Mitigating Diseases Transmitted by Aedes Mosquitoes: A Cluster-Randomised Trial of Permethrin-Impregnated School Uniforms

Proceedings of the 6th Asia Dengue Summit, June 2023

The 6th Asia Dengue Summit (ADS) themed "Road Map to Zero Dengue Death" was held in Thailand from 15th-16th June 2023. The summit was hosted by Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand in conjunction with Queen Saovabha Memorial Institute, The Thai Red Cross Society; Faculty of Tropical Medicine, Mahidol University; and the Ministry of Public Health. The 6th ADS was convened by Asia Dengue Voice and Action (ADVA); Global Dengue and Aedes Transmitted Diseases Consortium (GDAC); Southeast Asian Ministers of Education Tropical Medicine and Public Health Network (SEAMEO TROPMED); Fondation Mérieux (FMx) and the International Society for Neglected Tropical Diseases (ISNTD). Dengue experts from academia and research, and representatives from the Ministries of Health, Regional and Global World Health Organization (WHO) and International Vaccine Institute (IVI) participated in the three-day summit. With more than 51 speakers and 451 delegates from over 24 countries, 10 symposiums, and 2 full days, the 6th ADS highlighted the growing threat of dengue and its antigenic evolution, flagged the urgent need to overcome vaccine hesitancy and misinformation crisis, and focused on dengue control policies, newer diagnostics, therapeutics and vaccines, travel-associated dengue, and strategies to improve community involvement.

Dengue determinants: Necessities and challenges for universal dengue vaccine development

Dengue illness can range from mild illness to life-threatening haemorrhage. It is an Aedes-borne infectious disease caused by the dengue virus, which has four serotypes. Each serotype acts as an independent infectious agent. The antibodies against one serotype confer homotypic immunity but temporary protection against heterotypic infection. Dengue has become a growing health concern for up to one third of the world's population. Currently, there is no potent anti-dengue medicine, and treatment for severe dengue relies on intravenous fluid management and pain medications. The burden of dengue dramatically increases despite advances in vector control measures. These factors underscore the need for a vaccine. Various dengue vaccine strategies have been demonstrated, that is, live attenuated vaccine, inactivated vaccine, DNA vaccine, subunit vaccine, and viral-vector vaccines, some of which are at the stage of clinical testing. Unfortunately, the forefront candidate vaccine is less than satisfactory, and its performance depends on serostatus and age factors. The lessons from clinical studies depicted ambiguity concerning the efficacy of dengue vaccine. Our study highlighted that viral structural heterogeneity, epitope accessibility, autoimmune complications, genetic variants, genetic diversities, antigen competition, virulence variation, host-pathogen specific interaction, antibody-dependent enhancement, cross-reactive immunity among Flaviviruses, and host-susceptibility determinants not only influence infection outcomes but also hampered successful vaccine development. This review integrates dengue determinants allocated necessities and challenges, which would provide insight for universal dengue vaccine development.

Increasing Dengue Burden and Severe Dengue Risk in Bangladesh: An Overview

Dengue is a prevalent and rapidly spreading mosquito-borne viral disease affecting humans. The geographic range of dengue is expanding, and much like in many other tropical regions of the world, dengue has become a major public health issue in Bangladesh. Until a large epidemic dengue outbreak in 2000, sporadic outbreaks have occurred in Bangladesh since 1964. After 2000, varying intensities of dengue activity were observed each year until 2018. However, in 2019, Bangladesh experienced the largest dengue epidemic in its history, with 101,354 dengue cases and 164 dengue-related deaths. Notably, this outbreak occurred in many regions that were previously considered free of the disease. As of 10 December 2022, a total of 60,078 dengue cases and 266 dengue-related deaths were reported in Bangladesh, with the 2022 outbreak being the second largest since 2000. There is an increased genetic diversity of the dengue virus (DENV) in Bangladesh and all four DENV serotypes are prevalent and co-circulating, which increases the risk for severe dengue owing to the antibody-dependent enhancement effect. Vector control remains the mainstay of dengue outbreak prevention; however, the vector control programs adopted in Bangladesh seem inadequate, requiring improved vector control strategies. In this review, we provide an overview of the epidemiology of DENV infection and the risks for a severe dengue outbreak in Bangladesh. Additionally, we discuss different dengue vector control strategies, from which the most suitable and effective measures can be applied in the context of Bangladesh for tackling future dengue epidemics.

Interventions for Neglected Tropical Diseases Among Children and Adolescents: A Meta-analysis

BACKGROUND

Neglected tropical diseases (NTDs) are a group of communicable diseases affecting the poorest populations around the world.

OBJECTIVE

To assess the effectiveness of interventions, including mass drug administration (MDA), water, sanitation, and hygiene (WASH), vector control, health education, and micronutrients supplementation, for NTDs among children and adolescents.

METHODS

We conducted a literature search on the Cochrane Controlled Trials Register, Medline, and other databases until December 2020. We included randomized controlled trials and quasi-experimental studies conducted among children and adolescents. Two authors independently screened studies for relevance. Two authors independently extracted data, assessed the risk of bias, performed metaanalysis, and rated the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation.

