Permethrin-treated Bed Nets Research Articles

Assessing the impact of the addition of pyriproxyfen on the durability of permethrin-treated bed nets in Burkina Faso: a compound-randomized controlled trial

BackgroundLong-lasting insecticidal nets (LLINs) treated with pyrethroids are the foundation of malaria control in sub-Saharan Africa. Rising pyrethroid resistance in vectors, however, has driven the development of alternative net formulations. Here the durability of polyethylene nets with a novel combination of a pyrethroid, permethrin, and the insect juvenile hormone mimic, pyriproxyfen (PPF), compared to a standard permethrin LLIN, was assessed in rural Burkina Faso.MethodsA compound-randomized controlled trial was completed in two villages. In one village 326 of the PPF-permethrin nets (Olyset Duo) and 327 standard LLINs (Olyset) were distributed to assess bioefficacy. In a second village, 170 PPF-permethrin nets and 376 LLINs were distributed to assess survivorship. Nets were followed at 6-monthly intervals for 3 years. Bioefficacy was assessed by exposing permethrin-susceptible and resistant Anopheles gambiae sensu lato mosquito strains to standard World Health Organization (WHO) cone and tunnel tests with impacts on fertility measured in the resistant strain. Insecticide content was measured using high-performance liquid chromatography. LLIN survivorship was recorded with a questionnaire and assessed by comparing the physical integrity using the proportionate hole index (pHI).ResultsThe PPF-permethrin net met WHO bioefficacy criteria (≥ 80% mortality or ≥ 95% knockdown) for the first 18 months, compared to 6 months for the standard LLIN. Mean mosquito mortality for PPF-permethrin nets, across all time points, was 8.6% (CI 2.6–14.6%) higher than the standard LLIN. Fertility rates were reduced after PPF-permethrin net exposure at 1-month post distribution, but not later. Permethrin content of both types of nets remained within the target range of 20 g/kg ± 25% for 242/248 nets tested. The pyriproxyfen content of PPF-permethrin nets declined by 54%, from 10.4 g/kg (CI 10.2–10.6) to 4.7 g/kg (CI 3.5–6.0, p < 0.001) over 36 months. Net survivorship was poor, with only 13% of PPF-permethrin nets and 12% of LLINs still present in the original household after 36 months. There was no difference in the fabric integrity or survivorship between the two net types.ConclusionThe PPF-permethrin net, Olyset Duo, met or exceeded the performance of the WHO-recommended standard LLIN (Olyset) in the current study but both net types failed the 3-year WHO bioefficacy criteria.

Malaria infection in mosquitoes decreases the personal protection offered by permethrin-treated bednets

BackgroundInsecticides targeting adult mosquitoes are the main way of controlling malaria. They work not only by killing mosquitoes, but also by repelling and irritating them. Indeed their repellent action gives valuable personal protection against biting mosquitoes. In the context of malaria control this personal protection is especially relevant when mosquitoes are infectious, whereas to protect the community we would prefer that the mosquitoes that are not yet infectious are killed (so, not repelled) by the insecticide. As the infectious stage of malaria parasites increases the motivation of mosquitoes to bite, we predicted that it would also change their behavioural response to insecticides.ResultsWith two systems, a laboratory isolate of the rodent malaria Plasmodium berghei infecting Anopheles gambiae and several isolates of P. falciparum obtained from schoolchildren in Tanzania that infected Anopheles arabiensis, we found that mosquitoes harbouring the infectious stage (the sporozoites) of the parasite were less repelled by permethrin-treated nets than uninfected ones.ConclusionsOur results suggest that, at least in the laboratory, malaria infection decreases the personal protection offered by insecticide-treated nets at the stage where the personal protection is most valuable. Further studies must investigate whether these results hold true in the field and whether the less effective personal protection can be balanced by increased community protection.

