Variation in the effectiveness of insecticide treated nets against malaria and outdoor biting by vectors in Kilifi, Kenya

Mortality in rural coastal Kenya measured using the Kilifi Health and Demographic Surveillance System: a 16-year descriptive analysis

Background: The Kilifi Health and Demographic Surveillance System (KHDSS) was established in 2000 to define the incidence and prevalence of local diseases and evaluate the impact of community-based interventions. KHDSS morbidity data have been reported comprehensively but mortality has not been described. This analysis describes mortality in the KHDSS over 16 years. Methods: We calculated mortality rates from 2003-2018 in four intervals of equal duration and assessed differences in mortality across these intervals by age and sex. We calculated the period survival function and median survival using the Kaplan-Meier method and mean life expectancies using abridged life tables. We estimated trend and seasonality by decomposing a time series of monthly mortality rates. We used choropleth maps and random-effects Poisson regression to investigate geographical heterogeneity. Results: Mortality declined by 36% overall between 2003-2018 and by 59% in children aged <5 years. Most of the decline occurred between 2003 and 2006. Among adults, the greatest decline (49%) was observed in those aged 15-54 years. Life expectancy at birth increased by 12 years. Females outlived males by 6 years. Seasonality was only evident in the 1-4 year age group in the first four years. Geographical variation in mortality was ±10% of the median value and did not change over time. Conclusions: Between 2003 and 2018, mortality among children and young adults has improved substantially. The steep decline in 2003-2006 followed by a much slower reduction thereafter suggests improvements in health and wellbeing have plateaued in the last 12 years. However, there is substantial inequality in mortality experience by geographical location.

Mortality in rural coastal Kenya measured using the Kilifi Health and Demographic Surveillance System: a 16-year descriptive analysis

Background: The Kilifi Health and Demographic Surveillance System (KHDSS) was established in 2000 to define the incidence and prevalence of local diseases and evaluate the impact of community-based interventions. KHDSS morbidity data have been reported comprehensively but mortality has not been described. This analysis describes mortality in the KHDSS over 16 years. Methods: We calculated mortality rates from 2003–2018 in four intervals of equal duration and assessed differences in mortality across these intervals by age and sex. We calculated the period survival function and median survival using the Kaplan–Meier method and mean life expectancies using abridged life tables. We estimated trend and seasonality by decomposing a time series of monthly mortality rates. We used choropleth maps and random-effects Poisson regression to investigate geographical heterogeneity. Results: Mortality declined by 36% overall between 2003–2018 and by 59% in children aged <5 years. Most of the decline occurred between 2003 and 2006. Among adults, the greatest decline (49%) was observed in those aged 15–54 years. Life expectancy at birth increased by 12 years. Females outlived males by 6 years. Seasonality was only evident in the 1–4 year age group in the first four years. Geographical variation in mortality was ±10% of the median value and did not change over time. Conclusions: Between 2003 and 2018, mortality among children and young adults has improved substantially. The steep decline in 2003–2006 followed by a much slower reduction thereafter suggests improvements in health and wellbeing have plateaued in the last 12 years. However, there is substantial inequality in mortality experience by geographical location.

The effect of cattle-administered ivermectin and fipronil on the mortality and fecundity of Anopheles arabiensis Patton

Background

Malaria control primarily depends on two vector control strategies: indoor residual spraying (IRS) and long-lasting insecticide-treated nets (LLINs). Both IRS and LLIN target indoor-biting mosquitoes. However, some of the most important malaria vectors have developed resistance against the chemical compounds used in IRS and LLINs. Insecticide-induced behavioural changes in vectors, such as increased outdoor feeding on cattle and other animals, also limit the effectiveness of these strategies. Novel vector control strategies must therefore be found to complement IRS and LLINs. A promising tool is the use of cattle-applied endectocides. Endectocides are broad-spectrum systemic drugs that are effective against a range of internal nematodes parasites and blood-feeding arthropods. The aim of this study was to investigate the effect of two endectocide drugs, injectable ivermectin and topical fipronil, on the survival and fecundity of zoophilic Anopheles arabiensis.

Methods

Laboratory-reared mosquitoes were allowed to feed on cattle treated with either injectable ivermectin (0.2 mg/kg), topical fipronil (1.0 mg/kg) or saline (control) on days 0, 1, 4, 7, 13, 21 and 25 post-treatment, and mortality and egg production were recorded daily.

