Risk factors for malaria infection prevalence and household vector density between mass distribution campaigns of long-lasting insecticidal nets in North-western Tanzania.

BACKGROUND: Long-lasting insecticidal nets (LLINs) are the most widely deployed vector control intervention in sub-Saharan Africa to prevent malaria. Recent reports indicate selection of pyrethroid insecticide resistance is widespread in mosquito vectors. This paper explores risk factors associated with malaria infection prevalence and vector density between mass distribution campaigns, changes in net coverage, and loss of protection in an area of high pyrethroid resistance in Northwest Tanzania. METHODS: A cross sectional malaria survey of 3456 children was undertaken in 2014 in Muleba district, Kagera region west of Lake Victoria. Vector density was assessed using indoor light traps and outdoor tent traps. Anophelines were identified to species using PCR and tested for Plasmodium falciparum circumsporozoite protein. Logistic regression was used to identify household and environmental factors associated with malaria infection and regression binomial negative for vector density. RESULTS: LLIN use was 27.7%. Only 16.9% of households had sufficient nets to cover all sleeping places. Malaria infection was independently associated with access to LLINs (OR: 0.57; 95% CI 0.34-0.98). LLINs less than 2 years old were slightly more protective than older LLINs (53 vs 65% prevalence of infection); however, there was no evidence that LLINs in good condition (hole index < 65) were more protective than LLINs, which were more holed. Other risk factors for malaria infection were age, group, altitude and house construction quality. Independent risk factors for vector density were consistent with malaria outcomes and included altitude, wind, livestock, house quality, open eaves and LLIN usage. Indoor collections comprised 4.6% Anopheles funestus and 95.4% Anopheles gambiae of which 4.5% were Anopheles arabiensis and 93.5% were Anopheles gambiae sensu stricto. CONCLUSION: Three years after the mass distribution campaign and despite top-ups, LLIN usage had declined considerably. While children living in households with access to LLINs were at lower risk of malaria, infection prevalence remained high even among users of LLINs in good condition. While effort should be made to maintain high coverage between campaigns, distribution of standard pyrethroid-only LLINs appears insufficient to prevent malaria transmission in this area of intense pyrethroid resistance.

Guidance for Evaluating the Safety of Experimental Releases of Mosquitoes, Emphasizing Mark-Release-Recapture Techniques.

Experimental releases of mosquitoes are performed to understand characteristics of populations related to the biology, ability to transmit pathogens, and ultimately their control. In this article, we discuss considerations related to the safety of experimental releases of living mosquitoes, applying principles of good practice in vector biology that protect human health and comfort. We describe specific factors of experimental releases of mosquitoes that we believe are critical to inform institutional biosafety committees and similar review boards to which proposals to conduct mosquito release experiments have been submitted. In this study, "experimental releases" means those that do not significantly increase vector capacity or nuisance biting relative to the unperturbed natural baseline. This document specifically does not address releases of mosquitoes for ongoing control programs or trials of new control methods for which broader assessments of risk are required. It also does not address releases of transgenic or exotic (non-native) mosquito species, both of which require particular regulatory approval. Experimental releases may include females and males and evaluation must consider their effects based on the number released, their genotype and phenotype, the environment into which they are released, and postrelease collection activities. We consider whether increases of disease transmission and nuisance biting might result from proposed experimental releases against the backdrop of natural population size variation. We recommend that experimental releases be conducted in a manner that can be reasonably argued to have insignificant negative effects. Reviewers of proposals for experimental releases should expect applicants to provide such an argument based on evidence from similar studies and their planned activities. This document provides guidance for creating and evaluating such proposals.

Evidence of an 'invitation' effect in feeding sylvatic Stegomyia albopicta from Cambodia.

BACKGROUND: Orientation of haematophagous insects towards a potential host is largely mediated by kairomones that, in some groups or species may include chemicals produced during feeding by the insects themselves, the so called 'invitation' effect. METHODS: The 'invitation' effect in blood-feeding diurnally active Stegomyia albopicta was investigated over 33 days in secondary forest in Mondolkiri Province, Cambodia. Two human volunteers sitting inside a shelter collected mosquitoes and noted where and when they landed. A 10% emanator of a synthetic pyrethroid with high vapour action was in use on alternate days. RESULTS: Overall, 2726 mosquitoes were collected, 1654 of which had the landing site recorded. The heads of the volunteers were the locations with the highest density of landings per surface area whilst the knees and elbows accounted for most of the landings received on the arms and legs. Landings recorded within three minutes of each other on a collector were about 2.5 times more likely to be on the same body part than on a random body part, weighted for landing site preference. This preference did not vary with collector or pyrethroid. CONCLUSIONS: The 'invitation' effect may be due to a semio-chemical produced early in the feeding process. Incorporation of such a chemical into traps designed to control this important vector of dengue and chikungunya viruses might potentially improve their attractiveness.

