the validity of current management practices for KFD.

Current management recommendations for KFDV	Local empirical evidence	Evidence from other systems	Rationale for evidence score	Effectiveness of management practice	Rationale for effectiveness assessment	Recommendation
PPMs should be taken (long clothes covering neck, chest, back, and legs) before going to the forest	Green	Green	Good evidence from multiple systems that PPMs can reduce tick bites	Amber	Only effective in conjunction with application of effective repellents, washing the clothes and body, and effective checking and removal of attached ticks	PPMs should be recommended for any activity where persons may brush against vegetation that may harbour ticks, not just forests, and should include covering the feet and tucking in clothes
People living in the forest or visiting forest areas should use tick repellents (DMP oil, DEET, or local herbs) before going to the forest. Permethrin-based repellents should be used on clothing	Amber	Green	Good evidence that repellents prevent tick bites, but efficacy of locally available repellents may be poor or untested	Amber	Locally available repellents may have poor efficacy. Only effective in conjunction with appropriate clothing, washing the clothes and body, and effective checking and removal of attached ticks	Recommend applying repellents during any activity where persons may brush through vegetation that may harbour ticks, not just forests, and guidance on reapplying repellents regularly
People should wash their clothes and body with hot water and soap after returning from the forest	Amber	Green	Good evidence from other systems that washing can remove unattached ticks, but more limited local evidence and people use cold water	Amber	Only effective in conjunction with wearing of appropriate clothing, application of effective repellents, and effective checking and removal of attached ticks	Recommend that additional education is needed to inform people that washing alone will not remove attached ticks from the body
The spraying of insecticide (malathion) may be carried out in areas where monkey deaths have been reported within a radius of 50 feet around the location of the monkey death. It is also effective on forest tracks frequently visited by people for various activities	Red	Amber	May be effective over the area of spraying in the short term but effectiveness untested locally and little known about resistance	Red	Infected ticks likely to be found across broader habitats associated with monkey deaths so spraying a small area is likely ineffective. Malathion resistance may be problematic	Not recommended without empirical evidence of effectiveness and better knowledge of the scale of infection risk
Application/injection of insecticide on/into cattle can prevent ticks and the transportation of ticks from forests to dwelling premises	Amber	Amber	Acaricides can be effective at lessening tick burden on livestock (although caution needed due to resistance), but no evidence that they prevent tick movements	Red	May well prevent tick movements but no empirical evidence that cattle are associated with higher prevalence of human KFDV cases. Untested whether cattle might operate as diluting hosts for KFDV	Need more evidence before recommending as KFDV preventative measure but need to consider prevention of other tick transmitted infections too
Controlled burning of the dry leaves and bushes in the forest boundaries, premises of human habitats	Red	Amber	Conflicting evidence about the temporal scale over which this lowers tick abundance, lack of data on whether forests are main KFDV-risky habitat	Red	Unclear whether this may increase tick abundance in the longer term	Not recommended without empirical evidence of effectiveness and better knowledge of the scale of KFDV infection risk
Burning of monkey carcass	Red	Red	No empirical support that dying or dead monkeys create hotspots of infected ticks	Red	Infected ticks likely to be found across broader habitats and burning monkey carcass unlikely to be important for preventing KFD	Recommended as is a good way of disposal of carcasses which may pose a general risk to human health through disease transmission from bodily fluids. Robust postmortems and sample collection protocols needed prior to burning
Vaccination of people within a 5-km radius of cases	Green	Green	Substantial evidence that vaccination reduces human cases of KFDV	Amber	Vaccine efficacy and formulation needs to be improved. Vaccine uptake is poor as administration is painful, requires 3 initial doses, and annual boosters to confer immunity. Modelling is needed to optimise the spatial scale over which vaccination is targeted	Urgent need for a more effective vaccine with fewer doses required and better education to increase uptake. Need better understanding of the scale at which risk operates
Educate the villagers to avoid the forests areas where monkeys have died. Don’t visit the area where recent monkey death has been reported, especially an area where case of KFDV has been reported in the past	Amber		Evidence that monkeys may act as sentinels of human disease but poor empirical evidence over the mechanism and spatial scaling	Amber	If monkeys are effective sentinels then avoiding forests may help prevent human cases	Need better empirical evidence of tick habitat associations and better knowledge of the scale of infection risk. Education needed on effective PPM and risk associated with brushing against vegetation, not just in forests
