The non-inferiority efficacy of Piperonyl-butoxide Yorkool® G3 Insecticide treated nets in the experimental huts in Tanzania

The non-inferiority efficacy of Piperonyl-butoxide Yorkool® G3 Insecticide treated nets in the experimental huts in Tanzania | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The non-inferiority efficacy of Piperonyl-butoxide Yorkool® G3 Insecticide treated nets in the experimental huts in Tanzania Olukayode G. Odufuwa, Masudi Suleiman Maasayi, Emmanuel Mbuba, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4510891/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Oct, 2024 Read the published version in Malaria Journal → Version 1 posted 13 You are reading this latest preprint version Abstract Background Non-inferiority trials are recommended by the World Health Organization (WHO) to demonstrate that health products show comparable efficacy. As part of the WHO Global Malaria Programme (GMP) process of assessment of malaria vector control products, a second-in-class insecticide treated net (ITN) must be shown to be non-inferior to a first-in-class product based on mosquito mortality. The public health impact of the first-in-class pyrethroid-piperonyl butoxide (PBO) ITN, Olyset® Plus, has been demonstrated in epidemiological trials in areas with insecticide-resistant mosquitoes, but there is need to determine the efficacy of other pyrethroid-PBO nets to ensure timely market availability of nets and so to increase access to ITNs. The non-inferiority of a deltamethrin-PBO ITN Yorkool® G3 was evaluated entomologically against Olyset® Plus in experimental huts in Tanzania, following WHO guidelines for non-inferiority trials. Method The trial of the two pyrethroid-PBO ITNs was conducted in experimental huts in Lupiro, Tanzania, using a randomised double-blind 7 x 7 Latin Square block design. The study ran for 49 nights in 14 huts assessing the mosquito mortality and blood feeding of wild free-flying resistant Anopheles arabiensis . Using the non-inferiority approach, the efficacy (mosquito mortality at 24 hours and blood feeding) of unwashed and 20 times field-washed pyrethroid-PBO Yorkool® G3 ITNs, were compared with the first-in-class product Olyset® Plus and against a pyrethroid-only ITN, PermaNet® 2.0 ITNs, as a standard comparator. Results The experimental hut trial demonstrated the non-inferiority of Yorkool® G3 to Olyset® Plus based on mortality [51% vs 39%, respectively, OR 1.68 (95% CI: 1.50–1 .88)], given that lower 95% CI exceeded 0.74 (delta of 39%). Blood feeding inhibition was high for all treated ITNs (> 90%). The pyrethroid-PBO ITNs were superior to the pyrethroid-only net, PermaNet® 2.0, as determined by both the proportion of mortality and blood feeding of mosquitoes (p-value < 0.05). Conclusion Yorkool® G3 ITNs demonstrated non-inferiority to the first-in-class Olyset Plus and superiority over the standard pyrethroid-only ITN, PermaNet® 2.0 as measured by mortality and blood feeding inhibition of wild insecticide resistant An. arabiensis mosquitoes. Yorkool® G3 ITNs are therefore potential tools for the control of metabolic insecticide resistant malaria vectors. ITN non-inferiority insecticide resistance pyrethroid PBO Yorkool® G3 mosquito malaria experimental hut Tanzania Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Background Vector control, primarily through the use of insecticide treated nets (ITNs) are the cornerstone in the fight against malaria transmission [ 1 ], due to its primary ability for killing mosquitoes and reducing blood feeding success of mosquitoes that come into contact with the insecticide-treated surface. However, due to the extensive use of the same insecticides for mosquito control and agricultural practices [ 2 , 3 ], mosquitoes have developed resistance to the pyrethroid used on ITNs [ 4 , 5 ]. Nets treated with both pyrethroid and the synergist - piperonyl butoxide (PBO) have been developed to counteract metabolic resistant in mosquitoes [ 6 ]. The PBO inhibits the action of the metabolic enzymes that the mosquitoes use to detoxify pyrethroids [ 7 ]. Epidemiological data from a cluster-randomised trial conducted on the pyrethroid-PBO net Olyset® Plus in Tanzania demonstrated a 33% reduction in malaria prevalence over 21 months relative to a standard pyrethroid only net - Olyset® (permethrin incorporated net manufactured by A to Z textiles, Tanzania), in an area of insecticide resistance in mosquitoes [ 8 ]. Therefore, in 2017 the World Health Organization (WHO) identified PBO-incorporated nets as a new class of ITNs [ 9 ], with Olyset® Plus (the first pyrethroid-PBO incorporated net manufactured by Sumitomo, Japan) being the first-in-class (FIC) product prequalified by WHO [ 9 ]. WHO recommends that for new pyrethroid-PBO ITNs to be classified as efficacious second-in-class (SIC) products, non-inferiority trials using experimental huts may be used as a means of evaluation [ 10 ]. Mathematical modelling of entomological data from experimental hut trials has demonstrated that such studies can be used to predict the epidemiological effect of ITNs, thus supporting non-inferiority trials for the evaluation of novel ITNs [ 11 ]. Given that the FIC pyrethroid-PBO ITN (positive control) has been demonstrated to have an impact on malaria prevalence [ 12 , 13 ], non-inferiority entomological trials which follow established guidelines and procedures [ 14 , 15 ], can be used as a proxy to determine whether a new product would produce similar epidemiological results. Such entomological trials can be conducted in a shorter timeframe to epidemiological trials, thereby bringing new products to market sooner and so increasing access to ITNs. In a WHO-approved experimental hut non-inferiority trial, new vector control products should demonstrate a comparable entomological performance to the WHO prequalified FIC or SIC product with the same entomological mode of action as that of the product that is under investigation [ 14 , 15 ]. Performance is primarily assessed by mortality of malaria vectors with blood feeding as an additional endpoint [ 14 ]. For a new product to be deemed non-inferior to the FIC comparator, the difference in mosquito mortality must not be less than 7% [ 14 ]. This threshold is called the non-inferiority margin (NI). To be able to determine this statistically, this margin is translated into an odds ratio (OR) called the ‘delta’, and for a product to be deemed non-inferior, the lower limit of the 95% confidence interval (CI) of the OR of the candidate should be equal or above the estimated delta from the proportion derived for the FIC comparator [ 14 ]. In the assessment, it is also necessary to determine the susceptibility of the wild test mosquitoes to this class of insecticides through the exposure of mosquitoes to a ‘standard comparator’. For the assessment of pyrethroid-PBO products, a WHO prequalified pyrethroid only ITN known to be efficacious against susceptible malaria vectors (e.g. PermaNet® 2.0 treated with deltamethrin only) [ 16 ] is often used. In addition, an untreated net (negative control) should be included in the study to assess the quality of the experiment. The candidate product should ideally demonstrate superior efficacy over the standard comparator and untreated net using a significance level (P-value < 0.05) [ 15 ]. It is recommended that a robust power calculation be performed to estimate the adequate number of experimental nights required to determine non-inferiority of the candidate product, using estimates from a previous study conducted in the location of the experimental huts. The required sample size to determine with adequate power that a product falls within the NI margin compared to the FIC product, is calculated statistically using appropriate statistical or modelling tools, based on the expected mortality difference, mosquito density, mosquito distribution and overall study variation from a previous study [ 14 , 15 , 17 ]. A new ITN incorporated with pyrethroid insecticide (deltamethrin) and the synergist PBO named Yorkool® G3, has been developed by Yorkool International Trading Co., Ltd in China, as additional product in the pyrethroid-PBO ITN class. As a potential new product in this class, its non-inferiority to the FIC product, Olyset® Plus, or another prequalified product in this class, is necessary for it to be prequalified by WHO [ 15 ]. Robust experimental hut trials of its entomological efficacy are therefore needed, as products differ in terms of manufacturing technique and dosage. This paper presents experimental hut entomological studies to assess non-inferiority of Yorkool® G3 pyrethroid-PBO nets to the FIC product, Olyset® Plus, and superiority compared to a standard pyrethroid-only net, PermaNet® 2.0 following WHO procedures [ 14 , 15 , 17 ]. Methods Study area The experimental hut trial of Yorkool® G3 nets was carried out in Lupiro village (8.385°S and 36.670°E), which is located in Ulanga district, Morogoro region in the south-eastern part of Tanzania (Fig. 1 in grey). The yearly rainfall in the Morogoro region range from 1200 to 1800mm, with temperatures varying between 20°C and 34°C. The most abundant malaria vector in the area is Anopheles arabiensis which is resistant to pyrethroids and carbamates, and accounts for over 99.9% of the Anopheles gambiae complex species [ 18 ]. Pre-exposure to PBO resulted in lower knockdown rates and higher mortalities against pyrethroids