Can improved housing provide additional protection against clinical malaria over current best practice? A household-randomised controlled trial

Lead Research Organisation: Durham University
Department Name: Biosciences

Abstract

Malaria remains one of the greatest threats to global public health, with 207 million cases of falciparum malaria and 627,000 deaths occurring in 2012, with over 80% of deaths occurring in Africa. More than 80% of malaria is transmitted indoors at night, so the number of malaria mosquitoes which enter a house is critical for getting the disease - with people living in 'leaky' houses being at most risk. We have shown that closing the eaves (the gap between the top of the wall and the roof) and screening a house can reduce dramatically the number of malaria vectors entering a house. Here we propose to find out whether we can protect children against malaria by modifying half the study houses so that they (1) have a metal roof, (2) closed eaves, (3) screened doors and windows and (4) screened-air bricks which allow the warm air to rise out of the house, but not let any mosquitoes indoors. The other study houses will be left with thatched roofs and open eaves and the children in these houses will serve as a comparison group. Over the past thirty years a silent revolution in house design has been happening across Africa. The traditional thatched-roofed houses are being replaced steadily by metal-roofed houses as the continent develops. We hope to ride this wave of cultural change and further improve the design of houses to make them healthier to live in. Improved housing has the potential to improve the lives of millions of people across sub-Saharan Africa.

Technical Summary

Malaria remains one of the greatest threats to global public health, with 207 million cases of falciparum malaria and 627,000 deaths occurring in 2012, with over 80% of deaths occurring in Africa. More than 80% of malaria is transmitted indoors at night, so the number of infective mosquitoes which enter a house is critical for getting the disease - with people living in 'leaky' houses being at most risk. We have shown that closing the eaves (the gap between the top of the wall and the roof) and screening a house can reduce dramatically the number of malaria vectors entering a house. Here we propose to determine whether we can reduce the incidence of clinical malaria in children living in well-screened houses, which have a (1) a metal roof, (2) closed eaves, (3) screened doors and windows and (4) screened-air bricks which allow the warm air to rise out of the house, but not let any mosquitoes indoors. The control houses will be left with thatched roofs and open eaves. We will also carry out subsidiary studies to find out whether the interventions are cost effective and develop a strategy for scaling-up housing interventions. Across Africa a silent revolution in house design has been happening for several decades. The traditional thatched-roofed houses are being replaced by metal-roofed houses as the continent develops. We hope to ride this wave of cultural change and further improve the design of houses to make them healthier to live in. Improved housing has the potential to improve the lives of millions of people across sub-Saharan Africa.

Planned Impact

To our knowledge this is the first randomised controlled trial against clinical malaria where housing has been used as an intervention against malaria. This research is designed to improve housing and reduce malaria in rural (and urban) communities in The Gambia and other countries in sub-Saharan Africa. Over 144 million rural houses will be built in Africa by 2050, assuming an average family of about 5 people per house, and uninterrupted growth rates. This represents an extraordinary opportunity to help guide building design in rural areas; to modernise and create healthy homes, especially since consumer spending will almost double in Africa in the next decade, creating a markedly improved housing stock, with people investing in their own homes. The results of the proposed trial will help inform the Gambian Medical and Health Department and other African Departments of Health of the potential benefits of improved housing to control malaria. Perhaps more importantly it provides African Governments and the development community with a way of not only improving people's quality of life directly, but also indirectly by providing a healthy home. Thus the research will be of interest to NGOs like DfID and DANIDA, organisations with a special interest in housing such as Archive, Habitat for Humanity, Architects without Borders and UN Habitat, as well as providing the World Health Organisation, Roll Back Malaria and the United Nations Development Programme with valuable information on the benefits of a healthy home.There are also likely to be commercial benefits to this research. The construction of large numbers of houses will help boost the local construction industry in The Gambia, and elsewhere, providing income for builders and suppliers of building materials (air bricks, screening and metal roofing) locally and internationally. There are many commercial companies that produce mosquito screening (e.g. Vestergaard Frandsen, Bug Off Screens).
 
Description Presentation to Fifth meeting of the WHO technical expert group on malaria vector control (VCTEG) on housing as an intervention against malaria (15 Nov 17)
Geographic Reach Multiple continents/international 
Policy Influence Type Participation in a advisory committee
 
Description Architecture exhibition of screened doors 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This was an exhibition showing the development of screened doors for keeping mosquitoes out whilst keeping the house cool.
Year(s) Of Engagement Activity 2018
 
Description Article for UN Environment 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Article for UN Environment on how ,"Low-cost Housing could Cut Malaria Transmission in Africa by Half and Reduce use of Insecticides".
UN Environment in joint collaboration with the WHO recently launched a project with the support of the Global Environment Facility to strengthen national capacities for innovative implementation of integrated vector management for disease prevention and control in the WHO African region. This article provides the foundation to this work.
Year(s) Of Engagement Activity 2017
URL http://www.unep.org/stories/story/low-cost-housing-could-cut-malaria-transmission-africa-half-and-re...
 