RESULTS

We included 155 studies (231 articles) involving 262 299 participants. For soil-transmitted helminthiasis, MDA may reduce the prevalence of Ascaris, Trichuris, and hookworm by 58%, 36%, and 57%, respectively. We are uncertain of the effect of health education, WASH, and iron supplementation on soil-transmitted helminthiasis prevalence. For Schistosomiasis, health education probably reduces the intensity and prevalence of S. mansoni, whereas micronutrient supplementation may reduce anemia prevalence and the infection intensity of S. hematobium compared with no supplementation. We are uncertain of the effect of MDA and vector control on Schistosomiasis outcomes. For trachoma, health education probably reduces the prevalence of active Trachoma, whereas we are uncertain of the effect of MDA, WASH, and vector control on Trachoma outcomes. There is limited data on the effectiveness of interventions for NTDs targeting children and adolescents.

CONCLUSION

Future studies are needed to evaluate the relative effectiveness and cost-effectiveness of various interventions specifically targeting children and adolescents.

Permethrin-treated baby wraps for the prevention of malaria: results of a randomized controlled pilot study in rural Uganda

Background

Progress against malaria has stalled and may even be slipping backwards in high-burden countries. This is due to a range of factors including insecticide resistance and mosquito feeding behaviours that limit contact with widely-employed interventions including long-lasting insecticidal nets and indoor-residual spraying. Thus, further innovations in malaria control are urgently needed.

Methods

The pilot was a randomized, placebo-controlled pilot study of permethrin-treated baby wraps—known locally as lesus—in children 6–18 months of age at a single site in rural western Uganda. Fifty mother–infant pairs were assigned to permethrin-treated or untreated lesus in a 1:1 allocation. Participants and clinical staff were blinded to group assignments through use of sham treatment and re-treatment of lesus. Participants attended scheduled clinic visits every 2 weeks for a total 12 weeks. The primary outcome of interest was the safety of the intervention, assessed as changes in the frequency of use, rates of discontinuation, and incidence of adverse events, such as skin rash. Secondary outcomes included acceptability and feasibility of the intervention as measured through participant satisfaction and completion of study activities, respectively.

Results

Overall, rates of retention and participation were relatively high with 86.0% (43 of 50) of participants completing all scheduled visits, including 18 (75.0%) and 25 (96.2%) in the intervention and control arms respectively. By the conclusion of the 12-week follow-up period, one adverse event (0.35 events per 100 person-weeks, one-sided 95% CI 0.0–1.65) was reported. Satisfaction with the lesu was high in both groups. In each study arm, there were five incident RDT positive results, but the only PCR-positive results were observed in the control group (n = 2).

Conclusions

Permethrin-treated baby wraps were well-tolerated and broadly acceptable. Adverse events were infrequent and mild. These findings support future trials seeking to determine the efficacy of treated wraps to prevent P. falciparum malaria infection in young children as a complementary tool to existing household-based interventions.

Trial registration: ClinicalTrials.gov Identifier: NCT04102592, Registered 25 September 2019. Available at: https://clinicaltrials.gov/ct2/show/NCT04102592

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04086-w.

Vector control strategies in Brazil: a qualitative investigation into community knowledge, attitudes and perceptions following the 2015-2016 Zika virus epidemic

OBJECTIVE

The World Health Organization declared a Public Health Emergency of International Concern following the rapid emergence of neonatal microcephaly in Brazil during the 2015-2016 Zika virus (ZIKV) epidemic. In response, a national campaign sought to control Aedes mosquito populations and reduce ZIKV transmission. Achieving adherence to vector control or mosquito-bite reduction behaviours, including the use of topical mosquito repellents, is challenging. Coproduction of research at the community level is needed to understand and mitigate social determinants of lower engagement with Aedes preventive measures, particularly within disempowered groups.

DESIGN

In 2017, the Zika Preparedness Latin America Network (ZikaPLAN) conducted a qualitative study to understand individual and community level experiences of ZIKV and other mosquito-borne disease outbreaks. Presented here is a thematic analysis of 33 transcripts from community focus groups and semistructured interviews, applying the Health Belief Model (HBM) to elaborate knowledge, attitudes and perceptions of ZIKV and vector control strategies.

PARTICIPANTS

120 purposively sampled adults of approximate reproductive age (18-45); 103 women participated in focus groups and 17 men in semistructured interviews.

SETTING

Two sociopolitically and epidemiologically distinct cities in Brazil: Jundiaí (57 km north of São Paolo) and Salvador (Bahia state capital).

RESULTS

Four key and 12 major themes emerged from the analysis: (1) knowledge and cues to action; (2) attitudes and normative beliefs (perceived threat, barriers, benefits and self-efficacy); (3) behaviour change (household prevention and community participation); and (4) community preferences for novel repellent tools, vector control strategies and ZIKV messaging.

CONCLUSIONS

Common barriers to repellent adherence were accessibility, appearance and effectiveness. A strong case is made for the transferability of the HBM to inform epidemic preparedness for mosquito-borne disease outbreaks at the community level. Nationally, a health campaign targeting men is recommended, in addition to local mobilisation of funding to strengthen surveillance, risk communication and community engagement.

