Variation in the effectiveness of insecticide treated nets

Insecticide treated nets (ITNs) protect humans against bites from Background the mosquito vectors that transmit malaria, thereby reducing malaria Anopheles morbidity and mortality. It has been noted that ITN use leads to a switch from indoor to outdoor feeding among these vectors. It might be expected that outdoor feeding would undermine the effectiveness of ITNs that target indoors vectors, but data are limited. : We linked homestead level geospatial data to clinical surveillance Methods data at a primary healthcare facility in Kilifi County in order to map geographical heterogeneity in ITN effectiveness and observed vector feeding behaviour using landing catches and CDC light traps in six selected areas of varying ITN effectiveness. We quantified the interaction between mosquitoes and humans to evaluate whether outdoor vector biting is a potential explanation for the variation in ITN effectiveness. : We observed 37% and 46% visits associated with positive malaria Results slides among ITN users and non-ITN-users, respectively; ITN use was associated with 32% protection from malaria (crude OR = 0.68, 95% CI: 0.64, 0.73). We obtained significant modification of ITN effectiveness by geographical area (p=0.016), and identified significant hotspots using the spatial scan statistic. Majority of mosquitoes were caught outdoor (60%) and were of the group (75%). The overall propensity to feed at times An. funestus when most people are indoor was high; the vast majority of the Anopheles mosquitoes were caught at times when most people are indoor. Estimates for the proportion of human-mosquito contact between the first and last hour when most humans were indoor was consistently high, ranging from 0.83 to 1.00. : Our data therefore do not support the hypothesis that outdoor Conclusion biting limits the effectiveness of ITNs in our study area. 1 1-3 1,3 1