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Impact of Indoor Residual Spraying with Lambda-Cyhalothrin On Am. J. Trop. Med. Hyg., 86(6), 2012, pp. 997–1004 doi:10.4269/ajtmh.2012.11-0621 Copyright © 2012 by The American Society of Tropical Medicine and Hygiene Impact of Indoor Residual Spraying with Lambda-Cyhalothrin on Malaria Parasitemia and Anemia Prevalence among Children Less than Five Years of Age in an Area of Intense, Year-Round Transmission in Malawi Jacek Skarbinski,* Dyson Mwandama, Adam Wolkon, Madalitso Luka, James Jafali, Alison Smith, Themba Mzilahowa, John Gimnig, Carl Campbell, John Chiphwanya, Doreen Ali, and Don P. Mathanga Malaria Branch, and Entomology Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia; Malaria Alert Centre, and Department of Community Health, College of Medicine, Blantyre, Malawi; Center for Tropical and Global Emerging Diseases, University of Georgia, Athens, Georgia; National Malaria Control Programme, Ministry of Health, Lilongwe, Malawi Abstract. Little is known about the impact of indoor residual spraying (IRS) in areas with intense malaria transmis- sion such as sub-Saharan Africa. In Malawi, IRS with lambda-cyhalothrin has been applied annually in an area of intense year-long transmission since 2007. We evaluated the impact of IRS on parasitemia and anemia prevalence in children less than five years of age by using a cross-sectional household survey conducted in 2009, six months after the second IRS spray round. We measured malaria parasitemia and anemia (hemoglobin level < 11 g/dL) in 899 children less than five years of age and used binomial regression to assess the impact of IRS by comparing children living in a household sprayed with IRS (direct IRS) with those in a household not sprayed with IRS, but in an IRS area (indirect IRS) and those living in a household not sprayed with IRS and not in an IRS area (no IRS). In the IRS area, 77% of households reported receiving IRS. Adjusting for bed net use, house construction, and socioeconomic status, we found that receiving direct IRS and indirect IRS were significantly associated with a 33% (95% confidence interval [CI] = 1–54%) and 46% (95% CI = 20–64%) reduction in parasitemia and a 21% (95% CI = 4–34%) and 30% (95% CI = 12–45%) reduction in anemia prevalence, respectively. INTRODUCTION most of sub-Saharan Africa. Much of our early data on IRS efficacy in areas with intense, year-long malaria transmission Vector control interventions such as insecticide-treated nets comes from relatively small scale demonstration projects and (ITNs) and indoor residual spraying (IRS) are key malaria – cluster randomized trials.8 12 More recently, IRS use has control tools.1,2 Both of these strategies depend on the action increased in sub-Saharan Africa and has had demonstrated of insecticide either sprayed onto the wall or applied to the – impact in a number of different transmission settings.13 21 In netting material to kill adult female anopheline mosquitoes 2006, the World Health Organization has revised its recom- either before or after a blood meal and reduce both the size mendation for the use of IRS and endorsed IRS use in all and longevity of the adult mosquito population. In addition, malaria transmission zones, including much of sub-Saharan some insecticides, including the synthetic pyrethroids, also Africa.1 Although some historical examples of IRS use in high repel mosquitoes from households, leading to reduced human- 9,10,22 mosquito contact and increased mortality of adult mosquitos.3 transmission settings exist, there is a paucity of recent data Lastly, bed nets provide a physical barrier to human–mosquito on IRS use in areas of intense, year-long malaria transmission. contact. Both ITNs and IRS are most effective for endophagic Although IRS and ITNs have been shown to be effective at reducing malaria transmission,6,11 there are unanswered ques- and endophilic mosquito vectors, where they provide a 8 23–25 community-wide effect; thus persons who do not receive per- tions about their relative efficacy and cost effectiveness, sonal protection can still benefit from these interventions in as well as the additional protection afforded by the combined – 11,26 their communities.3 5 use of IRS and ITNs. There are few head-to-head com- Insecticide-treated nets have proven effective in a large num- parisons of ITN and IRS efficacy, and the data thus far are ber of field trials and have been shown to reduce mortality in mixed. A review of six previously conducted studies across children 1–59 months of age, asexual malaria parasitemia, and sub-Saharan Africa and South Asia concluded that IRS anemia prevalence, as well as uncomplicated malaria and appeared more protective in one trial conducted in a stable 6 malaria transmission area, but that ITNs seemed to be more severe malaria incidence. In recent years, because of their 11 proven efficacy and relative ease of implementation, ITNs protective than IRS in unstable transmission areas. In addi- have become the predominant vector control strategy in many tion, there is relatively little information to guide program 2 managers regarding the relative cost effectiveness of the two malaria-endemic areas of the world. 