Anopheles gambiae populations from Burkina Faso show minimal delayed mortality after exposure to insecticide-treated nets

Abstract Background The efficacy of long-lasting insecticidal nets (LLINs) in preventing malaria in Africa is threatened by insecticide resistance. Bioassays assessing 24-hour mortality post-LLIN exposure have established that resistance to the concentration of pyrethroids used in LLINs is widespread. However, although mosquitoes may no longer be rapidly killed by LLIN exposure, a delayed mortality effect has been shown to reduce the transmission potential of mosquitoes exposed to nets. This has been postulated to partially explain the continued efficacy of LLINs against pyrethroid-resistant populations. Burkina Faso is one of a number of countries with very high malaria burdens and pyrethroid-resistant vectors, where progress in controlling this disease has stagnated. We measured the impact of LLIN exposure on mosquito longevity in an area of the country with intense pyrethroid resistance to establish whether pyrethroid exposure was still shortening mosquito lifespan in this setting. Methods We quantified the immediate and delayed mortality effects of LLIN exposure using standard laboratory WHO cone tests, tube bioassays and experimental hut trials on Anopheles gambiae populations originating from the Cascades region of Burkina Faso using survival analysis and a Bayesian state-space model. Results Following single and multiple exposures to a PermaNet 2.0 LLIN only one of the four mosquito populations tested showed evidence of delayed mortality. No delayed mortality was seen in experimental hut studies using LLINs. A delayed mortality effect was only observed in WHO tube bioassays when deltamethrin concentration was increased above the standard diagnostic dose. Conclusions As mosquito pyrethroid-resistance increases in intensity, delayed effects from LLIN exposure are substantially reduced or absent. Given the rapid increase in resistance occurring in malaria vectors across Africa it is important to determine whether the failure of LLINs to shorten mosquito lifespan is now a widespread phenomenon as this will have important implications for the future of this pivotal malaria control tool.

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Evaluating the Evidence from Molecular Structure and Population Studies for Cross-Resistance to the Pyrethroids Used in Malaria Vector Control

10.21203/rs.3.rs-104446/v1 ◽

2020 ◽

Author(s):

Catherine L. Moyes ◽

Rosemary S. Lees ◽

Cristina Yunta ◽

Kyle J. Walker ◽

Kay Hemmings ◽

...

Keyword(s):

Binding Affinity ◽

Malaria Vector ◽

Pyrethroid Resistance ◽

Anopheles Funestus ◽

Malaria Vectors ◽

Cross Resistance ◽

Malaria Vector Control ◽

Insecticide Treated Nets ◽

The Common ◽

The Impact

Abstract The primary malaria control intervention in high burden countries is the deployment of long-lasting insecticide-treated nets (LLINs) treated with pyrethroids, alone or in combination with a second active ingredient or synergist. It is essential to understand whether the impact of pyrethroid resistance can be mitigated by switching between different pyrethroids or whether cross-resistance precludes this. Structural diversity within the pyrethroids could mean some compounds are better able to counteract the resistance mechanisms that have evolved in malaria vectors. Here we consider variation in vulnerability to the P450 enzymes that confer metabolic pyrethroid resistance in Anopheles gambiae s.l. and Anopheles funestus. We assess the relationships among pyrethroids in terms of their binding affinity to key P450s and the percent depletion by these P450s, in order to identify which pyrethroids diverge from the others. We then investigate whether these same pyrethroids also diverge from the others in terms of resistance in vector populations. We found that etofenprox, which lacks the common structural moiety of other pyrethroids, potentially diverges from the commonly deployed pyrethroids in terms of P450 binding affinity and resistance in malaria vector populations, but not depletion by the P450s tested. These results are supplemented by an analysis of resistance to the same pyrethroids in Aedes aegypti populations, which also found etofenprox diverges from the other pyrethroids in terms of resistance in wild populations. In addition, we found that bifenthrin, which also lacks the common structural moiety of most pyrethroids, diverges from the commonly deployed pyrethroids in terms of P450 binding affinity and depletion by P450s. However, resistance to bifenthrin in vector populations is largely untested. The prevalence of resistance to the pyrethroids α-cypermethrin, cyfluthrin, deltamethrin, λ-cyhalothrin, and permethrin was correlated across malaria vector populations and switching between these compounds as a tool to mitigate against pyrethroid resistance is not advised without strong evidence supporting a true difference in resistance.

