The MLW team held two successful local dissemination meetings in a COVID-19-safe format for St Montfort Hospital and Chikwawa District Hospital in mid-May 2021. The meetings were attended by representatives from the hospital management teams, lead clinical officers, district health officers, the matrons, and other members of staff from all sections of the hospitals including clinicians, nurses, anaesthetists and administrators. 

The meetings covered presentations on:

• Study operations review 
• Community field work               
• Scientific and statistical data       
• Social science key findings

The meetings were very well received and emphasised some basic practice points. Further meetings at a national level will be organised when the reference laboratory results are available later in the year. 

The social science team discussed their research from clinical observations and the focus on cotrimoxazole being the most frequently used drug at the facilities and within the community. 

The key take home messages were: 
•  A limited number of antibiotics are recognised and there are very low stocks of antibiotics in public health clinics – not suggesting that antibiotics are overused everywhere 
•  Health workers are very committed and manage in challenging conditions where essential medicines beyond those provided by the international donor  programme are very limited 
•   Opportunities exist for rapid gains through antimicrobial resistance policy that reflects the context of this limited access and centres on foregrounding care not restricting access to antibiotics.

FIEBRE finished recruiting patients in Malawi on 31 March 2021. Follow up activities will continue during April.

Congratulations to everyone involved in contributing to the study in both Blanytre and Chikwawa. Many thanks to the clinical, laboratory and technical staff, community engagement team, administrators, data scientists, patients and the local community.  

The first patient was enrolled on 4 July 2018 at Chikwawa District Hospital (CDH). In total, 1765 patients were recruited (over 6200 screened) and the team reached the outpatient recruitment target of 600 for both adults and children. Control recruitment was very effective at 98% and 28-day follow up was high at 91%. This reflects the dedication of the community engagement team.

Initially, FIEBRE started at CDH and second site opened at St Montfort Mission hospital in May 2019 in order to help increase inpatient recruitment.

Community engagement was integral to the study. FIEBRE was helped by long-established community sensitisation work to research in the area. There's been particular interest and concern about the amount of blood taken. These issues are addressed by the team through their continued commitment to working with the local community.
 
The team faced many challenges such as flooding, Cyclone Idai in March 2020, the COVID-19 pandemic and a high number of eligible patients declining to participate for a variety of reasons including:

• Concern about donating blood/large volume when anaemic (severe anaemia is commonplace in Chikwawa)
• Traditional beliefs about losing and sharing blood
• Wanting to seek consent from husband or elder

These sensitive issues were addressed over the course of the study by many staff and patient education and sensitisation sessions explaining the safety and desirability of blood testing in patients who might be suffering from infections. On the whole, these efforts were bearing fruit with increased inpatient recruitment until the arrival of COVID-19 in the spring of 2020.

The COVID-19 pandemic had a considerable impact on the study’s activities; national and institutional restrictions were imposed which slowed down enrolment and limited activities. Although personal protective equipment was available for staff, and infection control measures were in place, with masks and screening at the hospital entrance, people were reluctant to seek healthcare due to a fear of COVID-19 transmission in health centres and of being diagnosed and being sent to a COVID-19 treatment centre.

Despite all the challenges, the FIEBRE team have been able to help support and add to the overall level of care and treatment in the area by providing clinical microbiology services in CDH and SMH for the first time and diagnosing HIV and TB in patients who might otherwise have slipped through the net. FIEBRE staff followed up any positive blood cultures immediately and advised clinicians on antibiotic choice and length of treatment. The study hopes to leave a legacy whereby this service will be continued by the MLW core team.

Many of the FIEBRE team members in Malawi were undertaking their first research role. It has been rewarding to see the team develop and no surprise to see team members grow into more senior roles or be taken up by other studies, research support units or research institutions in Malawi.

Images of the MLW team working in the hospital and field (2018-21)

FIEBRE finished recruiting patients in Mozambique on 26 February 2021. Control and follow up activities will continue throughout March.

CISM began enrolling adult patients at Manhiça Health Research Centre on 13 March 2019 after paediatric recruitment started in November 2018.  A second site, Hospital Geral José Macamo in Maputo, was opened on 28 November 2019. This helped boost inpatient numbers significantly and improved the patients’ care with access to blood culture results.

