Mosquito feeding behavior and how it influences residual malaria transmission across Africa.

The antimalarial efficacy of the most important vector control interventions-long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS)-primarily protect against mosquitoes' biting people when they are in bed and indoors. Mosquito bites taken outside of these times contribute to residual transmission which determines the maximum effectiveness of current malaria prevention. The likelihood mosquitoes feed outside the time of day when LLINs and IRS can protect people is poorly understood, and the proportion of bites received outdoors may be higher after prolonged vector control. A systematic review of mosquito and human behavior is used to quantify and estimate the public health impact of outdoor biting across Africa. On average 79% of bites by the major malaria vectors occur during the time when people are in bed. This estimate is substantially lower than previous predictions, with results suggesting a nearly 10% lower proportion of bites taken at the time when people are beneath LLINs since the year 2000. Across Africa, this higher outdoor transmission is predicted to result in an estimated 10.6 million additional malaria cases annually if universal LLIN and IRS coverage was achieved. Higher outdoor biting diminishes the cases of malaria averted by vector control. This reduction in LLIN effectiveness appears to be exacerbated in areas where mosquito populations are resistant to insecticides used in bed nets, but no association was found between physiological resistance and outdoor biting. Substantial spatial heterogeneity in mosquito biting behavior between communities could contribute to differences in effectiveness of malaria control across Africa.

Attrition, physical integrity and insecticidal activity of long-lasting insecticidal nets in sub-Saharan Africa and modelling of their impact on vectorial capacity.

BACKGROUND: Long-lasting insecticidal nets (LLINs) are the primary malaria prevention and control intervention in many parts of sub-Saharan Africa. While LLINs are expected to last at least 3 years under normal use conditions, they can lose effectiveness because they fall out of use, are discarded, repurposed, physically damaged, or lose insecticidal activity. The contributions of these different interrelated factors to durability of nets and their protection against malaria have been unclear. METHODS: Starting in 2009, LLIN durability studies were conducted in seven countries in Africa over 5 years. WHO-recommended measures of attrition, LLIN use, insecticidal activity, and physical integrity were recorded for eight different net brands. These data were combined with analyses of experimental hut data on feeding inhibition and killing effects of LLINs on both susceptible and pyrethroid resistant malaria vectors to estimate the protection against malaria transmission-in terms of vectorial capacity (VC)-provided by each net cohort over time. Impact on VC was then compared in hypothetical scenarios where one durability outcome measure was set at the best possible level while keeping the others at the observed levels. RESULTS: There was more variability in decay of protection over time by country than by net brand for three measures of durability (ratios of variance components 4.6, 4.4, and 1.8 times for LLIN survival, use, and integrity, respectively). In some countries, LLIN attrition was slow, but use declined rapidly. Non-use of LLINs generally had more effect on LLIN impact on VC than did attrition, hole formation, or insecticide loss. CONCLUSIONS: There is much more variation in LLIN durability among countries than among net brands. Low levels of use may have a larger impact on effectiveness than does variation in attrition or LLIN degradation. The estimated entomological effects of chemical decay are relatively small, with physical decay probably more important as a driver of attrition and non-use than as a direct cause of loss of effect. Efforts to maximize LLIN impact in operational settings should focus on increasing LLIN usage, including through improvements in LLIN physical integrity. Further research is needed to understand household decisions related to LLIN use, including the influence of net durability and the presence of other nets in the household.

Adaptive introgression in an African malaria mosquito coincident with the increased usage of insecticide-treated bed nets.

