An updated review on the safety of N, N-diethyl-meta-toluamide insect repellent use in children and the efficacy of natural alternatives.

N, N-diethyl-meta-toluamide (DEET) has been considered the 'gold standard' for insect repellent use since the 1950s and constitutes most insect repellents on the market. However, conflicting data in the scientific literature and confusing information in the media are at the core of debates about the safety of DEET insect repellents for the protection of children against arthropod bites. The few fatal occurrences involving DEET insect repellents and complications of their use in the pediatric population are typically the result of accidental overdoses or misuse of insect repellents that disregard warnings on product labels. With appropriate application, the safety record of DEET insect repellents continues to be excellent with few side effects. The purpose of this review is to provide a summary of the literature on safety outcomes of DEET insect repellent use in children; outline the pediatric recommendations relating to DEET insect repellents; and provide an overview of EPA-approved and naturally derived alternatives to DEET that possess low toxicity while providing a similar level of protection to synthetic insect repellents.

Mosquito control exposures and breast cancer risk: analysis of 1071 cases and 2096 controls from the Ghana Breast Health Study.

Epidemiologic data on insecticide exposures and breast cancer risk are inconclusive and mostly from high-income countries. Using data from 1071 invasive pathologically confirmed breast cancer cases and 2096 controls from the Ghana Breast Health Study conducted from 2013 to 2015, we investigated associations with mosquito control products to reduce the spread of mosquito-borne diseases, such as malaria. These mosquito control products were insecticide-treated nets, mosquito coils, repellent room sprays, and skin creams for personal protection against mosquitos. Multivariable and polytomous logistic regression models were used to estimate odds ratios (ORadj) and 95% confidence intervals (CI) with breast cancer risk-adjusted for potential confounders and known risk factors. Among controls, the reported use of mosquito control products were mosquito coils (65%), followed by insecticide-treated nets (56%), repellent room sprays (53%), and repellent skin creams (15%). Compared to a referent group of participants unexposed to mosquito control products, there was no significant association between breast cancer risk and mosquito coils. There was an association in breast cancer risk with reported use of insecticide-treated nets; however, that association was weak and not statistically significant. Participants who reported using repellent sprays were at elevated risks compared to women who did not use any mosquito control products, even after adjustment for all other mosquito control products (OR = 1.42, 95% CI=1.15-1.75). We had limited power to detect an association with repellent skin creams. Although only a few participants reported using repellent room sprays weekly/daily or < month-monthly, no trends were evident with increased frequency of use of repellent sprays, and there was no statistical evidence of heterogeneity by estrogen receptor (ER) status (p-het > 0.25). Our analysis was limited when determining if an association existed with repellent skin creams; therefore, we cannot conclude an association. We found limited evidence of risk associations with widely used mosquito coils and insecticide-treated nets, which are reassuring given their importance for malaria prevention. Our findings regarding specific breast cancer risk associations, specifically those observed between repellent sprays, require further study.

Insect repellents: An updated review for the clinician.

Malaria, Zika virus, West Nile virus, Dengue fever, and Lyme disease are common causes of morbidity and mortality around the world. While arthropod bites may cause local inflammation and discomfort, a greater concern is the potential to develop deadly systemic infection. The use of insect repellents (IRs) to prevent systemic infections constitutes a fundamental public health effort. Cost effectiveness, availability, and high efficacy against arthropod vectors are key characteristics of an ideal IR. Currently, numerous IRs are available on the market, with N,N-diethyl-3-methylbenzamide (DEET) being the most widely used. DEET has an excellent safety profile and remarkable protection against mosquitoes and various other arthropods. Other Environmental Protection Agency-registered IR ingredients (eg, permethrin, picaridin, IR3535, oil of lemon eucalyptus, oil of citronella, catnip oil, and 2-undecanone) are alternative IRs of great interest because some of these ingredients have efficacies comparable to that of DEET. These alternative IRs possess low toxicity and favorable customer experiences in use (eg, cosmetically pleasant, naturally occurring). This review summarizes the currently available Environmental Protection Agency-registered IRs, including their origins, mechanisms of action, side effect profiles, and available formulations. This review will enable the clinician to select the best IR option to meet a patient's needs and provide the greatest protection from arthropod bites and their sequelae.

