Estimating the Malaria Prevention Impact of New Nets: Observational Analyses to Evaluate the Evidence Generated During Piloted New Net Distributions in Mozambique
NCT ID: NCT04716387
Last Updated: 2022-12-15
Study Results
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Basic Information
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COMPLETED
8726 participants
OBSERVATIONAL
2020-08-18
2022-09-30
Brief Summary
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This observational study will occur alongside a pilot distribution of next-generation ITNs in two regions of Mozambique. Over three years, data on the entomological and epidemiological impact of the different ITN types will be collected. Data collection will occur in six districts: two districts receiving the dual-active ingredient ITN Interceptor® G2 (BASF: alphacypermethrin + chlorfenapyr); one district that will receive the dual-active ingredient ITN Royal Guard® (Disease Control Technologies: alphacypermethrin + pyriproxyfen); one district receiving an ITN containing an insecticide plus an insecticide synergist , Olyset®Plus (Sumitomo Chemical: permethrin + piperonyl butoxide); and two districts receiving the standard pyrethroid-only ITNs DuraNet® (Shobikaa Impex Private Limited: alphacypermethrin). Data will be collected on malaria vector bionomics, disease epidemiology, and ITN use in order to help better demonstrate the public health value of next-generation ITNs and to support donors, policymakers, and National Malaria Control Programs in their ITN decision-making and planning processes.
Detailed Description
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Universal coverage of populations at risk with malaria vector control interventions, primarily insecticide treated nets (ITNs) and indoor residual spraying (IRS), in malaria-endemic countries is a global and national priority because of its fundamental importance for malaria control and elimination. Unfortunately, the effectiveness of these tools is threatened by the emergence and spread of pyrethroid resistance in key mosquito populations, which is now reported in more than 85% of all malaria endemic countries and poses significant risk to the future impact of these tools. Emerging evidence suggests, however, that increasing mosquito mortality and thereby continuing to reduce malaria transmission is possible in areas with pyrethroid resistance by introducing new insecticide formulations for IRS and ITNs. For example, Protopopoff et al. showed in Tanzania that the distribution of LLINs with piperonyl butoxide (PBO) plus pyrethroid reduced malaria prevalence by 13% compared to standard pyrethroid-only LLIN distribution (42% vs. 29%; p=0.0011), and Tiono et al., working in Burkina Faso, showed that the distribution of a dual active-ingredient ITN reduced clinical malaria incidence by 22% (Incidence Rate Ratio = 0.88; p=0.04) and potentially infective mosquito bites by 51% (entomological inoculation rate ratio = 0.49; p\<0.0001) compared to the distribution of a standard pyrethroid-only LLIN.
While there is evidence that standard LLINs can continue to provide effective personal protection to regular net users in regions with resistant vector populations, new classes of ITNs developed to perform against pyrethroid-resistant mosquitoes have been developed, with early trials and modelling suggesting that they may provide superior protective efficacy against malaria in areas with pyrethroid-resistant vectors. Access to these new resistance-breaking ITNs is restricted by need for efficacy data for continuing policy recommendations, high prices, lack of evidence of cost effectiveness compared to pyrethroid-only LLINs, and consequent poor demand in an uncertain market. Two types of next-generation ITNs, each utilizing a different mixture of active ingredients from different insecticide classes, have recently received WHO prequalification listing demonstrating that they perform to the thresholds required of pyrethroid-only ITNs and have no known specific side effects: Interceptor G2® (IG2; by BASF SE) and Royal Guard®(RG; by Disease Control Technologies, LLC). The IG2 ITN contains a mixture of a pyrethroid (alpha-cypermethrin) and a pyrrole (chlorfenapyr), while the RG ITN contains a mixture of the same pyrethroid (alpha-cypermethrin) and an insect growth regulator (pyriproxyfen). While both net types have been subsequently registered and approved for use in Mozambique based on this WHO listing, the Roll Back Malaria Vector Control Advisory Group guidance indicates that dual active ingredient ITNs will require further epidemiological evidence before policy recommendations are made for their use in preference to pyrethroid-only ITNs in certain settings.
