Use of DDT in fighting malaria

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Malaria affects people in many countries, including many African and Asian countries, and countries of the Americas as far north as Mexico. DDT has been an effective tool in fighting malaria, but at a high cost to the environment and human health.

As mosquitoes have developed resistance to DDT and alternatives have become available, the use of DDT has been greatly restricted. A global ban has not been implemented, however, as its particular properties make it useful in certain very restricted settings where local strains of mosquito are susceptible, and where dispersion in the environment can be minimized. Environmental groups, notably the WWF,W are lobbying for effective alternatives to DDT to be developed and implemented, allowing it to be eventually eliminated.

Contents

[edit] History

DDT (dichlorodiphenyltrichloroethane) is a synthetic pesticide with a controversial history.

DDT's insecticidal properties were discovered in 1939, and it was used in the second half of World War II to control the insect-borne diseases, malaria and typhus. This led to a Nobel Prize in Physiology or MedicineW in 1948.[1] After the war, DDT was used as an agricultural insecticide, and its production and use skyrocketed.[2]

[edit] Bans and restrictions on DDT use

In 1962, Silent Spring by American biologist Rachel Carson was published, describing the environmental impacts of the indiscriminate spraying of DDT in the US and questioned the logic of releasing large amounts of chemicals into the environment without fully understanding their effects on ecology or human health. The book suggested that DDT and other pesticides may cause cancer and that their agricultural use was a threat to wildlife, particularly birds. Its publication was one of the signature events in the birth of the environmental movement, and resulted in a large public outcry that eventually led to DDT being banned in the US in 1972.[3] DDT was subsequently banned for agricultural use worldwide under the Stockholm Convention, but its limited use in disease vector control continues to this day and remains controversial.[4]

Along with the passage of the Endangered Species Act, the US ban on DDT is cited by scientists as a major factor in the comeback of the bald eagle, the national bird of the United States,[5] from near-extinction in the contiguous US.[6]

Rachel Carson endorsed limited use of insecticide when needed - noting that limited rather than wasteful use would reduce problems of resistance.[7]

[edit] Production and use statistics

From 1950 to 1980, when DDT was extensively used in agriculture—more than 40,000 tonnes were used each year worldwide[8]—and it has been estimated that a total of 1.8 million tonnes of DDT have been produced globally since the 1940s.[9]

Today, 4-5,000 tonnes of DDT are used each year for the control of malaria and visceral leishmaniasis, with India being the largest consumer. India, China, and North Korea are the only countries still producing and exporting it, and production is reportedly on the rise.[10]

[edit] The benefits of DDT

There has been lobbying to prevent a global ban on DDT,W largely arguing for the importance of its role in preventing malaria.

DDT is associated in the public mind with harm to ecosystems, and it has mostly been replaced with other pesticides with less persistence in the environment. However it remains effective in specific settings where other pesticides are not.

[edit] Malaria

India, Brazil and Mexico, where 69% of all reported cases of malaria occur (Mosq Control Assoc, 1998). Malaria afflicts hundreds of millions of people and causes millions of human deaths each year. Swiss scientist Paul Muller was awarded the 1948 Nobel Prize in Physiology or Medicine for discovering (1939) DDT's insecticidal properties.

DDT kills mosquitoes. Malaria is transmitted to humans via mosquito bites. According to U.N. estimates, malaria kills one child every 30 seconds and more than a million people each year.[3]

[edit] Appropriate use

DDT is best used on surfaces, especially indoors, as a weapon against the resting mosquito. It is:

  • Potent - just two grams of DDT per square meter of wall surface is more than enough to kill a mosquito within its usual one-hour resting period.
  • Inexpensive.Template:Detail
  • Easily stored and transported[verification needed]
  • Relatively safe for the person doing the spraying.[verification needed]
  • Long lasting - it remains effective for many, many months.[verification needed]

Inappropriate use includes spraying into the environment, where its long-lasting nature becomes a harmful property.

[edit] The environmental impact

DDT is associated in the public mind with harm to ecosystems, and it has mostly been replaced with other pesticides with less persistence in the environment.

But the environmentalist will have a hard time thinking of the condition of many species if the 1972 U.S. ban of DDT would not have been sucessful[4]. The most important thing at this point will be an in-depth study on whether it would be beneficial for countries with the malaria epidemic to use DDT as a preventative measure. They will also have to keep in mind how DDT will impact not only the health of humans, but the habitats of animals and other wildlife that may be negatively affected by the insecticide. For species that rely on insects for food, using DDT could ruin a population even if it is benefiting another.

From an environmental standpoint, it would sound absolutely crazy to be using a toxic insecticide to aide in an epidemic like malaria.

[edit] Using DDT to stop malaria in African countries

The African American Environmentalist Association believes that DDT (Dichloro-diphenyl-trichloroethane) insecticide should be used to prevent deaths from malaria in African countries. DDT is an organochlorine pesticide that has been used as an insecticide in agriculture and to combat insect vectors of diseases such as malaria and typhus. Because of its effectiveness at killing insects with few acute effects on humans, DDT had been a mainstay to fight malaria, a parasitic disease that is a growing health threat in Africa and other parts of the world.

[edit] Controversy

Controversy has been fanned by claims of millions of deaths resulting from a ban in the use of DDT. This is a simplistic and inaccurate picture of what has actually happened - for a start, DDT has never been completely banned.

[edit] WWF's call for an eventual ban

There is no longer a question about whether DDT should be banned, only how soon it can happen while still ensuring developing countries access to safe, affordable alternative malaria controls

— Clifton Curtis, director of the WWF Global Toxics Initiative, Group calls for worldwide DDT ban, 1999, CNN

WWF initially called for a global phaseout and eventual ban on DDT production and use by the year 2007, together with financial and technical assistance to the developing world. The 2007 deadline was intended as a motivational tool to encourage the necessary financial and technical assistance. The proposal of a 2007 deadline drew considerable public attention to the scope of the world's malaria problem and the need to implement alternatives to DDT.

