'We spray and walk away': wall modifications decrease the impact of indoor residual spray campaigns through reductions in post-spray coverage

The epidemiology of malaria in four districts in southern Mozambique receiving indoor residual spray as part of a cross-border initiative

BACKGROUND

Imported malaria from southern Mozambique drives low levels of disease transmission in KwaZulu-Natal, South Africa. Therefore, the South African Department of Health funded implementation of indoor residual spraying (IRS) in Mozambiquan districts identified as sources of malaria infection for border communities in KwaZulu-Natal. IRS was initiated in districts of Guija, Inharrime, Panda and Zavala. To determine impact of spraying on malaria transmission in these districts, data relating to incidence and prevalence was collected before spraying (2018) and before the second round of spraying was completed (2023). Implementation of IRS was also monitored to ensure optimal spray coverage was achieved.

METHODS

The study was a cross-sectional survey conducted in 6 sentinel sites in each of the four afore-mentioned districts, focusing on children 6 months to < 15 years from selected households. There was a baseline and an endline cross-sectional survey. Baseline prevalence took place during March-April 2022 whereas the endline surveys occurred during February-March 2023. One hundred and twenty children from each sentinel site were tested for malaria using rapid diagnostic tests. Monthly malaria cases were obtained from health facilities in each study district. Spray data was obtained from LSDI2 initiative who implemented IRS in the targeted districts.

RESULTS

The study showed a definite impact of IRS on malaria prevalence in the targeted districts. Prevalence for sentinel sites in Guija district indicated that the prevalence of malaria increased slightly from baseline to endline in all sentinel sites in Guija. Overall, there was no significant change in prevalence in Zavala, from baseline to endline (p-value = 0.611). Panda's overall malaria prevalence decreased from 19.20% to 10.82% (p-value < 0.001) whereas overall prevalence in Inharrime, decreased from 27.68% to 19.50% (p-value < 0.001). Malaria prevalence in children younger than 5 years decreased significantly in all four districts. In Panda there was a decrease in numbers of males and females being infected between surveys (p < 0.001), whereas for Inharrime the decrease was significant in females (p < 0.001). High coverage with IRS (> 95%) resulted in greater population protection.

CONCLUSION

The study revealed that IRS implementation decreased malaria prevalence in Inharrime and Panda but not in Guija and Zavala. To ensure that cross-border movement of people does not result in increased malaria transmission, targeting areas identified as source of infection in travelers is paramount to reaching elimination.

Impact of four years of annually repeated indoor residual spraying (IRS) with Actellic 300CS on routinely reported malaria cases in an agricultural setting in Malawi

Indoor residual spraying (IRS) is one of the main vector control tools used in malaria prevention. This study evaluates IRS in the context of a privately run campaign conducted across a low-lying, irrigated, sugarcane estate from Illovo Sugar, in the Chikwawa district of Malawi. The effect of Actellic 300CS annual spraying over four years (2015-2018) was assessed using a negative binomial mixed effects model, in an area where pyrethroid resistance has previously been identified. With an unadjusted incidence rate ratio (IRR) of 0.38 (95% CI: 0.32-0.45) and an adjusted IRR of 0.50 (95% CI: 0.42-0.59), IRS has significantly contributed to a reduction in case incidence rates at Illovo, as compared to control clinics and time points outside of the six month protective period. This study shows how the consistency of a privately run IRS campaign can improve the health of employees. More research is needed on the duration of protection and optimal timing of IRS programmes.

Understanding psychosocial determinants of malaria behaviours in low-transmission settings: a scoping review

BACKGROUND

Recent estimates show progress toward malaria elimination is slowing in many settings, underscoring the need for tailored approaches to fight the disease. In addition to essential structural changes, human behaviour plays an important role in elimination. Engagement in malaria behaviours depends in part on psychosocial determinants such as knowledge, perceived risk, and community norms. Understanding the state of research on psychosocial determinants in low malaria transmission settings is important to augment social and behaviour change practice. This review synthesizes research on psychosocial factors and malaria behaviours in low-transmission settings.