The fabrication and assessment of mosquito repellent cream for outdoor protection.

Mosquito-borne infections like dengue, malaria, chikungunya, etc. are a nuisance and can cause profound discomfort to people. Due to the objectional side effects and toxicity associated with synthetic pyrethroids, N,N-diethyl-3-methylbenzamide (DEET), N,N-diethyl phenylacetamide (DEPA), and N,N-di ethyl benzamide (DEBA) based mosquito repellent products, we developed an essential oil (EO) based mosquito repellent cream (EO-MRC) using clove, citronella and lemongrass oil. Subsequently, a formulation characterization, bio-efficacy, and safety study of EO-MRC were carried out. Expression of Anti-OBP2A and TRPV1 proteins on mosquito head parts were studied by western blotting. In-silico screening was also conducted for the specific proteins. An FT-IR study confirmed the chemical compatibility of the EOs and excipients used in EO-MRC. The thermal behaviour of the best EOs and their mixture was characterized by thermogravimetric analysis (TGA). GC-MS examination revealed various chemical components present in EOs. Efficacy of EO-MRC was correlated with 12% N,N-diethyl benzamide (DEBA) based marketed cream (DBMC). Complete protection time (CPT) of EO-MRC was determined as 228 min. Cytotoxicity study on L-132 cell line confirmed the non-toxic nature of EO-MRC upon inhalation. Acute dermal irritation study, acute dermal dose toxicity study, and acute eye irritation study revealed the non-toxic nature of EO-MRC. Non-target toxicity study on Danio rerio confirmed EO-MRC as safer for aquatic non-target animals. A decrease in the concentration of acetylcholinesterase (AChE) was observed in transfluthrin (TNSF) exposed Wistar rats. While EO-MRC did not alter the AChE concentrations in the exposed animals. Results from western blotting confirmed that Anti-OBP2A and TRPV1 proteins were inhibited in TNSF exposed mosquitoes. Mosquitoes exposed to EO-MRC showed a similar expression pattern for Anti-OBP2A and TRPV1 as the control group. In silico study revealed eight identified compounds of the EOs play significant roles in the overall repellency property of the developed product. The study emphasizes the mosquito repellent activity of EO-MRC, which could be an effective, eco-friendly, and safer alternative to the existing synthetic repellents for personal protection against mosquitoes during field conditions.

Cellular and molecular mechanisms of DEET toxicity and disease-carrying insect vectors: a review.

BACKGROUND: Several insects such as mosquitoes, flies, ticks, fleas, lice, and mites are known to serve as vectors for a vast number of pathogens. Many such vectors are hematophagous, and therefore introduce pathogens directly into the host's bloodstream. Importantly, the capacity of these vectors to spread disease can lead to serious global health crises. Furthermore, crop damage can be exacerbated by pathogen infection and increased insect foraging due to recent global warming. METHODS: Our study categorized insect-associated damage into three groups: animal infection, plant infection, and direct crop damage due to insect foraging. To manage these problems, insect repellents and pesticides have been developed, among which DEET is the most broadly used and studied pest control agent. This review discusses the mode of action and possible mechanisms of DEET action, including olfactory and gustatory mechanisms and central nervous system impairment. CONCLUSION: To protect humans from malaria, yellow fever, dengue fever, zika, and filariasis, as well as to reduce economic losses associated with crop damage, considerably more efforts are needed to characterize the interactions between insects and insect repellents/pesticides to develop more potent pest control agents.

Who's afraid of DEET? Fearmongering in papers on botanical repellents.