Living on the edge: a longitudinal study of Anopheles funestus in an isolated area of Mozambique.

BACKGROUND: Understanding the survival strategies of malaria vectors at the edges of their distribution, where they are under stress from environmental conditions, may lead to the development of novel control techniques and may help predict the effects of climate change on these mosquitoes. METHODS: The population dynamics of an isolated population of Anopheles funestus from the peninsula of Linga Linga in southern Mozambique was studied over a period of 104 weeks from March 2009 to May 2011 by 917 light-trap and 390 exit collections, mostly in an area close to a seasonal pond. RESULTS: Over the sampling period, 3,684 An. funestus females were caught. Densities decreased with increasing distance from the pond. In 2009 and 2010, a single annual peak in An. funestus density coincident with the single annual peak in rainfall was observed, but a clear population peak was absent during the first 21 weeks of 2011. In between population peaks, An. funestus remained present at low densities. In light trap collections, the proportion of gravid mosquitoes was significantly higher during the 'low season' (the period between peaks) than during the peak season (RR = 4.3, p<0.001). In contrast, in exit collections, the proportion of gravid mosquitoes was significantly lower during low season than during the peak season (RR = 0.64, p<0.01). Also, in light traps, the proportion of part-fed females was higher during the low season than during the peak season (RR = 4.5, p<0.001), whereas this was inversed for engorged females (RR = 0.46, p<0.05).Thirteen out of 289 (4.5%) An. funestus tested positive in the sporozoite ELISA. The proportion of sporozoite positive females was higher during the low season (6.25%, six out of 96) than during the peaks (3.63%, seven out of 193), but this difference was not significant. CONCLUSIONS: It is suggested that a proportion of the mosquito population may become gonotrophically discordant during the long dry season resulting in enhanced mosquito survival and sustained malaria transmission.

Population dynamics and spatial structure of human-biting mosquitoes, inside and outside of houses, in the Chockwe irrigation scheme, southern Mozambique.

Focal control of malaria vectors, a potentially cost-effective alternative to conventional control, requires a spatio-temporal understanding of the mosquitoes. Trapping of African malaria vectors has generally been limited to inside houses making distribution estimates dependent on the location of dwellings. The development of tent-traps to sample outdoor biting mosquitoes has enabled more independent estimates. Here we describe both temporal and spatial variation in mosquito movements in an irrigation project village in southern Mozambique. Six hundred and ninety-three tent-trap collections (525 of which were paired with light-trap collections), 552 exit collections and 391 collections of mosquitoes resting inside houses were undertaken from March 2005 to April 2006. Fifteen species of mosquito were collected (five exclusively as larvae). Mansonia africana was the most common finding, numbers being greatest away from the village. Only Anopheles funestus, An. tenebrosus and Culex quinquefasciatus were collected in greater numbers in light-traps compared to tent-traps. Among the common mosquitoes, correlations in numbers of mosquito collected in paired tent and in light-traps were significant for all but An. tenebrosus. Inverse distance weighting was used to produce raster density maps of the most common mosquitoes. All species, with minor variations, in both hot and cool seasons, were collected in greatest numbers close to the edges of the village where water suitable for larval development was available. All exophilic anophelines species tested negative for sporozoites. It is suggested that focal control of larvae, applied by the villagers themselves, could be a suitable alternative to conventional control in this and similar villages.

Netting barriers to prevent mosquito entry into houses in southern Mozambique: a pilot study.

