The fabric of life: what if mosquito nets were durable and widely available but insecticide-free?

BACKGROUND: Bed nets are the commonest malaria prevention tool and arguably the most cost-effective. Their efficacy is because they prevent mosquito bites (a function of physical durability and integrity), and kill mosquitoes (a function of chemical content and mosquito susceptibility). This essay follows the story of bed nets, insecticides and malaria control, and asks whether the nets must always have insecticides. METHODS: Key attributes of untreated or pyrethroid-treated nets are examined alongside observations of their entomological and epidemiological impacts. Arguments for and against adding insecticides to nets are analysed in contexts of pyrethroid resistance, personal-versus-communal protection, outdoor-biting, need for local production and global health policies. FINDINGS: Widespread resistance in African malaria vectors has greatly weakened the historical mass mosquitocidal effects of insecticide-treated nets (ITNs), which previously contributed communal benefits to users and non-users. Yet ITNs still achieve substantial epidemiological impact, suggesting that physical integrity, consistent use and population-level coverage are increasingly more important than mosquitocidal properties. Pyrethroid-treatment remains desirable where vectors are sufficiently susceptible, but is no longer universally necessary and should be re-examined alongside other attributes, e.g. durability, coverage, acceptability and access. New ITNs with multiple actives or synergists could provide temporary relief in some settings, but their performance, higher costs, and drawn-out innovation timelines do not justify singular emphasis on insecticides. Similarly, sub-lethal insecticides may remain marginally-impactful by reducing survival of older mosquitoes and disrupting parasite development inside the mosquitoes, but such effects vanish under strong resistance. CONCLUSIONS: The public health value of nets is increasingly driven by bite prevention, and decreasingly by lethality to mosquitoes. For context-appropriate solutions, it is necessary to acknowledge and evaluate the potential and cost-effectiveness of durable untreated nets across different settings. Though ~ 90% of malaria burden occurs in Africa, most World Health Organization-prequalified nets are manufactured outside Africa, since many local manufacturers lack capacity to produce the recommended insecticidal nets at competitive scale and pricing. By relaxing conditions for insecticides on nets, it is conceivable that non-insecticidal but durable, and possibly bio-degradable nets, could be readily manufactured locally. This essay aims not to discredit ITNs, but to illustrate how singular focus on insecticides can hinder innovation and sustainability.

Semi-Field Evaluation of Metofluthrin-Impregnated Nets on Host-Seeking Aedes aegypti and Anopheles dirus.

The efficacy of a metofluthrin-impregnated net (MIN) known as the "Mushikonazu" on the house entry behavior of female Aedes aegypti and Anopheles dirus mosquitoes was evaluated using a semi-field 50-m tunnel setup. While the MIN is labeled for the control of chironomids and moth flies, this study determined the feasibility of using the device, given its current construction and metofluthrin formulation, as a spatial repellent against mosquitoes. Sentinel and cone bioassays were used to determine the insecticidal effect of the MIN. A spatial activity index (SAI) was calculated to evaluate responses of the mosquitoes. For the spatial repellent evaluation against Ae. aegypti, the overall mean of SAI was slightly less than 0 at wk 1 after the MIN application and then decreased for the last 4 wk showing a preference to treatment tent. For An. dirus, the mean SAI at wk 1 was positive, indicating a presumed repellent effect of the MIN against An. dirus. For the subsequent 4 wk, the SAI was negative, indicating a preference for the MIN. Results suggested that the MIN may not be a promising approach to repel Ae. aegypti and An. dirus under field conditions in Thailand. However, it remains probable that the MIN may be effective as a spatial repellent if modifications are made to the metofluthrin concentration or formulation and/or the construction of the device.

Evaluation of different mesh sizes of long lasting insecticidal nets against Phlebotomus argentipes Annandale and Brunetti (Diptera: Psychodidae), in Bihar state of India.