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Evidence supporting deployment of next generation insecticide treated nets in Burkina Faso: bioassays with either chlorfenapyr or piperonyl butoxide increase mortality of pyrethroid-resistant Anopheles gambiae s.l.

10.21203/rs.3.rs-609240/v1 ◽

2021 ◽

Author(s):

Sawdetuo Aristide HIEN ◽

Dieudonné D. Soma ◽

Dramane Coulibaly ◽

Abdoulaye Diabaté ◽

Allison Belemvire ◽

...

Keyword(s):

Burkina Faso ◽

Anopheles Gambiae ◽

High Intensity ◽

Large Scale ◽

Pyrethroid Resistance ◽

Piperonyl Butoxide ◽

Sub Saharan Africa ◽

Insecticide Treated Nets ◽

Bobo Dioulasso ◽

Sub Saharan

Abstract Background Pyrethroid resistance poses a major threat to the efficacy of insecticide treated nets (ITNs) in Burkina Faso and throughout sub-Saharan Africa, particularly when resistance is present at high intensity. For such areas there are alternative ITNs available, including the synergist piperonyl butoxide (PBO)-based ITNs and dual active ingredient ITNs such as Interceptor G2 (treated with chlorfenapyr and alpha-cypermethrin). Before deploying alternative ITNs on a large scale it is crucial to characterize the resistance profiles of primary malaria vector species for evidence-based decision making Methods Larvae from the predominant vector, Anopheles gambiae s.l., were collected from 15 sites located throughout Burkina Faso and reared to adults for bioassays to assess insecticide resistance status. Resistance intensity assays were conducted using WHO tube tests to determine the level of resistance to pyrethroids commonly used on ITNs at 1x, 5x and 10x times the diagnostic dose. WHO tube tests were also used for PBO synergist bioassays with deltamethrin and permethrin. Bottle bioassays were conducted to determine susceptibility to chlorfenapyr at a dose of 100µg/bottle. Results WHO tube tests revealed high intensity resistance in An. gambiae s.l. to deltamethrin and alpha-cypermethrin in all sites tested. Resistance intensity to permethrin was either moderate or high in 13 sites. PBO pre-exposure followed by deltamethrin restored full susceptibility in 1 site but partially restored susceptibility in all but one of the remaining sites (often reaching mortality greater than 80%). PBO pre-exposure followed by permethrin partially restored susceptibility in 12 sites. There was no significant increase in permethrin mortality after PBO pre-exposure in Kampti, Karangasso-Vigué or Mangodara; while in Seguenega, Orodara and Bobo-Dioulasso there was a significant increase in mortality, but rates remained below 50%. Susceptibility to chlorfenapyr was confirmed in 14 sites. Conclusion High pyrethroid resistance intensity in An. gambiae s.l. is widespread across Burkina Faso and may be a predictor of reduced pyrethroid ITN effectiveness. PBO + deltamethrin ITNs would likely provide greater control than pyrethroid nets. However, since susceptibility in bioassays was not restored in most sites following pre-exposure to PBO, Interceptor G2 may be a better long-term solution as susceptibility was recorded to chlorfenapyr in nearly all sites. This study provides evidence supporting the introduction of both Interceptor G2 nets and PBO nets, which were distributed in Burkina Faso in 2019 as part of a mass campaign.

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Evidence supporting deployment of next generation insecticide treated nets in Burkina Faso: bioassays with either chlorfenapyr or piperonyl butoxide increase mortality of pyrethroid-resistant Anopheles gambiae

Malaria Journal ◽

10.1186/s12936-021-03936-3 ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

Aristide S. Hien ◽

Dieudonné D. Soma ◽

Samina Maiga ◽

Dramane Coulibaly ◽

Abdoulaye Diabaté ◽

...