Description BOVA Network Twitter presence 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact BOVA Network Twitter presence @bovanetwork
Year(s) Of Engagement Activity 2017,2018
 
Description BOVA Network website 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact BOVA Network website
Year(s) Of Engagement Activity 2017,2018
URL http://www.bovanetwork.org
 
Description Gambian Government / MRC Joint Meeting (Fajara - 30/09/15) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Gambian Government / MRC Joint Meeting where RooPfs Study was summarized by Dr Jane Achan in her presentation of ongoing research in the Disease Control and Elimination Theme. Meeting attended by Minister of Health, several Gambian health related centres, University, Medical School etc.
Year(s) Of Engagement Activity 2015
 
Description Housing & malaria workstream for Roll Back Malaria 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? Yes
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact The workstream has led to new collaborations and recognition of the importance of housing for malaria control.

New networks of collaborators have been created.
Year(s) Of Engagement Activity 2014
 
Description Informal presentation (Banjul - 06/01/15) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact Informal presentation to the Hon. Omar Sey, Minister of Health and Social Welfare, and his Permanent Secretary, Dr Makie Taal, at the Ministry of Health , Banjul, The Gambia. Model house was presented.
Year(s) Of Engagement Activity 2015
 
Description Informal presentation (Basse - 17/11/14) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact Informal presentation to the Governor of the Upper River Region (URR) about the project
Year(s) Of Engagement Activity 2014
 
Description Informal presentation (Basse - 17/11/14) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact Informal presentation to the Director of the Regional Health Team in his Basse Office about RooPfs project.
Year(s) Of Engagement Activity 2014
 
Description Informal presentation (Sotuma Sainey Kandeh - 14/08/15) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact Informal presentation to Hon. Omar Sey, Minister of Health and Social Welfare, and his delegates at the Akalo's compound. Project update given. Unfortunately visit to houses was not possible due to the rain.
Year(s) Of Engagement Activity 2015
 
Description Information meeting regarding scale-up of RooPfs (05/03/16) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact Deputy Manager of the National Malaria Control Programme, Lamin Jarju, presented an update on the malaria situation in The Gambia and Margaret Pinder presented on current progress. The purpose of the meeting was to debate on the scale-up of housing interventions in The Gambia.
Year(s) Of Engagement Activity 2016
 
Description Internal project meetings (06/07/15) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Study participants or study members
Results and Impact Meetings with Elisa Sicuri (Economist) and Ballah Kandeh (NCMP) to discuss economic aspects of the study and visit to ministries as part of profile raising activity.
Year(s) Of Engagement Activity 2015
 
Description Introduction to the RooPfs Study - DCE Laboratory meeting (Fajara - 26/08/14) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact Introduction to the RooPfs Study
Year(s) Of Engagement Activity 2014
 
Description Magazine article (Malaria Day issue of TAMA - April 2015) 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Study participants or study members
Results and Impact Article in Malaria Day issue of TAMA, MRC Unit Gambia magazine.
Year(s) Of Engagement Activity 2015
 
Description Meeting with the Gambian Government 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Health professionals
Results and Impact Key members of the National Malaria Control Programme attended the talk, which sparked questions and discussion afterwards.

NMCP strongly supported this trial and were keen to collaborate in the future.
Year(s) Of Engagement Activity 2008
 
Description Membership of international policy group 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Co-Chair of the 5th Housing and malaria work stream for Roll Back Malaria. Geneva, Switzerland, 7th-9th February, 2018.
Year(s) Of Engagement Activity 2018
URL https://rollbackmalaria.com/wp-content/uploads/2017/08/Steve-Lindsay_Lucy-Tusting_Housing-work-strea...
 
Description Membership of international policy group 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Co-Chair of the 5th Housing and malaria work stream for Roll Back Malaria. Geneva, Switzerland, 7th-9th February, 2018.
Year(s) Of Engagement Activity 2018
 
Description Monthly DCE meeting - Progress in the Field and Planning for 2015/ early 2016 (Fajara - 26/08/15) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact RooPfs study progress meeting at DCE monthly meeting
Year(s) Of Engagement Activity 2014
 
Description NMCP update (The Gambia) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Type Of Presentation Paper Presentation
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact 10 senior members of the NMCP attended these meetings

NMCP provided support in personnel and facilitated importation of insecticides into the country. They are project partners in our research.
Year(s) Of Engagement Activity 2010,2011,2012
 