However, it also raised fears that DDT would be phased out without sufficient guarantees of protection of public health from malaria. To allay these fears, WWF has set aside discussion of the 2007 deadline, while retaining its commitment to eliminating DDT. Both the UNEP and WHO recognize that such elimination can be a "win-win" situation for public health and environmental protection.

DDT is also used in crop growth, and has been linked to the cause of attention deficit hyperactive disorder (ADHD) and also have an affect on the developing stages for children still in the utero. [verification needed]

[edit] Malaria Foundation International

The Malaria Foundation International[5] expresses fears of a rush to ban DDT before alternatives are in place, noting that in certain situations (giving the examples of KwaZulu-Natal and Ethiopia) there are few effective or affordable alternatives. Their website states:

Malaria and leishmaniasis are diseases that are in resurgence in many parts of the world. Diminished control efforts are, at least in part, responsible for this resurgence (Roberts et al. 1997, Roberts et al. 2000, Baird 2000).
The MFI has supported an eventual (not immediate) ban, with the proviso that an effective and affordable replacement is found before DDT is banned.
DDT is one tool of many in the malaria control worker's toolbox. The reason that it is being discussed at this site is that, unlike other tools, there is an imminent danger of it being taken away. This puts not just health, but lives, at stake. The MFI wants to see all possible tools for malaria control be readily available, because malaria is a serious, resurgent problem with drug resistance and increasing numbers of illnesses and deaths.[6]

[edit] DDT and the POPs Treaty

The Stockholm POPs Convention, a treaty to phase out persistent organic pollutants (POPs), including DDT, is currently open for ratification. WWF welcomes this historic agreement which involved provisions for phasing out DDT, while still allowing for its continued limited use for malaria control.

Evidence continues to accumulate about the dangerous health effects associated with DDT. The treaty provisions appropriately balance the need to reduce these hazards while promoting stronger malaria control programs. The accord states that "with the goal of reducing, and ultimately eliminating the use of DDT," individual countries may continue to use the chemical for controlling malaria. However, these countries will also be encouraged to prepare national implementation plans to reduce their reliance on DDT.

Specifically, the national plans would promote methods for reducing illegal uses of DDT, such as agricultural applications. Countries would also identify steps to implement alternative approaches and promote measures that strengthen health care and reduce the incidence of malaria. The parties to the treaty will periodically review the status of alternative approaches to determine whether DDT is still needed or whether it can be eliminated completely.[7]

[edit] From Wikipedia

These paragraphs need to be deleted or integrated as appropriate:

[edit] History

DDT (from its trivial name, dichlorodiphenyltrichloroethane) is one of the most well-known synthetic pesticides. It is a chemical with a long, unique, and controversial history.

First synthesized in 1874, DDT's insecticidal properties were not discovered until 1939, and it was used with great success in the second half of World War II to control malaria and typhus among civilians and troops. The Swiss chemist Paul Hermann Müller was awarded the Nobel Prize in Physiology or Medicine in 1948 "for his discovery of the high efficiency of DDT as a contact poison against several arthropods."[1] After the war, DDT was made available for use as an agricultural insecticide, and soon its production and use skyrocketed.[2]

[edit] Properties and chemistry

DDT is an organochlorine, similar in structure to the insecticide methoxychlor and the acaricide dicofol. It is a highly hydrophobic, colorless, crystalline solid with a weak, chemical odor. It is nearly insoluble in water but has a good solubility in most organic solvents, fats, and oils. DDT does not occur naturally, but is produced by the reaction of chloral (CCl3CHO) with chlorobenzene (C6H5Cl) in the presence of sulfuric acid, which acts as a catalyst. Trade names that DDT has been marketed under include Anofex, Cezarex, Chlorophenothane, Clofenotane, Dicophane, Dinocide, Gesarol, Guesapon, Guesarol, Gyron, Ixodex, Neocid, Neocidol, and Zerdane.[2]

[edit] Mechanism of action

In insects, it has potent insecticidal properties, where it kills by opening sodium ion channels in the neurons, causing them to fire spontaneously leading to spasms and eventual death. Insects with certain mutations in their sodium channel gene are resistant to DDT and other similar insecticides. DDT resistance is also conferred by up-regulation of genes expressing cytochrome P450 in some insect species.[11]

In humans, however, it may affect health through genotoxicity or endocrine disruption. See Effects on human health below

[edit] History

File:DDT.jpg
Commercial product containing 5% DDT

First synthesized in 1874 by Othmar Zeidler,[2] DDT's insecticidal properties were not discovered until 1939 by the Swiss scientist Paul Hermann Müller, who was awarded the 1948 Nobel Prize in Physiology and Medicine for his efforts.[1]

[edit] Use in the 1940s and 1950s

DDT is the best-known of a number of chlorine-containing pesticides used in the 1940s and 1950s. With pyrethrum in short supply, DDT was used extensively during World War II by the Allies to control the insect vectors of typhus—nearly eliminating the disease in many parts of Europe. In the South Pacific, it was sprayed aerially for malaria control with spectacular effects. While DDT's chemical and insecticide properties were important factors in these victories, advances in application equipment coupled with a high degree of organization and sufficient manpower were also crucial elements in the success of these wartime spray programs.[12] In 1945, it was made available to farmers as an agricultural insecticide.[2] DDT played a small role in the final elimination of malaria in Europe and North America, as malaria had already been eliminated from much of the developed world before the advent of DDT through the use of a range of public health measures and generally increasing health and living standards.[4] One CDC physician involved in the United States' DDT spraying campaign said of the effort that "we kicked a dying dog."[13]