The Global Fund and Unitaid have developed a market shaping program for next-generation ITNs with novel insecticide formulations. Evidence on the efficacy of IG2 and RG ITNs will be generated by the project through two randomized control trials taking place in Benin and Tanzania. In addition, through this program, these next-generation ITNs will be made available to countries for incorporation into their national distribution programs as pilot distributions with the aim of determining real-world effectiveness and cost-effectiveness in different contexts. In addition to the pilot distribution of IG2s taking place in Mozambique, three other countries will be piloting next-generation ITNs as part of the New Nets project: Burkina Faso, Nigeria, and Rwanda. This research will utilize these pilot distributions to understand the cost-effectiveness of the new ITNs in the chosen settings. The NMCP in Mozambique, in discussion with the Global Fund, chose to incorporate IG2, RG, and PBO ITNs into the 2020 mass distribution campaign. This study will collect information to determine the public health impact of the RG, PBO, and IG2 ITNs in Mozambique, in comparison to two sites that will receive standard pyrethroid-only ITNs. The aim of this research is to better understand the effectiveness and cost effectiveness of IG2 and RG ITNs in Mozambique and to collect data on community uptake of the ITNs.
During the upcoming pilot implementation enhanced entomological, epidemiological, and net use data will be collected in up to six study districts: two districts receiving the dual-active ingredient ITN Interceptor® G2 (BASF: alphacypermethrin + chlorfenapyr); one district that will receive the dual-active ingredient ITN Royal Guard® (Disease Control Technologies: alphacypermethrin + pyriproxyfen); one district receiving an ITN containing an insecticide plus an insecticide synergist, Olyset®Plus (Sumitomo Chemical: permethrin + piperonyl butoxide); and two districts receiving the standard pyrethroid-only ITNs DuraNet® (Shobikaa Impex Private Limited: alphacypermethrin). Data will be analyzed and results disseminated to support the NMCP, donors, policymakers, and other national and regional stakeholders in their ITN decision-making and planning processes. Each component aims specifically to:
* Epidemiological component - measure the epidemiological impact of the new IG2 ITNs, Royal Guard ITNs, PBO ITNs, and standard ITNs in real deployment scenarios through observational studies. These studies will compare trends in (1) malaria case incidence rates passively reported to the national health system (passive case detection (PCD)) and (2) malaria infection prevalence, measured through rapid diagnostic tests (RDTs), in children aged 6 months to 5 years of age from annual cross-sectional surveys during peak transmission periods.
* Entomological component - evaluate the impact of the different net types on vector populations and biting rates, compared to standard ITNs, through mosquito surveillance data that will measure trends in species-specific (1) adult vector densities (2) indoor and outdoor human landing rates (3) estimated entomological inoculation rates and (4) insecticide resistance patterns. These entomological surveillance activities are aligned with NMCP activities and are not part of the human subject research component of this study.
* Anthropological component - map patterns of ITN usage to determine transmission risk defined as the intersection between time at risk of mosquito blood feeding and human activities not under protection of an ITN, through gathering evidence on ITN uptake and usage. The collection of reliable data on such patterns, both indoors and outdoors, becomes thus an essential component of the evaluation of the ITN pilots for both modeling and contextual analysis of impact.
* Durability monitoring - monitoring of standard, IG2, RG and PBO ITNs in one district each, prospectively measuring physical durability, attrition, and chemical durability.
* Costing and cost-effectiveness component - estimate the cost and cost-effectiveness of IG2, RG and PBO ITNs in Mozambique through data on the price of the product, delivery and deployment costs, and product effectiveness based on case incidence rates measured during the epidemiological component of this study. Additionally, mean costs per case averted that might occur in other contexts will be modeled and incorporated into the cost-effectiveness evaluations.
Conditions
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Keywords
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Study Design
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COHORT
PROSPECTIVE
Study Groups
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Chlorfenapyr ITN
These study districts will receive Interceptor G2 ITNs during the mass distribution campaign.
Chlorfenapyr ITN
Insecticide-treated nets containing two active ingredients: alpha-cypermethrin, a pyrethroid insecticide, and chlorfenapyr, a pyrrole insecticide, manufactured by BASF.
Piperonyl butoxide ITN
This study district will receive piperonyl butoxide ITN during the mass distribution campaign.
Piperonyl butoxide ITN
Insecticide treated net containing permethrin, a pyrethroid, and piperonyl butoxide, an insecticide synergist, manufactured by Sumitomo Chemical.
Standard LLIN
These study districts will receive standard ITNs during the mass distribution campaign.
