Mosquito net coverage in years between mass distributions: a case study of Tanzania, 2013

Evaluation of household coverage with long-lasting insecticidal nets in central Côte d'Ivoire

BACKGROUND

To reduce malaria burden in Côte d'Ivoire, the Ministry of Health aims for 90% of its population to possess one long-lasting insecticidal net (LLIN) for every two persons by 2025. This study evaluated LLIN coverage two years after a mass distribution in central Côte d'Ivoire.

METHODS

A census was conducted in 43 villages. Data were collected on household geo-position, composition, number of sleeping units and LLINs owned. LLIN coverage was assessed using: 1/ownership; proportion of household with at least one LLIN; 2/household access; households with sufficient nets for every two persons and for every sleeping unit; and 3/population access; proportion of population with access to LLIN within households and sleeping units.

RESULTS

10,630 households (89.6% response rate) and 46,619 inhabitants were recruited. Household LLIN ownership was 63.8% (95% CI: 58.7-68.8). Household LLIN access was 37.6% (95% CI: 33.2-42.0) based on 1 LLIN per 2 persons and 37.1% (95% CI: 33.0-41.2) based on 1 net per sleeping unit. Population LLIN access based on 1 LLIN per 2 persons and 1 net per sleeping space was 53.3% (95% CI: 48.6-58.1) and 49.4% (95% CI: 45.1-53.6), respectively. Approximately 17% of households with access for every 2 persons did not have access by every sleeping unit and 9.7% of households with access by sleeping unit did not have access for every 2 persons. Households with adequate access by sleeping unit but not for every 2 persons tend to be larger with fewer sleeping units, and have children under 5 years old and female members. The largest households (>7 members) and households with at least one under-five member had the lowest access (20.8 and 27.3%, respectively).

CONCLUSION

LLIN access was low in this area of intense indoor malaria transmission, 2 years after the last mass distribution campaign. Strategies are needed to improve LLINs coverage.

Household predictors of malaria episode in northern Uganda: its implication for future malaria control

BACKGROUND

Uses of indoor residual spraying (IRS), long-lasting insecticidal nets (LLINS) and treatment with artemisinin-based combination therapy (ACT) are greatly promoted in the northern part of Uganda as mitigating strategies for malaria episodes. Unfortunately, the region remains the fourth highest malaria burden in Uganda with a prevalence of 12%. This study assesses household predictors of malaria episodes in northern Uganda and their impact on malaria episodes at the household level.

METHODS

A cross-sectional study was conducted in four districts of Gulu, Oyam, Kitgum and Agago covering sixteen villages in northern Uganda. Data was collected through a pre-tested structured questionnaire and systematically coded for analysis using R software.

RESULTS

In total, 193 households were surveyed with 112 (58%) of them headed by women and 605 individuals were declared to have spent the night before the interview in the 193 households. On average, there were at least two-bed nets (317/159) per household and a total of 460 individuals out of 535 (86%) spent the night before the interview under a bed net. The usage of bed nets in the study area overall was 86% while malaria incidence was 50% higher in children than in adults. Hierarchical clustering on principal components (HCPC) categorizes households in northern Uganda into three types: 1) households that use bed nets and sleep in houses sprayed with insecticides; 2) households that use bed nets but no indoor residual spraying with insecticides and 3) households that have no bed nets and no indoor residual spraying. When given a choice between IRS and treated bed nets, 1 in 3 households preferred treated bed nets. At the same time, data suggests that bed nets were perceived as unnecessary once the IRS was applied. If true, the driving force for spraying insecticides indoors then becomes the lack of a bed net.

CONCLUSIONS

Malaria episodes were strongly related to lack of bed nets or use thereof, and directly linked to the number of individuals in a household. Children were prone to malaria more than adults by a ratio of 2:1. The three categories of households in northern Uganda as revealed by HCPC provide an opportunity to tailor-make preventive/intervention malaria messages to fit the individual household clusters.

Assessing trends in non-coverage bias in mobile phone surveys for estimating insecticide-treated net coverage: a cross-sectional analysis in Tanzania, 2007-2017

Introduction

Monitoring insecticide-treated net (ITN) coverage and use generally relies on household surveys which occur on a relatively infrequent basis. Because indicators of coverage are used to forecast the need for ITNs and aid in planning ITN distribution campaigns, higher frequency monitoring could be helpful to guide programme strategies. The use of mobile phone-based survey (MPS) strategies in low-income and middle-income countries has emerged as a rapid and comparatively inexpensive complement to large-scale population-based household surveys, considering the dramatic growth trend of mobile phone ownership.

Methods

The potential for non-coverage bias in the calculation of ITN coverage estimates from MPSs was assessed through the use of five consecutive Tanzania-specific Demographic and Health Surveys (DHS). Primary comparisons were made between all households included in the data sets (the reference standard) and mobile phone-owning households (the comparator). Deviations in ITN coverage estimates between the reference standard and mobile phone-owning households were used as a proxy for assessing potential non-coverage bias, with estimates calculated using a bootstrap method.

Results

By the 2017 DHS, regional measures of non-coverage bias for ITN coverage indicators rarely exceeded a ±3 percentage point difference when comparing mobile phone-owning households to the overall sample. However, larger differences were observed when comparing mobile phone-owning households to non-mobile phone-owning households, particularly in periods without recent mass ITN distributions.

Conclusion

Results suggest that MPSs can reliably estimate ITN coverage at the population level when both ITN coverage and mobile phone ownership are high. However, as ITN coverage declines, the gap between phone-owning and non-phone-owning households widens, indicating potential non-coverage bias and underscoring the need for caution in interpreting MPS data under such conditions.

Mapping inequalities in health service coverage in Africa: a scoping review

OBJECTIVE

In this scoping review, we aim to consolidate the evidence on inequalities in service coverage in Africa using a comprehensive set of stratifiers. These stratifiers include place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status and social capital. Our approach provides a more holistic understanding of the different dimensions of inequality in the context of universal health coverage (UHC).

DESIGN

We conducted a scoping review following the Joanna Briggs Institute Manual for Evidence Synthesis.

DATA SOURCES

We searched MEDLINE, Embase, Web of Science, CINAHL, PyscINFO, Cochrane Library, Google Scholar and Global Index Medicus for articles published between 1 January 2005 and 29 August 2022 examining inequalities in utilisation of health services for reproductive, maternal, newborn and child health (RMNCH), infectious or non-communicable diseases in Africa.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included any empirical research that assessed inequalities in relation to services for RMNCH (eg, family planning), infectious diseases (eg, tuberculosis treatment) and non-communicable diseases (eg, cervical cancer screening) in Africa.

DATA EXTRACTION AND SYNTHESIS

The data abstraction process followed a stepwise approach. A pilot-tested form capturing study setting, inequality assessment and service coverage indicators was developed and finalised. Data were extracted by one reviewer and cross-checked by another, with discrepancies resolved through consensus meetings. If a consensus was not reached, senior reviewers made the final decision. We used a narrative approach to describe the study characteristics and mapped findings against PROGRESS-Plus stratifiers and health service indicators. Quantitative findings were categorised as 'proequity', 'antiequity' or 'equal' based on service utilisation across social groups.