DEET (N,N-Diethyl-meta-toluamide) is considered the gold standard in mosquito repellents, not only for its effectiveness, but also for its safety. DEET has been more extensively studied for safety than any other repellent, and is accepted as completely safe when used correctly (i.e. not consumed or bathed in). Researchers studying botanical repellents, however, often paint DEET as far more toxic than it really is, falsely claiming it is a menace to the public health or even the environment. These claims are unfounded, and often the only evidence given by such publications are references to other publications also studying botanical repellents. Such publications are biased, and may be attacking DEET's excellent safety record to justify their existence and the need for their research. The inconvenient yet undisputable fact is that no botanical repellent has been proven to be as safe as DEET, and the majority never had any safety testing whatsoever. The automatic assumption that botanical repellents are safer than DEET is the 'appeal to nature fallacy,' which also drives most of the market for "natural" repellents, yet natural repellents have side effects and even a body count. Finding a botanical repellent that works as well as DEET and is equally safe is a legitimate research goal on its own, and need not be justified by fear-mongering and irrational chemophobia. Researchers studying these alternatives should strive for integrity, raising the real issue of the lack of safety testing for botanical repellents rather than denying the proven safety of DEET.

Comparison of efficacy and safety of preventive measures used against canine leishmaniasis in southern European countries: Longitudinal retrospective study in 1647 client-owned dogs (2012-2016).

The best preventive strategy for canine leishmaniasis is, to date, unknown. In the last few years, new preventive measures have become available in Europe, including vaccination against leishmaniasis and the use of domperidone. The objective of the present study was to evaluate the efficacy and safety of the different preventive measures available against leishmaniasis in client-owned dogs. A database search of medical records was carried out in 52 private veterinary practices located in endemic areas of canine leishmaniasis in Spain, Italy and Portugal. Healthy seronegative dogs were included in the study. Serology was repeated at least 6 months later, and was used to retrospectively classify dogs into healthy, infected or sick. A total of 1647 dogs were included in the study. The use of preventive measures in this population was widespread. The single most utilized measure was repellents alone in 45.7% of dogs, followed by the combination of repellents and vaccination in 23.0%, repellents and domperidone in 11.3%, vaccination alone in 4.2%, vaccination and domperidone in 2.7%, domperidone alone in 2.3%, and the combination of the three measures in 0.2% of dogs. No preventive measure was applied in 10.7% dogs. The incidence of clinical leishmaniasis in the group with no preventive treatment applied was 12.5%. In the groups where prevention was applied, the reported incidence was the following: 10.1% for the vaccination only group, 4.5% for repellents only group, 4.0% for repellents + vaccination group, and 0.5% for repellents + domperidone group. No dogs in the groups of domperidone, vaccination + domperidone, and combination of the three measures developed clinical leishmaniasis. All preventive measures resulted in a significantly lower incidence of leishmaniasis compared to not applying any measure, except for vaccination alone. The majority of preventive strategies used, with exception of vaccination alone, decreased the incidence of leishmaniasis significantly. Adverse events, mild and self-limiting in most of the cases, were reported in 5.2% of dogs and were significantly more common in dogs following vaccination. In conclusion, this is the first large-scale field study investigating the efficacy and safety of the preventive measures used routinely against leishmaniasis in client-owned dogs. Most preventive strategies used, with exception of vaccination alone, had some benefit over not applying any preventive. In this field study, the use of repellents showed a good degree of protection in dogs living in endemic areas of canine leishmaniasis. Although lower numbers of dogs are included, the use of domperidone appeared to provide additional protection. The role of vaccination and its combination with other preventive strategies needs further study.

Environmental health risks and benefits of the use of mosquito coils as malaria prevention and control strategy.