In total, 2136 patients were enrolled during this period; the highest number of participants of all the sites. This is a great achievement. The team reached the outpatient child recruitment target of 600. The site is the only one which has recruited participants who tested positive for SARS-CoV-2.

Congratulations to everyone involved in contributing to the study’s success - the clinical, laboratory and technical staff, administrators, data scientists, patients and local communities.

Initially, there were some clinical issues which included difficulty in taking blood and urine samples from children. Day 28 follow up has been quite problematic with a high rate of refusals and some loss to follow up due to migration (families moving for work), accessibility during the rainy season and local perception of loss of blood. Blood extraction in particular is a sensitive issue and can be associated with ill-health especially among children. Moreover, some healthy people were not interested in participating as controls.

The COVID-19 pandemic had a considerable impact on the study’s activities; inpatient recruitment was closed down in Maputo and community activities were stopped during the first wave. National and institutional restrictions were imposed which slowed down enrolment and limited field activities. 

On a personal level, many of the clinical staff were infected with SARS-CoV-2 although none severely. This was a critical period during which infection protection measures and disinfection of working areas were reinforced.  It was a stressful time for all the staff and their families. Despite these COVID-19 issues along with rising patient numbers and infections in the community, the team managed to continue working throughout.

In spite of the many challenges, the team’s hard work and dedication has contributed greatly to the clinical diagnostic capacity at these hospitals through access to rapid diagnostic tests and laboratory cultures. This has benefitted both clinicians and patients, enabling clinicians to use the information to make accurate diagnoses and therefore quickly help provide the right treatment.

 Listen to Justina Bramugy and Campos Mucasse talking about their experience on FIEBRE.

The LOMWRU team returned to the study site at Vientiane Provincial Hospital on 19 January 2021 for the main dissemination meeting. The preliminary results of the study, some microbiology data and early reference laboratory results were presented to clinicians, nurses and laboratory technicians for feedback. 

The 2-hour session was chaired by Dr Siho Sengsavang, Deputy Director of Vientiane Provincial Hospital and Prof Mayfong Mayxay, Vice President of the University of Health Sciences, LOMWRU Head of Field Research and local PI who facilitated a discussion after talks by Dr Manophab Luangraj and Dr Vilayouth Phimolsarnnousith.

Watch a video summarising the study's activities.

The BRTI team held a series of successful dissemination meetings following the completion of recruitment in Zimbabwe on 30 September 2020,

Preliminary clinical results were presented at the polyclinics during October and November for the nurses and staff involved in FIEBRE.  These received interesting feedback and led to discussions about effective antimicrobials and antimicrobial resistance.

A research dissemination meeting for major stakeholders at a policy level took place in Harare (with online attendees) on 30 November. The meeting covered several projects as well as FIEBRE and ARGUS: B-GAP, FAST and BREATHE trial. 

Representatives from the Ministry of Health and Childcare, Harare Central Hospital, Parirenyatwa Hospital, Medicines control authority of Zimbabwe, Zimbabwe College of Public Health Physicians, National Microbiology Reference Laboratory, MSF, UNAIDS and many other institutions participated in the meeting. 

The FIEBRE and ARGUS presentations are available:

• Overview of FIEBRE: Evaluating causes of fever and antimicrobial resistance in sub-Saharan Africa and Southeast Asia (pdf), Heidi Hopkins
• FIEBRE: Preliminary results Ioana Ularu, Molly Sibanda
• The Zimbabwe typhoid outbreak & impact of vaccination on typhoid cases and antimicrobial resistance (pdf), Mutsawashe Chisenga
• FIEBRE Understanding the social context of antibiotic prescribing practices and antibiotic use in Zimbabwe (pdf), Salome Manyau, Justin Dixon 

• ARGUS: Prevalence of Gram-negative antimicrobial resistance in patients presenting with urinary tract infections in primary care facilities in Harare (pdf), Ioana Olaru

Recruitment of FIEBRE participants ended in Laos on 31 October 2020. The LOMWRU team started enrolling patients on 9 October 2018 at Vientiane Provincial Hospital. In total, 1961 participants were enrolled during this period. The team reached the adult recruitment target of 600 for both in- and outpatients.

Congratulations to everyone involved in contributing to the study’s success - the clinical and laboratory staff, hospital, participants and local communities. 
  
