Impact assessment of malaria vector control using routine surveillance data in Zambia: implications for monitoring and evaluation.

BACKGROUND: Malaria vector control using long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS), with pyrethroids and DDT, to reduce malaria transmission has been expansively implemented in Zambia. The impact of these interventions on malaria morbidity and mortality has not previously been formally assessed at the population level in Zambia. METHODS: The impact of IRS (15 urban districts) and LLINs (15 rural districts) implementation on severe malaria cases, deaths and case fatality rates in children below the age of five years were compared. Zambian national Health Management Information System data from 2007 to 2008 were retrospectively analysed to assess the epidemiological impact of the two interventions using odds ratios to compare the pre-scaling up year 2007 with the scaling-up year 2008. RESULTS: Overall there were marked reductions in morbidity and mortality, with cases, deaths and case fatality rates (CFR) of severe malaria decreasing by 31%, 63% and 62%, respectively between 2007 and 2008. In urban districts with IRS introduction there was a significant reduction in mortality (Odds Ratio [OR] = 0.37, 95% CI = 0.31-0.43, P = 0.015), while the reduction in mortality in rural districts with LLINs implementation was not significant (OR = 0.83, 95% CI = 0.67-1.04, P = 0.666). A similar pattern was observed for case fatality rates with a significant reduction in urban districts implementing IRS (OR = 0.34, 95% CI = 0.33-0.36, P = 0.005), but not in rural districts implementing LLINs (OR = 0.96, 95% CI = 0.91-1.00, P = 0.913). No substantial difference was detected in overall reduction of malaria cases between districts implementing IRS and LLINs (P = 0.933). CONCLUSION: Routine surveillance data proved valuable for determining the temporal effects of malaria control with two strategies, IRS and LLINs on severe malaria disease in different types of Zambian districts. However, this analysis did not take into account the effect of artemisinin-based combination therapy (ACT), which were being scaled up countrywide in both rural and urban districts.

Structure of an insect epsilon class glutathione S-transferase from the malaria vector Anopheles gambiae provides an explanation for the high DDT-detoxifying activity.

Glutathione S-transferases (GSTs), a major family of detoxifying enzymes, play a pivotal role in insecticide resistance in insects. In the malaria vector Anopheles gambiae, insect-specific epsilon class GSTs are associated with resistance to the organochlorine insecticide DDT [1,1,1-trichloro-2,2-bis-(p-chlorophenyl)ethane]. Five of the eight class members have elevated expression levels in a DDT resistant strain. agGSTe2 is considered the most important GST in conferring DDT resistance in A. gambiae, and is the only member of the epsilon class with confirmed DDT-metabolizing activity. A delta class GST from the same species shows marginal DDT-metabolizing activity but the activity of agGSTe2 is approximately 350x higher than the delta class agGST1-6. To investigate its catalytic mechanism and the molecular basis of its unusually high DDT-metabolizing ability, three agGSTe2 crystal structures including one apo form and two binary complex forms with the co-factor glutathione (GSH) or the inhibitor S-hexylglutathione (GTX) have been solved with a resolution up to 1.4A. The structure of agGSTe2 shows the canonical GST fold with a highly conserved N-domain and a less conserved C-domain. The binding of GSH or GTX does not induce significant conformational changes in the protein. The modeling of DDT into the putative DDT-binding pocket suggests that DDT is likely to be converted to DDE [1,1-dichloro-2,2-bis-(p-chlorophenyl)ethylene] through an elimination reaction triggered by the nucleophilic attack of the thiolate group of GS(-) on the beta-hydrogen of DDT. The comparison with the less active agGST1-6 provides the structural evidence for its high DDT-detoxifying activity. In short, this is achieved through the inclination of the upper part of H4 helix (H4'' helix), which brings residues Arg112, Glu116, and Phe120 closer to the GSH-binding site resulting in a more efficient GS(-)-stabilizing hydrogen-bond-network and higher DDT-binding affinity.

Acceptability and perceived side effects of insecticide indoor residual spraying under different resistance management strategies

OBJETIVO: Evaluar la aceptabilidad y los efectos secundarios del rociado intradomiciliar de insecticidas pyrethroides (PYR), carbamato y organophosphato rociados en rotación anual (ROT), en mosaico espacial (MOS), o solos (DDT o PYR) en hogares de comunidades de la costa de Chiapas. México.MATERIAL Y MÉTODOS: Se aplicó un cuestionario a un miembro de 30% de las familias de ocho localidades de Chiapas para evaluar aceptabilidad y efectos secundarios del rociado. Se usaron análisis de ji cuadrada para determinar la asociación de los insecticidas rociados con las respuestas y se comparó la intensidad de efectos secundarios referidos bajo los diferentes tratamientos en un modelo logístico ordenado usando un índice de severidad como variable de respuesta.RESULTADOS: Los insecticidas rociados como causa probable de síntomas fueron referidos por 2.1% de entrevistados, pero 12% de ellos asociaron los síntomas con otras causas. Un porcentaje significativamente alto de personas que refirieron visión borrosa, vértigo, estornudos, tos, entumecimiento, lagrimeo y comezón vivía en bajo MOS y ROT, mientras que el índice de severidad se asoció con el rociado ROT. La reducción en la picadura de mosquitos y en el número de cucarachas fueron los principales beneficios percibidos, y la mayoría de los lugareños que no percibieron los beneficios vivía en localidades tratadas con DDT. La mayoría de entrevistados aceptaron bien el rociado (83.7%), pero el mal olor y tener que sacar los muebles de las casas fueron los argumentos principales en contra.CONCLUSIONES: La cobertura de rociado correlacionó con la aceptabilidad, aunque la sugerencia más frecuente para incrementarla fue la de explicar los objetivos del rociado en las comunidades. La frecuencia de efectos secundarios fue baja, pero mayor en localidades donde se aplicó una combinación de insecticidas, lo que representa una limitación para el uso de esta estrategia de manejo de resistencia a estos químicos en salud pública.