and bendiocarb, compared to tests without the synergists [ 19 ]. The main malaria control intervention in the area is the use of ITNs [ 20 ]. Quality assessment of Yorkool® G3 nets were performed at the Vector Control Product Testing Unit (VCPTU) facility that is accredited (SANAS GLP0003) for Good Laboratory Practice, and situated at the Bagamoyo branch of Ifakara Health Institute (IHI) in Tanzania (Fig. 1, in green). Figure 1: Geographical location of study area Study design The experimental hut trial was executed between September and October 2020. The trial used a partially-randomised double-blinded approach; both nets and volunteers were randomly assigned to huts on the first day, with a sequential rotation strategy employed thereafter, with daily rotation of volunteers and rotation of nets at the end of each round (7 nights). The trial implemented two contiguous 7×7 Latin Squares design in fourteen huts, commonly referred to as the "Williams Design" [ 21 ]. Each treatment condition was tested 98 times over the course of 49 nights, following WHO guidelines [ 14 , 15 ], as depicted in Fig. 2. Figure 2: Experimental hut study design Description of test items Yorkool® G3 ITNs are made of 130 denier yarn, polyethylene fibres coated with 120 mg/m 2 deltamethrin and 440 mg/m 2 piperonyl butoxide (PBO). It is manufactured by Yorkool International Trading Co., Ltd, China. Olyset® Plus is a knitted monofilament polyethylene net of 150 denier yarn, treated with 20 g AI/kg (800 mg AI/m 2 ) permethrin and PBO contents of 10 g PBO/kg (400 mg PBO/m 2 ). The net is manufactured by Sumitomo Chemical Co., Ltd, Japan [ 23 ]. The standard comparator ITN used was PermaNet® 2.0, a 55 mg/m 2 deltamethrin-coated ITN manufactured by Vestergaard Frandsen SA [ 24 ]. To assess the quality of the experiment, Safi Net was used as a negative control, an untreated polyester net manufactured by A to Z Textiles Mills Limited, Tanzania. Mosquitoes The experimental hut trial used free-flying wild insecticide-resistant An. arabiensis (Lupiro strain) mosquitoes. The resistance of these mosquitoes is attributed to the overexpression of CYP450 enzymes [ 25 ]. Sugar-fed 2–5 day old, insecticide-susceptible An. gambiae sensu stricto (s.s) (Ifakara strain) and pyrethroid-resistant An. arabiensis (Kingani strain) mosquitoes were used for quality of nets’ bioefficacy before and after the experimental hut trial (supplementary material table 1 and 2 for insecticide susceptibility tests conducted at the time of the study). All mosquito colonies are maintained in insectaries at the VCPTU, Bagamoyo, following standard operating procedures (SOPs) adapted from the MR4 guidelines [ 26 ]. Net preparation Nineteen Yorkool® G3 ITNs from three production batches were prepared for the experimental hut trial (Fig. 2) as follows: Three nets (one per production batch), samples were removed when nets were unwashed and after 20x-washed for baseline quality checks of bioefficacy. Sixteen nets (from across the three production batches), eight of which remained unwashed and eight were washed 20 times. Per wash status, seven nets were used each for the experimental hut trials with a spare in case of need of replacement. For the pyrethroid-PBO positive control net and the standard positive control pyrethroid only net, an equivalent number of nets from one production batch was used, and all nets were the same colour for blinding of study technicians and investigators. Nets selected for washing, including those selected for quality checks, were field-washed at their appropriate wash interval day (one day for Yorkool® G3 and PermaNet® 2.0 and two days for Olyset® Plus [ 23 ]) in the facilities in Bagamoyo. Nets were washed in aluminium bowls containing 10 litres of filtered well water with a maximum hardness of 5dH and containing 2g/litre of soap ("Jamaa palm oil" soap flakes), using manual agitation of 20 rotations per minute for 10 minutes. Rinsing was done twice using filtered clean well water. Nets were dried horizontally in the shade then wrapped in foil and stored in labelled plastic bags at 21.4–30.9°C in the IHI store between washes. The procedure was repeated twenty times for all ITNs. Each net was assigned a unique four-digit code generated by personnel not involved in the study, ensuring that investigators, technicians and participants were blinded to the type of ITN. Before testing in the huts, all nets (unwashed and 20x washed) were deliberately holed. Holes each measuring 4 cm × 4 cm were made on each of four sides of the net: two holes at the centre in each of the long side panels, and one hole at the centre of the short panels. Seven nets per arm, plus a spare, were transferred to the net storage facilities in Lupiro where the experimental hut trial was conducted. For chemical analysis, five pieces of netting measuring 25 cm x 25 cm were cut from the three unwashed and washed nets used for bioefficacy, to give 15 netting pieces for each wash status to be studied before the experimental hut trial began. On completion of the hut trial, five pieces cut from two unwashed and two washed nets were used. Net pieces for chemical analyses and for bioassays were cut adjacent to one another [ 27 ]. All net pieces intended for chemical testing were promptly wrapped in aluminium foil after cutting and stored in a refrigerator at 4 ± 2°C for two weeks before they were shipped to the International Institute of Biotechnology and Toxicology (IIBAT) in India for analysis. Procedures for experimental hut trial Before the experimental hut trial, power of the study was estimated using estimates from an earlier trial conducted in the same site following the previous WHO non-inferiority guidelines [ 28 ]. A generalised linear mixed model (GLM) simulated 1000 times was used to determine the study power for a 7 x 7 arm trial in fourteen huts for 49 nights, using an estimated median number of 28 mosquitoes per night per hut, 22% mortality for the unwashed pyrethroid-PBO products and 14% mortality for the washed pyrethroid-PBO products, overall study variation of log of 1.034 and non-inferiority margin of 0.7 OR with treatment, volunteer, and hut adjusted for fixed effects, using R software [ 29 ]. The experiments were carried out in fourteen Ifakara experimental huts as detailed in a previous study [ 30 ]. The trial enrolled fourteen consenting adult male volunteers to occupy the huts at night. The trial had seven arms: (i) Yorkool® G3, unwashed, (ii) Yorkool® G3, washed 20× at a 1-day wash interval, (iii) Olyset® Plus, unwashed, (iv) Olyset® Plus, washed 20× at a 2 days wash interval, (v) PermaNet® 2.0, unwashed, (vi) PermaNet® 2.0, washed 20× at a 1-day wash interval, and (vii) untreated Safi Net as negative control. The primary outcome was proportion of 24-hr mortality of mosquitoes and the secondary outcome was proportion of mosquito blood feeding. Data were collected for seven nights, with a one-night airing period between rounds to reduce any chance of any residual effects before introducing the next treatment. During the study, the volunteers adhered to a predetermined roster as they sequentially rotated among the huts. They entered their assigned huts at 19:00 hours (hrs) and slept under the nets until 06:00 hrs the following morning. At 06:00 hrs, mosquitoes were collected from 1) inside the nets, 2) the floor, walls, ceiling, and 3) exit traps using aspirators. Subsequently, the collected mosquitoes were sorted and categorised based on their location, and status (dead and fed, dead and unfed, alive and fed, and alive and unfed). These mosquitoes were then held in a temperature-controlled room for 24-hr with access to a 10% sugar solution at 21.5–33.5°C temperature and 32.5–82.7% relative humidity, to assess mortality at 24 hr after capturing. Procedures for experimental hut trial quality checks: bioefficacy and chemical analysis Prior to the experimental hut trial, pre-test quality checks were conducted to assess the bioefficacy (≥ 95% KD60 / ≥ 80% M24) using cone bioassay and nets were stored for chemical analysis of the insecticide on the net at time 0, the day before the first wash. Bioefficacy and storage of samples for chemical analysis tests were again carried out after completing the necessary 20 field washes. Post-experimental checks were conducted at the end of the hut trial using the nets evaluated in the huts (both unwashed and 20x washed) against susceptible An. gambiae sensu stricto (s.s) (Ifakara strain), and strongly pyrethroid-resistant An. arabiensis (Kingani strain) exposed to nets using cone bioassay according to the WHO procedures [ 15 ], while samples for chemical content were shipped to IIBAT for insecticide chemical analysis. Data analysis Statistical analysis was conducted using STATA 16 software [ 31 ]. Descriptive analysis was conducted for cone bioassays for the primary outcomes, knockdown at 60 minutes (KD60) and 24-hr mortality for quality checks. Results were presented as arithmetic mean percentages with 95% Confidence Intervals (CI). Outcomes (both proportion of 24-hour mortality and blood feeding) in the experimental hut trial were analysed using binomial logistic regression. For the non-inferiority analyses, unwashed Yorkool® G3 nets were compared with unwashed Olyset® Plus nets, 20× washed Yorkool® G3 nets were compared with 20× washed Olyset® Plus nets, and a separate comparison of the average value of the outcomes for unwashed and 20x