The first set of samples were shipped to LSHTM in early 2020 and are now at international reference laboratories awaiting diagnostics. Analysis of these samples will produce the first results of the study aside from preliminary data from point-of-care tests carried out on site. The dried blood spots from Laos are also currently being used for the MOS-DEF biomarker project. 

The team faced clinical and logistical challenges including difficulty in taking blood samples from children and travelling long distances to recruit controls (healthy people who were not always interested in taking part). The team continued working throughout the COVID-19 epidemic despite national restrictions which slowed down enrolment and limited field activities. 
  
FIEBRE has helped with the clinical diagnostic capacity and treatment of infectious diseases in the local community, as blood culture and other tests were not available in the hospital previously. The information collected by the study may contribute to the development of treatment guidelines for fever and antibiotic stewardship in the future, especially in settings where there's limited laboratory diagnostics or little data available. 
 

The American Society of Tropical Medicine and Hygiene 2020 Annual Meeting (ASTMH 2020) took place 15-19 November 2020 virtually.

There are four FIEBRE-related activities (two presentations and two posters):

• Change in Salmonella Typhi incidence and antimicrobial resistance patterns following mass vaccination with the new typhoid conjugate vaccine (pdf), Ioana Olaru

  • Scientific Session 35: Bacteriology: Systemic Infections Session

  • Tuesday 17 Nov 9.00 am - 10.45 am US Eastern Time Zone

• Antibiotic use among residents in Uganda, Zimbabwe and Malawi – a mixed methods study (pdf), Clare Chandler

  • Scientific Session 152: Global Health: Maternal, Newborn, Child Health and Neglected Tropical Diseases

  • Thursday 19 Nov 3.00 pm - 4.45 pm US Eastern Time Zone

• Evaluation of the CompactDry EC culture plates for the diagnosis of urinary tract infections in Harare, Zimbabwe (pdf), Ioana Olaru
  • Poster Session A, Monday, 16 November
    1.30 pm – 3 pm US Eastern Time Zone
• Preliminary findings from the FIEBRE study in Mozambique: clinical findings and results of point-of-care tests and microbiology studies (pdf), Marta Valente 
  • Poster Session B, Tuesday, 17 November
    11.45 am – 1.15 pm US Eastern Time Zone

Join us online to find out more and share your news from the conference. Tweet @FeverStudies using #TropMed20  

Participant recruitment in Zimbabwe finished on 30 September 2020. Many congratulations to everyone involved in contributing to the success of the study - the collaborators, participants and local communities.  

Zimbabwe was the first FIEBRE site to start operating in June 2018. In total, 1923 participants were enrolled during this period. FIEBRE recruited patients presenting with fever to three major hospitals and three polyclinics in Harare.

The team at Biomedical Training and Research Institute (BRTI) continued working through outbreaks of cholera and typhoid, political and economic difficulties, despite all these challenges the outpatient adult target (of 600) was reached and many patients received life-saving diagnostics and treatment that otherwise they may not have been able to access. Through the study, a large number of patients with typhoid fever were diagnosed and received effective treatment. In addition, patients with other life-threatening infections such as tuberculosis, malaria and cryptococcal meningitis could be diagnosed.

Photos of team members working in Harare (before and during COVID-19)

A series of papers by Infectious Diseases Data Observatory (IDDO) that set out to explore the global distribution of infections that cause non-malarial febrile illness (NMFI) has been published in BMC Medicine.

The series was a collaboration by scientists and researchers from institutions across the world (including FIEBRE Pis from LSHTM, LOMWRU and University of Otago) who conducted large-scale systematic reviews of published literature to map the cause of febrile illness, once malaria had been excluded. Historically, malaria was assumed to be the cause of fever, however, the advent of rapid diagnostic tests, combined with intensified malaria control activities over the last decade, has substantially reduced incidence rates and it is now clear that most acute fever cases are of non-malaria aetiology. 

The results of these systematic reviews, covering Africa, Latin America, and Southern and South-Eastern Asia, have been incorporated into an open-access online database that supports an interactive map that can filter data by country, microorganism type, patient age, sample type, pathogen family, genus and species, study year, geographic region and sub-region.

The collection of articles are available on BMC Medicine. Read more details on the IDDO website. 

