Evaluation of lambdacyhalothrin-impregnated bednets in a malaria endemic area of India. Part 1. Implementation and acceptability of the trial

In malaria endemic forested villages in Orissa State, India, a 3-year comparison of nylon nets treated with lambdacyhalothrin at 25 mg/m2, untreated nets, and no nets was carried out. Treated nets retained high insecticidal efficacy for more than 7 months. Nets washed after 3 months of use gave 98% kill in a bioassay with a 3-min exposure. Based on these bioassays during the first year, nets were later reimpregnated at 6-monthly intervals with participation of the users. Compliance with the use of nets was good. Eighty-eight percent of nets were usable even after 3 years. The main benefits perceived by treated net users were reductions in malaria, mosquito bites, head louse infestations, and other nuisance insects. The trial was well accepted by the community. Issues related to social marketing and promotion of nets are discussed.     

Effects of educational intervention on long-lasting insecticidal nets use in a malarious area, southeast Iran

Long-lasting insecticidal nets (LLINs) have been advocated as an effective tool against malaria transmission. However, success of this community based intervention largely depends on the knowledge and practice regarding malaria and its prevention. According to the national strategy plan on evaluation of LLINs (Olyset nets), this study was conducted to determine the perceptions and practices about malaria and to improve use of LLINs in Bashagard district, one of the important foci of malaria in southeast Iran. The study area comprised 14 villages that were randomized in two clusters and designated as LLINs and untreated nets. Each of households in both clusters received two bed nets by the free distribution and delivery. After one month quantitative data collection method was used to collect information regarding the objectives of the study. On the basis of this information, an educational program was carried out in both areas to increase motivation for use of bed nets. Community knowledge and practice regarding malaria and LLIN use assessed pre- and post-educational program. The data were analyzed using SPSS ver.16 software. At baseline, 77.5% of respondents in intervention and 69.4 % in control area mentioned mosquito bite as the cause of malaria, this awareness increased significantly in intervention (90.3%) and control areas (87.9%), following the educational program. A significant increase also was seen in the proportion of households who used LLINs the previous night (92.5%) compared with untreated nets (87.1%). Educational status was an important predictor of LLINs use. Regular use of LLIN was considerably higher than the targeted coverage (80%) which recommended by World Heaths Organization. About 81.1% and 85.3% of respondents from LLIN and control areas reported that mosquito nuisance and subsequent malaria transmission were the main determinants of bed net use. These findings highlight a need for educational intervention in implementation of long-lasting insecticidal nets; this should be considered in planning and decision-making in the national malaria control program during the next campaigns of LLINs in Iran.     

Community factors affecting long-lasting impregnated mosquito net use for malaria control in Sri Lanka

The Anti Malaria Campaign distributed approximately 300,000 long-lasting impregnated nets (LLINs) to malaria-endemic areas in Sri Lanka during the years 2005 to 2007. We conducted a community-based cross-sectional survey among 2467 households distributed among the three major ethnic groups of Sri Lanka to study the perceptions and practices with regard to the use of LLINs in order to improve their use. In a majority of households the number of LLINs available was not sufficient for the number of people, although there was a small percentage of households that had excess nets. The information and advice given at the time of distribution regarding use of the nets differed amongst the three groups and was not consistent. Dissemination of this knowledge within the family was not observed. A relationship between knowledge regarding LLINs and reported practices on washing and drying of LLINs was found. It was noted that net shape may influence net use, with cone shaped nets being more popular. Efforts to increase knowledge on LLINs using behaviour change communication techniques would have more effectively contributed to achieve planned outcomes. Proper use of LLINs will undoubtedly contribute to further reduction of malaria in Sri Lanka.     

A trial of bed nets (mosquito nets) as a malaria control strategy in a rural area of The Gambia, West Africa

An intervention trial was undertaken in a rural area of The Gambia to assess the impact on malaria morbidity of the use of bed nets. Bed nets were allocated at random among a group of 16 Fula hamlets, where they were previously rarely used. The incidence of febrile episodes with associated malaria parasitaemias throughout the rainy season and the prevalence of splenomegaly and parasitaemia at the end of the rainy season were determined in 233 children aged 1-9 years who slept under bed nets and in 163 children who did not. Bed nets were used correctly by the children in the study cohort, but direct observations showed that a significant number of children left their nets for a period during the night. There was no significant difference in the incidence of clinical attacks of malaria or in any other malariometric measurement between the 2 groups. Thus, bed nets were not effective in reducing malaria morbidity in this group of children. The apparent protection from bed nets demonstrated in previous retrospective surveys may have been due to an increased number of infective bites being received by exposed individuals sleeping close to users of bed nets.     

