Durability of the deltamethrin-treated polypropylene long-lasting net LifeNet® in a pyrethroid resistance area in south western Benin: A phase III trial.

BACKGROUND: Long-lasting insecticidal bed nets (LLINs) are a key measure for preventing malaria and their evaluation is coordinated by the World Health Organization Pesticide Evaluation Scheme (WHOPES). LifeNet® was granted WHOPES time-limited interim recommendation in 2011 after successful Phase I and Phase II evaluations. Here, we evaluated the durability and community acceptance of LifeNet® in a Phase III trial from June 2014 to June 2017 in Benin rural area. METHODS: A prospective longitudinal, cluster-randomized, controlled trial with households as the unit of observation was designed to assess the performance of LifeNet® over a three-year period, using a WHOPES fully recommended LLIN (PermaNet® 2.0) as a positive control. The primary outcomes were the bioassay performance using WHO cone assays and tunnel tests, the insecticide content and physical integrity. RESULTS: At baseline, 100% of LLINs were within the tolerance limits of their target deltamethrin concentrations. By 36 months only 17.3% of LifeNet® and 8.5% of PermaNet® LLINs still were within their target deltamethrin concentrations. Despite these low rates, 100% of both LLINs meet WHO efficacy criteria (≥ 80% mortality or ≥ 95% knockdown or tunnel test criteria of ≥ 80% mortality or ≥ 90% blood-feeding inhibition) after 36 months using WHO cone bio-assays and tunnel tests. The proportion of LLINs in good physical condition was 33% for LifeNet® and 29% for PermaNet® after 36 months. After 36 M the survivorship was 21% and 26% for LifeNet® and PermaNet® respectively. Although both LLINs were well accepted by the population, complaints of side effects were significantly higher among LifeNet® users than PermaNet® ones. CONCLUSION: LifeNet® LLINs did meet WHO criteria for bio-efficacy throughout the study period and were well accepted by the population. This is an important step towards getting a full WHO recommendation for use in malaria endemic countries.

Measuring entomological parameters before implementing a study on asymptomatic carriers of Plasmodium falciparum in the Zè District in southern Benin.

BACKGROUND: The objective of this study was to estimate malaria transmission and insecticide resistance status in malaria vectors in Adjrako village from Zè District in Southern Benin. The present study was carried out prior to investigations on infectivity of blood from asymptomatic carriers of Plasmodium falciparum to malaria vector mosquitoes. METHODS: Human landing collections (HLCs) were performed in Adjrako village during the rainy season (September-November 2021). In this village, host-seeking mosquitoes were collected during three nights per survey from 22:00 to 06:00 in six randomly selected houses. Malaria vectors were dissected in orders to determinate their parity. Plasmodium falciparum infection in malaria vectors was determined by qPCR and the entomological inoculation rate (EIR) was calculated. The World Health Organization (WHO) insecticide susceptibility test-kits were used to evaluate the susceptibility of Anopheles gambiae sensu lato (s.l.) to deltamethrin at 0.05% and bendiocarb at 0.1%. RESULTS: A total of 3260 females of mosquitoes belonging to 4 genera (Anopheles, Culex, Aedes and Mansonia) were collected. Most of the mosquitoes collected were An. gambiae sensu lato (s.l.). The entomological inoculation rate (EIR) for the three collection months was 8.7 infective bites per person and the parity rate was 84%. Mortality rates of An. gambiae s.l. exposed to 0.05% deltamethrin and 0.1% bendiocarb were 18% and 96%, respectively, indicating that this vector population was resistant to deltamethrin and possibly resistant to bendiocarb in the study area. CONCLUSION: This study showed that malaria transmission is effective in the study area and that An. gambiae s.l. is the main malaria vector. The entomological parameters indicate this study area is potentially favourable for investigations on P. falciparum asymptomatic carriers.

Human biting rhythm of Anopheles gambiae Giles, 1902 (Diptera: Culicidae) and sleeping behaviour of pregnant women in a lagoon area in Southern Benin.