Results

Compared to controls, the mortality of An. arabiensis increased by 3.52- and 2.43-fold with injectable ivermectin and topical fipronil, respectively. The overall fecundity of mosquitoes that fed on both ivermectin- and fipronil-treated cattle was significantly reduced by up to 90 and 60%, respectively, compared to the control group. The effects of both drugs attenuated over a period of 3 weeks. Injectable ivermectin was more effective than topical fipronil and increased mosquito mortality by a risk factor of 1.51 higher than fipronil. Similarly, both drugs significantly reduced the fecundity of An. arabiensis.

Conclusions

This study demonstrates that injectable ivermectin and topical fipronil are able to suppress An. arabiensis density and could help to reduce outdoor malaria transmission. Data from the present study as well as from other similar studies suggest that current-generation endectocides have a limited duration of action and are expensive. However, new-generation, sustained-release formulations of ivermectin have a multi-week, high mortality impact on vector populations, thus holding promise of an effective reduction of outdoor malaria transmission.

Graphical abstract

Entomological and Anthropological Factors Contributing to Persistent Malaria Transmission in Kenya, Ethiopia, and Cameroon

Introduction

In order to improve our understanding of the fundamental limits of core interventions and guide efforts based on prioritization and identification of effective/novel interventions with great potentials to interrupt persistent malaria transmission in the context of high vector control coverage, the drivers of persistent disease transmission were investigated in three eco-epidemiological settings; forested areas in Cameroon, coastal area in Kenya and highland areas in Ethiopia.

Methods

Mosquitoes were sampled in three eco-epidemiological settings using different entomological sampling techniques and analysed for Plasmodium infection status and blood meal origin in blood-fed specimens. Human behavioural surveys were conducted to assess the knowledge and attitude of the population on malaria and preventive measures, their night activities, and sleeping pattern. The parasitological analysis was conducted to determine the prevalence of Plasmodium infection in the population using rapid diagnostic tests.

Results

Despite the diversity in the mosquito fauna, their biting behaviour was found to be closely associated to human behaviour in the three settings. People in Kenya and Ethiopia were found to be more exposed to mosquito bites during the early hours of the evening (18-21h) while it was in the early morning (4-6 am) in Cameroon. Malaria transmission was high in Cameroon compared to Kenya and Ethiopia with over 50% of the infected bites recorded outdoors. The non-users of LLINs were 2.5 to 3 times more likely to be exposed to the risk of acquiring malaria compared to LLINs users. Malaria prevalence was high (42%) in Cameroon, and more than half of the households visited had at least one individual infected with Plasmodium parasites.

Conclusions

The study suggests high outdoor malaria transmission occurring in the three sites with however different determinants driving residual malaria transmission in these areas.

Quantifying and characterizing hourly human exposure to malaria vectors bites to address residual malaria transmission during dry and rainy seasons in rural Southwest Burkina Faso

Background

To sustain the efficacy of malaria vector control, the World Health Organization (WHO) recommends the combination of effective tools. Before designing and implementing additional strategies in any setting, it is critical to monitor or predict when and where transmission occurs. However, to date, very few studies have quantified the behavioural interactions between humans and Anopheles vectors in Africa. Here, we characterized residual transmission in a rural area of Burkina Faso where long lasting insecticidal nets (LLIN) are widely used.

Methods

We analysed data on both human and malaria vectors behaviours from 27 villages to measure hourly human exposure to vector bites in dry and rainy seasons using a mathematical model. We estimated the protective efficacy of LLINs and characterised where (indoors vs. outdoors) and when both LLIN users and non-users were exposed to vector bites.

Results

The percentage of the population who declared sleeping under a LLIN the previous night was very high regardless of the season, with an average LLIN use ranging from 92.43 to 99.89%. The use of LLIN provided > 80% protection against exposure to vector bites. The proportion of exposure for LLIN users was 29–57% after 05:00 and 0.05–12% before 20:00. More than 80% of exposure occurred indoors for LLIN users and the estimate reached 90% for children under 5 years old in the dry cold season.

Conclusions

LLINs are predicted to provide considerable protection against exposure to malaria vector bites in the rural area of Diébougou. Nevertheless, LLIN users are still exposed to vector bites which occurred mostly indoors in late morning. Therefore, complementary strategies targeting indoor biting vectors in combination with LLIN are expected to be the most efficient to control residual malaria transmission in this area.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10304-y.

The relationship between facility-based malaria test positivity rate and community-based parasite prevalence

INTRODUCTION

Malaria surveillance is a key pillar in the control of malaria in Africa. The value of using routinely collected data from health facilities to define malaria risk at community levels remains poorly defined.

METHODS

Four cross-sectional parasite prevalence surveys were undertaken among residents at 36 enumeration zones in Kilifi county on the Kenyan coast and temporally and spatially matched to fever surveillance at 6 health facilities serving the same communities over 12 months. The age-structured functional form of the relationship between test positivity rate (TPR) and community-based parasite prevalence (PR) was explored through the development of regression models fitted by alternating the linear, exponential and polynomial terms for PR. The predictive ranges of TPR were explored for PR endemicity risk groups of control programmatic value using cut-offs of low (PR <5%) and high (PR ≥ 30%) transmission intensity.

