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[afro-nets] Mosquito and Malaria Control (45)

Mosquito and Malaria Control (45)

Dear All, 

There exists an extensive body of correctly done, peer-reviewed research that 
decisively shows the effectiveness of insecticide treated bednets (ITNs) for 
greatly reducing the burden of malaria. Further, the vast majority of reputable 
studies, subjected to peer-review, call for a integrated mix of interventions, 
including ITNs, IRS, IPT and wide-spread use of ACTs, and have done so for 
several years.  Integrated malaria management has been the basis of WHO and RBM 
recommendations in SSA for years.

Those honestly seeking to control and eliminate malaria in SSA recognize that 
Africa is NOT a homogenous set of identical countries with identical disease 
patterns. No single intervention works in all environments. The appropriate mix 
of scientifically proven and locally appropriate malaria control interventions 
depends on the specific epidemiological setting: this varies within countries 
as well as between countries. See for a 
table showing how WHO and RBM have used evidence to help countries choose 
control strategies appropriate to their epidemiological needs. Infrastructure 
and country capacity to afford routine maintenance varies widely: many 
countries currently are unable to finance routine vehicle maintenance for 
public health centers and programs, like EPI. So affordability matters, 
including training costs and the costs of explaining to communities the risks 
of interventions.  

Spraying can not occur without the consent of community members. Those who 
actually work in Africa know how time-consuming and expensive it is to do such 
community sensitization to any new technology, even ULV spraying.

Please see the article �Socio-economic inequity in demand for 
insecticide-treated nets, in-door residual house spraying, larviciding and 
fogging in Sudan� [Malaria Journal. 2005 Dec 15;4:62];
See also �The scope and limitations of insecticide spraying in rural vector 
control programmes in the states of Karnataka and Tamil Nadu in India�, which 
shows how the effectiveness of spraying is reduced by cultural and 
environmental factors [Ecol Dis. 1982;1(4):243-55].  
By the way, this has nothing to do with the use of DDT! The use of DDT for 
vector control, but not for agriculture, is approved by the Stockholm 
Convention on Persistent Organic Pollutants. DDT used for IRS, if local 
governmental authorities and health professionals feel it is indicated, is 
supported by RBM partners. See �Anopheles arabiensis and An. quadriannulatus 
resistance to DDT in South Africa� [Med Vet Entomol. 2003 Dec;17(4):417-22]
USAID, the USA's CDC and the WHO, among many other respected organizations, 
have repeatedly stated that ITNs are an important part of a  SUITE of 
interventions. These include indoor residual spraying (IRS) and prophylactic 
anti-malarial medicines for pregnant women (IPT), as well as environmental 
management techniques (swap drainage) and behavior change to avoid sources of 
still water for breeding (e.g. used tires and open containers holding 
rainwater).  None, not one, of these organizations recommend the use of 
wide-spread aerial spraying of any type of insecticide for malaria control in 
SSA at this time.
The anti-malarial interventions they DO recommend are proven to work. The 
following articles in leading scientific journals have had to undergo stringent 
peer-review: i.e. the science behind the conclusions has been critically 
reviewed to ensure it is theoretically and methodologically correct.  
For evidence on ITNs:
1) The article �Malaria control--two years' use of insecticide-treated bednets 
compared with insecticide house spraying in KwaZulu-Natal� [S Afr Med J. 2001 
Nov;91(11):978-83 ] which indicated ITNs  are superior to IRS alone.
2) The article �Insecticide-treated nets� [Adv Parasitol. 2006;61:77-128 ] 
which provides several studies to support its contention that the evidence 
shows ITNs to be extremely effective as well as cost-effective:
3) Concerning newer Long-lasting ITNs, see �Evaluation of long-lasting 
insecticidal nets after 2 years of household use� [Trop Med Int Health. 2005 
For evidence on IRS:
1) The article �A steep decline of malaria morbidity and mortality trends in 
Eritrea between 2000 and 2004: the effect of combination of control methods� 
[Malaria J. 2006 Apr 24;5:33] which provides clear evidence that ITNs plus IRS 
was responsible for the dramatic reduction of malaria in Eritrea from 2000 to 
2) The article �Impact of different strategies to control Plasmodium infection 
and anaemia on the island of Bioko (Equatorial Guinea); which states �IRS and 
ITNs have proven to be effective control strategies on the island of Bioko. The 
choice of one or other strategy is, above all, a question of operational 
feasibility and availability of local resources�
For evidence on IPT please see
1) �Effectiveness of intermittent preventive treatment with 
sulphadoxine-pyrimethamine for control of malaria in pregnancy in western 
Kenya: a hospital-based study�, showing confirms that IPT with SP is effective 
in reducing placental malaria and Low Birth Weight  [Trop Med Int Health. 2004 
 �Prevention of anaemia in pregnancy using insecticide-treated bednets and 
sulfadoxine-pyrimethamine in a highly malarious area of Kenya: a randomized 
controlled trial� which showed that ITNs plus IPT was most successful [Trans R 
Soc Trop Med Hyg. 2003 May-Jun;97(3):277-82].
For environmental management see:
1) �Reducing the burden of malaria in different eco-epidemiological settings 
with environmental management: a systematic review� [Lancet Infect Dis. 2005 
2) �Engineering and malaria control: learning from the past 100 years� [Acta 
Trop. 2004 Jan;89(2):99-108]

Finally, new Artemisinin-based Combination Therapies (ACTs) medicines are a 
proven and cost-effective intervention, and should be combined with ITNs, IPT 
and IRS. See  �Cost effectiveness analysis of strategies to combat malaria in 
developing countries [BMJ. 2005 Dec 3;331(7528):1299. Epub 2005 Nov 10]
These interventions work. No similar articles have appeared in any of the 
dozens of top-tier scientific magazines showing any evidence that wide-spread 
spraying, regardless of insecticide used, as any proven role in malaria control 
The constraint to global malaria control is that developed countries have not 
lived up to their written commitments to fully fund the GFATM and provide 
developing countries the means to greatly scale up use of these proven and 
effective interventions.
Best regards,
Tom O�Connell
Consultant, health policy and planning
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