Category Archives: Mosquitoes

Mis-Use of Insecticide Treated Nets May Actually Be Rational

People have sometimes question whether insecticide treated nets (ITNs) provided for free are valued by the recipients. Although this is not usually a specific question in surveys, researchers found in a review of 14 national household surveys that free nets received through a campaign were six times more likely to be given away than nets obtained through other avenues such as routine health care or purchased from shops.

Giving nets away to other potential users, not hanging nets or not sleeping under nets at least imply that the nets could potentially be used for their intended purpose. What concerns many is that nets may be used for unintended and inappropriate reasons. Often the evidence is anecdotal, but photos from Nigeria and Burkina Faso shown here document cases where nets were found to cover kiosks, make football goalposts, protect vegetable seedlings and fence in livestock.

Newspapers tend to quote horrified health or academic staff when reporting this, such as this statement from Mozambique, “The nets go straight out of the bag into the sea.”  The Times said that net misuse squandered money and lives when they observed that “Malaria nets distributed by the Global Fund have ended up being used for fishing, protecting livestock and to make wedding dresses.”

Two years ago the New York Times reported that, “Across Africa, from the mud flats of Nigeria to the coral reefs off Mozambique, mosquito-net fishing is a growing problem, an unintended consequence of one of the biggest and most celebrated public health campaigns in recent years.”5 Not only were people not being protected from malaria, but the pesticide in these ‘fishing nets’ was causing environmental damage. The article explains that the problem of such misuse may be small, but that survey respondents are very unlikely to admit to alternative uses to interviewers.

Similarly El Pais website featured an article on malaria in Angola this year with a striking lead photo of children fishing in the marshes near their village in Cubal with a LLIN. A video from the New York Times frames this problem in a stark choice: sleep under the nets to prevent malaria or them it to catch fish and prevent starvation.[v]

More recently, researchers who examined net use data from Kenya and Vanuatu found that alternative LLIN use is likely to emerge in impoverished populations where these practices had economic benefits like alternative ITN uses sewing bednets together to create larger fishing nets, drying fish on nets spread along the beach, seedling crop protection, and granary protection. The authors raise the question whether such uses are in fact rational from the perspective of poor people.

An important fact is that not all ovserved ‘mis-use’ of nets is really inappropriate use. A qualitative study in the Kilifi area of coastal Kenya demonstrated local ‘recycling’ of old ineffective nets. The researchers clearly found that in rural, peri-urban and urban settings people adopted innovative and beneficial ways of re-using old, expired nets, and those that were damaged beyond repair. Fencing for livestock, seedlings and crops were the most common uses in this predominantly agricultural area. Other domestic uses were well/water container covers, window screens, and braiding into rope that could be used for making chairs, beds and clotheslines. Recreational uses such as making footballs, football goals and children’s swings were reported

What we have learned here is that we should not jump to conclusions when we observe a LLIN that is set up for another purpose than protecting people from mosquito bites. Alternative uses of newly acquired nets do occur and may seem economically rational to poor communities. At the same time we must ensure that mass campaigns pay more attention to community involvement, culturally appropriate health education and onsite follow-up, especially the involvement of community health workers. Until such time as feasible safe disposal of ‘retired’ nets can be established, it would be good to work with communities to help them repurpose those nets that no longer can protect people from malaria.

Population Health: Malaria, Monkeys and Mosquitoes

On World Population Day (July 11) one often thinks of family planning. A wider view was proposed by resolution 45/216 of December 1990, of the United Nations General Assembly which encouraged observance of “World Population Day to enhance awareness of population issues, including their relations to the environment and development.”

A relationship still exists between family planning and malaria via preventing pregnancies in malaria endemic areas where the disease leads to anemia, death, low birth weight and stillbirth. Other population issues such as migration/mobility, border movement, and conflict/displacement influence exposure of populations to malaria, NTDs and their risks. Environmental concerns such as land/forest degradation, occupational exposure, population expansion (even into areas where populations of monkeys, bats or other sources of zoonotic disease transmission live), and climate warming in areas without prior malaria transmission expose more populations to mosquitoes and malaria.

Ultimately the goal of eliminating malaria needs a population based focus. The recent WHO malaria elimination strategic guidance encourages examination of factors in defined population units that influence transmission or control.

