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Background Malaria is the notorious impediment of public health and economic development. Long-lasting insecticide-treated bed nets/insecticide-treated bed nets (LLINs/ITNs) are among major intervention strategies to avert the impact the disease. However, effectiveness of LLINs/ITNs depends on, inter alia , possessing sufficient number, proper utilization and timely replacement of nets. Thus, the World Health Organization (WHO) recommends surveys to evaluate possession and proper use of LLINs/ITNs by households. Methods A cross-sectional comparative household survey was conducted during peak malaria transmission season using interviewer-introduced questionnaires in southwest Ethiopia. A study site was selected from villages around a man-made lake, Gilgel-Gibe (GG) and a control site, with similar geographic and socio-economic features but far away from the lake, was identified. A total of 2,373 households from randomly selected cluster of households were included into the study and heads/spouses of the households responded to interviews. Binary and multinomial logistic regressions were used to identify predictors of LLIN ownership and utilization. Results LLIN/ITN ownership among the study populations was 56.6%, while 43.4% of households did not own a net. A higher proportion of households in GG reported owning at least one LLITN/ITN compared to control village (OR =2. 2, P <0.001) and more households in GG reported having only one LLITN/ITN in contrast to households in the control village (OR = 2.1, P <0.001). The mean number of LLINs/ITNs owned was 1.6 for GG residents and 1.8 for control village with a mean difference of -0.26 (95% CI = - 0.34, -0.19). The age of household heads, household relative wealth index (RWI), distance to nearest health service and accessibility to transportation showed a significant association with ownership of LLINs/ITNs. The probability of owning two or more LLINs/ITNs was positively associated with age of household head. Marital status of household heads, RWI, distance to nearest health service, accessibility to transport, residence and household size showed a significant association with utilization of LLINs/ITNs. Conclusion Attention needs to be given to the poor, distant and inaccessible households in the efforts of malaria intervention programmes, such as free distribution of LLINs/ITNs. Well-tailored information, education and communication is needed to address the problem of non-users.

Background Attaining the goal of reducing the global malaria burden is threatened by recent setbacks in maintaining the effectiveness of vector control interventions partly due to the emergence of pyrethroid resistant vectors. One potential strategy to address these setbacks could be combining indoor residual spraying (IRS) with non-pyrethroids and standard insecticide-treated nets (ITNs). This study aimed to provide evidence on the incremental epidemiological benefit of using third-generation IRS product in a highly endemic area with high ITN ownership. Methods A cluster-randomized, open-label, parallel-arms, superiority trial was conducted in the Mopeia district in Zambezia, Mozambique from 2016 to 2018. The district had received mass distribution of alphacypermethrin ITNs two years before the trial and again mid-way. 86 clusters were defined, stratified and randomized to receive or not receive IRS with pirimiphos-methyl (Actellic®300 CS). Efficacy of adding IRS was assessed through malaria incidence in a cohort of children under five followed prospectively for two years, enhanced passive surveillance at health facilities and by community health workers, and yearly cross-sectional surveys at the peak of the transmission season. Findings A total of 1536 children were enrolled in the cohort. Children in the IRS arm experienced 4,801 cases (incidence rate of 3,532 per 10,000 children-month at risk) versus 5,758 cases in the no-IRS arm (incidence rate of 4,297 per 10,000 children-month at risk), resulting in a crude risk reduction of 18% and an incidence risk ratio of 0.82 (95% CI 0.79–0.86, p-value < 0.001). Facility and community passive surveillance showed a malaria incidence of 278 per 10,000 person-month in the IRS group (43,974 cases over 22 months) versus 358 (95% CI 355–360) per 10,000 person-month at risk in the no-IRS group (58,030 cases over 22 months), resulting in an incidence rate ratio of 0.65 (95% CI 0.60–0.71, p < 0.001). In the 2018 survey, prevalence in children under five in the IRS arm was significantly lower than in the no-IRS arm (OR 0.54, 95% CI, 0.31–0.92, p = 0.0241). Conclusion In a highly endemic area with high ITN access and emerging pyrethroid resistance, adding IRS with pirimiphos-methyl resulted in significant additional protection for children under five years of age. Trial registration: ClinicalTrials.gov identifier NCT02910934, registered 22 September 2016, https://clinicaltrials.gov/ct2/show/NCT02910934?term=NCT02910934&draw=2&rank=1 .