Don’t bring the leaves of trees from KFDV-infected area to the village for cattle bedding material	Amber		Ticks have been found in leaf litter but survival times in such litter are unknown	Amber	May prevent the spread of infected ticks but need for better empirical evidence. Alternative sources of bedding may not be available	Need better empirical testing of the risks posed by leaf collection from different habitats, and the levels of tick infestation in leaf litter used for animal fodder and bedding. Also need more education on appropriate PPM
Don’t handle the infected monkey carcass by bare hand without personal protective equipment	Amber	Amber	Good evidence from multiple systems that protective clothing can reduce tick bites but needs to be more than wearing gloves	Amber	Only effective in conjunction with application of effective repellents, washing the clothes and body, and effective checking and removal of attached ticks. Needs to be undertaken not just when handling monkey carcasses	Monkeys should not be handled by members of the public. PPM should be recommended for any activity where persons may brush against vegetation that may harbour ticks, not just when handling monkeys
Highlighting risky activities: for example, to not sit on the ground or in bushy areas of the forest	Amber	Amber	Evidence that ticks move onto humans when they brush against vegetation, some species actively quest. Limited empirical quantification of questing behaviour in vectors associated with KFDV in the wild and of the risk associated with different habitats and human activities	Amber	Difficult to judge effectiveness without further empirical data on how activities in different habitats increase KFD risk and on tick habitat associations. Emphasis should not just be on forests without better empirical data on risk	Reasonable to keep recommendation but to expand to be aware that risk of ticks may occur in habitats other than forests and that effective PPM, use of repellents, and checking for ticks are essential
Human disease surveillance: surveillance of fever cases between December and May with sera screened for KFDV antibodies in order to target vaccination	Green	Green	Surveillance is a useful way of monitoring past and present spillover	Amber	Surveillance needs to be undertaken strategically across areas both within and out with the historical KFD regions	Recommended but improvements could be made to how surveillance effort is targeted
Tick surveillance: surveillance is undertaken within 5 km of areas where human cases were recorded in the previous year (for up to 5 years) or within 5 km of areas with current monkey deaths. Surveillance is not undertaken if current human cases are recorded	Green	Green	Surveillance of ticks can be an effective way of monitoring past and present spillover	Amber	Effectiveness difficult to judge without better empirical knowledge of KFDV infection–tick–host–habitat associations so that surveillance can be effectively targeted. Surveillance needs to be undertaken strategically across areas both within and out with the historical KFD regions with more systematic sampling of habitats and across seasons	Valuable management tool. Needs better underpinning by empirical evidence to enable better targeting of habitats and seasonality. Need additional information on hosts to be able to determine best surveillance strategies in terms of habitats and spatial scale and hosts (e.g., rodents) to target
Monkey disease surveillance: testing of dead and dying monkeys for KFDV infection	Green	Green	Monkeys are known to be amplifying hosts for the virus so are useful sentinels that may give warning of impending human infections	Amber	Stratified proactive sampling of monkeys is not undertaken, just reactive sampling of dead or dying monkeys	More stratified sampling of monkey blood for both antibodies and active infection with KFDV at sentinel sites. Better education about reporting dying/dead monkeys and faster response and sampling of monkeys and sampling for ticks around carcasses and the broader environment are recommended

Empirical support underpinning each management recommendation are assessed based on a traffic light scale at both the local level (Western Ghats of India for KFD) and also at a more global scale if evidence for this management being effective has been observed in other tick-borne disease systems (left blank if not applicable). Red indicates no or poor support; amber indicates some support from observations and laboratory studies but lacking rigorous empirical data in a field setting; and green indicates good support including rigorous empirical field data. Management effectiveness was also scored on a traffic light scale: Red indicates that the management practice is unlikely to significantly reduce human cases of KFD; amber indicates that it is unknown whether the management practice will reduce human cases; and green indicates that the management practice will reduce human cases of KFD.

DMP, dimethyl phthalate; KFD, Kyasanur Forest Disease; KFDV, Kyasanur Forest Disease Virus; PPM, personal protection measure.