Today public health advocates are using the term population health more. The University of Wisconsin Department of Population Health Sciences in its blog explained that “Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” World Population Day is a good time to consider how the transmission or prevention of malaria, or even neglected tropical diseases, is distributed in our countries, and which groups and communities within that population are most vulnerable.

World Population Day has room to consider many issues related to the health of populations whether it be reproductive health, communicable diseases or chronic diseases as well as the services to address these concerns.

Earth Day, Climate, Environment and Malaria

The Earth Day website notes that, “Our planet is currently losing over 15 billion trees each year—that’s 56 acres of forest every minute. We’re working hard to reverse that trend by supporting global reforestation projects. Earth Day Network’s Reforestation Campaign benefits local communities, increases habitat for species, and combats climate change.”

This habitat change if often conducive to the spread of malaria in areas and among populations that may not have been affected before. Specifically, “More risks associated with El Niño are: flooding and landslides in the Americas, drought in Southeast Asia and Australia, scrambled fisheries, and malaria, cholera, and dengue outbreaks.”

Terry Devitt reported that the incidence of malaria jumps when Amazon forests are cut, establishing a firm link between environmental change and human disease. The report, which combines detailed information on the incidence of malaria in 54 Brazilian health districts and high-resolution satellite imagery of the extent of logging in the Amazon forest, shows that clearing tropical forest landscapes boosts the incidence of malaria by nearly 50 percent (according to Olson and colleagues).

Moyes et al. Predicted the geographical distributions of the macaque hosts and mosquito vectors of Plasmodium knowlesi malaria in forested and non-forested areas of Southeast Asia.  When urbanization and deforestation bring people into habitats they never lived in, zoonotic transmission of malaria results. Fornace et al. similarly observed that, “Marked spatial heterogeneity in P. knowlesi incidence was observed, and village-level numbers of P. knowlesi cases were positively associated with forest cover and historical forest loss in surrounding areas. These results suggest the likelihood that deforestation and associated environmental changes are key drivers in P. knowlesi transmission in these areas” of Malaysia.

Back to Brazil, de Alvarenga  and co-researchers reported in the transmission of Plasmodium simian malaria in the Brazilian Atlantic forest as a natural infection of capuchin monkeys (Cebinae subfamily). Because of human movement into forest areas, cases among people have now been documented.

The zoonotic transmission of malaria to humans due to changes in climate, environment and habitat pose another unwanted challenge to global efforts to eliminate malaria. On Earth Day it is imperative for malaria control and elimination workers to collaborate closely with colleagues in environmental health and protection.

Malaria, Dengue, Mosquitoes – evolving in the urban environment

As the world increasingly urbanizes, we need to address the role of urban ecosystems and the evolution of disease vectors and organisms.  Marina Alberti and colleagues explained that …

“Recent studies show that cities might play a major role in contemporary evolution by accelerating phenotypic changes in wildlife, including animals, plants, fungi, and other organisms. Many studies of ecoevolutionary change have focused on anthropogenic drivers, but none of these studies has specifically examined the role that urbanization plays in ecoevolution or explicitly examined its mechanisms.”

In their own study they looked at “five types of urban disturbances including habitat modifications, biotic interactions, habitat heterogeneity, novel disturbances, and social interactions.” The researchers learned that, “clear urban signal; rates of phenotypic change are greater in urbanizing systems compared with natural and nonurban anthropogenic systems.” They concluded that there is need to continually “uncover insights for maintaining key ecosystem functions upon which the sustainability of human well-being depends.”

Of particular concern in the area of tropical health are the unique urban manifestations of diseases like yellow fever, dengue and malaria. Although Zika virus, for example, was first discovered in forests, it has adapted to an urban cycle involving humans and domestic mosquito vectors in tropical areas where dengue is endemic. Musso and Gubler in their review further explain that although there may be sylvatic cycles of Dengue, “Arboviruses such as DENV have adapted completely to humans and can be maintained in large tropical urban centers in a mosquito-human-mosquito transmission cycle that does not depend on nonhuman reservoirs.”

