Armel Djènontin

Combination of malaria vector control interventions in pyrethroid resistance area in Benin: a cluster randomised controlled trial

BACKGROUND Malaria control efforts and elimination in Africa are being challenged by the development of resistance of parasites to antimalarial drugs and vectors to insecticides. We investigated whether the combination of long-lasting insecticidal mosquito nets (LLINs) with indoor residual spraying (IRS) or carbamate-treated plastic sheeting (CTPS) conferred enhanced protection against malaria and better management of pyrethroid-resistance in vectors than did LLINs alone. METHODS We did a cluster randomised controlled trial in 28 villages in southern Benin, west Africa. Inclusion criteria of the villages were moderate level of pyrethroid resistance in malaria vectors and minimum distance between villages of 2 km. We assessed four malaria vector control interventions: LLIN targeted coverage to pregnant women and children younger than 6 years (TLLIN, reference group), LLIN universal coverage of all sleeping units (ULLIN), TLLIN plus full coverage of carbamate-IRS applied every 8 months (TLLIN+IRS), and ULLIN plus full coverage of CTPS lined up to the upper part of the household walls (ULLIN+CTPS). The interventions were allocated to villages by a block randomisation on the basis of preliminary surveys and children of each village were randomly selected to participate with computer-generated numbers. The primary endpoint was the incidence density rate of Plasmodium falciparum clinical malaria in children younger than 6 years as was analysed by Poisson regression taking into account the effect of age and the sampling design with a generalised estimating equation approach. Clinical and parasitological information were obtained by active case detection of malaria episodes during 12 periods of 6 consecutive days scheduled at six weekly intervals and by cross-sectional surveys of asymptomatic plasmodial infections. Children or study investigators were not masked to study group. This study is registered with Current Controlled Trials, number ISRCTN07404145. FINDINGS Of 58 villages assessed, 28 were randomly assigned to intervention groups. 413-429 children were followed up in each intervention group for 18 months. The clinical incidence density of malaria was not reduced in the children from the ULLIN group (incidence density rate 0·95, 95% CI 0·67-1·36, p=0·79), nor in those from the TLLIN+IRS group (1·32, 0·90-1·93, p=0·15) or from the ULLIN+CTPS group (1·05, 0·75-1·48, p=0·77) compared with the reference group (TLLIN). The same trend was observed with the prevalence and parasite density of asymptomatic infections (non significant regression coefficients). INTERPRETATION No significant benefit for reducing malaria morbidity, infection, and transmission was reported when combining LLIN+IRS or LLIN+CTPS compared with a background of LLIN coverage. These findings are important for national malaria control programmes and should help the design of more cost-effective strategies for malaria control and elimination. FUNDING Ministère Français des Affaires Etrangères et Européennes (FSP project 2006-22), Institut de Recherche pour le Développement, Presidents Malaria Initiative (PMI) of US Governement.

Culicidae diversity, malaria transmission and insecticide resistance alleles in malaria vectors in Ouidah-Kpomasse-Tori district from Benin (West Africa): A pre-intervention study

BackgroundTo implement an Insecticide Resistance Management (IRM) strategy through a randomized controlled trial (phase III), 28 villages were selected in southern Benin. No recent entomological data being available in these villages, entomological surveys were performed between October 2007 and May 2008, before vector control strategies implementation, to establish baseline data.MethodsMosquitoes were sampled by human landing collection (16 person-nights per village per survey per village) during 5 surveys. Mosquitoes were identified morphologically and by molecular methods. The Plasmodium falciparum circumsporozoïte indexes were measured by ELISA, and the entomological inoculation rates (EIRs) were calculated. Molecular detection of pyrethroid knock down resistance (Kdr) and of insensitive acetylcholinesterase were performed.Results44,693 mosquitoes belonging to 28 different species were caught from October 2007 to May 2008. Among mosquitoes caught, 318 were An. gambiae s.s., 2 were An. nili, 568 were An. funestus s.s., and one individual was An. leesoni. EIR was 2.05 ± 1.28 infective bites per human per 100 nights on average, of which 0.67 ± 0.60 were from An. funestus and 1.38 ± 0.94 infective bites were from An. gambiae. Important variations were noted between villages considering mosquito density and malaria transmission indicating a spatial heterogeneity in the study area. The kdr allelic frequency was 28.86% in An. gambiae s.s. on average and significantly increases from October 2007 (10.26%) to May 2008 (33.87%) in M molecular form of An. gambiae s.s. Ace 1 mutation was found in S molecular of An. gambiae s.s at a low frequency (< 1%).ConclusionThis study updates information on mosquito diversity and malaria risk in rural villages from south Benin. It showed a high spatial heterogeneity in mosquito distribution and malaria transmission and underlines the need of further investigations of biological, ecological, and behavioral traits of malaria vectors species and forms. This study is a necessary prerequisite to cartography malaria risk and to improve vector control operations in southern Benin.