METHODS

A systematic search of peer-reviewed literature and supplemental manual search of grey literature was conducted using key terms and eligibility criteria defined a priori. Publications from 2000-2020 in the English language were identified, screened, and analysed using inductive methods to determine the relationship between the measured psychosocial factors and malaria behaviours.

RESULTS

Screening of 961 publications yielded 96 for inclusion. Nineteen articles collected data among subpopulations that are at increased risk of malaria exposure in low-transmission settings. Purposive and cluster randomized sampling were common sampling approaches. Quantitative, qualitative, and mixed-methods study designs were used. Knowledge, attitudes, and perceived risk were commonly measured psychosocial factors. Perceived response-efficacy, perceived self-efficacy, and community norms were rarely measured. Results indicate positive associations between malaria knowledge and attitudes, and preventive and care-seeking behaviour. Studies generally report high rates of correct knowledge, although it is comparatively lower among studies of high-risk groups. There does not appear to be sufficient extant evidence to determine the relationship between other psychosocial variables and behaviour.

CONCLUSIONS

The review highlights the need to deploy more consistent, comprehensive measures of psychosocial factors and the importance of reaching subpopulations at higher risk of transmission in low transmission contexts. Malaria-related knowledge is generally high, even in settings of low transmission. Programmes and research should work to better understand the psychosocial factors that have been positively associated with prevention and care-seeking behaviours, such as norms, perceived response efficacy, perceived self-efficacy, and interpersonal communication. These factors are not necessarily distinct from that which research has shown are important in settings of high malaria transmission. However, the importance of each factor and application to malaria behaviour change programming in low-transmission settings is an area in need of further research. Existing instruments and approaches are available to support more systematic collection of psychosocial determinants and improved sampling approaches and should be applied more widely. Finally, while human behaviour is critical, health systems strengthening, and structural interventions are essential to achieve malaria elimination goals.

Genome-wide association studies reveal novel loci associated with pyrethroid and organophosphate resistance in Anopheles gambiae and Anopheles coluzzii

Resistance to insecticides in Anopheles mosquitoes threatens the effectiveness of malaria control, but the genetics of resistance are only partially understood. We performed a large scale multi-country genome-wide association study of resistance to two widely used insecticides: deltamethrin and pirimiphos-methyl, using sequencing data from An. gambiae and An. coluzzii from ten locations in West Africa. Resistance was highly multi-genic, multi-allelic and variable between populations. While the strongest and most consistent association with deltamethrin resistance came from Cyp6aa1, this was based on several independent copy number variants (CNVs) in An. coluzzii, and on a non-CNV haplotype in An. gambiae. For pirimiphos-methyl, signals included Ace1, cytochrome P450s, glutathione S-transferases and the nAChR target site of neonicotinoid insecticides. The regions around Cyp9k1 and the Tep family of immune genes showed evidence of cross-resistance to both insecticides. These locally-varying, multi-allelic patterns highlight the challenges involved in genomic monitoring of resistance, and may form the basis for improved surveillance methods.

Implementation and acceptance of government-sponsored malaria control interventions in Meghalaya, India

Background

India has made considerable progress in malaria reduction over the past two decades, with government-sponsored indoor residual spraying (IRS) and insecticide-treated bed net (ITN) or long-lasting insecticidal nets (LLIN) distribution being the main vector-related prevention efforts. Few investigations have used non-participant observational methods to assess malaria control measures while they were being implemented, nor documented people’s perceptions and acceptance of IRS or LLINs in India, and none have done so in the northeast region. This study evaluated household (HH)-level operation of IRS and distribution of LLINs by India’s National Vector Borne Disease Control Programme (NVBDCP) in 50 villages of Meghalaya state, and documented their acceptance and use.

