Increased Biting Rate of Insecticide-Resistant Culex Mosquitoes and Community Adherence to IRS for Malaria Control in Urban Malabo, Bioko Island, Equatorial Guinea.

Sustaining high levels of indoor residual spraying (IRS) coverage (≥85%) for community protection against malaria remains a challenge for IRS campaigns. We examined biting rates and insecticide resistance in Culex species and Anopheles gambiae s.l., and their potential effect on community adherence to IRS. The average IRS coverage in urban Malabo between 2015 and 2017 remained at 80%. Culex biting rate increased 6.0-fold (P < 0.001) between 2014 and 2017, reaching 8.08 bites per person per night, whereas that of An. gambiae s.l. remained steady at around 0.68. Although An. gambiae s.l. was susceptible to carbamates and organophosphates insecticides, Culex spp. were phenotypically resistant to all four main classes of WHO-recommended IRS insecticides. Similarly, the residual activity of the organophosphate insecticide used since 2017, ACTELLIC 300CS, was 8 mo for An. gambiae s.l., but was almost absent against Culex for 2 mo post-spray. A survey conducted in 2018 within urban Malabo indicated that 77.0% of respondents related IRS as means of protection against mosquito bites, but only 3.2% knew that only Anopheles mosquitoes transmit malaria. Therefore, the increasing biting rates of culicines in urban Malabo, and their resistance to all IRS insecticides, is raising concern that a growing number of people may refuse to participate in IRS as result of its perceived failure in controlling mosquitoes. Although this is not yet the case on Bioko Island, communication strategies need refining to sensitize communities about the effectiveness of IRS in controlling malaria vectors in the midst of insecticide resistance in nonmalaria vector mosquitoes.

Rapid selection of a pyrethroid metabolic enzyme CYP9K1 by operational malaria control activities.

Since 2004, indoor residual spraying (IRS) and long-lasting insecticide-impregnated bednets (LLINs) have reduced the malaria parasite prevalence in children on Bioko Island, Equatorial Guinea, from 45% to 12%. After target site-based (knockdown resistance; kdr) pyrethroid resistance was detected in 2004 in Anopheles coluzzii (formerly known as the M form of the Anopheles gambiae complex), the carbamate bendiocarb was introduced. Subsequent analysis showed that kdr alone was not operationally significant, so pyrethroid-based IRS was successfully reintroduced in 2012. In 2007 and 2014-2015, mass distribution of new pyrethroid LLINs was undertaken to increase the net coverage levels. The combined selection pressure of IRS and LLINs resulted in an increase in the frequency of pyrethroid resistance in 2015. In addition to a significant increase in kdr frequency, an additional metabolic pyrethroid resistance mechanism had been selected. Increased metabolism of the pyrethroid deltamethrin was linked with up-regulation of the cytochrome P450 CYP9K1. The increase in resistance prompted a reversion to bendiocarb IRS in 2016 to avoid a resurgence of malaria, in line with the national Malaria Control Program plan.