Outdoor vector control tools such as spatial repellents, including VP, promise to be an important addition to the vector control toolbox because they protect multiple users within a defined space. The current study compared the efficacies of the gold standard, HLC, and two exposure-free mosquito-collection methods, MET and BGS trap. The protective efficacy measured by each trapping method was evaluated either independently or in the presence of an additional HLC to simulate competition between blood hosts and its impact on mosquito behaviour [20].
Traps and HLC measure similar protective effect of transfluthrin in the no-choice test
This study demonstrated that in the absence of a HLC competitor, similar protective efficacy of VP was measured by BGS trap, MET and HLC using the basic formula based on unadjusted mean mosquito landings. However, in the statistical model, a significant interaction between trap and treatment showed that MET and HLC measured the protective effect of the transfluthrin differently. The differences between the model estimates for the OR and the basic formula for PE may be explained by the fact that the model is adjusted to other variables. However, this difference between HLC/BGS and MET, MET being 10% lower than the others is too small for the basic PE formula to detect. Therefore, it can be inferred that field experiments to evaluate VP using exposure-free methods of Ae. aegypti collection are possible provided the experiments are sufficiently well powered and are designed to ensure independence of observations without the bias of alternative host cues. Because it is not ethical to measure PE in the viral endemic area using HLC, this small degree of error in estimating PE is acceptable. Furthermore, in field experiments, the incidence rate ratio will be calculated from mosquito count data adjusted for sources of variation, which allow estimation of the adjusted protective efficacy using IRR [33]. In the current experiments, a binomial distribution was used because the data collected from the semi-field system include a known number of released mosquitoes. Independence of observations is an essential consideration in the design of experiments, and field trials using METs or BGS traps, as a proxy for HLC must be conducted in locations away from competing sources of attraction. This result was encouraging because the use of METs or BGS traps would allow safer field evaluation of VP in areas of active arbovirus transmission where HLC is not possible, although it must be understood that measures of protection are not exact due to the limitations of the traps used.
In the control, MET collected approximately half the number of mosquitoes caught by HLC, and the BGS trap about 15% fewer. Similar results have been seen repeatedly in other studies with different traps because traps generally provide some but not the complete suite of host cues required to maximise mosquito attraction. One exception is the host decoy trap (HDT), which provides whole-host odour, visual cues and heat [18]. Even so, the number of Anopheles mosquitoes caught by HLC was higher than that with HDT in southeast Asia [34] and compared to other human-baited traps, such as human double net trap in Laos [17] and the MET in Tanzania [35]. In a study in Colombia, the MET collected slightly higher Ae. aegypti densities than did the BGS trap [26], which contrasts with the current findings. This difference may be due to the closed SFS environment in which the traps were evaluated for the current study or to the low density of Ae. aegypti captured in the Colombian study. Furthermore, in the Colombian study Culex quinquefasciatus was highly abundant and the MET collected fewer of this species than did the BGS trap [26].
The presence of host cues is an important consideration in testing repellents because it is known that molecules such as N, N-diethyl-3-methylbenzamide (DEET) interact with host odour receptors [36]. As the MET and HLC methods use humans as bait, we would expect similar proportions of recaptured mosquitoes. The differences in catch size may be explained by the fact that day-active Ae. aegypti use visual cues to locate their host [37]. It is therefore possible that they are more aware of the electric grid [38] or are unable to pick up as many short-range cues such as thermal and water-vapour cues [39, 40]. Nonetheless, this finding warrants further comparison of BGS traps and METs under field conditions to confirm these promising SFS findings for monitoring Ae. aegypti in Tanzania. There are several advantages of using MET or BGS trap mosquito-collection methods as an alternative to HLC for monitoring human exposure to Ae. aegypti: it removes variation caused by individual skill and motivation to collect mosquitoes, it is far safer and it does not require extensive training to use successfully.
Traps and HLC did not measure similar protective efficacy of transfluthrin in the choice test
The presence of a second competitor HLC in the SFS strongly affected the estimated personal PE of the FTPE. It is difficult to interpret the results because very few mosquitoes were caught in the MET or BGS trap when there was a human competitor and therefore the power to measure the difference in treatment and control was very low. This result showed that human competitor could significantly affect the traps’ collection ability. These experiments were conducted in the SFS, where the number of mosquitoes is limited to those released, and it may therefore be possible to increase power to detect the difference by using more mosquitoes. Because space and host options for the mosquitoes are also limited, it would be useful to confirm if these results would be reflected in a field trial. However, there are ethical concerns in doing HLC in the field except in an area with no known arbovirus transmission.
A significant interaction between trap and treatment showed that METs, HLC and BGS traps measure the effect of transfluthrin differently. This was consistent even when the basic formula for PE was used to assess the efficacy of the collection methods in evaluating VP. The presence of a competitor HLC reduced the precision of METs and BGS traps to measure PE. However, this may reflect the true PE that could be measured in the field, where the possibility of finding someone in isolation is very small. The average PE was 62% in the no-choice experiments, which is consistent with other evaluations of FTPEs [29]. However, in the choice tests, BGS traps measured a reduced PE and increased PE was measured by METs. This is explained by the presence of a second HLC, which introduces other cues, causing variability in the data. It is known that mosquitoes orient to carbon dioxide (CO2) from over 20 m [41] and select between hosts at distances of approximately 15 m [42]. Consequently, it is recommended that topical repellents be tested with individuals over 20 m apart [43] in no-choice tests [44] to ensure independence of observations. The current data adds weight to this recommendation. It is consistent with observations that household mosquito densities are correlated with the number of occupants [45]. In addition, other studies of transfluthrin PE in semi-field systems demonstrated that the addition of a CO2-baited Suna trap reduced transfluthrin PE and that the trap did not perform well in the presence of a human [46]. This is consistent with the current findings that protective efficacy of transfluthrin was lower, but not significantly so, in the presence of a second competitor HLC; BGS traps and METs collected substantially fewer mosquitoes.