Reviewing School Uniform through a Public Health Lens: Evidence about the Impacts of School Uniform on Education and Health

This study uses a public health lens to review evidence about the impacts of wearing a school uniform on students’ health and educational outcomes. It also reviews the underlying rationales for school uniform use, exploring historical reasons for uniform use, as well as how questions of equity, human rights, and the status of children as a vulnerable group are played out in debates over school uniforms. The literature identified indicates that uniforms have no direct impact on academic performance, yet directly impact physical and psychological health. Girls, ethnic and religious minorities, gender-diverse students and poorer students suffer harm disproportionately from poorly designed uniform policies and garments that do not suit their physical and socio-cultural needs. Paradoxically, for some students, uniform creates a barrier to education that it was originally instituted to remedy. The article shows that public health offers a new perspective on and contribution to debates and rationales for school uniform use. This review lays out the research landscape on school uniform and highlights areas for further research.

Recent Insights Into the Molecular Mechanism of Toll-Like Receptor Response to Dengue Virus Infection

Dengue is the most prevalent and rapidly spreading mosquito-borne viral disease caused by dengue virus (DENV). Recently, DENV has been affecting humans within an expanding geographic range due to the warming of the earth. Innate immune responses play a significant role in antiviral defense, and Toll-like receptors (TLRs) are key regulators of innate immunity. Therefore, a detailed understanding of TLR and DENV interactions is important for devising therapeutic and preventive strategies. Several studies have indicated the ability of DENV to modulate the TLR signaling pathway and host immune response. Vaccination is considered one of the most successful medical interventions for preventing viral infections. However, only a partially protective dengue vaccine, the first licensed dengue vaccine CYD-TDV, is available in some dengue-endemic countries to protect against DENV infection. Therefore, the development of a fully protective, durable, and safe DENV vaccine is a priority for global health. Here, we demonstrate the progress made in our understanding of the host response to DENV infection, with a particular focus on TLR response and how DENV avoids the response toward establishing infection. We also discuss dengue vaccine candidates in late-stage development and the issues that must be overcome to enable their success.

Behavioural response of mosquito vectors Aedes aegypti, Anopheles stephensi and Culex quinquefasciatus to synthetic pyrethroid and organophosphorus-based slow-release insecticidal paint

BACKGROUND

The direct toxicological impact of insecticides on vector mosquitoes has been well emphasized; however, behavioural responses such as excito-repellency and physical avoidance as a result of insecticide exposure have not been much studied. We have demonstrated the excito-repellency and behavioural avoidance in certain vector mosquito species on exposure to a slow-release insecticidal paint (SRIP) formulation in addition to direct toxicity.

METHODS

A SRIP formulation developed by the Defence Research and Development Establishment, Gwalior, contains chlorpyriphos, deltamethrin and pyriproxyfen as active insecticides. Anopheles stephensi, Culex quinquefasciatus and Aedes aegypti mosquitoes were used to study the excito-repellency response of the formulation. The experiments were performed in a specially designed dual-choice exposure and escape chamber made of transparent polymethyl methacrylate. For the experiments, the SRIP formulation was applied undiluted at a rate of 8 m² per kg on 15 cm² metallic surfaces. Mosquitoes were introduced into the exposure chamber, and observations of the movement of mosquitoes into the escape chamber through the exit portal were taken at 1-min intervals for up to 30 min.

RESULTS

The evaluated formulation displayed strong excito-repellency against all three tested vector mosquito species. Results showed that the ET₅₀ (escape time 50%) for Ae. aegypti, An. stephensi and Cx. quinquefasciatus was 20.9 min, 14.5 min and 17.9 min for contact exposure (CE) respectively. Altogether in CE, the escape rates were stronger in An. stephensi mosquitoes at different time intervals compared to Ae. aegypti and Cx. quinquefasciatus mosquitoes. The probit analysis revealed that the determined ET did not deviate from linearity for both non-contact exposure (NCE) and placebo exposure (PE) (χ² ≤ 7.9; p = 1.0) for Ae. aegypti mosquitoes and for NCE (χ² = 8.3; p = 1.0) and PE (χ² = 1.7; p = 1.0) treatments in Cx. quinquefasciatus. Mortality (24 h) was found to be statistically higher (F = 6.4; p = 0.02) in An. stephensi for CE but did not vary for NCE (p ≥ 0.3) and PE (p = 0.6) treatments among the tested mosquito species. Survival probability response suggested that all the three tested species displayed similar survival responses for similar exposures (χ² ≤ 2.3; p ≥ 0.1).

CONCLUSION

The study demonstrates the toxicity and strong behavioural avoidance in known vector mosquito species on exposure to an insecticide-based paint formulation. The combination of insecticides in the present formulation will broaden the overall impact spectrum for protecting users from mosquito bites. The efficacy data generated in the study provide crucial information on the effectiveness of the tested formulation and could be useful in reducing the transmission intensity and disease risk in endemic countries.