Background As malaria cases increase in some of the highest burden countries, more strategic deployment of new and proven interventions must be evaluated to meet global malaria reduction goals. Methods The cost and cost-effectiveness of indoor residual spraying (IRS) with pirimiphos-methyl (Actellic®300 CS) were assessed in a high transmission district (Mopeia) with high access to pyrethroid insecticide-treated nets (ITNs), compared to ITNs alone. The major mosquito vectors in the area were susceptible to primiphos-methyl, but resistant to pyrethoids. A decision analysis approach was followed to conduct deterministic and probabilistic sensitivity analyses in a theoretical cohort of 10,000 children under five years of age (U5) and 10,000 individuals of all ages, separately. Model parameters and distributions were based on prospectively collected cost and epidemiological data from a cluster-randomized control trial and a literature review. The primary analysis used health facility-malaria incidence, while community cohort incidence and cross-sectional prevalence rates were used in sensitivity analyses. Lifetime costs, malaria cases, deaths and disability-adjusted life-years (DALYs) were calculated to determine the incremental costs per DALY averted through IRS. Results The average IRS cost per person protected was US$8.26 and 51% of the cost was insecticide. IRS averted 46,609 (95% CI 46,570–46,646) uncomplicated and 242 (95% CI 241–243) severe lifetime cases in a theoretical children U5 cohort, yielding an incremental cost-effectiveness ratio (ICER) of US$400 (95% CI 399–402) per DALY averted. In the all-age cohort, the ICER was higher: US$1,860 (95% CI 1,852–1,868) per DALY averted. Deterministic and probabilistic results were consistent. When adding the community protective effect of IRS, the cost per person protected decreased (US$7.06) and IRS was highly cost-effective in children U5 (ICER = US$312) and cost-effective in individuals of all ages (ICER = US$1,431), compared to ITNs alone. Conclusion This study provides robust evidence that IRS with pirimiphos-methyl can be cost-effective in high transmission regions with high pyrethroid ITN coverage where the major vector is susceptible to pirimiphos-methyl but resistant to pyrethroids. The finding that insecticide cost is the main driver of IRS costs highlights the need to reduce the insecticide price without jeopardizing effectiveness. Trial registration : ClinicalTrials.gov identifier NCT02910934 (Registered 22 September 2016). https://clinicaltrials.gov/ct2/show/NCT02910934?term=NCT02910934&draw=2&rank=1

Background There is growing awareness of the likely impact increased numbers of LLINs will have on the environment, if not disposed of or recycled appropriately. As part of a World Health Organization (WHO) and United Nations Environment Programme (UNEP) pilot study to assess environmentally-sound and cost-effective LLIN recycling strategies, the USAID-Deliver Project collected 22,559 used bed nets in Madagascar. A social science study was conducted to provide data on socio-cultural factors related to collection and replacement of LLINs, including impact on primary and other net uses. Methods Ethnographic exploratory research was carried out following the pilot USAID-Deliver net collection and recycling campaign in Betioky, Tsihombe, Fenerive Est and Ambanja districts of Madagascar, triangulating participant observation, interviewing and group discussions. Sampling was theoretical and data analysis was a continuous and iterative process concurrent to data collection. Final analysis was conducted using NVivo10. Results The following themes emerged as contributing to the success of collecting expired LLINs in the community for recycling purposes: (i) net adequacy and preference: characteristic differences between collected and newly distributed nets lead to communities’ reticence to relinquish old nets before confirming new nets were appropriate for intended use. Where newly distributed nets failed to meet local requirements, this was expected to increase alternative uses and decrease household turn over. (ii) Net collection strategies: the net collection campaign brought net use out of the private sphere and into the public arena. Net owners reported feeling ashamed when presenting damaged nets in public for collection, leading to reduced net relinquishment. (iii) Net lifecycle: communities perceived nets as being individually owned and economic value was attributed both to good-condition nets for sleeping and to worn nets for alternative/secondary purposes. Collecting nets at the stage of waste rather than at their prescribed end of life was locally acceptable. Conclusion The collection of LLINs for recycling/disposal can lead to lower coverage under certain conditions. Collecting used LLINs may be appropriate under the following conditions: (i) nets are collected at the stage of waste; (ii) new nets are in line with community preferences; and (iii) collection strategies have been agreed upon within the community prior to replacement activities. Any collection/recycling of old LLINs should be based on in-depth understanding of the local context and include participatory processes to prevent reduced coverage.