Animal species adapt to changes in their environment, including man-made changes such as the introduction of insecticides, through selection for advantageous genes already present in populations or newly arisen through mutation. A possible alternative mechanism is the acquisition of adaptive genes from related species via a process known as adaptive introgression. Differing levels of insecticide resistance between two African malaria vectors, Anopheles coluzzii and Anopheles gambiae, have been attributed to assortative mating between the two species. In a previous study, we reported two bouts of hybridization observed in the town of Selinkenyi, Mali in 2002 and 2006. These hybridization events did not appear to be directly associated with insecticide-resistance genes. We demonstrate that during a brief breakdown in assortative mating in 2006, A. coluzzii inherited the entire A. gambiae-associated 2L divergence island, which includes a suite of insecticide-resistance alleles. In this case, introgression was coincident with the start of a major insecticide-treated bed net distribution campaign in Mali. This suggests that insecticide exposure altered the fitness landscape, favoring the survival of A. coluzzii/A. gambiae hybrids, and provided selection pressure that swept the 2L divergence island through A. coluzzii populations in Mali. We propose that the work described herein presents a unique description of the temporal dynamics of adaptive introgression in an animal species and represents a mechanism for the rapid evolution of insecticide resistance in this important vector of human malaria in Africa.

A village level cluster-randomized entomological evaluation of combination long-lasting insecticidal nets containing pyrethroid plus PBO synergist in Southern Mali.

BACKGROUND: There is growing concern that malaria vector resistance to pyrethroid insecticides may reduce the effectiveness of long-lasting insecticidal nets (LLINs). Combination LLINs are designed to control susceptible and pyrethroid-resistant mosquito populations through a mixture of pyrethroid with piperonyl butoxide (PBO) synergist. A cluster randomized trial with entomology outcome measures was conducted in Mali to determine the added benefit over mono-treated pyrethroid predecessors. Four LLIN treatments; permethrin + PBO, permethrin, deltamethrin + PBO, and deltamethrin, were randomly allocated to four villages each (16 villages total) and distributed to cover every sleeping place. Entomological monitoring of indoor Anopheles resting densities, host preference, vector longevity, and sporozoite rates were monitored every 2 months over 2 years in 2014 and 2015. RESULTS: Bottle bioassays confirmed permethrin and deltamethrin resistance in Anopheles gambiae sensu lato (s.l.), (the predominant species throughout the study) with pre-exposure to PBO indicating partial involvement of oxidases. Between 2014 and 2015 the mean indoor resting density was greater in the deltamethrin + PBO LLIN arm than the deltamethrin LLIN arm at 3.05 (95% CI 3.00-3.10) An. gambiae s.l. per room per day compared with 1.9 (95% CI 1.87-1.97). There was no significant difference in sporozoite rate at 3.97% (95% CI 2.91-5.02) for the deltamethrin LLIN arm and 3.04% (95% CI 2.21-3.87) for deltamethrin + PBO LLIN arm (P = 0.17). However, when analysed by season there was some evidence that the sporozoite rate was lower in the deltamethrin + PBO LLIN arm than deltamethrin LLIN arm during the rainy/high malaria transmission seasons at 1.95% (95% CI 1.18-2.72) and 3.70% (95% CI 2.56-4.84) respectively (P = 0.01). CONCLUSIONS: While there was some evidence that An. gambiae s.l. sporozoite rates were lower in villages with deltamethrin + PBO LLINs during the high malaria transmission seasons of 2014-2015, there was no reduction in parity rates or indoor resting densities. There was also no evidence that permethrin + PBO LLINs provided any improved control when compared with permethrin LLINs. Combination nets may have a greater impact in areas where mixed function oxidases play a more important role in pyrethroid resistance.

The effectiveness of non-pyrethroid insecticide-treated durable wall lining to control malaria in rural Tanzania: study protocol for a two-armed cluster randomized trial.

