BackgroundMalaria is an important cause of illness and death in many parts of the world, especially in sub-Saharan Africa. There has been a renewed emphasis on preventive measures at community and individual levels. Insecticide-treated nets (ITNs) are the most prominent malaria preventive measure for large-scale deployment in highly endemic areas. ObjectivesTo assess the impact of insecticide-treated bed nets or curtains on mortality, malarial illness (life-threatening and mild), malaria parasitaemia, anaemia, and spleen rates.

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BackgroundMalaria prevention in Africa merits particular attention as the world strives toward a better life for the poorest. Insecticide-treated nets (ITNs) represent a practical means to prevent malaria in Africa, so scaling up coverage to at least 80% of young children and pregnant women by 2010 is integral to the Millennium Development Goals (MDG). Targeting individual protection to vulnerable groups is an accepted priority, but community-level impacts of broader population coverage are largely ignored even though they may be just as important. We therefore estimated coverage thresholds for entire populations at which individual- and community-level protection are equivalent, representing rational targets for ITN coverage beyond vulnerable groups.Methods and FindingsUsing field-parameterized malaria transmission models, we show that high (80% use) but exclusively targeted coverage of young children and pregnant women (representing <20% of the population) will deliver limited protection and equity for these vulnerable groups. In contrast, relatively modest coverage (35%–65% use, with this threshold depending on ecological scenario and net quality) of all adults and children, rather than just vulnerable groups, can achieve equitable community-wide benefits equivalent to or greater than personal protection.ConclusionsCoverage of entire populations will be required to accomplish large reductions of the malaria burden in Africa. While coverage of vulnerable groups should still be prioritized, the equitable and communal benefits of wide-scale ITN use by older children and adults should be explicitly promoted and evaluated by national malaria control programmes. ITN use by the majority of entire populations could protect all children in such communities, even those not actually covered by achieving existing personal protection targets of the MDG, Roll Back Malaria Partnership, or the US President's Malaria Initiative.

Historical and programme documentation has clearly established the impact of IRS. However, the number of high-quality trials are too few to quantify the size of effect in different transmission settings. The evidence from randomized comparisons of IRS versus no IRS confirms that IRS reduces malaria incidence in unstable malaria settings, but randomized trial data from stable malaria settings is very limited. Some limited data suggest that ITN give better protection than IRS in unstable areas, but more trials are needed to compare the effects of ITNs with IRS, as well as to quantify their combined effects.

The authors present a framework for analysis and action to explore and improve access to health care in resource-poor countries, especially in Africa.

Summary Indoor residual house‐spraying (IRS) mainly with dichlorodiphenyltrichloroethane (DDT) was the principal method by which malaria was eradicated or greatly reduced in many countries in the world between the 1940s and 1960s. In sub‐Saharan Africa early malarial eradication pilot projects also showed that malaria is highly responsive to vector control by IRS but transmission could not be interrupted in the endemic tropical and lowland areas. As a result IRS was not taken to scale in most endemic areas of the continent with the exception of southern Africa and some island countries such as Reunion, Mayotte, Zanzibar, Cape Verde and Sao Tome. In southern Africa large‐scale malarial control operations based on IRS with DDT and benzene hexachloride (BHC) were initiated in a number of countries to varying degrees. The objective of this review was to investigate the malarial situation before and after the introduction of indoor residual insecticide spraying in South Africa, Swaziland, Botswana, Namibia, Zimbabwe and Mozambique using historical malarial data and related information collected from National Malaria Control Programmes, national archives and libraries, as well as academic institutions in the respective countries. Immediately after the inception of IRS with insecticides, dramatic reductions in malaria and its vectors were recorded. Countries that developed National Malaria Control Programmes during this phase and had built up human and organizational resources made significant advances towards malarial control. Malaria was reduced from hyper‐ to meso‐endemicity and from meso‐ to hypo‐endemicity and in certain instances to complete eradication. Data are presented on the effectiveness of IRS as a malarial control tool in six southern African countries. Recent trends in and challenges to malarial control in the region are also discussed.

This record should be cited as: Lengeler C. Insecticide-treated bednets and curtains for preventing malaria. The Cochrane Database of Systematic Reviews (Complete Reviews) , Issue . Art. No.: CD000363.