Indoor residual spray and insecticide-treated bednets for malaria control: theoretical synergisms and antagonisms.

Indoor residual spray (IRS) of insecticides and insecticide-treated bednets (ITNs) are the two most important malaria vector control tools in the tropical world. Application of both tools in the same locations is being implemented for malaria control in endemic and epidemic Africa. The two tools are assumed to have synergistic benefits in reducing malaria transmission because they both act at multiple stages of the transmission cycle. However, this assumption has not been rigorously examined, empirically or theoretically. Using mathematical modelling, we obtained the conditions for which a combination strategy can be expected to improve upon single control tools. Specifically, spraying of dichlorodiphenyltrichloroethane (DDT) in all houses where residents are not using ITNs can reduce transmission of malaria (R(0)) by up to 10 times more than the reduction achieved through ITNs alone. Importantly, however, we also show how antagonism between control tools can arise via interference of their modes of action. Repellent IRS reduces the likelihood that ITNs are contacted within sprayed houses and ITNs reduce the rate at which blood-fed mosquitoes rest on sprayed walls. For example, 80 per cent coverage of ITNs and DDT used together at the household level resulted in an R(0) of 11.1 when compared with an R(0) of 0.1 achieved with 80 per cent ITN coverage without DDT. While this undesired effect can be avoided using low-repellence pyrethroid chemicals for IRS, the extent of the potential benefits is also attenuated. We discuss the impact that this result will likely have on future efforts in malaria control combination strategy.