In 1955, the World Health Organization commenced a program to eradicate malaria worldwide, relying largely on DDT. The program was initially highly successful, eliminating the disease in "Taiwan, much of the Caribbean, the Balkans, parts of northern Africa, the northern region of Australia, and a large swath of the South Pacific"[14] and dramatically reducing mortality in Sri Lanka and India.[15] However resistance soon emerged in many insect populations as a consequence of widespread agricultural use of DDT. In many areas, early victories against malaria were partially or completely reversed, and in some cases rates of transmission even increased.[16] The program was successful in eliminating malaria only in areas with "high socio-economic status, well-organized healthcare systems, and relatively less intensive or seasonal malaria transmission".[17]

DDT was less effective in tropical regions due to the continuous life cycle of mosquitoes and poor infrastructure. It was not pursued at all in sub-Saharan Africa due to these perceived difficulties, with the result that mortality rates in the area were never reduced to the same dramatic extent, and now constitute the bulk of malarial deaths worldwide, especially following the resurgence of the disease as a result of microbe resistance to drug treatments and the spread of the deadly malarial variant caused by Plasmodium falciparum. The goal of eradication was abandoned in 1969, and attention was focused on controlling and treating the disease. Spraying programs (especially using DDT) were curtailed due to concerns over safety and environmental effects, as well as problems in administrative, managerial and financial implementation, but mostly because mosquitoes were developing resistance to DDT.[16] Efforts were shifted from spraying to the use of bednets impregnated with insecticides and other interventions.[17][18]

[edit] Silent Spring and the U.S. ban

As early as the 1940s, scientists in the U.S. had begun expressing concern over possible hazards associated with DDT, and in the 1950s the government began tightening some of the regulations governing its use.[19] However, these early events received little attention, and it was not until 1957, when the New York Times reported an unsuccessful struggle to restrict DDT use in Nassau County, New York, that the issue came to the attention of the popular naturalist-author, Rachel Carson. William Shawn, editor of The New Yorker, urged her to write a piece on the subject, which developed into her famous book Silent Spring, published in 1962. The book argued that pesticides, including DDT, were poisoning both wildlife and the environment and were also endangering human health.[3]

Silent Spring was a best seller, and public reaction to it launched the modern environmental movement in the United States. The year after it appeared, President Kennedy ordered his Science Advisory Committee to investigate Carson's claims. The report the committee issued "add[ed] up to a fairly thorough-going vindication of Rachel Carson’s Silent Spring thesis," in the words of the journal Science,[20] and recommended a phaseout of "persistent toxic pesticides".[21] DDT became a prime target of the growing anti-chemical and anti-pesticide movements, and in 1967 a group of scientists and lawyers founded the Environmental Defense Fund (EDF) with the specific goal of winning a ban on DDT. Victor Yannacone, Charles Wurster, Art Cooley and others associated with inception of EDF had all witnessed bird kills or declines in bird populations and suspected that DDT was the cause. In their campaign against the chemical, EDF petitioned the government for a ban and filed a series of lawsuits.[22] Around this time, toxicologist David Peakall was measuring DDE levels in the eggs of peregrine falcons and California condors and finding that increased levels corresponded with thinner shells.

In response to an EDF suit, the U.S. District Court of Appeals in 1971 ordered the EPA to begin the de-registration procedure for DDT. After an initial six-month review process, William Ruckelshaus, the Agency's first Administrator rejected an immediate suspension of DDT's registration, citing studies from the EPA's internal staff stating that DDT was not an imminent danger to human health and wildlife.[19] However, the findings of these staff members were criticized, as they were performed mostly by economic entomologists inherited from the United States Department of Agriculture, whom many environmentalists felt were biased towards agribusiness and tended to minimize concerns about human health and wildlife. The decision not to ban thus created public controversy.[12]

The EPA then held seven months of hearings in 1971-1972, with scientists giving evidence both for and against the use of DDT. In the summer of 1972, Ruckelshaus announced the cancellation of most uses of DDT—an exemption allowed for public health uses under some conditions.[19] Immediately after the cancellation was announced, both EDF and the DDT manufactures filed suit against the EPA, with the industry seeking to overturn the ban, and EDF seeking a comprehensive ban. The cases were consolidated, and in 1973 the U.S. Court of Appeals for the District of Columbia ruled that the EPA had acted properly in banning DDT.[19]

The U.S. DDT ban took place amid a climate of growing public mistrust of industry, with the Surgeon General issuing a report on smoking in 1964, the Cuyahoga River catching fire in 1969, the fiasco surrounding the use of diethylstilbestrol (DES), and the well-publicized decline in the bald eagle population.[21]

Some uses of DDT continued under the public health exemption. For example, in June 1979, the California Department of Health Services was permitted to use DDT to suppress flea vectors of bubonic plague.[23] DDT also continued to be produced in the US for foreign markets until as late as 1985, when over 300 tonnes were exported.[9]

[edit] Restrictions on usage

In the 1970s and 1980s, agricultural use of DDT was banned in most developed countries, beginning with Hungary in 1968[24] then in Norway and Sweden in 1970, and the US in 1972, but not banned in the United Kingdom until 1984. The use of DDT in vector control has not been banned, but it has been largely replaced by less persistent alternative insecticides.