washed nets was conducted. The delta to assess the non-inferiority for 24-hour mortality was estimated using: \(\frac{x-7}{100-(x-7)}/\frac{x}{100-x}\) , where x was the 24-hour mortality of mosquitoes captured in the huts with the comparator pyrethroid-PBO nets, Olyset® Plus. The delta for blood feeding was estimated using: \(\frac{x+7}{100-(x+7)}/\frac{x}{100-x}\) , where x was the proportion of blood feeding of mosquitoes captured from the huts with Olyset® Plus net. Non-inferiority was established when the lower confidence interval model-estimated odds ratio (OR) of Yorkool® G3 nets compared to Olyset® Plus nets was not lower than the delta of the proportion of mosquito mortality, and when the upper confidence interval of the OR of the Yorkool® G3 nets in comparison to Olyset® Plus nets was not higher than the delta of the proportion of mosquito blood feeding. For the superiority analysis, the following comparisons were made for each of the study outcomes: unwashed Yorkool® G3 and unwashed Olyset® Plus nets compared to unwashed PermaNet® 2.0 nets; 20× washed Yorkool® G3 and 20× washed Olyset® Plus nets compared to 20× PermaNet® 2.0 nets; and the average value of the study outcomes for unwashed and 20x washed pyrethroid-PBO nets against pyrethroid nets. The pyrethroid-PBO products were deemed superior when the OR for proportion of 24-hour mortality was higher than 1.00 and the p-value < 0.05, and the OR was lower than 1.00 and the p-value < 0.05 for proportion of mosquitoes’ blood feeding. In these model analyses, fixed effects included the treatment, hut, volunteer, and day of sleeping in the huts. For the analysis performed on the average of the outcomes, the wash status (unwashed and 20x washed) of net was added as a fixed effect. A post hoc simulation was conducted to check the power of the study following the new guideline [ 14 ]. The new guidelines detailed the change of the threshold of non-inferiority from 0.7 OR to 7% difference in proportion of mosquito mortality. This was done by simulating a generalised linear mixed model a thousand times, with treatment, volunteer, hut and day adjusted as fixed effect using R software [ 29 ]. Actual estimates of the study were used in the simulation: median number of 26 mosquitoes per hut, overall study variation of 93%, and 40% dispersion of mosquitoes following a negative binomial distribution and a non-inferiority margin of 7% difference in the proportion of mosquito mortality. For unwashed condition, 53% mortality from Yorkool® G3 and 44% for Olyset® Plus, and for 20x washes, 49% mortality from Yorkool® G3 and 35% mortality for Olyset® Plus nets were used in the simulation. Results Experimental hut study power Before the experimental hut trial, power of the study was estimated to be 97% for unwashed nets and 82% for 20x washed nets. Following the latest guideline, the post hoc study power was 98.4% for unwashed nets and 99.9% for 20x washed nets. Experimental hut trial Night-time temperature ranged between 21.0–32.3°C and relative humidity was between 45–85% in Lupiro during the study period. Nets were stored at room temperature (< 32°C) throughout the trial. The experimental trial started four days after the last wash (washing ended on the 29th of August 2020 and the trial started on the 2nd of September 2020). A total number of 21,974 An. arabiensis mosquitoes were collected over 49 nights of data collection. Median number of mosquitoes captured per night per hut was 26 (Interquartile range (IQR):14–43), but was heterogeneous and varied by product (Fig. 3). Figure 3. Violin plot of the distribution of numbers of female Anopheles arabiensis mosquitoes collected per hut-night. Filled violins: Unwashed nets; unfilled violins: 20x washed nets. Green: pyrethroid only nets, orange: first-in-class pyrethroid-PBO nets, blue: pyrethroid-PBO candidate nets. Mortality Yorkool® G3 nets induced significantly higher mortality at 24-hr [50.9% (95% confidence interval (CI): 47.5–54.3)] than all other ITNs: Olyset® Plus [39.2% (95% CI: 36.1–42.3)], PermaNet® 2.0 [27.2% (95% CI: 24.7–29.7)] and untreated net [11.1% (95% CI: 8.1–14.1)] (Fig. 4). Based on the WHO non-inferiority margin of 7% difference in mosquito mortality, Yorkool® G3 was non-inferior to Olyset® Plus nets [odds ratio (OR): 1.78 (95% CI: 1.65–1 .92)], as the lower confidence interval value was greater than delta (δ = 0.74), with the direction of effect being higher for both the unwashed and 20x washed Yorkool® G3 nets over Olyset® Plus nets (Fig. 5 and Table 1). Furthermore, a superiority analysis demonstrated that pyrethroid-PBO ITNs had a higher killing effect than pyrethroid only ITNs of all wash conditions (Table 2). This was also seen for ITNs over untreated nets (the negative control) (Table 2). Additional results are in supplementary file 3. Figure 4. Proportion of female Anopheles arabiensis mosquitoes dying at 24 hours (95% CI) after collection from experimental huts. Circles represent unwashed, hollow circles 20x-washed and triangles unwashed and 20x-washed combined. Figure 5. Mortality (95% CI) of female Anopheles arabiensis mosquitoes at 24 hours after collection from experimental huts demonstrating non-inferiority of Yorkool® G3 compared to Olyset® Plus nets. Circles represent unwashed, hollow circles 20x-washed and triangles unwashed and 20x-washed combined. Pink semi-circle represents the non-inferiority margin, that estimates must not fall within to be deemed non-inferior. Table 1 Non inferiority analysis of pyrethroid-PBO nets: Yorkool® G3 compared to Olyset® Plus Blood Feeding The proportions of mosquito blood feeding were substantially lower for all treated nets than those of the untreated nets, with all ITNs inducing more than 90% feeding inhibition (Fig. 6). The lowest proportions of blood feeding were seen for Olyset® Plus nets (Fig. 6). Yorkool® G3 nets were non-inferior [OR 1.87 (95% CI: 1.46–2 .39 )] to Olyset® Plus nets; the upper confidence interval value was lower than the delta (δ = 4.85) (Table 1, Fig. 7). As was seen for mortality in the superiority analysis, pyrethroid-PBO ITNs reduced blood feeding significantly more than the pyrethroid only ITNs (Table 2), indicating the additional benefit of the PBO synergist. Likewise, all ITNs significantly reduced An. arabiensis blood feeding compared to untreated net (Table 2). Additional results are in supplementary file 3. Figure 6. Proportion of female Anopheles arabiensis mosquitoes that blood-fed (95%) after collection. Figure 7. Blood feeding (95% CI) of female Anopheles arabiensis mosquitoes after collection from experimental huts demonstrating non-inferiority of Yorkool® G3 compared to Olyset® Plus nets. Circles represent unwashed, hollow circles 20x-washed and triangles unwashed and 20x-washed combined. Pink semi-circle represents the non-inferiority margin, that estimates must not fall within to be deemed non-inferior. Table 2 Superiority analysis of pyrethroid-PBO products Quality assurance bioefficacy All the pieces of both unwashed and 20x-washed Yorkool® G3 ITNs which were tested before (15 out of 15 samples) and after (10 out of 10 samples) the experimental hut trial met acceptable quality performances of ≥ 95% mosquito knockdown after 60 minutes or ≥ 80% mosquito mortality at 24 hours after exposure (WHO criterion for bioefficacy [ 17 ]) of the laboratory-reared resistant An. arabiensis and susceptible An. gambiae mosquitoes. This was also seen for the pyrethroid only ITNs before and after the trial on susceptible An. gambiae mosquitoes. However, for the pyrethroid-PBO positive control, Olyset® Plus ITNs, quality assurance was met based on proportion of knock down (KD60) for unwashed condition only, and not on 20x-washed condition, indicating that Olyset® Plus was not as wash resistant, Table 3. Table 3 Cone test data before washing, after washing 20 times, and after experimental hut trial with pyrethroid susceptible Anopheles gambiae (Ifakara strain) and pyrethroid resistant Anopheles arabiensis (Kingani strain). Number of mosquitoes exposed (No.), number (No.), percent (%) knockdown at 60 minutes (KD60), % 24-hour (24hr) mortality (adjusted for control). Chemical content The chemical content of all the nets tested before washing were within the 25% +/- of target dose as per WHO guidelines [ 17 ]. However, after washing, only Yorkool® G3 nets, both the deltamethrin and PBO content, were within the target dose, while the pyrethroid and PBO AI target doses of none of the other positive controls were within the range. Although all the nets had high (> 95%) wash resistance indices, washing resulted in lower concentration of the active ingredients with Yorkool® nets retaining 94% and 76% of deltamethrin and PBO, respectively, Olyset® Plus 69% of permethrin and 57% of PBO, and PermaNet® 2.0 61% of deltamethrin. The greater retainment of the pyrethroid compared to PBO indicates that the PBO is lost more quickly after 20 washes (Table 4). Table 4 Insecticidal content of nets by wash: Number of samples tested (N), active ingredient (AI) content (g/kg) with standard deviation (SD), % of nets within 25% +/- of target dose, AI within net spatial variation (% RSD), and wash retention index of Yorkool® G3, Olyset® Plus and PermaNet® 2.0 net samples before and after 20 washes. Discussion Yorkool® G3 nets, treated with deltamethrin and PBO are considered a new product under the second class of nets described by WHO, ‘ITNs designed