Raised houses reduce mosquito bites

Large-Scale Deployment of Lehmann's Funnel Entry Traps to Control Malaria Mosquito Populations

Effective tools to prevent mosquito bites are essential for malaria control. The Lehmann Funnel Entry Trap (LFET), a window screen proven effective in reducing mosquito density, was tested for its large-scale impact on malaria vector control and community acceptance. A total of 1313 traps were deployed in Vallée du Kou 3 (VK3), with 12 traps randomly selected for detailed evaluation against untrapped houses in Vallée du Kou 5 (VK5). Traps were placed in windows with doors blocked by curtains. From July to October, mosquitoes were collected for nine days per month from VK3 traps and VK5 control houses. Morphological identification, density analysis, resistance gene screening, and female age structure determination were conducted. The trap's impact was assessed via pyrethrum spray catch (PSC) and for nine days per month, while trap fabric integrity and community perceptions were also evaluated. Traps reduced mosquito entry density by more than 90% in VK3 houses. VK3 had 33% higher house mosquito density pre-intervention and 47% lower house mosquito density post-intervention than VK5. Old female mosquito numbers rose in VK5 but not VK3. Pyrethroid resistance was high (kdr mutation frequency > 0.9) in both control and intervention sites. VK3 residents appreciated the traps for reducing bites and improving sleep. The LFET effectively controls malaria vectors and is well-suited for widespread use in malaria elimination efforts.

The status of insecticide resistance of Anopheles coluzzii on the islands of São Tomé and Príncipe, after 20 years of malaria vector control

BACKGROUND

Insecticide-based malaria vector control has been implemented on the islands of São Tomé and Príncipe (STP) for more than 20 years. During this period malaria incidence was significantly reduced to pre-elimination levels. While cases remained low since 2015, these have significantly increased in the last year, challenging the commitment of the country to achieve malaria elimination by 2025. To better understand the reasons for increasing malaria cases, levels and underlying mechanisms of insecticide resistance in the local Anopheles coluzzii populations were characterized.

METHODS

Mosquito larval collections were performed in the rainy and dry seasons, between 2022 and 2024, in two localities of São Tomé and one locality in Príncipe. Susceptibility to permethrin, α-cypermethrin, pirimiphos-methyl and DDT was assessed using WHO bioassays and protocols. Intensity of resistance and reversal by PBO pre-exposure were determined for pyrethroid insecticides. The kdr locus was genotyped by PCR assays in subsamples of the mosquitoes tested.

RESULTS

Anopheles coluzzii populations were fully susceptible to pirimiphos-methyl, but high levels of resistance to pyrethroids and DDT were detected, particularly in São Tomé rainy season collections. Increasing the pyrethroid and DDT dosages to 5 × and 10 × did not restore full susceptibility in all populations. Pre-exposure to PBO resulted into partial reversal of the resistance phenotype suggesting the presence of cytochrome P450 oxidases-mediated metabolic resistance. The L1014F knockdown resistance mutation was present in An. coluzzii on both islands but at much higher frequency in São Tomé where it was associated with the resistant phenotype.

CONCLUSIONS

Future vector control interventions should consider the use of non-pyrethroid insecticides or combination with synergists to overcome the high levels of pyrethroid resistance. Alternative control methods not dependent on the use of insecticides should be additionally implemented to achieve malaria elimination in STP.

The behaviour of adult Anopheles gambiae, sub-Saharan Africa's principal malaria vector, and its relevance to malaria control: a review

BACKGROUND

Mosquitoes of the Anopheles gambiae complex are one of the major vectors of malaria in sub-Saharan Africa. Their ability to transmit this disease of major public health importance is dependent on their abundance, biting behaviour, susceptibility and their ability to survive long enough to transmit malaria parasites. A deeper understanding of this behaviour can be exploited for improving vector surveillance and malaria control.

FINDINGS

Adult mosquitoes emerge from aquatic habitats at dusk. After a 24 h teneral period, in which the cuticle hardens and the adult matures, they may disperse at random and search upwind for a mate or to feed. Mating generally takes place at dusk in swarms that form over species-specific 'markers'. Well-nourished females may mate before blood-feeding, but the reverse is true for poorly-nourished insects. Females are monogamous and only mate once whilst males, that only feed on nectar, swarm nightly and can potentially mate up to four times. Females are able to locate hosts by following their carbon dioxide and odour gradients. When in close proximity to the host, visual cues, temperature and relative humidity are also used. Most blood-feeding occurs at night, indoors, with mosquitoes entering houses mainly through gaps between the roof and the walls. With the exception of the first feed, females are gonotrophically concordant and a blood meal gives rise to a complete egg batch. Egg development takes two or three days depending on temperature. Gravid females leave their resting sites at dusk. They are attracted by water gradients and volatile chemicals that provide a suitable aquatic habitat in which to lay their eggs.

CONCLUSION

Whilst traditional interventions, using insecticides, target mosquitoes indoors, additional protection can be achieved using spatial repellents outdoors, attractant traps or house modifications to prevent mosquito entry. Future research on the variability of species-specific behaviour, movement of mosquitoes across the landscape, the importance of light and vision, reproductive barriers to gene flow, male mosquito behaviour and evolutionary changes in mosquito behaviour could lead to an improvement in malaria surveillance and better methods of control reducing the current over-reliance on the indoor application of insecticides.

House modifications for preventing malaria

BACKGROUND

Malaria remains an important public health problem. Research in 1900 suggested house modifications may reduce malaria transmission. A previous version of this review concluded that house screening may be effective in reducing malaria. This update includes data from five new studies.

OBJECTIVES

To assess the effects of house modifications that aim to reduce exposure to mosquitoes on malaria disease and transmission.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register; Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library; MEDLINE (PubMed); Embase (OVID); Centre for Agriculture and Bioscience International (CAB) Abstracts (Web of Science); and the Latin American and Caribbean Health Science Information database (LILACS) up to 25 May 2022. We also searched the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, and the ISRCTN registry to identify ongoing trials up to 25 May 2022.

SELECTION CRITERIA

Randomized controlled trials, including cluster-randomized controlled trials (cRCTs), cross-over studies, and stepped-wedge designs were eligible, as were quasi-experimental trials, including controlled before-and-after studies, controlled interrupted time series, and non-randomized cross-over studies. We sought studies investigating primary construction and house modifications to existing homes reporting epidemiological outcomes (malaria case incidence, malaria infection incidence or parasite prevalence). We extracted any entomological outcomes that were also reported in these studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected eligible studies, extracted data, and assessed the risk of bias. We used risk ratios (RR) to compare the effect of the intervention with the control for dichotomous data. For continuous data, we presented the mean difference; and for count and rate data, we used rate ratios. We presented all results with 95% confidence intervals (CIs). We assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

One RCT and six cRCTs met our inclusion criteria, with an additional six ongoing RCTs. We did not identify any eligible non-randomized studies. All included trials were conducted in sub-Saharan Africa since 2009; two randomized by household and four at the block or village level. All trials assessed screening of windows, doors, eaves, ceilings, or any combination of these; this was either alone, or in combination with roof modification or eave tube installation (an insecticidal "lure and kill" device that reduces mosquito entry whilst maintaining some airflow). In one trial, the screening material was treated with 2% permethrin insecticide. In five trials, the researchers implemented the interventions. A community-based approach was adopted in the other trial. Overall, the implementation of house modifications probably reduced malaria parasite prevalence (RR 0.68, 95% CI 0.57 to 0.82; 5 trials, 5183 participants; moderate-certainty evidence), although an inconsistent effect was observed in a subpopulation of children in one study. House modifications reduced moderate to severe anaemia prevalence (RR 0.70, 95% CI 0.55 to 0.89; 3 trials, 3643 participants; high-certainty evidence). There was no consistent effect on clinical malaria incidence, with rate ratios ranging from 0.38 to 1.62 (3 trials, 3365 participants, 4126.6 person-years). House modifications may reduce indoor mosquito density (rate ratio 0.63, 95% CI 0.30 to 1.30; 4 trials, 9894 household-nights; low-certainty evidence), although two studies showed little effect on this parameter.

AUTHORS' CONCLUSIONS

House modifications - largely screening, sometimes combined with insecticide and lure and kill devices - were associated with a reduction in malaria parasite prevalence and a reduction in people with anaemia. Findings on malaria incidence were mixed. Modifications were also associated with lower indoor adult mosquito density, but this effect was not present in some studies.

Six decades of malaria vector control in southern Africa: a review of the entomological evidence-base

BACKGROUND

Countries in the southern Africa region have set targets for malaria elimination between 2020 and 2030. Malaria vector control is among the key strategies being implemented to achieve this goal. This paper critically reviews published entomological research over the past six decades in three frontline malaria elimination countries namely, Botswana Eswatini and Namibia, and three second-line malaria elimination countries including Mozambique, Zambia, and Zimbabwe. The objective of the review is to assess the current knowledge and highlight gaps that need further research attention to strengthen evidence-based decision-making toward malaria elimination.