Methods

Study field teams accompanied the government health system teams during August-October, 2019 and 2020 to observe deployment of LLINs, and record HH-level data on LLIN numbers and use. In addition, NVBDCP spray teams were followed during 2019–2021 to observe IRS preparation and administration. HH members were interviewed to better understand reasons for acceptance or refusal of spraying.

Results

A total of 8386 LLINs were distributed to 2727 HHs in 24 villages from five Primary Health Centres, representing 99.5% of planned coverage. Interviews with 80 HH residents indicated that they appreciated the LLIN dissemination programme, and generally made regular and appropriate use of LLINs, except during overnight travel or when working in agricultural fields. However, HH-level IRS application, which was observed at 632 HHs, did not always follow standard insecticide preparation and safety protocols. Of 1,079 occupied HHs visited by the spray team, 632 (58.6%) refused to allow any spraying. Only 198 (18.4%) HHs agreed to be sprayed, comprising 152 (14.1%) that were only partly sprayed, and 46 (4.3%) that were fully sprayed. Reasons for refusal included: inadequate time to rearrange HH items, young children were present, annoying smell, staining of walls, and threat to bee-keeping or Eri silk moth cultivation.

Conclusions

These findings are among the first in India that independently evaluate people's perceptions and acceptance of ongoing government-sponsored IRS and LLIN programmes for malaria prevention. They represent important insights for achieving India's goal of malaria elimination by 2030.

Real-time, spatial decision support to optimize malaria vector control: The case of indoor residual spraying on Bioko Island, Equatorial Guinea

Public health interventions require evidence-based decision-making to maximize impact. Spatial decision support systems (SDSS) are designed to collect, store, process and analyze data to generate knowledge and inform decisions. This paper discusses how the use of a SDSS, the Campaign Information Management System (CIMS), to support malaria control operations on Bioko Island has impacted key process indicators of indoor residual spraying (IRS): coverage, operational efficiency and productivity. We used data from the last five annual IRS rounds (2017 to 2021) to estimate these indicators. IRS coverage was calculated as the percentage of houses sprayed per unit area, represented by 100x100 m map-sectors. Optimal coverage was defined as between 80% and 85%, and under and overspraying as coverage below 80% and above 85%, respectively. Operational efficiency was defined as the fraction of map-sectors that achieved optimal coverage. Daily productivity was expressed as the number of houses sprayed per sprayer per day (h/s/d). These indicators were compared across the five rounds. Overall IRS coverage (i.e. percent of total houses sprayed against the overall denominator by round) was highest in 2017 (80.2%), yet this round showed the largest proportion of oversprayed map-sectors (36.0%). Conversely, despite producing a lower overall coverage (77.5%), the 2021 round showed the highest operational efficiency (37.7%) and the lowest proportion of oversprayed map-sectors (18.7%). In 2021, higher operational efficiency was also accompanied by marginally higher productivity. Productivity ranged from 3.3 h/s/d in 2020 to 3.9 h/s/d in 2021 (median 3.6 h/s/d). Our findings showed that the novel approach to data collection and processing proposed by the CIMS has significantly improved the operational efficiency of IRS on Bioko. High spatial granularity during planning and deployment together with closer follow-up of field teams using real-time data supported more homogeneous delivery of optimal coverage while sustaining high productivity.

Household modifications after the indoor residual spraying (IRS) campaign in Mozambique reduce the actual spray coverage and efficacy