OBJECTIVE: In the framework of EVALMOUS study aiming to assess the use and effectiveness of mosquito nets by pregnant women and other members of their household in a lagoon area in southern Benin, the behaviour of pregnant women relative to the time they go to bed using the net were recorded. Malaria vectors biting rhythm, Plasmodium falciparum infection and insecticide resistance genes in malaria vectors were also determined. RESULTS: Overall, 3848 females of Anopheles gambiae s. l were collected and 280 pregnant women responded to the survey. Almost all Anopheles gambiae s. l. tested were Anopheles coluzzi Coetzee and Wilkerson 2013 (Diptera: Culicidae). The CSP index in malaria vector was 1.85% and the allelic frequency of kdr gene was 74.4%. Around 90% of bites and Plasmodium falciparum Welch, 1897 (Haemosporida: Plasmodiidae) transmission occurred between 10 p.m. and 6 a.m., which coincides with the period when more than 80% of pregnant women were under bednet. Despite a slight early evening and early morning biting activity of malaria vectors in the study area, the good use of nets might remain a useful protection tool against mosquito biting and malaria transmission.

Plasmodium falciparum merozoite surface antigen-specific cytophilic IgG and control of malaria infection in a Beninese birth cohort.

BACKGROUND: Substantial evidence indicates that cytophilic IgG responses to Plasmodium falciparum merozoite antigens play a role in protection from malaria. The specific targets mediating immunity remain unclear. Evaluating antibody responses in infants naturally-exposed to malaria will allow to better understand the establishment of anti-malarial immunity and to contribute to a vaccine development by identifying the most appropriate merozoite candidate antigens. METHODS: The study was based on parasitological and clinical active follow-up of infants from birth to 18 months of age conducted in the Tori Bossito area of southern Benin. For 399 infants, plasma levels of cytophilic IgG antibodies with specificity for five asexual stage malaria vaccine candidate antigens were determined by ELISA in infants' peripheral blood at 6, 9, 12 and 15 months of age. Multivariate mixed logistic model was used to investigate the association between antibody levels and anti-malarial protection in the trimester following the IgG quantification. Moreover, the concentrations of merozoite antigen-specific IgG were compared between a group of infants apparently able to control asymptomatic malaria infection (CAIG) and a group of infants with no control of malaria infection (Control group (NCIG)). Protective effect of antibodies was also assessed after 15 months of malaria exposure with a Cox regression model adjusted on environmental risk. RESULTS: Cytophilic IgG responses to AMA1, MSP1, MSP2-3D7, MSP2-FC27, MSP3 and GLURP R2 were associated with increasing malarial infection risk in univariate analysis. The multivariate mixed model showed that IgG1 and IgG3 to AMA1 were associated with an increased risk of malarial infection. However infants from CAIG (n = 53) had significantly higher AMA1-, MSP2-FC27-, MSP3-specific IgG1 and AMA1-, MSP1-, MSP2-FC27-, MSP3 and GLURP-R2-specific IgG3 than those from NCIG (n = 183). The latter IgG responses were not associated with protection against clinical malaria in the whole cohort when protective effect is assessed after 15 months of malaria exposition. CONCLUSION: In this cohort, merozoite antigen-specific cytophilic IgG levels represent a marker of malaria exposure in infants from 6 to 18 months of age. However, infants with resolution of asymptomatic infection (CAIG) seem to have acquired naturally immunity against P. falciparum. This observation is encouraging in the context of the development of multitarget P. falciparum vaccines.

Small-scale field testing of alpha-cypermethrin water-dispersible granules in comparison with the recommended wettable powder formulation for indoor residual spraying against malaria vectors in Benin.

BACKGROUND: Pyrethroids are the most common class of insecticide used worldwide for indoor residual spraying (IRS) against malaria vectors. Water-dispersible granules (WG) are a pyrethroid formulation to be applied after disintegration and dispersion in water with less risks of inhalation than using the usual wettable powder (WP) formulation. The objective of this small-scale field study was to evaluate efficacy and duration of insecticidal action of a new alpha-cypermethrin WG (250 g a.i./kg) against susceptible Anopheles gambiae in comparison with the WHO reference product (alpha-cypermethrin WP, 50 g a.i./kg) on the most common indoor surfaces in Benin. METHODS: Both formulations were applied at two target-dose concentrations in houses made of mud and cement in the Tokoli village in southern Benin. We measured the applied dose of insecticide by chemical analysis of filter paper samples collected from the sprayed inner walls. We recorded An. gambiae mortality and knock-down rates every 15 days during 6 months using standard WHO bioassays. RESULTS: The alpha-cypermethrin WG formulation did not last as long as the WP formulation on both surfaces. The difference is higher with the 30 mg/m2 concentration for which the WP formulation reached the 80% mortality threshold during 2 months on the mud-plastered walls (3 months on cement) whereas the WG formulation last only one month (2 months on cement). CONCLUSIONS: The new WG formulation has a shorter efficacy than the WHO recommended WP formulation. In this trial, both the WG and WP formulations had low durations of efficacy that would need at least two rounds of spray to cover the entire transmission season.

