Potential benefits of combining transfluthrin-treated sisal products and long-lasting insecticidal nets for controlling indoor-biting malaria vectors

Background Transfluthrin vapour prevents mosquito bites by disrupting their host-seeking behaviors. We measured the additional benefits of combining transfluthrin-treated sisal decorations and long-lasting insecticidal nets (LLINs) with an aim of extending protection against early evening, indoor-biting malaria vectors when LLINs are ineffective. Methods We investigated the indoor protective efficacy of locally made sisal decorative baskets (0.28 m2) treated with 2.5 ml and 5.0 ml transfluthrin, in terms of mosquito density, exposure to bites and 24 h mortality. Experiments were conducted in experimental huts, located in Lupiro village, Ulanga District, south-eastern Tanzania. Human landing catches (HLC) were used to measure exposure to bites between 19:00–23:00 h. Each morning, at 06:00 h, mosquitoes were collected inside huts and in exit traps and monitored for 24 h mortality. Results Sisal decorative baskets (0.28 m2) treated with 2.5 ml and 5.0 ml transfluthrin deterred three-quarters of Anopheles arabiensis mosquitoes from entering huts (relative rate, RR = 0.26, 95% confidence interval, CI: 0.20–0.34, P < 0.001 and RR= 0.29, 95% CI: 0.22–0.37, P < 0.001, respectively). Both treatments induced a 10-fold increase in 24 h mortality of An. arabiensis mosquitoes (odds ratio, OR = 12.26, 95% CI: 7.70–19.51, P < 0.001 and OR = 18.42, 95% CI: 11.36–29.90, P < 0.001, respectively). Conclusions Sisal decorative items treated with spatial repellents provide additional household and personal protection against indoor biting malaria and nuisance mosquitoes in the early evening, when conventional indoor vector control tools, such as LLINs, are not in use. We recommend future studies to investigate the epidemiological relevance of combining LLINs and transfluthrin decorated baskets in terms of their effect on reduction in malaria prevalence.


Background
Long-lasting insecticidal nets (LLINs), indoor residual spraying (IRS), improved diagnosis and treatment have brought about substantial decline in malaria transmission, particularly in sub-Saharan Africa [1][2][3]. Despite these achievements, residual malaria transmission that occurs even with high coverage of LLINs and/or IRS continues to threaten efforts towards malaria elimination. Additionally, insecticide resistance in Africa is another challenge in consolidating, and sustaining the gains accrued by vector control tools [4][5][6][7].
Effectiveness of LLINs depends on factors that influence human-vector contact, such as time and place of malariatransmitting mosquito bites [8], user's sleeping hours, proper use, installation and maintenance of nets, as well as user's compliance [9]. When LLINs are not available, the risk of exposure to infectious bites increases during meal times, at social events and or when students are doing homework. In addition, in rural Africa most people live in houses that are not sufficiently proofed to prevent mosquito entry [10].
Topical repellents [11,12] and protective clothing [13] represent some of the options used as personal protection against mosquito bites when LLINs are not in use. Although these tools confer some protection, they have some limitations: (i) they divert mosquitoes to non-users [14]; (ii) they require reapplication often hourly; and (iii) they often fail due to non-compliance by users [15]. Additionally, topical repellents are unlikely to be practical for daily use, and may not be affordable for continuous use in low and middle-income populations [16]. Due to high temperatures in some regions, and costs required for reapplication, the use of protective clothing may not be feasible in most tropical countries. Development of new, efficacious, low-cost, context specific, practical and scalable vector control tools, that target indoor biting mosquitoes when LLINs are not in use, would complement the protective efficacy of LLINs and IRS.
Spatial repellents are vapour-phase insecticides that incapacitate mosquitoes and prevent them from locating hosts and obtaining blood meals [17]. Examples of spatial repellent delivery formats include pyrethroid-treated mosquito coils, vaporizer mats, aerosols, and paper strips as well as traditional practices such as burning and smoldering plants [18].
Previous studies have shown that transfluthrin prevents mosquitoes from feeding [19], and induces mosquito mortality [20]. Here, we quantified the potential benefits of combining spatial repellent with LLINs, as a complementary strategy against indoor biting mosquitoes in the early evening, when LLINs are not in use.