RESULTS

Among 28,134 febrile patients encountered for malaria diagnostic testing in the health facilities, 12,143 (43.2%: 95% CI: 42.6%, 43.7%) were positive. The overall community PR was 9.9% (95% CI: 9.2%, 10.7%) among 6,479 participants tested for malaria. The polynomial model was the best fitting model for the data that described the algebraic relationship between TPR and PR. In this setting, a TPR of ≥ 49% in all age groups corresponded to an age-standardized PR of ≥ 30%, while a TPR of < 40% corresponded to an age-standardized PR of < 5%.

CONCLUSION

A non-linear relationship was observed between the relative change in TPR and changes in the PR, which is likely to have important implications for malaria surveillance programs, especially at the extremes of transmission. However, larger, more spatially diverse data series using routinely collected TPR data matched to community-based infection prevalence data are required to explore the more practical implications of using TPR as a replacement for community PR.

Patterns of human exposure to malaria vectors in Zanzibar and implications for malaria elimination efforts

Background

Zanzibar provides a good case study for malaria elimination. The islands have experienced a dramatic reduction in malaria burden since the introduction of effective vector control interventions and case management. Malaria prevalence has now been maintained below 1% for the past decade and the islands can feasibly aim for elimination.

Methods

To better understand factors that may contribute to remaining low-level malaria transmission in Zanzibar, layered human behavioural and entomological research was conducted between December 2016 and December 2017 in 135 randomly selected households across six administrative wards. The study included: (1) household surveys, (2) structured household observations of nighttime activity and sleeping patterns, and (3) paired indoor and outdoor mosquito collections. Entomological and human behavioural data were integrated to provide weighted estimates of exposure to vector bites, accounting for proportions of people indoors or outdoors, and protected by insecticide-treated nets (ITNs) each hour of the night.

Results

Overall, 92% of female Anopheles mosquitoes were caught in the rainy season compared to 8% in the dry season and 72% were caught outdoors compared to 28% indoors. For individual ITN users, ITNs prevented an estimated two-thirds (66%) of exposure to vector bites and nearly three quarters (73%) of residual exposure was estimated to occur outdoors. Based on observed levels of ITN use in the study sites, the population-wide mean personal protection provided by ITNs was 42%.

Discussion/conclusions

This study identified gaps in malaria prevention in Zanzibar with results directly applicable for improving ongoing programme activities. While overall biting risk was low, the most notable finding was that current levels of ITN use are estimated to prevent less than half of exposure to malaria vector bites. Variation in ITN use across sites and seasons suggests that additional gains could be made through targeted social and behaviour change interventions. However, even for ITN users, gaps in protection remain, with a majority of exposure to vector bites occurring outdoors before going to sleep. Supplemental interventions targeting outdoor exposure to malaria vectors, and groups that may be at increased risk of exposure to malaria vectors, should be explored.

Methods and indicators for measuring patterns of human exposure to malaria vectors

BACKGROUND

Effective targeting and evaluation of interventions that protect against adult malaria vectors requires an understanding of how gaps in personal protection arise. An improved understanding of human and mosquito behaviour, and how they overlap in time and space, is critical to estimating the impact of insecticide-treated nets (ITNs) and determining when and where supplemental personal protection tools are needed. Methods for weighting estimates of human exposure to biting Anopheles mosquitoes according to where people spend their time were first developed over half a century ago. However, crude indoor and outdoor biting rates are still commonly interpreted as indicative of human-vector contact patterns without any adjustment for human behaviour or the personal protection effects of ITNs.

MAIN TEXT

A small number of human behavioural variables capturing the distribution of human populations indoors and outdoors, whether they are awake or asleep, and if and when they use an ITN over the course of the night, can enable a more accurate representation of human biting exposure patterns. However, to date no clear guidance is available on what data should be collected, what indicators should be reported, or how they should be calculated. This article presents an integrated perspective on relevant indicators of human-vector interactions, the critical entomological and human behavioural data elements required to quantify human-vector interactions, and recommendations for collecting and analysing such data.

CONCLUSIONS

If collected and used consistently, this information can contribute to an improved understanding of how malaria transmission persists in the context of current intervention tools, how exposure patterns may change as new vector control tools are introduced, and the potential impact and limitations of these tools. This article is intended to consolidate understanding around work on this topic to date and provide a consistent framework for building upon it. Additional work is needed to address remaining questions, including further development and validation of methods for entomological and human behavioural data collection and analysis.

