![]() ![]() Despite their individual efficacy, few studies have evaluated the joint effect of both interventions, particularly in high transmission settings. A key factor for the success of both interventions is the effectiveness of the insecticides applied. The effectiveness and cost-effectiveness of malaria vector control strategies are well documented, and currently most sub-Saharan African countries recommend the implementation of either ITNs or IRS as preventive measures in malaria risk regions, in alignment with World Health Organization (WHO) recommendations. Optimizing the use of vector control interventions is one of the key tools to meeting global targets. This trend reversal is in part explained by reduced malaria prevention coverage, reduced effectiveness of pyrethroid insecticides used on ITNs due to increasing pyrethroid resistance among the primary malaria vectors, lack of political commitment, inadequate guidance to adapt new strategies in local settings of high burden countries, stagnation of investments and insufficient funds for malaria control and limited national cooperation across-sectors. This increase jeopardizes the achievement of current malaria burden targets. ĭespite these gains, ten sub-Saharan African countries with the highest malaria burden, accounting for more than half of the global disease burden, registered an increase in the number of malaria cases in 2017. As such, the continued reduction of the global malaria burden is successfully shrinking the geographical distribution of the disease and has laid the foundation for recent malaria elimination initiatives. Worldwide reductions in malaria morbidity and mortality are largely due to the scale-up of vector control strategies for malaria prevention, mainly insecticide-treated nets (ITNs) and indoor residual spraying (IRS), as well as the introduction of effective therapies and reliable diagnostic tools. Įffective vector control programmes have direct health benefits by reducing vector-borne diseases burden and have increased labour productivity, economic development and strengthened health systems. ![]() Trial registration: identifier NCT02910934 (Registered 22 September 2016). The finding that insecticide cost is the main driver of IRS costs highlights the need to reduce the insecticide price without jeopardizing effectiveness. 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. ![]() 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. Deterministic and probabilistic results were consistent. In the all-age cohort, the ICER was higher: US$1,860 (95% CI 1,852–1,868) per DALY averted. 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. The average IRS cost per person protected was US$8.26 and 51% of the cost was insecticide. Lifetime costs, malaria cases, deaths and disability-adjusted life-years (DALYs) were calculated to determine the incremental costs per DALY averted through IRS. The primary analysis used health facility-malaria incidence, while community cohort incidence and cross-sectional prevalence rates were used in sensitivity analyses. Model parameters and distributions were based on prospectively collected cost and epidemiological data from a cluster-randomized control trial and a literature review. 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. The major mosquito vectors in the area were susceptible to primiphos-methyl, but resistant to pyrethoids. 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. 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. ![]()
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