Effectiveness of mosquito nets treated with a tablet formulation of deltamethrin for malaria control in a hyperendemic tribal area of Sundargarh District, Orissa, India

A village-scale trial on the efficacy of mosquito nets treated with a tablet formulation of deltamethrin (K-OTAB) against malaria in comparison to untreated nets or no net was conducted in Sundargarh District of Orissa, India, which is characterized by perennial transmission with Plasmodium falciparum accounting for more than 80% of malaria cases. Three villages with similar topographical and epidemiological situations were selected and randomly assigned to 3 arms of the study: treated net, untreated net, and no net. Distribution of nets, based on a sleeping pattern survey, was carried out to cover 100% of the population in treated-net and untreated-net villages. Longitudinal and cross-sectional surveys were conducted to measure malaria incidence, prevalence, and splenomegaly. Malaria incidence was reduced by 64.3% in the village with treated nets, 45.2% in the village with plain nets, and 21.4% in the control village without nets. Comparison of malaria incidence data after 1 year of intervention showed significant difference between villages with treated net vs. untreated net (P < 0.05) and treated net vs. no net (P < 0.005). The incidence of clinical attack rate due to P. falciparum was significantly lower in the population using treated nets than in those using untreated nets and no nets. However, no age-specific protective efficacy of treated nets or untreated nets was observed. A significant reduction occurred in spleen rate and parasite rate in children aged 2-9 years using treated nets or untreated nets. An overall significant reduction was found in parasite rate in the total population using treated and untreated nets as compared to nonusers.     

Cost-effectiveness of social marketing of insecticide-treated nets for malaria control in the United Republic of Tanzania

OBJECTIVE: To assess the costs and consequences of a social marketing approach to malaria control in children by means of insecticide-treated nets in two rural districts of the United Republic of Tanzania, compared with no net use. METHODS: Project cost data were collected prospectively from accounting records. Community effectiveness was estimated on the basis of a nested case-control study and a cross-sectional cluster sample survey. FINDINGS: The social marketing approach to the distribution of insecticide-treated nets was estimated to cost 1560 US dollars per death averted and 57 US dollars per disability-adjusted life year averted. These figures fell to 1018 US dollars and 37 US dollars, respectively, when the costs and consequences of untreated nets were taken into account. CONCLUSION: The social marketing of insecticide-treated nets is an attractive intervention for preventing childhood deaths from malaria.     

Monitoring community response to malaria control using insecticide-impregnated bed nets, curtains and residual spray at Nsukka, Nigeria

A project testing the efficacy of insecticide (permethrin)-impregnated bed nets, compared with impregnated door and window curtains, residual house spraying, and a control group was implemented in 12 village clusters in the Nsukka Local Government Area of Enugu State, Nigeria, using epidemiologic and entomologic indicators. The appropriate materials and services were given free to all families. During the first year of study, three monitoring exercises were carried out in a random selection of homes where children under 5 years of age resided. Information was collected on perceived effectiveness of the interventions, condition of nets and curtains, reasons for not sleeping under nets, and recall of steps required in caring for nets and curtains. Bed nets were perceived as more effective in reducing mosquito bites compared with the two other interventions. At the last monitoring period, which occurred a few weeks before a re-impregnation exercise, respondents also perceived bed nets to be most effective in preventing malaria. These findings coincided with epidemiologic evidence. Curtains, especially those at doors, were more likely to be torn and dirty than bed nets. Although holes would not reduce the effectiveness of the insecticide, they could reduce the 'beauty' of the curtains, a perceived benefit that initially attracted villagers to both curtains and nets. Bed net owners reported significantly less frequent use of other mosquito control measures in their homes than did members of the other groups. Finally, bed net users demonstrated increased knowledge of use and care steps than did those with curtains. These findings suggested a high level of social acceptability of bed nets, and point to the need to test their acceptability further under conditions where people would pay for nets and communities would manage distribution and re-impregnation systems.     