BACKGROUND: One of the best ways to control the transmission of malaria is by breaking the vector-human link, either by reducing the effective population size of mosquitoes or avoiding infective bites. Reducing house entry rates in endophagic vectors by obstructing openings is one simple way of achieving this. Mosquito netting has previously been shown to have this effect. More recently different materials that could also be used have come onto the market. Therefore, a pilot study was conducted to investigate the protective effect of three types of material against Anopheles funestus and Anopheles gambiae s.l entry into village houses in Mozambique when applied over the large opening at the gables and both gables and eaves. METHODS: A two-step intervention was implemented in which the gable ends of houses (the largest opening) were covered with one of three materials (four year old mosquito bed nets; locally purchased untreated shade cloth or deltamethrin-impregnated shade cloth) followed by covering both gable ends and eaves with material. Four experimental rounds (each of three weeks duration), from four houses randomly assigned to be a control or to receive one of the three intervention materials, were undertaken from March to August 2010 in the village of Furvela in southern Mozambique. Mosquito entry rates were assessed by light-trap collection and the efficacy of the different materials was determined in terms of incidence rate ratio (IRR), obtained through a Generalized Estimating Equations (GEE), of mosquito entry in a treated house compared to the untreated (control) house. RESULTS: Altogether 9,692 An. funestus and 1,670 An. gambiae s.l. were collected. Houses treated with mosquito netting or the untreated shade cloth had 61.3% [IRR = 0.39 (0.32-0.46); P <0.0001] and 70% [IRR = 0.30 (0.25 - 0.37); P <0.001] fewer An. funestus in relation to untreated houses, but there was no difference in An. funestus in houses treated with the deltamethrin-impregnated shade cloth [IRR = 0.92 (0.76 -1.12); P = 0.4] compared to untreated houses. Houses treated with mosquito netting reduced entry rates of An. gambiae s.l, by 84% [IRR = 0.16 (0.10 - 0.25); P <0.001], whilst untreated shade cloth reduced entry rates by 69% [IRR = 0.31 (0.19 -0.53); P <0.001] and entry rates were reduced by 76% [IRR = 0.24 (0.15 0.38); P <0.001] in houses fitted with deltamethrin-impregnated shade cloth.

The effect of rainstorms on adult Anopheles funestus behavior and survival.

We describe the effect that the passage of a cold front, with a subsequent heavy rainstorm ten days later, had on a population of Anopheles funestus mosquitoes collected exiting houses or in light-traps from a village in southern Mozambique. Temperature effects explained 40% (r=0.634; p <0.001) of the variation in numbers of males collected and 19% of the variation in gravid females collected (r=0.437; p=0.033). The age structure of mosquitoes varied according to distance from the breeding site (χ(2) = 64.1, df 6, p <0.001). The proportion of parous insects that were caught in the light-traps with sacs (χ(2) = 6.33, d.f. 2, p=0.042) and young insects that had mated before being collected (χ(2) = 13,3, d.f. 2, p=0.001) were reduced on the night of the rain but this effect was short lived. It is concluded that the effect of rain on mosquito populations depends on the kind of water body used for larval development.

Artemisinin-based combination therapy does not measurably reduce human infectiousness to vectors in a setting of intense malaria transmission.

BACKGROUND: Artemisinin-based combination therapy (ACT) for treating malaria has activity against immature gametocytes. In theory, this property may complement the effect of terminating otherwise lengthy malaria infections and reducing the parasite reservoir in the human population that can infect vector mosquitoes. However, this has never been verified at a population level in a setting with intense transmission, where chronically infectious asymptomatic carriers are common and cured patients are rapidly and repeatedly re-infected. METHODS: From 2001 to 2004, malaria vector densities were monitored using light traps in three Tanzanian districts. Mosquitoes were dissected to determine parous and oocyst rates. Plasmodium falciparum sporozoite rates were determined by ELISA. Sulphadoxine-pyrimethamine (SP) monotherapy was used for treatment of uncomplicated malaria in the contiguous districts of Kilombero and Ulanga throughout this period. In Rufiji district, the standard drug was changed to artesunate co-administered with SP (AS + SP) in March 2003. The effects of this change in case management on malaria parasite infection in the vectors were analysed. RESULTS: Plasmodium falciparum entomological inoculation rates exceeded 300 infective bites per person per year at both sites over the whole period. The introduction of AS + SP in Rufiji was associated with increased oocyst prevalence (OR [95%CI] = 3.9 [2.9-5.3], p < 0.001), but had no consistent effect on sporozoite prevalence (OR [95%CI] = 0.9 [0.7-1.2], p = 0.5). The estimated infectiousness of the human population in Rufiji was very low prior to the change in drug policy. Emergence rates and parous rates of the vectors varied substantially throughout the study period, which affected estimates of infectiousness. The latter consequently cannot be explained by the change in drug policy. CONCLUSIONS: In high perennial transmission settings, only a small proportion of infections in humans are symptomatic or treated, so case management with ACT may have little impact on overall infectiousness of the human population. Variations in infection levels in vectors largely depend on the age distribution of the mosquito population. Benefits of ACT in suppressing transmission are more likely to be evident where transmission is already low or effective vector control is widely implemented.