Non-malarial febrile illness: a systematic review of published aetiological studies and case reports from Africa, 1980–2015
Jeanne Elven, Prabin Dahal, Elizabeth A. Ashley, Nigel V. Thomas, Poojan Shrestha, Kasia Stepniewska, John A. Crump, Paul N. Newton, David Bell, Hugh Reyburn, Heidi Hopkins and Philippe J. Guérin

Febrile illness mapping—much of the world without data and without evidence-based treatments
Paul N. Newton and Philippe J. Guerin

When fever is not malaria in Latin America: a systematic review
José Moreira, Janaina Barros, Oscar Lapouble, Marcus V. G. Lacerda, Ingrid Felger, Patricia Brasil, Sabine Dittrich and Andre M. Siqueira

Non-malarial febrile illness: a systematic review of published aetiological studies and case reports from Southern Asia and South-eastern Asia, 1980–2015
Poojan Shrestha, Prabin Dahal, Chinwe Ogbonnaa-Njoku, Debashish Das, Kasia Stepniewska, Nigel V. Thomas, Heidi Hopkins, John A. Crump, David Bell, Paul N. Newton, Elizabeth A. Ashley and Philippe J. Guérin

Researchers from the Anthropology of Antimicrobial Resistance (AMIS) team at the LSHTM work in countries across Africa and Asia, including Ghana, Uganda, Malawi, Zimbabwe, China, Myanmar and Thailand, to understand how antibiotics are used in society. The FIEBRE social science team has contributed valuable insights into this work on antibiotics and the rise globally in antimicrobial resistance. See what their research has discovered about the differing roles of antibiotics in Malawi and Zimbabwe.

The FIEBRE protocol paper is now available on BMJ Open:

Febrile Illness Evaluation in a Broad Range of Endemicities (FIEBRE): protocol for a multisite prospective observational study of the causes of fever in Africa and Asia
Heidi Hopkins, Quique Bassat, Clare IR Chandler, John A Crump, Nicholas A Feasey, Rashida A Ferrand, Katharina Kranzer, David G Lalloo, Mayfong Mayxay, Paul N Newton, David Mabey, and FIEBRE Consortium co-authors

This paper provides an overview of FIEBRE’s clinical, epidemiological and laboratory activities.  The study aims to identify infections that are treatable and/or preventable, to assess antimicrobial susceptibility of bacterial pathogens, to evaluate host response biomarkers that may help in predicting illness severity and distinguishing bacterial from other causes of fever, and to collect qualitative data on care-seeking and treatment behaviours in each study area.

The paper details the harmonised study design, clinical and laboratory assessments, and data analysis plan; gives information about the sites; and outlines the study’s strengths and limitations. Listen to Prof David Mabey introduce the paper:

It is with great sadness that we announce the sudden death last week of our dear friend and former colleague Dr Amit Bhasin, who was our FIEBRE programme manager from 2016-2019.  Amit first joined the School in 2002 as manager of the Gates Malaria Programme, and moved to Cambridge University in 2019 to run the Cambridge-Africa Programme. He will be greatly missed by his many friends around the world. Read the full tribute to Amit here, find out how to send your condolences to his family, about a memorial scholarship and other memorial events to be arranged in the future.

Read about Ja Seng Bawk's experience in quarantine when she returned home to Myanmar in March. She works as a Research consultant for FIEBRE social science in Myanmar. 

On 22 March 2020, I cut my trip to London for the FIEBRE Social Science Analysis meeting short due to the COVID-19 pandemic and ensuing lockdowns. When I arrived at Yangon International Airport, no one asked for a medical certificate (although this was stated as a requirement on the official website, resulting in me spending the last two days in London in a futile effort to acquire one). Instead, I had to fill out a Health Declaration card, which was handed out on the plane and I gave to the airport authorities on arrival. They gave me the choice of a public medical centre free of charge or a hotel at 7 MMK lakhs (around 500 USD) up front in cash for the 14 days of quarantine. I chose the hotel, which was assigned by the authorities at the airport. 

During my time in quarantine at the hotel I was able to join the FIEBRE meeting online and work on transcription. I felt very safe as I was tested for fever and symptoms every morning by a team of about 2 doctors and 3 nurses wearing full personal protective equipment. Food was delivered to the hotel door. I also received approximately four phone calls a day from a department of the Ministry of Health and Sports asking me about my daily condition during quarantine. Because of the very limited availability of PCR testing at the time in the country, I wasn’t tested. After 14 days with no symptoms, I finally returned to my home, safe and sound. 