The Stockholm Convention, which entered into force in 2004, outlawed several persistent organic pollutants, and restricted the use of DDT to vector control. The Convention has been ratified by more than 160 countries and is endorsed by most environmental groups. Recognizing that a total elimination of DDT use in many malaria-prone countries is currently unfeasible because there are few affordable or effective alternatives, the public health use of DDT was exempted from the ban until alternatives are developed. The Malaria Foundation International states that "The outcome of the treaty is arguably better than the status quo going into the negotiations...For the first time, there is now an insecticide which is restricted to vector control only, meaning that the selection of resistant mosquitoes will be slower than before."[25]

Despite the worldwide ban on agricultural use of DDT, its use in this context continues in India[26] North Korea, and possibly elsewhere.[10]

Today, about 4-5,000 tonnes of DDT are used each year for vector control.[10] In this context, DDT is applied to the inside walls of homes to kill or repel mosquitos entering the home. This intervention, called indoor residual spraying (IRS), greatly reduces environmental damage compared to the earlier widespread use of DDT in agriculture. It also reduces the risk of resistance to DDT.[27] This use only requires a small fraction of that previously used in agriculture; for example, the amount of DDT that might have been used on Template:Convert/haTemplate:Convert/test/Aoff of cotton during a typical growing season in the U.S. is estimated to be enough to treat roughly 1,700 homes.[28]

[edit] Environmental impact

DDT is a persistent organic pollutant that is extremely hydrophobic and strongly absorbed by soils. Depending on conditions, its soil half life can range from 22 days to 30 years. Routes of loss and degradation include runoff, volatilization, photolysis and aerobic and anaerobic biodegradation. When applied to aquatic ecosystems it is quickly absorbed by organisms and by soil or it evaporates, leaving little DDT dissolved in the water itself. Its breakdown products and metabolites, DDE and DDD, are also highly persistent and have similar chemical and physical properties.[9] These products together are known as "total DDT". DDT and its breakdown products are transported from warmer regions of the world to the Arctic by the phenomenon of global distillation, where they then accumulate in the region's food web.[29]

DDT, DDE, and DDD magnify through the food chain, with apex predators such as raptor birds having a higher concentration of the chemicals than other animals sharing the same environment. They are very lipophilic and are stored mainly in body fat. DDT and DDE are very resistant to metabolism; in humans their half-lives are 6 and up to 10 years, respectively. In the United States, these chemicals were detected in almost all human blood samples tested by the Centers for Disease Control in 2005, though their levels have sharply declined since most uses were banned in the US.[30] Estimated dietary intake has also declined,[30] despite it still being commonly detected in food samples tested by the FDA.[31]

Marine algae (seaweeds) have been shown to act as bioremediation agents and can reduce the toxicity of soil contaminated by DDT by up to 80% within six weeks.[32]

[edit] Effects on wildlife and eggshell thinning

DDT is toxic to a wide range of animals in addition to insects. It is highly toxic to aquatic life, including crayfish, daphnids, sea shrimp and many species of fish. It is less toxic to mammals but cats are very susceptible, and in several instances cat populations were significantly depleted in malaria control operations that used DDT, often leading to explosive growth in rodent populations.[33] DDT may be moderately toxic to some amphibian species, especially in the larval stages. Most famously, it is a reproductive toxicant for certain birds species, and it is a major reason for the decline of the bald eagle,[6] brown pelican[34] peregrine falcon, and osprey.[9] Birds of prey, waterfowl, and song birds are more susceptible to eggshell thinning than chickens and related species, and DDE appears to be more potent than DDT.[9]

The biological mechanism for the thinning is not entirely known, but there is strong evidence that p,p'-DDE inhibits calcium ATPase in the membrane of the shell gland and reduces the transport of calcium carbonate from blood into the eggshell gland. This results in a dose-dependent reduction in eggshell thickness.[9][35][36][37] There is also evidence that o,p'-DDT disrupts the development of the female reproductive tract, thereby impairing the quality of the eggshells produced by the bird once it matures.[38] Multiple mechanisms may be at work, or different mechanisms may operate in different species.[9] Some studies have shown that although DDE levels have fallen dramatically, eggshell thickness remains 10–12 percent thinner than before DDT was first used.[39]

[edit] Effects on human health

Potential mechanisms of DDT on humans are genotoxicity and endocrine disruption. DDT may have direct genotoxicity,[40] but may also induce enzymes that produce other genotoxic intermediates and DNA adducts.[40] It is an endocrine disruptor; The DDT metabolite DDE acts as an antiandrogen (but not as an estrogen). o,p'-DDT, a minor component in commercial DDT has weak estrogenic activity. However, p,p'-DDT, the main component of DDT, has little or no androgenic or estrogenic activity.[40]

[edit] Acute toxicity

DDT is classified as "moderately toxic" by the United States National Toxicology Program (NTP)[41] and "moderately hazardous" by WHO, based on the rat oral LD50 of 113 mg/kg.[42] DDT has on rare occasions been administered orally as a treatment for barbiturate poisoning.[43]

[edit] Chronic toxicity

[edit] Diabetes

Organochlorine compounds, generally, and DDT and DDE, specifically, have been linked to diabetes. A number of studies from the US, Canada, and Sweden have found that the prevalence of the disease in a population increases with serum DDT or DDE levels.[44][45][46][47][48][49]

[edit] Developmental and reproductive toxicity

DDT and DDE, like other organochlorines, have been shown to have xenoestrogenic activity, meaning they are chemically similar enough to estrogens to trigger hormonal responses in animals. This endocrine disrupting activity has been observed toxicological studies involving mice and rats, and available epidemiological evidence indicates that these effects may be occurring in humans as a result of DDT exposure. There is therefore concern that DDT may cause developmental and reproductive toxicity.