METHODS

Publications were searched on the PubMed engine using search terms: "(malaria vector control OR vector control OR malaria vector*) AND (Botswana OR Swaziland OR Eswatini OR Zambia OR Zimbabwe OR Mozambique)". Opinions, perspectives, reports, commentaries, retrospective analysis on secondary data protocols, policy briefs, and reviews were excluded.

RESULTS

The search resulted in 718 publications with 145 eligible and included in this review for the six countries generated over six decades. The majority (139) were from three countries, namely Zambia (59) and Mozambique (48), and Zimbabwe (32) whilst scientific publications were relatively scanty from front-line malaria elimination countries, such as Namibia (2), Botswana (10) and Eswatini (4). Most of the research reported in the publications focused on vector bionomics generated mostly from Mozambique and Zambia, while information on insecticide resistance was mostly available from Mozambique. Extreme gaps were identified in reporting the impact of vector control interventions, both on vectors and disease outcomes. The literature is particularly scanty on important issues such as change of vector ecology over time and space, intervention costs, and uptake of control interventions as well as insecticide resistance.

CONCLUSIONS

The review reveals a dearth of information about malaria vectors and their control, most noticeable among the frontline elimination countries: Namibia, Eswatini and Botswana. It is of paramount importance that malaria vector research capacity and routine entomological monitoring and evaluation are strengthened to enhance decision-making, considering changing vector bionomics and insecticide resistance, among other determinants of malaria vector control.

Assessing the impact of a novel house design on the incidence of malaria in children in rural Africa: study protocol for a household-cluster randomized controlled superiority trial

Background

Traditional rural housing in hot, humid regions of sub-Saharan Africa usually consists of single-level, poorly ventilated dwellings. Houses are mostly poorly screened against malaria mosquitoes and limited airflow discourages the use of bednets resulting in high indoor transmission. This study aims to determine whether living in a novel design house with elevated bedrooms and permeable screened walls reduces malaria, respiratory tract infections, and diarrhoea among children in rural Tanzania.

Methods/study design

This is a household-randomized, controlled study in 60 villages in Mtwara, Tanzania. A total of 550 households are randomly selected, 110 of which are allocated a novel design house and 440 households continue to reside in traditional houses. A dynamic cohort of about 1650 children under 13 years will be enrolled and followed for 3 years, approximately 330 living in novel design houses and 1320 in traditional rural houses. The primary endpoint is the incidence of malaria; secondary endpoints are incidences of acute respiratory tract infections and diarrhoea diseases detected by passive and active surveillance. Exposure to malaria vectors will be assessed using light traps in all study houses. Structural, economic, and social science studies will assess the durability, cost-effectiveness, and acceptability of the new houses compared with traditional housing. Environmental data will be collected indoors and outdoors in study homes to assess the differences between house typologies.

Discussion

This is the first randomized controlled trial to assess the protective efficacy of a new house design targeting malaria in sub-Saharan Africa. The findings of this study could influence the future construction of homes in hot and humid zones of Africa.

Trial registration

ClinicalTrials.govNCT04529434. Registered on August 27, 2020

The relationship between house height and mosquito house entry: an experimental study in rural Gambia

Most malaria infections in sub-Saharan Africa are acquired indoors, thus finding effective ways of preventing mosquito house entry should reduce transmission. Since most malaria mosquitoes fly less than 1 m from the ground, we tested whether raising buildings off the ground would prevent the entry of Anopheles gambiae, the principal African malaria vector, in rural Gambia. Nightly collections of mosquitoes were made using light traps from four inhabited experimental huts, each of which could be moved up or down. Mosquito house entry declined with increasing height, with a hut at 3 m reducing An. gambiae house entry by 84% when compared with huts on the ground. A propensity for malaria vectors to fly close to the ground and reduced levels of carbon dioxide, a major mosquito attractant, in elevated huts, may explain our findings. Raised buildings may help reduce malaria transmission in Africa.

House modifications for preventing malaria

BACKGROUND

Despite being preventable, malaria remains an important public health problem. The World Health Organization (WHO) reports that overall progress in malaria control has plateaued for the first time since the turn of the century. Researchers and policymakers are therefore exploring alternative and supplementary malaria vector control tools. Research in 1900 indicated that modification of houses may be effective in reducing malaria: this is now being revisited, with new research now examining blocking house mosquito entry points or modifying house construction materials to reduce exposure of inhabitants to infectious bites.

OBJECTIVES

To assess the effects of house modifications on malaria disease and transmission.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register; Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library; MEDLINE (PubMed); Embase (OVID); Centre for Agriculture and Bioscience International (CAB) Abstracts (Web of Science); and the Latin American and Caribbean Health Science Information database (LILACS), up to 1 November 2019. We also searched the WHO International Clinical Trials Registry Platform (www.who.int/ictrp/search/en/), ClinicalTrials.gov (www.clinicaltrials.gov), and the ISRCTN registry (www.isrctn.com/) to identify ongoing trials up to the same date.

SELECTION CRITERIA

Randomized controlled trials, including cluster-randomized controlled trials (cRCTs), cross-over studies, and stepped-wedge designs were eligible, as were quasi-experimental trials, including controlled before-and-after studies, controlled interrupted time series, and non-randomized cross-over studies. We only considered studies reporting epidemiological outcomes (malaria case incidence, malaria infection incidence or parasite prevalence). We also summarised qualitative studies conducted alongside included studies.

DATA COLLECTION AND ANALYSIS

Two review authors selected eligible studies, extracted data, and assessed the risk of bias. We used risk ratios (RR) to compare the effect of the intervention with the control for dichotomous data. For continuous data, we presented the mean difference; and for count and rate data, we used rate ratios. We presented all results with 95% confidence intervals (CIs). We assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

Six cRCTs met our inclusion criteria, all conducted in sub-Saharan Africa; three randomized by household, two by village, and one at the community level. All trials assessed screening of windows, doors, eaves, ceilings or any combination of these; this was either alone, or in combination with eave closure, roof modification or eave tube installation (a "lure and kill" device that reduces mosquito entry whilst maintaining some airflow). In two trials, the interventions were insecticide-based. In five trials, the researchers implemented the interventions. The community implemented the interventions in the sixth trial. At the time of writing the review, two of the six trials had published results, both of which compared screened houses (without insecticide) to unscreened houses. One trial in Ethiopia assessed screening of windows and doors. Another trial in the Gambia assessed full screening (screening of eaves, doors and windows), as well as screening of ceilings only. Screening may reduce clinical malaria incidence caused by Plasmodium falciparum (rate ratio 0.38, 95% CI 0.18 to 0.82; 1 trial, 184 participants, 219.3 person-years; low-certainty evidence; Ethiopian study). For malaria parasite prevalence, the point estimate, derived from The Gambia study, was smaller (RR 0.84, 95% CI 0.60 to 1.17; 713 participants, 1 trial; low-certainty evidence), and showed an effect on anaemia (RR 0.61, 95% CI 0.42, 0.89; 705 participants; 1 trial, moderate-certainty evidence). Screening may reduce the entomological inoculation rate (EIR): both trials showed lower estimates in the intervention arm. In the Gambian trial, there was a mean difference in EIR between the control houses and treatment houses ranging from 0.45 to 1.50 (CIs ranged from -0.46 to 2.41; low-certainty evidence), depending on the study year and treatment arm. The Ethiopian trial reported a mean difference in EIR of 4.57, favouring screening (95% CI 3.81 to 5.33; low-certainty evidence). Pooled analysis of the trials showed that individuals living in fully screened houses were slightly less likely to sleep under a bed net (RR 0.84, 95% CI 0.65 to 1.09; 2 trials, 203 participants). In one trial, bed net usage was also lower in individuals living in houses with screened ceilings (RR 0.69, 95% CI 0.50 to 0.95; 1 trial, 135 participants).

AUTHORS' CONCLUSIONS

Based on the two trials published to date, there is some evidence that screening may reduce malaria transmission and malaria infection in people living in the house. The four trials awaiting publication are likely to enrich the current evidence base, and we will add these to this review when they become available.

Predictors of malaria rapid diagnostic test positivity in a high burden area of Paletwa Township, Chin State in Western Myanmar

Background

Despite major reductions in malaria burden across Myanmar, clusters of the disease continue to persist in specific subregions. This study aimed to assess the predictors of test positivity among people living in Paletwa Township of Chin State, an area of persistently high malaria burden.

Methods

Four villages with the highest malaria incidence from Paletwa Township were purposively selected. The characteristics of 1045 subjects seeking malaria diagnosis from the four assigned village health volunteers from January to December, 2018 were retrospectively analyzed. Their household conditions and surroundings were also recorded using a checklist. Descriptive statistics and logistic regression models were applied to investigate potential associations between individual and household characteristics and malaria diagnosis.

