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Keywords:

  • insecticide-treated bednets;
  • malarial morbidity;
  • marketing vs. free provision;
  • mass effect;
  • sustainability of impact;
  • Tanzania

Summary

Objectives  To investigate (1) benefits due to personal protection of individual net users vs. mass killing of mosquitoes within villages as a result of widespread net usage; (2) sustainability over several years of benefits against malarial morbidity of insecticide-treated nets; (3) distribution of the benefits in different age groups of children and (4) whether, as a result of fading immunity, older age groups ‘paid for’ the benefits which they had enjoyed when younger.

Methods  (1) Tabulation of earlier data to compare personal and community-wide effects against mosquito vectors; (2) two cross-sectional surveys for malaria parasitaemia, malarial fever, anaemia and splenomegaly in children in eight Tanzanian villages, in which there had been community-wide use of bednets which had been annually re-treated with alphacypermethrin for 3–4 years; (3) comparison between children of different age groups and with intact, torn or no nets in these villages and in 4–6 villages without nets.

Results  A 90–95% reduction in infective bites outside nets in netted villages and an additional 54–82% reduction of bites among individual net users. Highly significant reductions (by 55–75%) in malarial morbidity for children aged 6 months to 2 years were found in netted villages with, for some outcomes, better results among individuals who themselves had intact treated nets. For older children, benefits were less clear or absent, but there was no sign that the benefits early in life were ‘paid for’ by worse outcomes in the netted villages later in childhood.

Conclusions  The overall benefits to the community of widespread use of treated nets are sustainable and are not reversed in 3–4 years as a result of fading immunity. It is important to ensure high enough coverage to realize the full potential of the treated net method. By showing an impact on the vector population in the community these results provide a strong argument for organized free provision of net treatment, rather than relying on marketing.