Week 3 resubmitted

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Global Malaria Programme

The use of DDT

in malaria vector control

WHO position statement

© World Health Organization, 2011
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WHO/HTM/GMP/2011

Global Malaria Programme

THE USE OF DDT
IN MALARIA VECTOR CONTROL

WHO Position Statement

THE USE OF DDT IN MALARIA VECTOR CONTROL

CONTENTS

1. Introduction ………………………………………………………………………….. 1

2. Why is DDT still recommended? ……………………………………………………… 2
2.1 Efficacy and effectiveness of DDT ……………………………………………………. 2
2.2 Concerns about the safety of DDT ……………………………………………………. 2
2.3 Insecticide resistance and the use of DDT …………………………………………… 3

3. The use of DDT in disease vector control …………………………………………….. 4

4. Safe and effective use of DDT ………………………………………………………… 5
Strict conditions to be met when using DDT ………………………………………… 5

5. Achieving sustainable malaria vector control in the context
of the Stockholm Convention …………………………………………………………. 7

6. Conclusion …………………………………………………………………………… 8

References and background documents …………………………………………….. 9

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Global Malaria Programme 1

1. Introduction

Indoor residual spraying (IRS) is a major intervention for malaria control (1).
There are currently 12 insecticides recommended for IRS, including DDT.

The production and use of DDT are strictly restricted by an international
agreement known as the Stockholm Convention on Persistent Organic Pollut-
ants (2). The Convention’s objective is to protect both human health and the
environment from persistent organic pollutants. DDT is one of 12 chemicals
identified as a persistent organic pollutant that the Convention restricts. In
May 2007, 147 countries were parties to the Convention.

The Convention has given an exemption for the production and public health
use of DDT for indoor application to vector-borne diseases, mainly because of
the absence of equally effective and efficient alternatives. WHO actively sup-
ports the promotion of chemical safety1 and, together with the United Na-
tions Environment Programme, shares a common commitment to the global
goal of reducing and eventually eliminating the use of DDT while minimizing
the burden of vector-borne diseases.

It is expected that there will be a continued role for DDT in malaria control
until equally cost-effective alternatives are developed. A premature shift to
less effective or more costly alternatives to DDT, without a strengthening of
the capacity (human, technical, financial) of Member States will not only be
unsustainable, but will also have a negative impact on the disease burden in
endemic countries.

This position statement summarizes the issues surrounding the use of DDT
for vector-control purposes.

1. World Health Assembly Resolution 50.13. Promotion of chemical safety, with
special attention to persistent organic pollutants, 1997.

THE USE OF DDT IN MALARIA VECTOR CONTROL2

2. Why is DDT still recommended?

2.1 Efficacy and effectiveness of DDT

DDT has several characteristics that are of particular relevance in malaria
vector control. Among the 12 insecticides currently recommended for this in-
tervention, DDT is the one with the longest residual efficacy when sprayed on
walls and ceilings (6–12 months depending on dosage and nature of sub-
strate).

In similar conditions, other insecticides have a much shorter residual efficacy
(pyrethroids: 3–6 months; organophosphates and carbamates: 2–6 months).
Depending on the duration of the transmission season, the use of DDT alterna-
tives might require more than two spray cycles per year, which would be very
difficult (if not impossible) to achieve and sustain in most settings.

DDT has a spatial repellency and an irritant effect on malaria vectors that
strongly limit human-vector contact. Vector mosquitoes that are not directly
killed by DDT are repelled and obliged to feed and rest outdoors, which con-
tributes to effective disease-transmission control.

2.2 Concerns about the safety of DDT

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DDT has a low acute toxicity on skin contact, but if swallowed it is more toxic
and must be kept out of the reach of children. Because of the chemical sta-
bility of DDT, it accumulates in the environment through food chains and in
tissues of exposed organisms, including people living in treated houses. This
has given rise to concern in relation to possible long-term toxicity.

The risks that DDT poses to human health are re-evaluated by WHO whenever
there is significant new scientific information. In 2000, the Joint FAO/WHO
Meeting on Pesticide Residues* undertook a comprehensive re-evaluation of
DDT and its primary metabolites including storage of DDT and its metabolites
in human body fat; the presence of residues in human milk and the poten-
tial carcinogenicity; and biochemical and toxicological information including
hormone-modulating effects. While a wide range of effects were reported in
laboratory animals, epidemiological data did not support these findings in
humans.

* World Health Organization (2011). Environmental Health Criteria 241. DDT in In-
door Residual Spraying: Human Health Aspects. World Health Organization, Geneva.