Results

In 2017, the Paletwa township presented 20.9% positivity and an annual parasite index of 46.9 cases per 1000 people. Plasmodium falciparum was the predominant species and accounted for more than 80.0% of all infections. Among 1045 people presenting at a clinic with malaria symptoms, 31.1% were diagnosed with malaria. Predictors for test positivity included living in a hut [adjusted odds ratios (a OR): 2.3, 95% confidence intervals (CI): 1.2–4.6], owning farm animals (aOR: 1.7, 95% CI: 1.1–3.6), using non-septic type of toilets (aOR: 1.9, 95% CI: 1.1–8.4), presenting with fever (aOR: 1.9, 95% CI: 1.1–3.0), having a malaria episode within the last year (aOR: 2.9, 95% CI: 1.4–5.8), traveling outside the village in the previous 14 days (aOR: 4.5, 95% CI: 1.5–13.4), and not using bed nets (a OR: 3.4, 95% CI: 2.3–5.1). There were no statistically significant differences by age or gender in this present analysis.

Conclusions

The results from this study, including a high proportion of P. falciparum infections, little difference in age, sex, or occupation, suggest that malaria is a major burden for these study villages. Targeted health education campaigns should be introduced to strengthen synchronous diagnosis-seeking behaviors, tighten treatment adherence, receiving a diagnosis after traveling to endemic regions, and using bed nets properly. We suggest increased surveillance, early diagnosis, and treatment efforts to control the disease and then to consider the local elimination.

Monitoring mosquito nuisance for the development of a citizen science approach for malaria vector surveillance in Rwanda

BACKGROUND

Many countries, including Rwanda, have mosquito monitoring programmes in place to support decision making in the fight against malaria. However, these programmes can be costly, and require technical (entomological) expertise. Involving citizens in data collection can greatly support such activities, but this has not yet been thoroughly investigated in a rural African context.

METHODS

Prior to the implementation of such a citizen-science approach, a household entomological survey was conducted in October-November 2017 and repeated one year later in Busoro and Ruhuha sectors, in southern and eastern province of Rwanda, respectively. The goal was to evaluate the perception of mosquito nuisance reported by citizens as a potential indicator for malaria vector hotspots. Firstly, mosquito abundance and species composition were determined using Centers for Disease Control and Prevention (CDC) light traps inside the houses. Secondly, household members were interviewed about malaria risk factors and their perceived level of mosquito nuisance.

RESULTS

Tiled roofs, walls made of mud and wood, as well as the number of occupants in the house were predictors for the number of mosquitoes (Culicidae) in the houses, while the presence of eaves plus walls made of mud and wood were predictors for malaria vector abundance. Perception of mosquito nuisance reported indoors tended to be significantly correlated with the number of Anopheles gambiae sensu lato (s.l.) and Culicidae collected indoors, but this varied across years and sectors. At the village level, nuisance also significantly correlated with An. gambiae s.l. and total mosquito density, but only in 2018 while not in 2017.

CONCLUSIONS

Perception of mosquito nuisance denoted in a questionnaire survey could be used as a global indicator of malaria vector hotspots. Hence, involving citizens in such activities can complement malaria vector surveillance and control.

Randomized trials of housing interventions to prevent malaria and Aedes-transmitted diseases: A systematic review and meta-analysis

BACKGROUND

Mosquito-borne diseases remain a significant public health problem in tropical regions. Housing improvements such as screening of doors and windows may be effective in reducing disease transmission, but the impact remains unclear.

OBJECTIVES

To examine whether housing interventions were effective in reducing mosquito densities in homes and the impact on the incidence of mosquito-borne diseases.

METHODS

In this systematic review and meta-analysis, we searched 16 online databases, including NIH PubMed, CINAHL Complete, LILACS, Ovid MEDLINE, and Cochrane Central Register of Controlled Trials for randomized trials published from database inception to June 30, 2020. The primary outcome was the incidence of any mosquito-borne diseases. Secondary outcomes encompassed entomological indicators of the disease transmission. I2 values were used to explore heterogeneity between studies. A random-effects meta-analysis was used to assess the primary and secondary outcomes, with sub-group analyses for type of interventions on home environment, study settings (rural, urban, or mixed), and overall house type (traditional or modern housing).

RESULTS

The literature search yielded 4,869 articles. After screening, 18 studies were included in the qualitative review, of which nine were included in the meta-analysis. The studies enrolled 7,200 households in Africa and South America, reporting on malaria or dengue only. The type of home environmental interventions included modification to ceilings and ribbons to close eaves, screening doors and windows with nets, insecticide-treated wall linings in homes, nettings over gables and eaves openings, mosquito trapping systems, metal-roofed houses with mosquito screening, gable windows and closed eaves, and prototype houses using southeast Asian designs. Pooled analysis depicted a lower risk of mosquito-borne diseases in the housing intervention group (OR = 0.68; 95% CI = 0.48 to 0.95; P = 0.03). Subgroup analysis depicted housing intervention reduced the risk of malaria in all settings (OR = 0.63; 95% CI = 0.39 to 1.01; P = 0.05). In urban environment, housing intervention was found to decrease the risk of both malaria and dengue infections (OR = 0.52; 95% CI = 0.27 to 0.99; P = 0.05).Meta-analysis of pooled odds ratio showed a significant benefit of improved housing in reducing indoor vector densities of both Aedes and Anopheles (OR = 0.35; 95% CI = 0.23 to 0.54; P<0.001).

CONCLUSIONS

Housing intervention could reduce transmission of malaria and dengue among people living in the homes. Future research should evaluate the protective effect of specific house features and housing improvements associated with urban development.

Assessment of novel Lehmann's funnel entry trap prototypes performance to control malaria mosquito populations

Background

There is a global consensus that new intervention tools are needed for the final steps toward malaria elimination/eradication. In a recent study in Burkina Faso, the Lehmann Funnel Entry Trap (LFET) has shown promising results in the reduction of mosquito densities, even in areas where insecticide resistance is as high as 80%. The LFET requires no chemicals and is self-operated. However, one of the issues with the original LFET is the size of the funnel, which often occupies too much space within users’ homes. Here, the performance of three new, smaller-sized LFET prototypes that combine a screening and killing effect on mosquitoes was assessed.

Methods

The study was carried out over three months during the rainy season in low and high malaria vector density sites, Soumousso and Vallée du Kou, respectively. The original LFET (or ‘Prototype 1’/‘P1’) was modified to produce three new prototypes, which were referred to as prototype 2 (‘the Medium’ or ‘P2’), prototype 3 (P3) and prototype 4 (P4). Each of the new prototypes was tested on eight days per month over the three-month period to assess their effectiveness in trapping and killing mosquitoes entering houses through the windows compared to the original LFET.

Results

Overall, 78,435 mosquitoes (mainly Anopheles gambiae sensu lato) were collected in the two study sites, both in the traps and in the houses. A total of 56,430 (72%) mosquitoes were collected from the traps. In Vallée du Kou, the original LFET caught a greater number of mosquitoes than the medium (prototype 2), whereas no difference was observed between the other new prototypes (3 and 4) and the medium. In Soumousso, both the original and medium LFETs collected significantly greater numbers of mosquitoes compared to prototypes 3 and 4.

Conclusion

This study has shown that the new LFET prototypes are effective in trapping mosquitoes in high mosquito density settings. A large-scale study with one of the prototypes will be needed to assess community acceptance of the traps and their ability to control malaria vectors.

House modifications for preventing malaria

BACKGROUND

Despite being preventable, malaria remains an important public health problem. The World Health Organization (WHO) reports that overall progress in malaria control has plateaued for the first time since the turn of the century. Researchers and policymakers are therefore exploring alternative and supplementary malaria vector control tools. Research in 1900 indicated that modification of houses may be effective in reducing malaria: this is now being revisited, with new research now examining blocking house mosquito entry points or modifying house construction materials to reduce exposure of inhabitants to infectious bites.

OBJECTIVES

To assess the effects of house modifications on malaria disease and transmission.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register; Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library; MEDLINE (PubMed); Embase (OVID); Centre for Agriculture and Bioscience International (CAB) Abstracts (Web of Science); and the Latin American and Caribbean Health Science Information database (LILACS), up to 1 November 2019. We also searched the WHO International Clinical Trials Registry Platform (www.who.int/ictrp/search/en/), ClinicalTrials.gov (www.clinicaltrials.gov), and the ISRCTN registry (www.isrctn.com/) to identify ongoing trials up to the same date.

SELECTION CRITERIA

Randomized controlled trials, including cluster-randomized controlled trials (cRCTs), cross-over studies, and stepped-wedge designs were eligible, as were quasi-experimental trials, including controlled before-and-after studies, controlled interrupted time series, and non-randomized cross-over studies. We only considered studies reporting epidemiological outcomes (malaria case incidence, malaria infection incidence or parasite prevalence). We also summarised qualitative studies conducted alongside included studies.

