Vector control for malaria prevention during humanitarian emergencies: a systematic review and meta-analysis

Abstract

Background: Humanitarian emergencies can lead to population displacement, food insecurity, severe health system disruptions, and malaria epidemics among individuals who are immunologically naive. We aimed to assess the impact of different vector control interventions on malaria disease burden during humanitarian emergencies.

Methods: In this systematic review and meta-analysis, we searched ten electronic databases and two clinical trial registries from database inception to Oct 19, 2020, with no restrictions on language or study design. We also searched grey literature from 59 stakeholders. Studies were eligible if the population was affected by a humanitarian emergency in a malaria endemic region. We included studies assessing any vector control intervention and in which the primary outcome of interest was malaria infection risk. Reviewers (LAM, JF-A, KC, BP, and LP) independently extracted information from eligible studies, without masking of author or publication, into a database. We did random-effects meta-analyses to calculate pooled risk ratios (RRs) for randomised controlled trials, odds ratios (ORs) for dichotomous outcomes, and incidence rate ratios (IRR) for clinical malaria in non-randomised studies. Certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. This study is registered with PROSPERO, CRD42020214961.

Findings: Of 12 475 studies screened, 22 studies were eligible for inclusion in our meta-analysis. All studies were conducted between Sept 1, 1989, and Dec 31, 2018, in chronic emergencies, with 616 611 participants from nine countries, evaluating seven different vector control interventions. Insecticide-treated nets significantly decreased Plasmodium falciparum incidence (RR 0·55 [95% CI 0·37-0·79]; high certainty) and Plasmodium vivax incidence (RR 0·69 [0·51-0·94]; high certainty). Evidence for an effect of indoor residual spraying on P falciparum (IRR 0·57 [95% CI 0·53-0·61]) and P vivax (IRR 0·51 [0·49-0·52]) incidence was of very low certainty. Topical repellents were associated with reductions in malaria infection (RR 0·58 [0·35-0·97]; moderate certainty). Moderate-to-high certainty evidence for an effect of insecticide-treated chaddars (equivalent to shawls or blankets) and insecticide-treated cattle on malaria outcomes was evident in some emergency settings. There was very low certainty evidence for the effect of insecticide-treated clothing.

Interpretation: Study findings strengthen and support WHO policy recommendations to deploy insecticide-treated nets during chronic humanitarian emergencies. There is an urgent need to evaluate and adopt novel interventions for malaria control in the acute phase of humanitarian emergencies.

Funding: WHO Global Malaria Programme.