Dengue: Status of current and under-development vaccines

Dengue is an emerging mosquito-borne viral infection with increasing reports of outbreaks. The clinical picture ranges from a benign febrile illness through to severe and potentially fatal manifestations. No specific anti-viral treatment exists, and therapy only consists of supportive care. During the last three decades, several attempts to develop an effective vaccine have been made. The first dengue vaccine to obtain licensure was Dengvaxia, which was authorized in 2015 and is currently available in over 20 countries. Its use has been approved with strict limitations regarding age and serostatus of the recipients, highlighting the necessity for a more safe and efficacious vaccine. At present several vaccine, candidates are undergoing clinical and pre-clinical trials. The most advanced candidates are TDV and TDV 003/005, two live-attenuated vaccines, but another 15 vaccines are under development, introducing novel immunization strategies to the traditional dengue vaccine scenario. This work reviews the current research status on dengue vaccines.

Dengue vaccine development: status and future

Dengue, the most common arbovirus, represents an increasingly significant cause of morbidity worldwide, including in travelers. After decades of research, the first dengue vaccine was licensed in 2015: CYD-TDV, a tetravalent live attenuated vaccine with a yellow fever vaccine backbone. Recent analyses have shown that vaccine performance is dependent on serostatus. In those who have had a previous dengue infection, i.e., who are seropositive, the efficacy is high and the vaccine is safe. However, in seronegative vaccinees, approximately 3 years after vaccination the vaccine increases the risk of developing severe dengue when the individual experiences a natural dengue infection.

The World Health Organization recommends that this vaccine be administered only to seropositive individuals. Current efforts are underway to develop rapid diagnostic tests to facilitate prevaccination screening. Two second-generation dengue vaccine candidates, both also live attenuated recombinant vaccines in late-stage development, may not present the same limitations because of differences in the backbone used, but results of phase 3 trials need to be available before firm conclusions can be drawn.

Dengue is increasingly frequent in travelers, but the only licensed dengue vaccine to date can be used only in seropositive individuals. However, the vast majority of travelers are seronegative. Furthermore, the primary series of three doses given 6 months apart renders this vaccine difficult in the travel medicine context.

Pre-vaccination screening strategies for the use of the CYD-TDV dengue vaccine: A meeting report

The first licensed dengue vaccine, CYD-TDV (Dengvaxia) is efficacious in seropositive individuals, but increases the risk for severe dengue in seronegative persons about two years after administration of the first dose. For countries considering the introduction of Dengvaxia, WHO recommends a pre-vaccination screening strategy whereby only persons with evidence of a past dengue infection would be vaccinated. Policy-makers need to consider the risk-benefit of vaccination strategies based on such screening tests, the optimal age to introduce the vaccine, communication and implementation strategies. To address these questions, the Global Dengue and Aedes-transmitted diseases Consortium (GDAC) organized a 3-day workshop in January 2019 with country representatives from Asia and Latin America. The meeting discussions highlighted many challenges in introducing Dengvaxia, in terms of screening test characteristics, costs of such tests combined with a 3-dose schedule, logistics, achieving high coverage rates, vaccine confidence and communication; more challenges than for any other vaccine introduction programme. A screening test would require a high specificity to minimize individual risk, and at the same time high sensitivity to maximize individual and population benefit. The underlying seroprevalence dependent positive predictive value is the best indicator for an acceptable safety profile of a pre-vaccination screening strategy. The working groups discussed many possible implementation strategies. Addressing the bottlenecks in school-based vaccine introduction for Dengvaxia will also benefit other vaccines such as HPV and booster doses for tetanus and pertussis. Levels of public trust are highly variable and context specific, and understanding of population perceptions and concerns is essential to tailor interventions, monitor and mitigate risks.

Comparative evaluation of an improved test method for bioefficacy of insecticidal fabrics against dengue and malaria vectors

Background

Insecticidal fabrics are important personal protective measures against mosquitoes, ticks and other disease vectors. In the absence of internationally accepted guidelines, bioefficacy tests have been carried out using continuous exposure and three minutes exposure bioassay methods. Recently, we have reported an improved method for bioefficacy testing of insecticidal fabrics, which involves continuous exposure of mosquitoes to the test fabrics. The present paper reports the comparative evaluation of the outcomes of the continuous exposure bioassay and the three minutes bioassay on the same fabric samples.

Methods

Permethrin content in the treated fabric samples was determined through HPLC analysis and NMR studies were performed to establish the stability of the analyte. Bioefficacy tests were carried out against dengue vector Aedes aegypti and malaria vector Anopheles stephensi as per the improved test method and the three minutes bioassay method.

Results

The permethrin doses in the fabric samples ranged from 60 to 3000 mg/m² and 36.2% of permethrin was retained after 10 washings. The extraction and chromatographic analysis were not found to affect the stability of permethrin. In continuous exposure, all fabric samples showed bioefficacy, as the mean complete knockdown time for both Ae. aegypti (10.5–34.5 min) and An. stephensi (14.5–36.8 min) was ≤ 71.5 min. The same samples were found to be not effective when tested using the three minutes bioassay method, since the knockdown and mortality percentages were well below the required bioefficacy values. The bioefficacy of the fabric samples in terms of complete knockdown time was significantly higher against Ae. aegypti in comparison to An. stephensi. The mean complete knockdown time of Ae. aegypti increased to 48.3 min after 10 washings indicating a significant reduction in bioefficacy.