RESULTS

We included 178 studies in our review, most studies published within the last 5 years (61.1%). Most studies assessed inequality using socioeconomic status (70.6%), followed by age (62.4%), education (60.7%) and place of residence (59.0%). Few studies focused on disability, social capital and ethnicity/race and intersectionality of stratifiers. Most studies were on RMNCH services (53.4%) and infectious disease services (43.3%). Few studies were qualitative or behavioural analyses. Results highlight significant inequalities across different equity stratifiers and services with inconsistent trends of inequalities over time after the implementation of strategies to increase demand of services and strengthen health systems.

CONCLUSION

There is a need to examine equity in service coverage for a variety of health conditions among various populations beyond the traditional classification of social groups. This also requires using diverse research methods identifying disparities in service use and various barriers to care. By addressing these knowledge gaps, future research and health system reforms can support countries in moving closer to achievement of UHC targets.

National genomic profiling of Plasmodium falciparum antimalarial resistance in Zambian children participating in the 2018 Malaria Indicator Survey

The emergence of antimalarial drug resistance is a major threat to malaria control and elimination. Using whole genome sequencing of 282 P. falciparum samples collected during the 2018 Zambia National Malaria Indicator Survey, we determined the prevalence and spatial distribution of known and candidate antimalarial drug resistance mutations. High levels of genotypic resistance were found across Zambia to pyrimethamine, with over 94% (n=266) of samples having the Pfdhfr triple mutant (N51I, C59R, and S108N), and sulfadoxine, with over 84% (n=238) having the Pfdhps double mutant (A437G and K540E). In northern Zambia, 5.3% (n=15) of samples also harbored the Pfdhps A581G mutation. Although 29 mutations were identified in Pfkelch13, these mutations were present at low frequency (<2.5%), and only three were WHO-validated artemisinin partial resistance mutations: P441L (n=1, 0.35%), V568M (n=2, 0.7%) and R622T (n=1, 0.35%). Notably, 91 (32%) of samples carried the E431K mutation in the Pfatpase6 gene, which is associated with artemisinin resistance. No specimens carried any known mutations associated with chloroquine resistance in the Pfcrt gene (codons 72-76). P. falciparum strains circulating in Zambia were highly resistant to sulfadoxine and pyrimethamine but remained susceptible to chloroquine and artemisinin. Despite this encouraging finding, early genetic signs of developing artemisinin resistance highlight the urgent need for continued vigilance and expanded routine genomic surveillance to monitor these changes.

Plasmodium knowlesi infection is associated with elevated circulating biomarkers of brain injury and endothelial activation

Introduction

Malaria remains a major public health concern with substantial morbidity and mortality worldwide. In Malaysia, the emergence of Plasmodium knowlesi has led to a surge in zoonotic malaria cases and deaths in recent years. Signs of cerebral involvement have been observed in a non-comatose, fatal case of severe knowlesi infection, but the potential impact of this malaria species on the brain remains underexplored. To address this gap, we investigated circulating levels of brain injury, inflammation, and vascular biomarkers in a cohort of knowlesi-infected patients and controls.

Methods

Archived plasma samples from 19 patients with confirmed symptomatic knowlesi infection and 19 healthy, age-matched controls from Peninsular Malaysia were analysed. A total of 52 plasma biomarkers of brain injury, inflammation, and vascular activation were measured using Luminex and SIMOA assays. Wilcoxon tests were used to examine group differences, and biomarker profiles were explored through hierarchical clustering heatmap analysis.

Results

Bonferroni-corrected analyses revealed significantly elevated brain injury biomarker levels in knowlesi-infected patients, including S100B (p<0.0001), Tau (p=0.0007), UCH-L1 (p<0.0001), αSyn (p<0.0001), Park7 (p=0.0006), NRGN (p=0.0022), and TDP-43 (p=0.005). Compared to controls, levels were lower in the infected group for BDNF (p<0.0001), CaBD (p<0.0001), CNTN1 (p<0.0001), NCAM-1 (p<0.0001), GFAP (p=0.0013), and KLK6 (p=0.0126). Hierarchical clustering revealed distinct group profiles for circulating levels of brain injury and vascular activation biomarkers.

Conclusions

Our findings highlight for the first time the impact of Plasmodium knowlesi infection on the brain, with distinct alterations in cerebral injury and endothelial activation biomarker profiles compared to healthy controls. Further studies are warranted to investigate the pathophysiology and clinical significance of these altered surrogate markers, through both neuroimaging and long-term neurocognitive assessments.

Efficacy of chlorfenapyr-pyrethroid and piperonyl butoxide-pyrethroid long-lasting insecticidal nets (LLINs) compared to pyrethroid-only LLINs for malaria control in Côte d'Ivoire: a three group, cluster randomised trial

BACKGROUND

The massive scale-up of long-lasting insecticidal nets (LLIN) has led to a major reduction in malaria burden in many sub-Saharan African (SSA) countries. The World Health Organization (WHO) has recently issued a strong recommendation for the use of chlorfenapyr-pyrethroid LLINs compared to standard pyrethroid-only LLINs in areas of high insecticide resistance intensity. However, there is still a lack of conclusive evidence on the efficacy of piperonyl butoxide-pyrethroid (PBO-py) LLINs, especially in West Africa, where vector composition and resistance mechanisms may be different from vectors in East Africa.

METHODS

This is a three-arm, superiority, triple-blinded, cluster randomised trial, with village as the unit of randomisation. This study conducted in Côte d'Ivoire will evaluate the efficacy on epidemiological and entomological outcomes of (1) the control arm: MAGNet® LN, which contains the pyrethroid, alpha-cypermethrin, (2) VEERALIN® LN, a net combining the synergist PBO and alpha-cypermethrin, and (3) Interceptor® G2 LN, which incorporates chlorfenapyr and alpha-cypermethrin, two adulticides with different mechanisms of action. A total of 33 villages with an average of 200 households per village will be identified, mapped, and randomised in a ratio of 1:1:1. Nets will be distributed at a central point following national guidelines with 1 net for every 2 people. The primary outcome of the trial will be incidence of malaria cases (confirmed by rapid diagnostic test (RDT)) in a cohort of 50 children aged 6 months to 10 years in each cluster, followed for 12 months (active case detection). Secondary outcomes are cross-sectional community prevalence of malaria infection (confirmed by RDT) in the study population at 6 and 12 months post-intervention (50 randomly selected persons per cluster), vector density, entomological inoculation rate (EIR), and phenotypic and genotypic insecticide resistance at baseline and 12 months post-intervention in 3 sentinel villages in each treatment arm.

DISCUSSION

In addition to generating further evidence for next-generation LLINs, this study will also provide the first evidence for pyrethroid-PBO nets in a West African setting. This could further inform WHO recommendations on the pragmatic use of pyrethroid-PBO nets.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05796193. Registered on April 3, 2023.