Background Despite targeted indoor residual spraying (IRS) over a six-year period and free mass distribution of long-lasting insecticide-treated nets (ITNs), malaria rates in northern Ghana remain high. Outdoor sleeping and other night-time social, cultural and economic activities that increase exposure to infective mosquito bites are possible contributors. This study was designed to document these phenomena through direct observation, and to explore the context in which they occur. Methods During the late dry season months of February and March 2014, study team members carried out continuous household observations from dusk to dawn in one village in Ghana’s Northern Region and one in Upper West Region. In-depth interviews with health workers and community residents helped supplement observational findings. Results Study team members completed observations of 182 individuals across 24 households, 12 households per site. Between the two sites, they interviewed 14 health workers, six community health volunteers and 28 community residents. In early evening, nearly all study participants were observed to be outdoors and active. From 18.00-23.00 hours, socializing, night school, household chores, and small-scale economic activities were common. All-night funerals, held outdoors and attended by large numbers of community members, were commonly reported and observed. Outdoor sleeping was frequently documented at both study sites, with 42% of the study population sleeping outdoors at some time during the night. While interviewees mentioned bed net use as important to malaria prevention, observed use was low for both indoor and outdoor sleeping. Net access within households was 65%, but only 17% of those with access used a net at any time during the night. Participants cited heat as the primary barrier and reported higher net use during the rainy season. Discussion Outdoor sleeping and other night-time activities were extensive, and could significantly increase malaria risk. These findings suggest that indoor-oriented control measures such as ITNs and IRS are insufficient to eliminate malaria in this setting, especially given the low net use observed. Development and evaluation of complementary outdoor control strategies should be prioritized. A research agenda is proposed to quantify the relative risk of outdoor night-time activities and test potential vector control interventions that might reduce that risk.

Background Continuous distribution of insecticide-treated nets (ITNs) has now been accepted as one way of sustaining ITN universal coverage. Community-based channels offer an interesting means of delivering ITNs to households to sustain universal ITN coverage. The objective of this study was to provide proof of concept for this channel. Methods A 9-month, community-based, distribution pilot was implemented beginning 1 year after a mass campaign in Lainya County, South Sudan from 2012 to 2013. Following social mobilization, community members could request an ITN from a net coupon holder. Eligibility criteria included having lost an ITN, giving birth outside of the health facility, or not having enough ITNs for all household members. After verification, households could exchange the coupon for an ITN at a distribution point. The evaluation was a pre/post design using representative household surveys with two-stage cluster sampling and a sample size of 600 households per survey. Results At endline, 78% of respondents were aware of the scheme and 89% of those also received an ITN through community-based distribution. Population access to ITNs nearly doubled, from 38% at baseline to 66% after the pilot. Household ownership of any ITN and enough ITNs (1 for 2 people) also increased significantly, from 66 to 82% and 19 to 46%, respectively. Community-based distribution was the only source of ITNs for 53.4% of households. The proportion of the population using an ITN last night increased from 22.7% at baseline to 53.9% at endline. A logistic regression model indicates that although behaviour change communication was positively associated with an increase in ITN use, access to enough nets was the greatest determinant of use. Conclusions ITN access and use improved significantly in the study area during the pilot, coming close to universal coverage targets. This pilot serves as proof of concept for the community-based distribution methodology implemented as a mechanism to sustain ITN universal coverage. Longer periods of implementation should be evaluated to determine whether community-based distribution can successfully maintain ITN coverage beyond the short term, and reach all wealth quintiles equitably.