Global Malaria Programme 3

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2.3 Insecticide resistance and the use of DDT

Only insecticides to which vectors are susceptible (including DDT) should be
used for IRS. Insecticide resistance in malaria vectors has commonly resulted
from the use of the same insecticides for crop protection. In certain settings,
products sprayed on crops contaminate malaria vector breeding sites. This
direct exposure has resulted in the development of vector resistance in sev-
eral parts of the world. Despite decades of widespread and intensive applica-
tion, significant levels of DDT resistance in malaria vectors have been limited
to some vector species and geographical areas. Since DDT use is restricted
to public health activities, vector populations are no longer exposed to DDT
through other applications, which further reduces prospects for selection and
spread of vector resistance.

Effective management of insecticide resistance entails the use of several un-
related insecticides in combination or rotation. The 12 insecticides recom-
mended for IRS belong to only four chemical groups, and DDT represents one
group by itself. Given the very limited arsenal of recommended insecticides,
it is advisable to retain DDT for resistance management until suitable alterna-
tives are available.

New information published since 2000 was evaluated by a WHO Expert Con-
sultation held in December 2010. This information included new epidemio-
logical studies, up-to-date reported levels in human milk, and new information
on exposures to DDT occurring as a result of IRS. A detailed exposure assess-
ment was undertaken, including potential exposure to both residents in IRS-
treated homes as well as to spray operators. The WHO Expert Consultation
concluded that in general, levels of exposure reported in studies were below
levels of concern for human health. In order to ensure that all exposures are
below levels of concern, best application practices must be strictly followed to
protect both residents and workers.

Based on the most recent information, WHO has no reason to change its cur-
rent recommendations on the safety of DDT for disease vector control. How-
ever, WHO’s position on the safety and use of DDT will be revised if new
information on the potential hazards of DDT becomes available justifying such
a revision.

THE USE OF DDT IN MALARIA VECTOR CONTROL4

3. The use of DDT in disease vector control

In high-transmission areas, such as in most parts of sub-Saharan Africa, IRS
and insecticide-treated nets are the most effective interventions to control
malaria. When transmission and prevalence of the parasites have been sub-
stantially reduced through these two interventions, alternative measures can
increasingly contribute in the context of integrated vector management.

WHO recommends DDT only for indoor residual spraying. Coun-
tries can use DDT for as long as necessary, in the quantity needed,
provided that the guidelines and recommendations of WHO and
the Stockholm Convention are all met, and until locally appropri-
ate and cost-effective alternatives are available for a sustainable
transition from DDT. At its third meeting in May 2007, the Confer-
ence of the Parties of the Stockholm Convention concluded that
there is a continued need for use of DDT in disease vector control.
This need will be evaluated every two years.

Many malaria-endemic countries have replaced DDT with alternative insec-
ticides, mostly pyrethroids. In some instances this change has compromised
the efficacy of vector-control programmes. For instance, in South Africa the
switch from DDT to pyrethroids in 1997 soon resulted in the reappearance of
Anopheles funestus, a major malaria vector, eliminated from the country for
decades and found to be resistant to pyrethroids. This reappearance resulted
in severe malaria outbreaks, which justified reintroduction of DDT in 2000.
This situation raised awareness of the risks associated with insecticide resist-
ance and potential danger of eliminating DDT too early. Subsequently, several
countries in Africa have introduced, or are planning to reintroduce, DDT in IRS
operations.

Global Malaria Programme 5

4. Safe and effective use of DDT

DDT should be used under strict control and only for the intended purpose,
according to a WHO position statement on IRS (1). Using it in any other way
would have important consequences, such as the contamination of food and
agricultural products, including export goods, with a potential impact on inter-
national trade. Effective use and safe storage of DDT rely on compliance with
well-established and well-enforced rules and regulations in accordance with
national guidelines and with WHO technical guidance. This should be within
the context of the Stockholm Convention.

There are strict conditions to be met when using DDT and they are described
below.

(i) As DDT is one of the 12 insecticides recommended by WHO for
IRS, the prerequisites for safe and effective implementation of IRS
(1) apply to DDT, including susceptibility status of vectors and
proper monitoring of insecticide resistance to implement resist-
ance-management tactics.

(ii) The use of DDT for IRS must be closely monitored and reported to
WHO and to the Secretariat of the Stockholm Convention2.

(iii) To avoid undue exposure of householders and spray operators
to DDT, standard operating procedures and national guidelines
should be in place and strictly followed. Appropriate management
of DDT also entails adoption and enforcement of stringent rules
and regulations to avoid leakage (into e.g. agriculture) and misuse
(when used in, e.g., domestic hygiene). This includes the pos-
sibility of appropriate legal measures in the event that individuals
or entities do not comply with this condition.

(iv) To complement the continued review of information on DDT safety
by the International Programme on Chemical Safety, there is a need
to establish and implement appropriate monitoring strategies to
better characterize DDT exposure (to humans and the environ-
ment) under the operational conditions in which DDT is used for
vector control.

