Remarks The conditionality of the recommendation to deploy pyrethroid-chlorfenapyr ITNs instead of pyrethroid-PBO ITNs is based on the GDG’s judgement that the balance of desirable and undesirable effects probably favours pyrethroid-chlorfenapyr ITNs over pyrethroid-PBO ITNs. However, the evidence for this recommendation is from only one trial in Africa. In deciding whether to deploy pyrethroid-chlorfenapyr ITNs instead of pyrethroid-only LLINs or pyrethroid-PBO ITNs, malaria programmes should:

• determine whether resources are adequate to cover the extra costs compared to pyrethroid-only LLINs or pyrethroid-PBO ITNs, 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). ITNs for prevention of malaria in adults and children in areas with pyrethroid resistance; and
• note that WHO recommends that ITNs prequalified by WHO be selected for deployment

Practical info Given that pyrethroid‐chlorfenapyr ITNs are designed to provide improved impact against insecticide-resistant mosquitoes, pyrethroid resistance in potential target areas should be confirmed using standard procedures [22], as should the susceptibility of local vectors to chlorfenapyr. In any case, pyrethroid‐chlorfenapyr 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, which includes assessments of ITN integrity, each time a campaign uses a new product such as pyrethroid‐chlorfenapyr ITNs. Such studies will provide information on the product’s life span 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, 34% of pyrethroid‐chlorfenapyr ITNs were torn (defined as hole area ≥ 790 cm²) and therefore not fit for use, compared to 28% of pyrethroid-only LLINs and 43% of pyrethroid-PBO ITNs.