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As part of a community-based, group-randomized, controlled trial of insecticide-treated bed nets (ITNs) in an area with intense malaria transmission in western Kenya, a birth cohort (n = 833) was followed monthly until the age of 24 months to determine the potential beneficial and adverse effects of reduced malaria exposure during pregnancy and infancy. Malaria transmission and morbidity were comparable pre-intervention. The ITNs reduced malaria attack rates (force of infection) in infancy by 74%, and delayed the median time-to-first parasitemia (4.5 to 10.7 months; P < 0.0001). The incidence of both clinical malaria and moderate-severe anemia (hemoglobin level <7 g/dL) were reduced by 60% (P < 0.001 for both). Protective efficacy was greatest in infants less than three months old and similar in older infants and one-year-old children. Efficacy was lowest in the dry season. Infants from ITN villages experienced better height and weight gain. In areas of intense perennial malaria transmission, ITNs substantially reduce exposure to malaria and subsequent malaria-associated morbidity in children less than 24 months old. Reduced malaria exposure during infancy did not result, with continued ITN use, in increased malaria morbidity in one-year-old children.
Acknowledgments: We express our gratitude to the children and caretakers who participated in the study and the many people that assisted with this project. We thank Pauline Abdullah, Benta Kamire, Lucy Atieno, Christi Murray, Erik Schoute, Sue Binder, and Dan Colley for their continued support. We are grateful to Drs. Laurence Slutsker and Richard Steketee (Centers for Disease Control and Prevention) for reviewing this manuscript. We also thank the Director of the Kenya Medical Research Institute for his permission to publish this work.
Financial support: The ITN project was funded by the United States Agency for International Development. Feiko O. ter Kuile and Dianne J. Terlouw were partly supported by a grant from the Nether-lands Foundation for the Advancement of Tropical Research (WOTRO) (The Hague, The Netherlands). Lisa B. Mirel acknowledges administrative support from the Oak Ridge Institute for Science and Education. Jennifer F. Friedman was supported by a United States Fulbright Award.
Disclaimer: The opinions or assertions contained in this manuscript are the private ones of the authors and are not to be construed as official or reflecting the views of the U.S. Public Health Service or Department of Health and Human Services. Use of trade names is for identification only and does not imply endorsement by the U.S. Public Health Service or Department of Health and Human Services.
Authors’ addresses: Feiko O. ter Kuile, Dianne J. Terlouw, Penelope A. Phillips-Howard, Lisa B. Mirel, William A. Hawley, Margarette S. Kolczak, and Altaf A. Lal, Division of Parasitic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Mailstop F-22, 4770 Buford Highway, Atlanta, GA 30341. Simon K. Kariuki, Ya Ping Shi, and John M. Vulule, Centre for Vector Biology and Control Research, Kenya Medical Research Institute, PO Box 1578, Kisumu, Kenya. Jennifer F. Friedman, International Health Institute, Brown University, Box G-B 495, Providence, RI 02912. Bernard L. Nahlen, Roll Back Malaria, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland.
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