BACKGROUND: Malaria is an infectious disease that causes many deaths in sub-Saharan Africa. In resource-poor malaria endemic communities, mosquito coils are commonly applied in households to repel the vector mosquito that transmits malaria parasites. In applying these coils, users have mainly been interested in the environmental health benefits potentially derived from repelling the mosquito, while oblivious of the environmental health risks that may be associated with exposure to emissions from the use of mosquito coil. This study evaluated the effectiveness of the mosquito coil, ascertained and/or estimated the toxic emissions that may emanate from the coil, and determined its overall appropriateness by conducting a risk-benefit analysis of the use of this strategy in malaria prevention at household levels. METHODS: The repellent ability of mosquito coils was tested by conducting a mosquito knockdown/mortality test in experimental chambers synonymous of local room spaces and conditions. The gaseous and particulate emissions from the mosquito coil were also analysed. Additional scenarios were generated with the Monte Carlo technique and a risk-benefit analysis was conducted applying @Risk software. RESULTS: Mosquito mortality arising from the application of various mosquito coils averagely ranged between 24 and 64%, which might not provide adequate repellency effect. Emissions from the mosquito coil were also found to contain CO, VOCs, SO2, NO2, PM2.5 and PM10. The Hazard Index of the respective pollutants characterized over a lifetime exposure scenario was low (< 1 for each pollutant), which suggests that the concentrations of the specific chemicals and particulate matter emitted from the mosquito coil may not constitute adverse environmental health risk. CONCLUSION: Although the risk of morbidity from the use of the mosquito coil was low, the coil yielded limited protection as a mosquito avoidance method. It may, therefore, have a reduced benefit in controlling malaria and should be applied sparingly in a highly regulated manner only when traditionally proven effective vector control strategies are not available or too expensive for resource-poor malaria endemic regions.

Evaluation of the anti-feeding and insecticidal effects of a topically administered combination of imidacloprid and permethrin (Advantix®) against Phlebotomus (Larroussius) perniciosus (Newstead, 1911) in dogs following monthly administration.

BACKGROUND: Two laboratory experiments (Studies 1 and 2) were conducted to confirm the efficacy of an imidacloprid and permethrin combination (Advantix® Spot-on, Bayer) to repel and kill Phlebotomus (Larroussius) perniciosus sand flies when applied once a month topically to dogs. METHODS: Both studies compared dogs treated with a combination containing 100 mg/ml imidacloprid + 500 mg/ml permethrin (Advantix® Spot-on, Bayer) to placebo treated dogs. The treatments were applied topically on Day -28 (Study 2) and Day 0 (Studies 1 and 2). Sand fly exposures with 80 unfed females were performed before the first treatment for allocation purposes and post-treatment on study days (SDs) 1, 7, 14, 21 and 28 (following first or second monthly treatment for Studies 1 and 2, respectively). After 60 min, sand flies were assessed for mortality and engorgement status. RESULTS: Repellent evaluation (anti-feeding effect) on all days post-infestation showed efficacies that ranged between 88.1-99.3% during the first month and 92.2-98.9% during the second. Analyses of the comparison of fed sand fly counts for each treatment group resulted in a highly significant reduction (P < 0.0001) at all post-infestation time points for those dogs treated with Advantix®. A significant (P < 0.0001 for all time points) insecticidal effect was equally demonstrated. No treatment related adverse events were observed during the study. CONCLUSIONS: In the present studies Advantix® Spot-on demonstrated to be safe and to provide excellent four-week sand fly (P. perniciosus) repellency of ≥88.1% and ≥92.2% after a first and second monthly treatment, respectively. A significant insecticidal effect was also observed.

Unusual modes of action of the repellent DEET in insects highlight some human side effects.

N,N-diethyl-m-toluamide (DEET) induces favorable repellency against insects by acting on the sensory nervous system. According to emerging literature reports, DEET side effects in humans involve new molecular targets including the cholinergic system, acetylcholinesterase (AChE), muscarinic M1 and M3 receptor and the participation of the second messenger nitric oxide (NO). Most of these molecular events targeted by DEET have previously been characterized in insects while they have been considered as marginal compared to classical repellent properties. Despite these uncommon actions in insects, there is no consensus on the effects in human. Based on these data, this review provides new insights on side effects in human and more largely in mammals by identifying the unusual properties of DEET in insects, which seem to be correlated with adverse effects in mammals. These data will be very helpful to understand better the toxicological effects observed in order to protect non-target organisms from the toxicity.