Conclusions

Bioefficacy testing of the insecticidal fabrics using the improved method resulted in outcomes, which could be correlated better with the permethrin content in the fabric samples. The improved method is more appropriate for the testing of insecticidal fabrics than the three minutes bioassay method. Further evaluation of the improved method using different test arthropods could help in the formulation of specific guidelines for the bioefficacy testing of insecticidal fabrics.

Autocidal gravid ovitraps protect humans from chikungunya virus infection by reducing Aedes aegypti mosquito populations

Background

Public health responses to outbreaks of dengue, chikungunya, and Zika virus have been stymied by the inability to control the primary vector, Aedes aegypti mosquitos. Consequently, the need for novel approaches to Aedes vector control is urgent. Placement of three autocidal gravid ovitraps (AGO traps) in ~85% of homes in a community was previously shown to sustainably reduce the density of female Ae. aegypti by >80%. Following the introduction of chikungunya virus (CHIKV) to Puerto Rico, we conducted a seroprevalence survey to estimate the prevalence of CHIKV infection in communities with and without AGO traps and evaluate their effect on reducing CHIKV transmission.

Methods and findings

Multivariate models that calculated adjusted prevalence ratios (aPR) showed that among 175 and 152 residents of communities with and without AGO traps, respectively, an estimated 26.1% and 43.8% had been infected with CHIKV (aPR = 0.50, 95% CI: 0.37–0.91). After stratification by time spent in their community, protection from CHIKV infection was strongest among residents who reported spending many or all weekly daytime hours in their community:10.3% seropositive in communities with AGO traps vs. 48.7% in communities without (PR = 0.21, 95% CI: 0.11–0.41). The age-adjusted rate of fever with arthralgia attributable to CHIKV infection was 58% (95% CI: 46–66%). The monthly number of CHIKV-infected mosquitos and symptomatic residents were diminished in communities with AGO traps compared to those without.

Conclusions

These findings indicate that AGO traps are an effective tool that protects humans from infection with a virus transmitted by Ae. aegypti mosquitos. Future studies should evaluate their protective effectiveness in large, urban communities.

Aedes species mosquitos transmit pathogens of public health importance, including dengue, Zika, and chikungunya viruses. No tools exist to control these mosquitos that sustainably and effectively prevent human infections. Autocidal gravid ovitraps (AGO traps) have been shown to sustainably reduce Aedes populations by >80%. After chikungunya virus was introduced into Puerto Rico, we conducted serosurveys in communities with and without AGO traps. We observed a two-fold lower prevalence of chikungunya virus infection among residents of communities with AGO traps compared to communities without. Among infected residents of communities with traps, a significant proportion likely had been infected while outside their community. These findings indicate that AGO traps are an effective tool that protects humans from infection with pathogens transmitted by Aedes mosquitos.

Dengue

Mortality from severe dengue is low, but the economic and resource burden on health services remains substantial in endemic settings. Unfortunately, progress towards development of effective therapeutics has been slow, despite notable advances in the understanding of disease pathogenesis and considerable investment in antiviral drug discovery. For decades antibody-dependent enhancement has been the prevalent model to explain dengue pathogenesis, but it was only recently demonstrated in vivo and in clinical studies. At present, the current mainstay of management for most symptomatic dengue patients remains careful observation and prompt but judicious use of intravenous hydration therapy for those with substantial vascular leakage. Various new promising technologies for diagnosis of dengue are currently in the pipeline. New sample-in, answer-out nucleic acid amplification technologies for point-of-care use are being developed to improve performance over current technologies, with the potential to test for multiple pathogens using a single specimen. The search for biomarkers that reliably predict development of severe dengue among symptomatic individuals is also a major focus of current research efforts. The first dengue vaccine was licensed in 2015 but its performance depends on serostatus. There is an urgent need to identify correlates of both vaccine protection and disease enhancement. A crucial assessment of vector control tools should guide a research agenda for determining the most effective interventions, and how to best combine state-of-the-art vector control with vaccination.

Rapid diagnostic tests for determining dengue serostatus: a systematic review and key informant interviews

Objectives

Vaccination for dengue with the live attenuated tetravalent CYD-TDV vaccine (Dengvaxia®) is only recommended in individuals who have had prior dengue virus (DENV) infection. Rapid diagnostic tests (RDT) for past DENV infection would offer a convenient method for pre-vaccination screening at point-of-care. A systematic review was conducted to evaluate the performance of current dengue RDTs for determining dengue serostatus, using IgG antibodies against DENV as a marker of past infection.

Methods

PubMed and EMBASE databases were searched from 2000 to 2018 to identify studies evaluating dengue RDTs in individuals with known or possible previous DENV infection. Study quality was evaluated using GRADE and QUADAS-2 criteria. Semi-structured interviews were also performed with available dengue RDT manufacturers.

Results

The performance of four dengue IgG RDTs was determined in 3137 individuals across ten studies conducted in 13 countries, with serum used in most of the studies. No studies reported data for determining dengue serostatus, and limited data were available regarding cross-reactivity with other viruses. The majority of studies demonstrated sensitivities and specificities between 80% and 100% for dengue IgG detection in samples from secondary infection or convalescent time-points after recent infection.