Standard LLIN
Long-lasting insecticidal net containing alphacypermethrin, a pyrethroid insecticide, and manufactured by Shobikaa Impex Private Limited.
Pyriproxyfen ITN
This study district will receive Royal Guard ITNs during the mass distribution campaign.
Pyriproxyfen ITN
Insecticide treated net containing alpha-cypermethrin, a pyrethroid, and pyriproxyfen, an insect growth regulator, manufactured by Disease Control Technologies.
Interventions
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Standard LLIN
Long-lasting insecticidal net containing alphacypermethrin, a pyrethroid insecticide, and manufactured by Shobikaa Impex Private Limited.
Piperonyl butoxide ITN
Insecticide treated net containing permethrin, a pyrethroid, and piperonyl butoxide, an insecticide synergist, manufactured by Sumitomo Chemical.
Pyriproxyfen ITN
Insecticide treated net containing alpha-cypermethrin, a pyrethroid, and pyriproxyfen, an insect growth regulator, manufactured by Disease Control Technologies.
Chlorfenapyr ITN
Insecticide-treated nets containing two active ingredients: alpha-cypermethrin, a pyrethroid insecticide, and chlorfenapyr, a pyrrole insecticide, manufactured by BASF.
Other Intervention Names
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Eligibility Criteria
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Inclusion Criteria
* Households in the district (Cross-sectional)
* Residents of the household visited (Cross-sectional
* Questionnaire: parent or guardian giving written informed consent (cross-sectional)
* Malaria screening: child aged 6 to 59 months from the above consenting household.
Exclusion Criteria
* Malaria screening: history of recent (within one month) malaria infection or treatment with anti-malarial medication (cross-sectional)
* Parents or guardians who have not yet reached age of consent (18 years) and their children will not be included in study activities requiring consent.
* Head of household unwilling and/or unable to give consent
6 Months
ALL
No
Sponsors
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Tropical Health LLP
UNKNOWN
Ministry of Health, Mozambique
OTHER_GOV
Instituto Nacional de Saúde, Mozambique
OTHER_GOV
Tulane University
OTHER
Liverpool School of Tropical Medicine
OTHER
PATH
OTHER
Responsible Party
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Principal Investigators
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Joseph Wagman, PhD
Role: PRINCIPAL_INVESTIGATOR
PATH
Locations
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Programa Nacional de Controle da Malaria, Ministry of Health
Maputo, , Mozambique
Countries
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References
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Abilio AP, Marrune P, de Deus N, Mbofana F, Muianga P, Kampango A. Bio-efficacy of new long-lasting insecticide-treated bed nets against Anopheles funestus and Anopheles gambiae from central and northern Mozambique. Malar J. 2015 Sep 17;14:352. doi: 10.1186/s12936-015-0885-y.
Alonso P, Noor AM. The global fight against malaria is at crossroads. Lancet. 2017 Dec 9;390(10112):2532-2534. doi: 10.1016/S0140-6736(17)33080-5. Epub 2017 Nov 29. No abstract available.
Bass C, Nikou D, Donnelly MJ, Williamson MS, Ranson H, Ball A, Vontas J, Field LM. Detection of knockdown resistance (kdr) mutations in Anopheles gambiae: a comparison of two new high-throughput assays with existing methods. Malar J. 2007 Aug 13;6:111. doi: 10.1186/1475-2875-6-111.
Bhatt S, Weiss DJ, Cameron E, Bisanzio D, Mappin B, Dalrymple U, Battle K, Moyes CL, Henry A, Eckhoff PA, Wenger EA, Briet O, Penny MA, Smith TA, Bennett A, Yukich J, Eisele TP, Griffin JT, Fergus CA, Lynch M, Lindgren F, Cohen JM, Murray CLJ, Smith DL, Hay SI, Cibulskis RE, Gething PW. The effect of malaria control on Plasmodium falciparum in Africa between 2000 and 2015. Nature. 2015 Oct 8;526(7572):207-211. doi: 10.1038/nature15535. Epub 2015 Sep 16.
Fornadel CM, Norris LC, Franco V, Norris DE. Unexpected anthropophily in the potential secondary malaria vectors Anopheles coustani s.l. and Anopheles squamosus in Macha, Zambia. Vector Borne Zoonotic Dis. 2011 Aug;11(8):1173-9. doi: 10.1089/vbz.2010.0082. Epub 2010 Dec 13.