Managing insecticide resistance in malaria vectors by combining carbamate-treated plastic wall sheeting and pyrethroid-treated bed nets

BackgroundPyrethroid resistance is now widespread in Anopheles gambiae, the major vector for malaria in sub-Saharan Africa. This resistance may compromise malaria vector control strategies that are currently in use in endemic areas. In this context, a new tool for management of resistant mosquitoes based on the combination of a pyrethroid-treated bed net and carbamate-treated plastic sheeting was developed.MethodsIn the laboratory, the insecticidal activity and wash resistance of four carbamate-treated materials: a cotton/polyester blend, a polyvinyl chloride tarpaulin, a cotton/polyester blend covered on one side with polyurethane, and a mesh of polypropylene fibres was tested. These materials were treated with bendiocarb at 100 mg/m2 and 200 mg/m2 with and without a binding resin to find the best combination for field studies. Secondly, experimental hut trials were performed in southern Benin to test the efficacy of the combined use of a pyrethroid-treated bed net and the carbamate-treated material that was the most wash-resistant against wild populations of pyrethroid-resistant An. gambiae and Culex quinquefasciatus.ResultsMaterial made of polypropylene mesh (PPW) provided the best wash resistance (up to 10 washes), regardless of the insecticide dose, the type of washing, or the presence or absence of the binding resin. The experimental hut trial showed that the combination of carbamate-treated PPW and a pyrethroid-treated bed net was extremely effective in terms of mortality and inhibition of blood feeding of pyrethroid-resistant An. gambiae. This efficacy was found to be proportional to the total surface of the walls. This combination showed a moderate effect against wild populations of Cx. quinquefasciatus, which were strongly resistant to pyrethroid.ConclusionThese preliminary results should be confirmed, including evaluation of entomological, parasitological, and clinical parameters. Selective pressure on resistance mechanisms within the vector population, effects on other pest insects, and the acceptability of this management strategy in the community also need to be evaluated.

Malaria infection and disease in an area with pyrethroid-resistant vectors in southern Benin

BackgroundThis study aimed to investigate baseline data on malaria before the evaluation of new vector control strategies in an area of pyrethroid-resistance of vectors. The burden of malaria was estimated in terms of infection (prevalence and parasite density) and of clinical episodes.MethodsBetween December 2007 and December 2008 in the health district of Ouidah - Kpomassè - Tori Bossito (southern Benin), a descriptive epidemiological survey of malaria was conducted. From 28 selected villages, seven were randomized from which a total of 440 children aged 0 to 5 years were randomly selected. Clinical and parasitological information was obtained by active case detection of malaria episodes carried out during eight periods of six consecutive days scheduled at six weekly intervals and by cross-sectional surveys of asymptomatic infection. Entomological information was also collected. The ownership, the use and the correct use of long-lasting insecticide-treated nets (LLINs) were checked over weekly-survey by unannounced visits at home in the late evening.ResultsMean parasite density in asymptomatic children was 586 P. falciparum asexual forms per μL of blood (95%CI 504-680). Pyrogenic parasite cut-off was estimated 2,000 P. falciparum asexual blood forms per μL. The clinical incidence of malaria was 1.5 episodes per child per year (95%CI 1.2-1.9). Parasitological and clinical variables did not vary with season. Anopheles gambiaes.l. was the principal vector closely followed by Anopheles funestus. Entomological inoculation rate was 5.3 (95%CI 1.1-25.9) infective bites per human per year. Frequency of the L1014F kdr (West) allele was around 50%. Annual prevalence rate of Plasmodium falciparum asymptomatic infection was 21.8% (95%CI 19.1-24.4) and increased according to age. Mean rates of ownership and use of LLINs were 92% and 70% respectively. The only correct use of LLINs (63%) conferred 26% individual protection against only infection (OR = 0.74 (95%IC 0.62-0.87), p = 0.005).ConclusionThe health district of Ouidah-Kpomassè-Tori Bossito is a mesoendemic area with a moderate level of pyrethroid-resistance of vectors. The used LLINs rate was high and only the correct use of LLINs was found to reduce malaria infection without influencing malaria morbidity.