Conclusions

Although current dengue IgG RDTs have shown reasonable performance compared with laboratory-based tests in secondary infection, additional research is needed to determine how RDTs would perform in relevant populations targeted for vaccination. New RDTs or modifications to current RDTs are feasible and may optimize the performance of these tests for use in a pre-vaccination screening approach.

Alternative strategies for mosquito-borne arbovirus control

Background

Mosquito-borne viruses—such as Zika, chikungunya, dengue fever, and yellow fever, among others—are of global importance. Although vaccine development for prevention of mosquito-borne arbovirus infections has been a focus, mitigation strategies continue to rely on vector control. However, vector control has failed to prevent recent epidemics and arrest expanding geographic distribution of key arboviruses, such as dengue. As a consequence, there has been increasing necessity to further optimize current strategies within integrated approaches and advance development of alternative, innovative strategies for the control of mosquito-borne arboviruses.

Methods and findings

This review, intended as a general overview, is one of a series being generated by the Worldwide Insecticide resistance Network (WIN). The alternative strategies discussed reflect those that are currently under evaluation for public health value by the World Health Organization (WHO) and represent strategies of focus by globally recognized public health stakeholders as potential insecticide resistance (IR)-mitigating strategies. Conditions where these alternative strategies could offer greatest public health value in consideration of mitigating IR will be dependent on the anticipated mechanism of action. Arguably, the most pressing need for endorsement of the strategies described here will be the epidemiological evidence of a public health impact.

Conclusions

As the burden of mosquito-borne arboviruses, predominately those transmitted by Aedes aegypti and A. albopictus, continues to grow at a global scale, new vector-control tools and integrated strategies will be required to meet public health demands. Decisions regarding implementation of alternative strategies will depend on key ecoepidemiological parameters that each is intended to optimally impact toward driving down arbovirus transmission.

International public health workers are challenged by the burden of arthropod-borne viral diseases, to include mosquito-borne arboviruses transmitted by Aedes aegypti and A. albopictus due in part to lack of sustainable vector control and insecticide resistance (IR), as well as the inability to scale up and sustain existing interventions for prevention of urban epidemics. As a consequence, there has been increasing interest to advance the development of alternative methods. This review provides a general overview of alternative vector-control strategies under development for the control of arbovirus mosquito vectors and highlights how each could offer innovative public health value. Considerations to regulations, acceptance, and sustainability are also provided.

Field evaluation of personal protection methods against outdoor-biting mosquitoes in Lao PDR

Background

Protecting people outdoors against mosquito-borne diseases is a major challenge. Here we compared commercially available personal protection methods to identify the most effective method for outdoor use in northern Lao PDR.

Methods

From June to August 2016 the protective efficacy of treatments were compared in a secondary forest during the afternoon and a village during the evening. Comparisons were made using a replicated Latin square design between: (i) short permethrin-treated overalls; (ii) long permethrin-treated overalls; (iii) short untreated overalls with para-menthane-3,8-diol (PMD) applied topically; (iv) short permethrin-treated overalls plus PMD applied topically; (v) short untreated overalls with metofluthrin coils in a metal casing worn on a belt; and (vi) long untreated overalls. Short untreated overalls served as the control. Cone tests were conducted on the treated and untreated fabric before and after field experiments. A questionnaire survey was used to measure social acceptability.

Results

Mosquito coils in a metal casing worn on a belt resulted in 92.3% (95% confidence interval, CI: 88.9–94.6%). landing protection from female mosquitoes in the afternoon and 68.8% (95% CI: 41.7–83.3%) protection in the evening compared to short untreated clothing. PMD was protective both when combined with short permethrin-treated overalls (afternoon, 68.2%, 95% CI: 52.6–78.7%; evening, 52.3%, 95% CI: 33.8–65.7%) and when used in combination with short untreated overalls (afternoon, 55.0%, 95% CI: 41.7–65.2%; evening, 25.2%, 95% CI: 9.4–38.2%). Whilst long permethrin-treated overalls were protective (afternoon, 61.1%, 95% CI: 51.4–68.8%; evening, 43.0%, 95% CI: 25.5–56.4%), short permethrin-treated overalls and long untreated overalls were not. Exposure to new permethrin-treated fabric in cone tests resulted in 25.0% (95% CI, 17.8–32.2%) and 26.2% (95% CI 16.7–35.8%) mortality for susceptible Ae. albopictus and susceptible Ae. aegypti, respectively. There was a loss of efficacy of permethrin-treated clothing after use in the field, with 3 min knockdown rates of Ae. albopictus and 1 h knockdown of Ae. aegypti decreasing over time. Participants considered all treatments acceptable.

Conclusions

The portable mosquito coils were highly protective against outdoor biting mosquitoes, although there are safety concerns related to its use. The combination of permethrin-treated clothing and PMD repellent represent an alternative treatment for protection against outdoor-biting mosquitoes.

Electronic supplementary material

The online version of this article (10.1186/s13071-018-3239-0) contains supplementary material, which is available to authorized users.

Integrated Aedes management for the control of Aedes-borne diseases

BACKGROUND

Diseases caused by Aedes-borne viruses, such as dengue, Zika, chikungunya, and yellow fever, are emerging and reemerging globally. The causes are multifactorial and include global trade, international travel, urbanisation, water storage practices, lack of resources for intervention, and an inadequate evidence base for the public health impact of Aedes control tools. National authorities need comprehensive evidence-based guidance on how and when to implement Aedes control measures tailored to local entomological and epidemiological conditions.

