Cooperative actions to achieve malaria control without the use of DDT

The success of regional networks to provide incentives and mechanisms for sharing information is illustrated through the North American Regional Action Plan on DDT (NARAP). This NARAP was designed to reduce human and environmental exposure to DDT and its metabolites in North America through cooperative efforts. The increasing role of environmental concerns in the planning and design of Mexico's DDT phase-out program motivated the Mexican Ministry of Health to undertake an alternative program for malaria control maximizing community participation without negatively affecting human and ecosystem health. This program relies on: 1) elimination of parasites in people, 2) improvement of personal and household hygiene, and 3) use of environmental management practices to eliminate mosquito breeding sites. This new strategy resulted in the elimination of DDT for malaria control in Mexico in the year 2000. While malaria and its corresponding vectors show considerable variability within a single country and certainly around the globe, the case example of Mexico provides a methodology for developing alternatives to DDT.     

Nonmalarial infant deaths and DDT use for malaria control

Although dichlorodiphenyl trichloroethane (DDT) is being banned worldwide, countries in sub-Saharan Africa have sought exemptions for malaria control. Few studies show illness in children from the use of DDT, and the possibility of risks to them from DDT use has been minimized. However, plausible if inconclusive studies associate DDT with more preterm births and shorter duration of lactation, which raise the possibility that DDT does indeed have such toxicity. Assuming that these associations are causal, we estimated the increase in infant deaths that might result from DDT spraying. The estimated increases are of the same order of magnitude as the decreases from effective malaria control. Unintended consequences of DDT use need to be part of the discussion of modern vector control policy.     

Specifications of the International Cooperation Administration for DDT water-dispersible powder for use in malaria control programmes

Background information is presented on the development of specifications for 75% DDT water-dispersible powder for use in malaria control programmes supported by the International Cooperation Administration (ICA) of the United States Government. Early difficulties with DDT powders used in these programmes were investigated and it was found that the most critical requirements involved packaging, suspensibility and storage stability. ICA specifications were evolved to meet these requirements. The suspensibility test developed is described, and the importance of inspection of the material procured is discussed.     

An evaluation of the residual lifespan of DDT in malaria control

The insecticide lifespan of DDT was assessed in huts sprayed for malaria control. The age of the spray deposits ranged from 3 up to 22 months. Blood-fed female Anopheles arabiensis were either released into the huts or exposed on sprayed surfaces by a bioassay technique. Mosquitoes released were recovered in exit traps fitted on windows or dead on the floor. Only 50% or less of mosquitoes released in sprayed huts were recovered. Mortality figures for recovered mosquitoes ranged from 94% at 3 months, declining to 19% for huts sprayed 18 months previously. Of the recovered mosquitoes, 60% or more attempted to escape from sprayed huts within two hours postrelease up to 15 months postspray. Bioassays gave average mortalities of 95 and 76% on thatch and mud walls, respectively. Analysis of mud samples from test huts showed that target dose of 2 g AI/m2 of DDT was not being achieved. The results support the need for an annual spraying cycle.     

Transfer of DDT used in malaria control to infants via breast milk.

The transfer of p,p'-DDT (1,1,1-tricholoro-2,2-bis(4-chlorophenyl)ethane) and its metabolites to infants via breast-feeding was studied in an area of KwaZulu, South Africa, where DDT is used to interrupt malaria transmission. Samples of whole blood were collected from 23 infants, together with samples of breast milk from their respective mothers. The mean sigma DDT (total DDT) in the whole blood was 127.03 micrograms.l-1 and that in the breast milk, 15.06 mg.kg-1 (milk fat). The % DDT (% DDT of sigma DDT) was significantly higher in the infant blood than in the breast milk (P less than 0.05). A multiplicative regression analysis indicated that sigma DDT increased significantly (P less than 0.01) in infant whole blood with infant age. Multiple regression showed that 70.0% of the variation in sigma DDT was due to the variation in parity of the mother, age of the infant, and the sigma DDT in breast milk. These variables accounted also for 76.3% of the variation in p,p'-DDE but only for 38.2% of that in p,p'-DDT. Organochlorines were therefore largely transferred to the infant from the mother, with DDT in the environment playing a secondary role.     

Levels of DDT and metabolites in breast milk from Kwa-Zulu mothers after DDT application for malaria control

Concentrations of DDT, DDE and DDD were determined in the breast milk of Kwa-Zulu mothers residing in two different areas--with and without annual intra-domiciliary applications of DDT for the interruption of malaria transmission (exposed and control groups, respectively). While no significant change in levels with time was found in the control group, both DDT and DDE in breast milk of the exposed group increased after DDT application and this continued for three more months, after which it did not decrease appreciably. Percentage DDT increased from 42.57% (sigma DDT = 12.21 mg/kg milk fat) before spraying to 50.87% (sigma DDT = 13.79 mg/kg milk fat) following DDT application. At 6 and 9 months after the application it was 45.85% (sigma DDT = 19.49 mg/kg milk fat) and 43.27% (sigma DDT = 18.34 mg/kg milk fat), respectively. These results suggest a risk to the health of the infants in the exposed group.     