Indoor Use of Plastic Sheeting Impregnated with Carbamate Combined with Long-Lasting Insecticidal Mosquito Nets for the Control of Pyrethroid-Resistant Malaria Vectors

The combined efficacy of a long-lasting insecticidal net (LLIN) and a carbamate-treated plastic sheeting (CTPS) or indoor residual spraying (IRS) for control of insecticide-resistant mosquitoes was evaluated in experimental huts in Burkina Faso. Anopheles gambiae from the area is resistant to pyrethroids and to a lesser extent, carbamates. Relatively low mortality rates were observed with the LLIN (44%), IRS (42%), and CTPS (52%), whereas both combinations killed significantly more mosquitoes (~70% for LLIN + CTPS and LLIN + IRS). Blood feeding by An. gambiae was uninhibited by IRS and CTPS compared with LLIN (43%), LLIN + CTPS (58%), and LLIN + IRS (56%). No evidence for selection of the kdr and ace-1(R) alleles was observed with the combinations, whereas a survival advantage of mosquitoes bearing the ace-1(R) mutation was observed with IRS and CTPS. The results suggest that the combination of the two interventions constitutes a potential tool for vector-resistance management.

Human Exposure to Early Morning Anopheles funestus Biting Behavior and Personal Protection Provided by Long-Lasting Insecticidal Nets.

A shift towards early morning biting behavior of the major malaria vector Anopheles funestus have been observed in two villages in south Benin following distribution of long-lasting insecticidal nets (LLINs), but the impact of these changes on the personal protection efficacy of LLINs was not evaluated. Data from human and An. funestus behavioral surveys were used to measure the human exposure to An. funestus bites through previously described mathematical models. We estimated the personal protection efficacy provided by LLINs and the proportions of exposure to bite occurring indoors and/or in the early morning. Average personal protection provided by using of LLIN was high (≥80% of the total exposure to bite), but for LLIN users, a large part of remaining exposure occurred outdoors (45.1% in Tokoli-V and 68.7% in Lokohoué) and/or in the early morning (38.5% in Tokoli-V and 69.4% in Lokohoué). This study highlights the crucial role of LLIN use and the possible need to develop new vector control strategies targeting malaria vectors with outdoor and early morning biting behavior. This multidisciplinary approach that supplements entomology with social science and mathematical modeling illustrates just how important it is to assess where and when humans are actually exposed to malaria vectors before vector control program managers, policy-makers and funders conclude what entomological observations imply.

Dry Season Determinants of Malaria Disease and Net Use in Benin, West Africa

Background To achieve malaria eradication, control efforts have to be sustained even when the incidence of malaria cases becomes low during the dry season. In this work, malaria incidence and its determinants including bed net use were investigated in children of under 5 years of age in 28 villages in southern Benin during the dry season. Methods and Findings Mean malaria clinical incidence was measured in children aged 0–5 years by active case detection in 28 villages of the Ouidah-Kpomasse-Tori Bossito sanitary district between November 2007 and March 2008. Using Poisson mixed-effect models, malaria incidence was assessed according to the level of transmission by different vector species, and Long-Lasting Insecticide-treated mosquito Nets (LLIN) use and ownership. Then, a Binomial mixed-effect model was developed to assess whether nighttime temperature (derived from MODIS remote sensing data), biting nuisance and LLIN ownership are good predictors of LLIN use >60%. Results suggested that Anopheles funestus (Incidence Rates Ratio (IRR) = 3.38 [IC95 1.91–6]) rather than An. gambiae s.s. is responsible for malaria transmission. A rate of LLIN use >60% was associated with a lower risk of malaria (IRR = 0.6 [IC95 0.37–0.99]). Low nocturnal temperature and high biting nuisance were good predictors of LLIN use >60%. Conclusions As recommended by the Malaria Eradication (MalERA) Consultative Group on Modelling, there is a need to understand better the effects of seasonality on malaria morbidity. This study highlights the need to take into account the specificity of malaria epidemiology during the dry-hot season and get a better understanding of the factors that influence malaria incidence and net use. These findings should help National Malaria Control Programmes to implement more effective and sustainable malaria control strategies in Africa.