to kill host-seeking insecticide-resistant mosquitoes’, and that provide greater protection than pyrethroid-only nets [ 15 ]. For prequalification of this product by WHO, we investigated the wash interval of Yorkool® G3 nets in the laboratory following 2013 WHO guidelines [ 17 ] and entomological efficacy in experimental huts in Tanzania according to WHO prequalification guidance [ 15 ], and the non-inferiority guidelines of Global Malaria Programme (GMP) at WHO [ 14 ] with a conservative budget to fulfil both of their requirements. Yorkool® G3 nets were found to be non-inferior to the first-in-class pyrethroid-PBO ITNs, Olyset® Plus, in terms of inducing mosquito mortality, and superiority over the first-in-class ITNs. Reasons to this finding could be the technique of dosing, as Yorkool® G3 nets utilise coating technique which allows the insecticide to be readily available on the surface of the net while for Olyset® Plus nets, the insecticide is incorporated into the fibres of the net which is gradually released overtime. The higher mortality seen with the Yorkool® G3 nets may also be attributed to the different pyrethroids used in each net. Olyset® Plus nets are treated with permethrin which is known to have high repellency effect [ 32 ]. This may result in less contact with the net and therefore less time to pick up a lethal dose, compared to deltamethrin with less of a repellency effect. The lower blood-feeding inhibition of Yorkool® G3 nets compared to Olyset® Plus nets is consistent with a recent study comparing Olyset® Plus with another deltamethrin-PBO net, PermaNet® 3.0 [ 33 ], which was also attributed to the effect of the different pyrethroids used. For an ideal controlled experiment, products with identical chemicals should be used, however the availability of such products may be limited particularly if manufacturers are reluctant to provide their net for testing. For quality purposes, nets used in non-inferiority analyses should be sourced from the manufacturers directly. Entomological efficacy of enhanced mortality and reduced blood feeding induced by the addition of PBO to pyrethroid ITNs to metabolic pyrethroid resistant malaria vectors was demonstrated in this study for both PBO products, confirming the utility of such nets for malaria control. Similar effects have been reported in previous experimental hut trials in northern Tanzania [ 34 ], Benin [ 13 , 33 , 35 ], Burkina Faso [ 36 ] and Ivory coast [ 37 ]. However, the magnitude of the observed effects can vary depending on factors such as hut design, location, and the resistance intensity and mechanism of vector in different areas [ 38 , 39 ]. The current study was conducted in an area where An. arabiensis is the most dominant vector and which is metabolic resistance to all classes of pyrethroid [ 40 ]. The epidemiological efficacy of pyrethroid-PBO nets have been confirmed in large-scale cluster randomised-controlled trials in Tanzania and Uganda [ 8 , 41 ]. Given the comparable performance of Yorkool® G3 nets to the-first-in class pyrethroid-PBO ITN, Olyset® Plus, the net evaluated in these trials, it could be assumed that Yorkool® G3 nets would also be of public health value, however community durability studies are needed to ensure that the ITNs are durable such that they provide sustained protection and remain cost-effective over three years, usually the interval of ITN campaigns [ 42 ]. Durability in the field (the strength of the fabric and insecticide resistance to abrasion, wear and tears) of an ITN is not equal to the simulated ‘aging’ of the nets through washing (20x-washes). Factors that affect net durability when used in the community, and not accounted for through laboratory or field washing, including how the nets are used and maintained (human behaviour) and environmental conditions that affect insecticide evaporation loss, washing, and abrasion, among many others [ 43 ]. One of the factors that makes a net “long lasting” is the ability of the net to consistently have sufficient chemical content available at its surface to induce high mortality of mosquitoes following contact. This was seen for Yorkool® G3 in the quality checks, 100% of the original chemical content was observed after 20x-washes. In bioefficacy evaluations before the hut trials, 67% of exposed insecticide resistant mosquitoes died, whilst mortality following the studies was 95%. This was not the case for the pyrethroid-PBO comparator net; none of the net pieces evaluated were within the target dose range for a chemical retention for the pyrethroid-PBO comparator, and poor mortality recorded in the cone bioassay experiment. This may be due to the difference in the treatment technique, as one utilised coating of the insecticide on the net surface and the other incorporated the insecticide within the fibres. Furthermore, different pyrethroids were compared, deltamethrin in the Yorkool® G3 nets and permethrin in the Olyset® Plus nets. As indicated before, the first-in-class product in this case differed in a number of aspects and may have been considered an inappropriate control in non-inferiority and superiority studies generally. One potential limitation of non-inferiority analyses where a first-in-class product has to be the standard comparator, is when the entomological efficacy in terms of mosquito mortality is lower than any other product to be compared. In this case second or third in class products may always appear non-inferior. Conversely, if the first-in-class product results in very high mosquito mortality, then future products that may still have public health value, may be shown to be inferior in many instances. This was taken into account by WHO and resulted in the non-inferiority margin being widened from 5–7% [ 14 ]. Given the current situation of increasing resistance in malaria-vectors, that contributes to the stalling or increase in malaria prevalence in certain malaria-endemic regions [ 46 ], rotation of pyrethroids has been suggested for management of insecticide resistance [ 47 ], however studies have shown no significant effect in the restoring of susceptibility of malaria vectors to pyrethroid insecticides [ 48 , 49 ]. A promising strategy is to explore the rotation of classes of AI, such as using Yorkool® G3 ITNs in rotation with other limited classes of AI, instead of ignoring pyrethroid-PBO products due to the evidence of a superiority efficacy of a chlorfenapyr product over a pyrethroid-PBO product [ 50 ]. In a nutshell, it is pertinent to encourage more classes of AI for development to ensure the swift feasibility of rotation of AI for insecticide resistance management. Our studies fulfilled WHO recommended requirements for conducting non-inferiority studies in experimental huts [ 14 ] as follows: 1) selection of a study site where the primary vectors against which the nets are designed to target dominate, i.e. for pyrethroid-PBO nets the primary malaria vectors resistant to pyrethroids. In Lupiro, the dominant malaria vector is Anopheles arabiensis and has been shown to be resistant to several pyrethroids. Studies of insecticide susceptibility at the time of the experiment demonstrated mortalities of 16%, 48% and 22% against permethrin, deltamethrin and alpha-cypermethrin, respectively (Supplementary Table 2)., 2) using recommended hut designs. Our studies were conducted in Ifakara experimental huts, one of the listed designs by WHO [ 15 ], 3) using a study design that reduces variability. Using a 7×7 Latin Square design in fourteen huts, our study aimed to minimise variability as far as possible. With the use of many huts, multiple replicates could be undertaken in a short time period with minimal budget implications, 4) ensuring the study is of sufficient power, i.e. >80%, Using a thousand simulation of the model of the data analysis and accounting for estimates (using data from previous studies, the number of mosquitoes per night, % mortality of mosquitoes, and variation between huts, volunteers and day) it was estimated that the study had greater than 98% power. 