Temporal and spatial dynamics of Plasmodium falciparum clonal lineages in Guyana

Plasmodium parasites, the causal agents of malaria, are eukaryotic organisms that obligately undergo sexual recombination within mosquitoes. However, in low transmission settings where most mosquitoes become infected with only a single parasite clone, parasites recombine with themselves, and the clonal lineage is propagated rather than broken up by outcrossing. We investigated whether stochastic/neutral factors drive the persistence and abundance of Plasmodium falciparum clonal lineages in Guyana, a country with relatively low malaria transmission, but the only setting in the Americas in which an important artemisinin resistance mutation (pfk13 C580Y) has been observed. To investigate whether this clonality was potentially associated with the persistence and spatial spread of the mutation, we performed whole genome sequencing on 1,727 Plasmodium falciparum samples collected from infected patients across a five-year period (2016-2021). We characterized the relatedness between each pair of monoclonal infections (n=1,409) through estimation of identity by descent (IBD) and also typed each sample for known or candidate drug resistance mutations. A total of 160 clones (mean IBD ≥ 0.90) were circulating in Guyana during the study period, comprising 13 highly related clusters (mean IBD ≥ 0.40). In the five-year study period, we observed a decrease in frequency of a mutation associated with artemisinin partner drug (piperaquine) resistance (pfcrt C350R) and limited co-occurence of pfcrt C350R with duplications of plasmepsin 2/3, an epistatic interaction associated with piperaquine resistance. We additionally report polymorphisms exhibiting evidence of selection for drug resistance or other phenotypes and reported a novel pfk13 mutation (G718S) as well as 61 nonsynonymous substitutions that increased markedly in frequency. However, P. falciparum clonal dynamics in Guyana appear to be largely driven by stochastic factors, in contrast to other geographic regions. The use of multiple artemisinin combination therapies in Guyana may have contributed to the disappearance of the pfk13 C580Y mutation.

Longitudinal changes in iron homeostasis in human experimental and clinical malaria

Background

The interaction between iron deficiency and malaria is incompletely understood. We evaluated longitudinal changes in iron homeostasis in volunteers enrolled in malaria volunteer infection studies (VIS) and in Malaysian patients with falciparum and vivax malaria.

Methods

We retrieved samples and associated data from 55 participants enrolled in malaria VIS, and 171 malaria patients and 30 healthy controls enrolled in clinical studies in Malaysia. Ferritin, hepcidin, erythropoietin, and soluble transferrin receptor (sTfR) were measured by ELISA.

Results

In the VIS, participants' parasitaemia was correlated with baseline mean corpuscular volume (MCV), but not iron status (ferritin, hepcidin or sTfR). Ferritin, hepcidin and sTfR all increased during the VIS. Ferritin and hepcidin normalised by day 28, while sTfR remained elevated. In VIS participants, baseline iron status (ferritin) was associated with post-treatment increases in liver transaminase levels. In Malaysian malaria patients, hepcidin and ferritin were elevated on admission compared to healthy controls, while sTfR increased following admission. Hepcidin normalised by day 28; however, ferritin and sTfR both remained elevated 4 weeks following admission.

Conclusion

Our findings demonstrate that parasitaemia is associated with an individual's MCV rather than iron status. The persistent elevation in sTfR 4 weeks post-infection in both malaria VIS and clinical malaria may reflect a causal link between malaria and iron deficiency.

Linkages between malaria and malnutrition in co-endemic regions of India

INTRODUCTION

Malaria and malnutrition are key public health challenges in India. However, the relationship between them is poorly understood. Here, we aimed to elucidate the potential interactions between the two health conditions by identifying the areas of their spatial overlap.

METHODS

We have analysed the district-wise undernutrition and malaria data of 638 districts of India across 28 states and 8 union territories. Data on malnutrition parameters viz. stunting, wasting, underweight and anaemia, sourced from the fourth National Family Health Survey (2015-2016), and malaria Annual Parasite Index (API) data of the same year (i.e, 2015), sourced from National Center of Vector Borne Diseases Control were analysed using local Moran's I Index and logistic regression.

RESULTS

Among all the malnutrition parameters, we found underweight in children and anaemia in men to co-occur with malaria in the districts of Chhattisgarh, Jharkhand, Madhya Pradesh and Odisha. Further, districts with more than 36% underweight children (OR (95% CI): 2.31 (1.53 to 3.48)) and/or more than 23.6% male population with anaemia (OR (95% CI): 2.06 (1.37 to 3.11)) had higher odds of being malaria endemic districts (ie, Annual Parasite Index >1).

CONCLUSION

Malaria and malnutrition co-occur in the malaria-endemic parts of India. The high prevalence of undernutrition in children and anaemia among men may contribute to malaria endemicity in a particular region. Therefore, future research should be prioritised to generate data on the individual level. Further, malaria control interventions could be tailored to integrate nutrition programmes to disrupt indigenous malaria transmission in endemic districts.

Ideational factors associated with consistent use of insecticide-treated nets: a multi-country, multilevel analysis

BACKGROUND

Malaria remains a major cause of morbidity and mortality in sub-Saharan Africa. Using insecticide-treated nets (ITNs) every night, year-round is critical to maximize protection against malaria. This study describes sociodemographic, psychosocial, and household factors associated with consistent ITN use in Cameroon, Côte d'Ivoire and Sierra Leone.

METHODS

Cross-sectional household surveys employed similar sampling procedures, data collection tools, and methods in three countries. The survey sample was nationally representative in Côte d'Ivoire, representative of the North and Far North regions in Cameroon, and representative of Bo and Port Loko districts in Sierra Leone. Analysis used multilevel logistic regression and sociodemographic, ideational, and household independent variables among households with at least one ITN to identify correlates of consistent ITN use, defined as sleeping under an ITN every night the preceding week.

FINDINGS

Consistent ITN use in Côte d'Ivoire was 65.4%, 72.6% in Cameroon, and 77.1% in Sierra Leone. While several sociodemographic and ideational variables were correlated with consistent ITN use, these varied across countries. Multilevel logistic regression results showed perceived self-efficacy to use ITNs and positive attitudes towards ITN use were variables associated with consistent use in all three countries. The perception of ITN use as a community norm was positively linked with consistent use in Cameroon and Côte d'Ivoire but was not significant in Sierra Leone. Perceived vulnerability to malaria was positively linked with consistent use in Cameroon and Sierra Leone but negatively correlated with the outcome in Côte d'Ivoire. Household net sufficiency was strongly and positively associated with consistent use in all three countries. Finally, the findings revealed strong clustering at the household and enumeration area (EA) levels, suggesting similarities in net use among respondents of the same EA and in the same household.

CONCLUSIONS

There are similarities and differences in the variables associated with consistent ITN use across the three countries and several ideational variables are significant. The findings suggest that a social and behaviour change strategy based on the ideation model is relevant for increasing consistent ITN use and can inform specific strategies for each context. Finally, ensuring household net sufficiency is essential.

Social network correlates of free and purchased insecticide-treated bed nets in rural Uganda

BACKGROUND

Malaria is a major cause of mortality and morbidity in Uganda. Despite Uganda's efforts to distribute bed nets, only half of households have achieved the World Health Organization (WHO) Universal Coverage Criteria (one bed net for every two household members). The role of peer influence on bed net ownership remains underexplored. Data on the complete social network of households were collected in a rural parish in southwestern Uganda to estimate the association between household bed net ownership and peer household bed net ownership.

METHODS

Data on household sociodemographics, bed net ownership, and social networks were collected from all households across one parish in southwestern Uganda. Bed nets were categorized as either purchased or free. Purchased and free bed net ownership ratios were calculated based on the WHO Universal Coverage Criteria. Using network name generators and complete census of parish residents, the complete social network of households in the parish was generated. Linear regression models that account for network autocorrelation were fitted to estimate the association between households' bed net ownership ratios and bed net ownership ratios of network peer households, adjusting for sociodemographics and network centrality.