Trends in insect repellent formulations: A review.

The use of natural and synthetic repellents, marketed in different pharmaceutical forms, is growing in the world due to the emerging vector-borne viral diseases as Dengue, Zika, Chikungunya, Yellow Fever and Malaria. The choice of the ideal formulation will depend on a series of factors to be analyzed: type of repellent active (natural or synthetic), pharmaceutical forms (spray, lotion, cream, gel), action time duration (short or long), environment of exposure and the user (adult, pregnant women, children, newborn). The most used repellents are DEET, IR3535 (Ethyl Butylacetylaminopropionate) (EB), Icaridin (Picaridin) and essential oils, each of them presenting advantages and disadvantages. DEET is the oldest and the most powerful repellent available in the market, thus being the reference standard. For this reason, there are many classic formulations available in the market containing the chemical component DEET in spray forms and lotions. However, due to its toxicity, DEET is not recommended for children up to 6 months and pregnant women. DEET has been an option along with other market-shared products as IR3535 and Icaridin (Picaridin), which present less toxicity in their composition. IR3535 is the less toxic and may be prescribed for children over 6 months of age and pregnant women so that they have been the best option because of the lower toxicity levels presented. IR3535 is the one that has the lowest toxicity level among the three options and may be prescribed for children above 6 months of age and pregnant women. Icaridin is as potent as DEET, but less toxic, and has the advantage of having the long-lasting action among the aforementioned repellents. The new formulations have been based on controlled release systems (CRS). The CRSs for repellents comprise polymer micro/nanocapsules, micro/solid lipid nanoparticles, nanoemulsions/microemulsions, liposomes/niosomes, nanostructured hydrogels and cyclodextrins. There are many formulations based on micro and nanocapsules containing DEET and essential oils to increase repellent action time duration and decrease permeation and consequently, systemic toxicity. The development of new formulations for the IR3535 and Icaridin is a research field yet to be explored. The current trend is the use of natural repellent actives such as essential oils, which present low toxicity, do not harm the environment, but present reduced repellent action time due to rapid evaporation after skin application. CRSs have been used as vehicle of natural repellents to improve long-lasting repellent action, reduce skin permeation and systemic effects.

Role of geraniol against lead acetate-mediated hepatic damage and their interaction with liver carboxylesterase activity in rats.

In this study, the effect of geraniol (50 mg/kg for 30 d), a natural antioxidant and repellent/antifeedant monoterpene, in a rat model of lead acetate-induced (500 ppm for 30 d) liver damage was evaluated. Hepatic malondialdehyde increased in the lead acetate group. Reduced glutathione unchanged, but glutathione S-transferase, glutathione reductase, as well as carboxylesterase activities decreased in geraniol, lead acetate and geraniol + lead acetate groups. 8-OhDG immunoreactivity, mononuclear cell infiltrations and hepatic lead concentration were lower in the geraniol + lead acetate group than the lead acetate group. Serum aspartate aminotransferase and alanine aminotransferase activities increased in the Pb acetate group. In conclusion, lead acetate causes oxidative and toxic damage in the liver and this effect can reduce with geraniol treatment. However, we first observed that lead acetate, as well as geraniol, can affect liver carboxylesterase activity.

Urinary concentrations of 3-(diethylcarbamoyl)benzoic acid (DCBA), a major metabolite of N,N-diethyl-m-toluamide (DEET) and semen parameters among men attending a fertility center.

