METHODS• AsystematicliteraturereviewwasperformedinMedline,EmbaseandCentral.• AnIndianseachfilterwasdeveloped(includingallIndianStates)tosearchforIndianstudies.

• Inclusionandexclusioncriteria:• Population:studiesdoneinIndiawithlaypeople,communityhealthworkers.• Intervention:studiesontheeffectivenessof(un)treatedbednets.Themin-imumtargetimpregnationdoseofthetreatedbednetswas200mg/m2permethrinoretofenprox,30mg/m2cyfluthrin,20mg/m2alphacyper-methrinor10mg/m2deltamethrin/lambdacyhalothrin.

• Comparison:nobednets.• Malariaoutcomes:parasiteprevalence(=numberofmalariacases(posi-tivebloodslideforanyparasite)dividedbythepopulationundersurveil-lance)wasassessedafteradoor-to-doorfortnightlysurveillancewascar-

riedoutandbloodsmearsofall fever caseswere collected(fingerprickmethod,Figure1).

• Design: observational or ex-perimentalstudies.

• Language/time window: norestriction.

• Theoveralleffectofusing(un)treatedbednetscomparedtonobednetsonmalaria(parasiteprevalence) was investigatedbygroupingall studies inameta-analysis (random-effectsmodel) andcalculatingthepooledriskratios(RR).

RESULTS• Box 1 represents the study selection flowchart. Fourteen from the 16includedtrialswereselectedforthemeta-analysis(duetoavailabilityofdataonmalariacases)

• Studiesweredivided intosubgroupsaccording to theAnnualParasiteIncidence (API); low endemic area (API<2) versus high endemic area(API≥2)(Figure2).

• Meta-analysisshowedthatuntreatedbednetsreducedtheriskofmalariaby58%inlowendemicareas(pooledRR0.42[95%CI;0.30,0.60])andby39%inhighendemicareas(pooledRR0.61[95%CI;0.57,0.65]).Whenusingtreatedbednets, the riskofmalariawas further reduced;by82%(pooledRR0.18[95%CI;0.08,0.42])andby65%(pooledR0.35[95%CI;0.26,0.47]inlowandhighendemicareas,respectively(Box2).

• TheCochraneSystematicReview(randomizednon-Indiantrials,2004)showedthattreatedbednetshadaprotectiveimpactonmalaria(averageRR0.87forstablemalariaareascomparedtonobednetuse).

BEDNETS TO PREVENT MALARIA: META-ANALYSIS OF INDIAN TRIALS CONFIRMING RESULTS OF A COCHRANE SYSTEMATIC REVIEW

HANS VAN REMOORTEL1, EMMY DE BUCK1, PHILIPPE VANDEKERCKHOVE1,2, SATYA PAUL AGARWAL3

References:1WorldMalariaReport2012bytheWorldHealthOrganisation;2LengelerC.CochraneDatabaseofSystematicReviews2004;3Ansarietal.IndianJMalariol2002;4Sreeharietal.JVectorBorneDis2007;5Mittaletal.JVectorBorneDis2012;6Ansarietal.JVectorBorneDis2003;7Devetal.ActaTrop2011;8Bhatiaetal.SocSciMed2004;9Dasetal.SoutheastAsianJTropMedPublicHealth1993;10Sahuetal.ActaTrop2003;11Sahuetal.IndianJMedRes2008;12Bhattetal.MalarJ2012;13Sharmaetal.JAmMosqControlAssoc2006;14Sharmaetal.ActaTrop2009;15Yadavetal.JAmMosqControlAssoc1998;16Yadavetal.JMedEntomol2001;17http://www.nhp.gov.in.

Budget and funding:Thedevelopmentofevidence-basedIndianfirstaidandpreventionguidelineswasfinancedbyBelgianRedCross-Flanderswithco-fundingfromtheBelgianDirectorate-GeneralforDevelopmentCooperation(DGD)

1 BELGIAN RED CROSS-FLANDERS, MECHELEN, BELGIUM 2 DEPARTMENT OF PUBLIC HEALTH AND PRIMARY CARE, CATHOLIC UNIVERSITY OF LEUVEN, LEUVEN, BELGIUM

3 INDIAN RED CROSS SOCIETY, NEW DELHI, INDIA

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CONCLUSIONS• Thereisevidencefrom16experimentalIndianstudiesthatusing(insecticidetreated)bednetsisaneffectiveinterventiontopreventmalaria,whichisinlinewiththefindingsoftheCochranesystematicreview,performedoutsideIndia.

• Thepresentfindingssupportthecurrentbednetuse intheNationalVec-torBorneDiseaseControlProgrammeinIndia17andwillbeincludedintheIndianfirstaidandpreventiveguidelines.

INTRODUCTION & OBJECTIVESNewmalariacasesinIndiaareestimatedat24millionperyearbytheWorldHealthOrganization,resultinginahighsocio-economicburden1.ACochranesystematic review, based on randomized controlled trials in non-Indiancountries, showed that insecticide treated bednets are highly effective inreducingmorbidity frommalaria2.Aspartof thedevelopmentofevidence-

based Indian first aid and prevention guidelines, a cooperation betweenBelgianRedCross-Flandersand the IndianRedCrossSociety,weaimedtoinvestigate the effectiveness of both insecticide-treated and untreatedbednetsonmalariainIndianfamilies.

Figure 1. Active malaria detection via the finger prick method.

Figure 2. Classification of the included studies into low endemic versus high endemic area, based on the Annual Parasite Incidence.

Box 2: Meta-analysis with calculation of the pooled effect of treated bed nets on parasite prevalence

Box 1: Study selection flowchart for preventive bednet intervention for malaria, identified in Indian studies(B:levelofevidencemoderateaccordingtoGRADE)

Records identified through database searching (n=479)DetailedsearchstrategyinMedline,EmbaseandCentral.

Title and abstractscreening(n=393)

Full-textarticlesassessedforeligibility(n=28)

Studiesincludedfordataextractionandquantitativesynthesis(n=16)(B):

Clusterrandomizedcontrolledtrials(n=9)Controlledinterruptedtimeseries(n=7)

Recordsexcluded(n=365)

Removingduplicates/triplicates(n=86)

Full-textarticlesexcluded(n=12)-Outcome(n=6)-Design(n=4)-Intervention(n=2)

Iden

tifica

tion

Scre

enin

gEl

igib

ility

Incl

uded

Lowendemicarea(API<2)1.Ansari20023

2.Sreehari20074

3.Mittal20125

4.Ansari20036

Highendemicarea(API≥2)5.Dev20117

6.Bhatia20048

7.Das19939

8.Sahu200310

9.Sahu200811

10.Bhatt201212

11.Sharma200613

12.Sharma200914

13.Yadav199815

14.Yadav200116

0–2 2–5 >5

Annual Parasite Incidence

1

23

4

5

6

78 910

1112 13 14

E IDENCE-BASED PRACTICERealized by the centre for

of the Belgian Red Cross-Flanders