Insecticide-treated nets (ITNs), particularly long-lasting insecticide-treated nets (LLINs), are important for malaria control; however, the rise of insecticide resistance, behavioral adaptations in mosquito vectors, and diminishing net durability May affect their efficacy. The objective of this systematic literature review and meta-analysis to synthesize recent epidemiological evidence (2021-2025) on the correlation between ITN/LLIN use and Plasmodium falciparum infection prevalence and to explore sources of heterogeneity across populations, settings, and type of nets. Searches across PubMed, Scopus, andWeb of Science yielded 3151 records, of which 10 met the inclusion criteria. Two separate meta-analyses were performed for crude and adjusted effect estimates using random-effects models. The crude-effects meta-analysis included six studies comprising 7466 participants and yielded a pooled odds ratio of 0.67 (95% CI: 0.42-1.07; p equivalent 0.078), indicating no statistically significant association between ITN/LLIN use and P. falciparum infection. Significant heterogeneity was observed (I2 equivalent 79.8%), which was partially explained by population type (59.3%) and study design (36.1%). Subgroup analysis revealed comparable infection prevalence-based associations for ITNs (OR equivalent 0.72) and LLINs (OR equivalent 0.59) use. Assessment of publication bias indicated slight asymmetry; however, the trim-and-fill adjustment did not significantly change the conclusions. The adjusted-effects meta-analysis, comprising nine studies, yielded a non-significant pooled effect (aOR equivalent 0.88; 95% CI: 0.42-1.86; p equivalent 0.71) with substantial heterogeneity (I2 equivalent 88.7%). Meta-regression analyses indicated that effect estimates varied by population group and country, with statistically significant modifiers observed for children under five years (p equivalent 0.0098) and for studies conducted in Uganda (p equivalent 0.0378). The type of net contributed to variation between studies, with insecticidetreated nets (ITNs) exhibiting lower pooled odds than long-lasting insecticide-treated nets (LLINs) (p equivalent 0.0415). Overall, this meta-analysis found no conclusive evidence of a statistically significant association between ITN/LLIN use and P. falciparum infection in contemporary epidemiological studies. The substantial heterogeneity across settings underscores the context-dependent nature of observed associations and highlights the need for integrated vector-control strategies and continued evaluation of net technologies under conditions of increasing resistance.

The private sector in Tanzania has played an essential role in improving coverage and access to mosquito nets. This follow-up study assessed the overall market share for untreated and insecticide-treated nets (ITNs) and misleading or counterfeit ITN products in commercial markets. This study was conducted from March to April 2024 in ten regions in Tanzania. The study used mixed methods: (1) a quantitative survey among sampled outlets supported by photographic documentation of all net products and (2) key informant interviews of retailers and wholesalers. We assessed the relationship between market share and population access using ANOVA and Pearson correlation. No counterfeit or misleading nets were found, consistent with results from 2017, 2021, and 2022 surveys. Untreated nets dominated all markets, comprising 99% of all products observed and 99% of estimated net sales 3 months before the survey. Legitimate ITNs were crowded out from the studied markets. Leaked nets from free distributions were present but extremely limited (1%) and at their lowest level of the survey rounds. Untreated nets were more expensive than leaked ITNs for both regular- and queen-size nets. Despite ongoing efforts, increasing the share of legitimate ITNs remains a significant challenge in a context of large-scale public sector distributions.