Keyword(s):

Burkina Faso ◽

Anopheles Gambiae ◽

High Intensity ◽

Large Scale ◽

Pyrethroid Resistance ◽

Piperonyl Butoxide ◽

Sub Saharan Africa ◽

Insecticide Treated Nets ◽

Bobo Dioulasso ◽

Sub Saharan

Abstract Background Pyrethroid resistance poses a major threat to the efficacy of insecticide-treated nets (ITNs) in Burkina Faso and throughout sub-Saharan Africa, particularly where resistance is present at high intensity. For such areas, there are alternative ITNs available, including the synergist piperonyl butoxide (PBO)-based ITNs and dual active ingredient ITNs such as Interceptor G2 (treated with chlorfenapyr and alpha-cypermethrin). Before deploying alternative ITNs on a large scale it is crucial to characterize the resistance profiles of primary malaria vector species for evidence-based decision making. Methods Larvae from the predominant vector, Anopheles gambiae sensu lato (s.l.) were collected from 15 sites located throughout Burkina Faso and reared to adults for bioassays to assess insecticide resistance status. Resistance intensity assays were conducted using WHO tube tests to determine the level of resistance to pyrethroids commonly used on ITNs at 1×, 5 × and 10 × times the diagnostic dose. WHO tube tests were also used for PBO synergist bioassays with deltamethrin and permethrin. Bottle bioassays were conducted to determine susceptibility to chlorfenapyr at a dose of 100 µg/bottle. Results WHO tube tests revealed high intensity resistance in An. gambiae s.l. to deltamethrin and alpha-cypermethrin in all sites tested. Resistance intensity to permethrin was either moderate or high in 13 sites. PBO pre-exposure followed by deltamethrin restored full susceptibility in one site and partially restored susceptibility in all but one of the remaining sites (often reaching mortality greater than 80%). PBO pre-exposure followed by permethrin partially restored susceptibility in 12 sites. There was no significant increase in permethrin mortality after PBO pre-exposure in Kampti, Karangasso-Vigué or Mangodara; while in Seguenega, Orodara and Bobo-Dioulasso there was a significant increase in mortality, but rates remained below 50%. Susceptibility to chlorfenapyr was confirmed in 14 sites. Conclusion High pyrethroid resistance intensity in An. gambiae s.l. is widespread across Burkina Faso and may be a predictor of reduced pyrethroid ITN effectiveness. PBO + deltamethrin ITNs would likely provide greater control than pyrethroid nets. However, since susceptibility in bioassays was not restored in most sites following pre-exposure to PBO, Interceptor G2 may be a better long-term solution as susceptibility was recorded to chlorfenapyr in nearly all sites. This study provides evidence supporting the introduction of both Interceptor G2 nets and PBO nets, which were distributed in Burkina Faso in 2019 as part of a mass campaign.

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Cis-regulatory CYP6P9b P450 variants associated with loss of insecticide-treated bed net efficacy against Anopheles funestus

Nature Communications ◽

10.1038/s41467-019-12686-5 ◽

2019 ◽

Vol 10 (1) ◽

Cited By ~ 12

Author(s):

Leon M. J. Mugenzi ◽

Benjamin D. Menze ◽

Magellan Tchouakui ◽

Murielle J. Wondji ◽

Helen Irving ◽

...

Keyword(s):

Pyrethroid Resistance ◽

Resistance Management ◽

Anopheles Funestus ◽

Central Africa ◽

Malaria Vectors ◽

Insecticide Treated Nets ◽

Metabolic Resistance ◽

P450 Gene ◽

Regulatory Variants ◽

The Impact

Abstract Elucidating the genetic basis of metabolic resistance to insecticides in malaria vectors is crucial to prolonging the effectiveness of insecticide-based control tools including long lasting insecticidal nets (LLINs). Here, we show that cis-regulatory variants of the cytochrome P450 gene, CYP6P9b, are associated with pyrethroid resistance in the African malaria vector Anopheles funestus. A DNA-based assay is designed to track this resistance that occurs near fixation in southern Africa but not in West/Central Africa. Applying this assay we demonstrate, using semi-field experimental huts, that CYP6P9b-mediated resistance associates with reduced effectiveness of LLINs. Furthermore, we establish that CYP6P9b combines with another P450, CYP6P9a, to additively exacerbate the reduced efficacy of insecticide-treated nets. Double homozygote resistant mosquitoes (RR/RR) significantly survive exposure to insecticide-treated nets and successfully blood feed more than other genotypes. This study provides tools to track and assess the impact of multi-gene driven metabolic resistance to pyrethroids, helping improve resistance management.

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Use of Novel Lab-Assays to Examine the Effect of Pyrethroid-Treated Bed Nets on Blood Feeding Success and Longevity of Highly Insecticide-Resistant Anopheles Gambiae S.I. Mosquitoes.