Malaria, Intestinal Parasitic Infection, Anemia, and Malnourishment in Rural Cameroonian Villages with an Assessment of Early Interventions

Malaria, water-borne diarrheal diseases, and geohelminth infections, combined with severe malnutrition ravage entire villages throughout subSaharan Africa. The Bawa Health Initiative (BHI) is a 501c(3) non-profit organization with the goal of implementing a comprehensive public health program in an attempt to address these problems in a series of rural villages located in the West Province of Cameroon, Africa. Interventions include the provision of permethrin-treated bed nets to reduce the transmission of malaria, the installation of biosand water filters to reduce the prevalence of water-borne diseases, and a geohelminth control program utilizing mass treatment with albendazole. This study details the results of surveys conducted to monitor the success of the interventions. Since implementation of interventions, the number of clinical cases of malaria, diarrheal disease and typhoid has decreased, the prevalence of water-borne protozoan parasites has decreased, the prevalence and intensities of geohelminth infections has significantly decreased, and the prevalence of anemia has significantly decreased. When viewed in its entirety, these data show that the comprehensive approach to public health challenges in these villages initiated by BHI has been extremely successful. However, much work remains to be done. The primary purpose of this paper is to further inform academicians, students, and the general public about the continuing problems associated with these diseases and to describe and assess the effectiveness of some current interventions being used to combat them.

A preliminary test of the protective efficacy of permethrin-treated bed nets in an area of Anopheles gambiae metabolic resistance to pyrethroids in north Cameroon

A trial of permethrin-treated nets (PTNs) versus untreated nets (UTNs) was conducted in Pitoa (north Cameroon), where the main malaria vectors, Anopheles gambiae s.l. and Anopheles arabiensis, show metabolic-based permethrin resistance. The deterrent effect of permethrin greatly reduced A. gambiae biting rate inside rooms where PTNs were installed. After 3 months of net use, malaria reinfection rate was significantly lower in children sleeping under a PTN, but no such effect was observed after 6 months. Parasitaemia was not significantly different between the two arms. These findings suggest good, although transitory, personal protection against malaria conferred by PTNs in an area of metabolic-based permethrin resistance.

FIRST RECORD OF ANOPHELES MINIMUS C AND SIGNIFICANT DECREASE OF AN. MINIMUS A IN CENTRAL VIETNAM

Before August 1998, in the Khanh Phu commune (central Vietnam), Anopheles minimus s.l. individuals were identified as species A and showed the typical species A wing form. After a significant decrease over the 3 years 1999-2001, an increase in 2002 of An. minimus s.l. possessing a different wing pattern was observed. To determine the specific status of the An. minimus species collected in 2002 and to follow changes in the species composition, an allele-specific polymerase chain reaction was applied to samples collected from 1993 to 2002. This study reports the first record of An. minimus C in central Vietnam and, since 1998, a significant reduction of An. minimus A that coincided with the wide use of permethrin-treated bednets. This change in anopheline composition may have important consequences on malaria transmission. This work shows that the geographic distribution of malaria vectors in southeast Asia is only partially known and highlights the importance of species identification for understanding changes in the vector composition as a result of selective vector control.

THE EFFICACY OF PERMETHRIN-TREATED BED NETS ON CHILD MORTALITY AND MORBIDITY IN WESTERN KENYA I. DEVELOPMENT OF INFRASTRUCTURE AND DESCRIPTION OF STUDY SITE

Randomized controlled trials in sub-Saharan Africa have shown that permethrin-treated bed nets and curtains reduce all-cause child mortality by 15-33% in areas with low or high but seasonal malaria transmission. This report describes the study site for a community-based, group-randomized, controlled trial in an area of high and year-round malaria transmission in western Kenya. We outline the development of the human and physical infrastructure required to conduct this trial and discuss some of the difficulties encountered and lessons learned in conducting it.

IMPACT OF PERMETHRIN-TREATED BED NETS ON ENTOMOLOGIC INDICES IN AN AREA OF INTENSE YEAR-ROUND MALARIA TRANSMISSION

The effect of permethrin-treated bed nets (ITNs) on malaria vectors was studied as part of a large-scale, randomized, controlled trial in western Kenya. Indoor resting densities of fed Anopheles gambiae s.l. and An. funestus in intervention houses were 58.5% (P = 0.010) and 94.5% (P = 0.001) lower, respectively, compared with control houses. The sporozoite infection rate in An. gambiae s.l. was 0.8% in intervention areas compared with 3.4% (P = 0.026) in control areas, while the sporozoite infection rates in An. funestus were not significantly different between the two areas. We estimated the overall transmission of Plasmodium falciparum in intervention areas to be 90% lower than in control areas. Permethrin resistance was not detected during the study period. As measured by densities of An. gambiae s.l., the efficacy of bed nets decreased if one or more residents did not sleep under a net or if bed nets had not been re-treated within six months. These results indicate that ITNs are optimally effective if used every night and if permethrin is reapplied at least biannually.