5) using mortality as the primary outcome, assess non-inferiority and superiority of products using appropriate statistical analyses where the treatment, hut, volunteer and day are included in the model as fixed effects [ 14 ]. Conclusion Yorkool® G3 ITNs were shown to be non-inferior to the first-in-class product within the pyrethroid-PBO ITN intervention class, Olyset® Plus, based on induced mosquito mortality and blood-feeding inhibition. Yorkool® G3 nets were also found to be superior to the standard pyrethroid-only ITN – PermaNet® 2.0. Yorkool® G3 ITNs therefore meet the WHO’s criteria for being prequalified as an efficacious vector control tool to be used in areas with metabolic resistant malaria vectors. Our non-inferiority and superiority evaluations were easy to implement and could be feasibly conducted within the recommended time frame and to a reasonable cost, following the guidelines set by the prequalification team and GMP at WHO. Abbreviations AI Active Ingredient An Anopheles FIC First-in-Class IHI Ifakara health institute ITN Insecticide-treated net M24 Mortality at 24 hours PBO Piperonyl butoxide RT Regeneration time SIC Second-in-class VCPTU Vector Control Product Testing Unit WHO World health organization Declarations Acknowledgements Heartfelt appreciation goes to the entire team of VCPTU both based in Bagamoyo and Lupiro for their dedication and implementation of the study. A huge thanks to the people of Lupiro for their cooperation during the study. We extend our gratitude to Fu Haili, Yin Qing and the entire team of the Yorkool® International Trading Co., Ltd, China for the funding provided to implement the study. Authors’ contributions OGO conceptualised and conducted the experimental hut trial, analysed all data and drafted the manuscript; MSM co-drafted the manuscript; EM substantially adviced on the implementation of the study and reviewed the manuscript; WN supervised the experimental hut trial and reviewed the manuscript; RP provided logistics support and reviewed the manuscript; SN, ABM, IM conducted all bioassays testing and reviewed the manuscript; HN and GL supervised volunteers, record observations and reviewed the manuscripts, JM adviced on the implementation of the study designs and reviewed the manuscript; YM and JS substantially reviewed the manuscript; and SJM was the principal investigator who conceptualised the study and substantially reviewed the manuscript. All authors approved the final draft of the manuscript. Funding Tianjin Yorkool International Trading Co., Ltd, China provided fund for the testing of the products. Availability of data and materials Data are available in supplementary files. File 4 contains cone bioassay data on unwashed net pieces before experimental hut trial, file 5 contains cone bioassay data for 20x wash net pieces before experimental hut trial, file 6 contains cone bioassay data for unwashed and 20x washed net pieces after experimental hut trial, file 7 contains experimental hut trial data and file 8 contains chemical analysis data. Ethical approval and consent to participate The study was approved by the IHI Review Board with certificate number IHI/IRB/No: 29-2020 and the National Institute for Medical Research-Tanzania (NIMR) with a certificate number NIMR/HQ/R.8a/Vol.IX/3521. Consent for publication Permission to publish was granted by the National Institute for Medical Research-Tanzania (NIMR) referenced BD.242/437/01B/14. Competing interests OGO, MSM, JS, EM, KS, RP, SN, ABM, IM, HN, JM, and SJM test vector control products. 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Tables Table 1 Non inferiority analysis of pyrethroid-PBO nets: Yorkool® G3 compared to Olyset® Plus Outcomes Product Condition Delta for 7% difference OR (95%CI) Test outcome Mortality at 24 hrs (Primary Outcome) Olyset® Plus Pooled* 0.74 1 Yorkool® G3 1.78 ( 1.65 – 1.92) Non-inferior Olyset® Plus Unwashed 0.75 1 Yorkool® G3 1.69 ( 1.51 – 1.90) Non-inferior Olyset® Plus 20x washed 0.72 1 Yorkool® G3 1.85 ( 1.68 – 2.05) Non-inferior Blood feeding (Secondary outcome) Olyset® Plus Pooled* 4.85 1 Yorkool® G3 1.87 (1.46 – 2.39 ) Non-inferior Olyset® Plus Unwashed 4.85 1 Yorkool® G3 2.55 (1.73 – 3.75 ) Non-inferior Olyset® Plus 20x washed 4.85 1 Yorkool® G3 1.49 (1.08 – 2.05 ) Non-inferior *unwashed and washed nets combined. Odds ratio for the effect of Yorkool® G3 ITNs compared to the pyrethroid-PBO positive control, Olyset® Plus, estimated using logistic regression adjusting for the effect of volunteer, day, and hut as fixed effects. For the pooled analysis, wash condition was adjusted for as a fixed effect. For 24-hr mortality, lower margin of the confidence interval must be higher than delta. For blood feeding, upper margin of the confidence interval must be lower than delta. Table 2 Superiority analysis of pyrethroid-PBO products Outcomes Product Condition OR (95%CI) P-value Test outcome Odds ratio for the effect of pyrethroid-PBO ITNs compared to the pyrethroid positive control, PermaNet® 2.0, Mortality at 24 hrs (Primary Outcome) PermaNet® 2.0 Pooled* 1 Olyset® Plus 1.63 (1.52 – 1.76) <0.0001 Superior Yorkool® G3 2.91 (2.69 – 3.14) <0.0001 Superior PermaNet® 2.0 Unwashed 1 Olyset® Plus 2.16 (1.93 – 2.43) <0.0001 Superior Yorkool® G3 3.66 (3.24 – 4.13) <0.0001 Superior PermaNet® 2.0 20x washed 1 Olyset® Plus 1.33 (1.20 – 1.47) <0.0001 Superior Yorkool® G3 2.46 (2.23 – 2.72) <0.0001 Superior Blood feeding (Secondary outcome) PermaNet® 2.0 Pooled* 1 Olyset® Plus 0.36 (0.29 – 0.45) <0.0001 Superior Yorkool® G3 0.68 (0.55 – 0.83) <0.0001 Superior PermaNet® 2.0 Unwashed 1 Olyset® Plus 0.28 (0.19 – 0.40) <0.0001 Superior Yorkool® G3 0.71 (0.52 – 0.96) 0.027 Superior PermaNet® 2.0 20x washed 1 Olyset® Plus 0.44 (0.33 – 0.58) <0.0001 Superior Yorkool® G3 0.65 (0.50 – 0.86) 0.002 Superior Outcomes Product Condition OR (95%CI) P-value Test outcome Odds ratio for the effect of ITNs compared to the negative control, SafiNet Mortality at 24 hrs (Primary Outcome) Untreated net 1 PermaNet® 2.0 Pooled* 3.80 (3.14 – 4.60) <0.0001 Olyset® Plus 6.21 (5.15 – 7.50) <0.0001 Superior Yorkool® G3 11.05 (9.13 – 13.37) <0.0001 Superior PermaNet® 2.0 Unwashed 3.17 (2.60 – 3.87) <0.0001 Olyset® Plus 6.85 (5.65 – 8.31) <0.0001 Superior Yorkool® G3 11.59 (9.51 – 14.13) <0.0001 Superior PermaNet® 2.0 20x washed 3.12 (2.57 – 3.78) <0.0001 Olyset® Plus 4.14 (3.42 – 5.01) <0.0001 Superior Yorkool® G3 7.68 (6.34 – 9.30) <0.0001 Superior Blood feeding (Secondary outcome) Untreated 1 PermaNet® 2.0 Pooled* 0.38 (0.30 – 0.49) Olyset® Plus 0.14 (0.10 – 0.18) <0.0001 Superior Yorkool® G3 0.26 (0.20 – 0.34) <0.0001 Superior PermaNet® 2.0 Unwashed 0.40 (0.30 – 0.52) <0.0001 Olyset® Plus 0.11 (0.08 – 0.16) <0.0001 Superior Yorkool® G3 0.28 (0.21 – 0.38) <0.0001 Superior PermaNet® 2.0 20x washed 0.35 (0.27 – 0.44) <0.0001 Olyset® Plus 0.15 (0.11 – 0.20) <0.0001 Superior Yorkool® G3 0.23 (0.17 – 0.30) <0.0001 Superior *unwashed and washed nets combined Note: Estimations were done using logistic regression adjusting for the effect of volunteer, day, and hut as fixed effects. For the pooled analysis, wash condition was adjusted for fixed effect. For superiority on mortality, OR must be higher than 1.00 and p-value<0.05, and for blood feeding, OR must be lower than 1.00 and p-value <0.05. Table 3 Cone test data before washing, after washing 20 times, and after experimental hut trial with pyrethroid susceptible Anopheles gambiae (Ifakara strain) and pyrethroid resistant Anopheles arabiensis (Kingani strain). Number of mosquitoes exposed (No.), number (No.), percent (%) knockdown at 60 minutes (KD60), % 24-hour (24hr) mortality (adjusted for control). Olyset®® Plus Yorkool® G3 PermaNet® 2.0 Strain Treatment Arm No. No. KD60 % KD60 (95% CI) No. mortality % 24hr mortality (95% CI) No. KD60 % KD60 (95% CI) No. mortality % 24hr mortality (95% CI) No. KD60 % KD60 (95% CI) No. mortality % 24hr mortality (95% CI) Susceptible An. gambiae s.s. Baseline quality check 300 300 100 300 100 300 100 300 100 300 100 206 68.7 (62.2 – 75.1) 20x washed before hut 300 52 17.3 (12.9-21.7) 26 8.7 (5.3-12.0) 300 100 300 100 300 100 300 100 unwashed after hut 200 200 100 175 87.5 (79.3-95.7) 200 100 200 100 200 100 186 93.0 (88.3 – 97.7) 20x washed after hut 200 181 90.5 (85.3–95.7) 50 25.0 (16.7-33.3) 200 100 200 100 200 100 200 100 Resistant An. arabiensis Baseline quality check 300 300 100 300 100 300 100 206 68.7 (63.7-73.6) - - - - 20x washed before hut 300 18 6.0 (3.1–8.9) 37 12.3 (7.5-17.2) 300 100 201 67.0 (62.0-72.0) - - - - unwashed after hut 200 200 100 96 48.0 (37.2-58.8) 200 100 169 84.5 (79.4-89.6) - - - - 20x washed after hut 200 143 71.5 (64.6-78.4) 30 15.0 (9.6-20.4) 200 100 189 94.5 (91.3-97.7) - - - - Table 4 Insecticidal content of nets by wash: Number of samples tested (N), active ingredient (AI) content (g/kg) with standard deviation (SD), % of nets within 25% +/- of target dose, AI within net spatial variation (% RSD), and wash retention index of Yorkool® G3, Olyset® Plus and PermaNet® 2.0 net samples before and after 20 washes. Treatment Arm N AI content (g/kg) before trial Arithmetic Mean (SD) % Within target dose range AI Within Net Variation (% RSD) AI retained after 20 washes (%) Wash Resistance Index (%) (AI retained per wash) N AI Content (g/kg) after trial Arithmetic Mean (SD) 0 washes 20 washes 0 washes 20 washes 0 washes 20 washes 0 washes 20 washes Yorkool® G3 deltamethrin 15 3.08 (0.04) 2.91 (0.02) 100 100 1.30 0.69 94.3 99.7 5 3.07 (0.04) 2.91 (0.02) Yorkool® G3 PBO 11.26 (0.07) 8.52 (0.06) 100 100 0.62 0.70 75.7 98.6 11.21 (0.07) 8.53 (0.06) Olyset®®Plus permethrin 15 19.26 (0.13) 13.28 (0.2) 100 0 0.67 1.51 69.0 98.2 5 19.35 (0.08) 13.22 (0.08) Olyset®®Plus PBO 9.84 (0.1) 5.58 (0.09) 100 0 1.02 1.61 56.7 97.2 9.87 (0.06) 5.49 (0.06) PermaNet® 2.0 deltamethrin 15 1.43 (0.03) 0.88 (0.02) 100 0 2.10 2.27 61.2 97.6 5 1.44 (0.03) 0.87 (0.02) Supplementary File Supplementary File 7 is not available with this version. Additional Declarations Competing interest reported. OGO, MSM, JS, EM, KS, RP, SN, ABM, IM, HN, JM, and SJM test vector control products. Supplementary Files Supplementaryfile1.docx Supplementary information Supplementary file 1: Results of the susceptibility test conducted in November 2019 and 2020 for the laboratory-reared mosquitoes used in laboratory bioassays Supplementaryfile2.docx Supplementary file 2: Results of the susceptibility test conducted in November 2020 for the field strain mosquitoes used in experimental hut trial Supplementaryfile3.docx Supplementary file 3: Descriptive analysis of study products Supplementaryfile4.xlsx Supplementaryfile5.xlsx Supplementaryfile6.xlsx Supplementaryfile8.xlsx Cite Share Download PDF Status: Published Journal Publication published 16 Oct, 2024 Read the published version in Malaria Journal → Version 1 