Towards eradication: three years after the tsunami of 2004, has malaria transmission been eliminated from the island of Simeulue?

The island of Simeulue was the first landfall of the tsunami of December 2004. The tsunami destroyed many villages on the island, leaving one third of the population homeless. Malaria is endemic in Simeulue and an epidemic was reported to have occurred three months prior to the tsunami. Information concerning malaria was, however, not easily available. The earthquakes related to the tsunami may have created extensive potential breeding sites of Anopheles sundaicus, the probable vector, and increased vulnerability of the human population; a possibility of increased transmission made a further outbreak possible. Consequently, subsequent to the tsunami, considerable amounts of aid, including anti-malarial measures such as insecticide treated mosquito-nets, were deployed on the island. A series of island-wide cross-sectional surveys were conducted in 2005-2007 to determine whether these had had any effect on malaria prevalence. Larval sampling, and CDC light-trap and landing collections of hungry mosquitoes were also undertaken. The results indicate that despite the continuing presence of potential vectors in some places the anti-malaria measures introduced following the tsunami have controlled, and may be close to eliminating, malaria from the island.

Impact of promoting longer-lasting insecticide treatment of bed nets upon malaria transmission in a rural Tanzanian setting with pre-existing high coverage of untreated nets.

BACKGROUND: The communities of Namawala and Idete villages in southern Tanzania experienced extremely high malaria transmission in the 1990s. By 2001-03, following high usage rates (75% of all age groups) of untreated bed nets, a 4.2-fold reduction in malaria transmission intensity was achieved. Since 2006, a national-scale programme has promoted the use of longer-lasting insecticide treatment kits (consisting of an insecticide plus binder) co-packaged with all bed nets manufactured in the country. METHODS: The entomological inoculation rate (EIR) was estimated through monthly surveys in 72 houses randomly selected in each of the two villages. Mosquitoes were caught using CDC light traps placed beside occupied bed nets between January and December 2008 (n = 1,648 trap nights). Sub-samples of mosquitoes were taken from each trap to determine parity status, sporozoite infection and Anopheles gambiae complex sibling species identity. RESULTS: Compared with a historical mean EIR of approximately 1400 infectious bites/person/year (ib/p/y) in 1990-94; the 2008 estimate of 81 ib/p/y represents an 18-fold reduction for an unprotected person without a net. The combined impact of longer-lasting insecticide treatments as well as high bed net coverage was associated with a 4.6-fold reduction in EIR, on top of the impact from the use of untreated nets alone. The scale-up of bed nets and subsequent insecticidal treatment has reduced the density of the anthropophagic, endophagic primary vector species, Anopheles gambiae sensu stricto, by 79%. In contrast, the reduction in density of the zoophagic, exophagic sibling species Anopheles arabiensis was only 38%. CONCLUSION: Insecticide treatment of nets reduced the intensity of malaria transmission in addition to that achieved by the untreated nets alone. Impacts were most pronounced against the highly anthropophagic, endophagic primary vector, leading to a shift in the sibling species composition of the A. gambiae complex.

A new tent trap for sampling exophagic and endophagic members of the Anopheles gambiae complex.