BACKGROUND: Despite considerable reductions in malaria achieved by scaling-up long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS), maintaining sustained community protection remains operationally challenging. Increasing insecticide resistance also threatens to jeopardize the future of both strategies. Non-pyrethroid insecticide-treated wall lining (ITWL) may represent an alternate or complementary control method and a potential tool to manage insecticide resistance. To date no study has demonstrated whether ITWL can reduce malaria transmission nor provide additional protection beyond the current best practice of universal coverage (UC) of LLINs and prompt case management. METHODS/DESIGN: A two-arm cluster randomized controlled trial will be conducted in rural Tanzania to assess whether non-pyrethroid ITWL and UC of LLINs provide added protection against malaria infection in children, compared to UC of LLINs alone. Stratified randomization based on malaria prevalence will be used to select 22 village clusters per arm. All 44 clusters will receive LLINs and half will also have ITWL installed on interior house walls. Study children, aged 6 months to 11 years old, will be enrolled from each cluster and followed monthly to estimate cumulative incidence of malaria parasitaemia (primary endpoint), time to first malaria episode and prevalence of anaemia before and after intervention. Entomological inoculation rate will be estimated using indoor CDC light traps and outdoor tent traps followed by detection of Anopheles gambiae species, sporozoite infection, insecticide resistance and blood meal source. ITWL bioefficacy and durability will be monitored using WHO cone bioassays and household surveys, respectively. Social and cultural factors influencing community and household ITWL acceptability will be explored through focus-group discussions and in-depth interviews. Cost-effectiveness, compared between study arms, will be estimated per malaria case averted. DISCUSSION: This protocol describes the large-scale evaluation of a novel vector control product, designed to overcome some of the known limitations of existing methods. If ITWL is proven to be effective and durable under field conditions, it may warrant consideration for programmatic implementation, particularly in areas with long transmission seasons and where pyrethroid-resistant vectors predominate. Trial findings will provide crucial information for policy makers in Tanzania and other malaria-endemic countries to guide resource allocations for future control efforts. TRIAL REGISTRATION: NCT02533336 registered on 13 July 2014.

Spatiotemporal dynamics of gene flow and hybrid fitness between the M and S forms of the malaria mosquito, Anopheles gambiae.

The M and S forms of Anopheles gambiae have been the focus of intense study by malaria researchers and evolutionary biologists interested in ecological speciation. Divergence occurs at three discrete islands in genomes that are otherwise nearly identical. An "islands of speciation" model proposes that diverged regions contain genes that are maintained by selection in the face of gene flow. An alternative "incidental island" model maintains that gene flow between M and S is effectively zero and that divergence islands are unrelated to speciation. A "divergence island SNP" assay was used to explore the spatial and temporal distributions of hybrid genotypes. Results revealed that hybrid individuals occur at frequencies ranging between 5% and 97% in every population examined. A temporal analysis revealed that assortative mating is unstable and periodically breaks down, resulting in extensive hybridization. Results suggest that hybrids suffer a fitness disadvantage, but at least some hybrid genotypes are viable. Stable introgression of the 2L speciation island occurred at one site following a hybridization event.

Mobile soak pits improve spray team mobility, productivity and safety of PMI malaria control programs.

In the President's Malaria Initiative (PMI)-funded Africa Indoor Residual Spraying Project (AIRS), end-of-day clean-up operations require the safe disposal of wash water resulting from washing the exterior of spray tanks and spray operators' personal protective equipment. Indoor residual spraying (IRS) programs typically use soak pits - large, in-ground filters - to adsorb, filter and then safely degrade the traces of insecticide found in the wash water. Usually these soak pits are permanent installations serving 30 or more operators, located in a central area that is accessible to multiple spray teams at the end of their workday. However, in remote areas, it is often impractical for teams to return to a central soak pit location for cleanup. To increase operational efficiency and improve environmental compliance, the PMI AIRS Project developed and tested mobile soak pits (MSP) in the laboratory and in field applications in Madagascar, Mali, Senegal, and Ethiopia where the distance between villages can be substantial and the road conditions poor. Laboratory testing confirmed the ability of the easily-assembled MSP to reduce effluent concentrations of two insecticides (Actellic 300-CS and Ficam VC) used by the PMI AIRS Project, and to generate the minimal practicable environmental "footprint" in these remote areas. Field testing in the Mali 2014 IRS campaign demonstrated ease of installation and use, resulted in improved and more consistent standards of clean-up, decreased transportation requirements, improved spray team working conditions, and reduced potential for operator exposure to insecticide.