  • A review article in The Lancet concludes that, "research has shown that exposure to DDT at amounts that would be needed in malaria control might cause preterm birth and early weaning ... toxicological evidence shows endocrine-disrupting properties; human data also indicate possible disruption in semen quality, menstruation, gestational length, and duration of lactation."[18]
  • Human epidemiological studies suggest that DDT exposure is a risk factor for premature birth and low birth weight, and may harm a mother's ability to breast feed.[50] Some 21st century researchers argue that these effects may cause increases in infant deaths in areas where DDT is used for malaria control, and thus offset any benefit derived from its anti-malarial effects.[51][52][53] A 2008 study, however, failed to confirm the association between exposure and difficulty breastfeeding.[54]
  • Several recent studies demonstrate a link between in utero exposure to DDT or DDE and developmental neurotoxicity in humans. For example, a 2006 study conducted by the University of California, Berkeley suggests children who have been exposed to DDT while in the womb have a greater chance of experiencing development problems,[55] and other studies have found that even low levels of DDT or DDE in umbilical cord serum at birth are associated with decreased attention at infancy[56] and decreased cognitive skills at 4 years of age.[57] Similarly, Mexican researchers have demonstrated a link between DDE exposure in the first trimester of pregnancy and retarded psychomotor development.[58]
  • A number studies have documented decreases in semen quality among men with high exposures to DDT or DDE (generally from IRS).[59][60][61]
  • Several studies have examined the association between time to pregnancy (TTP) and levels of DDT or DDE in the blood of pregnant women. These studies have generally found that high exposure levels do not increase TTP.[62] There is some evidence that the daughters of highly exposed women may have more difficulty getting pregnant (i.e. increased TTP).[63]
  • DDT exposure is associated with early pregnancy loss, a type of miscarriage. A prospective cohort study of Chinese textile workers found "a positive, monotonic, exposure-response association between preconception serum total DDT and the risk of subsequent early pregnancy losses."[64] The median serum DDE level of study group was lower than that typically observed in women living in homes sprayed with DDT, suggesting that these findings are relevant to the debate about DDT and malaria control.[65]
  • A case-control study of congenital hypothyroidism in Japan concluded that in utero DDT exposure may affect thyroid hormone levels and "play an important role in the incidence and/or causation of cretinism."[66] Other studies have also found the DDT or DDE interfere with proper thyroid function.[67][68]

[edit] Other

Occupational exposure to DDT (either as a farmer or a malaria control worker) has been linked to:

[edit] Carcinogenicity

DDT is suspected to cause cancer. The NTP classifies it as "reasonably anticipated to be a human carcinogen", and the EPA classifies DDT, DDE, and DDD as a class B2 "probable" human carcinogens. The International Agency for Research on Cancer classifies it is as a "possible" human carcinogen. These evaluations are based mainly on the results of animal studies.[9][18]

There is epidemiological evidence (i.e. studies in humans) that DDT causes cancer of the liver,[18][30] pancreas[18][30] and breast.[30] There is mixed evidence that it contributes to leukemia,[30] lymphoma[30][71] and testicular cancer.[18][30][72]

In contrast, epidemiological studies suggest that DDT/DDE does not cause multiple myeloma,[18] or cancers of the prostate,[18] endometrium,[18][30] rectum,[18][30]lung,[30] bladder,[30] or stomach.[30]

[edit] Breast cancer

The question of whether DDT or DDE are risk factors of breast cancer has been the subject of numerous investigations. While individual studies have come to conflicting conclusions, the most recent reviews of all the evidence conclude that exposure to DDT before puberty increases the risk of breast cancer later in life.[30][73] Until recently, almost all studies measured DDT or DDE blood levels at the time of breast cancer diagnosis or after. This study design has been criticized, since the levels of DDT or DDE at diagnosis do not necessarily correspond to the levels present in a woman's body at the time when her cancer first started.[74] Such studies have thus yielded conflicting results and taken as a whole "do not support the hypothesis that exposure to DDT is an important risk factor for breast cancer."[40] The studies of this design have been extensively reviewed.[18][75][76]

In contrast to these studies, a study published in 2007 found a strong association between exposure to specifically the p,p-isomer of DDT early in life and breast cancer later in life. Unlike previous studies, this was prospective cohort study in which blood samples were collected from young mothers in the 1960s while DDT was still in use, and their breast cancer status was then monitored. In addition to suggesting that exposure to the p,p-isomer of DDT is the more significant risk factor of breast cancer, the study also suggests that the timing of exposure is critical. For the subset of women born more than 14 years prior to the introduction of DDT into US agriculture, there was no association between DDT levels and breast cancer. However, for women born more recently—and thus exposed earlier in life—the third who were exposed most to p, p-DDT had a fivefold increase in breast cancer incidence over the least exposed third, after correcting for the protective effect of o,p-DDT.[40][77] These results are supported by animal studies.[30]

[edit] DDT use against malaria

Malaria remains a major public health challenge in many parts of the world. The World Health Organization (WHO) estimates that in 2008 there were 243 million cases, resulting in 863,000 deaths. About 89% of these deaths occur in Africa, and mostly to children under the age of 5.[78] Spraying DDT is one of many public health interventions currently used to fight the disease. Its use in this context has been called everything from a "miracle weapon [that is] like Kryptonite to the mosquitoes,"[79] to "toxic colonialism."[80]

Before the advent of DDT, aggressive campaigns to eliminate mosquito breeding grounds by drainage or poisoning with Paris green or pyrethrum were used, sometimes successfully, to fight the disease. In many parts of the world, rising standards of living resulted in the elimination of malaria as a collateral benefit of the introduction of window screens and improved sanitation.[14] Today, a variety of interventions are used, and usually many are used simultaneously. These include the use of antimalarial drugs to prevent or treat malaria infections; improvements in public health infrastructure to quickly diagnose, sequester, and treat infected individuals; the distribution of bednets and other methods intended to keep mosquitoes from biting humans; and vector control strategies.[78] These include larvaciding with appropriate insecticides, ecological controls such as draining mosquito breeding grounds or introducing fish to eat larva, and indoor residual spraying (IRS) with insecticides. IRS involves the treatment of all interior walls and ceilings with insecticides, and is particularly effective against mosquitoes, since many species will rest on an indoor wall before or after feeding. DDT is one of 12 insecticides approved by the WHO for IRS, and the contemporary DDT debate revolves around how much of a role the chemical should play in this mix of strategies.