COMPARISON OF GOVERNMENT STATISTICS AND DEMOGRAPHIC SURVEILLANCE TO MONITOR MORTALITY IN CHILDREN LESS THAN FIVE YEARS OLD IN RURAL WESTERN KENYA

Estimates of mortality in children less than five years old using government civil registration statistics (passive surveillance) were compared against statistics generated by active demographic surveillance during a randomized controlled trial of permethrin-treated bed nets (ITNs) in western Kenya. Mortality rates were two-fold lower when estimated through civil registration compared with active prospective surveillance (rate ratio [RR] = 0.51, 95% confidence interval [CI] = 0.44-0.59). While civil registration underestimated deaths, particularly in the neonatal period, the age distribution of deaths in children 1-59 months of age was the same as with active surveillance. Seasonal mortality trends were also similar. There was no agreement between cause of death recorded by active and passive surveillance. Verbal autopsy estimated that half of all deaths were associated with malaria and pneumonia, but civil registration markedly under-reported these illnesses; incidence RR (95% CI) = 0.18 (0.14-0.24), and 0.05 (0.03-0.08), respectively, while over-reporting deaths due to measles (RR = 15.5 [95% CI = 7.3-33.2]). Government statistics under-represent mortality, particularly neonatal mortality, in children less than five years of age in rural areas of Kenya. They can provide accurate information on the age-distribution of deaths among children 1-59 months old, and on seasonal trends, but not on disease-specific mortality.

REDUCTION OF MALARIA DURING PREGNANCY BY PERMETHRIN-TREATED BED NETS IN AN AREA OF INTENSE PERENNIAL MALARIA TRANSMISSION IN WESTERN KENYA

The impact of insecticide (permethrin)-treated bed nets (ITNs) on malaria in pregnancy was studied in a rural area in western Kenya with intense perennial malaria transmission. All households in 40 of 79 villages were randomized to receive ITNs by January 1997. The ITNs were distributed in control villages two years later. Complete data on birth outcome were available on 2,754 (89.6%) of 3,072 deliveries. Women (n = 780) were followed monthly throughout pregnancy in 19 of 79 villages. Among gravidae 1-4, ITNs were associated with reductions of 38% (95% confidence interval [CI] = 17-54%) in the incidence of malaria parasitemia and 47% (95% CI = 6-71%) in the incidence of severe malarial anemia (hemoglobin level < 8 g/dL with parasitemia) during pregnancy. At the time of delivery, mean hemoglobin levels were 0.6 g/dL (95% CI = 0.01-1.2 g/dL) higher, the prevalence of placental or maternal malaria was reduced by 35% (95% CI = 20-47%), and the prevalence of low birth weight was reduced by 28% (95% CI = 2-47%) in gravidae 1-4 from ITN villages. No beneficial impact was observed in gravidae five or higher. In areas of intense perennial malaria transmission, permethrin-treated bed nets reduce the adverse effect of malaria during the first four pregnancies.

THE EFFICACY OF PERMETHRIN-TREATED BED NETS ON CHILD MORTALITY AND MORBIDITY IN WESTERN KENYA II. STUDY DESIGN AND METHODS

This paper describes the study design and methods used in a large community-based, group-randomized, controlled trial of permethrin-treated bed nets (ITNs) in an area with intense, perennial malaria transmission in western Kenya conducted between 1996 and 1999. A multi-disciplinary framework was used to explore the efficacy of ITNs in the reduction of all-cause mortality in children less than five years old, the clinical, entomologic, immunologic, and economic impact of ITNs, the social and behavioral determinants of ITN use, and the use of a geographic information system to allow for spatial analyses of these outcomes. Methodologic difficulties encountered in such large-scale field trials are discussed.

EFFECTS OF PERMETHRIN-TREATED BED NETS ON IMMUNITY TO MALARIA IN WESTERN KENYA I. ANTIBODY RESPONSES IN PREGNANT WOMEN AND CORD BLOOD IN AN AREA OF INTENSE MALARIA TRANSMISSION