10.21203/rs.3.rs-922010/v1 ◽

2021 ◽

Author(s):

Priscille Barreaux ◽

Jacob C. Koella ◽

Raphael N’Guessan ◽

Matthew B. Thomas

Keyword(s):

Insecticide Resistance ◽

Anopheles Gambiae ◽

Pyrethroid Resistance ◽

Blood Feeding ◽

Bed Nets ◽

Insecticide Treated Nets ◽

Term Survival ◽

Feeding Success ◽

Resistance Breaking ◽

The Impact

Abstract Background: There is a pressing need to improve understanding of how insecticide resistance affects the functional performance of Insecticide Treated Nets (ITNs). Standard WHO insecticide resistance monitoring assays are designed for resistance surveillance and do not necessarily provide insight into how different frequencies, mechanisms or intensities of resistance affect the ability of ITNs to reduce malaria transmission. Methods: The current study presents some novel laboratory-based assays that attempt to better simulate realistic exposure of mosquitoes to ITNs and to quantify impact of exposure not only on instantaneous mortality, but also blood feeding and longevity, two traits that are central to transmission. The assays evaluated the performance of a standard ITN (Permanet® 2.0), a ‘next generation’ combination ITN that includes a resistance breaking synergist (Permanet® 3.0), and an untreated net (UTN), against field-derived Anopheles gambiae s.l. mosquitoes from Côte d’Ivoire exhibiting 1500-fold pyrethroid resistance. Results: The study revealed that a standard ITN induced negligible instantaneous mortality against the resistant mosquitoes, whereas the resistance breaking net caused high mortality and a reduction in blood feeding. However, the ITNs still impacted long term survival relative to the UTN. The impact on longevity depended on feeding status, with blood-fed mosquitoes living longer than unfed mosquitoes following ITN exposure. The ITNs also reduced the blood feeding success, the time spent on the net, and blood-feeding duration, relative to the untreated net. Conclusion: Thus, while the standard ITN did not have as substantial instantaneous impact as the resistance breaking net, it still had significant impacts on traits important for transmission. These results highlight the benefit of improved bioefficacy assays that allow for realistic exposure and consider sub- or pre-lethal effects to help assess the functional significance of insecticide resistance.

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Pyrethroid Resistance Intensity of Anopheles gambiae sensu lato (Diptera: Culicidae) from Phase II Hut Trial Station in KOLOKOPE, Eastern Plateau Togo: A Potential Site to Assess the Next Generation of Long-Lasting Insecticidal Nets

10.1101/2020.08.19.257519 ◽

2020 ◽

Author(s):

Koffi Mensah Ahadji-Dabla ◽

Joseph Chabi ◽

Georges Apétogbo ◽

Edoh Koffi ◽

Melinda Patricia Hadi ◽

...

Keyword(s):

Mortality Rate ◽

Anopheles Gambiae ◽

Phase Ii ◽

Pyrethroid Resistance ◽

Malaria Vector Control ◽

Next Generation ◽

Pyrethroid Insecticides ◽

Experimental Hut ◽

The Impact ◽

Long Lasting Insecticidal Nets

AbstractPer WHO recommendations, the implementation of the next-generation of Long Lasting Insecticidal Nets (LLINs) for malaria vector control requires appropriate investigations on the insecticide resistance profile of the vector and the impact of the LLINs on the known resistant mosquitoes. The next-generation of LLINs are actually an incorporation of a mixture of pyrethroid insecticides and a synergist such as PBO. Several studies have proven the additional impact of PBO on the increase in the mortality rate of Anopheles gambiae s.l. (Diptera: Culicidae). However, further assessments need to be done at community level in order to set a stage for the acceleration of the WHO policies on the implementation of the next-generation of LLINs. Kolokopé is a cotton-growing area in the central region of Togo characterized by an intensive use of agro pesticides and insecticides. A phase II experimental hut station for the evaluation of mosquito control tools has been built in Kolokopé. For the characterization of the site, WHO susceptibility tests using diagnostic doses of eight insecticides, PBO synergist assay and intensity assay of three pyrethroids (5x and 10x) were conducted on adult female mosquitoes obtained from larvae collected around the site. Anopheles gambiae s.l. from Kolokopé showed high resistance to pyrethroids and DDT, but in lesser extent to carbamates and organophosphates. Likewise, high intensity of resistance to pyrethroid was observed with less than 40% mortality at 10x deltamethrin, 52 and 29% mortality at 10x permethrin and 10x alphacypermethrin, respectively. Also, the addition of PBO showed a reversal mortality which was similar to mortality rate at 10x doses of pyrethroids. The high pyrethroid intensity resistance recorded at Kolokopé could be mainly due to the pressure on An. gambiae s.l. through the excessive use of insecticide in agriculture. This can be used for the assessment of the next-generation of LLINs either in experimental hut or at a community trial.