Complex genome evolution in Anopheles coluzzii associated with increased insecticide usage in Mali.

In certain cases, a species may have access to important genetic variation present in a related species via adaptive introgression. These novel alleles may interact with their new genetic background, resulting in unexpected phenotypes. In this study, we describe a selective sweep on standing variation on the X chromosome in the mosquito Anopheles coluzzii, a principal malaria vector in West Africa. This event may have been influenced by the recent adaptive introgression of the insecticide resistance gene known as kdr from the sister species Anopheles gambiae. Individuals carrying both kdr and a nearly fixed X-linked haplotype, encompassing at least four genes including the P450 gene CYP9K1 and the cuticular protein CPR125, have rapidly increased in relative frequency. In parallel, a reproductively isolated insecticide-susceptible A. gambiae population (Bamako form) has been driven to local extinction, likely due to strong selection from increased insecticide-treated bed net usage.

A preliminary investigation of the relationship between water quality and Anopheles gambiae larval habitats in Western Cameroon.

BACKGROUND: Water quality and anopheline habitat have received increasing attention due to the possibility that challenges during larval life may translate into adult susceptibility to malaria parasite infection and/or insecticide resistance. METHODS: A preliminary study of Anopheles gambiae s.s. larval habitats in the north-west and south-west regions of Cameroon was conducted in order to detect associations between An. gambiae s.s. molecular form and 2La inversion distributions with basic water quality parameters. Water quality was measured by temperature, pH, conductivity, total dissolved solids (TDS) at seven sites in Cameroon and one site in Selinkenyi, Mali. RESULTS: Principal components and correlation analyses indicated a complex relationship between 2La polymorphism, temperature, conductivity and TDS. Cooler water sites at more inland locations yielded more S form larvae with higher 2La inversion polymorphism while warmer water sites yielded more M form larvae with rare observations of the 2La inversion. DISCUSSION: More detailed studies that take into account the population genetics but also multiple life stages, environmental data relative to these life stages and interactions with both humans and the malaria parasite may help us to understand more about how and why this successful mosquito is able to adapt and diverge, and how it can be successfully managed.

Efficacy of long-lasting insecticidal nets in use in Macha, Zambia, against the local Anopheles arabiensis population.

BACKGROUND: The mosquito Anopheles arabiensis is the primary vector of Plasmodium falciparum in Macha, Zambia. A major portion of Zambia's current malaria control programme relies on long-lasting insecticide-treated nets (LLINs) and indoor residual spraying (IRS) with insecticides. Currently, the efficacy of these measures against An. arabiensis in Macha is unknown, and previous data has shown that An. arabiensis has continued to feed on human hosts, despite high ITN coverage. It is possible that this could be due to either decreased efficacy of ITNs in used in Macha, or pyrethroid resistance in the vector. METHODS: F1 offspring of field-collected adult An. arabiensis were tested for insecticide resistance, using CDC bottle bioassays and deltamethrin ITN susceptibility assays. The mosquitoes were characterized for the knock-down resistance (kdr) allele by PCR. LLINs that had been in use for two years in nearby villages were collected and tested for residual deltamethrin concentration and net quality, and were used in bioassays against susceptible colonized Anopheles gambiae s.s. Keele. Additionally, a survey on ITN use and care was conducted among LLIN owners. RESULTS: In the F1 An. arabiensis field population, low levels of resistance to DDT and deltamethrin-treated net material were detected by bioassay, although the knock-down resistance (kdr) allele not present in the population. ITN evaluations revealed high variability in residual deltamethrin concentration, quality of the nets, and mosquito mortality in bioassays. Mortality against An. gambiae s.s. in bioassays was correlated with residual deltamethrin concentration, which was dependent upon the number of washes each net had received. CONCLUSIONS: Proper LLIN care was a strong determinant of LLIN efficacy, indicating that education on the importance of LLIN use and care is key when distributing nets. As there is little insecticide resistance in the local vector population, degradation of LLINs most likely allowed for continued human feeding by An. arabiensis. Continued monitoring and assessment of both the vector population and the efficacy of LLINs in use is necessary in order to appropriately modify vector control operations and prevent the development of pyrethroid resistance.