The WHO's anti-malaria campaign of the 1950s and 1960s relied heavily on DDT and initially the results were promising, though short lived. Experts tie the resurgence of malaria to numerous factors, including poor leadership, management, and funding of malaria control programs; poverty; civil unrest; and increased irrigation. The evolution of resistance of the malaria parasite to the drugs traditionally used to treat the disease (e.g. chloroquine) and evolution of resistance of mosquitoes to insecticides have greatly exacerbated the situation.[10][81] Resistance of mosquitoes to DDT was largely fueled by its often unrestricted use in agriculture. This, coupled with the awareness that DDT may be harmful both to humans and the environment led many governments to restrict or curtail the use of DDT in vector control.[16]

Once the mainstay of anti-malaria campaigns, as of 2008 only 12 countries were still using DDT, including India and some southern African states,[78] though the number is expected to rise.[10]

[edit] Overall effectiveness of DDT against malaria

When it was first introduced in World War II, DDT was very effective in reducing malaria morbidity and mortality.[12] The WHO's anti-malaria campaign, which consisted mostly of spraying DDT, was initially very successful as well. For example, in Sri Lanka, the program reduced cases from about 3 million per year before spraying to just 29 in 1964. Thereafter the program was halted to save money, and malaria rebounded to 600,000 cases in 1968 and the first quarter of 1969. The country resumed DDT spraying, but it was largely ineffective because mosquitoes had acquired resistance to the chemical in the interim, presumably because of its continued use in agriculture. The program was forced to switch to malathion, which though more expensive, proved effective.[15]

Today, DDT remains on the WHO's list of insecticides recommended for IRS. Since the appointment of Arata Kochi as head of its anti-malaria division, WHO's policy has shifted from recommending IRS only in areas of seasonal or episodic transmission of malaria, to also advocating it in areas of continuous, intense transmission.[82] The WHO has none-the-less affirmed its commitment to eventually phasing DDT out, aiming "to achieve a 30% cut in the application of DDT world-wide by 2014 and its total phase-out by the early 2020s if not sooner" while simultaneously combating malaria. The WHO plans to implement alternatives to DDT to achieve this goal.[83]

South Africa is one country that continues to use DDT under WHO guidelines. In 1996, the country switched to alternative insecticides and malaria incidence increased dramatically. Returning to DDT and introducing new drugs brought malaria back under control.[84] According to DDT advocate Donald Roberts, malaria cases increased in South America after countries in that continent stopped using DDT. Research data shows a significantly strong negative relationship between DDT residual house sprayings and malaria rates. In a research from 1993 to 1995, Ecuador increased its use of DDT and resulted in a 61% reduction in malaria rates, while each of the other countries that gradually decreased its DDT use had large increase in malaria rates.[28]

[edit] Mosquito resistance to DDT

The evolution of resistance to DDT in mosquitoes has greatly reduced its effectiveness in many parts of the world, and current WHO guidelines require that before the chemical is used in an area, susceptibility of local mosquitoes to DDT must be confirmed.[85] The appearance of DDT-resistance is largely due to its use in agriculture, where it was used in much greater amounts than the relatively small quantities used for disease prevention. According to one study that attempted to quantify the lives saved by banning agricultural uses of DDT and thereby slowing the spread of resistance, "it can be estimated that at current rates each kilo of insecticide added to the environment will generate 105 new cases of malaria."[16]

Resistance was noted early in spray campaigns, with Paul Russell, a former head of the Allied Anti-Malaria campaign, observing in 1956 that eradication programs had to be wary of relying on DDT for too long as "resistance has appeared [after] six or seven years."[14] DDT has lost much of its effectiveness in many parts of the world including Sri Lanka, Pakistan, Turkey and Central America, and it has largely been replaced by organophosphate or carbamate insecticides, e.g. malathion or bendiocarb.[86]

In many parts of India, DDT has largely lost its effectiveness.[87] Agricultural uses were banned in 1989, and its use for anti-malarial purposes has been declining. Its use in urban areas has been halted completely.[88] Nevertheless, DDT is still manufactured and used in the country,[89] and one study had concluded that "DDT is still a viable insecticide in indoor residual spraying owing to its effectivity in well supervised spray operation and high excito-repellency factor."[90]

Studies of malaria-vector mosquitoes in KwaZulu-Natal Province, South Africa found susceptibility to 4% DDT (the WHO susceptibility standard), in 63% of the samples, compared to the average of 86.5% in the same species caught in the open. The authors concluded that "Finding DDT resistance in the vector An. arabiensis, close to the area where we previously reported pyrethroid-resistance in the vector An. funestus Giles, indicates an urgent need to develop a strategy of insecticide resistance management for the malaria control programmes of southern Africa."[91]

It has been argued that DDT can still be effective against resistant mosquitoes,[92] and that the avoidance of DDT-sprayed walls by mosquitoes is an additional benefit of the chemical.[90] For example, a 2007 study reported that DDT-resistant mosquitoes still avoided DDT-treated huts. The researchers argued that DDT was the best pesticide for use in IRS (even though it did not afford the most protection from mosquitoes out of the three test chemicals) because the others pesticides worked primarily by killing or irritating mosquitoes—modes of action the authors presume mosquitoes will develop resistance to.[92] Others have argued that the avoidance of DDT sprayed walls by mosquitoes is detrimental to the actual eradication of the disease.[93] Unlike other insecticides such as pyrethroids, DDT requires a long period of contact before mosquitoes pick up a lethal dose; however its irritant property makes them fly off before this occurs. "For these reasons, when comparisons have been made, better malaria control has generally been achieved with pyrethroids than with DDT."[86] In India, with its outdoor sleeping habits and frequent night duties, "the excito-repellent effect of DDT, often reported useful in other countries, actually promotes outdoor transmission."[94]

