Deltamethrin Impregnated Bed Nets in a Malaria Control Program in Chabahar, Southeast Baluchistan, I.R. Iran

Abstract

A field trial was carried out in the Chabahar District of Sistan and Baluchistan Province, southeastern Iran on the efficacy of mosquito nets treated with a suspension formulation of deltamethrin (K-O THRIN ®) against malaria vectors. Treated nets were used in three villages, and in the two control villages, one used untreated nets and the other used indoor spraying with deltamethrin (WP 10%), without nets. Treatment of polyester mosquito net with a target dose of 25 mg/m 2 active ingredient, carried out in mid-April 2005. Bioassays repeated on domestically used nets over 7 months showed persistence of almost 100% mortality of Anopheles stephensi over this period. Adult mosquitoes were collected by pyrethroid space spray catch of living quarters and stables, cattle bait and pit shelter catches. Overall, An. culicifacies Giles s.l. predominated (49.8%), followed by An. stephensi Liston s.l.(36.9%), An. pulcherrimus Theobald (7.3 %), An. dthali Patton (5.7%) and An. fluviatilis James (0.3%). Acknowledge, Attitude and Practice (KAP) study showed that about 97% of respondents in communities agreed that they would like to participate in malaria control activities such as personal protection using impregnation bed net. Therefore, in planning for future large scale trials, comparison of new compounds and formulations such as tablets and long lasting insecticides impregnated bed net is recommended.

Full text

Iranian J Arthropod-Borne Dis, (2007), 1(1): 43-51 SH Moosa-Kazemi et al.: Deltamethrin Impregnated…
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Original Article
Deltamethrin Impregnated Bed Nets in a Malaria Control
Program in Chabahar, Southeast Baluchistan, I.R. Iran
*SH Moosa-Kazemi 1, H Vatandoost 1, A Raeisi 2, K Akbarzadeh 3
1Dept. of Medical Entomology, School of Public Health and Institute of Health Research, Medical Sciences/
University of Tehran, I.R. Iran
2 Dept. of Malaria Control, Ministry of Health and Medical Education, Tehran, I.R. Iran
3 Iranshahr Health Research and Training Center, Medical Sciences/ University of Tehran, Tehran, I.R. Iran
(Received 30 Sep 2006; accepted 26 Mar 2007)
ABSTRACT
A field trial was carried out in the Chabahar District of Sistan and Baluchistan Province, southeastern Iran on the
efficacy of mosquito nets treated with a suspension formulation of deltamethrin (K-O THRIN®) against malaria vectors.
Treated nets were used in three villages, and in the two control villages, one used untreated nets and the other used indoor
spraying with deltamethrin (WP 10%), without nets. Treatment of polyester mosquito net with a target dose of 25 mg/m2
active ingredient, carried out in mid-April 2005. Bioassays repeated on domestically used nets over 7 months showed
persistence of almost 100% mortality of Anopheles stephensi over this period. Adult mosquitoes were collected by
pyrethroid space spray catch of living quarters and stables, cattle bait and pit shelter catches. Overall, An. culicifacies Giles
s.l. predominated (49.8%), followed by An. stephensi Liston s.l.(36.9%), An. pulcherrimus Theobald (7.3 %), An. dthali
Patton (5.7% ) and An. fluviatilis James (0.3%). Acknowledge, Attitude and Practice (KAP) study showed that about 97%
of respondents in communities agreed that they would like to participate in malaria control activities such as personal
protection using impregnation bed net. Therefore, in planning for future large scale trials, comparison of new compounds
and formulations such as tablets and long lasting insecticides impregnated bed net is recommended.
