title: Comparative field evaluation of combinations of long-lasting insecticide treated nets and indoor residual spraying, relative to either method alone, for malaria prevention in an area where the main vector is Anopheles arabiensis.
abstract: BACKGROUND
  Long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) are commonly used together in the same households to improve malaria control despite inconsistent evidence on whether such combinations actually offer better protection than nets alone or IRS alone.
  
  
  METHODS
  Comparative tests were conducted using experimental huts fitted with LLINs, untreated nets, IRS plus untreated nets, or combinations of LLINs and IRS, in an area where Anopheles arabiensis is the predominant malaria vector species. Three LLIN types, Olyset®, PermaNet 2.0® and Icon Life® nets and three IRS treatments, pirimiphos-methyl, DDT, and lambda cyhalothrin, were used singly or in combinations. We compared, number of mosquitoes entering huts, proportion and number killed, proportions prevented from blood-feeding, time when mosquitoes exited the huts, and proportions caught exiting. The tests were done for four months in dry season and another six months in wet season, each time using new intact nets.
  
  
  RESULTS
  All the net types, used with or without IRS, prevented >99% of indoor mosquito bites. Adding PermaNet 2.0® and Icon Life®, but not Olyset® nets into huts with any IRS increased mortality of malaria vectors relative to IRS alone. However, of all IRS treatments, only pirimiphos-methyl significantly increased vector mortality relative to LLINs alone, though this increase was modest. Overall, median mortality of An. arabiensis caught in huts with any of the treatments did not exceed 29%. No treatment reduced entry of the vectors into huts, except for marginal reductions due to PermaNet 2.0® nets and DDT. More than 95% of all mosquitoes were caught in exit traps rather than inside huts.
  
  
  CONCLUSIONS
  Where the main malaria vector is An. arabiensis, adding IRS into houses with intact pyrethroid LLINs does not enhance house-hold level protection except where the IRS employs non-pyrethroid insecticides such as pirimiphos-methyl, which can confer modest enhancements. In contrast, adding intact bednets onto IRS enhances protection by preventing mosquito blood-feeding (even if the nets are non-insecticidal) and by slightly increasing mosquito mortality (in case of LLINs). The primary mode of action of intact LLINs against An. arabiensis is clearly bite prevention rather than insecticidal activity. Therefore, where resources are limited, priority should be to ensure that everyone at risk consistently uses LLINs and that the nets are regularly replaced before being excessively torn. Measures that maximize bite prevention (e.g. proper net sizes to effectively cover sleeping spaces, stronger net fibres that resist tears and burns and net use practices that preserve net longevity), should be emphasized.
authors: Environmental Health and Ecological Sciences Thematic Group, Ifakara Health Institute, Ifakara, Tanzania. fredros@ihi.or.tz
authors: Fredros O
authors: FO
authors: Okumu
authors: Edgar
authors: E
authors: Mbeyela
authors: Godfrey
authors: G
authors: Lingamba
authors: Jason
authors: J
authors: Moore
authors: Alex J
authors: AJ
authors: Ntamatungiro
authors: Deo R
authors: DR
authors: Kavishe
authors: Michael G
authors: MG
authors: Kenward
authors: Elizabeth
authors: E
authors: Turner
authors: Lena M
authors: LM
authors: Lorenz
authors: Sarah J
authors: SJ
authors: Moore
mesh_terms: D000293:Adolescent; D000328:Adult; D000336:Aerosols; D000818:Animals; D000852:Anopheles / Q000187:drug effects* / Q000502:physiology; D003634:DDT / Q000494:pharmacology; D006798:Housing; D006801:Humans; D007299:Insect Bites and Stings; D007305:Insecticide Resistance; D057148:Insecticide-Treated Bednets; D007306:Insecticides / Q000494:pharmacology*; D008288:Malaria / Q000517:prevention & control* / Q000635:transmission; D008297:Male; D009032:Mosquito Control / Q000379:methods*; D009570:Nitriles / Q000494:pharmacology; D009946:Organothiophosphorus Compounds / Q000494:pharmacology; D011722:Pyrethrins / Q000494:pharmacology; D013636:Tanzania; D013997:Time Factors; D055815:Young Adult
chemical_list: D000336:Aerosols; D007306:Insecticides; D009570:Nitriles; D009946:Organothiophosphorus Compounds; D011722:Pyrethrins; C014153:pirimiphos methyl; D003634:DDT; C037304:cyhalothrin