The study present result of long lasting insecticidal nets (LLINs) of different mesh sizes viz. PermaNet(R) 156mesh/inch(2), PermaNet(R) 196mesh/inch(2), PermaNet(R) 196mesh/inch2+75cm border of fine cloth in reducing Phlebotomus argentipes population along with community acceptance in three intervention villages. Entire experimental period of treatments maximum reduction 93.67% was observed in PermaNet(R) 196mesh/inch(2)+75cm border followed by PermaNet(R) 196mesh/inch(2) 91.90 and 74.29% in PermaNet(R)156mesh/inch(2), when compared to control all the LLINs were showed significant reduction of P. argentipes population while compare to between them there was no significant difference. The significant reduction in gravid P. argentipes, was recorded as 71.87, 87.92 and 91.27%, in PermaNet(R) 156mesh/inch(2), PermaNet(R) 196mesh/inch(2) and PermaNet(R) 196mesh/inch(2)+75cm, respectively. The preference was high for PermaNet(R) 156mesh/inch(2) without any side effect of LLINs.

Video studies of passage by Anopheles gambiae mosquitoes through holes in a simulated bed net: effects of hole size, hole orientation and net environment.

BACKGROUND: Holes in netting provide potential routes for mosquitoes to enter ITNs. Despite this, there is little information on how mosquitoes respond to holes in bed nets and how their responses are affected by hole size, shape and orientation or by ambient conditions around the net. METHODS: Female Anopheles gambiae (G3) were recorded in a simulated bed net consisting of two sizes of untreated netting-covered behavioural arenas placed above and beside (to simulate the bed net roof and sides respectively) the experimenter who was a source of host cues from 'inside' the net. A round hole of 9 mm or 13 mm diameter was cut into the centre of the netting of each arena. Videos of unfed female mosquitoes in arenas were analysed for time spent flying, walking and standing still and for exit through the hole. The effects of the experimenter on temperature and relative humidity around the simulated net were also measured. RESULTS: Mosquitoes were significantly more active in overhead arenas than in arenas to the side. Hole passage was significantly more likely in smaller arenas than larger ones and for larger holes than smaller ones. In arenas to the side, hole passage rate through small holes was about 50% less likely than what could be explained by area alone. Passage rate through holes in overhead arenas was consistent with hole area. Temperature in arenas did not strongly reflect the experimenter's presence in the simulated net. Relative humidity and absolute humidity in overhead arenas, but not in arenas to the side, were immediately affected by experimenter presence. CONCLUSIONS: Higher levels of activity in overhead arenas than in arenas to the side were likely due to the rising heat and humidity plume from the experimenter. Lower than expected passage rates through smaller vertically oriented holes may have been be due to an edge effect that does not apply to horizontally oriented holes. Results suggest that current methods of assessing the importance of physical damage to ITNs may not accurately reflect mosquito entry risk in all cases.

Quantifying the impact of decay in bed-net efficacy on malaria transmission.

Insecticide-treated nets (ITNs) are at the forefront of malaria control programs and even though the percentage of households in sub-Saharan Africa that owned nets increased from 3% in 2000 to 53% in 2012, many children continue to die from malaria. The potential impact of ITNs on reducing malaria transmission is limited due to inconsistent or improper use, as well as physical decay in effectiveness. Most mathematical models for malaria transmission have assumed a fixed effectiveness rate for bed-nets, which can overestimate the impact of nets on malaria control. We develop a model for malaria spread that captures the decrease in ITN effectiveness due to physical and chemical decay, as well as human behavior as a function of time. We perform uncertainty and sensitivity analyses to identify and rank parameters that play a critical role in malaria transmission. These analyses show that the basic reproduction number R0, and the infectious human population are most sensitive to bed-net coverage and the biting rate of mosquitoes. Our results show the existence of a backward bifurcation for the case in which ITN efficacy is constant over time, which occurs for some range of parameters and is characterized by high malaria mortality in humans. This result implies that bringing R0 to less than one is not enough for malaria elimination but rather additional efforts will be necessary to control the disease. For the case in which ITN efficacy decays over time, we determine coverage levels required to control malaria for different ITN efficacies and demonstrate that ITNs with longer useful lifespans perform better in malaria control. We conclude that malaria control programs should focus on increasing bed-net coverage, which can be achieved by enhancing malaria education and increasing bed-net distribution in malaria endemic regions.

Long-term insecticidal activity and physical integrity of Olyset nets in Tafea Province, Vanuatu.