BACKGROUND: Mosquito sampling methods are essential for monitoring and evaluating malaria vector control interventions. In urban Dar es Salaam, human landing catch (HLC) is the only method sufficiently sensitive for monitoring malaria-transmitting Anopheles. HLC is labour intensive, cumbersome, hazardous, and requires such intense supervision that is difficulty to sustain on large scales. METHODS: Novel tent traps were developed as alternatives to HLC. The Furvela tent, designed in Mozambique, incorporates a CDC Light trap (LT) components, while two others from Ifakara, Tanzania (designs A and B) require no electricity or moving parts. Their sensitivity for sampling malaria vectors was compared with LT and HLC over a wide range of vector abundances in rural and urban settings in Tanzania, with endophagic and exophagic populations, respectively, using randomised Latin-square and cross- over experimental designs. RESULTS: The sensitivity of LTs was greater than HLC while the opposite was true of Ifakara tent traps (crude mean catch of An. gambiae sensu lato relative to HLC = 0.28, 0.65 and 1.30 for designs A, B and LT in a rural setting and 0.32 for design B in an urban setting). However, Ifakara B catches correlated far better to HLC (r2 = 0.73, P < 0.001) than any other method tested (r2 = 0.04, P = 0.426 and r2 = 0.19, P = 0.006 for Ifakara A and LTs respectively). Only Ifakara B in a rural setting with high vector density exhibited constant sampling efficiency relative to HLC. The relative sensitivity of Ifakara B increased as vector densities decreased in the urban setting and exceeded that of HLC at the lowest densities. None of the tent traps differed from HLC in terms of the proportions of parous mosquitoes (P >or= 0.849) or An. gambiae s.l. sibling species (P >or= 0.280) they sampled but both Ifakara A and B designs failed to reduce the proportion of blood-fed mosquitoes caught (Odds ratio [95% Confidence Interval] = 1.6 [1.2, 2.1] and 1.0 [0.8, 1.2], P = 0.002 and 0.998, respectively), probably because of operator exposure while emptying the trap each morning. CONCLUSION: The Ifakara B trap may have potential for monitoring and evaluating a variety of endophagic and exophagic Afrotropical malaria vectors, particularly at low but epidemiologically relevant population densities. However, operator exposure to mosquito bites remains a concern so additional modifications or protective measures will be required before this design can be considered for widespread, routine use.

Do bednets reduce malaria transmission by exophagic mosquitoes?

The impact of bednet coverage on malaria prevalence in a suburb of São Tomé was monitored, by passive case detection, over a three-year period (1997-1999), when bednet use increased from 20 to 74%. Malaria parasites were detected in 1651 (41.6%) of the 3967 slides taken during the study. All four human malaria parasites were seen, with Plasmodium falciparum being the predominant species (94.9% of positive slides). Prevalence of malaria among residents decreased, particularly in 1-4 year olds. In addition, there was a concomitant decrease in prevalence also among non-net users, suggesting a mass effect on transmission, even though the only vector in the area is largely exophagic and zoophilic.

Raised houses reduce mosquito bites.

BACKGROUND: In many parts of continental Africa house construction does not appear to impede entry of malaria vectors and, given their generally late biting cycle, the great majority of transmission takes place indoors. In contrast, many houses in São Tomé, 140 km off the coast of Gabon, are raised on stilts and built of wooden planks. Building on stilts is a time-honoured, but largely untested, way of avoiding mosquito bites. Exposure may also be affected by mosquito activity times and age composition of host-seeking females. A study was therefore undertaken on the island of São Tomé to determine if exposure to Anopheles gambiae, the only vector on the island, varied with house construction or time of the night. METHODS: A series of all-night landing collections were undertaken out of doors at ground level, inside houses at ground level, on the verandas of, and inside houses built on stilts. The gonotrophic age of an unselected sample of insects from the first three hours of landing collection (18:00-21:00) was determined by dissection. In addition, 1,149 miniature light-trap collections were obtained from 125 houses in the study area. Numbers collected were related to house construction. RESULTS: Biting of An. gambiae took place primarily outside at ground level. Less than one third of biting occurred inside houses. Houses built on stilts had half the number of An. gambiae in them compared to those built at ground level. Conversely houses with an eaves gap had more An. gambiae in them than houses without such a gap. Gonotrophic age did not affect house entry rates in An. gambiae. House construction affected Culex quinquefasciatus less than An. gambiae. Mean density per house, derived from a series of 1,490 randomly assigned light-trap collections, was over-dispersed with 18% of houses having 70% of the vectors. CONCLUSION: House construction plays an important role in determining exposure to malaria vectors in São Tomé. Neighbours can have very different exposure levels. Recommendations for improvement in control are given.

Malaria and its possible control on the island of Príncipe.