Indoor residual spraying of insecticides (IRS) is a key malaria vector control strategy. Whilst human attitude towards IRS is monitored before or shortly after implementation, human activities leading to the modification of insecticide-treated walls post-IRS are not. This could inadvertently reduce the protective effects of IRS. We monitored the extent of modifications to the sprayed indoor wall surfaces by household owners for six months post-IRS campaigns in two districts targeted for malaria elimination in southern Mozambique. In parallel, we assessed building of any additional rooms onto compounds, and mosquito net use. We quantified the contribution of wall modifications, added rooms, prolonged spray campaigns, and product residual efficacies on actual IRS coverage and relative mosquito bite reduction, using a mechanistic approach. Household owners continually modified insecticide-treated walls and added rooms onto compounds. Household surveys in southern Mozambique showed frequent modification of indoor walls (0-17.2% of households modified rooms monthly) and/or added rooms (0-16.2% of households added rooms monthly). Actual IRS coverage reduced from an assumed 97% to just 39% in Matutuine, but only from 96% to 91% in Boane, translating to 43% and 5.8% estimated increases in relative daily mosquito bites per person. Integrating post-IRS knowledge, attitude, and practice (KAP) surveys into programmatic evaluations to capture these modification and construction trends can help improve IRS program efficiency and product assessment.

Acceptability and associated factors of indoor residual spraying for malaria control by households in Luangwa district of Zambia: A multilevel analysis

The global burden of malaria has increased from 227 million cases in 2019 to 247 million cases in 2020. Indoor residual spraying (IRS) remains one of the most effective control strategies for malaria. The current study sought to measure the acceptability level and associated factors of indoor residual spraying. A cross sectional study was conducted from October to November 2020 in sixteen urban and rural communities of Luangwa district using a cluster sampling method, Multilevel analysis was used to account for the hierarchical structure of the data. The acceptability level of indoor residual spraying among household heads was relatively high at 87%. Individuals who felt the timing was not appropriate were associated with decreased odds of accepting IRS (AOR = 0.55, 95% CI: 0.20-0.86). Positive attitude was associated with increased odds of accepting IRS (AOR = 29.34, 95% CI: 11.14-77.30). High acceptability level was associated with unemployment (AOR = 1.92, 95% CI: 1.07-3.44). There were no associations found between acceptability levels and community-level factors such as information, education, communication dissemination, awareness achieved through door-to-door sensitization, and public address system. Acceptability level of indoor residual spraying was relatively high among households of Luangwa District suggesting that the interventions are more acceptable which is essential in reaching malaria elimination by 2030. Finding that community factors known to influence acceptability such as information, education and communication as well as awareness were not important to influencing acceptability suggests need for reinforcing messages related to indoor residual spraying and redefining the community sensitization approaches to make indoor residual spraying more acceptable.

Insecticide-treated eave ribbons for malaria vector control in low-income communities

Supplementary tools are required to address the limitations of insecticide-treated nets (ITNs) and indoor residual spraying (IRS), which are currently the core vector control methods against malaria in Africa. The eave ribbons technology exploits the natural house-entry behaviours of major malaria vectors to deliver mosquitocidal or repellent actives around eave spaces through which the Anopheles mosquitoes usually enter human dwellings. They confer protection by preventing biting indoors and in the peri-domestic outdoor spaces, and also killing a significant proportion of the mosquitoes. Current versions of eave ribbons are made of low-cost hessian fabric infused with candidate insecticides and can be easily fitted onto multiple house types without any additional modifications. This article reviews the evidence for efficacy of the technology, and discusses its potential as affordable and versatile supplementary approach for targeted and efficient control of mosquito-borne diseases, particularly malaria. Given their simplicity and demonstrated potential in previous studies, future research should investigate ways to optimize scalability and effectiveness of the ribbons. It is also important to assess whether the ribbons may constitute a less-cumbersome, but more affordable substitute for other interventions, such as IRS, by judiciously using lower quantities of selected insecticides targeted around eave spaces to deliver equivalent or greater suppression of malaria transmission.

Unlocking the human factor to increase effectiveness and sustainability of malaria vector control

Background

Progress in the fight against malaria has stalled in recent years, highlighting the importance of new interventions and tailored approaches. A critical factor that must be considered across contexts and interventions is human behaviour.

