Mitigating Diseases Transmitted by Aedes Mosquitoes: A Cluster-Randomised Trial of Permethrin-Impregnated School Uniforms.

BACKGROUND: Viral diseases transmitted via Aedes mosquitoes are on the rise, such as Zika, dengue, and chikungunya. Novel tools to mitigate Aedes mosquitoes-transmitted diseases are urgently needed. We tested whether commercially insecticide-impregnated school uniforms can reduce dengue incidence in school children. METHODS: We designed a cluster-randomised controlled trial in Thailand. The primary endpoint was laboratory-confirmed dengue infections. Secondary endpoints were school absenteeism; and impregnated uniforms' 1-hour knock-down and 24 hour mosquito mortality as measured by standardised WHOPES bioassay cone tests at baseline and after repeated washing. Furthermore, entomological assessments inside classrooms and in outside areas of schools were conducted. RESULTS: We enrolled 1,811 pupils aged 6-17 from 5 intervention and 5 control schools. Paired serum samples were obtained from 1,655 pupils. In the control schools, 24/641 (3.7%) and in the intervention schools 33/1,014 (3.3%) students had evidence of new dengue infections during one school term (5 months). There was no significant difference in proportions of students having incident dengue infections between the intervention and control schools, with adjustment for clustering by school. WHOPES cone tests showed a 100% knock down and mortality of Aedes aegypti mosquitoes exposed to impregnated clothing at baseline and up to 4 washes, but this efficacy rapidly declined to below 20% after 20 washes, corresponding to a weekly reduction in knock-down and mosquito mortality by 4.7% and 4.4% respectively. Results of the entomological assessments showed that the mean number of Aedes aegypti mosquitoes caught inside the classrooms of the intervention schools was significantly reduced in the month following the introduction of the impregnated uniforms, compared to those collected in classrooms of the control schools (p = 0.04). CONCLUSIONS: Entomological assessments showed that the intervention had some impact on the number of Aedes mosquitoes inside treatment schools immediately after impregnation and before insecticidal activity declined. However, there was no serological evidence of protection against dengue infections over the five months school term, best explained by the rapid washing-out of permethrin after 4 washes. If rapid washing-out of permethrin could be overcome by novel technological approaches, insecticide-treated clothes might become a potentially cost-effective and scalable intervention to protect against diseases transmitted by Aedes mosquitoes such as dengue, Zika, and chikungunya. TRIAL REGISTRATION: ClinicalTrials.gov NCT01563640

Acceptability of impregnated school uniforms for dengue control in Thailand: a mixed methods approach

Background: As current dengue control strategies have been shown to be largely ineffective in reducing dengue in school-aged children, novel approaches towards dengue control need to be studied. Insecticide-impregnated school uniforms represent an innovative approach with the theoretical potential to reduce dengue infections in school children. Objectives: This study took place in the context of a randomised control trial (RCT) to test the effectiveness of permethrin-impregnated school uniforms (ISUs) for dengue prevention in Chachoengsao Province, Thailand. The objective was to assess the acceptability of ISUs among parents, teachers, and principals of school children involved in the trial. Methodology: Quantitative and qualitative tools were used in a mixed methods approach. Class-clustered randomised samples of school children enrolled in the RCT were selected and their parents completed 321 self-administered questionnaires. Descriptive statistics and logistic regression were used to analyse the quantitative data. Focus group discussions and individual semi-structured interviews were conducted with parents, teachers, and principals. Qualitative data analysis involved content analysis with coding and thematic development. Results: The knowledge and experience of dengue was substantial. The acceptability of ISUs was high. Parents (87.3%; 95% CI 82.9–90.8) would allow their child to wear an ISU and 59.9% (95% CI 53.7–65.9) of parents would incur additional costs for an ISU over a normal uniform. This was significantly associated with the total monthly income of a household and the educational level of the respondent. Parents (62.5%; 95% CI 56.6–68.1) indicated they would be willing to recommend ISUs to other parents. Conclusions: Acceptability of the novel tool of ISUs was high as defined by the lack of concern along with the willingness to pay and recommend. Considering issues of effectiveness and scalability, assessing acceptability of ISUs over time is recommended

Proportions of dengue infections in 1,655 Thai school children with paired serum samples at 10 schools randomised to insecticide-treated school uniforms (intervention) or untreated school uniforms (control).

<p>Proportions of dengue infections in 1,655 Thai school children with paired serum samples at 10 schools randomised to insecticide-treated school uniforms (intervention) or untreated school uniforms (control).</p

Flowchart showing numbers of participants in both intervention and control groups at all stages of the trial.

<p>Flowchart showing numbers of participants in both intervention and control groups at all stages of the trial.</p