Keywords: Malaria control, Deltamethrin, Iran
INTRODUCTION
Despite several years campaigning against
malaria, about 107 countries and territories have
areas at risk of malaria transmission. Some 3.2
billion people live in areas at risk of malaria
transmission. An estimated 350-500 million clini-
cal malaria episodes occur annually; most of
these are caused by Plasmodium falciparum
and P. vivax (WHO 2005). Malaria is still the
most important parasitic and vector-borne dis-
ease in the country. It is one of the main health
problems in the south-east provinces. Expect
cases from southeastern districts of Iran and a
few endemic foci of the other parts of the country,
the other clinical cases of the diseases are im-
ported (Vatandoost et al. 2006). A total of 18700
malaria cases were reported in 2005, among
which only 70% were Iranian, with the remain-
ing coming from abroad. According to current
reports, 90% of cases have been reported from
three provinces in the southeast: Hormozgan,
Kerman and Sistan and Baluchestan. In these
three provinces, chloroquine and sulfadoxine
was still the drug of choice for malaria treat-
ment (Center for Diseases Control and Preven-
tion, unpublished data). Malaria transmission in
this endemic area occurs through the year, most
of the malaria cases were observed from May to
November almost in the age groups of 5-25 yr
*Corresponding author: SH Moosa-Kazemi, Tel: +98 21
66465404 (Ext: 2160), Fax: +98 21 88951393, E-mail:
moosakazemi@sina.tums.ac.ir

Iranian J Arthropod-Borne Dis, (2007), 1(1): 43-51 SH Moosa-Kazemi et al.: Deltamethrin Impregnated…
44
old (Moosa kazemi et al. 2006). An. culicifacies
and An. stephensi are responsible for the trans-
mission of 60-70% of the malaria in Iran (Zaim
1998).
Synthetic pyrethroids such as, lambdacy-
halothrin and cyfluthrin have been evaluated in
the field for their effectiveness against disease
vectors (Ansari et al. 1986, Singh et al. 1989,
Yadav et al. 2001). Mosquito nets treated with
synthetic pyrethroids have proved to be an im-
portant tool for the control of malaria and other
vector borne diseases (Lengeler 2000). There is
much emphasis on social marketing of insecti-
cide-treated nets and some doubt whether nets
provided free-of-charge will be looked after by
householders (Maxwell et al. 2006).
In Iran, trials of insecticide-treated nets car-
ried out during the 1995 to 2000 in southern
provinces have shown promising results against
malaria transmitted by An. stephensi Liston
(Moosa-Kazemi et al. 2000, Rassi et al. 2002),
and An. culicifacies (Zaim et al. 1998). Insecti-
cide-treated mosquito nets are now one of the
operational strategies recommended by the World
Health Organization and Center for diseases con-
trol and prevention of Iranian Ministry of Health.
Because of the importance of the Chabahar
County not only for malaria transmission but
also for its economic situation in Iran, it was
decided to evaluate the effectiveness of del-
tamethrin impregnated bed nets on Anopheles
mosquitoes for the first time in this area during
2005. The aim was to obtain new data which
would be valuable to develop programmes for
improving community health and future plan-
ning of malaria control in this endemic area of
malaria, southeastern Iran.
MATERIALS AND METHODS
A field trial study was performed from Mar.
to Nov. 2005 in Sistan and Baluchistan Province.
This study took place in five randomly selected
rural villages in Zar-Abad rural district (57°14'N,
26°19'E), 220-250 km far from the city of Chaba-
har, Iran. It is situated at an altitude of 17 m in a
plain area. In 2005 the maximum and minimum
mean monthly temperatures were 32.5 °C and 6
°C in July and Jan., respectively. The total annual
rainfall was 220.5 mm, the minimum of 3.4 mm
in July and maximum of 65 mm in April. The
mean annual relative humidity was 74%. The
main economic activity of the people is hus-
bandry of cow, goats and fishing.
On the basis of available epidemiological
data from the Chabahar Health Centre, some
villages were short-listed and preliminary rapid
fever and entomological surveys were carried
out. On this basis, five villages with 1092 houses
and 4464 population were selected and ran-
domly three villages assigned as the trial village
to receive treated nets with deltamethrin SC
0.05 (AgrEvo, Marseille, France), one village
with 892 inhabitants to receive untreated nets
and one control villages with a total of 881
were also selected randomly that received no
nets and carried out indoor residual spraying
with deltamethrin (WP 10%) in 2005.
An open-ended questionnaire was applied
to obtain knowledge and belief of people about
malaria transmission, before the residual insec-
ticides application began. To validate and ad-
just the questionnaire to the understanding of
the population, a preliminary and piloted ver-
sion was conducted to 20 mothers of a village
in the study area and no problem was identified.
