title: Nets, spray or both? The effectiveness of insecticide-treated nets and indoor residual spraying in reducing malaria morbidity and child mortality in sub-Saharan Africa.
abstract: BACKGROUND
  Malaria control programmes currently face the challenge of maintaining, as well as accelerating, the progress made against malaria with fewer resources and uncertain funding. There is a critical need to determine what combination of malaria interventions confers the greatest protection against malaria morbidity and child mortality under routine conditions.
  
  
  METHODS
  This study assesses intervention effectiveness experienced by children under the age of five exposed to both insecticide-treated nets (ITNs) and indoor residual spraying (IRS), as compared to each intervention alone, based on nationally representative survey data collected from 17 countries in sub-Saharan Africa.
  
  
  RESULTS
  Living in households with both ITNs and IRS was associated with a significant risk reduction against parasitaemia in medium and high transmission areas, 53% (95% CI 37% to 67%) and 31% (95% CI 11% to 47%) respectively. For medium transmission areas, an additional 36% (95% CI 7% to 53%) protection was garnered by having both interventions compared with exposure to only ITNs or only IRS. Having both ITNs and IRS was not significantly more protective against parasitaemia than either intervention alone in low and high malaria transmission areas. In rural and urban areas, exposure to both interventions provided significant protection against parasitaemia, 57% (95% CI 48% to 65%) and 39% (95% CI 10% to 61%) respectively; however, this effect was not significantly greater than having a singular intervention. Statistically, risk for all-cause child mortality was not significantly reduced by having both ITNs and IRS, and no additional protectiveness was detected for having dual intervention coverage over a singular intervention.
  
  
  CONCLUSIONS
  These findings suggest that greater reductions in malaria morbidity and health gains for children may be achieved with ITNs and IRS combined beyond the protection offered by IRS or ITNs alone.
authors: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. nf4@uw.edu
authors: Nancy
authors: N
authors: Fullman
authors: Roy
authors: R
authors: Burstein
authors: Stephen S
authors: SS
authors: Lim
authors: Carol
authors: C
authors: Medlin
authors: Emmanuela
authors: E
authors: Gakidou
mesh_terms: D000293:Adolescent; D000328:Adult; D000336:Aerosols / Q000008:administration & dosage*; D017954:Africa South of the Sahara / Q000453:epidemiology; D046688:Child Mortality; D002675:Child, Preschool; D005260:Female; D006801:Humans; D015994:Incidence; D007223:Infant; D057148:Insecticide-Treated Bednets / Q000706:statistics & numerical data*; D007306:Insecticides / Q000008:administration & dosage*; D008288:Malaria / Q000453:epidemiology* / Q000401:mortality / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D009032:Mosquito Control / Q000379:methods*; D055815:Young Adult
chemical_list: D000336:Aerosols; D007306:Insecticides
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