Weaver et al. note that Zika in spreading to Asia, “emerged on multiple occasions into urban transmission cycles involving Aedes (Stegomyia) spp. Mosquitoes.” In addition it can be hypothesized that phenotypic changes in Asian lineage ZIKV strains made rare disease outcomes such as congenital microcephaly and Guillain-Barré more common and visible.

According to Estelle Martin and co-researchers, “Puerto Rico, a major metropolitan center in the Caribbean, has experienced increasingly larger and clinically more severe epidemics following the introduction of all four dengue serotypes.” They found that Dengue serotype 4 replaced earlier strains and that “this epidemic strain progressed rapidly, suggesting that the epidemic strain was more fit, and that natural selection may have acted on these mutations to drive them to fixation.”

In addition to virus evolution, mosquito changes have been documented by Caroline Louise and colleagues in “One of the world’s largest urban agglomerations infested by Ae. aegypti … the Brazilian megalopolis of Sao Paulo.”  They detected microevolution despite a short observational period and stress the implications of the “rapid evolution and high polymorphism of this mosquito vector on the efficacy of control methods.”

“The adaptation of malaria vectors to urban areas is becoming a serious challenge for malaria control,” is a major concern of Antonio-Nkondjio and co-workers. They found, “rapid evolution of pyrethroid resistance in vector populations from the cities of Douala and Yaoundé,” Members of this team also learned that the M form of Anopheles gambiae predominated in the centre of urban agglomerates in Cameroon. Previously it was known that larval habitats polluted with decaying organic matter as found in densely populated urban agglomerates, were unsuitable for Anopheles gambiae. The recent study showed that the “M form showed greater tolerance to ammonia (arising from organic matter) compared to the S form. This trait may be part of the physiological machinery allowing forest populations of the M form to colonize polluted larval habitats.”

The evolutionary response of vectors and disease organisms to urban environments needs continued monitoring. Urban disease control and elimination efforts must adapt to such adaptations in the disease process.

Decreasing Household Costs of Dengue Prevention at Low-Altitudes in Colombia …

… Redirecting Resources into the Hands of People Who Slap Mosquitoes Everyday.

Class members from the course “Social and Behavioral Foundations of Primary Health Care” at the Johns Hopkins Bloomberg School of Public Health write a policy advocacy blog as part of their assignments. Here we are sharing the blog posted by . read more on this and other SBFPHC blog posts by clicking here

Squito(Photo by James Gathany)

Colombia bears high burdens associated with dengue.  During the 2010 epidemic, disability-adjusted-life-years lost were 1178.93 (per 1 million inhabitants) versus just 88.38 averaged for 2011-2012.  Rodriguez et. al (2016) estimated economic burdens higher than $129.9 million USD each year, with most of the burden at the individual household level (46%, 62%, and 64%) for preventing/controlling mosquitos.

The Colombian Ministry of Health and Social Protection uses the 1,800m elevation mark when allocating money to low-altitude departments for dengue-related expenditures.  This suggests that only half of Colombia’s 47 million residents are at risk for dengue.  However, many people vacation at low altitudes where they risk becoming infected and bringing dengue back home.  If low-altitude residents were better equipped to control mosquitos, then both residents and visitors would be better protected.  Unfortunately, low-altitude residents shoulder a greater financial burden for mosquito prevention than the government.  Rodriquez et al. (2016) reported that almost $85 million USD was the highest household burden (for prevention alone) between 2010 and 2012, while the highest government burden was only $35 million USD (for prevention, awareness campaigns, and control combined).

If the Ministry of Health and Social Protection’s vision of equity-based protection and healthcare resources for all is to come to fruition, more money must flow into prevention and control.  Residents should not have to buy expensive sprays when they already live in poverty.  If Ministry-controlled finances were earmarked for inexpensive yet effective household supplies, such as curtains and water container covers, then less money would be required for treatment.  I advocate for reshuffling some of the dengue-related funds to reflect the prevention priority; increase amounts for household prevention and decrease treatment allocations.

Let’s not make low-altitude residents choose between buying expensive sprays or food to eat.  It’s hard enough already just to slap together supper.

