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Indoor residual spraying (IRS) is a key tool for controlling and eliminating malaria by targeting vectors. To support the development of effective intervention strategies it is important to understand the impact of vector control tools on malaria incidence and on the spread of insecticide resistance. In 2006, the World Health Organization (WHO) stated that countries should report on coverage and impact of IRS, yet IRS coverage data are still sparse and unspecific. Here, the subnational coverage of IRS across sub-Saharan Africa for the four main insecticide classes from 1997 to 2017 were estimated.
This study highlights the gaps between policy and practice, emphasizing the continuing potential of IRS to drive resistance. The data presented here can improve studies on the impact of IRS on malaria incidence and help to guide future malaria control efforts.
Little is known about the large-scale deployment of IRS over the last 20 years and the impact it has had on the development of insecticide resistance in malaria vectors. In 2006, the World Health Organization (WHO) stated that countries should report on coverage and impact of IRS . Regrettably, this did not result in comprehensive reporting or mapping. The available data for IRS are still limited and unspecific. Despite the important implications associated with the choice of compounds sprayed , studies that have considered the impact of heterogeneous IRS coverage on malaria transmission in Africa typically consider it a single intervention without distinguishing between the different insecticides used [1, 2, 9]. In contrast to insecticide-treated nets (ITNs), which primarily uses pyrethroids, the WHO has approved 16 insecticide formulations from five insecticide classes for IRS . The main classes are carbamates, organochlorines, organophosphates and pyrethroids, with neonicotinoids recently added. These insecticide classes have different residual activity, cost and efficacy in the field (Table 1). Cost of the insecticide is about 30% of the total IRS campaign expenses . Due to the low cost and longer residual decay rates compared to other insecticides, DDT and pyrethroids have been most popular. However, development of resistance has forced the use of alternative insecticides, which can be up to 19 times more expensive . Although the prices have dropped in recent years , these new compounds are still more expensive than DDT and pyrethroids. The various insecticide classes have different residual activity, impact on local malaria vector populations, cost implications and levels of social acceptance . This has important implications for local malaria vector populations and consequently local malaria epidemiology [3, 4]. The insecticide choice can also drive resistance to the compound used, and to other insecticide classes via cross-resistance . The different IRS formulations can thus be considered as distinct control methods.
Data is presented for 951 country-years. If data was collated from multiple sources, the main source is represented. Household is a person or group of people that live and eat together; Structure is a permanent building with a roof and walls, such as houses, sheds and animal shelters; People protected is defined as the residents living in households that were sprayed; Insecticide quantity is the amount of insecticide used to spray an area (in kilogram or litres). Spray reports are spray campaign reports published by the organization conducting the spray campaigns; Stakeholder reports are reports from secondary sources on spray campaigns; NMCPs are governmental organizations that oversee the malaria control activities in country; Personal communication is information received through personal contact with stakeholders, such as members of the NMCP, malaria researchers and non-governmental organization employees in-country. Literature is published scientific literature. WHO reports are reports accessed through the World Health Organization webpage. The MAP data is data collated by the Malaria Atlas Project freely accessible through their webpage.
Figure 1 shows that all countries relied heavily on organochlorines (DDT) and pyrethroids (alpha-cypermethrin, deltamethrin and lambda-cyhalothrin). A slight peak in organochlorine use can be seen the year after DDT was approved for vector control by the Stockholm Convention in 2004. At this time, carbamates were only used on Bioko island in Equatorial Guinea and in small areas of Mozambique and South Africa. Similarly, organophosphates (malathion) were only sprayed in Comoros, Eritrea and Sudan.
To limit resistance development, GPIRM recommends avoiding the use of pyrethroid IRS in an area with high ITN cover . With IRS activity now differentiated between the insecticide classes, it is possible to identify areas where overlap in pyrethroid-based vector control has occurred. Comparing the modelled ITN coverage  (Additional file 2) and pyrethroid IRS coverage (Additional file 1) shows that overlap in pyrethroid-based vector control has occurred. In 2000, no ITNs were distributed and there was limited pyrethroid IRS. Five years later ITNs were used throughout the centre of sub-Saharan Africa, some areas in west Africa and the parts of Madagascar. Conversely, pyrethroid IRS was implemented in other areas of Madagascar, Botswana and South Africa, where ITNs were not distributed. Only minor overlap was seen in Angola, Kenya, Mozambique, Rwanda and Zambia. In 2007, almost all countries in sub-Saharan Africa had some ITN coverage except Nigeria, Mauritania, parts of DRC and southern Africa (Namibia, Botswana and South Africa). Again, pyrethroid IRS was most intense in southern Africa, where ITNs were not distributed. There was overlap in pyrethroid use in neighbouring countries (Zambia and Angola), with other small areas of overlap throughout Africa. In 2010, all regions except southern Africa were, in part, protected by ITNs, with overlap with pyrethroid IRS apparent in at least 17 countries. In 2015, the extent of ITN coverage was similar to 2010, albeit more intense, with pyrethroid IRS use declining. Pyrethroid IRS was mainly implemented in the southern countries where ITNs were not distributed. Only minor overlaps were seen in Somalia, Eritrea, Sudan, Malawi and Mozambique.
The exponential growth in people protected by ITNs compared to IRS highlights the challenges associated with deploying IRS, which requires regular re-spraying, is expensive and labour intensive. The exclusive use of pyrethroids on bed nets in the past has made the implementation of pyrethroids for any other vector control method controversial. The maps show that overlap between ITNs and pyrethroid IRS has occurred until as recently as 2015, mostly in southern and north-eastern Africa. Unfortunately, disaggregated data is missing for countries such as Angola, Somalia, Sudan and Angola to identify the extent of the overlap. Reassuringly, pyrethroid and organochlorine IRS use is most common in countries where ITNs are not mass-distributed (i.e. South Africa, Namibia and Botswana).
The results presented here provide insight into spatial and temporal trends in IRS deployment and have allowed us to investigate whether GPIRM guidelines are being followed. The IRS coverage maps can also feed into future work on insecticide resistance management and malaria control. The GPIRM recommends focal IRS with a non-pyrethroid insecticide should be introduced in addition to LLINs in areas that are resistance hotspots. Once insecticide resistance maps become available, it will be possible to ascertain whether focal IRS has been deployed in resistance hotspots and to investigate what happens in hotspots where LLINs alone or LLINs in combination with IRS have been deployed . The results provided here also mean that it will be possible to investigate the relative roles of ITN use and pyrethroid or organochlorine IRS use in the development of resistance. Ultimately the aim of vector control, including resistance management, is to prevent transmission of the malaria parasite. Previous studies that have investigated the heterogenous impact of ITN and IRS use over space and time have considered IRS as a single intervention type without distinguishing between the different insecticides used [1, 2, 9]. The maps provided by this study now allow malaria models to incorporate data on the different types of IRS and evaluate the role they have played. 2b1af7f3a8