Evidence for Divergent Selection on Immune Genes between the African Malaria Vectors, Anopheles coluzzii and A. gambiae.

During their life cycles, microbes infecting mosquitoes encounter components of the mosquito anti-microbial innate immune defenses. Many of these immune responses also mediate susceptibility to malaria parasite infection. In West Africa, the primary malaria vectors are Anopheles coluzzii and A. gambiae sensu stricto, which is subdivided into the Bamako and Savanna sub-taxa. Here, we performed whole genome comparisons of the three taxa as well as genotyping of 333 putatively functional SNPs located in 58 immune signaling genes. Genome data support significantly higher differentiation in immune genes compared with a randomly selected set of non-immune genes among the three taxa (permutation test p < 0.001). Among the 58 genes studied, the majority had one or more segregating mutations (72.9%) that were significantly diverged among the three taxa. Genes detected to be under selection include MAP2K4 and Raf. Despite the genome-wide distribution of immune genes, a high level of linkage disequilibrium (r2 > 0.8) was detected in over 27% of SNP pairs. We discuss the potential role of immune gene divergence as adaptations to the different larval habitats associated with A. gambiae taxa and as a potential force driving ecological speciation in this group of mosquitoes.

Mitochondrial genomes of Anopheles arabiensis, An. gambiae and An. coluzzii show no clear species division.

Here we report the complete mitochondrial sequences of 70 individual field collected mosquito specimens from throughout Sub-Saharan Africa. We generated this dataset to identify species specific markers for the following Anopheles species and chromosomal forms: An. arabiensis, An. coluzzii (The Forest and Mopti chromosomal forms) and An. gambiae (The Bamako and Savannah chromosomal forms).  The raw Illumina sequencing reads were mapped to the NC_002084 reference mitogenome sequence. A total of 783 single nucleotide polymorphisms (SNPs) were detected on the mitochondrial genome, of which 460 are singletons (58.7%). None of these SNPs are suitable as molecular markers to distinguish among An. arabiensis, An. coluzzii and An. gambiae or any of the chromosomal forms. The lack of species or chromosomal form specific markers is also reflected in the constructed phylogenetic tree, which shows no clear division among the operational taxonomic units considered here.

Multi-country assessment of residual bio-efficacy of insecticides used for indoor residual spraying in malaria control on different surface types: results from program monitoring in 17 PMI/USAID-supported IRS countries.

