Effective case management is central for malaria control, but not all of those affected by malaria have access to prompt, effective treatment. In Kenya, free malaria treatment has been implemented since 2006. However, questions remain regarding effective treatment. We conducted cross-sectional epidemiological and questionnaire surveys in four counties in western Kenya in 2004, 2010, and 2016, and antimalarial availability surveys in 2016. We found a significant decline in self-reported malaria cases and an improvement in knowledge of malaria prevention and treatment since 2004. Parasite prevalence declined significantly from 2004 to 2010; however, it has remained unchanged since then. Artemisinin-based combination therapies (ACTs) and sulfadoxine-pyrimethamine (SP) drugs were widely available everywhere. The proportion of ACT usage increased from none in 2004 to 48% and 69%, respectively, in 2010 and 2016, whereas SP drug usage declined from 88% in 2004 to 39% in 2010 and 27% in 2016. During the 2016 survey, non-intermittent preventive treatment in pregnancy use of SP was common (20.9% of all surveyed individual treatments). In 2004, 27.2% (168/617) of households sought hospital treatment alone, and this number increased to 50.6% in 2016. The key factors affecting treatment-seeking behavior were education level, wealth index, household size, and distance to hospitals. Our results indicated that gaps in malaria case management remain and out-of-policy treatment is still a concern.

Background

Indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs) are the first-line tools for malaria prevention and control in Africa. Vector resistance to insecticides has been extensively studied, however the insecticidal effects of the nets and sprayed walls on pyrethroid resistant mosquitoes has not been studied thoroughly. We evaluated the bioefficacy of LLINs of different ages and lambda-cyhalothrin (ICON 10cs) on the sprayed mud walls for a period of time on malaria vector survivorship.

Methods

WHO tube bioassay was performed using diagnostic doses of lambda-cyhalothrin (0.05%), permethrin (0.75%) and deltamethrin (0.05%). Cone bioassays were conducted on netting materials from 0 to 3 years old long-lasting insecticide-impregnated nets. Wall bioassays were performed monthly on mud slabs sprayed with lambdacyhalothrin over a period of seven months. All bioassays used An. gambiae mosquitoes collected from the field and the laboratory susceptible reference Kisumu strain. Concentration of the insecticides on the netting materials was examined using the gas chromatography method. Mosquitoes were identified to species level using PCR and genotyped for the kdr gene mutation frequencies.

Results

WHO bioassays results showed that populations from five sites were highly resistant to the pyrethroids (mortalities ranged from 52.5 to 75.3%), and two sites were moderately resistant to these insecticides (80.4 - 87.2%). Homozygote kdr mutations of L1014S ranged from 73 to 88% in An. gambiae s.s. dominant populations whereas L1014S mutation frequencies were relatively low (7-31%) in An. arabiensis dominant populations. There was a significant decrease (P < 0.05) in mosquito mortality with time after the spray with both lambda-cyhalothrin (75% mortality after six months) and with the age of LLINs (60% mortality after 24 month). Field collected mosquitoes were able to survive exposure to both IRS and LLINs even with newly sprayed walls (86.6-93.5% mortality) and new LLINs (77.5-85.0% mortality), Wild mosquitoes collected from the field had significantly lower mortality rates to LLINs (59.6-85.0%) than laboratory reared susceptible strain (100%). Insecticide concentration decreased significantly from 0.14 μg/ml in the new nets to 0.077 μg/ml in nets older than 18 months (P < 0.05).

Conclusion

This study confirms that insecticide decay and developing levels of resistance have a negative contribution to reduced efficacy of ITN and IRS in western Kenya. These factors contribute to decreased efficacy of pyrethroid insectides in ongoing malaria control programs. In order to mitigate against the impact of insecticide resistance and decay it is important to follow the WHO policy to provide the residents with new LLINs every three years of use while maintaining a high level of LLINs coverage and usage. There is also need for urgent development and deployment of non-pyrethroid based vector control tools.