2. Stockholm Convention on Persistent Organic Pollutants, Annex B, paragraph 4.

THE USE OF DDT IN MALARIA VECTOR CONTROL6

(v) The status of insecticide resistance, including to DDT, must be
continuously monitored in order to (a) select insecticides to which
vectors are susceptible and (b) implement resistance-manage-
ment tactics, such as rotation of unrelated insecticides.

(vi) The continued need for DDT should be evaluated regularly by the
parties to the Stockholm Convention and reports made to WHO
and the Secretariat of the Stockholm Convention3. The results
from these evaluations will depend, among other things, on: in-
secticide resistance status of local vectors; availability of alter-
native insecticides; control methods and strategies; and level of
funding allocated to malaria vector control.

2. Stockholm Convention on Persistent Organic Pollutants, Annex B, paragraph 6.

Global Malaria Programme 7

5. Achieving sustainable malaria vector control
in the context of the Stockholm Convention

To improve the cost-effectiveness, ecological soundness and sustainability of
vector control, a global strategic framework for integrated vector management
(IVM) has been developed (4). IVM involves the use of proven vector-control
methods, separately or in combination, tailored according to knowledge of
local determinants of disease, including vector ecology, disease epidemiol-
ogy and human behaviour. IVM is based on the premise that effective control
requires the collaboration of actors within the health sector itself and their col-
laboration with other sectors, and the engagement of local communities and
other stakeholders.

IRS, including DDT, should be used as a component of an IVM strategy. This
ensures that options for control of local malaria vectors are determined by a
sound understanding of local eco-epidemiological conditions, and are appro-
priate and effective. IVM creates opportunities to generate synergies between
different vector-borne disease-control programmes: a single intervention can
control more than one vector-borne disease, such as malaria, leishmaniasis or
lymphatic filariasis, that is transmitted by indoor resting vectors.

Alternative insecticides or alternative vector-control strategies and methods of
equivalent efficacy will have to be developed to reduce reliance on DDT. The
first step is the development of new formulation technologies to increase re-
sidual life of existing insecticides to a level equivalent to that of DDT. Addition-
ally, it will be essential to develop new insecticides or active molecules that will
replace DDT, as soon as possible, and that will respond to the challenges of
pyrethroid resistance. These steps require a sustained and high level of effort
and resource mobilization in the context of public-private partnerships. DDT is
still needed today because investment to develop alternatives over the past 30
years has been grossly inadequate.

Non-chemical vector-control methods, such as environmental management or
improvement of house construction (e.g. window screens), should be actively
promoted. Additionally, greater resources should be allocated to research and
development in such methods.

THE USE OF DDT IN MALARIA VECTOR CONTROL8

6. Conclusion

DDT is still needed and used for disease vector control simply because there is
no alternative of both equivalent efficacy and operational feasibility, especially
for high-transmission areas. The reduction and ultimate elimination of the use
of DDT for public health must be supported technically and financially. It is
essential that adequate resources and technical support are rapidly allocated
to countries so that they can adopt appropriate measures for sound manage-
ment of pesticides in general and of DDT in particular. There is also an urgent
need to develop alternative products and methods, not only to reduce reliance
on DDT and to achieve its ultimate elimination, but also to sustain effective
malaria vector control.

Global Malaria Programme 9

References and background documents

1. Indoor residual spraying: use of indoor residual spraying for scaling up global malaria control
and elimination. Geneva, World Health Organization, 2006 (WHO/HTM/MAL/2006.1112).

2. Stockholm Convention on persistent organic pollutants. New York, NY, United Nations En-
vironment Programme, 2001 (http://www.pops.int/documents/convtext/convtext_en , ac-
cessed 20 July 2007).

3. Pesticide residues in food 2000: DDT (para,para’-Dichlorodiphenyltrichloroethane) (ad-
dendum) (http://www.inchem.org/documents/jmpr/jmpmono/v00pr03.htm, accessed 20 July
2007).

4. Global strategic framework for integrated vector management. Geneva, World Health Organi-
zation, 2004 (WHO/CDS/CPE/PVC/2004.10).

5. Najera J A, Zaim M. Malaria vector control: insecticides for indoor residual spraying. Geneva,
World Health Organization, 2001 (WHO/CDS/WHOPES/2001.3).

6. Manual for indoor residual spraying: application of residual sprays for vector control. Ge-
neva, World Health Organization, 2002 (WHO/CDS/WHOPES/GCDPP/2000.3/Rev.1).

For further information, please contact:

Global Malaria Programme
World Health Organization

20. avenue Appia – CH-1211 Geneva 27
infogmp@

who.int

www.who.int/malaria

who.int
DDT position statement revised 2011