RESULTS

One thousand seven hundred forty-seven respondents were interviewed, accounting for 716 households. The median number of peer households to which a household was directly connected was 7. Eighty-six percent of households owned at least one bed net, and 41% of households met the WHO Universal Coverage Criterion. The median bed net ownership ratios were 0.67 for all bed nets, 0.33 for free bed nets, and 0.20 for purchased bed nets. In adjusted multivariable models, purchased bed net ownership ratio was associated with average household wealth among peer households (b = 0.06, 95% CI 0.03, 0.10), but not associated with average purchased bed net ownership ratio of peer households. Free bed net ownership ratio was associated with the number of children under 5 (b = 0.08, 95% CI 0.05, 0.10) and average free bed net ownership ratios of peer households (b = 0.66, 95% CI 0.46, 0.85).

CONCLUSIONS

Household bed net ownership was associated with bed net ownership of peer households for free bed nets, but not for purchased bed nets. The findings suggest that public health interventions may consider leveraging social networks as tools for dissemination, particularly for bed nets that are provided free of charge.

LLIN Evaluation in Uganda Project (LLINEUP2)-Factors associated with coverage and use of long‑lasting insecticidal nets following the 2020-21 national mass distribution campaign: a cross-sectional survey of 12 districts

BACKGROUND

In 2020-2021, long-lasting insecticidal nets (LLINs) were distributed nationwide in Uganda during the COVID-19 pandemic. A cross-sectional survey was conducted in 12 districts to evaluate the impact of the campaign 1-5 months after LLIN distribution.

METHODS

During April-May 2021, households were randomly selected from target areas (1-7 villages) surrounding 12 government-run health facilities established as Malaria Reference Centres; at least 50 households were enrolled per cluster. Outcomes included household ownership of LLINs distributed through the universal coverage campaign (UCC) (at least one UCC LLIN), adequate coverage of UCC LLINs (at least one UCC LLIN per 2 residents), and use of LLINs (resident slept under a LLIN the previous night). Multivariate logistic regression models were used to identify household- and individual-level factors associated with outcomes, controlling for clustering around health facilities.

RESULTS

In total, 634 households, with 3342 residents and 1631 bed-nets, were included. Most households (93.4%) owned at least 1 UCC LLIN, but only 56.8% were adequately covered by UCC LLINs. In an adjusted analysis, the factor most strongly associated with adequate coverage by UCC LLINs was fewer household residents (1-4 vs 7-14; adjusted odds ratio [aOR] 12.96, 95% CI 4.76-35.26, p < 0.001; 5-6 vs 7-14 residents; aOR 2.99, 95% CI 1.21-7.42, p = 0.018). Of the 3166 residents of households that owned at least one UCC LLIN, only 1684 (53.2%) lived in adequately covered households; 89.9% of these used an LLIN the previous night, compared to 1034 (69.8%) of 1482 residents living in inadequately covered households. In an adjusted analysis, restricted to residents of inadequately covered households, LLIN use was higher in children under-five than those aged 5-15 years (aOR 3.04, 95% CI 2.08-4.46, p < 0.001), and higher in household heads than distantly-related residents (aOR 3.94, 95% CI 2.38-6.51, p < 0.001).

CONCLUSIONS

Uganda's 2021-21 campaign was successful, despite the COVID-19 pandemic. In future campaigns, strategies should be adopted to ensure high LLIN coverage, particularly for larger households. A better understanding of the drivers of LLIN use within households is needed to guide future interventions, educational messages, and behaviour change communication strategies; school-aged children and distantly-related residents appear vulnerable and could be targeted.

Insecticide-treated eave nets and window screens for malaria control in Chalinze district, Tanzania: a study protocol for a household randomised control trial

BACKGROUND

Long-lasting insecticidal nets (LLINs) have contributed to the reduction of malaria in sub-Saharan Africa, including Tanzania. However, they rely on daily user behaviour and high coverage which is difficult to maintain. Also, insecticide resistance among malaria vector mosquitoes is contributing to reduced efficacy of control tools. To overcome these problems, we propose to evaluate a new tool for house modification, the insecticide-treated eave nets (ITENs) in combination with insecticide-treated window screens (ITWS) incorporated with dual active ingredient (dual AI) for the control of malaria.

METHODS

Four hundred and fifty (450) households with intact walls, open eaves without screens or nets on the windows in Chalinze district will be eligible and recruited upon written informed consent. The households will be randomly allocated into two arms: one with ITENs and ITWS installed and the other without. Malaria parasite detection using a quantitative polymerase chain reaction (qPCR) will be conducted shortly after the long rain (June/July, 2022) as the primary outcome and shortly after the short rain (January/February, 2022) as the secondary outcome. Other secondary outcomes include clinical malaria cases, and density of malaria vectors and nuisance after the short rain and long rain. In addition, surveys will be conducted in households with ITENs and ITWS to estimate the intervention's cost during installation, adverse effects one month after installation, and presence, fabric integrity and user acceptance six and twelve months after installation. Bioefficacy and chemical content will be evaluated twelve months after installation.

DISCUSSION

ITENs and ITWS have been shown in Kenya to reduce indoor mosquito density. However, it is not known if indoor mosquito density reduction translates into reduction of malaria cases. Data from the study will measure the potential public health value of an additional intervention for malaria control at the household level in areas of mosquito insecticide resistance that does not require daily adherence.

TRIAL REGISTRATION

The study is registered on ClinicalTrials.gov .

Factors associated with hospital length of stay in patients admitted with suspected malaria in Kenya: secondary analysis of a cross-sectional survey

OBJECTIVES

To investigate factors associated with hospital length of stay (LOS) in patients admitted with suspected malaria using a competing risk approach.

SETTING

County government referrals and major faith-based hospitals in Kenya in 2018.

DESIGN

Secondary analysis of a cross-sectional survey data.

PARTICIPANTS

Data were extracted from 2396 medical records of patients admitted with suspected malaria at 90 hospitals.

OUTCOME MEASURES

LOS, defined as time to discharge, was the primary event of interest, and time to death was the competing event against patient factors assessed during admission and hospitalisation.

RESULTS

Among the patients analysed, 2283 were discharged, 49 died and 64 were censored. The median LOS was 4 days (IQR: 3-6 days). The cumulative incidence of discharge significantly decreased (p<0.05) by 12.7% (subdistribution-HR (SDHR): 0.873; 95% CI 0.789 to 0.967) when the respiratory rate was assessed, by 14.1% (SDHR 0.859; 95% CI 0.754 to 0.978) when oxygen saturation was monitored, by 23.1% (SDHR 0.769; 95% CI 0.709 to 0.833) and 23.4% (SDHR 0.766; 95% CI 0.704 to 0.833) when haemoglobin/haematocrit and glucose/random blood sugar were performed, respectively, and by 30.4% (SDHR 0.696; 95% CI 0.626 to 0.774) when patients had at least one clinical feature of severe malaria. Conversely, patients with confirmed severe malaria and those treated with injectable artesunate had a significantly increased cumulative incidence of discharge by 21.4% (SDHR 1.214; 95% CI 1.082 to 1.362) and 33.9% (SDHR 1.339; 95% CI 1.184 to 1.515), respectively.

CONCLUSIONS

Factors of inpatient clinical processes that influence hospital LOS were identified. These can be targeted during quality improvement interventions to enhance health service delivery in Kenya. Early recognition and appropriate management of the signs of malaria severity could greatly affect beneficial outcomes. Strengthening clinical practices and nursing care according to national case management guidelines should be a priority for malaria control managers in Kenya.