Shortly after this, Yangon went into lockdown. I had to stop all fieldwork and since then, I have been focusing on transcription of interviews at home. As of today (29 May 2020), Myanmar authorities have reported 206 confirmed COVID-19 cases and six deaths since the first cases were reported on 23 March 2020. 

The team at Centro de Investigação em Saúde de Manhiça (CISM) in Mozambique have been operational for a year. CISM began enrolling adult patients at Manhiça Health Research Centre on 13 March 2019 after paediatric recruitment started in 23 November 2018. They reached their 1000th patient in November 2019.

Recruitment started at a new site, Hospital Geral José Macamo, Maputo, on 28 November 2019. This has helped boost inpatient numbers considerably and improved the patients’ care with the performance of blood culture, urine culture and antibiotic susceptibility testing. Latest data from end of February shows 1406 patients enrolled of which 916 are outpatients and 490 inpatients. More children than adults have been enrolled. 

The team has faced several recruitment challenges during the study. Over the years, inpatient numbers have dropped at Manhiça District Hospital and there has been overlap with other studies making inpatient recruitment particularly difficult. 

Day 28 follow up has been challenging  with a high rate of refusals and some loss to follow up due to migration, accessibility and local perception of loss of blood.

Throughout the study, the team has received positive feedback from both patients and the hospital. FIEBRE has contributed to the clinical diagnostic capacity at these hospitals through access to rapid diagnostic tests and laboratory cultures. This has helped both clinicians and patients, enabling clinicians to use the information to make an accurate diagnosis and therefore provide the right treatment.

The third FIEBRE Co-investigators meeting, hosted by LOMWRU, took place in Vientiane, Laos from 11-14 February 2020.

Over 45 members of the partner organisations involved in FIEBRE attended the meeting including London School of Hygiene & Tropical Medicine, Barcelona Institute for Global Health (ISGlobal), Biomedical Research and Training Institute (BRTI), Centro de Investigacao em Saude de Manhica, Liverpool School of Tropical Medicine, Malawi-Liverpool Wellcome Trust Research Programme, Mahidol Oxford Tropical Medicine Research Unit (MORU), University of Oxford, Bangladesh Institute of Tropical & Infectious Diseases and Chattogram Medical College Hospital.

Researchers from the Aga Khan University also joined the meeting to learn more about the possibility of setting up a similar study in Karachi, Pakistan.

The event was attended by representatives from all aspects of the study - data, clinical, laboratory, microbiology and social science. There was a packed agenda covering updates on:

• Country sites  -  personnel, number of patients and controls recruited, logistical recruitment challenges
• Sharing solutions to operational challenges
• Laboratory activities
• Reference laboratories – status on sample shipment
• Microbiology data and early analysis
• Quantitative data analysis plan
• Social science activities
• Complementary and associated studies
• Dissemination of results and engagement
• Publications, follow-on studies and future plans 
• Potential new sites

The visit included a tour of the laboratory at Mahosot Hospital and the recruitment site Vientiane Provincial Hospital illustrating how the study operates from the initial recruitment of patients through data input to the samples being tested at the laboratory.

The meeting was very productive enabling all participants to share ideas and benefit from learning about the experiences of partners across sites and disciplines.

Members of the team and the DfID technical representative were also able to meet with the British Ambassador to explain the study.

A series of videos is being recorded of team members. These will give an insight into various different aspects of the study, from the hub at the London School of Hygiene & Tropical Medicine where FIEBRE is co-ordinated to the teams in Laos, Malawi, Mozambique and Zimbabwe who are enrolling the patients, taking samples and collecting the data.

The first video is with Dr Katharina Kranzer, the Principal Investigator in Zimbabwe, who explains how FIEBRE operates with BRTI in Harare. 

The LOMWRU team started enrolling patients on 9 October 2018 at Vientiane Provincial Hospital “Maria Teresa hospital” 60 km from Vientiane. The team recruited its 1000^th patient in early September.

Latest data from early October show 1165 patients enrolled of which 669 are inpatients and 495 outpatients.

The team comprises three doctors, two who are responsible for recruiting in- and outpatients, and one for control recruitment. There’s one laboratory technician and one person concentrating on 28-day follow-up.