23–25 Evidence of IRS efficacy in reducing or interrupting malaria interventions given mixed results from previous studies. transmission has been available since the 1940s, and many Moreover, we do not understand if there are additional bene- historical examples of successful IRS programs exist from the fits of combining IRS and ITNs. Thus far, field studies and Global Malaria Eradication Program era in the 1950s to 1970s.7 mathematical models are far from conclusive and suggest var- iable effects dependent on epidemiologic conditions as well as However, IRS was not a major component of malaria control 11,26–28 as part of the Global Malaria Eradication Program or after- choice of insecticide. Lastly, we do not fully understand wards in areas with intense, year-round transmission such as the impact of insecticide resistance on IRS and ITNs and their relative efficacy in the face of resistance as well as their use as insecticide resistance management tools.29 Although random- ized trials to address the role of ITNs versus IRS are being *Address correspondence to Jacek Skarbinski, Malaria Branch, Cen- ters for Disease Control and Prevention, 4770 Buford Highway NE, planned, observational data might provide some insights into Mailstop F22, Atlanta, GA 30341. E-mail: [email protected] the relative merits of each intervention individually versus 997 998 SKARBINSKI AND OTHERS their use in combination, especially in areas with intense, conducted only in the northern half of Nkhotakota.30 We year-round transmission. assessed the impact of IRS on malaria parasitemia and ane- In Malawi, the National Malaria Control Program with mia prevalence in children less than five years of age by using funding from the U.S. President’s Malaria Initiative initiated a cross-sectional household survey in the April 2009, approx- an IRS program administered by Research Triangle Interna- imately six months after the second IRS spray round. tional (Research Triangle Park, NC) by using 10% lambda- cyhalothrin slow-release capsule suspension (ICON 10 CS(R); MATERIALS AND METHODS Syngenta AG, Basel, Switzerland) in the northern half of Nkhotakota District, an area of intense year-round transmis- Study site. Nkhotakota District is in the Central Region of sion, in December 2007 (Figure 1).30 Nkhotakota District was Malawi and includes a main port on Lake Malawi. As of 2008, chosen for IRS on the basis of intensity of malaria transmis- the district had a population of 303,659.31 Nkhotakota lies sion and burden of disease, as well as the potential applica- at an elevation of 1,548 feet (472 meters) above sea level and bility to other rural areas in Malawi. In addition, the district has year-round malaria transmission with a seasonal peak was previously used for vector assessments, has distinct from December to June, after the main rainy season. Ninety- boundaries including Lake Malawi on the east and the eight percent of malaria infections in Malawi are caused by national forest on the west, and had included IRS as a pro- Plasmodium falciparum. Anopheles gambiae complex and posed activity in its District Implementation Plan. The first An. funestus are the primary malaria vectors.32 Malaria infec- round of IRS occurred in December 2007 (28,227 structures) tion burden is high in Nkhotakota District; according to a pre- in a limited geographic area and the second round of IRS IRS household survey conducted in 2007, 72% of children occurred in October–November of 2008 (42,044 structures) 6–30 months of age had malaria parasitemia (Mathanga D, in an expanded geographic area; both IRS rounds were unpublished data). No published data on malaria endemicity Figure 1. Districts and census enumeration areas included in the household survey in eight districts, Malawi 2009 (A) with a close-up of Nkhotakota District (B). Districts included in the household survey are shaded in green and sampled census enumeration areas with indoor residual spraying (IRS) for malaria control are indicated by red circles and those without IRS are indicated by black circles. IMPACT OF INDOOR RESIDUAL SPRAYING IN MALAWI 999 in Nkhotakota District exist, but distribution and seasonality artemether-lumefantrine within the past two weeks, but geospatial models suggest similar climate suitability to sustain remained febrile at the time of the survey, were treated with endemic malaria transmission in the northern and southern quinine. Children who were found to be seriously ill, as deter- halves of Nkhotkota District.33 mined by the survey nurses, were provided transportation to Household survey. Full details of data collection procedures the nearest health facility. have been described.34 In brief, we conducted a cross-sectional Definitions.
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