As part of a community-based group-randomized trial on the impact of permethrin-treated bed nets (ITNs) on malaria in pregnancy in a holoendemic area of western Kenya, we assessed their effects on antibody responses to Plasmodium falciparum pre-erythrocytic antigens (recombinant circumsporozoite protein [CSP] and peptides complimentary to the repeat region of the liver stage antigen-1 [LSA-1]) and blood stage antigen (recombinant C-terminal domain of the merozoite surface protein-1 [MSP-1(19) kD]) in paired maternal/cord plasma samples obtained from 296 deliveries (157 from ITN villages and 139 control villages). Levels of total IgG and IgG subclasses 1-3 to LSA-1 and total IgG and IgG3 to MSP-1 were lower, whereas those of total IgG to CSP were significantly higher in women from ITN villages than those from control villages. In cord plasma, levels of total IgG and IgG2 to LSA-1 and IgG3 to MSP-1 were lower in ITN villages than in control villages, but antibody responses to CSP were similar. Our results suggest that the use of ITNs decreases antibody responses to LSA-1 and MSP-1 antigens in pregnant women with associated reductions in levels of the same antibodies in cord blood. In contrast, ITN use was found to be associated with increased antibody responses to CSP in pregnant women, but had no effect on antibody levels to CSP in cord blood.

A mathematical model for the transmission of Plasmodium vivax malaria

We have proposed a mathematical model for the transmission of Plasmodium vivax malaria quantitatively, which is adjusted to the infected region, Guadalcanal, in the Solomon Islands. The simulation of a transmission model will be instrumental in planning the malaria control strategy. A characteristic of the life cycle of P. vivax is that a sporozoite injected into the blood stream by a mosquito bite may sometimes stay in a hepatocyte as a hypnozoite. Therefore, we have incorporated a phenomenon of renewed infections caused by a relapse into the transmission model. Also through the simulations we have attempted to evaluate the decline in prevalence caused by the programs of selective mass drug administration (MDA) and vector control such as the distribution of permethrin-treated bednets. The simulations have indicated that the concentrated repetition of MDA at 1-week intervals would reduce the prevalence of vivax malaria swiftly in the beginning and would keep the parasite rate below 1% for a few years but the prevalence would increase thereafter. In contrast, the parasite rate would remain below 1% for a long time if a trial of 1 or 2 times MDA is accompanied with some reduction of the vectorial capacity by the enforcement of vector control. In any case, it is important to beware of relapse cases because even after the execution of MDA it takes a long time to decrease the proportion of hypnozoite carriers.

Effect of Permethrin-Impregnated Nets on Exiting Behavior, Blood Feeding Success, and Time of Feeding of Malaria Mosquitoes (Diptera: Culicidae) in Western Kenya

The impact of permethrin-treated bednets on the feeding and house entering/exiting behavior of malaria vectors was assessed in two studies in western Kenya. In one study, matched pairs of houses were allocated randomly to receive bednets or no bednets. Exiting mosquitoes were collected in Colombian curtains hung around half of each house; indoor resting mosquitoes were collected by pyrethrum spray catches. The number of Anopheles gambiae Giles and An. arabiensis Patton estimated to have entered the houses was unaffected by the presence of bednets; Anopheles funestus Giles was less likely to enter a house if bednets were present. Anopheles gambiae and An. funestus were less likely to obtain a blood meal and significantly more likely to exit houses when bednets were present. No difference was detected in An. arabiensis rates of blood feeding and exiting. In a second experiment, hourly night biting collections were done on 13 nights during the rainy season to assess whether village-wide use of permethrin-treated bednets caused a shift in the time of biting of malaria vectors. A statistically significant shift was detected in the biting times of An. gambiae s.l., although the observed differences were small. No change was observed in the hourly distribution of An. funestus biting. Our study demonstrated that, at least in the short-term, bednets reduced human-vector contact and blood feeding success but did not lead to changes in the biting times of the malaria vectors in western Kenya.

Diversion of Anopheles gambiae from children to other hosts following exposure to permethrin-treated bednets.

Permethrin-treated bednets reduce mortality and morbidity from malaria in Gambian children. However, it is not certain how this effect is achieved, as neither mosquito numbers nor the human blood index of indoor-resting female Anopheles gambiae Giles sensu lato (Diptera: Culicidae) mosquitoes have been reduced when treated bednets were introduced into a community. One possibility is that insecticide-treated bednets divert mosquitoes from children to adults. To investigate this hypothesis, a cross-over trial with insecticide-treated bednets was undertaken in two small Gambian villages. To differentiate mosquitoes that had fed on children from those that had fed on adults, all children in the study villages were immunized with rabies vaccine before the trial. Using the detection of rabies antibody in a bloodmeal as an indicator that a mosquito had bitten a child, it was found that the percentage of blood-fed mosquitoes caught indoors that had bitten a child fell significantly from 30.8% to 9.2% and from 28.0% to 6.9% in each village after insecticide-treated bednets were introduced. To investigate the possibility that some diversion to animals had occurred, a PCR analysis for human beta-globin DNA was undertaken on selected samples. The results of this investigation were confusing, as some rabies-antibody positive bloodmeals were negative for human DNA. This may have been due to cross-reacting antibodies in animal sera and/or DNA degradation by digestion in the mosquito. Although good evidence for diversion of mosquitoes away from children was obtained, it remains uncertain whether diversion was mainly to adult humans, to animals or to both.