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Systematic review of the entomological impact of insecticide-treated nets evaluated using experimental hut trials in Africa

10.1101/2021.04.07.21254306 ◽

2021 ◽

Author(s):

Rebecca K Nash ◽

Ben C Lambert ◽

Raphael N'Guessan ◽

Corine Ngufor ◽

Mark Rowland ◽

...

Keyword(s):

Systematic Review ◽

Vector Control ◽

Pyrethroid Resistance ◽

Sub Saharan Africa ◽

Insecticide Treated Nets ◽

Experimental Hut ◽

Factors Influencing ◽

Sub Saharan ◽

The Impact ◽

The Relationship

Background: Resistance of anopheline mosquitoes to pyrethroid insecticides is spreading rapidly across sub-Saharan Africa, diminishing the efficacy of insecticide-treated nets (ITNs) - the primary tool for preventing malaria. The entomological efficacy of indoor vector control interventions can be measured in experimental hut trials (EHTs), which are specially designed to quantify the protection provided under controlled conditions. Experimental hut structures resemble local housing but allow collection of surviving exiting mosquitoes as well as dead or dying mosquitoes. There is a need to understand how the spread of resistance changes ITN efficacy and to elucidate factors influencing EHT results, including differences in experimental hut construction and design features, to support the development of novel vector control tools. Methods: A comprehensive database of EHTs was compiled and summarised following a systematic review to identify all known trials investigating ITNs or indoor residual spraying (IRS) across sub-Saharan Africa. This analysis focuses on EHTs investigating ITNs and uses Bayesian statistical models to characterise the complex interaction between ITNs and mosquitoes, the variability between studies, and the impact of pyrethroid resistance. Results: As resistance rises, the entomological efficacy of ITNs declines. They induce less mortality and are less likely to deter mosquitoes from entering huts. Despite this, ITNs continue to offer considerable personal protection by reducing mosquito feeding until resistance reaches high levels. There are clear associations between the different entomological impacts of ITNs, though there is still substantial variability between studies, some of which can be accounted for by hut design. The relationship between EHT outcomes and the level of resistance (as measured by discriminating dose bioassays) is highly uncertain. Conclusions: The meta-analyses show that EHTs are an important reproducible assay for capturing the complex entomological efficacy of ITNs on blood-feeding mosquitoes. The impact of pyrethroid resistance on these measures appears broadly consistent across a wide geographical area once hut design is accounted for, suggesting results can be extrapolated beyond the sites where the trials were conducted. Further work is needed to understand factors influencing EHT outcomes and how the relationship between outcomes and resistance varies when different methods are used to assess the level of resistance in wild mosquito populations. This will allow more precise estimates of the efficacy of these important vector control tools.

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Insecticide resistance status of malaria vectors Anopheles gambiae (s.l.) of southwest Burkina Faso and residual efficacy of indoor residual spraying with microencapsulated pirimiphos-methyl insecticide

Parasites & Vectors ◽

10.1186/s13071-020-04563-8 ◽

2021 ◽

Vol 14 (1) ◽

Author(s):

Dieudonné Diloma Soma ◽

Barnabas Zogo ◽

Domonbabele François de Sales Hien ◽

Aristide Sawdetuo Hien ◽

Didier Alexandre Kaboré ◽

...