Increased financial accessibility and targeted education messages could increase ownership and use of mosquito nets in Purulia District, West Bengal, India

Insecticide-treated mosquito nets are effective in reducing malaria transmission and mortality, yet they are underused for prevention. In this study, 561 households in 33 clusters were surveyed to estimate the coverage of net ownership and the frequency of use according to selected characteristics. Of the 540 participating household heads, 247 (46%) owned mosquito nets. Of 1681 individuals in households with mosquito nets, 1359 (81%) used the nets. A household monthly income ≥2000 Indian rupees (US$45) was strongly associated with mosquito net ownership (prevalence ratio = 12, 95% CI 7.8-82). Factors independently associated with net use in multivariate analysis included age < 35 years (P < 0.001), sleeping inside (P < 0.001), use of repellent (P = 0.03) as well as knowledge that mosquitoes cause malaria (P = 0.002) and that malaria is severe in children (P < 0.001). Whilst household income is the strongest determinant of mosquito net ownership, selected knowledge elements are associated with net use. It is necessary to improve financial accessibility to nets and to communicate that malaria is a disease transmitted by mosquitoes that could be fatal in children.     

新疆北湾地区药物处理蚊帐对蚊虫击倒效果研究

目的通过药物处理蚊帐对蚊虫进行击倒实验,在北湾地区室内环境中通过药物处理蚊帐对蚊虫快速击倒效果进行研究。方法研究中选用经BASF药物处理蚊帐、20次洗涤的BASF药物处理蚊帐、5ml有效成分10％的奋斗呐处理的普通蚊帐（WHO推荐）,普通军用蚊帐作为对照,在野外环境中用吸蚊器采集当地优势蚊种刺扰伊蚊分别放入4种处理蚊帐中,观察4种处理蚊帐对当地蚊虫的首数击倒、半数击倒、全数击倒时间,最后比较分析4种处理蚊帐对当地主要蚊种的快速击倒效果。结果在对当地主要蚊种刺扰伊蚊的快速击倒效果上,经药物处理的BASF蚊帐〉清洗20次药物处理的BASF蚊帐〉WHO推荐的奋斗呐处理的蚊帐。3种处理蚊帐在7min以内都能形成对蚊虫的首数击倒,3种蚊帐在首次击倒时间上差异无统计学意义（F＝2．375,P=0．174）,在17min内形成半数击倒,BASF药物处理蚊帐与奋斗呐处理蚊帐在时间上差异有统计学意义（P=0．036）;BASF2种处理蚊帐在27min内可以全部击倒蚊虫,奋斗呐处理的蚊帐则要54min才能全部击倒蚊虫,BASF2种处理蚊帐与奋斗呐处理蚊帐间差异均有统计学意义（P〈0．001）。结论经过药物处理的蚊帐比不经任何处理的普通蚊帐对蚊虫击倒效果要好,适当选择药物处理蚊帐可以为北湾边防部队提供有效的保护。     

Seasonal vector density and disease incidence patterns of malaria in an area of Zimbabwe

Anopheline mosquitoes were studied in an area of Zimbabwe to correlate their population densities with seasonality in malaria incidence. Four trapping methods were employed for adult mosquitoes: pit traps, outdoor and indoor man-baited nets and a sheep-baited net. Anopheles funestus exhibited two population peaks during the year, one in March and the other in September/October. The following over-all proportions of the An. gambiae complex were recorded: An. gambiae Giles (2.5%), An. arabiensis Patton (14.3%) and An. guadriannulatus Theobald (83.2%). Peak populations were observed in March, with most An. gambiae and An. arabiensis preferring outdoor man-baited nets. Approximately equal preference for outdoor nets and pit traps was observed for An. guadriannulatus, which was the only species present throughout the year. The implications of these findings for malaria transmission, which showed a peak in April, and the suitability of the sampling methods employed are discussed.     

Case reduction and cost-effectiveness of the RTS,S/AS01 malaria vaccine alongside bed nets in Lilongwe,Malawi