DATA COLLECTION AND ANALYSIS

Two review authors selected eligible studies, extracted data, and assessed the risk of bias. We used risk ratios (RR) to compare the effect of the intervention with the control for dichotomous data. For continuous data, we presented the mean difference; and for count and rate data, we used rate ratios. We presented all results with 95% confidence intervals (CIs). We assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

Six cRCTs met our inclusion criteria, all conducted in sub-Saharan Africa; three randomized by household, two by village, and one at the community level. All trials assessed screening of windows, doors, eaves, ceilings or any combination of these; this was either alone, or in combination with eave closure, roof modification or eave tube installation (a "lure and kill" device that reduces mosquito entry whilst maintaining some airflow). In two trials, the interventions were insecticide-based. In five trials, the researchers implemented the interventions. The community implemented the interventions in the sixth trial. At the time of writing the review, two of the six trials had published results, both of which compared screened houses (without insecticide) to unscreened houses. One trial in Ethiopia assessed screening of windows and doors. Another trial in the Gambia assessed full screening (screening of eaves, doors and windows), as well as screening of ceilings only. Screening may reduce clinical malaria incidence caused by Plasmodium falciparum (rate ratio 0.38, 95% CI 0.18 to 0.82; 1 trial, 184 participants, 219.3 person-years; low-certainty evidence; Ethiopian study). For malaria parasite prevalence, the point estimate, derived from The Gambia study, was smaller (RR 0.84, 95% CI 0.60 to 1.17; 713 participants, 1 trial; moderate-certainty evidence), and showed an effect on anaemia (RR 0.61, 95% CI 0.42, 0.89; 705 participants; 1 trial, moderate-certainty evidence). Screening may reduce the entomological inoculation rate (EIR): both trials showed lower estimates in the intervention arm. In the Gambian trial, there was a mean difference in EIR between the control houses and treatment houses ranging from 0.45 to 1.50 (CIs ranged from -0.46 to 2.41; low-certainty evidence), depending on the study year and treatment arm. The Ethiopian trial reported a mean difference in EIR of 4.57, favouring screening (95% CI 3.81 to 5.33; low-certainty evidence). Pooled analysis of the trials showed that individuals living in fully screened houses were slightly less likely to sleep under a bed net (RR 0.84, 95% CI 0.65 to 1.09; 2 trials, 203 participants). In one trial, bed net usage was also lower in individuals living in houses with screened ceilings (RR 0.69, 95% CI 0.50 to 0.95; 1 trial, 135 participants).

AUTHORS' CONCLUSIONS

Based on the two trials published to date, there is some evidence that screening may reduce malaria transmission and malaria infection in people living in the house. The four trials awaiting publication are likely to enrich the current evidence base, and we will add these to this review when they become available.

Effects of indoor residual spraying and outdoor larval control on Anopheles coluzzii from São Tomé and Príncipe, two islands with pre-eliminated malaria

Background

Vector control is a key component of malaria prevention. Two major vector control strategies have been implemented in São Tomé and Príncipe (STP), indoor residual spraying (IRS) and outdoor larval control using Bacillus thuringiensis israelensis (Bti). This study evaluated post-intervention effects of control strategies on vector population density, composition, and knockdown resistance mutation, and their implications for malaria epidemiology in STP.

Methods

Mosquitoes were collected by indoor and outdoor human landing catches and mosquito light traps in seven districts. Mosquito density was calculated by numbers of captured adult mosquitoes/house/working hour. Mitochondrial cytochrome c oxidase subunit I (COI) was PCR amplified and sequenced to understand the spatial–temporal population composition of malaria vector in STP. Knockdown resistance L1014F mutation was detected using allele-specific PCR. To estimate the malaria transmission risks in STP, a negative binomial regression model was constructed. The response variable was monthly incidence, and the explanatory variables were area, rainfall, entomological inoculation rate (EIR), and kdr mutation frequency.

Results

Malaria vector in STP is exophilic Anopheles coluzzii with significant population differentiation between Príncipe and São Tomé (mean F_ST = 0.16, p < 0.001). Both vector genetic diversity and knockdown resistance mutation were relatively low in Príncipe (mean of kdr frequency = 15.82%) compared to São Tomé (mean of kdr frequency = 44.77%). Annual malaria incidence rate in STP had been rapidly controlled from 37 to 2.1% by three rounds of country-wide IRS from 2004 to 2007. Long-term application of Bti since 2007 kept the mosquito density under 10 mosquitoes/house/hr/month, and malaria incidence rate under 5% after 2008, except for a rising that occurred in 2012 (incidence rate = 6.9%). Risk factors of area (São Tomé compared to Príncipe), rainfall, outdoor EIR, and kdr mutation frequency could significantly increase malaria incidence by 9.33–11.50, 1.25, 1.07, and 1.06 fold, respectively.

Conclusions

Indoor residual spraying could rapidly decrease Anopheles density and malaria incidence in STP. Outdoor larval control using Bti is a sustainable approach for controlling local vector with exophilic feature and insecticide resistance problem. Vector control interventions should be intensified especially at the north-eastern part of São Tomé to minimize impacts of outbreaks.

Housing interventions for preventing malaria

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

Primary

To assess the effects of different structural house modifications on malaria disease burden.

Secondary

To explore whether effects vary with level of transmission.

Human population movement and behavioural patterns in malaria hotspots on the Thai-Myanmar border: implications for malaria elimination

BACKGROUND

Malaria is heterogeneously distributed across landscapes. Human population movement (HPM) could link sub-regions with varying levels of transmission, leading to the persistence of disease even in very low transmission settings. Malaria along the Thai-Myanmar border has been decreasing, but remains heterogeneous. This study aimed to measure HPM, associated predictors of travel, and HPM correlates of self-reported malaria among people living within malaria hotspots.

METHODS

526 individuals from 279 households in two malaria hotspot areas were included in a prospective observational study. A baseline cross-sectional study was conducted at the beginning, recording both individual- and household-level characteristics. Individual movement and travel patterns were repeatedly observed over one dry season month (March) and one wet season month (May). Descriptive statistics, random effects logistic regressions, and logistic regressions were used to describe and determine associations between HPM patterns, individual-, household-factors, and self-reported malaria.

RESULTS

Trips were more common in the dry season. Malaria risk was related to the number of days doing outdoor activities in the dry season, especially trips to Myanmar, to forest areas, and overnight trips. Trips to visit forest areas were more common among participants aged 20-39, males, individuals with low income, low education, and especially among individuals with forest-related occupations. Overnight trips were more common among males, and individual with forest-related occupations. Forty-five participants reported having confirmed malaria infection within the last year. The main place of malaria blood examination and treatment was malaria post and malaria clinic, with participants usually waiting for 2-3 days from onset fever to seeking diagnosis. Individuals using bed nets, living in houses with elevated floors, and houses that received indoor residual spraying in the last year were less likely to report malaria infection.

CONCLUSION

An understanding of HPM and concurrent malaria dynamics is important for consideration of targeted public health interventions. Furthermore, diagnosis and treatment centres must be capable of quickly diagnosing and treating infections regardless of HPM. Coverage of diagnosis and treatment centres should be broad, maintained in areas bordering malaria hotspots, and available to all febrile individuals.

Bicomponent fibres for controlled release of volatile mosquito repellents

Core-sheath structured fibres were developed for application as part of an alternative malaria vector control intervention aimed at reducing outdoor malaria transmission. The fibres were prepared by melt spinning of high density polyethylene (HDPE) as sheath and with a concentrate containing volatile N,N-Diethyl-m-toluamide (DEET) in poly(ethylene-co-vinyl acetate) (EVA) as core. The concentrate was prepared by a simple absorption processes to a content up to 40 wt% DEET. Scanning electron microscope imaging confirmed the formation of a bicomponent core-sheath fibre structure. Confocal Raman spectroscopy revealed the development of a concentration gradient of DEET in the sheath layer, suggesting a diffusion controlled release process. Excellent processability was demonstrated on an extrusion system melt spinning with take up speeds reaching 3000 m min^-1. Sample textiles knitted from such filaments showed high residual repellence activity even after 20 cold washes or after eight months ageing under laboratory conditions. These findings indicate that this technology offers an alternative way to prevent outdoor mosquito bites in an effective and affordable manner.