Keyword(s):

Insecticide Resistance ◽

Burkina Faso ◽

Anopheles Gambiae ◽

Local Population ◽

Residual Activity ◽

Indoor Residual Spraying ◽

Susceptible Strain ◽

Malaria Vectors ◽

Pirimiphos Methyl ◽

Residual Efficacy

Abstract Background The rapid spread of insecticide resistance in malaria vectors and the rebound in malaria cases observed recently in some endemic areas underscore the urgent need to evaluate and deploy new effective control interventions. A randomized control trial (RCT) was conducted with the aim to investigate the benefit of deploying complementary strategies, including indoor residual spraying (IRS) with pirimiphos-methyl in addition to long-lasting insecticidal nets (LLINs) in Diébougou, southwest Burkina Faso. Methods We measured the susceptibility of the Anopheles gambiae (s.l.) population from Diébougou to conventional insecticides. We further monitored the efficacy and residual activity of pirimiphos-methyl on both cement and mud walls using a laboratory susceptible strain (Kisumu) and the local An. gambiae (s.l.) population. Results An. gambiae (s.l.) from Diébougou was resistant to DDT, pyrethroids (deltamethrin, permethrin and alphacypermethrin) and bendiocarb but showed susceptibility to organophosphates (pirimiphos-methyl and chlorpyrimiphos-methyl). A mixed-effect generalized linear model predicted that pirimiphos-methyl applied on cement or mud walls was effective for 210 days against the laboratory susceptible strain and 247 days against the local population. The residual efficacy of pirimiphos-methyl against the local population on walls made of mud was similar to that of cement (OR = 0.792, [0.55–1.12], Tukey’s test p-value = 0.19). Conclusions If data on malaria transmission and malaria cases (as measured trough the RCT) are consistent with data on residual activity of pirimiphos-methyl regardless of the type of wall, one round of IRS with pirimiphos-methyl would have the potential to control malaria in a context of multi-resistant An. gambiae (s.l.) for at least 7 months.

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Increased Pyrethroid Resistance in Malaria Vectors and Decreased Bed Net Effectiveness, Burkina Faso

Emerging Infectious Diseases ◽

10.3201/eid2010.140619 ◽

2014 ◽

Vol 20 (10) ◽

Cited By ~ 73

Author(s):

Kobié H. Toé ◽

Christopher M. Jones ◽

Sagnon N’Fale ◽

Hanafy M. Ismail ◽

Roch K. Dabiré ◽

...

Keyword(s):

Burkina Faso ◽

Pyrethroid Resistance ◽

Malaria Vectors ◽

Bed Net

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Impact of insecticide resistance in Anopheles arabiensis on malaria incidence and prevalence in Sudan and the costs of mitigation

Proceedings of the National Academy of Sciences ◽

10.1073/pnas.1713814114 ◽

2017 ◽

Vol 114 (52) ◽

pp. E11267-E11275 ◽

Cited By ~ 12

Author(s):

Hmooda Toto Kafy ◽

Bashir Adam Ismail ◽

Abraham Peter Mnzava ◽

Jonathan Lines ◽

Mogahid Shiekh Eldin Abdin ◽

...

Keyword(s):

Insecticide Resistance ◽

Pyrethroid Resistance ◽

Malaria Incidence ◽

Disease Incidence ◽

Indoor Residual Spraying ◽

Sub Saharan Africa ◽

Malaria Vectors ◽

Incidence And Mortality ◽

Additional Protection ◽

The Impact

Insecticide-based interventions have contributed to ∼78% of the reduction in the malaria burden in sub-Saharan Africa since 2000. Insecticide resistance in malaria vectors could presage a catastrophic rebound in disease incidence and mortality. A major impediment to the implementation of insecticide resistance management strategies is that evidence of the impact of resistance on malaria disease burden is limited. A cluster randomized trial was conducted in Sudan with pyrethroid-resistant and carbamate-susceptible malaria vectors. Clusters were randomly allocated to receive either long-lasting insecticidal nets (LLINs) alone or LLINs in combination with indoor residual spraying (IRS) with a pyrethroid (deltamethrin) insecticide in the first year and a carbamate (bendiocarb) insecticide in the two subsequent years. Malaria incidence was monitored for 3 y through active case detection in cohorts of children aged 1 to <10 y. When deltamethrin was used for IRS, incidence rates in the LLIN + IRS arm and the LLIN-only arm were similar, with the IRS providing no additional protection [incidence rate ratio (IRR) = 1.0 (95% confidence interval [CI]: 0.36–3.0; P = 0.96)]. When bendiocarb was used for IRS, there was some evidence of additional protection [interaction IRR = 0.55 (95% CI: 0.40–0.76; P < 0.001)]. In conclusion, pyrethroid resistance may have had an impact on pyrethroid-based IRS. The study was not designed to assess whether resistance had an impact on LLINs. These data alone should not be used as the basis for any policy change in vector control interventions.

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