posted Editorial decision: Revision requested 18 Aug, 2024 Reviews received at journal 06 Aug, 2024 Reviews received at journal 18 Jul, 2024 Reviews received at journal 17 Jul, 2024 Reviewers agreed at journal 30 Jun, 2024 Reviewers agreed at journal 26 Jun, 2024 Reviewers agreed at journal 26 Jun, 2024 Reviewers agreed at journal 26 Jun, 2024 Reviewers agreed at journal 25 Jun, 2024 Reviewers invited by journal 23 Jun, 2024 Submission checks completed at journal 01 Jun, 2024 Editor assigned by journal 01 Jun, 2024 First submitted to journal 31 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Odufuwa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwElEQVRIiWNgGAWjYHACA4YKIMnPzMNwgHgtZ4CkZDNUCw/RWgwOQNUS1MLP3rxN4mDbYXnj47wHDzBU3GOw5yfgPsmeY2UgLYbbDvMlHGA4U8xA0EsGN3LMpD+23WbcdpjH4ABjWwIDD2MDYS1AW27bb26GaWEm4BeYlsQNzDAtbAS0AP1SbHHg3P/kGSCHJZxJ4OE5Q0ALMMQ23jhQlmbb33/G+MOHigQ59v4DBPSggATiYnIUjIJRMApGASEAAKGWQhNbXdE3AAAAAElFTkSuQmCC","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":true,"prefix":"","firstName":"Olukayode","middleName":"G.","lastName":"Odufuwa","suffix":""},{"id":313479305,"identity":"5b50b347-e5d6-4e95-b504-934a2a8a3528","order_by":1,"name":"Masudi Suleiman Maasayi","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Masudi","middleName":"Suleiman","lastName":"Maasayi","suffix":""},{"id":313479306,"identity":"89038a3e-fa7b-4d0b-821b-d1472a26f043","order_by":2,"name":"Emmanuel Mbuba","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Emmanuel","middleName":"","lastName":"Mbuba","suffix":""},{"id":313479307,"identity":"b6782ab0-d2b6-4c96-8d2f-3c8e2d66e7ce","order_by":3,"name":"Watson Ntabaliba","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Watson","middleName":"","lastName":"Ntabaliba","suffix":""},{"id":313479308,"identity":"d356f5a6-3bc9-4586-8d14-33c0bcb220b1","order_by":4,"name":"Rose Philipo","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Rose","middleName":"","lastName":"Philipo","suffix":""},{"id":313479311,"identity":"c2ba2dbf-e62b-4ae4-af94-fb417f8e4746","order_by":5,"name":"Safina Ngonyani","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Safina","middleName":"","lastName":"Ngonyani","suffix":""},{"id":313479312,"identity":"41f9c4ba-7676-482e-8bda-7c32c5047f95","order_by":6,"name":"Ahmadi Bakari Mpelepele","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Ahmadi","middleName":"Bakari","lastName":"Mpelepele","suffix":""},{"id":313479315,"identity":"d3be26f1-32c4-4ce0-b318-d24bed7eab80","order_by":7,"name":"Isaya Matanila","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Isaya","middleName":"","lastName":"Matanila","suffix":""},{"id":313479316,"identity":"b5691737-0975-41d9-a405-b874cf5ec126","order_by":8,"name":"Hassan Ngonyani","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Hassan","middleName":"","lastName":"Ngonyani","suffix":""},{"id":313479319,"identity":"ce5a34d4-c3a4-46a0-ad82-559b49f14121","order_by":9,"name":"Godfrey Ligema","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Godfrey","middleName":"","lastName":"Ligema","suffix":""},{"id":313479322,"identity":"3c2fd6ad-8705-439d-833f-2f9e362ce5d4","order_by":10,"name":"Jason Moore","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Jason","middleName":"","lastName":"Moore","suffix":""},{"id":313479323,"identity":"afa4e208-0d07-408f-8a21-60e320922696","order_by":11,"name":"Yeromin P Mlacha","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Yeromin","middleName":"P","lastName":"Mlacha","suffix":""},{"id":313479324,"identity":"e9438264-0e83-4e81-accd-3c24fea29951","order_by":12,"name":"Jennifer C Stevenson","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"C","lastName":"Stevenson","suffix":""},{"id":313479325,"identity":"b9281491-00ef-4140-99e1-ff0390450832","order_by":13,"name":"Sarah Jane Moore","email":"","orcid":"","institution":"Ifakara Health Institute","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"Jane","lastName":"Moore","suffix":""}],"badges":[],"createdAt":"2024-05-31 19:53:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4510891/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4510891/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12936-024-05130-7","type":"published","date":"2024-10-16T15:57:38+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":58415107,"identity":"1fe087ca-8ae4-4e93-a4c6-c9ee2da6540e","added_by":"auto","created_at":"2024-06-15 12:27:32","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":13203197,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGeographical location of study area\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4510891/v1/f68447ffd17ead28ea479709.jpg"},{"id":58415098,"identity":"f7984a7b-e72c-4972-a26e-a1020b434648","added_by":"auto","created_at":"2024-06-15 12:27:32","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":307886,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eExperimental hut study design\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4510891/v1/12921847e4038107b40f1cb8.jpg"},{"id":58415101,"identity":"3ce7279f-6d3c-4451-90aa-4964a100e77c","added_by":"auto","created_at":"2024-06-15 12:27:32","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":34365,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eViolin plot of the distribution of numbers of female \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eAnopheles arabiensis\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e mosquitoes collected per hut-night.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Placeholderimage3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4510891/v1/dc24bd18731cb294a9819c2d.jpg"},{"id":58415103,"identity":"ca276c0e-a63a-4299-8151-dc17632e4e36","added_by":"auto","created_at":"2024-06-15 12:27:32","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":34365,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProportion of female \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eAnopheles arabiensis\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e mosquitoes dying at 24 hours (95% CI) after collection from experimental huts. Circles represent unwashed, hollow circles 20x-washed and triangles unwashed and 20x-washed combined.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Placeholderimage4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4510891/v1/d8c4e187ab6688a5417f5ae6.jpg"},{"id":58415557,"identity":"349051d2-7dc8-4dcf-8899-f07e350839f5","added_by":"auto","created_at":"2024-06-15 12:43:32","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":34365,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMortality (95% CI) of female \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eAnopheles arabiensis\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e mosquitoes at 24 hours after collection from experimental huts demonstrating non-inferiority of Yorkool® G3 compared to Olyset® Plus nets. Circles represent unwashed, hollow circles 20x-washed and triangles unwashed and 20x-washed combined. Pink semi-circle represents the non-inferiority margin, that estimates must not fall within to be deemed non-inferior.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Placeholderimage5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4510891/v1/c968b12694b01d06590853fd.jpg"},{"id":58415108,"identity":"5e9fb31c-6e4e-424e-ba4b-9e192b926889","added_by":"auto","created_at":"2024-06-15 12:27:32","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":34365,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProportion of female \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eAnopheles arabiensis\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e mosquitoes that blood-fed (95%) after collection.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Placeholderimage6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4510891/v1/60c801bcaff444a896bf0a94.jpg"},{"id":58415105,"identity":"63e8e093-3f8c-4fe2-9be4-af0fc3b6bd81","added_by":"auto","created_at":"2024-06-15 12:27:32","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":34365,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBlood feeding (95% CI) of female \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003eAnopheles arabiensis\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003emosquitoes after collection from experimental huts demonstrating non-inferiority of Yorkool® G3 compared to Olyset® Plus nets. Circles represent unwashed, hollow circles 20x-washed and triangles unwashed and 20x-washed combined. Pink semi-circle represents the non-inferiority margin, that estimates must not fall within to be deemed non-inferior.