Prospects for malaria control in urban and rural Kinshasa.

Malaria is a major cause of paediatric illness and death in Kinshasa, and all 3 million inhabitants are at risk. In view of the increasing chloroquine-resistance of Plasmodium falciparum, the early treatment of fever cases as the sole malaria control measure is no longer acceptable. The prospects for vector control are determined by the effectiveness, the acceptability and the practicability of the various methods in the local conditions of Kinshasa. Pronounced differences in the level of endemicity exist between the various parts of the town. These differences, and the ecological and socio-economic factors that underlie them, must be taken into account when estimating the potential of a control method. The reduction of man-vector contact through personal protection with impregnated bednets is the only realistic goal at this moment, but even a very marked decrease of the inoculation rate will produce little apparent effect in the highly endemic (semi-)rural districts at the periphery of town. In the urbanized center of Kinshasa, where the moderate to low intensity of transmission is more susceptible to a critical reduction, the same method may have an impact on malaria morbidity. Moreover, the big nuisance from non-vector mosquitoes in the urban area is an important motivating factor for the acceptance and the use of bednets. A mass effect, on the other hand, only is to be expected in isolated villages. Field trials are needed to evaluate the short- and long-term effect on malaria transmission and on its' clinical expression, as well as on the build-up of natural immunity, in the epidemiologically distinct areas. However, the final outcome of a large scale implementation of malaria control with impregnated mosquitonets will equally depend on health education, on the availability of bednets at low cost, on the creation of the appropriate structures for the (re)impregnation and distribution of the nets, and finally on the sustainability of the whole effort.