The Effectiveness of Community Bed Net Use on Malaria Parasitemia among Children Less Than 5 Years Old in Liberia

Rebecca C. Stebbins Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina;

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Michael Emch Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina;
Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

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Steven R. Meshnick Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina;

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In 2013, the under-5 mortality rate in Liberia was 71 deaths per 1,000 live births, with malaria responsible for 22% of those deaths. One of the primary existing control tools, long-lasting insecticide-treated bed nets (LLINs), is thought to be dually effective, acting as a physical barrier but also decreasing the mosquito population in communities. However, there has been little investigation into the protective effects of community-wide bed net use above and beyond the individual level. Using data from the population-representative 2011 Liberia Malaria Indicator Survey, we estimated the association between proportion of a community using LLINs and malaria in children using multi-level logistic regression. To investigate the potential effect measure modification of the relationship by urbanicity, we included an interaction term and calculated stratum-specific prevalence odds ratios (PORs) for rural and urban communities. We calculated a POR of malaria for an absolute 10% increase in community bed net use of 1.13 (95% confidence interval [CI]: 0.91, 1.41) and 0.35 (95% CI: 0.13, 0.92) for rural and urban communities, respectively, indicating a strong, though imprecise, protective effect within urban communities only. Our results indicate that bed net use has an indirect protective effect in urban areas, above and beyond individual use. Little or no such effect of community-wide use is seen in rural areas, likely because of population density factors. Therefore, although all control efforts should be multifaceted, promotion of bed net use in urban areas in particular will likely be a highly effective tool for control.

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Author Notes

Address correspondence to Rebecca C. Stebbins, Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 123 East Franklin Street, Building C, Suite 440, Chapel Hill, NC 27599. E-mail: rebecca7@email.unc.edu

Financial support: National Science Foundation grant BCS-1339949.

Authors’ addresses: Rebecca C. Stebbins and Steven R. Meshnick, Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, E-mails: rebecca7@email.unc.edu and meshnick@unc.edu. Michael Emch, Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, NC, E-mail: emch@unc.edu.

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