BACKGROUND: Indoor residual spraying (IRS) is the application of insecticide to the interior walls of household structures that often serve as resting sites for mosquito vectors of malaria. Human exposure to malaria vectors is reduced when IRS involves proper application of pre-determined concentrations of the active ingredient specific to the insecticide formulation of choice. The impact of IRS can be affected by the dosage of insecticide, spray coverage, vector behavior, vector susceptibility to insecticides, and the residual efficacy of the insecticide applied. This report compiles data on the residual efficacy of insecticides used in IRS campaigns implemented by the United States President's Malaria Initiative (PMI)/United States Agency for International Development (USAID) in 17 African countries and compares observed length of efficacy to ranges proposed in World Health Organization (WHO) guidelines. Additionally, this study provides initial analysis on variation of mosquito mortality depending on the surface material of sprayed structures, country spray program, year of implementation, source of tested mosquitoes, and type of insecticide. METHODS: Residual efficacy of the insecticides used for PMI/USAID-supported IRS campaigns was measured in Benin, Burkina Faso, Ethiopia, Ghana, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Nigeria, Rwanda, Senegal, Tanzania, Uganda, Zambia and Zimbabwe. The WHO cone bioassay tests were used to assess the mortality rate of mosquitoes exposed to insecticide-treated mud, wood, cement, and other commonly used housing materials. Baseline tests were performed within weeks of IRS application and follow-up tests were continued until the mortality of exposed mosquitoes dropped below 80% or the program monitoring period ended. Residual efficacy in months was then evaluated with respect to WHO guidelines that provide suggested ranges of residual efficacy for insecticide formulations recommended for use in IRS. Where the data allowed, direct comparisons of mosquito mortality rates were then made to determine any significant differences when comparing insecticide formulation, country, year, surface type, and the source of the mosquitoes used in testing. RESULTS: The residual efficacy of alpha-cypermethrin ranged from 4 to 10 months (average = 6.4 months), with no reported incidents of underperformance when compared to the efficacy range provided in WHO guidelines. Deltamethrin residual efficacy results reported a range of 1 to 10 months (average = 4.9 months), with two instances of underperformance. The residual efficacy of bendiocarb ranged from 2 weeks to 7 months (average = 2.8 months) and failed to achieve proposed minimum efficacy on 14 occasions. Lastly, long-lasting pirimiphos-methyl efficacy ranged from 2 months to 9 months (average = 5.3 months), but reported 13 incidents of underperformance. CONCLUSIONS: Much of the data used to determine application rate and expected efficacy of insecticides approved for use in IRS programs are collected in controlled laboratory or pilot field studies. However, the generalizability of the results obtained under controlled conditions are limited and unlikely to account for variation in locally sourced housing materials, climate, and the myriad other factors that may influence the bio-efficacy of insecticides. Here, data are presented that confirm the variation in residual efficacy observed when monitoring household surfaces sprayed during PMI/USAID-supported IRS campaigns. All insecticides except alpha-cypermethrin showed evidence of failing to meet the minimum range of residual efficacy proposed in WHO criteria at least once. However, this initial effort in characterizing program-wide insecticide bio-efficacy indicates that some insecticides, such as bendiocarb and pirimiphos-methyl, may be vulnerable to variations in the local environment. Additionally, the comparative analysis performed in this study provides evidence that mosquito mortality rates differ with respect to factors including: the types of insecticide sprayed, surface material, geographical location, year of spraying, and tested mosquitoes. It is, therefore, important to locally assess the residual efficacy of insecticides on various surfaces to inform IRS programming.

Insecticide resistance status of three malaria vectors, Anopheles gambiae (s.l.), An. funestus and An. mascarensis, from the south, central and east coasts of Madagascar.

BACKGROUND: Insecticide-based vector control, which comprises use of insecticide-treated bed nets (ITNs) and indoor residual spraying (IRS), is the key method to malaria control in Madagascar. However, its effectiveness is threatened as vectors become resistant to insecticides. This study investigated the resistance status of malaria vectors in Madagascar to various insecticides recommended for use in ITNs and/or IRS. METHODS: WHO tube and CDC bottle bioassays were performed on populations of Anopheles gambiae (s.l.), An. funestus and An. mascarensis. Adult female An. gambiae (s.l.) mosquitoes reared from field-collected larvae and pupae were tested for their resistance to DDT, permethrin, deltamethrin, alpha-cypermethrin, lambda-cyhalothrin, bendiocarb and pirimiphos-methyl. Resting An. funestus and An. mascarensis female mosquitoes collected from unsprayed surfaces were tested against permethrin, deltamethrin and pirimiphos-methyl. The effect on insecticide resistance of pre-exposure to the synergists piperonyl-butoxide (PBO) and S,S,S-tributyl phosphorotrithioate (DEF) also was assessed. Molecular analyses were done to identify species and determine the presence of knock-down resistance (kdr) and acetylcholinesterase resistance (ace-1 R ) gene mutations. RESULTS: Anopheles funestus and An. mascarensis were fully susceptible to permethrin, deltamethrin and pirimiphos-methyl. Anopheles gambiae (s.l.) was fully susceptible to bendiocarb and pirimiphos-methyl. Among the 17 An. gambiae (s.l.) populations tested for deltamethrin, no confirmed resistance was recorded, but suspected resistance was observed in two sites. Anopheles gambiae (s.l.) was resistant to permethrin in four out of 18 sites (mortality 68-89%) and to alpha-cypermethrin (89% mortality) and lambda-cyhalothrin (80% and 85%) in one of 17 sites, using one or both assay methods. Pre-exposure to PBO restored full susceptibility to all pyrethroids tested except in one site where only partial restoration to permethrin was observed. DEF fully suppressed resistance to deltamethrin and alpha-cypermethrin, while it partially restored susceptibility to permethrin in two of the three sites. Molecular analysis data suggest absence of kdr and ace-1 R gene mutations. CONCLUSION: This study suggests involvement of detoxifying enzymes in the phenotypic resistance of An. gambiae (s.l.) to pyrethroids. The absence of resistance in An. funestus and An. mascarensis to pirimiphos-methyl and pyrethroids and in An. gambiae (s.l.) to carbamates and organophosphates presents greater opportunity for managing resistance in Madagascar.