STUDY QUESTION: Are specific gravity (SG)-adjusted urinary concentrations of 3-(diethylcarbamoyl)benzoic acid (DCBA) associated with semen parameters among men attending an academic fertility center? SUMMARY ANSWER: Our study did not demonstrate any association between SG-adjusted urinary DCBA concentrations and semen parameters among men attending an academic fertility center. WHAT IS KNOWN ALREADY: N,N-Diethyl-m-toluamide (DEET) is the most common active ingredient in consumer insect repellents. The recent rise in public health concerns regarding mosquito-borne diseases such as Zika, have led to an increased use of DEET insect repellents, especially among couples planning pregnancy. Animal studies have observed reproductive toxicity from DEET exposure. However, the reproductive health effects of DEET and its metabolites on human reproduction are unknown. STUDY DESIGN, SIZE, DURATION: Between 2007 and 2015, 90 men participating in a prospective cohort study at the Massachusetts General Hospital Fertility Center provided 171 urine samples and 250 semen samples for analysis. PARTICIPANTS/MATERIALS, SETTING, METHODS: The urinary concentrations of DEET, N,N-diethyl-3-hydroxymethylbenzamide (DHMB) and DCBA were quantified by isotope-dilution tandem mass spectrometry and adjusted by SG. We used linear mixed models to evaluate the association between tertiles of SG-adjusted urinary DCBA concentrations and semen parameters (semen volume, sperm concentration, total sperm count, progressive motility, total progressive motility count, normal morphology and total normal morphology count), adjusting for covariates. DEET and DHMB were not considered for analysis because of the low percentage of detectable concentrations (<7%). Effect modification by BMI and smoking status was explored. MAIN RESULTS AND THE ROLE OF CHANCE: Participants had a median age of 36 years and BMI of 27 kg/m2, and 68% had never smoked. The SG-adjusted geometric mean DCBA urinary concentration was 2.20 µg/l, with 85% detection frequency. The majority of semen parameters fell within the normal range with the exception of progressive motility, where 64% of the men had values below the WHO 2010 lower reference limits. SG-adjusted urinary DCBA concentrations were not associated with semen parameters in unadjusted or adjusted models. Men in the highest tertile of SG-adjusted urinary DCBA concentrations had comparable semen parameters to men in the lowest tertile (2.59 vs. 2.88 ml for semen volume, 47.9 vs. 45.8 million/ml for sperm concentration, 116 vs. 118 million for total sperm count, 25 vs. 24% for progressive sperm motility, and 6.1 vs. 5.8% for morphologically normal sperm). In addition, BMI and smoking status did not modify the associations. LIMITATIONS REASONS FOR CAUTION: We had a relatively small sample size with similar socioeconomic backgrounds and with overall relatively low urinary concentrations of DEET biomarkers. However, our sample size was enough to detect moderate differences with at least 80% statistical power, between the first and third tertiles of urinary DCBA concentrations. Limitations also include possible misclassification of DCBA exposure and difficulties in extrapolating the findings to the general population. WIDER IMPLICATIONS OF THE FINDINGS: Our study found no associations between urinary concentrations of DCBA, a major metabolite of the insect repellent DEET, and semen parameters in men presenting for infertility treatment. While these results are reassuring, further studies including larger sample sizes and higher exposures are warranted. STUDY FUNDING/COMPETING INTEREST(S): The project was financed by the National Institute of Health grants R01ES022955 and R01ES009718 and by grant P30ES000002 from the National Institute of Environmental Health Sciences (NIEHS). None of the authors has any conflicts of interest to declare. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. TRIAL REGISTRATION NUMBER: N/A.

Safety of a topical insect repellent (picaridin) during community mass use for malaria control in rural Cambodia.

BACKGROUND: While community distribution of topical repellents has been proposed as an additional malaria control intervention, the safety of this intervention at the population level remains poorly evaluated. We describe the safety of mass distribution of the picaridin repellent during a cluster-randomised trial in rural Cambodia in 2012-2013. METHODS: The repellent was distributed among 57 intervention villages with around 25,000 inhabitants by a team of village distributors. Information on individual adverse events, reported by phone by the village distributors, was obtained through home visits. Information on perceived side effects, reported at the family level, was obtained during two-weekly bottle exchange. Adverse events were classified as adverse reactions (events likely linked to the repellent), cases of repellent abuse and events not related to the repellent use, and classified as per Common Terminology Criteria for Adverse Events. FINDINGS: Of the 41 adverse events notified by phone by the village distributors, there were 22 adverse reactions, 11 cases of repellent abuse (6 accidental, 5 suicide attempts) and 8 non-related events. All adverse reactions were mild, occurred in the first few months of use, and mainly manifested as skin conditions. Of the 11 cases of abuse, 2 were moderate and 2 life-threatening. All cases with adverse reactions and repellent abuse recovered completely. 20% of families reported perceived side effects, mainly itching, headache, dizziness and bad smell, but few discontinued repellent use. CONCLUSIONS: Adverse reactions and abuse during mass use of picaridin were uncommon and generally mild, supporting the safety of the picaridin repellent for malaria control.