The long-term efficacy of long-lasting insecticidal nets (LLINs) depends on both the physical condition of the net and the residual activity of the insecticide. This study focused on monitoring these parameters in Olyset nets (Sumitomo Chemical Co., Osaka, Japan) (n = 101) that had been used for 1-3 yr in Tafea Province, Vanuatu. Net usage and frequency of washing was ascertained by questionnaire; the nets were assessed with regards to cleanliness and damage owing to holes. Insecticide efficacy was determined with cone bioassays using Anophelesfarauti Laveran. Net usage was high and 86.1% (87 of 101) of villages stated that they used the net every night. Washing of nets was low (11.9%, 12 of 101), and most nets (79.2%, 80 of 101) were considered dirty. Most nets were damaged (73.4% had holes), and 22.8% (23 of 101) had large holes (>200 cm2). The 24-h mortality of An. farauti exposed to nets aged 1-2 yr was 79.4%, while the mortality for nets 3 yr of age was significantly lower at 73.7%. There was no difference in the insecticidal activity of clean compared with dirty nets (mean 24-h mortality: Clean = 76.7%, Dirty = 77.1%). Although the majority of nets had holes, the physical condition of 8.9-22.8% of nets was altered so severely to potentially affect efficacy. Although the 3-yr-old nets would still be providing significant levels of insecticidal and personal protection, consideration should be given to replacing nets >3 yr old.

Field and in vitro insecticidal efficacy of alphacypermethrin-treated high density polyethylene mesh against Culicoides biting midges in South Africa.

The efficacy of untreated and alphacypermethrin-treated high density polyethylene (HDPE) mesh against Culicoides biting midges (Diptera: Ceratopogonidae) was determined using Onderstepoort downdraught black light traps and a contact bioassay. Three traps were operated overnight in four replicates of a 3×3 randomised Latin square design near horses under South African field conditions. Both the untreated and alphacypermethrin-treated HDPE mesh significantly (P<0.05) reduced the numbers of Culicoides midges, predominantly Culicoides (Avaritia) imicola Kieffer, collected in the light traps by 4.2 and 7.2 times, respectively. A repellent effect of the alphacypermethrin-treated mesh was not confirmed because the number of midges collected in the light traps with untreated and alphacypermethrin-treated HDPE mesh was not significantly different (P=0.656). Bioassay of the insecticidal contact efficacy indicated median C. imicola mortality of 100% from 30 and 10 min following exposure to the alphacypermethrin-treated HDPE mesh for 1 or 3 min, respectively. In the bioassay, mortality was significantly higher (P=0.016) at 5 min post exposure in the midges exposed to the alphacypermethrin-treated mesh for 3 min (74.8%) compared to the 1 min exposure group (59.5%). The HDPE mesh could be used to reduce exposure of housed animals to Culicoides midges, specifically C. imicola, and viruses transmitted by these midges. Mesh treated with alphacypermethrin had the additional benefit of a rapid insecticidal effect on C. imicola.

Evaluation of certain insecticides on nettings for their efficacy and wash resistance against mosquito species.

Five insecticides (Bifenthrin, Deltamethrin, Etofenprox, Permethrin and Lamda cyhalothrin) recommended by WHO, at their recommended dose were compared for their efficacy and wash resistance through bioassay against mosquito vectors, Culex quinquefasciatus, Aedes aegypti and Anopheles stephensi. Etofenprox treated nettings exhibited better knockdown and mortality than the other insecticides. The order of efficacy of the insecticides treated nettings was Etofenprox > or = Deltamethrin > Lambda cyhalothrin > Permethrin > Bifenthrin.

Strength of bed nets as function of denier, knitting pattern, texturizing and polymer.