"In starvation, a bone can also be meat": a mixed methods evaluation of factors associated with discarding of long-lasting insecticidal nets in Bagamoyo, Tanzania

BACKGROUND

Between 2000 and 2019, more than 1.8 billion long-lasting insecticidal nets (LLINs) were distributed in Africa. While the insecticidal durability of LLINs is around 3 years, nets are commonly discarded 2 years post distribution. This study investigated the factors associated with the decision of users to discard LLINs.

METHODS

A mixed-method sequential explanatory approach using a structured questionnaire followed by focus group discussions (FGDs) to collect information on experiences, views, reasons, how and when LLINs are discarded. Out of 6,526 households that responded to the questionnaire of LLINs durability trial, 160 households were randomly selected from the households in four villages in Bagamoyo Tanzania for FGDs but only 155 households participated in the FGDs. Five of the household representatives couldn't participate due to unexpected circumstances. A total of sixteen FGDs each comprising of 8-10 adults were conducted; older women (40-60 years), older men (40-60 years), younger women (18-39 years), younger men (18-39 years). During the FGDs, participants visually inspected seven samples of LLINs that were "too-torn" based on Proportionate Hole Index recommended by the World Health Organization (WHO) guidelines on LLIN testing, the nets were brought to the discussion and participants had to determine if such LLINs were to be kept or discarded. The study assessed responses from the same participants that attended FGD and also responded to the structured questionnaire, 117 participants fulfilled the criteria, thus data from only 117 participants are analysed in this study.

RESULTS

In FGDs, integrity of LLIN influenced the decision to discard or keep a net. Those of older age, women, and householders with lower income were more likely to classify a WHO "too-torn" net as "good". The common methods used to discard LLINs were burning and burying. The findings were seen in the quantitative analysis. For every additional hole, the odds of discarding a WHO "too-torn" LLIN increased [OR = 1.05 (95%CI (1.04-1.07)), p < 0.001]. Younger age group [OR = 4.97 (95%CI (3.25-7.32)), p < 0.001], male-headed households [OR = 6.85 (95%CI (4.44 -10.59)), p < 0.001], and wealthy households [OR = 3.88 (95%CI (2.33-6.46)), p < 0.001] were more likely to discard LLINs.

CONCLUSION

Integrity of LLIN was the main determinant for discarding or keeping LLINs and the decision to discard the net is associated with socioeconomic status of the household, and the age and gender of respondents. WHO "too torn" nets are encouraged to be used instead of none until replacement, and disposal of nets should be based on recommendation.

Spatial codistribution of HIV, tuberculosis and malaria in Ethiopia

Background

HIV, tuberculosis (TB) and malaria are the three most important infectious diseases in Ethiopia, and sub-Saharan Africa. Understanding the spatial codistribution of these diseases is critical for designing geographically targeted and integrated disease control programmes. This study investigated the spatial overlap and drivers of HIV, TB and malaria prevalence in Ethiopia.

Methods

HIV, TB and malaria data were obtained from different nationwide prevalence surveys, and geospatial covariates were obtained from publicly available sources. A Bayesian model-based geostatistical framework was applied to each survey leveraging the strength of high-resolution spatial covariates to predict continuous disease-specific prevalence surfaces and their codistribution.

Results

The national prevalence was 1.54% (95% CI 1.40 to 1.70) for HIV, 0.39% (95% CI 0.34 to 0.45) for TB and 1.1% (95%CI 0.95 to 1.32) for malaria. Substantial subnational variation was predicted with the highest HIV prevalence estimated in Gambela (4.52%), Addis Ababa (3.52%) and Dire Dawa (2.67%) regions. TB prevalence was highest in Dire Dawa (0.96%) and Gambela (0.88%), while malaria was highest in Gambela (6.1%) and Benishangul-Gumuz (3.8%). Spatial overlap of their prevalence was observed in some parts of the country, mainly Gambela region. Spatial distribution of the diseases was significantly associated with healthcare access, demographic, and climatic factors.

Conclusions

The national distribution of HIV, TB and malaria was highly focal in Ethiopia, with substantial variation at subnational and local levels. Spatial distribution of the diseases was significantly associated with healthcare access, demographic and climatic factors. Spatial overlap of HIV, TB and malaria prevalence was observed in some parts of the country. Integrated control programmes for these diseases should be targeted to these areas with high levels of co-endemicity.

Bio-efficacy and wash-fastness of a lambda-cyhalothrin long-lasting insecticide treatment kit (ICON® Maxx) against mosquitoes on various polymer materials

Background

Long-lasting efficacy of insecticide-treated nets is a balance between adhesion, retention and migration of insecticide to the surface of netting fibres. ICON^® Maxx is a twin-sachet ‘home-treatment kit’ of pyrethroid plus binding agent, recommended by the World Health Organization (WHO) for long-lasting, wash-fast treatment of polyester nets. While knitted polyester netting is widely used, fine woven polyethylene netting is increasingly available and nets made of cotton and nylon are common in Africa and Asia. It is important to investigate whether ICON Maxx is able to fulfill the WHO criteria of long-lasting treatment on a range of domestic fabrics to widen the scope for malaria protection.

Methods

This study was a controlled comparison of the bio-efficacy and wash-fastness of lambda-cyhalothrin CS, with or without binder, on nets made of cotton, polyethylene, nylon, dyed and undyed polyester. Evaluation compared an array of bioassays: WHO cone and cylinder, median time to knockdown and WHO tunnel tests using Anopheles mosquitoes. Chemical assay revealed further insight.

Results

ICON Maxx treated polyethylene and polyester netting met the WHO cone and tunnel test bio-efficacy criteria for LLIN after 20 standardized washes. Although nylon and cotton netting failed to meet the WHO cone and cylinder criteria, both materials passed the WHO tunnel test criterion of 80% mortality after 20 washes. All materials treated with standard lambda-cyhalothrin CS without binder failed to meet any of the WHO bio-efficacy criteria within 5 washes.

Conclusion

The bio-efficacy of ICON Maxx against mosquitoes on netting washed up to 20 times demonstrated wash durability on a range of synthetic polymer and natural fibres: polyester, polyethylene, nylon and cotton. This raises the prospect of making insecticide-binder kits into an effective approach for turning untreated nets, curtains, military clothing, blankets—and tents and tarpaulins as used in disasters and humanitarian emergencies—into effective malaria prevention products. It may provide a solution to the problem of reduced LLIN coverage between campaigns by converting commercially sourced untreated nets into LLINs through community or home treatment. It may also open the door to binding of non-pyrethroid insecticides to nets and textiles for control of pyrethroid resistant vectors.

Coverage, determinants of use and repurposing of long-lasting insecticidal nets two years after a mass distribution in Lihir Islands, Papua New Guinea: a cross-sectional study

BACKGROUND

Universal coverage with long-lasting insecticidal nets (LLINs) is an essential component of malaria control programmes. Three-yearly mass distribution of LLINs in Papua New Guinea (PNG) has been successful in reducing infection transmission since 2009, but malaria prevalence ramped up from 2015 onwards. Although LLIN universal coverage is mostly achieved during these campaigns, it may not be related with net use over time. Uses given to LLINs and non-compliance of this strategy were evaluated.

METHODS

A knowledge, attitude and practice (KAP) cross-sectional study was conducted in Lihir Islands, PNG, 2-2.5 years after the last LLIN mass distribution campaign. Data on bed net ownership, use and maintenance behaviour was collected using a household questionnaire administered by trained community volunteers. Logistic regression models were used to identify factors associated with owning at least one LLIN and sleeping under a LLIN the previous night.