[edit] Residents' resistance to use of DDT

For IRS to be effective, at least 80% of homes and barns in an area must be sprayed,[85] and if enough residents refuse spraying, the effectiveness of the whole program can be jeopardized. Many residents resist DDT spraying for various reasons. For instance, the smell lingers, it stains on the walls, and it sometime fails to kill—or even exacerbates problems with—other insect pests.[86][93][95] The use of pyrethroid insecticides (e.g. deltamethrin and lambda-cyhalothrin) can overcome some of these issues, and meets with less resistance than DDT.[86]

[edit] Human exposure associated with DDT spraying

People living in areas where DDT is used for IRS have high levels of the chemical and its breakdown products in their bodies. Compared to contemporaries living in countries where DDT is not used, South Africans living in sprayed homes have levels that are several orders of magnitude greater.[30] Breast milk from regions where DDT is used for malaria control contains enough DDT to greatly exceed the allowable daily intake of breast feeding infants.[96][97][98] These levels have been associated with neurological abnormalities in babies ingesting relatively large quantities of DDT in their milk.[86][96][97]

Most studies of DDT's health effects on human have been conducted in developed countries where DDT is not used and exposure is relatively low. Many experts are therefore concerned about the health consequences of its use in IRS, as this results in very high exposure. They urge that alternatives been used instead.[18][30] Epidemiologist Brenda Eskenazi argues that "We know DDT can save lives by repelling and killing disease-spreading mosquitoes. But evidence suggests that people living in areas where DDT is used are exposed to very high levels of the pesticide. The only published studies on health effects conducted in these populations have shown profound effects on male fertility. Clearly, more research is needed on the health of populations where indoor residual spraying is occurring, but in the meantime, DDT should really be the last resort against malaria rather than the first line of defense."[99]

Illegal diversion of DDT to agriculture is also a concern, as it is almost impossible to prevent, and its subsequent use on crops is totally unregulated. For example, DDT use is wide spread in Indian agriculture,[100] particularly mango production,[101] and is reportedly used by librarians in the country to protect books.[102] Other example include Ethiopia, where DDT intended for malaria control is reportedly being used in coffee production,[103] and Ghana where it is used for fishing."[104] The consequent insecticidal residues in crops at levels unacceptable for the export trade have been an important factor in recent bans of DDT for malaria control in several tropical countries".[86] Adding to this problem is a lack of skilled personnel and supervision.[93]

[edit] Criticism of restrictions on DDT use

Critics claim that restrictions on the use of DDT in vector control have resulted in substantial numbers of unnecessary deaths due to malaria. Estimates for the number of these deaths range from hundreds of thousands, according to Nicholas Kristof,[105] to much higher figures. Robert Gwadz of the National Institutes of Health said in 2007 that "The ban on DDT may have killed 20 million children."[106] These arguments have been called "outrageous" by former WHO scientist Socrates Litsios, and May Berenbaum, an entomologist at the University of Illinois, says that "to blame environmentalists who oppose DDT for more deaths than Hitler is worse than irresponsible."[79] Investigative journalist Adam Sarvana and others characterize this notion as a "myth" promoted principally by Roger Bate of the pro-DDT advocacy group Africa Fighting Malaria (AFM) in service of his anti-regulatory, free market ideology.[107][108]

Criticisms of a "ban" on DDT often specifically reference the 1972 US ban (with the erroneous implication that this constituted a worldwide ban and prohibited use of DDT in vector control). Reference is often made to Rachel Carson's Silent Spring even though she never pushed for a ban on DDT. John Quiggin and Tim Lambert have written that "the most striking feature of the claim against Carson is the ease with which it can be refuted."[109] Carson actually devoted a page of her book to considering the relationship between DDT and malaria, warning of the evolution of DDT resistance in mosquitoes and concluding:

It is more sensible in some cases to take a small amount of damage in preference to having none for a time but paying for it in the long run by losing the very means of fighting [is the advice given in Holland by Dr Briejer in his capacity as director of the Plant Protection Service]. Practical advice should be "Spray as little as you possibly can" rather than "Spray to the limit of your capacity."

According to Amir Attaran and Roger Bate, many environmental groups fought against the public health exception of DDT in the 2001 Stockholm Convention, over the objections of third world governments and many malaria researchers. Attaran strongly objected to an outright ban, writing, "Environmentalists in rich, developed countries gain nothing from DDT, and thus small risks felt at home loom larger than health benefits for the poor tropics. More than 200 environmental groups, including Greenpeace, Physicians for Social Responsibility and the World Wildlife Fund, actively condemn DDT..."[110]

It has also been argued that donor governments and agencies have refused to fund DDT spraying, or made aid contingent upon not using DDT. According a report in the British Medical Journal, use of DDT in Mozambique "was stopped several decades ago, because 80% of the country's health budget came from donor funds, and donors refused to allow the use of DDT."[111] Roger Bate asserts that "many countries have been coming under pressure from international health and environment agencies to give up DDT or face losing aid grants: Belize and Bolivia are on record admitting they gave in to pressure on this issue from [USAID]."[112]

The United States Agency for International Development (USAID) has been the focus of much criticism. While the agency is currently funding the use of DDT in some African countries,[113] in the past it has not. When John Stossel accused USAID of not funding DDT because it wasn't "politically correct," Anne Peterson, the agency's assistant administrator for global health, replied that "I believe that the strategies we are using are as effective as spraying with DDT ... So, politically correct or not, I am very confident that what we are doing is the right strategy."[114] USAID's Kent R. Hill states that the agency has been misrepresented: "USAID strongly supports spraying as a preventative measure for malaria and will support the use of DDT when it is scientifically sound and warranted."[115] With regard to decision to start funding the use of the chemical, the Agency's website states that "USAID has never had a 'policy' as such either 'for' or 'against' DDT for IRS. The real change in the past two years [2006/07] has been a new interest and emphasis on the use of IRS in general—with DDT or any other insecticide—as an effective malaria prevention strategy in tropical Africa."[113] The website further explains that in many cases alternative malaria control measures were judged to be more cost-effective that DDT spraying, and so were funded instead.[116]