Malaria vector abundance is associated with house structures in Baringo County, Kenya

Malaria, a major cause of morbidity and mortality, is the most prevalent vector borne disease in Baringo County; a region which has varied house designs in arid and semi-arid areas. This study investigated the association between house structures and indoor-malaria vector abundance in Baringo County. The density of malaria vectors in houses with open eaves was higher than that for houses with closed eaves. Grass thatched roof houses had higher density of malaria vectors than corrugated iron sheet roofs. Similarly, mud walled houses had higher vector density than other wall types. Houses in the riverine zone were significantly associated with malaria vector abundance (p<0.000) possibly due to more varied house structures. In Kamnarok village within riverine zone, a house made of grass thatched roof and mud wall but raised on stilts with domestic animals (sheep/goats) kept at the lower level had lower mosquito density (5.8 per collection) than ordinary houses made of same materials but at ground level (30.5 mosquitoes per collection), suggestive of a change in behavior of mosquito feeding and resting. House modifications such as screening of eaves, improvement of construction material and building stilted houses can be incorporated in the integrated vector management (IVM) strategy to complement insecticide treated bed nets and indoor residual spray to reduce indoor malaria vector density.

Spatial repellents and malaria transmission in an endemic area of Cambodia with high mosquito net usage

BACKGROUND

The spread of artemisinin resistant malaria from SE Asia to the rest of the world remains a threat that will only be ended by eliminating malaria from the region. Novel control approaches are required to mitigate this threat. Spatial repellents (SR) are one such approach. We therefore conducted a multiple cross-over experiment from April 2013 - April 2014, in which all houses in one of two villages in Mondolkiri Province, Cambodia were alternately supplied with an emanator of the spatial repellent metofluthrin per 30 m³ of protected area to cover all potential peridomestic areas where people might spend their time before sleeping. Emanators were replaced every month for a three-month period.

MATERIAL AND METHODS

Mosquito densities were simultaneously monitored in each village for two weeks every month using six CDC light-traps/night run from 18.00 to 07.00 hrs inside bedrooms and malaria prevalence, seroconversion and gSG6 protein rates assessed from prevalence surveys. After emanators were installed in the first village they were installed in the second village for a further three-month period and following that were again used in the initial village for a further three months. Surveys were undertaken before the initial installation of the emanators and at each cross-over point.

RESULTS

Anopheles dirus densities were highest in houses closest to the forest. Transmission rates were low even before the application of the emanators. Perhaps due to the low levels of malaria transmission in Mondolkiri no significant relationships were found in Plasmodium cases or seroconversion rates between villages, surveys or by intervention. Adult males, who might spend more time unprotected in the forest at night, appeared to be at greater risk of becoming infected with P. falciparum malaria as compared to women or young children.

CONCLUSION

At the malaria transmission levels present in Mondolkiri the metofluthrin emanators evaluated had no observable effect on malaria prevalence. This may be due to confounding by low prevalence rates.

Affordable house designs to improve health in rural Africa: a field study from northeastern Tanzania

BACKGROUND

The population of sub-Saharan Africa is currently estimated to be 1245 million and is expected to quadruple by the end of the century, necessitating the building of millions of homes. Malaria remains a substantial problem in this region and efforts to minimise transmission should be considered in future house planning. We studied how building elements, which have been successfully employed in southeast Asia to prevent mosquitos from entering and cooling the house, could be integrated in a more sustainable house design in rural northeastern Tanzania, Africa, to decrease mosquito density and regulate indoor climate.

METHODS

In this field study, six prototype houses of southeast Asian design were built in in the village of Magoda in Muheza District, Tanga Region, Tanzania, and compared with modified and unmodified, traditional, sub-Saharan African houses. Prototype houses were built with walls made of lightweight permeable materials (bamboo, shade net, or timber) with bedrooms elevated from the ground and with screened windows. Modified and unmodified traditional African houses, wattle-daub or mud-block constructions, built on the ground with poor ventilation served as controls. In the modified houses, major structural problems such as leaking roofs were repaired, windows screened, open eaves blocked with bricks and mortar, cement floors repaired or constructed, and rain gutters and a tank for water storage added. Prototype houses were randomly allocated to village households through a free, fair, and transparent lottery. The lottery tickets were deposited in a bucket made of transparent plastic. Each participant could draw one ticket. Hourly measurements of indoor temperature and humidity were recorded in all study houses with data loggers and mosquitoes were collected indoors and outdoors using Furvela tent traps and were identified with standard taxonomic keys. Mosquitoes of the Anopheles gambiae complex were identified to species using PCR. Attitudes towards the new house design were assessed 6-9 months after the residents moved into their new or modified homes through 15 in-depth interviews with household heads of the new houses and five focus group discussions including neighbours of each group of prototype housing.

FINDINGS

Between July, 2014, and July, 2015, six prototype houses were constructed; one single and one double storey building with each of the following claddings: bamboo, shade net, and timber. The overall reduction of all mosquitoes caught was highest in the double-storey buildings (96%; 95% CI 92-98) followed closely by the reduction found in single-storey buildings (77%; 72-82) and lowest in the modified reference houses (43%; 36-50) and unmodified reference houses (23%; 18-29). The indoor temperature in the new design houses was 2·3°C (95% CI 2·2-2·4) cooler than in the reference houses. While both single and two-storey buildings provided a cooler indoor climate than did traditional housing, two-story buildings provided the biggest reduction in mosquito densities (96%, 95% CI 89-100). Seven people who moved into the prototype houses and seven of their neighbours (three of whom had their houses modified) participated in in-depth interviews. After living in their new prototype houses for 6-9 months, residents expressed satisfaction with the new design, especially the second-storey sleeping area because of the privacy and security of upstairs bedrooms.

INTERPRETATION

The new design houses had fewer mosquitoes and were cooler than modified and unmodified traditional homes. New house designs are an underused intervention and hold promise to reduce malaria transmission in sub-Saharan Africa and keep areas malaria-free after elimination.

FUNDING

Ruth W Jensens Foundation, Copenhagen and Hanako Foundation, Singapore.

Roles and challenges of construction firms and public health entomologists in ending indoor malaria transmission in African setting

Indoor malaria transmission reduction across sub-Saharan Africa has been attained through implementation of long-lasting insecticidal nets and indoor residual spray interventions with small-scale larval source management. Improvement of house structures in sub-Saharan Africa can lead to zero indoor malaria transmission with evidence from West Africa, East Africa and Middle East countries. Residual malaria transmission cannot be targeted well with LLINs and IRS alone, but with incorporation of house structures modifications it may be possible.

Malaria Epidemiology in Kilifi, Kenya during the 21st Century: What Next?

Lorenz von Seidlein and Jakob Knudsen discuss the changes in malaria incidence recorded at a single site in Africa over 25 years, along with future implications for disease prevention.

Armigeres subalbatus colonization of damaged pit latrines: a nuisance and potential health risk to residents of resettlement villages in Laos

During the resettlement of 6500 persons living around the Nam Theun 2 hydroelectric project in Laos, more than 1200 pour-flush latrines were constructed. To assess the role of these latrines as productive larval habitats for mosquitoes, entomological investigations using Centers for Disease Control (CDC) light traps, visual inspection and emergence trapping were carried out in over 300 latrines during the rainy seasons of 2008-2010. Armigeres subalbatus (Diptera: Culicidae) were nine times more likely to be found in latrines (mean catch: 3.09) than in adjacent bedrooms (mean catch: 0.37) [odds ratio (OR) 9.08, 95% confidence interval (CI) 6.74-15.11] and mosquitoes were active in and around 59% of latrines at dusk. Armigeres subalbatus was strongly associated with latrines with damaged or improperly sealed septic tank covers (OR 5.44, 95% CI 2.02-14.67; P < 0.001). Armigeres subalbatus is a nuisance biter and a putative vector of Japanese encephalitis and dengue viruses. Dengue virus serotype 3 was identified from a single pool of non-blood-fed female A. subalbatus using reverse transcription polymerase chain reaction. Maintaining a good seal around septic tanks by covering them with a layer of soil is a simple intervention to block mosquito exit/entry and contribute to vector control in resettlement villages. The scale-up of this simple, cheap intervention would have global impact in preventing the colonization of septic tanks by nuisance biting and disease-transmitting mosquitoes.

High Mobility and Low Use of Malaria Preventive Measures Among the Jarai Male Youth Along the Cambodia-Vietnam Border

Malaria control along the Vietnam-Cambodia border presents a challenge for both countries' malaria elimination targets as the region is forested, inhabited by ethnic minority populations, and potentially characterized by early and outdoor malaria transmission. A mixed methods study assessed the vulnerability to malaria among the Jarai population living on both sides of the border in the provinces of Ratanakiri (Cambodia) and Gia Lai (Vietnam). A qualitative study generated preliminary hypotheses that were quantified in two surveys, one targeting youth (N = 498) and the other household leaders (N = 449). Jarai male youth, especially in Cambodia, had lower uptake of preventive measures (57.4%) and more often stayed overnight in the deep forest (35.8%) compared with the female youth and the adult population. Among male youth, a high-risk subgroup was identified that regularly slept at friends' homes or outdoors, who had fewer bed nets (32.5%) that were torn more often (77.8%). The vulnerability of Jarai youth to malaria could be attributed to the transitional character of youth itself, implying less fixed sleeping arrangements in nonpermanent spaces or non-bed sites. Additional tools such as long-lasting hammock nets could be suitable as they are in line with current practices.