Feasibility and Effectiveness of mHealth for Mobilizing Households for Indoor Residual Spraying to Prevent Malaria: A Case Study in Mali.

Components of mHealth are increasingly being added to development interventions worldwide. A particular case of interest is in Mali where the U.S. President's Malaria Initiative (PMI) Africa Indoor Residual Spraying (AIRS) Project piloted a mobile mass-messaging service in Koulikoro District in August 2014 to determine whether voice and/or text messages received on cell phones could effectively replace door-to-door mobilization for an indoor residual spraying (IRS) campaign. To measure the pilot's effectiveness, we evaluated structure preparedness (all household and food items removed) in 3 pilot intervention villages compared with 3 villages prepared for spray through door-to-door mobilization that was modified by incorporating town hall meetings and radio spots. Structure preparedness was significantly lower in households mobilized through the mobile-messaging approach compared with the door-to-door approach (49% vs. 75%, respectively; P = .03). Spray coverage of targeted households also was significantly lower among the mobile-messaging villages than the door-to-door mobilization villages (86% vs. 96%, respectively; P = .02). The mobile-messaging approach, at US$8.62 per structure prepared, was both more costly and less effective than the door-to-door approach at US$1.08 per structure prepared. While literacy and familiarity with technology were major obstacles, it also became clear that by removing the face-to-face interactions between mobilizers and household residents, individuals were not as trusting or understanding of the mobilization messages. These residents felt it was easier to ignore a text or voice message than to ignore a mobilizer who could provide reassurances and preparation support. In addition, men often received the mobile messages, as they typically owned the mobile phones, while women-who were more likely to be at home at the time of spray-usually interacted with the door-to-door mobilizers. Future attempts at using mHealth approaches for similar IRS mobilization efforts in Mali should be done in a way that combines mHealth tools with more common human-based interventions, rather than as a stand-alone approach, and should be designed with a gender lens in mind. The choice of software used for mass messaging should also be considered to find a local option that is both less expensive and perhaps more attuned to the local context than a U.S.-based software solution.

Phylogeny of anopheline (Diptera: Culicidae) species in southern Africa, based on nuclear and mitochondrial genes.

A phylogeny of anthropophilic and zoophilic anopheline mosquito species was constructed, using the nuclear internal transcribed spacer 2 (ITS2) and mitochondrial cytochrome oxidase subunit I (COI) genes. The ITS2 alignment, typically difficult due to its noncoding nature and large size variations, was aided by using predicted secondary structure, making this phylogenetically useful gene more amenable to investigation. This phylogeny is unique in explicitly including zoophilic, non-vector anopheline species in order to illustrate their relationships to malaria vectors. Two new, cryptic species, Anopheles funestus-like and Anopheles rivulorum-like, were found to be present in Zambia for the first time. Sequences from the D3 region of the 28S rDNA suggest that the Zambian An. funestus-like may be a hybrid or geographical variant of An. funestus-like, previously reported in Malawi. This is the first report of An. rivulorum-like sympatric with An. rivulorum (Leeson), suggesting that these are separate species rather than geographic variants.