Main text

Factors such as acceptance of insecticide-treated nets (ITNs) and indoor residual spraying (IRS), ability and willingness to consistently use and appropriately care for ITNs and refraining from post-spray wall modifications can all impact the success of core vector control interventions. Understanding factors that can drive or inhibit these behaviours can contribute to improved social and behaviour change strategies and in turn, improved outcomes. Likewise, patterns of nighttime activities can reveal specific gaps in protection that cannot be filled by core interventions and inform development and deployment of complementary tools that meet people’s needs and preferences. There is an opportunity to increase use of approaches such as human-centred design to engage affected communities more actively in identifying and developing sustainable solutions that meet their needs and lifestyles. Integration of social and behavioural research with entomological and epidemiological evaluations will provide a more complete picture of malaria transmission dynamics and inform improved targeting of context-appropriate interventions. Finally, for gains to be maintained, interventions must be rooted within systems that support long-term success. This includes a movement toward more sustainable vector control solutions, increased decision-making and ownership of research, implementation, and strategy development at the country level, and inclusive approaches that ensure all men, women, boys, and girls are engaged as part of the solution.

Conclusions

No matter how efficacious, a tool will remain ineffective if communities do not engage with it or use it regularly. Entering the next decade in the fight against malaria there is a critical opportunity to elevate the role of social and behaviour change to increase the impact and sustainability of malaria control and elimination efforts. This includes removing social and structural barriers to use of existing tools at all levels, human-centred and inclusive design and implementation of new tools, and movement toward long-term solutions led by affected communities.

Effect of wall type, delayed mortality and mosquito age on the residual efficacy of a clothianidin-based indoor residual spray formulation (SumiShield™ 50WG) in southern Mozambique

Indoor residual spraying (IRS) is one of the main malaria vector control strategies in Mozambique alongside the distribution of insecticide treated nets. As part of the national insecticide resistance management strategy, Mozambique introduced SumiShield™ 50WG, a third generation IRS product, in 2018. Its residual efficacy was assessed in southern Mozambique during the 2018-2019 malaria season. Using a susceptible Anopheles arabiensis strain, residual efficacy was assessed on two different wall surfaces, cement and mud-plastered walls, using standard WHO (World Health Organization) cone bioassay tests at three different heights. Female mosquitoes of two age groups (2-5 and 13-26 day old) were exposed for 30 minutes, after which mortality was observed 24h, 48h, 72h, and 96h and 120h post-exposure to assess (delayed) mortality. Lethal times (LT) 90, LT50 and LT10 were estimated using Bayesian models. Mortality 24h post exposure was consistently below 80%, the current WHO threshold value for effective IRS, in both young and old mosquitoes, regardless of wall surface type. Considering delayed mortality, residual efficacies (mosquito mortality equal or greater than 80%) ranged from 1.5 to ≥12.5 months, with the duration depending on mortality time post exposure, wall type and mosquito age. Looking at mortality 72h after exposure, residual efficacy was between 6.5 and 9.5 months, depending on wall type and mosquito age. The LT50 and LT10 (i.e. 90% of the mosquitoes survive exposure to the insecticides) values were consistently higher for older mosquitoes (except for LT10 values for 48h and 72h post-exposure mortality) and ranged from 0.9 to 5.8 months and 0.2 to 7.8 months for LT50 and LT10, respectively. The present study highlights the need for assessing mosquito mortality beyond the currently recommended 24h post exposure. Failure to do so may lead to underestimation of the residual efficacy of IRS products, as delayed mortality will lead to a further reduction in mosquito vector populations and potentially negatively impact disease transmission. Monitoring residual efficacy on relevant wall surfaces, including old mosquitoes that are ultimately responsible for malaria transmission, and assessing delayed mortalities are critical to provide accurate and actionable data to guide vector control programmes.