Mosquito-Borne and Tick-Borne Illness in Florida: Importance of Surveillance

Class members from the course “Social and Behavioral Foundations of Primary Health Care” at the Johns Hopkins Bloomberg School of Public Health write a policy advocacy blog as part of their assignments. Here we are sharing the blog posted by “jleblan5jhmiedu“. read more on this and other SBFPHC blog posts by clicking here. This posting is particularly relevant today on World Mosquito Day.

Vector-borne diseases make up some of the more common infections throughout the globe. The Centers for Disease Control and Prevention acknowledges mosquito-borne denque mosqdiseases, such as West Nile Virus, and tick-borne infections, such as Lyme disease, have a great impact on the United States. These vectors have found favor in climate change as they continuing to breed and pose a public health risk; carrying infectious agents that may be transmitted to humans through a bloodmeal.

In 2014, the State of Florida Department of Health published their mosquito borne diseases surveillance guidebook. Within these guidelines, specific mosquito-borne infections were addressed in regards to both detecting and preventing such diseases. Unfortunately, since this publication, the Zika virus outbreak developed and was found to have recently reached Miami-Dade county in Florida, where locally transmitted cases were confirmed. Given these locally acquired infections in Florida, the surveillance guidelines should be updated accordingly.

FL Zika

Number of Florida Acquired Zika Virus (gray line: per million)

While the Northeastern regions of the US are known to have their “tick season” in the Spring and Summer, Florida’s climate allows for a year-long risk of contracting a tick-borne diease. The standard lab diauos in newsgnostic criteria for Lyme disease, the ELISA, detects antibodies against the bacterium, Borelia burgdorferi sensu stricto. However, it has continued to demonstrate poor sensitivity and overall reliability. Research from the University of North Florida has identified different strains of Borrelia that cause disease in humans. Thus, should one be infected with one of the different strains of Borrelia, one’s test is likely to be negative despite having actual disease. In recent years, Florida was found to have a 140% increase in Lyme disease cases since 1993 while reports of other tick-borne diseases have also increased. Hence, Florida researchers and public health professionals must partner together to revise and implement more up-to-date/accurate screening and awareness for vector-borne diseases.

Manufacturing Mosquito Nets ‘At Home’

The technology of insecticide treated nets (ITNs) to prevent malaria has been around for over three decades. ITNs have evolved from a process of semi-annual soaking and impregnating nets with a safe insecticide at the household or community level to long lasting insecticide-treated nets (LLINs) where the insecticide is integrated into the nets during the manufacturing process. The challenge has always been guaranteeing enough currently treated nets to cover the population and impede malaria transmission.

IMAG0170Recently Rwanda announced its intentions to establish LLIN manufacturing in-country. The Ministry of Trade and Industry has begun screening of bidders. The government’s main rationale for this move is projected the need for a large and continuous supply of LLINs in the country through 2020, “making it a prudent to set up a production plant in the country.” When this information was shared with our malaria/tropical health update mailing list a number of readers expressed interest and hope that their own governments would follow suit. This post provides some background for readers to consider.

The idea of locally made mosquito nets is not new. MacCormack and Snow documented that, “95% of people were already sleeping under locally-made DSCN5582nets,” in The Gambia in the 1980s. Likewise in Burkina Faso it was common to find nets made from imported materials or local cotton that were sewn by local tailors.

The idea of drawing on the combination of local or regional textile and chemical industries to produce an ITN kit containing both net and approved insecticide for home/community soaking was tested in several countries by the USAID sponsored NetMark project between 1999–2009. Although the project made ITNs available at reduced prices and resulted in gains in  awareness, ownership, and use of nets, “none of the countries reached the ambitious Abuja targets.”

NARCHOct03 012Even at reduced prices the ITNs made available through this commercial sector approach were still more expensive than most families could afford. In addition partway through the project the emphasis shifted from local products to imported LLiNs leaving a leaving a very bitter taste, particularly in Nigeria with its large industrial sector, in mouths of the textile and chemical partners who during malaria partners meetings at the time expressed a sense of betrayal.

A-Z Olyset Commercial BagTalk arose in Nigeria about the potential for starting LLIN production in the country, but no one stepped forward with funding or technical assistance. In the meantime, on the other side of the continent, A to Z Textiles of Tanzania entered into a partnership and by 2003 LLINs were being produced in Arusha.  Sumitomo Chemical provided a royalty-free technology license to the company for its Olyset LLINs. “By 2010, Olyset Net production capacity (at A to Z) reached 30 million LLINs per year, creating 8,000 jobs; more than half of the global Olyset Net output and an outstanding contribution to the local economy.”