BACKGROUND: Malaria can be eradicated from islands. To assess the prospects for eradication of malaria from the island of Príncipe in the Gulf of Guinea, we fitted a mathematical model to age-prevalence curves and thus obtained estimates of the vectorial capacity and of the basic reproductive number (R0) for malaria. METHODS: A cross-sectional malariological survey was carried out, in mid-1999, in six communities, comprising circa 17% of the total 6,000 population of the island. All houses in these communities were registered and their mode of construction recorded. Thick and thin blood films were prepared from all consenting individuals. Each individual was asked whether they possessed a mosquito net, whether they had slept under a mosquito net the previous night, whether they were allergic to chloroquine, and whether they had visited the main island of São Tomé since the beginning of the year. Outpatient records from March 1999 until the end of December 2000 were also examined and the age and place of residence of diagnosed cases noted. RESULTS: 203 (19.8%) of the 1,026 individuals examined were found to be infected with Plasmodium falciparum. By fitting the mathematical model of the Garki project to the age-prevalence curve we estimate that the basic reproductive number, R0, on the island is approximately 1.6. Over a period of one year, a total of 1,792 P. falciparum cases reported to an outpatient facility at the island's hospital. Overall, 54% of the people interviewed slept under mosquito nets and were at reduced risk of infection. Conversely, people living in houses with openings between the top of the wall and the roof had higher risk of infection. CONCLUSION: This high incidence suggests that most of the malaria cases on the island attend the hospital and that treatment of these cases is an important factor reducing the effective rate of transmission. Providing that clinical cases are effectively treated, endemic malaria can probably be eliminated from the island mainly by reducing exposure to the vector with simple measures such as insecticide-treated nets and mosquito-proofing of dwellings. In contrast to traditional malaria eradication strategies, this would avoid the risk of malaria epidemics because the reduction in R0 should be sustainable.

'A mate or a meal'--pre-gravid behaviour of female Anopheles gambiae from the islands of São Tomé and Príncipe, West Africa.

BACKGROUND: Malaria prevalence differs between the two islands that comprise the archipelago of São Tomé and Príncipe. This may be due to differences in the biology of local Anopheles gambiae, the only vector on the islands. Survival rate and feeding frequency are two factors influencing vectorial capacity. Anophelines generally feed just once per gonotrophic (oviposition) cycle. Newly emerged insects, however, may feed two or more times during their first oviposition cycle thus increasing the likelihood of becoming infected. The reasons for multiple feeding are not clearly understood and it is still uncertain whether the behaviour is facultative or obligatory. We, therefore, determined survival and sporozoite rates, and examined the behaviour of An. gambiae from the two islands during their first gonotrophic cycle. METHODS: The wing size of 1,410, abdominal condition of 687, gonotrophic age and mated status of 7,264 female M form An. gambiae collected by light-trap, landing catch, resting outdoors or in copula, was determined from four sites in the archipelago. Sporozoite rates assessed by ELISA in 15,533 females from São Tomé and 2,111 from Príncipe were determined. RESULTS: Estimated survival rates ranged between 0.834-0.849 per day in São Tomé and 0.801-0.818 per day in Príncipe. Sporozoite rates of 0.63% in São Tomé were significantly higher than the 0.24% from Príncipe. Overall 49% of females mated on the second night after emergence before feeding, and 51% on the third night and thus fed before mating. The likelihood of mating before feeding increased with wing size. None of the 3,776 parous insects collected showed evidence of recent mating. All but two of the 198 females collected in copula had undeveloped ovaries. Mean wing sizes and the number of insects collected in a sentinel light-trap varied but the proportion of newly emerged insects in the collection did not. The estimated survival rate of the smallest insects was lower than other size groups, but the overall size distribution of each age group was normal. Parous insects were gonotrophically concordant. CONCLUSION: Differences in mosquito survival contributed to the lower sporozoite rates and endemicity of malaria on Príncipe compared to São Tomé. On both islands all newly emerged insects blood fed on the second night following emergence but only became gonotrophically active on the third night after emergence. Smaller insects had a higher 'mortality/emigration' rate than larger ones. We suggest that insufficiency of Juvenile Hormone until the third day of adult life is responsible for gonotrophic inactivity and that by partitioning mating between the second or third day after emergence females maximise their chances of out-crossing.

Reducing malaria by mosquito-proofing houses.

Sometimes, valuable lessons from history are forgotten, remain unknown, or worse, are ignored. This article reminds us of the pioneering work of Angelo Celli at the end of the 19th century, who demonstrated that people could be protected from malaria by screening their homes against mosquitoes. Since then, public health scientists have continued to show that simple changes in house design have the potential for protecting people against this life-threatening disease. Yet today, this type of intervention remains virtually ignored. The literature reviewed here demonstrates the enormous potential of these methods to reduce malaria, in the hope that it will stimulate scientific debate and further research.