Field efficacy of a new deltamethrin long lasting insecticidal net (LifeNet©) against wild pyrethroid-resistant Anopheles gambiae in Benin.

BACKGROUND: Malaria vector control is mostly based on Long-Lasting Insecticidal Nets (LLIN). To date, all LLINs fully recommended by the World Health Organization Pesticide Scheme (WHOPES) are made of polyester or polyethylene. In this context, a new LLIN named LifeNet©, made of polypropylene fiber is developed. According to the manufacturer, LifeNet©is made of soft filament, has a greater mechanical strength, a superior insecticide wash resistance with a short insecticide regeneration time, a better flammability profile and a better environmental profile compared to polyester or polyethylene nets. METHODS: Through a WHOPES supervised trial, the efficacy of LifeNet© was evaluated in Benin in experimental huts against free-flying wild mosquitoes. RESULTS: LifeNet© has equal or better performances in terms of wash resistance, exophily, blood feeding inhibition and mortality compared to conventionally treated nets (CTN) treated with deltamethrin at 25 mg/m2 and washed to just before exhaustion. CONCLUSIONS: The efficacy of LifeNet© observed in this trial indicates that this net fulfill World Health Organization Pesticide Scheme (WHOPES) requirement for Long Lasting technology in Phase II. Throughout a Phase III trial currently ongoing in Southern Benin, the durability and the acceptability of this long-lasting insecticidal mosquito nets will be assessed under community conditions.

Impact of the use and efficacy of long lasting insecticidal net on malaria infection during the first trimester of pregnancy - a pre-conceptional cohort study in southern Benin.

BACKGROUND: Malaria in pregnancy is prevalent in Sub-Saharan Africa. The first trimester of pregnancy is a critical period and the best preventive measure is Long Lasting Insecticidal Nets (LLIN). Unfortunately, few studies have been conducted which focuses on the usage and efficacy of LLIN on malaria prevention during the first trimester. METHODS: We assessed the use and effectiveness of LLIN in early pregnancy in Benin and its impact on malaria infection risk. We followed-up a cohort of 240 pregnant women from pre-conception to the end of the first trimester of pregnancy in Southern Benin. Parasitological, maternal and LLIN data were actively collected before, at the beginning and end of the first trimester of pregnancy. A Cox regression model was used to determine the relationship between the time to onset of the first malaria infection and the use, physical integrity, and bio-efficacy of the LLIN, adjusted for relevant covariables. RESULTS: The good use, good physical integrity and biological efficacy of LLIN were associated with a decreased risk of occurrence of the first malaria infection in early pregnancy (HRa = 0.38; (0.18-0.80); p < 0.001; HRa = 0.59; (0.29-1.19); p < 0.07; HRa = 0.97; (0.94-1.00); p < 0.04 respectively), after adjustment for other covariates. Primi/secundigravidity and malaria infection before pregnancy were associated with a risk of earlier onset of malaria infection. CONCLUSION: The classically used LLIN's indicators of possession and use may not be sufficient to characterize the true protection of pregnant women in the first trimester of pregnancy. Indicators of physical integrity and bio-efficacy should be integrated with those indicators in evaluation studies.

Acquisition of natural humoral immunity to P. falciparum in early life in Benin: impact of clinical, environmental and host factors.

To our knowledge, effects of age, placental malaria infection, infections during follow-up, nutritional habits, sickle-cell trait and individual exposure to Anopheles bites were never explored together in a study focusing on the acquisition of malaria antibody responses among infants living in endemic areas.Five hundred and sixty-seven Beninese infants were weekly followed-up from birth to 18 months of age. Immunoglobulin G (IgG), IgG1 and IgG3 specific for 5 malaria antigens were measured every 3 months. A linear mixed model was used to analyze the effect of each variable on the acquisition of antimalarial antibodies in 6-to18-month old infants in univariate and multivariate analyses. Placental malaria, nutrition intakes and sickle-cell trait did not influence the infant antibody levels to P. falciparum antigens. In contrary, age, malaria antibody levels at birth, previous and present malaria infections as well as exposure to Anopheles bites were significantly associated with the natural acquisition of malaria antibodies in 6-to18-month old Beninese infants. This study highlighted inescapable factors to consider simultaneously in an immuno-epidemiological study or a vaccine trial in early life.