RESULTS

Among 2694 households surveyed, 27.4 % (95 % CI: 25.8-29.2) owned at least one LLIN and 8.7 % (95 % CI: 7.6-9.8) had an adequate LLIN coverage (at least one LLIN for every two people). Out of 13,595 individuals in the surveyed households, 13.6 % (95 % CI: 13.0--4.2) reported having slept under a LLIN the preceding night. Determinants for sleeping under LLIN included living in a household with adequate LLIN coverage [adjusted OR (aOR) = 5.82 (95 % CI: 3.23-10.49)], household heads knowledge about LLINs [aOR = 16.44 (95 % CI: 8.29-32.58)], and female gender [aOR = 1.92 (95 % CI: 1.53-2.40)] (all p-values < 0.001). LLIN use decreased with older age [aOR = 0.29 (95 % CI: 0.21-0.40) for ≥ 15 year-olds, aOR = 0.38 (95 % CI: 0.27-0.55) for 5-14 year-olds] compared to < 5 year-olds (p-value < 0.001). Knowledge on the use of LLIN was good in 37.0 % of the household heads. Repurposed nets were reported serving as fishing nets (30.4 %), fruits and seedlings protection (26.6 %), covering up food (19.0 %) and bed linen (11.5 %).

CONCLUSIONS

Two years after mass distribution, LLIN coverage and use in Lihir Islands is extremely low. Three yearly distribution campaigns may not suffice to maintain an acceptable LLIN coverage unless knowledge on maintenance and use is promoted trough educational campaigns.

Spatial and epidemiological drivers of Plasmodium falciparum malaria among adults in the Democratic Republic of the Congo

Background

Adults are frequently infected with malaria and may serve as a reservoir for further transmission, yet we know relatively little about risk factors for adult infections. In this study, we assessed malaria risk factors among adults using samples from the nationally representative, cross-sectional 2013–2014 Demographic and Health Survey (DHS) conducted in the Democratic Republic of the Congo (DRC). We further explored differences in risk factors by urbanicity.

Methods

Plasmodium falciparum infection was determined by PCR. Covariates were drawn from the DHS to model individual, community and environmental-level risk factors for infection. Additionally, we used deep sequencing data to estimate the community-level proportions of drug-resistant infections and included these estimates as potential risk factors. All identified factors were assessed for differences in associations by urbanicity.

Results

A total of 16 126 adults were included. Overall prevalence of malaria was 30.3% (SE=1.1) by PCR; province-level prevalence ranged from 6.7% to 58.3%. Only 17% of individuals lived in households with at least one bed-net for every two people, as recommended by the WHO. Protective factors included increasing within-household bed-net coverage (Prevalence Ratio=0.85, 95% CI=0.76–0.95) and modern housing (PR=0.58, 95% CI=0.49–0.69). Community-level protective factors included increased median wealth (PR=0.87, 95% CI=0.83–0.92). Education, wealth, and modern housing showed protective associations in cities but not in rural areas.

Conclusions

The DRC continues to suffer from a high burden of malaria; interventions that target high-risk groups and sustained investment in malaria control are sorely needed. Areas of high prevalence should be prioritised for interventions to target the largest reservoirs for further transmission.

The consequences of declining population access to insecticide-treated nets (ITNs) on net use patterns and physical degradation of nets after 22 months of ownership

Background

As insecticide-treated nets (ITNs) wear out and are disposed, some household members are prioritized to use remaining ITNs. This study assessed how nets are allocated within households to individuals of different age categories as ITNs are lost or damaged and as new ITNs are obtained. The study also explored how ITN allocation affects ITN durability.

Methods

A cross-sectional household survey and ITN durability study was conducted among 2,875 households across Tanzania to determine the proportion of nets that remain protective (serviceable) 22 months after net distribution aiming for universal coverage. Allocation of study nets within houses, and re-allocation of ITNs when new universal replacement campaign (URC) nets arrived in study households in Musoma District, was also assessed.

Results

Some 57.0% (95% CI 53.9–60.1%) of households had sufficient ITNs for every household member, while 84.4% (95% CI 82.4–86.4%) of the population had access to an ITN within their household (assuming 1 net covers every 2 members). In households with sufficient nets, 77.5% of members slept under ITNs. In households without sufficient nets, pregnant women (54.6%), children < 5 years (45.8%) and adults (42.1%) were prioritized, with fewer school-age children 5–14 years (35.9%), youths 15–24 years (28.1%) and seniors > 65 years (32.6%) sleeping under ITNs. Crowding (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ 3 people sleeping under nets) was twice as common among people residing in houses without sufficient nets for all age groups, apart from children < 5. Nets were less likely to be serviceable if: \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ 3 people slept under them (OR 0.50 (95% CI 0.40–0.63)), or if nets were used by school-age children (OR 0.72 (95% CI 0.56–0.93)), or if the net product was Olyset®. One month after the URC, only 23.6% (95% CI 16.7–30.6%) of the population had access to a URC ITN in Musoma district. Householders in Musoma district continued the use of old ITNs even with the arrival of new URC nets.

Conclusion

Users determined the useful life of ITNs and prioritized pregnant women and children < 5 to serviceable ITNs. When household net access declines, users adjust by crowding under remaining nets, which further reduces ITN lifespan. School-age children that commonly harbour gametocytes that mediate malaria transmission are compelled to sleep under unserviceable nets, crowd under nets or remain uncovered. However, they were accommodated by the arrival of new nets. More frequent ITN delivery through the school net programme in combination with mass distribution campaigns is essential to maximize ITN effectiveness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-03686-2.

Exploring multilevel social determinants of depressive symptoms for Tanzanian adolescents: evidence from a cross-sectional study

Background

Depression has substantial and enduring impacts for adolescents, particularly those living in poverty. Yet, evidence on its determinants in low-income countries remains scarce. We examined the social determinants of depressive symptoms for Tanzanian adolescents.

Methods

We used cross-sectional data for 2458 adolescents (aged 14–19), to describe associations with depressive symptoms within and across five domains—demographic, economic, neighbourhood, environmental and social-cultural—using linear mixed models. We estimated depressive symptoms using the 10-item Centre for Epidemiological Studies Depression Scale, which ranges from 0 to 30 and increases with additional symptoms.

Results

Factors associated with depressive symptoms in the fully adjusted models included experiencing five or more household economic shocks (β=2.40; 95% CI 1.48 to 3.32), experiencing droughts/floods (β=0.76; 95% CI 0.36 to 1.17), being in a relationship (β=1.82; 95% CI 1.30 to 2.33), and having moderate (β=1.26; 95% CI 0.80 to 1.71) or low (β=2.27; 95% CI 1.81 to 2.74) social support. Exclusive schooling was protective compared with being engaged in both school and paid work (β=1.07; 95% CI 0.05 to 2.61) and not engaged in either (β=0.73; 95% CI 0.24 to 1.22). Household size and relationship status were more important factors for girls, while employment status, and extreme precipitation were more important for boys.

Conclusion

Mental health is associated with determinants from multiple domains. Results suggest that environmental shocks related to climate change contribute to poor mental health in adolescents, highlighting an important area for intervention and research.