No evidence of mosquito diversion from a protected individual to a second individual at 10 metres in the presence of transfluthrin
Spatial repellents, including VPs, are an important addition to the vector control toolbox because they protect multiple users within a defined space [47]. This study demonstrated that in the presence of FTPEs in all of the experimental configurations (HLC, MET and BGS trap) reduced mosquito numbers. The competitor HLC, located 10 metres from the FTPEs, also demonstrated approximately 50% PE. This is consistent with another study conducted against An. arabiensis in Tanzania in which protective efficacy of 50% extended 5 m in an outdoor setting [48]. This study showed that VPs act on mosquitoes over distances of several metres with a non-contact (spatial) mode of action [49]. From a public health perspective, this is a useful characteristic of VPs used as spatial repellents because they can protect multiple users with no need for daily compliance, unlike topical repellents, which suffer from diversion of users to non-users [50] and extremely low daily compliance among users in endemic countries [51], travellers [52] and military populations [53]. Further testing of the usefulness of METs for the evaluation of topical repellents that act over distances of just a few centimetres [54] is required to validate METs for evaluation of other bite prevention interventions, such as topical repellents and insecticide-treated clothing.
While there is some evidence that VPs can cause an increase in mosquito bites among non-repellent using households in villages with incomplete coverage of VP [55], it has also been observed that when applied at large scale, transfluthrin VP can reduce malaria [56]. This is because transfluthrin has multiple modes of action. It can cause rapid knockdown and kill [57] and feeding inhibition up to 12 hours post-exposure, referred to as “disarming” [58], as well as causing landing reduction, which is important when considering the use of this intervention at scale for public health [59]. While diversion was not observed in this study, we cannot rule out the possibility of diversion occurring in other settings where an individual may be positioned outside the reach of the protective radius of transfluthrin.
Evidence that humans at 10 metres attract majority of mosquitoes in the presence of BGS traps
This study also observed that humans positioned 10 m away from a BGS trap received all the mosquito landings, similar to if they had been positioned alone. While the presence of transfluthrin did continue to protect the HLC participant in the presence of the BGS, in the control arm, mosquito landings substantially increased. This is unsurprising, because mosquito sensitivity to skin odours has been shown to increase at least fivefold immediately following a brief encounter with a filament of CO2 [60]. This mechanism may also explain the findings of a similar study in an SFS in Kenya, where transfluthrin showed lower PE in the presence of an odour-baited Suna trap than when used without the trap [46]. However, the authors point out that the differing ambient temperatures, which may affect release rates of VPs, may have confounded their data.
The same finding was observed in push–pull evaluations in Tanzania [61] in which increasing odour-baited trap density around houses increased landings on people conducting HLC while moving traps farther away was protective [61]. Therefore, the location of traps with CO2 for Ae. aegypti surveillance should be carefully considered in areas of active arbovirus transmission to ensure that householders where traps are located do not experience increased bites. This finding has also be seen in Tanzania [22], where odour-baited traps lured large numbers of mosquitoes from a distance but could not compete with humans at short range and actually resulted in increased landings for those sitting close to odour-baited traps. This causes difficulties: if the traps are moved out of peridomestic areas, they will likely no longer be able to measure the impact of peridomestic interventions such as VPs. So while odour-baited traps with CO2 are being considered because their use will be safer for the HLC technicians, there may be unwanted side effects for community members.
Other considerations for repellent evaluations
In our study, the paired HLC captured similar proportions of mosquitoes in the absence of VPs, with a ratio of approximately 1:1. The participation of highly skilled technicians collecting over three hours allowed equivalent estimation of mosquito landings although the studies were performed at different times. This highlights the importance of training and supervision of staff involved in the conduct of entomological evaluations. The technical staff were highly motivated to perform the test accurately following discussion of the importance of the study and their role in the generation of accurate data [62].
Study limitations
First, during collection the BGS trap ran continuously for three hours while each hour a 10-minute break was provided for those conducting MET testing or HLC to stretch and to collect mosquitoes from the MET. Thus, the total sampling time for the BGS trap was three hours, whereas it was 2 hours 30 minutes for both HLC and the MET. Therefore, the number of mosquitoes caught by the BGS trap may be overestimated. Second, the volunteers observed that mosquitoes electrocuted by the MET occasionally recovered and flew away, which may contribute to a lower estimate of the mosquito landing rate. This study used 680 V generated by the MET, but for those experiment that do not need mosquito samples after electrocution, higher voltage may be used. Third, the experiments were conducted in the semi-field system using laboratory-reared mosquitoes. Although the mosquitoes were recently colonised, it is possible that these results may not represent what would happen in a real-world situation with wild mosquitoes. In addition, the results may not be generalisable to all mosquito species. While the data were consistent with those from other experiments using a similar dose of transfluthrin, the relative efficacy of the BGS trap and the MET to estimate PE may vary according to transfluthrin concentration. Further experiments with varying doses of transfluthrin conducted in multiple settings would be useful to strengthen the findings of this study.