When intensity of deltamethrin resistance in Anopheles gambiae s.l. leads to loss of Long Lasting Insecticidal Nets bio-efficacy: a case study in north Cameroon.

BACKGROUND: In Cameroon, insecticide resistance in Anopheles (An.) gambiae s.l. has been reported in several foci, prompting further investigations on associated patterns of Long-Lasting Insecticidal Nets (LLINs) bio-efficacy. The current study, conducted from June to August 2011, explored the intensity of deltamethrin resistance in An. gambiae s.l. from Pitoa and its impact on the residual bio-efficacy of LifeNet, a LLIN with deltamethrin incorporated into polypropylene nets (PND). METHODS: Two-four days old females An. gambiae s.l. reared from larval collections in Pitoa were tested for susceptibility to DDT, permethrin and deltamethrin, using standard World Health Organization (WHO) tube assays. Intensity of deltamethrin resistance was explored using WHO tube assays, but across six working concentrations from 0.001 % to 0.5 %. Bio-efficacy of unwashed and washed PND was assessed using WHO cone test. Species identification and kdr 1014 genotyping were performed on mosquito samples that were not exposed to insecticides, using PCR-RFLP and HOLA methods respectively. The Kisumu reference susceptible strain of An. gambiae s.s. was used for comparisons. RESULTS: A total of 1895 An. gambiae s.l. specimens from Pitoa were used for resistance and PND bio-efficacy testing. This mosquito population was resistant to DDT, permethrin and deltamethrin, with 18-40 min knockdown times for 50 % of tested mosquitoes and 59-77 % mortality. Deltamethrin Resistance Ratio compared with the Kisumu strain was estimated at ≥500 fold. LifeNets were effective against the susceptible Kisumu (100 % knockdown (KD60min) and mortality) and the resistant Pitoa samples (95 % KD60min, 83-95 % mortality). However, the bio-efficacy gradually dropped against the Pitoa samples when nets were washed (X (2) = 35.887, df = 8, p < 0.001), and fell under the WHO efficacy threshold (80 % mortality and/or 95 % KD60min) between 10 and 15 washes. The Pitoa samples were composed of three sibling species: An. arabiensis (132/154, 86 %), An. coluzzii (19/154, 12 %) and An. gambiae s.s. (3/154, 2 %). The kdr L1014F allele was found only in An. coluzzii (Npositive = 13/19), at 34 % frequency and heterozygote stage. No specimen carried the kdr L1014S allele. CONCLUSIONS: The current study showed that LifeNet might still offer some protection against the resistant An. gambiae s.l. population from Pitoa, provided appropriate dose of insecticide is available on the nets.

Do holes in long-lasting insecticidal nets compromise their efficacy against pyrethroid resistant Anopheles gambiae and Culex quinquefasciatus? Results from a release-recapture study in experimental huts.

BACKGROUND: Resistance of malaria vectors to pyrethroids threatens the effectiveness of long-lasting insecticidal nets (LLINs) as a tool for malaria control. Recent experimental hut and observational studies in Benin show that pyrethroid resistance reduces the insecticidal effect and personal protection of LLINs especially when they become torn. The World Health Organization has proposed a threshold for when nets are "too torn" at 1,000 cm(2) for rectangular holes and 790 cm(2) for round holes. This study examines whether there is a threshold above which LLINs no longer reduce malaria transmission. METHODS: Intact and artificially-holed LLINs under three months old and untreated nets were tested by releasing mosquitoes from a susceptible Anopheles gambiae colony, a pyrethroid-resistant An. gambiae population and a resistant Culex quinquefasciatus population in closed experimental huts in Southern Benin, West Africa. The efficacy of LLINs and untreated nets was evaluated in terms of protection against blood feeding, insecticidal effect and potential effect on malaria transmission. RESULTS: Personal protection by both LLINs and untreated nets decreased exponentially with increasing holed surface area, without evidence for a specific threshold beyond which LLINs could be considered as ineffective. The insecticidal effect of LLINs was lower in resistant mosquitoes than in susceptible mosquitoes, but holed surface area had little or no impact on the insecticidal effect of LLINs. LLINs with 22,500 cm(2) holed surface area and target insecticide content provided a personal protection of 0.60 (95 % CI 0.44-0.73) and a low insecticidal effect of 0.20 (95 % CI 0.12-0.30) against resistant An. gambiae. Nevertheless, mathematical models suggested that if 80 % of the population uses such nets, they could still prevent 94 % (95 % CI 89-97 %) of transmission by pyrethroid-resistant An. gambiae. CONCLUSIONS: Even though personal protection by LLINs against feeding mosquitoes is strongly reduced by holes, the insecticidal effect of LLINs is independent of the holed surface area, but strongly dependent on insecticide resistance. Badly torn nets that still contain insecticide have potential to reduce malaria transmission. The relationship between LLIN integrity and efficacy needs to be understood in order to guide LLIN distribution policy.