The team has faced many challenges since the start due in part to the weather. Patients present with fever relating to the season. Recruitment increased during the rainy season (May to October) despite only having three doctors during a dengue fever outbreak. The enrolment rate has sped up since recruitment started 24 hours a day/7 days a week with the help of a local assistant doctor. Another challenge for the team is handling children while taking blood from them. Parents are often not willing to give consent.

Day 28 follow up is quite successful at about 80% and varies depending on the weather. Reasons for refusal include feeling much better so there's no desire for further blood tests; moving (work or life -related); geography and distance; and inability to leave work.

Community control recruitment can be like an adventure, as the countryside is very diverse and the distances so far. Some trips can take up to two hours each way. None of the trips are easy and can even involve transporting the vehicle and equipment by boat across a river.

Throughout the study, the team has always received positive feedback from both patients and the hospital. FIEBRE has been able to contribute to the clinical diagnostic capacity of infectious diseases locally, as blood culture and other tests are not available in the hospital.

FIEBRE will attending the 11th European Congress on Tropical Medicine and International Health (ECTMIH) from 16-20 September 2019 in Liverpool, UK.

Members of the team will be presenting on two topics:

• FIEBRE (Febrile Illness Evaluation in a Broad Range of Endemicities): a multi-site prospective observational study of causes of fever in sub-Saharan Africa and Southeast Asia
  Hopkins H, Bassat Q, Chandler CIR, Crump JA, Feasey NA, Ferrand RA, Lalloo DG, Mayxay M, Newton PN, Mabey DCW
  (Tuesday 17 September, Rm 1a, 14.00 h) 
• Emergence of diminished ciprofloxacin-susceptibility Salmonella typhi in an ongoing outbreak from Harare, Zimbabwe
  Ioana D Olaru, Nicholas Feasey, Rashida Ferrand, David Mabey, Heidi Hopkins, Sekesai Zinyowera, Ben Amos, Katharina Kranzer
  (Thursday 19 September, Rm 1a, 15.00 h)

In Malawi, the first patient was enrolled on 4 July 2018; their 1000th patient, a child outpatient, was signed up at Chikwawa District Hospital on 11 June 2019. 

The Malawi-Liverpool Wellcome Trust Research Programme (MLW) team initially comprised 11 front line staff, working at Chikwawa District Hospital, rising to 15 in April 2019, as the second site in Ngabu, was opened to speed up inpatient recruitment, and weekend work started. The laboratory and freezers, where samples are further tested and stored, are based at MLW in Blantyre. 

Community engagement is integral to the study's success. FIEBRE has been helped by earlier community sensitisation work in the area. Two of the original fieldworkers are very well known and trusted in the community which has aided acceptance of the study. Before and during the study, there are regular engagement activities with the local community, including meetings with the district council where the local chiefs and villagers ask questions about the study. There's been particular interest and concern about the amount of blood taken (shown to a certain extent in some difficulties with getting blood samples from controls). Issues such as this are addressed by the team and their continued dedication in working with the local community. 
 
Chikwawa district and the Chikwawa district hospital are resource poor and constitute one of the most deprived areas and facilities in the country. The hospital is situated by the Shire river, in a largely rural district. In March, the study had to close for a week due to severe floods. The main road was washed away and one of the villages was badly affected with scores of homes washed away. Many of these people are living in temporary shelters and awaiting support for new homes to be built.  The situation was further compounded by Cyclone Idai causing flash floods shortly afterwards. St Montfort Hospital the second site is 30 km away from Chikwawa. This hospital is located in the major town in the district which services the main employer: Illovo Sugar.

In these settings, the FIEBRE team have been able to help support and add to the overall level of care and treatment in the area.  Moreover, a clinical microbiology and blood culture service has been provided enabling FIEBRE to contribute to the clinical diagnostic capacity at these hospitals. Even patients not on the study can access this service. Six cases of TB have been diagnosed in patients who otherwise would not have been diagnosed. This is likely to have been life-saving for some. There have been 16 positive blood cultures indicating septicaemia or blood poisoning. This is often fatal but thus far the patients have survived demonstrating further benefits to the community. 

Data for the year shows almost 4700 patients have been screened with about 1100 recruited. Loss to 28-day follow-up is at 7%, which reflects the good work of the team, as it can be challenging with inpatients as some reside outside the usual catchment area.