Over the years A to Z Textiles were hard pressed, just like the few other LLIN manufacturers, to meet global demand. Over the period, the focus changed from protecting young children and pregnant women to universal coverage of the population. Also research and actual use found that the lifespan of an LLIN was not the 5 years as initially projected, but more like two. These factors meant that supply could rarely meet demand for regular replacement nets. No wonder Rwanda wants its own LLIN factory!

ITNs Use TanzaniaIn addition to supply issues, does local availability of LLINs make a difference in fighting malaria? Regular studies by the Demographic and Health Survey group of USAID in Tanzania found that ITN use increased over time by children below five years of age. The most recent survey still shows that the 2010 Abuja target of 80% was not met (let alone a target of universal coverage), but the findings hint at the importance of having locally available LLINs.

Let’s wish Rwanda success in establishing its LLIN manufacturing capacity. For colleagues in Nigeria and elsewhere who have expressed interest in this issue, your advocacy work is just beginning.

 

World Mosquito Day Is Not Just About Malaria

World Mosquito Day Block the BiteOur colleagues at Roll Back Malaria remind is that 20 August is marked annually as World Mosquito Day since doctor Sir Ronald Ross first identified female Anopheles mosquitoes as the vector that transmits malaria between humans. This year, 2015 is the 118th annual observance.

It may seem obvious to state, but while malaria is carried by mosquitoes, not all types of mosquitoes carry malaria. And more specifically our control measures for combating the anopheles mosquitoes that carry malaria are not specifically aimed at aedes or culex. This has not stopped public health workers in the field, and health worker trainees in the classroom from broadcasting messages to the public implying that the control and destruction of any mosquito will prevent malaria.

In terms of health communication, if we convince people that any mosquito carries malaria, but institute measures like long lasting insecticide-treated nets and indoor residual spraying aimed at anopheles mosquitoes, we may lose some credibility as people will still see other types of mosquitoes flying about. And then when people develop another febrile illness from bites of those other mosquitoes, they may not differentiate illness types, but say our interventions do not work.

Old poster on malaria-mosquito presentionThe conflation of all mosquitoes with malaria is seen clearly in the image at the right from a common malaria poster. The dirty gutters may contain culex larvae; the cans and bottles may contain aedes larvae. Obviously none of these mosquito species is good for human health, so can we achieve clarity in health communication about mosquito-borne disease on World Mosquito Day and thereafter?

We often forget that people in the community are quite observant of their environment; sometimes more so the the public health inspectors who try to teach them about ways of preventing malaria by reducing mosquito breeding. Villagers deal with mosquitoes on a daily basis and can distinguish the coloring and posture of the different species.

Instead of telling people what to do, it would be more helpful for public health workers to engage in dialogue with people to learn what they know about different types of mosquitoes and different forms of febrile illness. Maybe by learning first from the people, health workers can then become better teachers about integrated vector management.

PS – maybe we can also educate the mass media to stop putting pictures of Aedes aegypti on their malaria stories!

Moving toward Malaria Elimination through Integrated Vector Control

As malaria control efforts are scaled up and sustained, we expect a drop in prevalence to the point where Ministries of Health may no longer devote a whole operational unit – a National Malaria Control Program – to the disease. This does not mean that malaria programming stops, otherwise countries would experience a resurgence.

Pf_mean_2010_NAMWe can learn from countries like Namibia and Rwanda that are on the frontline of malaria elimination efforts. In Namibia, “The National Vector-borne Disease Control Program (NVDCP) at the Namibia Ministry of Health and Social Services effectively controls the spread of malaria with interventions such as spraying dwellings with insecticides, distributing mosquito nets treated with insecticides, using malaria tests that can give accurate results within 15 minutes, and distributing medicines that kill the parasite.”

