Remark: The conditionality of the recommendation against the deployment of pyrethroid-pyriproxyfen ITNs instead of pyrethroidPBO ITNs is based on the GDG’s judgement that the balance of effects favours pyrethroid-PBO ITNs over pyrethroidpyriproxyfen ITNs and that, based on current cost and efficacy data, pyrethroid-PBO ITNs are more cost-effective. The GDG acknowledged that evidence to support this recommendation is derived from only a single trial in Africa. 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 [21], 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.