Efficacy of Olyset® Plus, a new long-lasting insecticidal net incorporating permethrin and piperonyl-butoxide against multi-resistant malaria vectors [corrected].

Due to the rapid extension of pyrethroid resistance in malaria vectors worldwide, manufacturers are developing new vector control tools including insecticide mixtures containing at least two active ingredients with different mode of action as part of insecticide resistance management. Olyset® Plus is a new long-lasting insecticidal net (LLIN) incorporating permethrin and a synergist, piperonyl butoxide (PBO), into its fibres in order to counteract metabolic-based pyrethroid resistance of mosquitoes. In this study, we evaluated the efficacy of Olyset® Plus both in laboratory and field against susceptible and multi-resistant malaria vectors and compared with Olyset Net, which is a permethrin incorporated into polyethylene net. In laboratory, Olyset® Plus performed better than Olyset® Net against susceptible Anopheles gambiae strain with a 2-day regeneration time owing to an improved permethrin bleeding rate with the new incorporation technology. It also performed better than Olyset® Net against multiple resistant populations of An. gambiae in experimental hut trials in West Africa. Moreover, the present study showed evidence for a benefit of incorporating a synergist, PBO, with a pyrethroid insecticide into mosquito netting. These results need to be further validated in a large-scale field trial to assess the durability and acceptability of this new tool for malaria vector control.

Association of IL-4 and IL-10 maternal haplotypes with immune responses to P. falciparum in mothers and newborns.

BACKGROUND: Particular cytokine gene polymorphisms are involved in the regulation of the antibody production. The consequences of already described IL-4, IL-10 and IL-13 gene polymorphisms on biological parameters and antibody levels were investigated among 576 mothers at delivery and their newborns in the context of P. falciparum placental malaria infection. METHODS: The study took place in the semi-rural area of Tori-Bossito, in south-west Benin, where malaria is meso-endemic. Six biallelic polymorphisms were determined by quantitative PCR using TaqMan® Pre-Designed SNP Genotyping Assays, in IL-4 (rs2243250, rs2070874), IL-10 (rs1800896, rs1800871, rs1800872) and IL-13 (rs1800925) genes. Antibody responses directed to P. falciparum MSP-1, MSP-2, MSP-3, GLURP-R0, GLURP-R2 and AMA-1 recombinant proteins were determined by ELISA. RESULTS: The maternal IL-4(-590)*T/IL-4(+33)*T haplotype (one or two copies) was associated with favorable maternal condition at delivery (high haemoglobin levels, absence of placental parasites) and one of its component, the IL-4(-590)TT genotype, was related to low IgG levels to MSP-1, MSP-2/3D7 and MSP-2/FC27. Inversely, the maternal IL-10(-1082)AA was positively associated with P. falciparum placenta infection at delivery. As a consequence, the IL-10(-819)*T allele (in CT and TT genotypes) as well as the IL-10(-1082)*A/IL-10(-819)*T/IL-10(-592)*A haplotype (one or two copies) in which it is included, were related to an increased risk for anaemia in newborns. The maternal IL-10(-1082)AA genotype was related to high IgG levels to MSP-2/3D7 and AMA-1 in mothers and newborns, respectively. The IL-13 gene polymorphism was only involved in the newborn's antibody response to AMA-1. CONCLUSION: These data revealed that IL-4 and IL-10 maternal gene polymorphisms are likely to play a role in the regulation of biological parameters in pregnant women at delivery (anaemia, P. falciparum placenta infection) and in newborns (anaemia). Moreover, IL-4, IL-10 and IL-13 maternal gene polymorphisms were related to IgG responses to MSP-1, MSP-2/3D7 and MSP-2/FC27 in mothers as well as to AMA-1 in newborns.

