title: The evidence for improving housing to reduce malaria: a systematic review and meta-analysis.
abstract: BACKGROUND
  The global malaria burden has fallen since 2000, sometimes before large-scale vector control programmes were initiated. While long-lasting insecticide-treated nets and indoor residual spraying are highly effective interventions, this study tests the hypothesis that improved housing can reduce malaria by decreasing house entry by malaria mosquitoes.
  
  
  METHODS
  A systematic review and meta-analysis was conducted to assess whether modern housing is associated with a lower risk of malaria than traditional housing, across all age groups and malaria-endemic settings. Six electronic databases were searched to identify intervention and observational studies published from 1 January, 1900 to 13 December, 2013, measuring the association between house design and malaria. The primary outcome measures were parasite prevalence and incidence of clinical malaria. Crude and adjusted effects were combined in fixed- and random-effects meta-analyses, with sub-group analyses for: overall house type (traditional versus modern housing); screening; main wall, roof and floor materials; eave type; ceilings and elevation.
  
  
  RESULTS
  Of 15,526 studies screened, 90 were included in a qualitative synthesis and 53 reported epidemiological outcomes, included in a meta-analysis. Of these, 39 (74%) showed trends towards a lower risk of epidemiological outcomes associated with improved house features. Of studies assessing the relationship between modern housing and malaria infection (n=11) and clinical malaria (n=5), all were observational, with very low to low quality evidence. Residents of modern houses had 47% lower odds of malaria infection compared to traditional houses (adjusted odds ratio (OR) 0°53, 95% confidence intervals (CI) 0°42-0°67, p< 0°001, five studies) and a 45-65% lower odds of clinical malaria (case-control studies: adjusted OR 0°35, 95 % CI 0°20-0°62, p<0°001, one study; cohort studies: adjusted rate ratio 0°55, 95% CI 0°36-0°84, p=0°005, three studies). Evidence of a high risk of bias was found within studies.
  
  
  CONCLUSIONS
  Despite low quality evidence, the direction and consistency of effects indicate that housing is an important risk factor for malaria. Future research should evaluate the protective effect of specific house features and incremental housing improvements associated with socio-economic development.
authors.affiliation: Department of Disease Control, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK. lucy.tusting@lshtm.ac.uk.
authors.forename: Lucy S
authors.initials: LS
authors.lastname: Tusting
authors.affiliation: Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, 1830 Building Room 450B, 600 North Wolfe Street, Baltimore, MD, 21287, USA. mippolito@jhu.edu.
authors.forename: Matthew M
authors.initials: MM
authors.lastname: Ippolito
authors.affiliation: Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK. barbara.willey@lshtm.ac.uk.
authors.forename: Barbara A
authors.initials: BA
authors.lastname: Willey
authors.affiliation: Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK. immo.kleinschmidt@lshtm.ac.uk.
authors.forename: Immo
authors.initials: I
authors.lastname: Kleinschmidt
authors.affiliation: Department of Medicine, University of California, San Francisco, CA, 94143, USA. gdorsey@medsfgh.ucsf.edu.
authors.forename: Grant
authors.initials: G
authors.lastname: Dorsey
authors.affiliation: Global Health Group, University of California, San Francisco, CA, 94105, USA. goslingr@globalhealth.ucsf.edu.
authors.forename: Roly D
authors.initials: RD
authors.lastname: Gosling
authors.affiliation: School of Biological and Biomedical Sciences, Durham University, Durham, DH1 3LE, UK. s.w.lindsay@durham.ac.uk.
authors.forename: Steve W
authors.initials: SW
authors.lastname: Lindsay
mesh_terms: D006798:Housing / Q000592:standards*; D006801:Humans; D015994:Incidence; D008288:Malaria / Q000453:epidemiology* / Q000469:parasitology / Q000517:prevention & control*; D009032:Mosquito Control; D015995:Prevalence