Urban and architectural risk factors for malaria in indigenous Amazonian settlements in Brazil: a typological analysis

In the Amazon, m alaria is highly endemic in indigenous populations, which are often considered one of the last barriers to malaria elimination due to geographic isolation. Although the improvement of housing conditions is a good strategy towards the control and prevention of vector-borne diseases, such as malaria, this preventive practice has been barely undertaken in Latin America. An analysis of the architectural and urban features of indigenous Amazonian populations is essential to define and adapt these vector control measures. A total of 32 villages of 29 different ethnicities were studied and mapped by reviewing literature and visual information, and using a geographic information system. The most important architectural and urban characteristics influencing malaria were analysed according to the following categories: number of households and dimensions, supporting area, openings, materials, lifespan and location. Housing typologies found were classified within each of these variables. The results of this typological analysis included an easy-to-handle working template and revealing of features that benefit or hamper the presence of malaria vectors in Amerindians communities. Among risk factors, presence of open eaves, permeable walls, open-side constructions, large number of sleepers indoors, temporary-ephemeral houses, linear villages along stream banks, houseboats villages, poor urban drainage and villages surrounded by anthropogenic environments were highlighted. Indigenous settlements very permissive for anophelines were identified in ethnic groups, such as the Yanomami, Palikur, Paumari, Waimiri-Atroari and Wajãpi. Positive features were also recognized, including opaque and closed houses, large radial villages on bare soil, highly elevated stilted houses and the fire indoors, found among the Yawalapiti, Ashaninka, and Gavião-Parkatejê tribes. However, as Amazonian indigenous settlement typologies vary greatly even among villages of the same ethnic group, it is imperative to undertake an individual study for each community. Using the working template in Amazonian settlements it is possible to obtain data that will help researchers not only understand how architectural and urban features affect transmission, but also define vector control measures easily applicable by health authorities and acceptable by these communities.

Biting behaviour of African malaria vectors: 1. where do the main vector species bite on the human body?

BACKGROUND

Malaria control in Africa relies heavily on indoor vector management, primarily indoor residual spraying and insecticide treated bed nets. Little is known about outdoor biting behaviour or even the dynamics of indoor biting and infection risk of sleeping household occupants. In this paper we explore the preferred biting sites on the human body and some of the ramifications regarding infection risk and exposure management.

METHODS

We undertook whole-night human landing catches of Anopheles arabiensis in South Africa and Anopheles gambiae s.s. and Anopheles funestus in Uganda, for seated persons wearing short sleeve shirts, short pants, and bare legs, ankles and feet. Catches were kept separate for different body regions and capture sessions. All An. gambiae s.l. and An. funestus group individuals were identified to species level by PCR.

RESULTS

Three of the main vectors of malaria in Africa (An. arabiensis, An. gambiae s.s. and An. funestus) all have a preference for feeding close to ground level, which is manifested as a strong propensity (77.3% - 100%) for biting on lower leg, ankles and feet of people seated either indoors or outdoors, but somewhat randomly along the lower edge of the body in contact with the surface when lying down. If the lower extremities of the legs (below mid-calf level) of seated people are protected and therefore exclude access to this body region, vector mosquitoes do not move higher up the body to feed at alternate body sites, instead resulting in a high (58.5% - 68.8%) reduction in biting intensity by these three species.

CONCLUSIONS

Protecting the lower limbs of people outdoors at night can achieve a major reduction in biting intensity by malaria vector mosquitoes. Persons sleeping at floor level bear a disproportionate risk of being bitten at night because this is the preferred height for feeding by the primary vector species. Therefore it is critical to protect children sleeping at floor level (bednets; repellent-impregnated blankets or sheets, etc.). Additionally, the opportunity exists for the development of inexpensive repellent-impregnated anklets and/or sandals to discourage vectors feeding on the lower legs under outdoor conditions at night.

Determinants of low socio-economic status and risk of Plasmodium vivax malaria infection in Panama (2009-2012): a case-control study

Background

Identification of risk factors is important for the establishment of malaria elimination programmes tailored to specific regions. Type of house construction had been associated with increasing risk of acquiring malaria. This study aimed at establishing the association between determinants of low socio-economic status (SES) and type of house construction with the likelihood of living in a Plasmodium vivax malarious corregimiento (smallest political division) in Panama during 2009–2012.

Methods

To determine the association between type-2 houses (build with deciduous materials) and other determinants of low SES, with living in a malarious corregimiento, this study analyzed demographic and housing census data (2010), and malaria incidence aggregated at the corregimiento level (2009–2012), using a Spearman’s non-parametric correlation test to explore for associations, followed by a case–control study and a reduced multivariate logistic regression approach for confirmation.

Results

A descriptive temporal and spatial analysis indicated that P. vivax in Panama was associated with Amerindian reservations. Moreover, this study demonstrated that a strong correlation (deleterious effect) existed between living in a malarious corregimiento and being exposed to a type-2 house (OR = > 1.0) (p < 0.001), while, it showed an inverse correlation for exposure to type-1 houses (protective effect) (build with permanent materials) (OR = < 1.0) (p < 0.001). In the same way, a significant association between exposure to type-2 houses and the outcome of living in a malarious corregimiento was found using a case–control study approach (Chi² test = p < 0.001), that was confirmed applying a reduced multivariate logistic regression fitted model.

Conclusions

This study demonstrated that living in a P. vivax malarious corregimiento in Panama during 2009–2012 was strongly correlated with those corregimientos having a high proportion of type-2 houses. A multivariate logistic regression approach at the house and corregimiento level indicated a strong association of type-2 houses, dirt floors and illiteracy with the likelihood of living in a malarious corregimiento. It is expected that these findings will help implement a multi-sectorial approach for the elimination of malaria in poor areas of Panama where malaria is endemic, which emphasizes house improvements such as mosquito-proofing and socio-economic development.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-014-0529-7) contains supplementary material, which is available to authorized users.

Application of loop analysis for evaluation of malaria control interventions

Background

Despite continuous efforts and recent rapid expansion in the financing and implementation of malaria control interventions, malaria still remains one of the most devastating global health issues. Even in countries that have been successful in reducing the incidence of malaria, malaria control is becoming more challenging because of the changing epidemiology of malaria and waning community participation in control interventions. In order to improve the effectiveness of interventions and to promote community understanding of the necessity of continued control efforts, there is an urgent need to develop new methodologies that examine the mechanisms by which community-based malaria interventions could reduce local malaria incidence.

Methods

This study demonstrated how the impact of community-based malaria control interventions on malaria incidence can be examined in complex systems by qualitative analysis combined with an extensive review of literature. First, sign digraphs were developed through loop analysis to analyse seven interventions: source reduction, insecticide/larvicide use, biological control, treatment with anti-malarials, insecticide-treated mosquito net/long-lasting insecticidal net, non-chemical personal protection measures, and educational intervention. Then, for each intervention, the sign digraphs and literature review were combined to analyse a variety of pathways through which the intervention can influence local malaria incidence as well as interactions between variables involved in the system. Through loop analysis it is possible to see whether increases in one variable qualitatively increases or decreases other variables or leaves them unchanged and the net effect of multiple, interacting variables.

Results

Qualitative analysis, specifically loop analysis, can be a useful tool to examine the impact of community-based malaria control interventions. Without relying on numerical data, the analysis was able to describe pathways through which each intervention could influence malaria incidence on the basis of the qualitative patterns of the interactions between variables in complex systems. This methodology is generalizable to various disease control interventions at different levels, and can be utilized by a variety of stakeholders such as researchers, community leaders and policy makers to better plan and evaluate their community-based disease control interventions.

Promoting health and advancing development through improved housing in low-income settings

There is major untapped potential to improve health in low-income communities through improved housing design, fittings, materials and construction. Adverse effects on health from inadequate housing can occur through a range of mechanisms, both direct and indirect, including as a result of extreme weather, household air pollution, injuries or burns, the ingress of disease vectors and lack of clean water and sanitation. Collaborative action between public health professionals and those involved in developing formal and informal housing could advance both health and development by addressing risk factors for a range of adverse health outcomes. Potential trade-offs between design features which may reduce the risk of some adverse outcomes whilst increasing the risk of others must be explicitly considered.

Effects of changing mosquito host searching behaviour on the cost effectiveness of a mass distribution of long-lasting, insecticidal nets: a modelling study

Background

The effectiveness of long-lasting, insecticidal nets (LLINs) in preventing malaria is threatened by the changing biting behaviour of mosquitoes, from nocturnal and endophagic to crepuscular and exophagic, and by their increasing resistance to insecticides.