Preparation of transfluthrin-treated sisal fabrics
Circular pieces of sisal 0.28 m 2 were treated with either 2.5 ml or 5 ml of 97% transfluthrin (Shenzhen Sunrising Industry Company, Limited, Shenzhen, China) following the method previously described [28][29][30]. Control pieces were soaked in a mixture of water and detergent only as previously described [28][29][30]. All pieces were enclosed in colorfully beaded iron welded baskets as previously described [30].
Rationale for delivering transfluthrin using sisal decorative baskets Sisal fabrics are versatile products from the sisal plant, available in most of the tropical countries like Tanzania. These fabrics can be made into various household products, such as mats, baskets, curtains, wall picture frame, etc. The uniqueness of the sisal fabrics are: (i) they have relatively high absorbance of liquid such as water; and (ii) they allow slow release of transfluthrin in air, this way transfluthrintreated sisal fabrics may remain effective for a duration of more than six months or a year [28,31]. Nevertheless, as the sisal products fits for different households decorative items, using these items indoor, when are treated with transfluthrin, may serve two purposes: decorate house and act as an indoor vector control tool.

Study design
Experiments were conducted from 6th January 2015 to 7th February 2015. The effect of combining transfluthrintreated sisal baskets and permethrin-treated LLINs on the proportion of indoor mosquito density, the proportion of early evening indoor mosquito bites and survival of mosquitoes in experimental huts (Fig. 1a) was investigated. The treatments included: (i) control arm with permethrin-treated LLIN and four untreated sisal baskets; (ii) four transfluthrin-treated (2.5 ml) sisal baskets and one permethrin-treated LLIN; and (iii) four transfluthrintreated sisal baskets (5 ml) and one permethrin-treated LLIN. Initially, treatments were randomly allocated to 3 experimental huts, using a lottery method and later treatment and control arms were rotated between 3 huts after 9 consecutive experimental nights using a 3 × 3 Latin square design. A sisal basket (Fig. 1b) [30], was suspended in each of the four corners of the huts (Fig. 1c). They were placed 1.84 m off the ground and 0.52 m from the wall. In each hut, a male volunteer conducted human landing catches from 19:00 to 23:00 h. This coincided with the time when most people within this community are likely to be awake but not protected by LLINs. Moreover, mosquitoes were also collected from exit traps, fitted on eaves and windows of the huts as well as on the floor at 06:00 h. All mosquitoes were kept in a field insectary situated approximately 50 m from the nearest experimental hut. The temperature in the experimental huts was 26.94°C during the day and 25.65°C at night and relative humidity was 81.0% during the day and 86.5% at night. Mosquitoes were provided 10% glucose solution for 24 h after which mortality was recorded. After 24 h, mosquitoes were sorted and recorded as dead, live, blood-fed or unfed. Morphological identification keys [32] were used to identify mosquitoes to their genus and species. Standard polymerase chain reaction (PCR) [33,34] was used to differentiate a subsample of sibling species of An. gambiae (s.l.) and An. funestus (s.l.) mosquitoes that were randomly selected each day. The primary outcomes measured included: (i) mosquito deterrence, which is reduction in the density of indoor mosquitoes; (ii) indoor human mosquito biting rate, which is the proportion of mosquitoes that landed and attempted to bite volunteers that were conducting HLC; and (iii) insecticide-induced 24 h mortality.

Data analysis
Deterrence was determined statistically using log-normal Poisson generalized linear mixed effects models (GLMMs) in R statistical software version 3.1.3, with lme4 package [35]. The response variable was the total number of mosquitoes collected from experimental huts including those collected indoors by those conducting HLC. Experimental huts and day of experiment were treated as random independent variables, while treatment was coded as a fixed variable. An over-dispersion random variable accounting for the random fluctuating nature of mosquito count data on different experimental days was included. An. arabiensis, An. funestus (s.l.) and Culex species mosquitoes were analyzed in separate models. The same analysis was used to measure reduction in the proportion of biting mosquitoes in the early evening. The total number of mosquitoes collected by HLC in experimental huts between 19:00 and 23:00 h was fitted as the dependent variable. The hut and the day of experiment were treated as random variables, while treatment arm was coded as a fixed variable. Insecticide induced mortality was determined by fitting a GLMMs with a binomial distribution and a logit-link function. The proportion of dead and live mosquitoes was coded as dependent binomial variable, treatment arms as fixed variable whereas day of experiment and experimental huts were treated as random variables.

Results
The total number of mosquitoes collected was 7125.
Indoor human mosquito biting rate Figure 3 and Table 2 show that both 2.5 ml and 5.0 ml transfluthrin-treated baskets, combined with LLINs, reduced the proportion of An. arabiensis mosquito bites by more than three quarters (2.    Table 5, there were no differences in effect between the 2.5 ml and 5 ml treatments in reducing indoor mosquito biting rate.  Fig. 4). Additionally, as shown in Fig. 4 and Table 6, there were no differences in effect between the 2.5 ml and 5 ml treatments in inducing mosquito mortality rate.