Insecticide resistance status of malaria vectors Anopheles gambiae (s.l.) of southwest Burkina Faso and residual efficacy of indoor residual spraying with microencapsulated pirimiphos-methyl insecticide

Background

The rapid spread of insecticide resistance in malaria vectors and the rebound in malaria cases observed recently in some endemic areas underscore the urgent need to evaluate and deploy new effective control interventions. A randomized control trial (RCT) was conducted with the aim to investigate the benefit of deploying complementary strategies, including indoor residual spraying (IRS) with pirimiphos-methyl in addition to long-lasting insecticidal nets (LLINs) in Diébougou, southwest Burkina Faso.

Methods

We measured the susceptibility of the Anopheles gambiae (s.l.) population from Diébougou to conventional insecticides. We further monitored the efficacy and residual activity of pirimiphos-methyl on both cement and mud walls using a laboratory susceptible strain (Kisumu) and the local An. gambiae (s.l.) population.

Results

An. gambiae (s.l.) from Diébougou was resistant to DDT, pyrethroids (deltamethrin, permethrin and alphacypermethrin) and bendiocarb but showed susceptibility to organophosphates (pirimiphos-methyl and chlorpyrimiphos-methyl). A mixed-effect generalized linear model predicted that pirimiphos-methyl applied on cement or mud walls was effective for 210 days against the laboratory susceptible strain and 247 days against the local population. The residual efficacy of pirimiphos-methyl against the local population on walls made of mud was similar to that of cement (OR = 0.792, [0.55–1.12], Tukey’s test p-value = 0.19).

Conclusions

If data on malaria transmission and malaria cases (as measured trough the RCT) are consistent with data on residual activity of pirimiphos-methyl regardless of the type of wall, one round of IRS with pirimiphos-methyl would have the potential to control malaria in a context of multi-resistant An. gambiae (s.l.) for at least 7 months.

Estimating the optimal interval between rounds of indoor residual spraying of insecticide using malaria incidence data from cohort studies

Background

Indoor residual spraying (IRS) reduces vector densities and malaria transmission, however, the most effective spraying intervals for IRS have not been well established. We estimated the optimal timing interval for IRS using a statistical approach.

Methods

Six rounds of IRS were implemented in Tororo District, a historically high malaria transmission setting in Uganda, during the study period (3 rounds with bendiocarb active ingredient (Ficam®): December 2014 to December 2015, and 3 rounds with pirimiphos methyl active ingredient (Actellic 300®CS): June 2016 to July 2018). A generalized additive model was used to estimate the optimal timing interval for IRS based on the predicted malaria incidence. The model was fitted to clinical incidence data from a cohort of children aged 0.5–10 years from selected households observed throughout the study period.

Results

494 children, 67% aged less than 5 years at enrolment were analysed. Six-months period incidence of malaria decreased from 2.96 per person-years at the baseline to 1.74 following the first round of IRS and then to 0.02 after 6 rounds of IRS. The optimal time interval for IRS differed between bendiocarb and pirimiphos methyl and by IRS round. To retain an optimum impact, bendiocarb would require respraying 17 (95% CI: 14.2–21.0) weeks after application whereas pirimiphos methyl could remain impactful for 40 (95% CI: 37.0–42.8) weeks, although in the final year this estimates 36 (95% CI: 32.7–37.7) weeks. However, we could not estimate from the data the optimal time after the second and third rounds of bendiocarb and after the second round of pirimiphos methyl. Neither the amount of rainfall nor the EIR nor the distribution of nets were found to be statistically significant for determining the time period between spray rounds.

Conclusion

In our setting, the effect of the two IRS products was distinct. Statistically, pirimiphos methyl provided a longer window of protection than bendiocarb, although impact varied between different spray rounds and years which was not explained by rainfall or EIR or distribution of nets in our statistical approach. Understanding the effectiveness of IRS and how long it lasts can help for planning campaigns, but one should consider the financial cost and insecticide resistance. Monitoring the timing of spray campaigns using clinical incidence could be repeated in future programs to help determine the average period of protectivity of these products.