Modeling the influence of local environmental factors on malaria transmission in Benin and its implications for cohort study.

Malaria remains endemic in tropical areas, especially in Africa. For the evaluation of new tools and to further our understanding of host-parasite interactions, knowing the environmental risk of transmission--even at a very local scale--is essential. The aim of this study was to assess how malaria transmission is influenced and can be predicted by local climatic and environmental factors.As the entomological part of a cohort study of 650 newborn babies in nine villages in the Tori Bossito district of Southern Benin between June 2007 and February 2010, human landing catches were performed to assess the density of malaria vectors and transmission intensity. Climatic factors as well as household characteristics were recorded throughout the study. Statistical correlations between Anopheles density and environmental and climatic factors were tested using a three-level Poisson mixed regression model. The results showed both temporal variations in vector density (related to season and rainfall), and spatial variations at the level of both village and house. These spatial variations could be largely explained by factors associated with the house's immediate surroundings, namely soil type, vegetation index and the proximity of a watercourse. Based on these results, a predictive regression model was developed using a leave-one-out method, to predict the spatiotemporal variability of malaria transmission in the nine villages.This study points up the importance of local environmental factors in malaria transmission and describes a model to predict the transmission risk of individual children, based on environmental and behavioral characteristics.

Infections in infants during the first 12 months of life: role of placental malaria and environmental factors.

BACKGROUND: The association between placental malaria (PM) and first peripheral parasitaemias in early infancy was assessed in Tori Bossito, a rural area of Benin with a careful attention on transmission factors at an individual level. METHODOLOGY: Statistical analysis was performed on 550 infants followed weekly from birth to 12 months. Malaria transmission was assessed by anopheles human landing catches every 6 weeks in 36 sampling houses and season defined by rainfall. Each child was located by GPS and assigned to the closest anopheles sampling house. Data were analysed by survival Cox models, stratified on the possession of insecticide-treated mosquito nets (ITNs) at enrolment. PRINCIPAL FINDINGS: Among infants sleeping in a house with an ITN, PM was found to be highly associated to first malaria infections, after adjusting on season, number of anopheles, antenatal care (ANC) visits and maternal severe anaemia. Infants born from a malaria infected placenta had a 2.13 fold increased risk to present a first malaria infection than those born from a non infected placenta ([1.24-3.67], p<0.01) when sleeping in a house with an ITN. The risk to present a first malaria infection was increased by 3.2 to 6.5, according to the level of anopheles exposure (moderate or high levels, compared to the absence of anopheles). CONCLUSIONS: First malaria infections in early childhood can be attributed simultaneously to both PM and high levels of exposure to infected anopheles. Protective measures as Intermittent Preventive Treatment during pregnancy (IPTp) and ITNs, targeted on both mothers and infants should be reinforced, as well as the research on new drugs and insecticides. In parallel, investigations on placental malaria have to be strengthened to better understand the mechanisms involved, and thus to protect adequately the infants high risk group.

Prevention of malaria during pregnancy: assessing the effect of the distribution of IPTp through the national policy in Benin.

The efficiency of malaria prevention during pregnancy was compared between three studies in Benin for malaria infection of the placenta (MIP) and low birth weight (LBW). The first was carried out when chloroquine prophylaxis was still recommended, the second was an intermittent preventive treatment in pregnancy (IPTp) clinical trial comparing sulfadoxine pyrimetamine (SP) versus mefloquine, and the third was an observational study after SP-IPTp national implementation. We showed an association between the use of IPTp and the reduction of LBW (10% with national IPTp and 8.7% in IPTp trial versus 15.7% in pre-trial study). The effect on MIP was better in the trial (2.9% versus 11.2% and 16.7% for national IPTp and pre-trial studies, respectively). In spite of a good overall compliance with the national IPTp (with 84% of women taking at least one dose of SP), there are still failures in adherence to the directly observed therapy (DOT) scheme and needs for better training of health staff.