BackgroundRTS,S/AS01, the most advanced vaccine against malaria, is now undergoing pilot implementation in Malawi, Ghana, and Kenya where an estimated 360,000 children will be vaccinated each year. In this study we evaluate RTS,S/AS01 alongside bed net use and estimate cost-effectiveness.MethodsRTS,S/AS01 phase III trial and bed net prevalence data were used to determine the effect of vaccination in the urban/periurban and rural areas of Lilongwe, Malawi. Cost data were used to calculate the cost-effectiveness of various interventions over three years.FindingsSince bed nets reduce malaria incidence and homogeneous vaccine efficacy was assumed, participants without bed nets received greater relative benefit from vaccination with RTS,S/AS01 than participants with bed nets. Similarly, since malaria incidence in rural Lilongwe is higher than in urban Lilongwe, the impact and cost-effectiveness of vaccine interventions is increased in rural areas. In rural Lilongwe, we estimated that vaccinating one child without a bed net would prevent 2·59 (1·62 to 3·38) cases of malaria over three years, corresponding to a cost of $10·08 (7·71 to 16·13) per case averted. Alternatively, vaccinating one child with a bed net would prevent 1·59 (0·87 to 2·57) cases, corresponding to $16·43 (10·16 to 30·06) per case averted. Providing RTS,S/AS01 to 30,000 children in rural Lilongwe was estimated to cost $782,400 and to prevent 58,611 (35,778 to 82,932) cases of malaria over a three-year period. Joint interventions providing both vaccination and bed nets (to those without them) were estimated to prevent additional cases of malaria and to be similarly cost-effective, compared to vaccine-only interventions.InterpretationTo maximize malaria prevention, vaccination and bed net distribution programs could be integrated.FundingImpacts of Environment, Host Genetics and Antigen Diversity on Malaria Vaccine Efficacy (1R01AI137410-01)     

Influence of deltamethrin treatment of bed nets on malaria transmission in the Kou valley, Burkina Faso.

A 3-year entomological study was carried out on the transmission of malaria in a village of 900 inhabitants in a rice-growing area of Burkina Faso. In the study area inhabitants use bed nets to protect themselves from mosquito bites. In the first year of the study, baseline data were collected; in the second year, the village was divided in two parts and all the bed nets in the southern part were sprayed with deltamethrin (25 mg/m2); and in the third year, all the bed nets in both parts of the village were sprayed. The inoculation rate was estimated by hand collection of mosquitos on human volunteers who were not protected by bed nets. The overall inoculation rate in the first year was 55 infected bites per person and was higher in the southern than in the northern part of the village. During the second year the rate increased to 70 bites per person on average (but was slightly lower than this in the southern part of the village). During the third year, the inoculation rate fell to three infected bites per year, i.e., a reduction of 94% compared with the first year. This reduction arose primarily because of a marked decrease in the sporozoitic index and a lower density of vectors. Thus, use of pyrethroid-impregnated bed nets by all members of the community appears to be a major tool in preventing transmission of malaria.     

Determinants of hanging and use of ITNs in the context of near universal coverage in Zambia

Roll Back Malaria recently recommended a policy of universal coverage with insecticide-treated nets (ITNs) so that all age groups can benefit from protection against malaria. Countries adopting the 'universal access' policy include Zambia. Policy implementation in many settings involves mass distribution of free ITNs to achieve a measure of universal coverage. This study examines ITN deployment and use in the context of mass distribution efforts towards achieving universal coverage in a malaria-endemic district in Zambia. We use multiple logistic regression to identify predictors of ITN deployment and use by anyone in the household and by children under five. Among ITN-owning households with a child under five, 69% used at least one ITN the night before the survey. About half of those children (54%) in ITN-owning households were covered the previous night. A strong and consistent predictor of use is household deployment of at least one ITN. Just over half of all ITNs were observed hanging, and reported use of nets for purposes other than malaria prevention was only 3%. Net characteristics, including shape, colour and whether or not the ITN was purchased, were not associated with net deployment. However, ITNs in poor condition are more likely to be observed hanging than ITNs in new or good condition. In the context of free mass distribution of ITNs, behaviour change communication and activities are necessary to improve use. Results suggest campaigns and messages that persuade recipients to hang up their ITNs would contribute towards closing the gap between ownership and use.     

Mass use of insecticide-treated bednets in malaria endemic poor countries: public health concerns and remedies

Epidemiological evidence arising mainly from studies undertaken in sub-Saharan Africa suggests that sleeping under insecticide-treated mosquito nets is a cost-effective and efficacious method of controlling malaria. For this reason, promotion of use of insecticide-treated nets (ITNs) has become a key malaria control strategy. In 1999, the United Nations Children's Fund (UNICEF) and WHO set the goal of providing 32 million nets and 320 million net treatments a year for the next 10 years to protect 80% of African households against malaria. All pesticides are toxic by nature and are associated with adverse health risks that depend on the toxicity of each chemical, as well as the type and degree of exposure. Thus, massive scale-up of use of ITNs in malaria endemic poor countries can be expected to present tangible risks to health, especially where the insecticides for net treatment and re-treatment are handled mostly by untrained persons in uncontrolled settings. This paper examines potential health risks of mass use of ITNs in malaria endemic poor countries and calls for the implementation of strategies to minimize potential risks through careful selection of products, appropriate labeling (including labeling in the local languages of the user communities), pesticide safety education of the public and training of health personnel, and active monitoring of adverse health effects to document actual and potential hazards, and to facilitate planning of mitigation efforts.     

