These results show the global situation on the management of pesticides in the practice of vector control, serving as baseline for future initiatives to strengthen the management of vector control pesticides. The survey is exceptional in its high coverage of populations at risk of malaria and other major vector-borne diseases.
The study had several limitations. It was assumed that respondents represented institutional memory, but their actual period in office could have limited the accuracy of their responses. The questionnaire did not allow for qualified statements and in-depth interpretation of results. Moreover, the choice to count all countries as equal, rather than weighting country responses according to population size or disease burden, may have introduced a bias; e.g. if large countries have better developed pesticide management systems than small countries. This problem was partly circumvented by examining the country responses per Region; e.g. with the South-East Asian Region consisting of few but large countries, or with the African Region consisting mostly of highly endemic countries.
It is encouraging to observe that several basic conditions of policy and coordination for pesticide management have been established in many countries, which are: the use of the Code of Conduct, a national IVM policy, a national vector control unit, and statistics on pesticide usage. These conditions are indicative of a country's strategy or prospect for improving pesticide management in the practice of vector control.
Nevertheless, the results have exposed some major gaps in pesticide management globally, in particular in the areas of procurement, training, pesticide application, safety and disposal. Also, the authors have noticed that there are different perceptions of the IVM concept in the Regions.
Regarding pesticide procurement for vector control programmes, national guidelines are absent in half of the countries, after-sales stewardship commitment of the manufacturer not required in almost half of the countries, and quality control not required by some countries. Positive aspects are that procurement is mostly through the ministry of health and is often conducted through public tenders. These are conditions through which procurement procedures could potentially be improved, for example by incorporating stewardship commitments on training of applicators on low-risk and appropriate use and safe disposal of waste.
Training on decision making and implementation of vector control is another area of concern, which will be most acute in situations where decision making has been decentralized to the district level. In some countries, none of those responsible had received any training on vector control or public health pesticide management. In its handbook on IVM, the WHO proposes ways to improve the efficacy, cost-effectiveness, ecological soundness and sustainability of vector control . Means to achieve this are an increasing emphasis on local evidence, adoption of a multi-disease approach, and combining vector control interventions wherever appropriate. Processes through which this could be achieved are the integration within the health sector, collaboration between sectors and participation of communities. Clearly, training investment is required, including on pesticide management, to generate skills of analysis, decision making and facilitation at the national, district and village level.
All chemical pesticides are inherently toxic to humans, and precaution is required to minimize exposure and adverse health effects. Applicators and handlers of pesticides may have a particularly high exposure risk if not protected, especially in tropical climates where use of protective equipment is often lacking owing to personal inconvenience. Further study is needed to determine the coverage, quality, use and maintenance of personal protective equipment in relation to the degree of hazard of pesticides used.
Health monitoring of vector control pesticide applicators is not being given due attention in most countries, highlighting another gap. Under the Code of Conduct, governments are obliged to carry out health surveillance programmes of occupationally exposed workers, and to investigate and document poisoning cases. Furthermore, certification schemes for pesticide applicators and national scheme for quality control of equipment for vector control pesticide application were missing in the majority of countries.
Public awareness programmes, lacking in the majority of countries, are needed wherever pesticides are applied in or around houses to promote people's compliance with the interventions. Furthermore, safe disposal of pesticide-related waste was inadequately addressed in the majority of countries; while governments and industry are obliged under the Code of Conduct to cooperate on this topic with the industry to provide stewardship support.
Since 2002, the WHO, through its Pesticide Evaluation Scheme, has expanded its support to member states in the low-risk and judicious use of public health pesticides and their sound management. The survey results show that WHO's recommendations and standards were adopted by most countries, indicating an important advisory and technical support role of the Organization in the management of vector control pesticides globally .
The gaps identified in this study highlight the need for further action. Foremost, awareness-raising is needed for policy makers and programme managers about the urgency of good pesticide management and evidence-based decision making within malaria vector control programmes. The WHO has begun to assist a number of countries in conducting an analysis on the national situation on public health pesticide management, and in preparing national action plans to address shortcomings [19, 20]. Nevertheless, countries need to mobilize resources and build capacity to implement those plans. International agencies should assist countries in developing policies and adopting international guidelines, facilitate regional collaboration (e.g. on insecticide resistance monitoring) and offer support for capacity building on pesticide management as component of IVM.