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Placeholderimage7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4510891/v1/890a1a1cf3901f163bb76aa5.jpg"},{"id":67148995,"identity":"3ab8425a-a5b7-4286-85f7-1b281195c3df","added_by":"auto","created_at":"2024-10-21 16:10:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":17452423,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4510891/v1/31de3e65-3f6f-4f44-b1e0-9594207e276b.pdf"},{"id":58415329,"identity":"923d125d-6152-4f88-8f7e-eb5da66bbc9f","added_by":"auto","created_at":"2024-06-15 12:35:32","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13678,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eSupplementary file 1: Results of the susceptibility test conducted in November 2019 and 2020 for the laboratory-reared mosquitoes used in laboratory bioassays\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Supplementaryfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4510891/v1/ad9262f1658a3924bdabb538.docx"},{"id":58415556,"identity":"102bb7cd-6cb1-4e87-bce3-5a1c84ea3939","added_by":"auto","created_at":"2024-06-15 12:43:32","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":12777,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eSupplementary file 2: Results of the susceptibility test conducted in November 2020 for the field strain mosquitoes used in experimental hut trial\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Supplementaryfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4510891/v1/71b2f74f2f8455bb040d15b7.docx"},{"id":58415331,"identity":"02c7858e-d927-4c13-a095-93d0d7c389dd","added_by":"auto","created_at":"2024-06-15 12:35:32","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":13692,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eSupplementary file 3: Descriptive analysis of study products\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Supplementaryfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-4510891/v1/79d85347348dd3e2b35b3a2f.docx"},{"id":58415102,"identity":"25f4f33b-4f15-4c3c-aa8a-9a5913b1260f","added_by":"auto","created_at":"2024-06-15 12:27:32","extension":"xlsx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":45207,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile4.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4510891/v1/3845e1fb0047a4a463bfefab.xlsx"},{"id":58415110,"identity":"c870e4c0-0b39-4dba-8933-c889574ab897","added_by":"auto","created_at":"2024-06-15 12:27:32","extension":"xlsx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":45268,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile5.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4510891/v1/4d3392142956f5bd34280592.xlsx"},{"id":58415111,"identity":"7796d0f1-d881-454d-a254-57b3e9a0dea3","added_by":"auto","created_at":"2024-06-15 12:27:32","extension":"xlsx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":54651,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile6.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4510891/v1/7dd1f5e40b50f32e090e9789.xlsx"},{"id":58415333,"identity":"defc7890-2c02-4b8b-bd0f-808e56c7ee0b","added_by":"auto","created_at":"2024-06-15 12:35:32","extension":"xlsx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":14671,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile8.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4510891/v1/a1234dc8ff2797a50cb77922.xlsx"}],"financialInterests":"Competing interest reported. OGO, MSM, JS, EM, KS, RP, SN, ABM, IM, HN, JM, and SJM test vector control products.","formattedTitle":"The non-inferiority efficacy of Piperonyl-butoxide Yorkool® G3 Insecticide treated nets in the experimental huts in Tanzania","fulltext":[{"header":"Background","content":"\u003cp\u003eVector control, primarily through the use of insecticide treated nets (ITNs) are the cornerstone in the fight against malaria transmission [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], due to its primary ability for killing mosquitoes and reducing blood feeding success of mosquitoes that come into contact with the insecticide-treated surface. However, due to the extensive use of the same insecticides for mosquito control and agricultural practices [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], mosquitoes have developed resistance to the pyrethroid used on ITNs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Nets treated with both pyrethroid and the synergist - piperonyl butoxide (PBO) have been developed to counteract metabolic resistant in mosquitoes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The PBO inhibits the action of the metabolic enzymes that the mosquitoes use to detoxify pyrethroids [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Epidemiological data from a cluster-randomised trial conducted on the pyrethroid-PBO net Olyset\u0026reg; Plus in Tanzania demonstrated a 33% reduction in malaria prevalence over 21 months relative to a standard pyrethroid only net - Olyset\u0026reg; (permethrin incorporated net manufactured by A to Z textiles, Tanzania), in an area of insecticide resistance in mosquitoes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Therefore, in 2017 the World Health Organization (WHO) identified PBO-incorporated nets as a new class of ITNs [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], with Olyset\u0026reg; Plus (the first pyrethroid-PBO incorporated net manufactured by Sumitomo, Japan) being the first-in-class (FIC) product prequalified by WHO [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWHO recommends that for new pyrethroid-PBO ITNs to be classified as efficacious second-in-class (SIC) products, non-inferiority trials using experimental huts may be used as a means of evaluation [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Mathematical modelling of entomological data from experimental hut trials has demonstrated that such studies can be used to predict the epidemiological effect of ITNs, thus supporting non-inferiority trials for the evaluation of novel ITNs [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Given that the FIC pyrethroid-PBO ITN (positive control) has been demonstrated to have an impact on malaria prevalence [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], non-inferiority entomological trials which follow established guidelines and procedures [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], can be used as a proxy to determine whether a new product would produce similar epidemiological results. Such entomological trials can be conducted in a shorter timeframe to epidemiological trials, thereby bringing new products to market sooner and so increasing access to ITNs.\u003c/p\u003e \u003cp\u003eIn a WHO-approved experimental hut non-inferiority trial, new vector control products should demonstrate a comparable entomological performance to the WHO prequalified FIC or SIC product with the same entomological mode of action as that of the product that is under investigation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Performance is primarily assessed by mortality of malaria vectors with blood feeding as an additional endpoint [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. For a new product to be deemed non-inferior to the FIC comparator, the difference in mosquito mortality must not be less than 7% [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This threshold is called the non-inferiority margin (NI). To be able to determine this statistically, this margin is translated into an odds ratio (OR) called the \u0026lsquo;delta\u0026rsquo;, and for a product to be deemed non-inferior, the lower limit of the 95% confidence interval (CI) of the OR of the candidate should be equal or above the estimated delta from the proportion derived for the FIC comparator [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In the assessment, it is also necessary to determine the susceptibility of the wild test mosquitoes to this class of insecticides through the exposure of mosquitoes to a \u0026lsquo;standard comparator\u0026rsquo;. For the assessment of pyrethroid-PBO products, a WHO prequalified pyrethroid only ITN known to be efficacious against susceptible malaria vectors (e.g. PermaNet\u0026reg; 2.0 treated with deltamethrin only) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] is often used. In addition, an untreated net (negative control) should be included in the study to assess the quality of the experiment. The candidate product should ideally demonstrate superior efficacy over the standard comparator and untreated net using a significance level (P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. It is recommended that a robust power calculation be performed to estimate the adequate number of experimental nights required to determine non-inferiority of the candidate product, using estimates from a previous study conducted in the location of the experimental huts. The required sample size to determine with adequate power that a product falls within the NI margin compared to the FIC product, is calculated statistically using appropriate statistical or modelling tools, based on the expected mortality difference, mosquito density, mosquito distribution and overall study variation from a previous study [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA new ITN incorporated with pyrethroid insecticide (deltamethrin) and the synergist PBO named Yorkool\u0026reg; G3, has been developed by Yorkool International Trading Co., Ltd in China, as additional product in the pyrethroid-PBO ITN class. As a potential new product in this class, its non-inferiority to the FIC product, Olyset\u0026reg; Plus, or another prequalified product in this class, is necessary for it to be prequalified by WHO [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Robust experimental hut trials of its entomological efficacy are therefore needed, as products differ in terms of manufacturing technique and dosage.\u003c/p\u003e \u003cp\u003eThis paper presents experimental hut entomological studies to assess non-inferiority of Yorkool\u0026reg; G3 pyrethroid-PBO nets to the FIC product, Olyset\u0026reg; Plus, and superiority compared to a standard pyrethroid-only net, PermaNet\u0026reg; 2.0 following WHO procedures [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy area\u003c/h2\u003e \u003cp\u003eThe experimental hut trial of Yorkool\u0026reg; G3 nets was carried out in Lupiro village (8.385\u0026deg;S and 36.670\u0026deg;E), which is located in Ulanga district, Morogoro region in the south-eastern part of Tanzania (Fig.