To the Editor: The article by Roberts et al. regarding DDT use and malaria in South America (1) correctly observes that health policy makers have shifted the emphasis of malaria control programs from vector control to case detection and treatment and that malaria control has been woefully underfunded in recent years. However, their conclusions that increased malaria is due to decreased spraying of homes with DDT and that DDT is still needed for malaria control do not withstand close scrutiny.

The authors did not mention several factors influencing malaria increase in recent decades, including growing antimalarial-drug resistance, the deterioration of public health systems responsible for malaria control, and large-scale migration to areas at high risk for malaria (e.g., almost all Brazilian malaria cases occur in the Amazon region) (2,3). Extradomiciliary malaria transmission, poor housing conditions, and human behavior in frontier areas such as the Amazon region limit the usefulness of insecticides. Thus, the deduction of causality between less house spraying with DDT and increased malaria incidence under those circumstances is questionable.

Roberts et al. have not actually linked increased malaria with eliminating DDT use but rather with eliminating house spraying altogether, without implementing effective alternatives. Malaria's recent decline in Brazil is due to a strategy that combines health education, aggressive case detection and treatment, and environmental management to eliminate Anopheles breeding sites (C. Catão Prates, unpub. data). A similar strategy has sharply reduced malaria incidence and deaths in Colombia (W. Rojas, unpub. data). In Mexico, use of two synthetic pyrethroid insecticides (deltamethrin and lambda cyhalothrin) for bed-net treatment and house spraying is controlling malaria at a much lower cost than the use of the alternative insecticides tried earlier and mentioned by Roberts et al. (4). Far from being pursued "without meaningful debate," the reduction and phaseout of DDT and other persistent organic pollutants is the subject of a 3-year United Nations–facilitated global negotiation process begun in June 1998.

Roberts et al. assert that DDT applied indoors does not move easily from the application site; however, a mass balance model indicates that 60% to 80% of the DDT ends up outdoors within 6 months (K. Feltmate, A model and assessment of the fate and exposure of DDT following indoor application [bachelor's thesis]. Ontario: Trent University; 1998). From there, DDT can be transported long distances in air, waterborne sediments, and biota, accumulating in humans and other nontarget species (5). Meanwhile, residents of sprayed houses accumulate high, persistent body levels of DDT through skin contact and food contaminated with DDT from air and dust (6).

Long considered a probable human carcinogen, DDT also is associated with reduced lactation, premature births, absorbed fetuses, and lower birth weights (7-9). In addition, recent animal research has raised the possibility that exposure of human fetuses or infants to DDT may cause permanent behavioral changes and impairment of body systems (10-12).

Synthetic pyrethroid insecticides used on bed nets or for house spraying against malaria-infected mosquitoes seem safer for human health than DDT because humans and other mammals possess the ability to hydrolyze the pyrethroids rapidly and excrete them from the body (13-14). Nevertheless, DDT and pyrethroids share known health risks, notably endocrine disruption, and the possible transgenerational consequences of chronic human exposure to pyrethroids have not yet been studied (10,15-16). Optimal protection of human health requires the development of integrated malaria control strategies that eliminate or reduce routine insecticide use by taking maximum advantage of environmental management, biological controls, and other nonchemical vector control measures (17).

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