Real-World Costs and Cost-Effectiveness of Next-Generation Insecticide Treated Bednets: controlled interrupted time-series based economic evaluations of dual–active ingredient (AI) or piperonyl butoxide (PBO) insecticide-treated bed nets (ITNs) versus pyrethroid-only ITNs for malaria prevention

Growing insecticide resistance and other causes of residual transmission of malaria parasites have led to a global stagnation in progress in malaria control, despite widespread deployment of insecticide-treated bed nets (ITNs). New bed net technologies including dual active ingredient (AI) and piperonyl butoxide plus pyrethroid (PBO + P) nets have been developed to address these problems and be more effective malaria prevention tools. Two types of dual-AI ITNs and PBO + P ITNs were evaluated across five countries in pilot studies coupled with economic evaluations. Chlorfenapyr + pyrethroid (C + P) ITNs showed the best overall performance in terms of incidence rate reduction (Incidence rate ratio 0.62 vs. standard ITN) and generally in terms of incremental cost-effectiveness ratio, but using any dual-AI or PBO + P ITN was favored over standard pyrethroid-only ITNs alone. There was significant overlap between the recommended strategy in any given study location due to high uncertainty in cases averted and relatively similar product costs. While the addition of indoor residual spraying (IRS) to standard ITNs was a more effective strategy than dual-AI or PBO + P ITNs, this evidence was based on only one study site and the incremental cost for the addition of IRS was substantially greater than the incremental cost of dual-AI or PBO ITNs compared to standard ITNs (ICER 18.59 USD per case averted vs. 1.51 USD per case averted for C + P ITN in this settings). The switch from standard ITNs to dual-AI or PBO ITNs is recommended in most African settings, with the chlorfenapyr + pyrethroid (C + P) nets being the broadly favored choice. Ultimately programs will need to incorporate local information on the malaria burden and up to date product price information to determine the most efficient malaria prevention strategy in the settings in which they serve.