Malaria remains a major public health problem in Ethiopia. Consequently, Ethiopia designed the 2011-2015, Malaria Prevention and Control Strategic Plan to fight the vector. It was discovered that most of the studies conducted on the use of insecticide-treated nets (ITNs) were not in line with the strategic plan of the country. This study aimed to assess ITN ownership and utilization, and includes barriers related to its use among the target-area population at household (HH) level. A cross-sectional design was employed in Itang for this study. Data were collected by trained nurses through face-to-face interview and observation. A total of 845 participants were selected through multistage sampling, and the size was determined by using a single-population proportion formula. EPI Info and SPSS was used for analysis, and all necessary statistical association was computed in order to explain the outcome variable through explanatory variables of this study. Among 845 HHs interviewed, 81.7% (690) had at least one ITN, while 52.3% (361) had used the ITN the night preceding the data-collection day. HH awareness of malaria prevention, number of ITNs, family size, number of family members sharing sleeping area/beds, sleeping patterns of adolescents, HH-head age, and inconvenience of using ITNs were found to be barriers to the use of ITNs in this study. The study concluded that very few HHs owned ITNs and there was very low usage of ITNs. In recommendation, the regional health bureau and district health office should consider bigger nets that can accommodate family members who share the same sleeping area/bed in the area.

Many sub-Saharan African countries have achieved substantial gains in insecticide treated bednet coverage since 2005. The Tanzania National Malaria Control Programme identified school-based net distribution as one potential ‘keep-up’ strategy for the purpose of maintaining long-lasting insecticidal net (LLIN) coverage after a nationwide mass campaign in 2011. The School Net Programme (SNP) was implemented in three regions of southern Tanzania and distributed one LLIN to each enrolled child attending schools in primary grades (standards) 1, 3, 5 and 7, and secondary grades (forms) 2 and 4 in 2013 and again with slightly modified eligibility criteria in 2014 and 2015. Household surveys in the programme area as well as in a control area were conducted after each of the SNP distributions to measure ownership and use of long-lasting insecticide treated nets. Ownership of at least one LLIN after the first distribution was 76.1% (95% CI 70.8–80.7) in the intervention area and 78.6% (95% CI 74.4–82.3) in the control area. After the second distribution, ownership of at least one LLIN had dropped significantly in the control area to 65.4% (95% CI 59.5–71.0) in 2015 (P < 0.001), while coverage in the intervention area was maintained at 79.3% (95% CI 75.4 × 82.6). Ownership of at least one LLIN in intervention area remained stable following the second round of net distribution. During the same period LLIN ownership, especially of enough nets to ensure all household member access, fell significantly in the control area. These results demonstrate that the SNP may be sufficient to maintain stable LLIN coverage following a mass distribution of LLINs. De nombreux pays d’Afrique subsaharienne ont réalisé des gains substantiels depuis 2005, dans le cadre de la couverture par les moustiquaires imprégnées d’insecticide à longue durée d’action. Le Programme national de lutte contre le paludisme de la Tanzanie a identifié la distribution des moustiquaires imprégnées d’insecticide à longue durée d’action dans les écoles comme une stratégie potentielle de «suivi» visant à maintenir une bonne couverture par les moustiquaires imprégnées d’insecticide à longue durée d’action (MILDA) à la suite d’une vaste campagne nationale menée en 2011. Le programme School Net (SNP) a été mis en œuvre dans trois régions du sud de la Tanzanie et a distribué une MILDA à