Using a miniaturized double-net trap (DN-Mini) to assess relationships between indoor-outdoor biting preferences and physiological ages of two malaria vectors, Anopheles arabiensis and Anopheles funestus

BACKGROUND

Effective malaria surveillance requires detailed assessments of mosquitoes biting indoors, where interventions such as insecticide-treated nets work best, and outdoors, where other interventions may be required. Such assessments often involve volunteers exposing their legs to attract mosquitoes [i.e., human landing catches (HLC)], a procedure with significant safety and ethical concerns. Here, an exposure-free, miniaturized, double-net trap (DN-Mini) is used to assess relationships between indoor-outdoor biting preferences of malaria vectors, Anopheles arabiensis and Anopheles funestus, and their physiological ages (approximated by parity and insemination states).

METHODS

The DN-Mini is made of UV-resistant netting on a wooden frame and PVC base. At 100 cm × 60 cm × 180 cm, it fits indoors and outdoors. It has a protective inner chamber where a volunteer sits and collects host-seeking mosquitoes entrapped in an outer chamber. Experiments were conducted in eight Tanzanian villages using DN-Mini to: (a) estimate nightly biting and hourly biting proportions of mosquitoes indoors and outdoors; (b) compare these proportions to previous estimates by HLC in same villages; and, (c) compare distribution of parous (proxy for potentially infectious) and inseminated mosquitoes indoors and outdoors.

RESULTS

More than twice as many An. arabiensis were caught outdoors as indoors (p < 0.001), while An. funestus catches were marginally higher indoors than outdoors (p = 0.201). Anopheles arabiensis caught outdoors also had higher parity and insemination proportions than those indoors (p < 0.001), while An. funestus indoors had higher parity and insemination than those outdoors (p = 0.04). Observations of indoor-biting and outdoor-biting proportions, hourly biting patterns and overall species diversities as measured by DN-Mini, matched previous HLC estimates.

CONCLUSIONS

Malaria vectors that are behaviourally adapted to bite humans outdoors also have their older, potentially infectious sub-populations concentrated outdoors, while those adapted to bite indoors have their older sub-populations concentrated indoors. Here, potentially infectious An. arabiensis more likely bite outdoors than indoors, while potentially infectious An. funestus more likely bite indoors. These observations validate previous evidence that even outdoor-biting mosquitoes regularly enter houses when young. They also demonstrate efficacy of DN-Mini for measuring indoor-outdoor biting behaviours of mosquitoes, their hourly biting patterns and epidemiologically relevant parameters, e.g., parity and insemination status, without exposure to volunteers. The trap is easy-to-use, easy-to-manufacture and affordable (prototypes cost ~ 100 US$/unit).

Measuring and characterizing night time human behaviour as it relates to residual malaria transmission in sub-Saharan Africa: a review of the published literature

Background

Malaria cases and deaths decreased dramatically in recent years, largely due to effective vector control interventions. Persistence of transmission after good coverage has been achieved with high-quality vector control interventions, namely insecticide-treated nets or indoor residual spraying, poses a significant challenge to malaria elimination efforts. To understand when and where remaining transmission is occurring, it is necessary to look at vector and human behaviour, and where they overlap. To date, a review of human behaviour related to residual malaria transmission has not been conducted.

Methods

Studies were identified through PubMed and Google Scholar. Hand searches were conducted for all references cited in articles identified through the initial search. The review was limited to English language articles published between 2000 and 2017. Publications with primary data from a malaria endemic setting in sub-Saharan Africa and a description of night time human behaviours were included.

Results

Twenty-six publications were identified that met inclusion criteria. Study results fit into two broad categories: when and where people are exposed to malaria vectors and what people are doing at night that may increase their contact with malaria vectors. Among studies that quantified human-vector interaction, a majority of exposure occurred indoors during sleeping hours for unprotected individuals, with some variation across time, contexts, and vector species. Common night time activities across settings included household chores and entertainment during evening hours, as well as livelihood and large-scale socio-cultural events that can last throughout the night. Shifting sleeping patterns associated with travel, visitors, illness, farming practices, and outdoor sleeping, which can impact exposure and use of prevention measures, were described in some locations.

Conclusions

While the importance of understanding human-vector interaction is well-established, relatively few studies have included human behaviour when measuring exposure to malaria vectors. Broader application of a standardized approach to measuring human-vector interaction could provide critical information on exposure across settings and over time. In-depth understanding of night time activities that occur during times when malaria vectors are active and barriers to prevention practices in different contexts should also be considered. This information is essential for targeting existing interventions and development and deployment of appropriate complementary prevention tools.