The questionnaire included two sections: the
first part 20 questions were designed to obtain
information on address of the families; family
size, age, sex, marital status, level of education,
occupation, sign and symptom of malaria, ma-
laria episodes and background treatment. In the
second part, 25 questions, including their knowl-
edge about most important diseases in the area,
route of malaria transmission, control measure,
their beliefs and practices, including medication
and use of health services, perceived effect of
indoor residual insecticides, the prefer spraying
frequency, the use of other prevention methods
such as bed nets and repellents were included.
To avoid bias questionnaire were completed
without the presence of health workers (Table 1).

Iranian J Arthropod-Borne Dis, (2007), 1(1): 43-51 SH Moosa-Kazemi et al.: Deltamethrin Impregnated…
45
The mosquito nets were of polyester poly
filament fiber, 100-denier strength, white in color,
156-mesh hole size (12×13 holes/in2) in family
(130×180×150cm) and X-Family sizes (190×
180×150) cm (WHO, 1997). Individual bed net
were soaked in a known volume of water, wrung
out and allowed to drip so that the excess water
in the bucket was meseared and the different
between this and the original volume was the
amount of the water retained by the net. This
was divided by the surface area of the net to
obtain the retention capacity in milliliters per
square meter. The concentration of insecticide
on the absorptive capacity and target dose (25
mg ai/m2) of the bed net, were prepared. After
impregnations, the bed nets were laid on plastic
sheet in the shade to partially dry and then hung
on the wire to dry completely before they were
distributed to the people. A total of 983 bed net,
423 family and 560 X-Family sizes, were im-
pregnated and distributed free of charge in the
area. The net impregnators and net users were
questioned regarding to any perceived side-ef-
fects of the insecticide-treated mosquito nets.
Before starting the trial, village meetings
were organized to inform inhabitants about proper
and regular use of nets and of the aims and im-
portance of the study. Nets were distributed free
of charge based on a survey of where people
slept in the mid of April 2005. The size and
number of nets distributed to each household
were recorded. The study population was re-
quested not to wash the nets during the study
and this was complied with very well. Project
staff demonstrated the impregnation process
and subsequently nets were treated by house-
holders under the supervision of the project
team. Normal precautions, such as use of rub-
ber gloves, avoiding contact with eyes, nose
and mouth, and washing of hands thoroughly
after impregnation, were followed. Small pieces
of netting of a similar type were then sewn to
the net for bioassay analysis.
The persistence of the insecticide on nets in
regular use was determined by contact bioassay
using a standard procedure (WHO 1980). Be-
cause a laboratory colony of An. culicifacies
was not available, we used a susceptible labo-
ratory colony of An. stephensi for detecting
changes in the persistence of insecticides on the
bed net. The contact bioassay test was per-
formed immediately after net treatment and
thereafter at monthly intervals. The mosquitoes
used were 12 to 24- h old, unfed, laboratory-
reared female An. stephensi and they were ex-
posed for 3 min in group of 5, into the adult
WHO bioassay test conical. The control female
mosquitoes were exposed to untreated mosqui-
toes netting. At the end of the exposure time the
mosquitoes were transferred to clean cups where
they were maintained on 10% sucrose solution.
The number of mosquitoes that were knocked
down by the end of the exposure period and the
mortality rate after 24 h holding was recorded.
Five replicates of tests, each with 10 mosqui-
toes, were exposed on each side of the net.
The insecticide susceptibility status of wild
caught adult An. culicifacies and An. stephensi
against DDT (4%) and deltamethrin (0.05%) was
determined by standard 30, 60, 90 and 120 min
exposures to insecticide-impregnated papers, fol-
lowed by 24-h keeping in holding tube (WHO
1975,1981).
Pyrethroum space spray mosquitoes collec-
tion were conducted between 05.00 and 08.00 h
monthly in eight fixed animal and human shel-
ter randomly on each villages from April through
November, 2005 (WHO 1975). Before spray-
ing, all the eaves, windows, doors and other exit
points were closed and cloth sheets were spread
on the floor. Pyrethrum (0.2% in kerosene) was
sprayed using a pressurized hand sprayer. After
spraying, the room was kept closed for 15 min
and the knocked-down mosquitoes were then
collected from the floor sheet with forceps and
placed in Petri-dishes lined with moist cotton.