Discussion
Here, we investigated the complementary effects of transfluthrin treated baskets combined with LLINs in terms of mosquito deterrence, biting rate and 24 h mortality. We show that transfluthrin treated baskets provided  comprehensive protection against An. arabiensis than An. funestus or Culex spp. Long-lasting insecticidal nets confer protection via a range of modes of action, including excito-repellency, induced mortality of mosquitoes as well as providing physical barrier [36]. However, the emergence of insecticide resistance is undermining the benefits of LLINs and efforts towards malaria elimination [4][5][6][7]. Changing biting behavior and residual malaria transmission [37][38][39] have also significantly reduced the outputs of LLINs and IRS, which calls for complementary strategies.
A combination of transfluthrin-treated sisal baskets and LLINs reduced the overall numbers of indoor density of An. arabiensis mosquitoes by three quarters, compared to LLINs with untreated sisal baskets (Table 1, Fig. 2). However, this reduction was not observed for An. funestus and for Culex spp. Preceding studies, for example Hill et al. [40], demonstrated that a combination of transfluthrin-treated mosquito coil and LLINs resulted in massive reduction of indoor mosquito densities. Similarly, Ogoma et al. [20] demonstrated that combination of transfluthrintreated coils and LLINs resulted in reduction of indoor mosquito densities. These studies suggest the combination of transfluthrin-based spatial repellents and LLINs may reduce the number of mosquitoes entering dwellings, thereby reducing the risk of malaria transmission.
Our findings support a most recently developed mathematical model, which suggested that combining a highlytoxic insecticide and an efficacious repellent could combat insecticide resistance while protecting people from mosquito bites [41].
Secondly, transfluthrin-treated sisal baskets reduced exposure to early evening bites of An. arabiensis mosquitoes, where LLINs alone may not have been effective (Table 2, Fig. 3). A similar effect, albeit lower, was observed with An. funestus and Culex spp. Didzie et al.  [12] demonstrated a dramatic reduction in indoor mosquitoes bites when LLINs were used in combination with topical repellent (NO MAS, a water-based lotion with its principle active ingredient para-methane-diol and lemongrass). Similarly, Syafruddin et al. [42] demonstrated that a combination of LLINs and topical repellent (picaridin, KBR3023, SC Johnson, Racine, WI, USA) reduced indoor mosquito biting rates. The risk of malaria transmission is highest before bed time, considering the fact that LLINs will not be in use at that time. Spatial repellents that provide protection to multiple people in a wide area would be a complementary strategy to LLNs [43]. Mathematical models applied in previous studies postulate that a combination of repellent and LLINs attenuate community-wise benefit by diverting the vectors away from lethal, insecticide treated surfaces [44]. Surprisingly, a 10-fold increase in mortality of An. arabiensis was observed when transluthrin was used in combination with LLINs (Table 3, Fig. 4). Previously, Ogoma et al. [20] also demonstrated an increase in mortality of An. arabiensis and An. gambiae (s.s.) in the presence of transfluthrin coils. However, we did not observe any added benefits of combining transfluthrin decorated baskets with LLINs in terms of inducing mortality of An. funestus and Culex spp. The low mortality observed for An. funestus may be partly explained by pyrethroid resistance exhibited by these mosquitoes as demonstrated previously [26], and confirmed recently [27]. The findings from this study indicate that the efficacy of both 2.5 ml and 5.0 ml 97% transfluthrin treatments was similar (Tables 4, 5 and 6, Figs. 2, 3 and 4). Therefore, a lower dose is recommended for use in future studies.
Combining transfluthrin-treated household decorations and permethrin-treated LLINs was beneficial, and potentially enhanced protection by LLINs, against indoor biting malaria vectors by reducing indoor mosquito density and biting rate and increasing 24 h mortality. Transfluthrin is a pyrethroid, and its efficacy was less pronounced on suspected pyrethroid resistant An. funestus (s.l.). This calls for frequent insecticide susceptibility tests to monitor emergence of resistance.

Conclusions
Here, we have demonstrated that transfluthrin-treated emanators combined with LLINs reduce indoor mosquito entry and protect people against indoor mosquito bites when LLINs are not in effect. The emanators increase mortality of major malaria vectors in the area. Future studies should focus on measuring epidemiological endpoints of these combined interventions.