The NVDCP falls under the Primary Health Care Services Directorate with its five divisions: Epidemiology; Public and Environmental Health Services; Family Planning; Information, Education and Communication (IEC); Disability Prevention and Rehabilitation. Contrary to what one might think, malaria activities are not lost, but are teaming up with international partners like UCSF Global Health Group’s Malaria Elimination Initiative, the Novartis Foundation for Sustainable Development, the London School of Hygiene and Tropical Medicine, the Clinton Health Access Initiative and the Bill & Melinda Gates Foundation.

In Rwanda we now have the Malaria and Other Parasitic Diseases Division (MOPDD) within the Rwanda Biomedical Center within the Ministry of Health. Major donors like the US Presidents Malaria Initiative are supporting the MOPDD to achieve Rwanda’s national strategic plan of reaching the pre-elimination stage by 2018.

PAMCA logo smEven if a country is still highly malaria endemic, it is important to ensure that integrated vector management is taking place so that in the future the country’s malaria efforts will have a strong ‘home base’ to approach elimination. This is why the opportunity presented by upcoming the Second Pan-African Mosquito Control Association is important.  According to the organizers …

The 2nd Pan African Mosquito Control Association (PAMCA) Conference themed, “Emerging mosquito-borne diseases in sub-Saharan Africa” will be held in Dar-es- Salaam, Tanzania, from 6-8th October 2015. The 2nd Annual PAMCA conference will build on the momentum generated following the successful hosting of the 1st PAMCA Annual Conference in Nairobi, Kenya. The main objective is to bring professionals, students, research institutions and other stakeholders working in mosquito control and mosquito-borne diseases research together under common agenda to discuss the challenges of emerging and re-emerging mosquito-borne diseases across the African continent. The conference will seek to illuminate this subject of emerging mosquito-borne diseases and develop progressive resolutions that will serve as guidelines to tackling this challenge going forward. The conference will also offer a platform for participants to exchange knowledge and ideas on mosquito control, forge new collaborations and strengthen existing ones.

We hope that colleagues will submit abstracts soonest focusing on the various conference themes:

  • Emerging mosquito-borne diseases: new Public Health challenges
  • Mosquito resistance to insecticides and population genetics
  • Translating research into practice: Linking interventions to mosquito behavior
  • Multidisciplinary approaches to tackling mosquito-borne disease
  • Mosquito biology & ecology
  • Impact of climate change on mosquito control

 

Indoor Residual Spraying – not a one-trick pony

Jasson Urbach and Donald Roberts claim that the malaria fight is hurt by flimsy anti-DDT research as they opine in Business Day (South Africa) on 9th May 2014. They are particularly exercised by an article on possible DDT effects on bird egg shells. Despite the controversy sparked by the article, there is no evidence that any individual country nor WHO itself is recommending removal of DDT from the arsenal of chemicals used in indoor residual spraying (IRS) to control malaria.

PMI: http://www.pmi.gov/how-we-work/technical-areas/indoor-residual-spraying

PMI: http://www.pmi.gov/how-we-work/technical-areas/indoor-residual-spraying

There is something about DDT that raises hackles among proponents and detractors. But malaria vector control planners do have choices. WHO recommends 14 insecticides for indoor residual spraying against malaria vectors as seen below in an list updated on 25 October 2013:

  1. DDT
  2. Malathion
  3. Fenitrothion
  4. Pirimiphos-methyl
  5. Pirimiphos-methyl
  6. Bendiocarb
  7. Propoxur
  8. Alpha-cypermethrin
  9. Bifenthrin
  10. Cyfluthrin
  11. Deltamethrin
  12. Deltamethrin
  13. Etofenprox
  14. Lambda-cyhalothrin

Ironically DDT tops the list.  No chemical is 100% safe, so the caveat with any of these chemicals is that, “WHO recommendations on the use of pesticides in public health are valid ONLY if linked to WHO specifications for their quality control. WHO specifications for public health pesticides are available on the Internet.

Interestingly, a bigger concern should be the potential for mosquitoes to develop resistance to any of the above mentioned insecticides.  This is why it is important to avoid putting all our eggs – soft or hard shelled – in one basket. Ideally insecticides should be rotated often to prevent resistance from developing.

Decisions to embark on IRS and choice of insecticides should be based on national and sub-national environmental and epidemiological characteristics, not emotional attachment to any particular product.