Attempts were also made to catch mosquitoes
resting outdoors using mouth suction tube. All
collected mosquitoes were identified to species
and classified based on abdominal condition
(Shahgudian 1960).

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RESULTS
The population, history of malaria and num-
ber of questionnaire applied in the treated, un-
treated and control villages, during the years
2004-2005 are presented in Table 1.
A total of 1092 people were interviewed;
1216 from treated and 186,198 from untreated
and control villages, respectively, comprising
4464 inhabitants in five villages. A total of 1984
questionnaires were obtained. The age groups
in three areas almost was the same and 32% of
the population was under 15 yr old, 35% be-
tween 15-29 yr old, 16% between 30-44 and
18% were 45 yr and older, family size was 4 to
5 years, the majority of head families were ac-
tive in husbandry and fishing (30%). The rest
domestic activities (19%), government workers
(14%), self employed (13%) and unemployed
(8%). Almost over two- third (70%) of the popu-
lation were illiterate and the others were em-
ployed schooling.
Most of the mothers were house keeper, the
others were engaged as husbandry and fishing
activities.
Eighty seven percent of interweaves (n= 950)
indicated that they have malaria experience,
56% (n= 611) indicated that at least one mem-
ber of their family had malaria during the pervi-
ous years. In this study, the most known sign of
malaria were the same and comprises fever 52%,
chills 25%, headache 10.5%, dizziness 5%, oth-
ers 1.7%. The majority of interweaves believed
it was transmitted by mosquitoes bites (98%)
and the rest stated that is was transmitted by
stale food, non potable water and unhygienic
surrounding. Significantly residual spraying was
mach more common stated in treated and con-
trol villages interweaves (odds ratios= 2.41, X2=
42.79, df= 1, P= 0.0001). When they were asked
about the time of use, 25% indicated in evening
and night and75% using at night in both areas,
63% to 67% of the interweaves stated they rest
outdoor (in the yard) whereas, of the them stated
indoor places through warm season. A total of
99% responded that thy brought at least one
product for treatment against malaria.
Fig. 1 presents the results of the 24 h mor-
tality of 12 to 24 h old, unfed laboratory reared
female An. stephensi when exposed to mosqui-
toes net impregnated with deltamethrin for 3
min. Mortality rates were considered more stable.
The susceptibility test on An. stephensi and
An. culicifacies wild strain is presented in Table
2. Insecticide susceptibility tests showed that
for An. stephensi 39.4% survival with DDT
(4% a.i.) after one hour exposure, but there was
complete susceptibility to deltamethrin (0.05%
a.i.). An. culicifacies was completely suscepti-
ble to all two of these insecticides.
From April to November 2005, a total of
9843 female Anoheles mosquitoes were col-
lected by pyrethrum space spray catches from
indoor places of living quarters and stables
(Table 3). Overall, An. culicifacies Giles s.l pre-
dominated (49.8%), followed by An. stephensi
Liston s.l. (36.9%), An. pulcherrimus Theobald
(7.3 %), An. dthali Patton (5.7%) and An. fluvi-
atilis James (0.3%). In the control village, where
no residual spraying has been used the density
of mosquitoes was higher than other places and
An. stephensi Liston was predominated (48.8%)
followed by An. culicifacies Giles s.l. (38.5%),
An. fluviatilis James (6.7%), An. pulcherrimus
Theobald (5.57%) and An. dthali Patton (0.22%).
In the untreated area An. culicifacies Giles s.l
was predominated (60.5%) followed by An.
stephensi Liston (25.9%), An. fluviatilis James
(7.8%), An. pulcherrimus Theobald (1.75%) and
An. dthali Patton (0.45%). The composition of
anopheline species was different in control and
untreated villages as this area. In treated area An.
culicifacies Giles s.l was predominated (51.6%)
followed by An. stephensi Liston (34.5%), An.
fluviatilis James (7.4%), An. pulcherrimus Theo-
bald (6.3 %) and An. dthali Patton (0.245%).