The effects of untreated bednets on malaria infection and morbidity on the Kenyan coast

A study was conducted in order to determine whether children that slept under untreated bednets were protected against both malaria infection and clinical disease compared with children not sleeping under bednets. The study was conducted in Kilifi District, Kenya, during the malaria season (June-August, 2000) and involved 416 children aged < or = 10 years. Data collected from a cross-sectional survey showed evidence of protection against malaria infection among children sleeping under untreated bednets in good condition compared with those not using nets (adjusted odds ratio [AOR] = 0.4, 95% CI 0.22-0.72, P = 0.002). There was no evidence of a protective effect against infection when comparing those that used untreated bednets that were worn and those not using nets (AOR = 0.75, 95% CI 0.34-1.63, P = 0.47). When these same children were followed-up during the malaria season, there was evidence of a lower rate of clinical malaria among those that used untreated nets in good condition (adjusted incidence rate ratio = 0.65, 95% CI 0.45-0.94, P = 0.022), while the rate of clinical malaria among those that used untreated bednets that were worn was similar to that of those that did not use bednets. In the face of persistent failure of communities to take up net retreatment, there is hope that untreated nets will offer some protection against malaria infection and disease compared with not using nets at all.     

Exploring the contributions of bed nets, cattle, insecticides and excitorepellency to malaria control: a deterministic model of mosquito host-seeking behaviour and mortality

Domestic and personal protection measures against malaria exposure either divert host-seeking vectors to other hosts or kill those attempting to feed. Here, we explicitly model mosquito host-seeking processes in the context of local host availability and elucidate the impacts and mechanisms of pyrethroid-treated bed nets in Africa. It has been suggested that excitorepellent insecticides could increase exposure of unprotected humans by concentrating mosquito biting activity on this vulnerable group. This worst-case scenario is confirmed as a possibility where vector populations lack alternative hosts, but an approximate 'break-even' scenario, with users experiencing little overall change in exposure, is more likely because of increased mosquito mortality while foraging for resources. Insecticidal nets are predicted to have epidemiologically significant impacts on transmission experienced by users and non-users at levels of coverage that can be achieved by sustainable net distribution systems, regardless of excitorepellency or the ecological setting. The results are consistent with the outcome of several randomised controlled trials, predicting enormous reductions in transmission at individual and community levels. As financial support, technology and distribution systems for insecticide-treated nets improve, massive reductions in malaria transmission could be realised.     

Usefulness of a dispensary-based case-control study for assessing morbidity impact of a treated net programme

BACKGROUND: Case-control studies have been proposed as an appropriate tool for health impact evaluation of insecticide-treated nets (ITN) programmes. METHODS: A dispensary-based case-control study was carried out in one village in Tanzania. Each case of fever and parasitaemia in a child under 5 years was paired with one community and one dispensary control without fever and parasitaemia. Cases and controls were compared with regard to ITN ownership and other factors assessed by a questionnaire. A cross-sectional survey of factors associated with parasitaemia, including ITN use, was carried out during the study. Dispensary attendance rates of the study children were calculated using passive case detection data. RESULTS: Cases and dispensary controls had higher dispensary attendance rates compared to community controls and children with nets attended more for most of the illness events. A comparison of cases and community controls showed a strong and statistically significant association between untreated net use and being a case (odds ratio [OR] = 2.1, 95% CI : 1.3-3.4). For those with ITN there was a smaller and weaker association between risk of being a case and ITN use (OR =1.4, 95% CI : 0.9-2.2). Comparison of cases and dispensary controls showed no association between untreated or treated nets and the risk of being a case (for treated nets OR = 0.9, 95% CI : 0.5-1.4 and for untreated nets OR = 1.2, 95% CI : 0.7-2.0). These results are contrary to those from the cross-sectional assessment, where children with ITN had a lower prevalence of parasitaemia than those with no nets (OR = 0.5, 95% CI : 0.3-0.9), and also contrary to other assessments of the health impact of ITN in this population. CONCLUSIONS:The positive association between mild malaria and net ownership is counter-intuitive and best explained by attendance bias, since children with nets attended more frequently for all curative and preventive services at the dispensary than those without nets. Dispensary-based case-control studies may not be appropriate for assessing impact of treated nets on clinical malaria, while cross-sectional surveys might represent an attractive alternative.     