BACKGROUND: Bursting strength is a standard method for evaluating mosquito net strength. This article suggests that tension strength with one grab and one hook better represent how holes are generated in bed nets in real life. METHODS: Measurements of bursting strength and tension strengths in the two directions are analysed for eight model nets created for the study. The nets were made in the most commonly used denier (75 and 100 D) and mesh (156 holes/inch(2)) for multifilament polyester yarns, texturized or not, and with 4 or 6 sided holes. All were made from one polyester quality. Data was arranged in a randomized, complete block design and analysed for significant variables and their interactions. Data was then subjected to regression analyses using net square metre weight as a weighting factor with stepwise removal of variables. This revealed how the four textile variables interacted and allowed for making predictions for the strength of commercial nets in polyester or polyethylene. RESULTS: For the model nets, higher denier provided higher bursting strength and tension strengths, texturizing weakened nets and four-sided holes were stronger than six-sided holes. Even when compensating for square metre weight, 100 D nets are stronger than 75 D nets. Results for the commercial polyester net nets are less clear, probably because of different qualities of polyester. Tensile strength: a 75 denier net knitted tightly to provide the same square metre weight as a standard 100 denier net therefore does not obtain the same strength. Polyethylene nets are made of mono-fibre yarns and, therefore, have higher tension strength in both directions than multifilament polyester nets. For bursting strength results overlap for 100 denier yarns of both yarn types. As a class, commercial polyethylene nets are stronger than commercial polyester net whatever method is used for evaluation. CONCLUSION: Tension strength measured in the length and width directions of the net using one hook and one clamp provide new relevant data as this method more closely imitates the cause of tear holes in nets as they occur in real life use. Using this methodology, the commercial monofilament yarn polyethylene nets are significantly stronger than the commercial multifilament polyester nets. This test method should be applied for nets used for years in the field.

Which family members use the best nets? An analysis of the condition of mosquito nets and their distribution within households in Tanzania.

BACKGROUND: Household ownership of insecticide-treated mosquito nets (ITNs) is increasing, and coverage targets have been revised to address universal coverage with ITNs. However, many households do not have enough nets to cover everyone, and the nets available vary in physical condition and insecticide treatment status. Since 2004, the Government of Tanzania has been implementing the Tanzania National Voucher Scheme (TNVS), which distributes vouchers for ITNs through antenatal clinics to target pregnant women and their infants. This analysis aimed to determine the following: (1) coverage patterns of bed nets within households according to physical condition and treatment status; (2) who might be at risk if mosquitoes were diverted from occupants of untreated nets to those not using nets? (3) the degree to which those at highest risk of malaria use the most protective nets. METHODS: Data from the 2006 TNVS household survey were analysed to assess within-household distribution of net use. The associations between net characteristics and net user were also evaluated. Multivariate analysis was applied to the relationship between the number of holes per net and user characteristics while adjusting for confounders. RESULTS: In households with a net:person ratio better than 1:4 (one net for every four household members), more than 80% of the people in such households reported using a net the previous night. ITNs were most likely to be used by infants, young children (1-4 y), and women of childbearing age; they were least likely to be used by older women (>or=50 y), older children (5-14 y), and adult men. The nets used by infants and women of childbearing age were in better-than-average physical condition; the nets used by older women and older children were in worse-than-average condition; while young children and adult men used nets in intermediate (average) condition. When adjusted for confounders, the nets used by young and older children had more holes than nets used by infants. CONCLUSIONS: Infants and other vulnerable groups were most likely to sleep under the most protective nets. Nevertheless, more communication efforts are needed to increase use of intact ITNs within households for children. Further research is necessary to fully understand motivations influencing within-household net distribution.

Wash resistance and residual efficacy of long-lasting polyester netting coated with alpha-cypermethrin (Interceptor) against malaria-transmitting mosquitoes in Assam, northeast India.

Malaria is endemic in Assam, northeast India, with low-to-moderate transmission of the causative parasites, mostly by Anopheles minimus. Plasmodium falciparum is the predominant parasite (>60%), with remaining cases being due to P. vivax. As an alternative intervention for malaria control, long-lasting insecticidal nets [Interceptor coated with alpha-cypermethrin 10% suspension concentrate (SC), 0.667% w/w, 0.2g/m(2)] underwent field evaluation for laboratory wash resistance and residual efficacy in field conditions against malaria-transmitting mosquitoes. Based on entomological observations, the Interceptor net intervention was the most effective, corresponding to the lowest mosquito vector density in experimental villages. There was virtual disappearance of A. minimus in Interceptor net villages in contrast to the untreated net intervention and the no-net control. Contact cone bioassay tests revealed 100% mortality in the A.minimus group of mosquito species in the community using the Interceptor net, which was consistent during the follow-up monitoring period (October 2006 to April 2007) in field conditions. Similar levels of mortality were observed in laboratory-washed nets compared with unwashed nets, and wash resistance was consistent even after the 20th serial wash at fortnightly intervals. Community compliance and acceptance of the Interceptor net was high, with decreased nuisance due to biting mosquitoes and other household insect pests being reported.