Iranian J Arthropod-Borne Dis, (2007), 1(1): 43-51 SH Moosa-Kazemi et al.: Deltamethrin Impregnated…
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0
20
40
60
80
100
120
April
May
June
July
Augest
September
October
November
December
Months
Percent Mortality
Treatment Control
Fig. 1. Bioassy test with 3-minutes exposure to mosquitoes net treated with deltamethrin against Anopheles stephensi in Zar
Abad, Chabahar, Sistan and Baluchistan Province, Iran 2005
Table 1. Inhabitants, history of malaria cases, annual parasite incidence (API) per 1000 population and number of
questionnaires applied per villages in Chabahar, Sistan and Baluchestan Province, 2004-2005
2004 2005
Area
Pop. No. cases API Pop. No. cases API
Families
interview
Questionnaires
applied
Treatment 2736 114 41.6 2798 104 37.2 608 1216
Untreated 859 46 57.5 892 43 48.8 186 372
Control 877 43 49.4 881 44 50.0 198 396
Table 2. Susceptibility test on An. stephensi and An. culicifacies in Chabahar County, Southeastern Iran (2004-2005)*
Mortality percent after exposure to insecticide impregnated
paper and 24 h post exposure holding
Insecticides Species
Control 30 60 90 120
An. stephensi 0 (76) 14.5 (89) 29.4 (85) 46.8 (78) 100 (98)
DDT
An. culicifacies 0 (82) 62.4 (98) 100 (94) 91.3 (112) 100 (108)
An. stephensi 0 (84) 100 (109) 100 (104) 100 (108) 100 (96) Deltamethrin
An. culicifacies 0 (96) 100 (122) 100 (92) 100 (110) 100 (98)
*Figures in parenthesis are number of mosquitoes tested

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48
Table 3. Total number, the monthly mean indoor resting density, of mosquitoes catches by pyrethrum space spray and
hand collection from various sites of study villages in Zar Abad District, Sistan and Baluchestan Province 2004-2005.
Treated Untreated Control Total
Species No. mean % No. mean % No. mean % No. %
An. culicifacies 1524 261.1 51.6 1989 248.6 60.5 1389 173.6 38.5 4902 49.8
An. stephensi 1017 127.1 34.5 854 106.7 25.9 1761 220.2 48.8 3632 36.9
An. fluviatilis 219 27.3 7.4 256 32 7.8 244 30.5 6.7 719 7.3
An. pulcherrimus 187 23.3 6.3 173 21.6 1.75 201 25.1 5.57 561 5.7
An. dthali 6 0.75 0.2 15 1.87 0.45 8 1 0.22 29 0.3
DISCUSSION
This is the first report of the evaluation of
deltamethrin impregnated bed net to malaria
control in Chabahar County. Previous study in
Iran was carried out in Dishmook, Bandar Abbas
and Ghassreghand Counties. The use of protec-
tive and preventive measure against malaria is
related to family income and consequently to
the capability of purchasing explicitly stated by
the participant in our study. In spite of the lim-
itation mosquito nets are a familiar household
item and 83% of the mothers’ families in Cha-
bahar stated they used bed net and 13% and
17% some times user in this area.
Bed net has been used in different parts of
the world with varying results. Untreated mos-
quito nets provide some protection against mos-
quitoes and malaria, provided that the nets are
intact (Bradley et al. 1986, Lines et al. 1987,
Curtis et al. 1996, Mwangi et al. 2003). Pyre-
throid treatment much improves protection by
preventing mosquitoes from biting through nets,
killing them before they find holes in torn nets
and by having a community wide 'mass effect'
on the vector population when there is high com-
munity coverage (Lines et al. 1987, Maxwell
et al. 2006). The density of the vectors was re-
duced when impregnated bed net were intro-
duced (Zaim et al. 1998, Moosa Kazemi et al.
2000, Rassi et al. 2002). Our study showed that
the use of deltamethrin impregnated bed net can
provide any protection from the bite of Anophe-
les species and subsequently interrupted the
malaria transmission but does not provide com-
plete protection from the diseases.
Although, there is a reduction in the density
of female An. culicifacies in indoor places of
treated compared with the untreated also An.
stephensi compared with the control villages
but the results showed no significant different
between these area (P< 0.05).
