Abstract
BackgroundThe global malaria burden has fallen since 2000, sometimes before large-scale vector control programmes were initiated. While long-lasting insecticide-treated nets and indoor residual spraying are highly effective interventions, this study tests the hypothesis that improved housing can reduce malaria by decreasing house entry by malaria mosquitoes.MethodsA systematic review and meta-analysis was conducted to assess whether modern housing is associated with a lower risk of malaria than traditional housing, across all age groups and malaria-endemic settings. Six electronic databases were searched to identify intervention and observational studies published from 1 January, 1900 to 13 December, 2013, measuring the association between house design and malaria. The primary outcome measures were parasite prevalence and incidence of clinical malaria. Crude and adjusted effects were combined in fixed- and random-effects meta-analyses, with sub-group analyses for: overall house type (traditional versus modern housing); screening; main wall, roof and floor materials; eave type; ceilings and elevation.ResultsOf 15,526 studies screened, 90 were included in a qualitative synthesis and 53 reported epidemiological outcomes, included in a meta-analysis. Of these, 39 (74 %) showed trends towards a lower risk of epidemiological outcomes associated with improved house features. Of studies assessing the relationship between modern housing and malaria infection (n = 11) and clinical malaria (n = 5), all were observational, with very low to low quality evidence. Residents of modern houses had 47 % lower odds of malaria infection compared to traditional houses (adjusted odds ratio (OR) 0°53, 95 % confidence intervals (CI) 0°42–0°67, p < 0°001, five studies) and a 45–65 % lower odds of clinical malaria (case–control studies: adjusted OR 0°35, 95 % CI 0°20–0°62, p <0°001, one study; cohort studies: adjusted rate ratio 0°55, 95 % CI 0°36–0°84, p = 0°005, three studies). Evidence of a high risk of bias was found within studies.ConclusionsDespite low quality evidence, the direction and consistency of effects indicate that housing is an important risk factor for malaria. Future research should evaluate the protective effect of specific house features and incremental housing improvements associated with socio-economic development.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-015-0724-1) contains supplementary material, which is available to authorized users.
Highlights
The global malaria burden has fallen since 2000, sometimes before large-scale vector control programmes were initiated
In the 53 observational studies included in the meta-analysis, comparisons included modern versus traditional housing (n = 15); modern versus traditional wall (n = 22), roof (n = 18), and floor (n = 4) materials and closed versus open eaves (n = 11)
The present analysis suggests that modern house improvements should be further evaluated in relation to malaria, in addition to specific house modifications including screening
Summary
The global malaria burden has fallen since 2000, sometimes before large-scale vector control programmes were initiated. While long-lasting insecticide-treated nets and indoor residual spraying are highly effective interventions, this study tests the hypothesis that improved housing can reduce malaria by decreasing house entry by malaria mosquitoes. Reductions have been achieved mainly through extensive long-lasting insecticide-treated net (LLIN) distribution and indoor residual spraying (IRS) campaigns. House screening was the first intervention trialed in Italy after the link between malaria and mosquitoes was discovered [8]. Screening homes was subsequently shown to reduce malaria risk in India, South Africa and the USA [6] and better housing contributed to malaria elimination in the USA and Europe [9]. In a randomized-controlled trial (RCT) in The Gambia, untreated door and window screens and closed eaves halved the prevalence of anaemia in children [11]
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