Reproductive effects of occupational DDT exposure among male malaria control workers

To assess potential effects of human DDT [1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethane] exposure, we evaluated the reproductive history of 2,033 workers in the antimalaria campaign of Mexico. Data on occupational exposure to DDT and reproductive outcomes were gathered through a questionnaire, and workers provided information about 9,187 pregnancies. We estimated paternal exposure to DDT before each pregnancy using three approaches: a) a dichotomous indicator for pregnancies before and after exposure began, b) a qualitative index of four exposure categories, and c) an estimation of the DDT metabolite DDE [1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene] accumulated in fat. To assess associations, we used logistic regression models that accounted for correlated observations and adjusted for parents' age at each child's birth, exposure to other pesticides, exposure to chemical substances in other employment, smoking, and alcohol consumption. The odds ratio for birth defects comparing pregnancies after and before the first exposure was 3.77 [95% confidence interval (95% CI), 1.19-9.52]. Compared with the lowest quartile of estimated DDE in fat, the ORs were 2.48 (95% CI, 0.75-8.11), 4.15 (95% CI, 1.38-12.46), and 3.76 (95% CI, 1.23-11.44) for quartiles 2, 3, and 4, equivalent to p,p -DDE in fat of 50, 82, and 298 microg/g fat, respectively. No significant association was found for spontaneous abortion or sex ratio. We found an increased risk of birth defects associated with high occupational exposure to DDT in this group of workers. The significance of this association at lower exposure levels found in the general population remains uncertain.     

DDT reintroduction for malaria control: the cost-benefit debate for public health

DDT is a persistent insecticide that was widely used in the world from the 1940s until the 70s, when it was banned in the United States and other countries. Most of its toxic effects are not observed in the acute forms, but particularly after chronic exposure. These long-term issues include reproductive effects, varying according to the time of life in which the individuals were exposed. The aims of the current study were to review the principal toxicological effects of DDT on reproduction, stratifying by physiological periods of exposure, and based on the magnitude of these effects, to discuss the cost-benefit relationship of reintroducing DDT with the specifically defined vector control criteria.     

Exposure assessment for workers applying DDT to control malaria in Veracruz, Mexico.

DDT has systematically been used in sanitation campaigns against malaria in Mexico. To assess chronic occupational exposure, we studied a group of workers dedicated to spraying houses to control malaria vectors in the state of Veracruz. Exposure was directly estimated for a subgroup of 40 workers by measuring DDT metabolites in adipose tissue samples and indirectly estimated for 331 workers by using a questionnaire to determine their occupational history. Participants ranged in age from 20 to 70 years, and 80% of the workers had been employed in the sanitation campaign for at least 20 years. The mean concentrations of extractable lipids found in adipose tissue samples were as follows: total DDT, 104.48 micrograms/g; p,p'-DDE, 60.98 micrograms/g; p,p'-DDT, 31.0 micrograms/g; o,p'-DDT, 2.10 micrograms/g; and p,p'-DDD, 0.95 microgram/g. The DDT metabolite p,p'-DDE was selected as the indicator of chronic exposure. An index of chronic occupational exposure was constructed according to worker position and based on the historical duration and intensity of DDT application. A linear model including this index, the use of protective gear, and recent weight loss explained 55% of the variation of p,p'-DDE concentrations in adipose tissue. By this model, the predicted values of p,p'-DDE concentration in adipose tissue for the 331 workers are between 9.56 micrograms/g and 298.4 micrograms/g of fat, with a geometric mean of 67.41 micrograms/g. These high levels of DDT in adipose tissue call for exposure prevention programs and the promotion of more secure application measures and hygiene. We also discuss the use of indirect measures of DDT exposure in epidemiological studies of health effects.     

DDT and malaria prevention: addressing the paradox

Background

The debate regarding dichlorodiphenyltrichloroethane (DDT) in malaria prevention and human health is polarized and can be classified into three positions: anti-DDT, centrist-DDT, pro-DDT.

Objective

We attempted to arrive at a synthesis by matching a series of questions on the use of DDT for indoor residual spraying (IRS) with literature and insights, and to identify options and opportunities.

Discussion

Overall, community health is significantly improved through all available malaria control measures, which include IRS with DDT. Is DDT “good”? Yes, because it has saved many lives. Is DDT safe as used in IRS? Recent publications have increasingly raised concerns about the health implications of DDT. Therefore, an unqualified statement that DDT used in IRS is safe is untenable. Are inhabitants and applicators exposed? Yes, and to high levels. Should DDT be used? The fact that DDT is “good” because it saves lives, and “not safe” because it has health and environmental consequences, raises ethical issues. The evidence of adverse human health effects due to DDT is mounting. However, under certain circumstances, malaria control using DDT cannot yet be halted. Therefore, the continued use of DDT poses a paradox recognized by a centrist-DDT position. At the very least, it is now time to invoke precaution. Precautionary actions could include use and exposure reduction.