Description Planning meeting 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Planning meeting. Healthy housing and reducing infectious diseases, the Royal Danish Academy of Fine Arts, School of Architecture, Design and Conservation, The School of Architecture Copenhagen, Denmark, 27th January, 2018.
Year(s) Of Engagement Activity 2018
 
Description Presentation 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Invited speaker. Urbanization and slums: new transmission pathways of infectious diseases in the built environment, The National Academies of Sciences, Engineering and Medicine, Washington, USA, 13th December, 2017.
Year(s) Of Engagement Activity 2017
 
Description Presentation at DCE (Disease Control Elimination) Monthly Meeting (Fajara - 26/11/14) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact Brief presentation at the DCE Monthly Meeting, based on RooPfs collaborator meeting in Durham.
Year(s) Of Engagement Activity 2015
 
Description Presentation to MRC Scientific Advisory Board (17/03/15) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact Project update included in Dr Anna Roca's DCE (Disease Control Elimination) presentation to the MRC Scientific Advisory Board
Year(s) Of Engagement Activity 2015
 
Description Prof Lindsay gave talk at 70th Anniversary of the MRC Unit The Gambia, Fajara, The Gambia (28 Nov 17) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Prof Lindsay gave talk at 70th Anniversary of the MRC Unit The Gambia, Fajara, The Gambia (28 Nov 17) on under-pinning work to support studies on malaria transmission in The Gambia including mention of the RooPfs trial and BOVA Network.
Year(s) Of Engagement Activity 2017
 
Description Prof Lindsay invited speaker at Urbanization and slums: new transmission pathways of infectious diseases in the built environment, The National Academies of Sciences, Engineering and Medicine, Washington, USA (13 Dec 17) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Prof Lindsay gave a remote talk on 'vector-borne diseases and the built environment' to attendees of the meeting: Urbanization and slums: new transmission pathways of infectious diseases in the built environment, The National Academies of Sciences, Engineering and Medicine, Washington, USA
Year(s) Of Engagement Activity 2017
 
Description Report to Basse HDSS Local User Group Meeting (07/05/15) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Study participants or study members
Results and Impact Report given by Margaret Pinder to Basse HDSS Local User Group to inform them that the Study will involve ~800 households on north and south bank, with a before and after comparison. Also discussed - construction of household modifications planned for 2015 and clinical surveillance in 2016-2017.
Year(s) Of Engagement Activity 2015
 
Description RooPfs Project Collaborator Meeting (Durham - 27/07/15) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Study participants or study members
Results and Impact 2 day meeting involving project partners to review progress and discuss new ideas.
Year(s) Of Engagement Activity 2015
 
Description RooPfs investigator meeting (Durham - 31/01/17) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Study participants or study members
Results and Impact Group discussed current progress and plans for the future.
Year(s) Of Engagement Activity 2017
 
Description Site visit to RooPfs Study in Basse with government representatives (Basse - 24/03/16) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact Four representatives of the government, parastatal housing and community development, plus representatives from the National Malaria Control Programme joined Prof Lindsay and Dr Pinder on a tour of RooPfs. The visit included an introductory talk on the study, visit to 2 villages and a discussion on the intervention components and the way forward.
Year(s) Of Engagement Activity 2016
 
Description Social science student visit from the University of The Gambia (Basse - 04/06/16) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Undergraduate students
Results and Impact Visit from approximately 125 social science students from the University of The Gambia to the Medical Research Council The Gambia, in Basse. Social scientist gave overview of the RooPfs project and details of the social science elements of the study. Field co-ordinator gave presentations on the building aspects of the project.
Year(s) Of Engagement Activity 2016
 
Description Talk 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Invited speaker. Under-pinning work to support studies on malaria transmission in The Gambia. 70th Anniversary of the MRC Unit The Gambia, Fajara, The Gambia, 28th November, 2017.
Year(s) Of Engagement Activity 2017
 
Description Village meetings 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Participants in your research and patient groups
Results and Impact Whole communities attended the talks, which sparked questions and discussions afterwards.

Communities asked to participate in future MRC trials.
Year(s) Of Engagement Activity 2008
 
Description Visit to Director of the Regional Health Team for the Upper River Region (Basse - 19/10/16) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact Social science and epidemiological update to local policy makers on number of malaria cases in the study group and exit study.
Year(s) Of Engagement Activity 2016
 
Description Visit to National Malaria Control Programme Office (Kanifing - 30/06/16) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Policymakers/politicians
Results and Impact Visit of Dr Caroline Jones, Dr Elisa Sicuri and Miss Aji Matty Manjang to NMCP Offices to describe progress on RooPfs to the centre manager and to discuss aspects of the economic study with the Health Economist.
Year(s) Of Engagement Activity 2016