Hybrid mosquitoes? Evidence from rural Tanzania on how local communities conceptualize and respond to modified mosquitoes as a tool for malaria control

Background

Different forms of mosquito modifications are being considered as potential high-impact and low-cost tools for future malaria control in Africa. Although still under evaluation, the eventual success of these technologies will require high-level public acceptance. Understanding prevailing community perceptions of mosquito modification is, therefore, crucial for effective design and implementation of these interventions. This study investigated community perceptions regarding genetically-modified mosquitoes (GMMs) and their potential for malaria control in Tanzanian villages where no research or campaign for such technologies has yet been undertaken.

Methods

A mixed-methods design was used, involving: (i) focus group discussions (FGD) with community leaders to get insights on how they frame and would respond to GMMs, and (ii) structured questionnaires administered to 490 community members to assess awareness, perceptions and support for GMMs for malaria control. Descriptive statistics were used to summarize the findings and thematic content analysis was used to identify key concepts and interpret the findings.

Results

Nearly all survey respondents were unaware of mosquito modification technologies for malaria control (94.3%), and reported no knowledge of their specific characteristics (97.3%). However, community leaders participating in FGDs offered a set of distinctive interpretive frames to conceptualize interventions relying on GMMs for malaria control. The participants commonly referenced their experiences of cross-breeding for selecting preferred traits in domestic plants and animals. Preferred GMMs attributes included the expected reductions in insecticide use and human labour. Population suppression approaches, requiring as few releases as possible, were favoured. Common concerns included whether the GMMs would look or behave differently than wild mosquitoes, and how the technology would be integrated into current malaria control policies. The participants emphasised the importance and the challenge of educating and engaging communities during the technology development.

Conclusions

Understanding how communities perceive and interpret novel technologies is crucial to the design and effective implementation of new vector control programmes. This study offers vital clues on how communities with no prior experience of modified mosquitoes might conceptualize or respond to such technologies when deployed in the context of malaria control programmes. Drawing upon existing interpretive frames and locally-resonant analogies when deploying such technologies may provide a basis for more durable public support in the future.

Assessing the efficacy of two dual-active ingredients long-lasting insecticidal nets for the control of malaria transmitted by pyrethroid-resistant vectors in Benin: study protocol for a three-arm, single-blinded, parallel, cluster-randomized controlled trial

BACKGROUND

Long-lasting insecticidal nets (LLINs) are currently the primary method of malaria control in sub-Saharan Africa and have contributed to a significant reduction in malaria burden over the past 15 years. However, this progress is threatened by the wide-scale selection of insecticide-resistant malaria vectors. It is, therefore, important to accelerate the generation of evidence for new classes of LLINs.

METHODS

This protocol presents a three-arm superiority, single-blinded, cluster randomized controlled trial to evaluate the impact of 2 novel dual-active ingredient LLINs on epidemiological and entomological outcomes in Benin, a malaria-endemic area with highly pyrethroid-resistant vector populations. The study arms consist of (i) Royal Guard® LLIN, a net combining a pyrethroid (alpha-cypermethrin) plus an insect growth regulator (pyriproxyfen), which in the adult female is known to disrupt reproduction and egg fertility; (ii) Interceptor G2® LLIN, a net incorporating two adulticides (alpha-cypermethrin and chlorfenapyr) with different modes of action; and (iii) the control arm, Interceptor® LLIN, a pyrethroid (alpha-cypermethrin) only LLIN. In all arms, one net for every 2 people will be distributed to each household. Sixty clusters were identified and randomised 1:1:1 to each study arm. The primary outcome is malaria case incidence measured over 24 months through active case detection in a cohort of 25 children aged 6 months to 10 years, randomly selected from each cluster. Secondary outcomes include 1) malaria infection prevalence (all ages) and prevalence of moderate to severe anaemia in children under 5 years old, measured at 6 and 18 months post-intervention; 2) entomological indices measured every 3 months using human landing catches over 24 months. Insecticide resistance intensity will also be monitored over the study period.

DISCUSSION

This study is the second cluster randomised controlled trial to evaluate the efficacy of these next-generation LLINs to control malaria transmitted by insecticide-resistant mosquitoes. The results of this study will form part of the WHO evidence-based review to support potential public health recommendations of these nets and shape malaria control strategies of sub-Saharan Africa for the next decade.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03931473 , registered on 30 April 2019.

Individual and Community Factors Associated with Household Insecticide-Treated Bednet Usage in the Sunyani West District of Ghana Two Years after Mass Distribution

Purpose

In the year 2015, the Ghana Health Service launched a free mass insecticide-treated net (ITN) distribution campaign in the Sunyani West district of Ghana with the aim of improving household ownership to increase usage. This study determined the level of ownership and usage of ITNs and associated factors among households in the Sunyani West district two years after the mass distribution campaign.

Methods

Study participants were identified using the systematic approach in all five subdistricts of the Sunyani West district and interviewed, and data were collected on household ITN ownership. Data were also collected on the source of the ITN and whether the respondent slept under an ITN the previous night. Data on individual and community factors associated with ITN ownership and usage were also collected. Pearson chi-square tests and logistic regression were performed to determine factors significantly associated with ITN ownership and usage.

Results

The level of ITN ownership was 78.93% and usage was 55.93%. Most of the participants (73.62%) received their nets during the 2015 mass distribution campaign, 39 (11.96%) received their ITNs during antenatal care visits, whilst 27 (8.28%) bought the nets from the store. People who experience irritation (χ² = 23.32; p < 0.001) and respondents who did not perceive themselves as likely to be beaten by mosquitoes or get malaria (χ² = 26.61; p < 0.001) were less likely to use ITNs. Respondents who used other malaria/mosquito bite prevention methods were also less likely to use the ITNs (χ² = 206.26; p = 0.001), but individuals who received free nets were likely to use them.

Conclusion

ITN ownership was high, but usage was low and far below the national target. Intense health education emphasizing the fact that everybody is susceptible to malaria may help improve usage.

The fabric of life: what if mosquito nets were durable and widely available but insecticide-free?

BACKGROUND

Bed nets are the commonest malaria prevention tool and arguably the most cost-effective. Their efficacy is because they prevent mosquito bites (a function of physical durability and integrity), and kill mosquitoes (a function of chemical content and mosquito susceptibility). This essay follows the story of bed nets, insecticides and malaria control, and asks whether the nets must always have insecticides.

METHODS

Key attributes of untreated or pyrethroid-treated nets are examined alongside observations of their entomological and epidemiological impacts. Arguments for and against adding insecticides to nets are analysed in contexts of pyrethroid resistance, personal-versus-communal protection, outdoor-biting, need for local production and global health policies.

FINDINGS

Widespread resistance in African malaria vectors has greatly weakened the historical mass mosquitocidal effects of insecticide-treated nets (ITNs), which previously contributed communal benefits to users and non-users. Yet ITNs still achieve substantial epidemiological impact, suggesting that physical integrity, consistent use and population-level coverage are increasingly more important than mosquitocidal properties. Pyrethroid-treatment remains desirable where vectors are sufficiently susceptible, but is no longer universally necessary and should be re-examined alongside other attributes, e.g. durability, coverage, acceptability and access. New ITNs with multiple actives or synergists could provide temporary relief in some settings, but their performance, higher costs, and drawn-out innovation timelines do not justify singular emphasis on insecticides. Similarly, sub-lethal insecticides may remain marginally-impactful by reducing survival of older mosquitoes and disrupting parasite development inside the mosquitoes, but such effects vanish under strong resistance.