Conclusions

There are situations where DDT will provide the best achievable health benefit, but maintaining that DDT is safe ignores the cumulative indications of many studies. In such situations, addressing the paradox from a centrist-DDT position and invoking precaution will help design choices for healthier lives.     

DDT, global strategies, and a malaria control crisis in South America.

Malaria is reemerging in endemic-disease countries of South America. We examined the rate of real growth in annual parasite indexes (API) by adjusting APIs for all years to the annual blood examination rate of 1965 for each country. The standardized APIs calculated for Brazil, Peru, Guyana, and for 18 other malaria-endemic countries of the Americas presented a consistent pattern of low rates up through the late 1970s, followed by geometric growth in malaria incidence in subsequent years. True growth in malaria incidence corresponds temporally with changes in global strategies for malaria control. Underlying the concordance of these events is a causal link between decreased spraying of homes with DDT and increased malaria; two regression models defining this link showed statistically significant negative relationships between APIs and house-spray rates. Separate analyses of data from 1993 to 1995 showed that countries that have recently discontinued their spray programs are reporting large increases in malaria incidence. Ecuador, which has increased use of DDT since 1993, is the only country reporting a large reduction (61%) in malaria rates since 1993. DDT use for malaria control and application of the Global Malaria Control Strategy to the Americas should be subjects of urgent national and international debate. We discuss the recent actions to ban DDT, the health costs of such a ban, perspectives on DDT use in agriculture versus malaria control, and costs versus benefits of DDT and alternative insecticides.     

Global status of DDT and its alternatives for use in vector control to prevent disease

In this article I reviewed the status of dichlorodiphenyltrichloroethane (DDT), used for disease vector control, and its benefits and risks in relation to the available alternatives. Contemporary data on DDT use were obtained from questionnaires and reports as well as a Scopus search to retrieve published articles. Nearly 14 countries use DDT for disease control, and several others are reintroducing DDT. Concerns about the continued use of DDT are fueled by recent reports of high levels of human exposure associated with indoor spraying amid accumulating evidence on chronic health effects. There are signs that more malaria vectors are becoming resistant to the toxic action of DDT. Effective chemical methods are available as immediate alternatives to DDT, but the development of resistance is undermining the efficacy of insecticidal tools. Nonchemical methods are potentially important, but their effectiveness at program level needs urgent study. To reduce reliance on DDT, support is needed for integrated and multipartner strategies of vector control. Integrated vector management provides a framework for developing and implementing effective technologies and strategies as sustainable alternatives to reliance on DDT.     

Irritability to DDT of natural populations of the primary malaria vectors in Colombia

Natural populations of Anopheles albimanus, An. darlingi and An. nuneztovari were tested for their irritability to DDT in different regions of Colombia. Individual anophelines were exposed to filter papers impregnated with 2% DDT and irritability was determined based on the number of flights a mosquito made in 15 min. All three species showed variability in their irritability to DDT. Anopheles albimanus showed irritability only in Bolivar, but not in three other regions. Anopheles darlingi showed no irritability in neither the Atlantico nor Llanos regions, while An. nuneztovari showed irritability in the Oriente but not in Uraba. The irritability to DDT shown in some populations of An. albimanus and An. nuneztovari may reduce the effectiveness of residual applications of this insecticide by causing the mosquitoes to seek untreated surfaces and/or leave the house to rest outdoors and thus avoid a lethal dose.     

Susceptibility of malaria vectors to DDT in Greece; laboratory findings

The authors describe an investigation, started in Greece in the autumn of 1953 and continued during the 1954 malaria-transmission season, to determine the variations in the susceptibility to DDT of the anophelines in different localities, with a view to establishing a point of departure which would make it possible to follow any future changes in susceptibility to this insecticide.The degree of susceptibility of the mosquitos to DDT was assessed numerically by both the technique of topical application of microdoses of the insecticide and the technique devised by Busvine & Nash. The villages of Elos and Asterion (Skála area), the Agoulinitsa area, and the Georgioupolis (Crete) area were chosen for the investigation.The findings disclosed considerable differences in the susceptibility to DDT in the above areas, but showed that, on the whole, the tendency for anophelines to acquire resistance to DDT seemed to be continuing in Greece.     

Control of malaria in Africa: from the eradication of malaria to the control of malaria

The control strategies usually recommended in Africa south of the Sahara have not been followed by a lasting decline in the endemic level of the disease in the rural environment. The set-backs of the eradication period have revealed the need to redefine control objectives and strategies adapted to each type of malaria. Systematic chemotherapy for attacks of fever is a strategy that can be proposed in all circumstances; it avoids mortality from malaria; it can be carried out in the field on a country scale. The other means of control, directed against the parasites and the vectors, may be used depending of the specific situation in each country and on each type of malaria. Malaria control has to be integrated into the basic health system of each country, and we need to improve health education and develop primary health care. We must continue with our efforts to develop new antimalarial drugs, insecticides and vaccines; urgent steps must be taken to train malariologists capable of adapting the new techniques to the actual situation in the field. It is by associating socioeconomic development with the control means as a whole that we shall be able to control the various types of malaria and to reach out towards the objective of health for all by the year 2000.