METHODS AND FINDINGS

This review is one of a series being conducted by the Worldwide Insecticide resistance Network (WIN). It describes a framework for implementing Integrated Aedes Management (IAM) to improve control of diseases caused by Aedes-borne viruses based on available evidence. IAM consists of a portfolio of operational actions and priorities for the control of Aedes-borne viruses that are tailored to different epidemiological and entomological risk scenarios. The framework has 4 activity pillars: (i) integrated vector and disease surveillance, (ii) vector control, (iii) community mobilisation, and (iv) intra- and intersectoral collaboration as well as 4 supporting activities: (i) capacity building, (ii) research, (iii) advocacy, and (iv) policies and laws.

CONCLUSIONS

IAM supports implementation of the World Health Organisation Global Vector Control Response (WHO GVCR) and provides a comprehensive framework for health authorities to devise and deliver sustainable, effective, integrated, community-based, locally adapted vector control strategies in order to reduce the burden of Aedes-transmitted arboviruses. The success of IAM requires strong commitment and leadership from governments to maintain proactive disease prevention programs and preparedness for rapid responses to outbreaks.

Contact Irritancy and Toxicity of Permethrin-Treated Clothing for Ixodes scapularis, Amblyomma americanum, and Dermacentor variabilis Ticks (Acari: Ixodidae)

Clothing treated with the pyrethroid permethrin is available in the United States as consumer products to prevent tick bites. We used tick bioassays to quantify contact irritancy and toxicity of permethrin-treated clothing for three important tick vectors of human pathogens: the blacklegged tick, Ixodes scapularis Say (Acari: Ixodidae); the lone star tick, Amblyomma americanum (L.) (Acari: Ixodidae); and the American dog tick, Dermacentor variabilis (Say) (Acari: Ixodidae). We first demonstrated that field-collected I. scapularis nymphs from Minnesota were as susceptible as laboratory-reared nymphs to a permethrin-treated textile. Field ticks examined in bioassays on the same day they were collected displayed contact irritancy by actively dislodging from a vertically oriented permethrin-treated textile, and a forced 1-min exposure resulted in all ticks being unable to move normally, thus posing no more than minimal risk of biting, 1 h after contact with the treated textile. Moreover, we documented lack of normal movement for laboratory-reared I. scapularis nymphs by 1 h after contact for 1 min with a wide range of permethrin-treated clothing, including garments made from cotton, synthetic materials, and blends. A comparison of the impact of a permethrin-treated textile across tick species and life stages revealed the strongest effect on I. scapularis nymphs (0% with normal movement 1 h after a 1-min exposure), followed by A. americanum nymphs (14.0%), I. scapularis females (38.0%), D. variabilis females (82.0%), and A. americanum females (98.0%). Loss of normal movement for all ticks 1 h after contact with the permethrin-treated textile required exposures of 1 min for I. scapularis nymphs, 2 min for A. americanum nymphs, and 5 min for female I. scapularis, D. variabilis, and A. americanum ticks. We conclude that use of permethrin-treated clothing shows promise to prevent bites by medically important ticks. Further research needs are discussed.

A review on test methods for insecticidal fabrics and the need for standardisation

Insecticidal fabrics are effective personal protective measures against disease vectors and unlike bed nets, these fabrics can provide protection from day-biting mosquitoes and in outdoor environments. The rapid geographical expansion of day-biting mosquitoes and their role in disease transmission necessitate technological interventions, which can be effectively used during the daytime. There is a renewed interest in insecticidal fabrics mainly due to the recent outbreaks and geographical spread of dengue and chikungunya and with the emerging threat of Zika virus infection. Insecticidal fabrics are useful for protection from night-biting mosquitoes and also in situations were sleeping under a bed net is not possible. They are also effective against other biting arthropods like ticks, mites, tsetse flies, sand flies and body lice. Although long-lasting insecticidal fabrics factory-treated with permethrin are now commercially available for military and civilian use, there are no international guidelines for testing their efficacy. The different methods employed so far for testing bioefficacy, washing and quantification of permethrin are compiled in this review. The future prospects and challenges ahead for long-lasting insecticidal fabrics are discussed in the context of the increased threat from day-biting mosquitoes and the diseases transmitted by them. The review focuses on the need for standardisation of the test methods for ensuring adequate bioefficacy and safety to the user. The differences between long-lasting insecticidal nets and long-lasting insecticidal fabrics are elaborated, and the need for a separate registration and licencing procedure for long-lasting insecticidal fabrics is highlighted. A test procedure for insecticidal fabrics is described, which could be used until internationally accepted guidelines are available.