Control of malaria vectors: cost analysis in a province of northern Vietnam.

The cost of permethrin-treated bednets (50% EC; 0.2 g/m2, 2 rounds per year) was compared to the cost of residual spraying with lambdacyhalothrin 10% WP (0.03 g/m2, once yearly) in Hoa Binh, a mountainous province in northern Vietnam. Calculations of the amounts of insecticides needed were based on national guidelines, on data from a cross-sectional survey and on district activity reports. The actual cost of insecticide required per person per year was lower for impregnation (US$ 0.26) than for spraying (US$ 0.36), but the difference was smaller than expected. The total cost for impregnated bednets per person per year amounted to US$ 0.90 compared to USS 0.47 for spraying. The determining factor was the cost of the net, amounting to US$ 0.58 per person per year, assuming a 5-year life of the net. Other material (excluding nets), labour and transport combined, accounted for only 17% of the impregnation cost and 23% of spraying expenses. However, for the National Malaria Control Programme of Vietnam, the cost per person per year for impregnated bednets amounted to US$ 0.32 only, because the vast majority of nets are bought by the population. For spraying, the programme had to bear the entire cost.

Permethrin-treated bed nets do not have a ‘mass-killing effect’ on village populations of Anopheles gambiae s.l. in The Gambia

In The Gambia, the use of permethrin-treated bed nets has led to a reduction in morbidity and mortality from malaria in children. However, no clear evidence has been found for a ‘mass-killing effect’ on the mosquito vectors as a result of this intervention. Two further entomological studies to investigate this phenomenon have been carried out. In one study, 20 villages were paired so that bed nets in one member of each pair were treated with permethrin. In the other, a cross-over design was used in which treated and untreated bed nets were exchanged between 2 villages. Longevity, biting rate and resting density of the malaria vector population and sporozoite rates were assessed in both studies. Malaria vectors were equally abundant and long-lived, and as likely to be infective, in villages with treated bed nets as in those with untreated nets. However, a clear reduction in the density of the indoor-resting population of mosquitoes in rooms with treated bed nets was found, probably reflecting the excito-repellency of the insecticide. This study confirmed that, in The Gambia, the protection against death and morbidity from malaria seen in children using treated bed nets must be due primarily to personal protection rather than to a ‘mass-killing effect’ on the mosquito vector population at a village level.

Anopheles gambiae gonotrophic cycle duration, biting and exiting behaviour unaffected by permethrin-impregnated bednets in The Gambia.

Permethrin-impregnated bednets protect children against malaria in The Gambia, where Anopheles gambiae complex mosquitoes are the main vectors of malaria. However, no effect has been found on mosquito density, parous rates or sporozoite rates in An.gambiae sensu lato populations; only a reduction in the numbers of mosquitoes resting indoors in rooms with treated bednets. A possible explanation for this paradox is that exposure to treated bednets leads to changed vector behaviour such as a shift in biting time, a diversion to biting outdoors instead of indoors, to biting animals instead of humans, or to increased duration of the gonotrophic cycle. To investigate these possibilities, we observed the biting and existing behaviour of An.gambiae in ten pairs of villages, in half of which the residents used permethrin-treated bednets. The possible influence of treated bednets on the gonotrophic cycle length was evaluated by mark-release-recapture experiment. No significant difference was found between villages with treated and untreated bednets in the indoor/outdoor ratio of human biting, in mean biting times or in human blood indices of An.gambiae females found resting indoors in the mornings. The proportions of unfed, fed or gravid An.gambiae females collected in exit traps, and the number of females exiting showed no significant differences between rooms with treated and untreated bednets. Indications for a gonotrophic cycle length of 2 days were found. No evidence for any change in duration of the gonotrophic cycle in relation to exposure to treated bednets was found, although the number of recaptures was low in the villages with treated bednets. Since equal numbers of infective An.gambiae were found in villages with treated or untreated bednets, and no changes in mosquito behaviour were detected, we cannot account for how children are protected against malaria by treated bednets. One possibility is that mosquitoes divert to bite other hosts, including adults.