'I see you're angry': actor-reported anger scores.

BACKGROUND: Teaching communication skills using role-play addresses an important learning need for medical students, with the debriefing process being central to the learning that occurs. In this work we examine the feasibility of using actor-reported 'anger scores', during a challenging communication scenario, as a tool to stimulate debriefing. METHODS: This teaching session was delivered to 10 groups of final-year MBBS (Bachelor of Medicine and Bachelor of Surgery) students at Newcastle University. One student from each group took on the role of the foundation year 1 (F1) doctor and had 10 minutes to talk to an angry relative (actor), who was unhappy with the care her mother had received. During the scenario the actor recorded her level of anger on a 10-point Likert scale (1, 'no anger'; 10, 'extreme anger') at 1-minute intervals. Once the scenario was complete, the in-room tutor graphically presented these scores against time. During debriefing, students were asked to examine the graph produced: fluctuations in anger levels were identified, discussion was held regarding possible precipitants for the changes seen and strategies were developed for tackling future such incidents. RESULTS: Examples of graphs produced during the session are presented, including annotations highlighting the discussion topics that arose. Feedback on the session from both students and actor was positive, with no reports that the scoring process interfered with the fidelity of the scenario. DISCUSSION: We believe that actor-reported 'anger scores' provide a quick, simple and cheap method of producing a visual aid to the debriefing process that, in the context of a challenging communication scenario, provided a stimulus for discussion.

Heterogeneity and changes in inequality of malaria risk after introduction of insecticide-treated bed nets in Macha, Zambia.

In 2007, the first free mass distribution of insecticide-treated bed nets (ITNs) occurred in southern Zambia. To determine the effect of ITNs on heterogeneity in biting rates, human DNA from Anopheles arabiensis blood meals was genotyped to determine the number of hosts that had contributed to the blood meals. The multiple feeding rate decreased from 18.9% pre-ITN to 9.1% post-ITN, suggesting that mosquito biting had focused onto a smaller fraction of the population. Pre-ITN, 20% of persons in a household provided 40% of blood meals, which increased to 59% post-ITN. To measure heterogeneity over a larger scale, mosquitoes were collected in 90 households in two village areas. Of these households, 25% contributed 78.1% of An. arabiensis, and households with high frequencies of An. arabiensis were significantly spatially clustered. The results indicate that substantial heterogeneity in malaria risk exists at local and household levels, and household-level heterogeneity may be influenced by interventions, such as ITNs.

An analysis of two island groups as potential sites for trials of transgenic mosquitoes for malaria control.

Considerable technological advances have been made towards the generation of genetically modified mosquitoes for vector control. In contrast, less progress has been made towards field evaluations of transformed mosquitoes which are critical for evaluating the success of, and hazards associated with, genetic modification. Oceanic islands have been highlighted as potentially the best locations for such trials. However, population genetic studies are necessary to verify isolation. Here, we used a panel of genetic markers to assess for evidence of genetic isolation of two oceanic island populations of the African malaria vector, Anopheles gambiae s.s. We found no evidence of isolation between the Bijagós archipelago and mainland Guinea-Bissau, despite separation by distances beyond the known dispersal capabilities of this taxon. Conversely, the Comoros Islands appear to be genetically isolated from the East African mainland, and thus represent a location worthy of further investigation for field trials. Based on assessments of gene flow within and between the Comoros islands, the island of Grande Comore was found to be genetically isolated from adjacent islands and also exhibited local population structure, indicating that it may be the most suitable site for trials with existing genetic modification technologies.