Remarks The conditionality of the recommendation to deploy pyrethroid-pyriproxyfen ITNs instead of pyrethroid-only LLINs is based on the GDG’s concerns that the available evidence indicates poor cost-effectiveness of pyrethroid-pyriproxyfen ITNs compared to pyrethroid-only LLINs. Poor cost-effectiveness is a result of both the higher cost compared to a pyrethroid-only net, which would require extra resources to maintain the same coverage, and the relatively short-lived (12 months) additional impact obtained by deploying pyrethroid-pyriproxyfen nets over pyrethroid-only nets. In deciding whether pyrethroid-pyriproxyfen ITNs should be deployed instead of pyrethroid-only LLINs, malaria programmes should:

• determine whether resources are adequate to cover the extra cost compared to pyrethroid-only LLINs, while ensuring optimal coverage of populations at risk of malaria;
• generate additional information or conduct analyses with the aim of maximizing impact through targeted deployment (e.g. stratification of malaria risk, assessment of the characteristics of local vectors, such as pyrethroid resistance mechanisms); and
• note that WHO recommends that ITNs prequalified by WHO be selected for deployment. Note: Recommendations on deployment of pyrethroid-pyriproxyfen nets were separated into two distinct recommendations for better clarity, but share the same evidence to decision, justification, practical info and research needs. Please refer to the following section.

Practical info Given that pyrethroid‐pyriproxyfen ITNs are designed to provide improved impact against resistant mosquitoes, pyrethroid resistance in potential target areas should be confirmed using standard procedures [22], as should susceptibility of the local vectors to pyriproxyfen. In any case, pyrethroid‐pyriproxyfen ITNs should not be considered a tool that alone can effectively manage insecticide resistance in malaria vectors. As with all malaria interventions, post-distribution monitoring of ITNs to estimate coverage in terms of access to and use of ITNs is recommended. WHO also recommends that programmes conduct studies of ITN survival each time a campaign uses a new product such as pyrethroid‐pyriproxyfen ITNs, including assessment of ITN integrity. Such studies will provide information on the life span of the product under field conditions and thus enable estimation of the period over which the additional impact against malaria may be maintained. The systematic review reported that, two years after deployment, 39% of pyrethroid‐pyriproxyfen ITNs were torn (defined as having a total hole area ≥ 790 cm² and therefore assumed to be not fit for use), compared to 28% of pyrethroid-only LLINs and 43% of pyrethroid-PBO ITNs.