Control of endophagic Anopheles mosquitoes and human malaria in Guinea Bissau, West Africa by permethrin-treated bed nets

We compared the anti-mosquito and antimalarial potentialities of placebo-treated versus permethrin-impregnated bed nets in north-western Guinea Bissau. Baseline, pre-intervention entomological and parasitological data were collected during the rainy season of 1990 and bed nets were distributed shortly before the rainy season of 1991. Pairs of 3 ethnically different villages were investigated. The villages in each pair were at least 2 km apart but belonged to the same ethnic group in an ecologically similar area. After one year permethrin-treated bed nets were provided to all people in one village of each pair and placebo-treated bed nets to the other villages. About 98% of mosquitoes caught in bedrooms belonged to Anopheles gambiae and A. melas, which we consider to be the main malaria vectors in the study villages. Mean Plasmodium falciparum sporozoite rate in A. gambiae (9.6%) and A. melas (12.4%) was highest during October–November. The Plasmodium index in children 2–9 years old in the 6 villages, at the end of the rainy season 1990, ranged between 44% and 79%. Of these, 98% were identified as P. falciparum, 1% as P. malariae and 1% as mixed infections of these species. Significant reductions of Anopheles indoor resting densities and malaria parasite rates in humans were recorded in villages which had received permethrin-treated nets, but not in the control villages. The mean number of P. falciparum-infective mosquito bites received indoors in untreated villages during the rainy season was estimated to be about 4 per child and 20 per adult. This inoculation rate was reduced by at least 78% by the use of permethrin-impregnated bed nets. The malaria parasite rates and proportions of people experiencing ‘disease with fever’ decreased significantly in villages provided with permethrin-treated nets but not in the control villages. Impregnated nets may be an important tool to reduce disease and death due to malaria in Guinea Bissau.

Permethrin-impregnated bed nets for the prevention of malaria in schoolchildren on the Thai-Burmese border

A double-blind controlled trial was undertaken from August 1990 to February 1991 among Karen children on the Thai-Burmese border to evaluate the effects on malaria incidence and prevalence of permethrin-treated bed nets. Three hundred and fifty schoolchildren, aged 4 to 15 years, were allocated at random to receive either a permethrin-impregnated net or a non-treated net. The incidence of malaria infections, confirmed by a blood film, was assessed during 6 months. Three surveys were conducted, on admission and 3 and 6 months later, to measure the prevalence of infections and spleen rates. Compliance was assessed by monthly home visiting. The use of permethrin-treated bed nets reduced the number of parasitaemic Plasmodium falciparum infections by 38% and the number of symptomatic episodes by 42%. The number of P. vivax malaria attacks was similar in each group. The prevalence of positive blood films in the 2 groups did not change significantly during the study. A reduction in spleen rate by 50% in both groups at the end of the study period could not be related to the overall use of nets. Compliance was high and no side-effect was reported. The long-term effects on morbidity and mortality need to be assessed after distribution of permethrin treated bed nets at the village level.

Malaria: keeping the mosquitoes at bay

Neither the use of DDT nor chemoprophylaxis has significantly reduced malaria morbidity and mortality, especially among children. Low-technology measures of reducing man/vector contact are gaining in popularity. Malaria control trials in various sub-Saharan African countries show the promise of permethrin-treated bed nets. Researchers have compared the effect of permethrin-treated bed net use with that of chemoprophylaxis (maloprim) in 17 villages in a primary health care scheme in a rural area of the Gambia. They also gave some children a placebo. 86% of adults in the study area already used bed nets, but only 28% realized mosquitoes caused malaria. The permethrin-treated bed nets had a protective efficacy for overall mortality and malaria-specific mortality of 63% and 70%, respectively, in children from intervention villages. These bed nets reduced malaria morbidity and mortality, even though not all bed nets were impregnated with the target dose of permethrin and 50% of bed nets were laundered at least once a month. The bed nets were effective when people were under them, but not when the people were outdoors. Chemoprophylaxis did not reduce clinical episodes of malaria, prevalence of enlarged spleen, or the presence of parasites. Village reporters and the verbal autopsy technique may have underestimated the actual malaria mortality, however. Bed net impregnation was very cost effective and was as effective as other public health interventions, e.g., measles vaccination. The results of trials in other sub-Saharan countries will provide information on the success of bed net impregnation in areas with more intense malaria transmission and whose mosquito control measures are different from those in the Gambia.