Preventing malaria in pregnancy: a study of perceptions and policy implications in Mukono district, Uganda

Although the efficacy of insecticide-treated nets (ITNs) in malaria prevention is well documented, the low coverage of ITNs in malaria endemic countries necessitates investigation on factors that limit access to this intervention. An exploratory study was conducted in Mukono district, Uganda, to assess perceptions and use of ITNs. Results show that malaria is perceived as a serious illness among pregnant women and children, and there is high awareness on the benefits of ITNs. However, ITNs are used by few people, mainly because of their high cost and the perception that the chemicals used to treat them have dangerous effects on pregnancy and the foetus. Other factors that influence the use of ITNs include low utilization of antenatal care, husband's lack of interest in malaria prevention and the perception that adolescent girls and primigravidae are at a low risk of getting malaria. The policy implications of these findings include demystifying the negative perceptions on the chemicals used to treat nets and subsidizing the cost of ITNs in order to increase access to them. These findings provide important lessons for malaria control programmes that aim at increasing access to ITNs by pregnant women in developing countries.     

The effect of delivery mechanisms on the uptake of bed net re-impregnation in Kilifi District, Kenya.

The results of recently completed trials in Africa of insecticide-treated bed nets (ITBN) offer new possibilities for malaria control. These experimental trials aimed for high ITBN coverage combined with high re-treatment rates. Whilst necessary to understand protective efficacy, the approaches used to deliver the intervention provide few indications of what coverage of net re-treatment would be under operational conditions. Varied delivery and financing strategies have been proposed for the sustainable delivery of ITBNs and re-treatment programmes. Following the completion of a randomized, controlled trial on the Kenyan coast, a series of suitable delivery strategies were used to continue net re-treatment in the area. The trial adopted a bi-annual, house-to-house re-treatment schedule free of charge using research project staff and resulted in over 95% coverage of nets issued to children. During the year following the trial, sentinel dipping stations were situated throughout the community and household members informed of their position and opening times. This free re-treatment service achieved between 61-67% coverage of nets used by children for three years. In 1997 a social marketing approach, that introduced cost-retrieval, was used to deliver the net re-treatment services. The immediate result of this transition was that significantly fewer of the mothers who had used the previous re-treatment services adopted this revised approach and coverage declined to 7%. The future of new delivery services and their financing are discussed in the context of their likely impact upon previously defined protective efficacy and cost-effectiveness estimates.     

Does Insecticide Treated Mosquito Nets (ITNs) Prevent Clinical Malaria in Children Aged Between 6 and 59 Months Under Program Setting?

Inconsistent use of the mosquito nets and other social and technical factors were shown to influence efficacy of mosquito nets at field trials. But to date, experience with local factors influencing effectiveness of ITN programs remain very limited. The objective of this study was to assess the effectiveness of ITNs for preventing clinical malaria in under-five children of Omo Nada Woreda, Jimma Zone South West Ethiopia. Matched case-control study was conducted in the catchments population of Asendabo and Nada health centers, Omo Nada Woreda, South West Ethiopia on a sample of 273 under-five children. Each case of fever and parasitemia in a child was paired with two controls. Cases and controls were compared with regard to ITN ownership and other factors assessed by a pre-coded, pre-tested structured questionnaire. Data was analyzed using EPI-INFO version 3.3.2 software. To control the effect of confounding variables, conditional logistic regression model was used. Sleeping under the mosquito net the night (OR = 8.28 95% CI: 0.96, 71.1) and the week (OR = 2.41 95% CI: 0.41, 14.0) before the survey date were strongly, but not significantly associated with clinical malaria. Mosquito net possession and appropriate utilization of mosquito net were not associated with clinical malaria. In the comparison of cases with all the controls rolling out of mosquito net & corrugated iron roof were found to be independent predictors of clinical malaria. Knowledge about the sign and symptoms of malaria and its modes of transmission were also independent predictors of clinical malaria in comparison of cases with health center and community controls, respectively. With the presence of many programmatic deficiencies like poor ITN distribution and re-treatment services, ITNs were not significantly associated with clinical malaria in under-five children when used during low-transmission period. Further research using a large sample size is required. In line with ITN scale up, information Education Communication (IEC) about the preventive practices against malaria, causes of malaria, treatment and sign and symptoms of malaria should be given to the community.