A review of recommendations on the safe and effective use of topical mosquito repellents.

Mosquito-borne disease is an annual problem in Australia, with endemic pathogens such as Ross River virus infecting thousands of people each year. The recent emergence of Zika virus in South America and the Pacific, together with ongoing outbreaks of dengue viruses in Southeast Asia, generated great community interest in the most effective strategies to avoid mosquito bites. Large-scale mosquito control programs are not common in Australia and are limited in New South Wales (NSW). The use of topical insect repellents is a key recommendation by health authorities to prevent mosquito-borne disease. All products sold in Australia purporting to repel mosquitoes must be registered with the Australian Pesticides and Veterinary Medicines Authority. Despite around 100 commercial products registered as repelling mosquitoes, there are relatively few active ingredients used across these formulations. The most common are diethyltoluamide (DEET), picaridin, p-menthane-3,8-diol (PMD) and a range of plant-derived products (e.g. melaleuca, eucalyptus, citronella oils). Research has shown that each of these active ingredients varies in the duration of protection provided against biting mosquitoes. Recommendations by health authorities are informed by this research, but inconsistencies between recommendations and available repellent formulations and their concentration of active ingredients can cause confusion in the community. There are conflicts between the data resulting from scholarly research, marketing promotion by manufacturers and recommendations provided by overseas health authorities. A review was undertaken of NSW Health's current recommendations on choosing and using insect repellents, taking into consideration recent research and currently registered topical repellents.

The use of mosquito repellents at three sites in India with declining malaria transmission: surveys in the community and clinic.

BACKGROUND: Repellents such as coils, vaporizers, mats and creams can be used to reduce the risk of malaria and other infectious diseases. Although evidence for their effectiveness is limited, they are advertised as providing an additional approach to mosquito control in combination with other strategies, e.g. insecticide-treated nets. We examined the use of repellents in India in an urban setting in Chennai (mainly Plasmodium vivax malaria), a peri-urban setting in Nadiad (both P. vivax and P. falciparum malaria), and a more rural setting in Raurkela (mainly P. falciparum malaria). METHODS: The use of repellents was examined at the household level during a census, and at the individual level in cross-sectional surveys and among patients visiting a clinic with fever or other symptoms. Factors associated with their use were examined in a multivariate analysis, and the association between malaria and the use of repellents was assessed among survey- and clinic participants. RESULTS: Characteristics of participants differed by region, with more people of higher education present in Chennai. Use of repellents varied between 56-77 % at the household level and between 32-78 % at the individual level. Vaporizers were the main repellents used in Chennai, whereas coils were more common in Nadiad and Raurkela. In Chennai and Nadiad, vaporizers were more likely to be used in households with young male children. Vaporizer use was associated with higher socio-economic status (SES) in households in Chennai and Nadiad, whereas use of coils was greater in the lower SES strata. In Raurkela, there was a higher use of coils among the higher SES strata. Education was associated with the use of a repellent among survey participants in Chennai and clinic study participants in Chennai and Nadiad. Repellent use was associated with less malaria in the clinic study in Chennai and Raurkela, but not in the surveys, with the exception of the use of coils in Nadiad. CONCLUSIONS: Repellents are widely used in India. Their use is influenced by the level of education and SES. Information on effectiveness and guidance on choices may improve rational use.