How many holes is too many? A prototype tool for estimating mosquito entry risk into damaged bed nets

James Sutcliffe, Xin Ji, Shaoman Yin

Insecticide-treated bed nets (ITNs) have played an integral role in malaria reduction but how insecticide depletion and accumulating physical damage affect ITN performance is poorly understood. More accurate methods are needed to assess damage to bed nets so that they can be designed, deployed and replaced optimally. Video recordings of female Anopheles gambiae in near approach (1-½ cm) to occupied untreated rectangular bed nets in a laboratory study were used to quantify the amount of mosquito activity (appearances over time) around different parts of the net, the per-appearance probability of a mosquito coming close to holes of different sizes (hole encounter) and the per-encounter probability of mosquitoes passing through holes of different sizes (hole passage). Appearance frequency on different parts of the net reflected previously reported patterns: the area of the net under greatest mosquito pressure was the roof, followed by the bottom 30 cm of the sides, followed by the 30 cm area immediately above this, followed by the upper two-thirds of the sides. The ratio of activity in these areas was (respectively) 250:33:5:1. Per-appearance probability of hole encounter on all parts of the net was strongly predicted by a factor combining hole perimeter and area. Per-encounter probability of hole passage, in turn, was strongly predicted by hole width. For a given width, there was a 20% greater risk of passage through holes on the roof than holes on the sides. Appearance, encounter and passage predictors correspond to various mosquito behaviours that have previously been described and are combined into a prototype mosquito entry risk tool that predicts mosquito entry rates for nets with various amounts of damage. Scenarios that use the entry risk tool to test the recommendations of the WHOPES proportionate hole index (pHI) suggest that the pHI hole size categories and failure to account for hole location likely sometimes lead to incorrect conclusions about net serviceability that could be avoided by using an entry risk tool of the form presented here instead. Practical methods of collecting hole position, shape and size information for bed net assessments using the tool in the field are discussed and include using image analysis and on-line geometric analysis tools.