Characterization of the promoters of Epsilon glutathione transferases in the mosquito Anopheles gambiae and their response to oxidative stress.

Epsilon class GSTs (glutathione transferases) are expressed at higher levels in Anopheles gambiae mosquitoes that are resistant to DDT [1,1,1-trichloro-2,2-bis-(p-chlorophenyl)ethane] than in insecticide-susceptible individuals. At least one of the eight Epsilon GSTs in this species, GSTe2, efficiently metabolizes DDT to DDE [1,1-dichloro-2,2-bis-(p-chlorophenyl)ethane]. In the present study, we investigated the factors regulating expression of this class of GSTs. The activity of the promoter regions of GSTe2 and GSTe3 were compared between resistant and susceptible strains by transfecting recombinant reporter constructs into an A. gambiae cell line. The GSTe2 promoter from the resistant strain exhibited 2.8-fold higher activity than that of the susceptible strain. Six polymorphic sites were identified in the 352 bp sequence immediately upstream of GSTe2. Among these, a 2 bp adenosine indel (insertion/deletion) was found to have the greatest effect on determining promoter activity. The activity of the GSTe3 promoter was elevated to a lesser degree in the DDT-resistant strain (1.3-fold). The role of putative transcription-factor-binding sites in controlling promoter activity was investigated by sequentially deleting the promoter constructs. Several putative transcription-factor-binding sites that are responsive to oxidative stress were present within the core promoters of these GSTs, hence the effect of H2O2 exposure on the transcription of the Epsilon GSTs was investigated. In the DDT-resistant strain, expression of GSTe1, GSTe2 and GSTe3 was significantly increased by a 1-h exposure to H2O2, whereas, in the susceptible strain, only GSTe3 expression responded to this treatment.

Structure of an insect delta-class glutathione S-transferase from a DDT-resistant strain of the malaria vector Anopheles gambiae.

Glutathione S-transferases (GSTs) are a major family of detoxification enzymes which possess a wide range of substrate specificities. Most organisms possess many GSTs belonging to multiple classes. Interest in GSTs in insects is focused on their role in insecticide resistance; many resistant insects have elevated levels of GST activity. In the malaria vector Anopheles gambiae, elevated GST levels are associated with resistance to the organochlorine insecticide DDT [1,1,1-trichloro-2,2-bis-(p-chlorophenyl)ethane]. This mosquito is the source of an insect GST, agGSTd1-6, which metabolizes DDT and is inhibited by a number of pyrethroid insecticides. The crystal structure of agGSTd1-6 in complex with its inhibitor S-hexyl glutathione has been determined and refined at 2.0 A resolution. The structure adopts a classical GST fold and is similar to those of other insect delta-class GSTs, implying a common conjugation mechanism. A structure-based model for the binding of DDT to agGSTd1-6 reveals two subpockets in the hydrophobic binding site (H-site), each accommodating one planar p-chlorophenyl ring.

Knowledge and beliefs about malaria transmission and practices for vector control in Southern Mexico

OBJECTIVE: To investigate the knowledge and beliefs about malaria transmission and practices for vector control in eight villages on the coastal plain of Chiapas, Mexico. MATERIAL AND METHODS: A cross-sectional survey was conducted during May and June 1995 in Chiapas, Mexico. A questionnaire to investigate family structure, knowledge on malaria transmission, preventive measures and attitudes towards seeking treatment was applied to both family heads of a sample of households. Associations were analyzed by estimating odds ratios with confidence intervals and p values, using bivariate and multivariate logistic regression methods. RESULTS: Malaria knowledge was poor and only 48 percent associated malaria with mosquito bites. The perceived benefit of indoor residual spraying was associated to a reduction of mosquitoes, a reduction in the numbers of cockroaches and rats, but only 3 percent associated it directly with the prevention of malaria transmission. Most villagers (97.6 percent) agreed with the indoor residual spraying of insecticides. Ninety nine percent of villagers had mosquito bednets, 75.7 percent used them all year round. Other measures used by villagers to prevent mosquito bites were smoke and mosquito coils. Above 40 percent of villagers self-medicated when any member of the family had a fever episode, but 51 percent attended proper health services (community dispensary, private physician, health worker). About 61 percent used pesticides for agricultural or livestock purposes and 55 percent applied them themselves. Women had a greater participation as family health promoters, with 70 percent of the housewives being in charge of the application of self-protection preventive measures. CONCLUSIONS: Educational programs aimed at increasing awareness on the participation of mosquitoes on malaria transmission could promote community participation in malaria control in the region