chaque enfant inscrit dans les classes de SIL, CE1, CM1 et CM2 des écoles primaires et les classes de 5ème et de 2nde des collèges secondaires au cours de l’année 2013; et l’opération a été répétée avec des critères d’éligibilité légèrement modifiés en 2014 et 2015. Des enquêtes auprès des ménages dans la zone d’intervention du programme ainsi que dans une zone de contrôle ont été menées après chacune des interventions du programme SNP pour mesurer le taux de détention et d’utilisation de moustiquaires imprégnées d’insecticide à longue durée d’action. La détention d’au moins une MILDA après la première distribution était de 76,1% (95% IC 70,8-80,7) dans la zone d’intervention et de 78,6% (95% IC 74,4-82,3) dans la zone de contrôle. Après la deuxième distribution, la détention d’au moins une MILDA a considérablement diminué dans la zone de contrôle à 65,4% (95% IC 59,5- 71,0) en 2015 (P<0,001), tandis que la couverture dans la zone d’intervention s’est maintenue à 79,3% (95% IC 75.4- 82.6). La détention d’au moins une MILDA dans la zone d’intervention est restée stable après le deuxième cycle de distribution de moustiquaires. Au cours de la même période, la détention de MILDA, en nombre suffisant pour en garantir l’accès à tous les membres du ménage, a considérablement diminué dans la zone de contrôle. Ces résultats démontrent que le programme SNP peut permettre de maintenir une couverture stable en MILDA à la suite d’une vaste campagne de distribution de ces moustiquaires. 自2005年以来, 许多撒哈拉以南的非洲国家经杀虫剂处理的蚊 帐覆盖率显著提高。 2011年全国大规模运动后, 坦桑尼亚国家 疟疾控制项目将在校发放蚊帐作为维持长效驱虫蚊帐 （LLIN） 覆盖率的有效常规策略。学校蚊帐项目 （SNP） 在 坦桑尼亚南部三个地区实施, 2013年向低年级 （1、3、5、 7） 和中学 （2、4年级） 每名在校生发放一顶长效蚊帐, 2014 和2015年再次发放, 领取资格略有调整。每次SNP发放后, 在 项目区和对照区进行住户调查, 统计长效驱虫蚊帐占有率和使 用率。第一次发放后, 干预区至少拥有一顶蚊帐的住户为 76.1% （95% CI 70.8%-80.7%）, 对照区为78.6% （95% CI 74.4%-82.3%） 。第二次发放后, 对照区至少拥有一顶蚊帐的 住户在2015年显著降低至65.4% （95% CI 59.5%-71.0%） （P<0.001）, 干预区维持在79.3% （95% CI 75.4%-82.6%）。第二轮蚊帐发放后, 干预区至少拥有一顶LLIN的住 户比例维持稳定。同期在对照地区, 拥有LLIN的住户比例, 尤 其是有足够蚊帐保证所有家庭成员使用的住户比例严重下 降。上述结果显示SNP可维持大规模发放长效驱虫蚊帐后 LLIN的覆盖率。 Muchos países de África sub-Sahariana han alcanzado ganancias sustanciales en la cobertura de mosquiteros tratados con insecticida desde 2005. El Programa Nacional de Lucha contra la Malaria de Tanzania identificó la distribución de redes basada en la escuela como una estrategia potencial para mantener la cobertura de mosquiteros tratados con insecticida de larga duración (MILD) después de una campaña masiva a nivel nacional en 2011. El Programa Escolar de Mosquiteros (PEM) se implementó en tres regiones del sur de Tanzania y distribuyó un MILD a cada niño matriculado que asistía a las escuelas en los grados de primaria (estándares) 1, 3, 5 y 7, y los grados de secundaria 2 y 4 en 2013 y nuevamente con criterios de elegibilidad ligeramente modificados en 2014 y 2015. Se realizaron encuestas de hogares en el área del programa así como en un área de control después de cada una de las distribuciones del PEM para medir la propiedad y el uso de mosquiteros tratados con insecticida de larga duración. La propiedad de al menos un MILD después de la primera distribución fue de 76.1% (IC 95% 70.8-80.7) en el área de intervención y 78.6% (IC 95% 74.4-82.3) en el área de control. Después de la segunda distribución, la propiedad de al menos un MILD había disminuido significativamente en el área de control hasta el 65.4% (95% IC 59.5-71.0) en 2015 (P < 0.001), mientras que la cobertura en el área de intervención se mantuvo en 79.3% (95% CI 75.4 -82,6). La propiedad de al menos un MILD en el área de intervención se mantuvo estable tras la segunda ronda de distribución de mosquiteros. Durante el mismo período, la propiedad de los LLIN, especialmente de suficientes mosquiteros para asegurar el acceso de todos los miembros del hogar, disminuyó significativamente en el área de control. Estos resultados demuestran que el PEM puede ser suficiente para mantener una cobertura de MILD estable después de una distribución masiva de MILDs.