CONCLUSIONS

The public health value of nets is increasingly driven by bite prevention, and decreasingly by lethality to mosquitoes. For context-appropriate solutions, it is necessary to acknowledge and evaluate the potential and cost-effectiveness of durable untreated nets across different settings. Though ~ 90% of malaria burden occurs in Africa, most World Health Organization-prequalified nets are manufactured outside Africa, since many local manufacturers lack capacity to produce the recommended insecticidal nets at competitive scale and pricing. By relaxing conditions for insecticides on nets, it is conceivable that non-insecticidal but durable, and possibly bio-degradable nets, could be readily manufactured locally. This essay aims not to discredit ITNs, but to illustrate how singular focus on insecticides can hinder innovation and sustainability.

Opinions of key stakeholders on alternative interventions for malaria control and elimination in Tanzania

Background

Malaria control in Tanzania currently relies primarily on long-lasting insecticidal nets and indoor residual spraying, alongside effective case management and behaviour change communication. This study explored opinions of key stakeholders on the national progress towards malaria elimination, the potential of currently available vector control interventions in helping achieve elimination by 2030, and the need for alternative interventions that could be used to supplement malaria elimination efforts in Tanzania.

Methods

In this exploratory qualitative study, Focus group discussions were held with policy-makers, regulators, research scientists and community members. Malaria control interventions discussed were: (a) improved housing, (b) larval source management, (c) mass drug administration (MDA) with ivermectin to reduce vector densities, (d) release of modified mosquitoes, including genetically modified or irradiated mosquitoes, (e) targeted spraying of mosquito swarms, and (f) spatial repellents.

Results

Larval source management and spatial repellents were widely supported across all stakeholder groups, while insecticide-spraying of mosquito swarms was the least preferred. Support for MDA with ivermectin was high among policy makers, regulators and research scientists, but encountered opposition among community members, who instead expressed strong support for programmes to improve housing for poor people in high transmission areas. Policy makers, however, challenged the idea of government-supported housing improvement due to its perceived high costs. Techniques of mosquito modification, specifically those involving gene drives, were viewed positively by community members, policy makers and regulators, but encountered a high degree of scepticism among scientists. Overall, policy-makers, regulators and community members trusted scientists to provide appropriate advice for decision-making.

Conclusion

Stakeholder opinions regarding alternative malaria interventions were divergent except for larval source management and spatial repellents, for which there was universal support. MDA with ivermectin, housing improvement and modified mosquitoes were also widely supported, though each faced concerns from at least one stakeholder group. While policy-makers, regulators and community members all noted their reliance on scientists to make informed decisions, their reasoning on the benefits and disadvantages of specific interventions included factors beyond technical efficiency. This study suggests the need to encourage and strengthen dialogue between research scientists, policy makers, regulators and communities regarding new interventions.

Eave ribbons treated with transfluthrin can protect both users and non-users against malaria vectors

BACKGROUND

Eave ribbons treated with spatial repellents effectively prevent human exposure to outdoor-biting and indoor-biting malaria mosquitoes, and could constitute a scalable and low-cost supplement to current interventions, such as insecticide-treated nets (ITNs). This study measured protection afforded by transfluthrin-treated eave ribbons to users (personal and communal protection) and non-users (only communal protection), and whether introducing mosquito traps as additional intervention influenced these benefits.

METHODS

Five experimental huts were constructed inside a 110 m long, screened tunnel, in which 1000 Anopheles arabiensis were released nightly. Eave ribbons treated with 0.25 g/m2 transfluthrin were fitted to 0, 1, 2, 3, 4 or 5 huts, achieving 0, 20, 40, 60, 80 and 100% coverage, respectively. Volunteers sat near each hut and collected mosquitoes attempting to bite them from 6 to 10 p.m. (outdoor-biting), then went indoors to sleep under untreated bed nets, beside which CDC-light traps collected mosquitoes from 10 p.m. to 6 a.m. (indoor-biting). Caged mosquitoes kept inside the huts were monitored for 24 h-mortality. Separately, eave ribbons, UV-LED mosquito traps (Mosclean) or both the ribbons and traps were fitted, each time leaving the central hut unfitted to represent non-user households and assess communal protection. Biting risk was measured concurrently in all huts, before and after introducing interventions.

RESULTS

Transfluthrin-treated eave ribbons provided 83% and 62% protection indoors and outdoors respectively to users, plus 57% and 48% protection indoors and outdoors to the non-user. Protection for users remained constant, but protection for non-users increased with eave ribbons coverage, peaking once 80% of huts were fitted. Mortality of mosquitoes caged inside huts with eave ribbons was 100%. The UV-LED traps increased indoor exposure to users and non-users, but marginally reduced outdoor-biting. Combining the traps and eave ribbons did not improve user protection relative to eave ribbons alone.

CONCLUSION

Transfluthrin-treated eave ribbons protect both users and non-users against malaria mosquitoes indoors and outdoors. The mosquito-killing property of transfluthrin can magnify the communal benefits by limiting unwanted diversion to non-users, but should be validated in field trials against pyrethroid-resistant vectors. Benefits of the UV-LED traps as an intervention alone or alongside eave ribbons were however undetectable in this study. These findings extend the evidence that transfluthrin-treated eave ribbons could complement ITNs.

Low use of long-lasting insecticidal nets for malaria prevention in south-central Ethiopia: A community-based cohort study

Introduction

A decline in malaria morbidity and mortality has been documented in Ethiopia since 2005 following a scale-up of the distribution of long-lasting insecticidal nets (LLINs). However, universal access to LLINs ownership and use has not yet been achieved. This study aimed to determine ownership and use of LLINs over time in south-central Ethiopia.

Methods

A cohort of 17,142 individuals residing in 3,006 households was followed-up from October 2014 to January 2017 (121 weeks). New PermaNet2.0 LLINs were given to households in October 2014. Once per week, the LLIN use status was documented for each individual. A survey was conducted after 110 weeks of LLIN distribution to determine LLIN ownership. A multilevel negative binomial regression model was fitted to identify significant predictors of LLIN use.

Results

At baseline, the LLIN ownership was 100%. After 110 weeks only 233 (8%) of the households owned at least one LLIN. The median proportion of LLIN use per individuals during the study period was only 14%. During the first year (week 1–52) the average LLIN use per individuals was 36% and during the second year (week 53–104) it was 4.6%. More frequent LLIN use was reported among age group [5–14 years (adjusted IRR = 1.13, 95% CI 1.04–1.22), 15–24 years (adjusted IRR = 1.33, 95% CI 1.23–1.45), ≥25 years (adjusted IRR = 1.99, 95% CI 1.83–2.17)] compared to <5 years, and household head educational status [read and write (adjusted IRR = 1.17, 95% CI 1.09–1.26), primary (adjusted IRR = 1.20, 95% CI 1.12–1.27), secondary or above (adjusted IRR = 1.20, 95% CI (1.11–1.30)] compared to illiterate. Having a family size of over five persons (adjusted IRR = 0.78, 95% CI 0.73–0.84) was associated with less frequent use of LLINs compared to a family size of ≤5 persons.

Conclusions

The study showed a low LLIN ownership after 110 weeks and a low LLIN use during 121 weeks of follow-up, despite 100% LLIN coverage at baseline. The study highlights the need to design strategies to increase LLIN ownership and use for setting similar to those studied here.