First attempt to validate human IgG antibody response to Nterm-34kDa salivary peptide as biomarker for evaluating exposure to Aedes aegypti bites.

Background Much effort is being devoted for developing new indicators to evaluate the human exposure to Aedes mosquito bites and the risk of arbovirus transmission. Human antibody (Ab) responses to mosquito salivary components could represent a promising tool for evaluating the human-vector contact. Methodology/Principal findings To develop a specific biomarker of human exposure to Aedes aegypti bites, we measured IgG Ab response to Ae. aegypti Nterm-34 kDa salivary peptide in exposed children in 7 villages of Southern Benin (West Africa). Results showed that specific IgG response presented high inter-individual heterogeneity between villages. IgG response was associated with rainfall and IgG level increased from dry (low exposure) to rainy (high exposure) seasons. These findings indicate that IgG Ab to Nterm-34 kDa salivary peptide may represent a reliable biomarker to detect variation in human exposure to Ae. aegypti bites. Conclusion/Significance This preliminary study highlights the potential use of Ab response to this salivary peptide for evaluating human exposure to Ae. aegypti. This biomarker could represent a new promising tool for assessing the risk of arbovirus transmission and for evaluating the efficacy of vector control interventions.

Efficacy of Olyset® Duo, a permethrin and pyriproxyfen mixture net against wild pyrethroid-resistant Anopheles gambiae s.s. from Côte d’Ivoire: an experimental hut trial

Pyrethroid resistance in malaria vectors has spread across sub-Saharan Africa. Alternative tools and molecules are urgently needed for effective vector control. One of the most promising strategies to prevent or delay the development of resistance is to use at least two molecules having unrelated modes of action in combination in the same bed net. We evaluated in experimental huts in Côte d’Ivoire, a new polyethylene long-lasting insecticidal net (LN) product, Olyset® Duo, incorporating permethrin (PER) and pyriproxyfen (PPF), an insect growth regulator (IGR). PPF alone or in combination with permethrin had a significant impact on fertility (7–12% reduction relative to control) and no effect on fecundity of wild multi-resistant An. gambiae s.s. These results triggered crucial research questions on the behaviour of targeted mosquitoes around the LN. To maximize the sterilizing effect of PPF in the combination, there would be a need for a trade-off between the necessary contact time of the insect with PPF and the surface content of the pyrethroid insecticide that is bioavailable and induces excito-repellency.

Field Efficacy of Vectobac GR as a Mosquito Larvicide for the Control of Anopheline and Culicine Mosquitoes in Natural Habitats in Benin, West Africa

Introduction The efficacy of Vectobac GR (potency 200 ITU/mg), a new formulation of bacterial larvicide Bacillus thuringiensis var. israelensis Strain AM65-52, was evaluated against Anopheles gambiae and Culex quinquefasciatus in simulated field and natural habitats in Benin. Methods In simulated field conditions, Vectobac GR formulation was tested at 3 dosages (0.6, 0.9, 1.2 g granules/m2 against An. gambiae and 1, 1.5, 2 g granules/m2 against Cx. quinquefasciatus) according to manufacturer’s product label recommendations. The dosage giving optimum efficacy under simulated field conditions were evaluated in the field. The efficacy of Vectobac GR in terms of emergence inhibition in simulated field conditions and of reduction of larval and pupal densities in rice fields and urban cesspits was measured following WHO guidelines for testing and evaluation of mosquito larvicides. Results Vectobac GR caused emergence inhibition of ≥80% until 21 [20]–[22] days for An. gambiae at 1.2 g/m2 dose and 28 [27–29] days for Cx. quinquefasciatus at 2 g/m2 in simulated field habitats. The efficacy of Vectobac GR in natural habitats was for 2 to 3 days against larvae and up to 10 days against pupae. Conclusions Treatment with Vectobac GR caused complete control of immature mosquito within 2–3 days but did not show prolonged residual action. Larviciding can be an option for malaria and filariasis vector control particularly in managing pyrethroid-resistance in African malaria vectors. Since use of larvicides among several African countries is being emphasized through Economic Community of West Africa States, their epidemiological impact should be carefully investigated.