Syntethic pyrethroid combines several ad-
vantages for use on the net. This compound as
having excito-repellency, quick-acting, and are
effective in the small quantities on the bed nets.
Deltamethrin and lambdacyhalothrin are re-
ported to persist on treated net for one year,
even with one or two washing (WHO 1980).
Our study showed that An. stephensi and An.
culicifacies to be completely susceptible to DDT
and deltamethrin insecticides. Mortality rates
were considered more stable when An. ste-
phensi exposed to mosquitoes net impregnated
with deltamethrin for 3 min. The bioassay re-
sults on nets in domestic use (Fig. 1) showed
continued high mortality of this species for the
7 months during which these tests continued. It
is widely believed that nets need to be re-treated
every 6 months, but in fact high insecticidal
activity has been found for much longer periods
of domestic use (Maxwell et al. 2006). The pre-
sent data suggest that good results would be
achieved against anopheline main vectors with
annual retreatment just before the peak trans-
mission season.
In the present trial the treated nets reduced
considerable numbers of mosquitoes (Table 3),
which suggests that they may have lead to a
'mass effect' on the village mosquito popula-
tions. This may have been at least part of the

Iranian J Arthropod-Borne Dis, (2007), 1(1): 43-51 SH Moosa-Kazemi et al.: Deltamethrin Impregnated…
49
reason for the observed lower catches of the
three vectors in the village with treated nets.
However, distinguishing a mass effect from in-
secticidal, deterrent and excito-repellent effects
in rooms with treated nets would require sam-
pling in rooms with and without treated nets in
villages with high usage of treated nets (Maxwell
et al. 2003). In Turkey, bednets treated with
tablet deltamethrin (K-O TAB®) did not reduce
the mean density of An. sacharovi in the inter-
vention areas compared with the control areas,
although reduction in malaria in the former ar-
eas was significant (Alten et al. 2003). Thus, in
this case, reduction in malaria was due to per-
sonal protection of net users without a 'bonus'
of a mass effect.
A number of field trials have evaluated nets
treated with different synthetic pyrethroids (Max-
well et al. 2006) or different formulations of the
same pyrethroid (WHO 1980, 2002). The pre-
sent field trial on the efficacy of a suspension
concentration formulation of deltamethrin against
malaria vectors showed generally comparable
results with a similar trial undertaken in the
same area (Yadav et al.,2001). However, in the
latter study bioassays showed 100% mortality
of An. culicifacies on nets 6 months after their
treatment with the SC formulation, which was
achieved on An. stephensi in the present study
(Fig. 1). In Chabahar County, malaria transmis-
sion is perennial and malaria morbidity is rela-
tively high in the young age groups (Center for
Diseases Control and Prevention, unpublished
data). Two distinct peaks of malaria transmis-
sion occur in the Chabahar County: one in April-
May and the other in September- October. In
the present study area, the peak of malaria inci-
dence coincides with the peak vectors density
of An. culicifacies and An. stephensi as the
main vectors, whereas An. fluviatilis plays only
a secondary role in the transmission. However
An. culicifacies, identified as species A of the
complex (Zaim and Javadian 1991), but species
B (28.0%) and C (72.0%) have been reported
from Sundargarh District (Nanda et al. 2000).
Conclusively, at the present time, with re-
gard to failure effects of vaccine against ma-
laria and the compliance of the residents with
the operational residual spraying, personal pro-
tection is an effective and sustainable means of
preventing of the diseases. The use of standard
tablet for net treated may be better than liquid
or suspension therefore in planning future large
scale trials, comparison of new compounds and
formulations such as tablets and long lasting of
insecticides recommended.
ACKNOWLEDGMENTS
This work was financially supported by Medi-
cal Sciences/University of Tehran and also
Dept. of Malaria Control, Ministery of Health
and Medical Education. We also would like to
express our appreciation to the people of
villages in Chabahar for their kind cooperation
through the study, many thanks also dedicated
for efforts of field staff of Iranshahr Health Re-
search and Training also Chabahar Health Cen-
ters who sincerely cooperate in performing this
research. Thanks to Dr Ranjbar, Dr Rakshani,
Dr Nazari, Mr Ahar, and Mr Shahbaksh who
are gratefully acknowledged for their participa-
tion in this surveys.
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