Methods

Using epidemiological stochastic simulation models, we studied the impact of a mass LLIN distribution on Plasmodium falciparum malaria. Specifically, we looked at impact in terms of episodes prevented during the effective life of the batch and in terms of net health benefits (NHB) expressed in disability adjusted life years (DALYs) averted, depending on biting behaviour, resistance (as measured in experimental hut studies), and on pre-intervention transmission levels.

Results

Results were very sensitive to assumptions about the probabilistic nature of host searching behaviour. With a shift towards crepuscular biting, under the assumption that individual mosquitoes repeat their behaviour each gonotrophic cycle, LLIN effectiveness was far less than when individual mosquitoes were assumed to vary their behaviour between gonotrophic cycles. LLIN effectiveness was equally sensitive to variations in host-searching behaviour (if repeated) and to variations in resistance. LLIN effectiveness was most sensitive to pre-intervention transmission level, with LLINs being least effective at both very low and very high transmission levels, and most effective at around four infectious bites per adult per year. A single LLIN distribution round remained cost effective, except in transmission settings with a pre-intervention inoculation rate of over 128 bites per year and with resistant mosquitoes that displayed a high proportion (over 40%) of determined crepuscular host searching, where some model variants showed negative NHB.

Conclusions

Shifts towards crepuscular host searching behaviour can be as important in reducing LLIN effectiveness and cost effectiveness as resistance to pyrethroids. As resistance to insecticides is likely to slow down the development of behavioural resistance and vice versa, the two types of resistance are unlikely to occur within the same mosquito population. LLINs are likely cost effective interventions against malaria, even in areas with strong resistance to pyrethroids or where a large proportion of host-mosquito contact occurs during times when LLIN users are not under their nets.

Risk factors for mosquito house entry in the Lao PDR

Background

Construction of the Nam Theun 2 hydroelectric project and flooding of a 450 km² area of mountain plateau in south-central Lao PDR resulted in the resettlement of 6,300 people to newly built homes. We examined whether new houses would have altered risk of house entry by mosquitoes compared with traditional homes built from poorer construction materials.

Methodology/Principal Findings

Surveys were carried out in the Nam Theun 2 resettlement area and a nearby traditional rice farming area in 2010. Mosquitoes were sampled in bedrooms using CDC light traps in 96 resettlement houses and 96 traditional houses and potential risk factors for mosquito house entry were recorded. Risk of mosquito house entry was more than twice as high in traditional bamboo houses compared with those newly constructed from wood (Putative Japanese Encephalitis (JE) vector incidence rate ratio (IRR) = 2.26, 95% CI 1.38–3.70, P = 0.001; Anopheline IRR = 2.35, 95% CI: 1.30–4.23, P = 0.005). Anophelines were more common in homes with cattle compared against those without (IRR = 2.32, 95% CI: 1.29–4.17, P = 0.005).Wood smoke from cooking fires located under the house or indoors was found to be protective against house entry by both groups of mosquito, compared with cooking in a separate room beside the house (Putative JE vector IRR = 0.43, 95% CI: 0.26–0.73, P = 0.002; Anopheline IRR = 0.22, 95% CI: 0.10–0.51, P<0.001).

Conclusions/Significance

Construction of modern wooden homes should help reduce human-mosquito contact in the Lao PDR. Reduced mosquito contact rates could lead to reduced transmission of diseases such as JE and malaria. Cattle ownership was associated with increased anopheline house entry, so zooprophylaxis for malaria control is not recommended in this area. Whilst wood smoke was protective against putative JE vector and anopheline house entry we do not recommend indoor cooking since smoke inhalation can enhance respiratory disease.

Netting barriers to prevent mosquito entry into houses in southern Mozambique: a pilot study

Background

One of the best ways to control the transmission of malaria is by breaking the vector-human link, either by reducing the effective population size of mosquitoes or avoiding infective bites. Reducing house entry rates in endophagic vectors by obstructing openings is one simple way of achieving this. Mosquito netting has previously been shown to have this effect. More recently different materials that could also be used have come onto the market. Therefore, a pilot study was conducted to investigate the protective effect of three types of material against Anopheles funestus and Anopheles gambiae s.l entry into village houses in Mozambique when applied over the large opening at the gables and both gables and eaves.

Methods

A two-step intervention was implemented in which the gable ends of houses (the largest opening) were covered with one of three materials (four year old mosquito bed nets; locally purchased untreated shade cloth or deltamethrin-impregnated shade cloth) followed by covering both gable ends and eaves with material. Four experimental rounds (each of three weeks duration), from four houses randomly assigned to be a control or to receive one of the three intervention materials, were undertaken from March to August 2010 in the village of Furvela in southern Mozambique. Mosquito entry rates were assessed by light-trap collection and the efficacy of the different materials was determined in terms of incidence rate ratio (IRR), obtained through a Generalized Estimating Equations (GEE), of mosquito entry in a treated house compared to the untreated (control) house.

Results

Altogether 9,692 An. funestus and 1,670 An. gambiae s.l. were collected. Houses treated with mosquito netting or the untreated shade cloth had 61.3% [IRR = 0.39 (0.32-0.46); P <0.0001] and 70% [IRR = 0.30 (0.25 – 0.37); P <0.001] fewer An. funestus in relation to untreated houses, but there was no difference in An. funestus in houses treated with the deltamethrin-impregnated shade cloth [IRR = 0.92 (0.76 –1.12); P = 0.4] compared to untreated houses. Houses treated with mosquito netting reduced entry rates of An. gambiae s.l, by 84% [IRR = 0.16 (0.10 – 0.25); P <0.001], whilst untreated shade cloth reduced entry rates by 69% [IRR = 0.31 (0.19 –0.53); P <0.001] and entry rates were reduced by 76% [IRR = 0.24 (0.15 0.38); P <0.001] in houses fitted with deltamethrin-impregnated shade cloth.

Airflow attenuation and bed net utilization: observations from Africa and Asia

BACKGROUND/METHODS

Qualitative studies suggest that bed nets affect the thermal comfort of users. To understand and reduce this discomfort the effect of bed nets on temperature, humidity, and airflow was measured in rural homes in Asia and Africa, as well as in an experimental wind tunnel. Two investigators with architectural training selected 60 houses in The Gambia, Tanzania, Philippines, and Thailand. Data-loggers were used to measure indoor temperatures in hourly intervals over a 12 months period. In a subgroup of 20 houses airflow, temperature and humidity were measured at five-minute intervals for one night from 21.00 to 6.00 hrs inside and outside of bed nets using sensors and omni-directional thermo-anemometers. An investigator set up a bed net with a mesh size of 220 holes per inch 2 in each study household and slept under the bed net to simulate a realistic environment. The attenuation of airflow caused by bed nets of different mesh sizes was also measured in an experimental wind tunnel.

RESULTS

The highest indoor temperatures (49.0 C) were measured in The Gambia. During the hottest months of the year the mean temperature at night (9 pm) was between 33.1 C (The Gambia) and 26.2 C (Thailand). The bed net attenuated the airflow from a minimum of 27% (Philippines) to a maximum of 71% (The Gambia). Overall the bed nets reduced airflow compared to un-attenuated airflow from 9 to 4 cm sec-1 or 52% (p<0.001). In all sites, no statistically significant difference in temperature or humidity was detected between the inside and outside of the bed net. Wind tunnel experiments with 11 different mesh-sized bed nets showed an overall reduction in airflow of 64% (range 55 - 71%) compared to un-attenuated airflow. As expected, airflow decreased with increasing net mesh size. Nets with a mesh of 136 holes inch-2 reduced airflow by 55% (mean; range 51 - 73%). A denser net (200 holes inch-2) attenuated airflow by 59% (mean; range 56 - 74%).

DISCUSSION

Despite concerted efforts to increase the uptake of this intervention in many areas uptake remains poor. Bed nets reduce airflow, but have no influence on temperature and humidity. The discomfort associated with bed nets is likely to be most intolerable during the hottest and most humid period of the year, which frequently coincides with the peak of malaria vector densities and the force of pathogen transmission.

CONCLUSIONS

These observations suggest thermal discomfort is a factor limiting bed net use and open a range of architectural possibilities to overcome this limitation.

Pyrethroid resistance in Anopheles gambiae leads to increased susceptibility to the entomopathogenic fungi Metarhizium anisopliae and Beauveria bassiana

BACKGROUND

Entomopathogenic fungi are being investigated as a new mosquito control tool because insecticide resistance is preventing successful mosquito control in many countries, and new methods are required that can target insecticide-resistant malaria vectors. Although laboratory studies have previously examined the effects of entomopathogenic fungi against adult mosquitoes, most application methods used cannot be readily deployed in the field. Because the fungi are biological organisms it is important to test potential field application methods that will not adversely affect them. The two objectives of this study were to investigate any differences in fungal susceptibility between an insecticide-resistant and insecticide-susceptible strain of Anopheles gambiae sensu stricto, and to test a potential field application method with respect to the viability and virulence of two fungal species

METHODS

Pieces of white polyester netting were dipped in Metarhizium anisopliae ICIPE-30 or Beauveria bassiana IMI391510 mineral oil suspensions. These were kept at 27 +/- 1 degrees C, 80 +/- 10% RH and the viability of the fungal conidia was recorded at different time points. Tube bioassays were used to infect insecticide-resistant (VKPER) and insecticide-susceptible (SKK) strains of An. gambiae s.s., and survival analysis was used to determine effects of mosquito strain, fungus species or time since fungal treatment of the net.

