Efficacy, Safety and Cost of Insecticide Treated Wall Lining, Insecticide Treated Bed Nets and Indoor Wall Wash with Lime for Visceral Leishmaniasis Vector Control in the Indian Sub-continent

A Multi-country Cluster Randomized Controlled Trial

Citation: Mondal D, Das ML, Kumar V, Huda MM, Das P, Ghosh D, et al. (2016) Efficacy, Safety and Cost of Insecticide Treated Wall Lining, Insecticide Treated Bed Nets and Indoor Wall Wash with Lime for Visceral Leishmaniasis Vector Control in the Indian Sub-continent: A Multi-country Cluster Randomized Controlled Trial. PLoS Negl Trop Dis 10(8): e0004932. doi:10.1371/journal.pntd.0004932
Published: August 17, 2016

Abstract
Mosquito_NettingBackground: We investigated the efficacy, safety and cost of lime wash of household walls plus treatment of sand fly breeding places with bleach (i.e. environmental management or EM), insecticide impregnated durable wall lining (DWL), and bed net impregnation with slow release insecticide (ITN) for sand fly control in the Indian sub-continent.
Methods: This multi-country cluster randomized controlled trial had 24 clusters in each three sites with eight clusters per high, medium or low sand fly density stratum. Every cluster included 45–50 households. Five households from each cluster were randomly selected for entomological measurements including sand fly density and mortality at one, three, nine and twelve months post intervention. Household interviews were conducted for socioeconomic information and intervention acceptability assessment. Cost for each intervention was calculated. There was a control group without intervention.
Findings: Sand fly mortality [mean and 95%CI] ranged from 84% (81%-87%) at one month to 74% (71%-78%) at 12 months for DWL, 75% (71%-79%) at one month to 49% (43%-55%) at twelve months for ITN, and 44% (34%-53%) at one month to 22% (14%-29%) at twelve months for EM. Adjusted intervention effect on sand fly density measured by incidence rate ratio ranged from 0.28 (0.23–0.34) at one month to 0.62 (0.51–0.75) at 12 months for DWL; 0.72 (0.62–0.85) at one month to 1.02 (0.86–1.22) at 12 months for ITN; and 0.89 (0.76–1.03) at one months to 1.49 (1.26–1.74) at 12 months for EM. Household acceptance of EM was 74% compared to 94% for both DWL and ITN. Operational cost per household in USD was about 5, 8, and 2 for EM, DWL and ITN, respectively. Minimal adverse reactions were reported for EM and ITN while 36% of households with DWL reported transient itching.
Interpretation: DWL is the most effective, durable and acceptable control method followed by ITN. The Visceral Leishmaniasis (VL) Elimination Program in the Indian sub-continent should consider DWL and ITN for sand fly control in addition to IRS.

Author Summary: Sand fly control is one of the main priorities of the Visceral Leishmaniasis (VL) Elimination Program in Bangladesh, India and Nepal. Currently, indoor residual spraying with insecticides (IRS) is the most effective method available for sand fly control. The efficacy of other methods of vector control remains poorly understood. To reach elimination, these additional techniques need to be explored in order to complement IRS or replace it if it is unavailable. In this multi-country study we investigated the efficacy, safety and cost of lime wash of household walls plus treatment of sand fly breeding places with bleach (EM), insecticide impregnated durable wall lining (DWL), and bed net impregnation with slow release insecticide (ITN) for sand fly control in the Indian sub-continent. Among these vector control methods, we found DWL to be the most effective tool for sand fly control followed by ITN. DWL and ITN should be considered, in addition to IRS, for sand fly control by the VL elimination program in the Indian sub-continent depending on need and affordability.

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