Pyrethroid insecticides maintain repellent effect on knock-down resistant populations of Aedes aegypti mosquitoes

Pyrethroid-treated clothing is commonly worn for protection against mosquitoes; pyrethroids are both insecticides and repellents. Pyrethroid resistance has become increasingly common in Aedes aegypti, the vector of dengue, Zika, and other arboviruses, but it is not clear whether resistance is associated with reductions in repellency. In order to determine whether long-lasting permethrin impregnated (LLPI) clothing is protective, we used Aedes aegypti from New Orleans, LA (pyrethroid-sensitive) and San Juan, PR (resistant) to measure both lethality and repellency. PCR and Sanger sequencing were used to confirm resistance status by detecting mutations in the kdr gene at positions 1016 and 1534. Arm-in-cage trials of 100 Aedes aegypti females from both populations were performed for 10 minutes to bare arm or an arm clothed in untreated military camouflage or military camouflage impregnated with deltamethrin, permethrin, or etofenprox. Trials were repeated 4–5 times on different days. Number of landings, number of blood meals, and immediate and 24-hour mortality were recorded. Mortality was extremely low in all trials. Compared to untreated cloth, mosquitoes demonstrated a trend towards a 2%-63% reduction in landings and a statistically significant 78–100% reduction in blood feeding on pyrethroid-treated cloth for most insecticides. Effects were observed in both pyrethroid-sensitive and pyrethroid-resistant mosquito populations. Our data show that kdr mutations are associated with pyrethroid resistance but are likely not the only contributors. Pyrethroids appear to maintain repellent effect against resistant mosquitoes. This finding suggests that even in places where pyrethroid resistance is widespread, permethrin still has a role for use as a repellent on clothing to protect against mosquito bites.

Permethrin treated clothing to protect outdoor workers: evaluation of different methods for mosquito exposure against populations with differing resistance status

Minimizing arthropod exposure (e.g. mosquito and tick bites) is vital to protect health of outdoor workers. Personal protective measures can help protect against exposure. Here, the quantity of permethrin was evaluated for different fabric types after washing. Cone and petri dish exposure assays were used to investigate the knockdown/mortality of permethrin-susceptible and permethrin-resistant populations of mosquitoes. Permethrin-treated clothing was effective against the tested mosquito population that was susceptible to permethrin but not a permethrin-resistant population. Permethrin quantity was significantly highest in the 100% cotton fabric and for the 0 wash group. Permethrin quantity in fabrics decreased with washing. No significant differences (p > 0.05) were observed in knockdown/mortality rates for either exposure method. The protective effect of permethrin-treated clothing against mosquitoes is impacted by many factors, e.g. wash frequency, fabric type, and the susceptibility/resistance status of local mosquito populations.

Novel tools for the surveillance and control of dengue: findings by the DengueTools research consortium

BACKGROUND

Dengue fever persists as a major global disease burden, and may increase as a consequence of climate change. Along with other measures, research actions to improve diagnosis, surveillance, prevention, and predictive models are highly relevant. The European Commission funded the DengueTools consortium to lead a major initiative in these areas, and this review synthesises the outputs and findings of this work conducted from 2011 to 2016. Research areas: DengueTools organised its work into three research areas, namely [1] Early warning and surveillance systems; [2] Strategies to prevent dengue in children; and [3] Predictive models for the global spread of dengue. Research area 1 focused on case-studies undertaken in Sri Lanka, including developing laboratory-based sentinel surveillance, evaluating economic impact, identifying drivers of transmission intensity, evaluating outbreak prediction capacity and developing diagnostic capacity. Research area 2 addressed preventing dengue transmission in school children, with case-studies undertaken in Thailand. Insecticide-treated school uniforms represented an intriguing potential approach, with some encouraging results, but which were overshadowed by a lack of persistence of insecticide on the uniforms with repeated washing. Research area 3 evaluated potential global spread of dengue, particularly into dengue-naïve areas such as Europe. The role of international travel, changing boundaries of vectors, developing models of vectorial capacity under different climate change scenarios and strategies for vector control in outbreaks was all evaluated.

CONCLUDING REMARKS

DengueTools was able to make significant advances in methods for understanding and controlling dengue transmission in a range of settings. These will have implications for public health agendas to counteract dengue, including vaccination programmes.

OUTLOOK

Towards the end of the DengueTools project, Zika virus emerged as an unexpected epidemic in the central and southern America. Given the similarities between the dengue and Zika viruses, with vectors in common, some of the DengueTools thinking translated readily into the Zika situation.

International workshop on insecticide resistance in vectors of arboviruses, December 2016, Rio de Janeiro, Brazil

Vector-borne diseases transmitted by insect vectors such as mosquitoes occur in over 100 countries and affect almost half of the world’s population. Dengue is currently the most prevalent arboviral disease but chikungunya, Zika and yellow fever show increasing prevalence and severity. Vector control, mainly by the use of insecticides, play a key role in disease prevention but the use of the same chemicals for more than 40 years, together with the dissemination of mosquitoes by trade and environmental changes, resulted in the global spread of insecticide resistance. In this context, innovative tools and strategies for vector control, including the management of resistance, are urgently needed. This report summarizes the main outputs of the first international workshop on Insecticide resistance in vectors of arboviruses held in Rio de Janeiro, Brazil, 5–8 December 2016. The primary aims of this workshop were to identify strategies for the development and implementation of standardized insecticide resistance management, also to allow comparisons across nations and across time, and to define research priorities for control of vectors of arboviruses. The workshop brought together 163 participants from 28 nationalities and was accessible, live, through the web (> 70,000 web-accesses over 3 days).