Kleinschmidt I, Bradley J, Knox TB, Mnzava AP, Kafy HT, Mbogo C, Ismail BA, Bigoga JD, Adechoubou A, Raghavendra K, Cook J, Malik EM, Nkuni ZJ, Macdonald M, Bayoh N, Ochomo E, Fondjo E, Awono-Ambene HP, Etang J, Akogbeto M, Bhatt RM, Chourasia MK, Swain DK, Kinyari T, Subramaniam K, Massougbodji A, Oke-Sopoh M, Ogouyemi-Hounto A, Kouambeng C, Abdin MS, West P, Elmardi K, Cornelie S, Corbel V, Valecha N, Mathenge E, Kamau L, Lines J, Donnelly MJ. Implications of insecticide resistance for malaria vector control with long-lasting insecticidal nets: a WHO-coordinated, prospective, international, observational cohort study. Lancet Infect Dis. 2018 Jun;18(6):640-649. doi: 10.1016/S1473-3099(18)30172-5. Epub 2018 Apr 9.
Koekemoer LL, Kamau L, Hunt RH, Coetzee M. A cocktail polymerase chain reaction assay to identify members of the Anopheles funestus (Diptera: Culicidae) group. Am J Trop Med Hyg. 2002 Jun;66(6):804-11. doi: 10.4269/ajtmh.2002.66.804.
Protopopoff N, Mosha JF, Lukole E, Charlwood JD, Wright A, Mwalimu CD, Manjurano A, Mosha FW, Kisinza W, Kleinschmidt I, Rowland M. Effectiveness of a long-lasting piperonyl butoxide-treated insecticidal net and indoor residual spray interventions, separately and together, against malaria transmitted by pyrethroid-resistant mosquitoes: a cluster, randomised controlled, two-by-two factorial design trial. Lancet. 2018 Apr 21;391(10130):1577-1588. doi: 10.1016/S0140-6736(18)30427-6. Epub 2018 Apr 11.
Ranson H, N'guessan R, Lines J, Moiroux N, Nkuni Z, Corbel V. Pyrethroid resistance in African anopheline mosquitoes: what are the implications for malaria control? Trends Parasitol. 2011 Feb;27(2):91-8. doi: 10.1016/j.pt.2010.08.004. Epub 2010 Sep 16.
Scott JA, Brogdon WG, Collins FH. Identification of single specimens of the Anopheles gambiae complex by the polymerase chain reaction. Am J Trop Med Hyg. 1993 Oct;49(4):520-9. doi: 10.4269/ajtmh.1993.49.520.
Sherrard-Smith E, Griffin JT, Winskill P, Corbel V, Pennetier C, Djenontin A, Moore S, Richardson JH, Muller P, Edi C, Protopopoff N, Oxborough R, Agossa F, N'Guessan R, Rowland M, Churcher TS. Systematic review of indoor residual spray efficacy and effectiveness against Plasmodium falciparum in Africa. Nat Commun. 2018 Nov 26;9(1):4982. doi: 10.1038/s41467-018-07357-w.
Tiono AB, Ouedraogo A, Ouattara D, Bougouma EC, Coulibaly S, Diarra A, Faragher B, Guelbeogo MW, Grisales N, Ouedraogo IN, Ouedraogo ZA, Pinder M, Sanon S, Smith T, Vanobberghen F, Sagnon N, Ranson H, Lindsay SW. Efficacy of Olyset Duo, a bednet containing pyriproxyfen and permethrin, versus a permethrin-only net against clinical malaria in an area with highly pyrethroid-resistant vectors in rural Burkina Faso: a cluster-randomised controlled trial. Lancet. 2018 Aug 18;392(10147):569-580. doi: 10.1016/S0140-6736(18)31711-2. Epub 2018 Aug 10.
Weill M, Malcolm C, Chandre F, Mogensen K, Berthomieu A, Marquine M, Raymond M. The unique mutation in ace-1 giving high insecticide resistance is easily detectable in mosquito vectors. Insect Mol Biol. 2004 Feb;13(1):1-7. doi: 10.1111/j.1365-2583.2004.00452.x.
Other Identifiers
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1482331
Identifier Type: -
Identifier Source: org_study_id