RESULTS

The resistant VKPER strain was significantly more susceptible to fungal infection than the insecticide-susceptible SKK strain. Furthermore, B. bassiana was significantly more virulent than M. anisopliae for both mosquito strains, although this may be linked to the different viabilities of these fungal species. The viability of both fungal species decreased significantly one day after application onto polyester netting when compared to the viability of conidia remaining in suspension.

CONCLUSIONS

The insecticide-resistant mosquito strain was susceptible to both species of fungus indicating that entomopathogenic fungi can be used in resistance management and integrated vector management programmes to target insecticide-resistant mosquitoes. Although fungal viability significantly decreased when applied to the netting, the effectiveness of the fungal treatment at killing mosquitoes did not significantly deteriorate. Field trials over a longer trial period need to be carried out to verify whether polyester netting is a good candidate for operational use, and to see if wild insecticide-resistant mosquitoes are as susceptible to fungal infection as the VKPER strain.

Importance of eaves to house entry by anopheline, but not culicine, mosquitoes

Screening homes is an effective way of reducing house entry by mosquitoes. Here, we assess how important blocking the eaves is for reducing house entry by anopheline and culicine mosquitoes for houses that have screened doors and no windows. Twelve houses, with two screened doors and no windows, in which a single adult male slept, were included in a simple crossover design. In the first period, six houses were randomly selected and had the eaves blocked using a mixture of rubble and mortar; the other six were left with open eaves. Mosquitoes were sampled using CDC light traps from each house twice a week for 4 wk. Mosquito control activities and the number and type of domestic animals within the compound was recorded on each sampling occasion. Before beginning the second sampling period, homes with blocked eaves had them opened, and those with open eaves had them closed. Mosquitoes were then sampled from each house for a further 4 wk. When houses had their eaves closed, a three-fold reduction in Anopheles gambiae s.l. Giles caught indoors was observed. However, there was no reduction in total culicine numbers observed. This study demonstrates that the eaves are the major route by which An. gambiae enters houses. By contrast, culicine mosquitoes enter largely through doors and windows. Sealing the eave gap is an important method for reducing malaria transmission in homes where doors and windows are screened.

Smoke and malaria: are interventions to reduce exposure to indoor air pollution likely to increase exposure to mosquitoes?

Indoor air pollution from the domestic use of biomass fuels by poor households in developing countries is known to be harmful to health, and efforts are being made to address this problem by changes in fuel type, stove technology, house design and fuel-use practices. However, anecdotal evidence suggests that smoke may play an important role by providing protection from biting insects and that efforts to reduce smoke may increase exposure, particularly to mosquitoes and malaria. This paper reviews the literature relating to the repellent effect of smoke on mosquitoes and finds that there is currently no evidence that smoke from domestic fuel use provides effective protection from mosquitoes and malaria. Given the limited number and quality of studies, this finding cannot be interpreted as conclusive. The literature relating to house ventilation and mosquito entry was also reviewed, and an association between eaves spaces and increased indoor mosquito density was noted. Additionally, literature on the effect of soot on the efficacy of insecticide-treated bed nets was considered, but no direct impact was shown. Efforts to reduce indoor air pollution remain desirable even in areas of malaria transmission.

Interdependence of domestic malaria prevention measures and mosquito-human interactions in urban Dar es Salaam, Tanzania

BACKGROUND

Successful malaria vector control depends on understanding behavioural interactions between mosquitoes and humans, which are highly setting-specific and may have characteristic features in urban environments. Here mosquito biting patterns in Dar es Salaam, Tanzania are examined and the protection against exposure to malaria transmission that is afforded to residents by using an insecticide-treated net (ITN) is estimated.

METHODS

Mosquito biting activity over the course of the night was estimated by human landing catch in 216 houses and 1,064 residents were interviewed to determine usage of protection measures and the proportion of each hour of the night spent sleeping indoors, awake indoors, and outdoors.

RESULTS

Hourly variations in biting activity by members of the Anopheles gambiae complex were consistent with classical reports but the proportion of these vectors caught outdoors in Dar es Salaam was almost double that of rural Tanzania. Overall, ITNs confer less protection against exophagic vectors in Dar es Salaam than in rural southern Tanzania (59% versus 70%). More alarmingly, a biting activity maximum that precedes 10 pm and much lower levels of ITN protection against exposure (38%) were observed for Anopheles arabiensis, a vector of modest importance locally, but which predominates transmission in large parts of Africa.

CONCLUSION

In a situation of changing mosquito and human behaviour, ITNs may confer lower, but still useful, levels of personal protection which can be complemented by communal transmission suppression at high coverage. Mosquito-proofing houses appeared to be the intervention of choice amongst residents and further options for preventing outdoor transmission include larviciding and environmental management.

Do bednets reduce malaria transmission by exophagic mosquitoes?

The impact of bednet coverage on malaria prevalence in a suburb of São Tomé was monitored, by passive case detection, over a three-year period (1997-1999), when bednet use increased from 20 to 74%. Malaria parasites were detected in 1651 (41.6%) of the 3967 slides taken during the study. All four human malaria parasites were seen, with Plasmodium falciparum being the predominant species (94.9% of positive slides). Prevalence of malaria among residents decreased, particularly in 1-4 year olds. In addition, there was a concomitant decrease in prevalence also among non-net users, suggesting a mass effect on transmission, even though the only vector in the area is largely exophagic and zoophilic.

Reducing the burden of malaria in different eco-epidemiological settings with environmental management: a systematic review

The public health and economic significance of malaria is enormous, and its control remains a great challenge. Many established malaria control methods are hampered by drug resistance and insecticide-resistant vectors. Malaria control measures built around environmental management are non-toxic, cost-effective, and sustainable. However, there has been no comprehensive review of the literature or meta-analysis examining the effect of these interventions. We therefore did a systematic literature review and identified 40 studies that emphasised environmental management interventions and reported clinical malaria variables as outcome measures. Of these 40 studies, environmental modification (measures aiming to create a permanent or long-lasting effect on land, water, or vegetation to reduce vector habitats--eg, the installation and maintenance of drains) was the central feature in 27 studies, environmental manipulation (methods creating temporary unfavourable conditions for the vector--eg, water or vegetation management) in four, and nine quantified the effect of modifications of human habitation. Most of the studies (n=34, 85%) were implemented before the Global Malaria Eradication Campaign (1955-69), which mainly relied on indoor residual spraying with dichlorodiphenyltrichloroethane (DDT). In 16 studies that applied environmental modification and in eight studies on modification of human habitation, the risk ratio of malaria was reduced by 88.0% (95% CI 81.7-92.1) and 79.5% (95% CI 67.4-87.2), respectively. We conclude that malaria control programmes that emphasise environmental management are highly effective in reducing morbidity and mortality. Lessons learned from these past successful programmes can inspire sound and sustainable malaria control approaches and strategies.

Environmental risks in the developing world: exposure indicators for evaluating interventions, programmes, and policies

BACKGROUND

Monitoring and empirical evaluation are essential components of evidence based public health policies and programmes. Consequently, there is a growing interest in monitoring of, and indicators for, major environmental health risks, particularly in the developing world. Current large scale data collection efforts are generally disconnected from micro-scale studies in health sciences, which in turn have insufficiently investigated the behavioural and socioeconomic factors that influence exposure.

STUDY DESIGN

A basic framework is proposed for development of indicators of exposure to environmental health risks that would facilitate the (a) assessment of the health effects of risk factors, (b) design and evaluation of interventions and programmes to deliver the interventions, and (c) appraisal and quantification of inequalities in health effects of risk factors, and benefits of intervention programmes and policies. Specific emphasis is put on the features of environmental risks that should guide the choice of indicators, in particular the interactions of technology, the environment, and human behaviour in determining exposure. The indicators are divided into four categories: (a) access and infrastructure, (b) technology, (c) agents and vectors, and (d) behaviour. The study used water and sanitation, indoor air pollution from solid fuels, urban ambient air pollution, and malaria as illustrative examples for this framework.

CONCLUSIONS

Organised and systematic indicator selection and monitoring can provide an evidence base for design and implementation of more effective and equitable technological interventions, delivery programmes, and policies for environmental health risks in resource poor settings.