Child Mortality in a West African Population Protected with Insecticide-Treated Curtains for a Period of Up to 6 Years

By Diallo, D. A.; Cousens, S. N. et al. | Bulletin of the World Health Organization, February 2004 | Go to article overview

Child Mortality in a West African Population Protected with Insecticide-Treated Curtains for a Period of Up to 6 Years


Diallo, D. A., Cousens, S. N., Cuzin-Ouattara, N., Nebie, I., Ilboudo-Sanogo, E., Esposito, F., Bulletin of the World Health Organization


Introduction

Large trials of insecticide-treated netting (ITN), conducted over 2-year periods in various epidemiological settings across Africa, have reported 15-33% reductions in all-cause child mortality (1-4). An outstanding concern regarding the translation of these findings into a policy of large-scale implementation oF ITN in malaria-endemic areas has been the extent to which this impact on child mortality is sustainable over longer periods of time (5-7). It has been hypothesized that reducing malaria transmission levels might slow the development of clinical immunity leading to a shift in child mortality to older ages ("delayed mortality"), with little or no long-term survival gain. Support for this hypothesis has been largely derived from ecological comparisons of the age distribution and clinical patterns of severe malaria as well as malaria-specific mortality rates between areas with different levels of malaria transmission across Africa (5, 6). This hypothesis triggered a fierce debate within the scientific community, since the interpretation of such comparisons is fraught with difficulty (8-11).

It would be unethical to perform controlled trials in which part of the study population does not receive ITN for many years. Thus, to address whether ITN has a long-term impact on child mortality, it is necessary to use other, less well-controlled, approaches. We report observational data on all-cause child mortality in communities in Burkina Faso which have used insecticide-treated curtains (ITC) for up to six years following a randomized, controlled trial of ITC conducted between 1993 and 1996.

Methods

Study area

The study was carried out in a rural setting, in Oubritenga Province, Burikina Faso, West Africa. Malaria transmission is stable but markedly seasonal, peaking in the rainy season (June-October) with only low levels of transmission occurring in the dry season. The annual rainfalls recorded in the study area in the years 1993-99 were 662, 860, 609, 637, 642, 831, and 772 mm, respectively. The main malaria vector is Anopheles gambiae s.s., with Anopheles arabiensis and Anopheles funestus contributing to a lesser extent (12-14). The average entomological inoculation rate (EIR) prior to intervention was estimated to be 300-500 infective bites/person/year (15). Plasmodium falciparum is responsible for more than 95% of malaria infections in children.

A district hospital and 10 dispensaries provide health care to the communities in the study area.

Study population

The study area was first censused in 1993, when a population of 88 087 inhabitants living in 158 villages was enrolled in the study. Most of the study population (>95%) belongs to the Mossi ethnic group and lives by subsistence farming. The population migration rate has been estimated at about 2.5% per year (4).

Study design

The initial study was designed as a randomized, controlled trial of the impact of ITC on all-cause child mortality. After the census in 1993, the 158 villages in the study area were grouped into 16 geographical clusters. Clusters were paired according to their baseline mortality rates, population size, and ecological features. In each pair, one cluster was randomly selected to receive the intervention in June-July 1994. The eight remaining clusters acted as control areas, receiving the intervention in June-July 1996. The intervention was maintained and mortality measured across the whole study area until May 2000.

Demographic surveillance

Details of the methods used to measure child mortality have been published elsewhere (16). In brief, annual censuses have been performed since 1993. At each census after the first, preprinted "rollcalls" have been used to register births, deaths, and migrations occurring since the previous census. Pregnancies were also recorded when identified. During the census in 1999 all married women aged less than 45 years who had not reported a birth in the past 2. …

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