[edit] Alternatives to DDT

[edit] DDT versus other insecticides

Advocates of increased use of DDT in IRS claim that alternative insecticides are more expensive, more toxic, or not as effective. As discussed above, susceptibility of mosquitoes to DDT varies geographically and the same is true for alternative insecticides, so its effectiveness vis-a-vis other chemicals varies. With regard to toxicity and cost-effectiveness versus other insecticides, actual data is lacking. The relative costs of employing various insecticides vary by location and ease of access, the habits of the particular mosquitoes prevalent in each area, the degrees of resistance to various pesticides exhibited by the mosquitoes, and the habits and compliance of the population, among other factors. Furthermore, the choice of insecticide has little impact on the overall cost of a round of spraying, since insecticide costs are only a fraction total budget for an IRS campaign. However, to be effective, IRS needs to be maintained throughout the malaria season, and DDT lasts longer than alternative insecticides, so needs to be applied less frequently.

Organophosphate and carbamate insecticides, e.g. malathion and bendiocarb, respectively, are more expensive than DDT per kilogram and are applied at roughly the same dosage. Pyrethroids such as deltamethrin are also more expensive than DDT, but are applied more sparingly (0.02-0.3 g/m2 vs 1-2 g/m2), so the net cost per house is about the same per 6 months.[17]

[edit] DDT versus non-chemical vector control

Before DDT, malaria was successfully eradicated or curtailed in several tropical areas by removing or poisoning the breeding grounds of the mosquitoes or the aquatic habitats of the larva stages, for example by filling or applying oil to places with standing water. These methods have seen little application in Africa for more than half a century.[117]

The relative effectiveness of IRS (with DDT or alternative insecticides) versus other malaria control techniques (e.g. bednets or prompt access to anti-malarial drugs) varies greatly and is highly dependent on local conditions.[17]

A study by the World Health Organization released in January 2008 found that mass distribution of insecticide-treated mosquito nets and artemisinin based drugs cut malaria deaths in half in Rwanda and Ethiopia, countries with very high malaria burdens. IRS with DDT was determined to not have played an important role in the reduction of mortality.[118]

Vietnam is an example of a country that has seen a continued decline in malaria cases after switching in 1991 from a poorly funded DDT-based campaign to a program based on prompt treatment, bednets, and the use of pyrethroid group insecticides. Deaths from malaria dropped by 97%.[119]

In Mexico, the use of a range of effective and affordable chemical and non-chemical strategies against malaria has been so successful that the Mexican DDT manufacturing plant ceased production voluntarily, due to lack of demand.[120] Furthermore, while the increased numbers of malaria victims since DDT usage fell out of favor would, at first glance, suggest a 1:1 correlation, many other factors are known to have contributed to the rise in cases.

A review of fourteen studies on the subject in sub-Saharan Africa, covering insecticide-treated nets, residual spraying, chemoprophylaxis for children, chemoprophylaxis or intermittent treatment for pregnant women, a hypothetical vaccine, and changing the first line drug for treatment, found decision making limited by the gross lack of information on the costs and effects of many interventions, the very small number of cost-effectiveness analyses available, the lack of evidence on the costs and effects of packages of measures, and the problems in generalizing or comparing studies that relate to specific settings and use different methodologies and outcome measures. The two cost-effectiveness estimates of DDT residual spraying examined were not found to provide an accurate estimate of the cost-effectiveness of DDT spraying; furthermore, the resulting estimates may not be good predictors of cost-effectiveness in current programs.[121]

However, a study in Thailand found the cost per malaria case prevented of DDT spraying ($1.87 US) to be 21% greater than the cost per case prevented of lambda-cyhalothrin-treated nets ($1.54 US),[122] at very least casting some doubt on the unexamined assumption that DDT was the most cost-effective measure to use in all cases. The director of Mexico's malaria control program finds similar results, declaring that it is 25% cheaper for Mexico to spray a house with synthetic pyrethroids than with DDT.[120] However, another study in South Africa found generally lower costs for DDT spraying than for impregnated nets.[123]

A more comprehensive approach to measuring cost-effectiveness or efficacy of malarial control would not only measure the cost in dollars of the project, as well as the number of people saved, but would also take into account the negative aspects of insecticide use on human health and ecological damage. One preliminary study regarding the effect of DDT found that it is likely the detriment to human health approaches or exceeds the beneficial reductions in malarial cases, except perhaps in malarial epidemic situations. It is similar to the earlier mentioned study regarding estimated theoretical infant mortality caused by DDT and subject to the criticism also mentioned earlier.[124]

A study in the Solomon Islands found that "although impregnated bed nets cannot entirely replace DDT spraying without substantial increase in incidence, their use permits reduced DDT spraying."[125]

A comparison of four successful programs against malaria in Brazil, India, Eritrea, and Vietnam does not endorse any single strategy but instead states "Common success factors included conducive country conditions, a targeted technical approach using a package of effective tools, data-driven decision-making, active leadership at all levels of government, involvement of communities, decentralized implementation and control of finances, skilled technical and managerial capacity at national and sub-national levels, hands-on technical and programmatic support from partner agencies, and sufficient and flexible financing."[126]

DDT resistant mosquitoes have generally proved susceptible to pyrethroids. Thus far, pyrethroid resistance in Anopheles has not been a major problem.[86]

[edit] See also

[edit] References

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