\u0026nbsp;1 in grey). The yearly rainfall in the Morogoro region range from 1200 to 1800mm, with temperatures varying between 20\u0026deg;C and 34\u0026deg;C. The most abundant malaria vector in the area is \u003cem\u003eAnopheles arabiensis\u003c/em\u003e which is resistant to pyrethroids and carbamates, and accounts for over 99.9% of the \u003cem\u003eAnopheles gambiae\u003c/em\u003e complex species [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Pre-exposure to PBO resulted in lower knockdown rates and higher mortalities against pyrethroids and bendiocarb, compared to tests without the synergists [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The main malaria control intervention in the area is the use of ITNs [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eQuality assessment of Yorkool\u0026reg; G3 nets were performed at the Vector Control Product Testing Unit (VCPTU) facility that is accredited (SANAS GLP0003) for Good Laboratory Practice, and situated at the Bagamoyo branch of Ifakara Health Institute (IHI) in Tanzania (Fig.\u0026nbsp;1, in green).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 1: Geographical location of study area\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThe experimental hut trial was executed between September and October 2020. The trial used a partially-randomised double-blinded approach; both nets and volunteers were randomly assigned to huts on the first day, with a sequential rotation strategy employed thereafter, with daily rotation of volunteers and rotation of nets at the end of each round (7 nights). The trial implemented two contiguous 7\u0026times;7 Latin Squares design in fourteen huts, commonly referred to as the \"Williams Design\" [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Each treatment condition was tested 98 times over the course of 49 nights, following WHO guidelines [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], as depicted in Fig.\u0026nbsp;2.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 2: Experimental hut study design\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDescription of test items\u003c/h2\u003e \u003cp\u003eYorkool\u0026reg; G3 ITNs are made of 130 denier yarn, polyethylene fibres coated with 120 mg/m\u003csup\u003e2\u003c/sup\u003e deltamethrin and 440 mg/m\u003csup\u003e2\u003c/sup\u003e piperonyl butoxide (PBO). It is manufactured by Yorkool International Trading Co., Ltd, China. Olyset\u0026reg; Plus is a knitted monofilament polyethylene net of 150 denier yarn, treated with 20 g AI/kg (800 mg AI/m\u003csup\u003e2\u003c/sup\u003e) permethrin and PBO contents of 10 g PBO/kg (400 mg PBO/m\u003csup\u003e2\u003c/sup\u003e). The net is manufactured by Sumitomo Chemical Co., Ltd, Japan [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The standard comparator ITN used was PermaNet\u0026reg; 2.0, a 55 mg/m\u003csup\u003e2\u003c/sup\u003e deltamethrin-coated ITN manufactured by Vestergaard Frandsen SA [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. To assess the quality of the experiment, Safi Net was used as a negative control, an untreated polyester net manufactured by A to Z Textiles Mills Limited, Tanzania.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eMosquitoes\u003c/h2\u003e \u003cp\u003eThe experimental hut trial used free-flying wild insecticide-resistant \u003cem\u003eAn. arabiensis\u003c/em\u003e (Lupiro strain) mosquitoes. The resistance of these mosquitoes is attributed to the overexpression of CYP450 enzymes [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Sugar-fed 2\u0026ndash;5 day old, insecticide-susceptible \u003cem\u003eAn. gambiae sensu stricto\u003c/em\u003e (s.s) (Ifakara strain) and pyrethroid-resistant \u003cem\u003eAn. arabiensis\u003c/em\u003e (Kingani strain) mosquitoes were used for quality of nets\u0026rsquo; bioefficacy before and after the experimental hut trial (supplementary material table 1 and 2 for insecticide susceptibility tests conducted at the time of the study). All mosquito colonies are maintained in insectaries at the VCPTU, Bagamoyo, following standard operating procedures (SOPs) adapted from the MR4 guidelines [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eNet preparation\u003c/h2\u003e \u003cp\u003eNineteen Yorkool\u0026reg; G3 ITNs from three production batches were prepared for the experimental hut trial (Fig.\u0026nbsp;2) as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThree nets (one per production batch), samples were removed when nets were unwashed and after 20x-washed for baseline quality checks of bioefficacy.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSixteen nets (from across the three production batches), eight of which remained unwashed and eight were washed 20 times. Per wash status, seven nets were used each for the experimental hut trials with a spare in case of need of replacement.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eFor the pyrethroid-PBO positive control net and the standard positive control pyrethroid only net, an equivalent number of nets from one production batch was used, and all nets were the same colour for blinding of study technicians and investigators.\u003c/p\u003e \u003cp\u003eNets selected for washing, including those selected for quality checks, were field-washed at their appropriate wash interval day (one day for Yorkool\u0026reg; G3 and PermaNet\u0026reg; 2.0 and two days for Olyset\u0026reg; Plus [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]) in the facilities in Bagamoyo. Nets were washed in aluminium bowls containing 10 litres of filtered well water with a maximum hardness of 5dH and containing 2g/litre of soap (\"Jamaa palm oil\" soap flakes), using manual agitation of 20 rotations per minute for 10 minutes. Rinsing was done twice using filtered clean well water. Nets were dried horizontally in the shade then wrapped in foil and stored in labelled plastic bags at 21.4\u0026ndash;30.9\u0026deg;C in the IHI store between washes. The procedure was repeated twenty times for all ITNs.\u003c/p\u003e \u003cp\u003eEach net was assigned a unique four-digit code generated by personnel not involved in the study, ensuring that investigators, technicians and participants were blinded to the type of ITN. Before testing in the huts, all nets (unwashed and 20x washed) were deliberately holed. Holes each measuring 4 cm \u0026times; 4 cm were made on each of four sides of the net: two holes at the centre in each of the long side panels, and one hole at the centre of the short panels. Seven nets per arm, plus a spare, were transferred to the net storage facilities in Lupiro where the experimental hut trial was conducted.\u003c/p\u003e \u003cp\u003eFor chemical analysis, five pieces of netting measuring 25 cm x 25 cm were cut from the three unwashed and washed nets used for bioefficacy, to give 15 netting pieces for each wash status to be studied before the experimental hut trial began. On completion of the hut trial, five pieces cut from two unwashed and two washed nets were used. Net pieces for chemical analyses and for bioassays were cut adjacent to one another [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. All net pieces intended for chemical testing were promptly wrapped in aluminium foil after cutting and stored in a refrigerator at 4\u0026thinsp;\u0026plusmn;\u0026thinsp;2\u0026deg;C for two weeks before they were shipped to the International Institute of Biotechnology and Toxicology (IIBAT) in India for analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eProcedures for experimental hut trial\u003c/h2\u003e \u003cp\u003eBefore the experimental hut trial, power of the study was estimated using estimates from an earlier trial conducted in the same site following the previous WHO non-inferiority guidelines [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. A generalised linear mixed model (GLM) simulated 1000 times was used to determine the study power for a 7 x 7 arm trial in fourteen huts for 49 nights, using an estimated median number of 28 mosquitoes per night per hut, 22% mortality for the unwashed pyrethroid-PBO products and 14% mortality for the washed pyrethroid-PBO products, overall study variation of log of 1.034 and non-inferiority margin of 0.7 OR with treatment, volunteer, and hut adjusted for fixed effects, using R software [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe experiments were carried out in fourteen Ifakara experimental huts as detailed in a previous study [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The trial enrolled fourteen consenting adult male volunteers to occupy the huts at night. The trial had seven arms: (i) Yorkool\u0026reg; G3, unwashed, (ii) Yorkool\u0026reg; G3, washed 20\u0026times; at a 1-day wash interval, (iii) Olyset\u0026reg; Plus, unwashed, (iv) Olyset\u0026reg; Plus, washed 20\u0026times; at a 2 days wash interval, (v) PermaNet\u0026reg; 2.0, unwashed, (vi) PermaNet\u0026reg; 2.0, washed 20\u0026times; at a 1-day wash interval, and (vii) untreated Safi Net as negative control. The primary outcome was proportion of 24-hr mortality of mosquitoes and the secondary outcome was proportion of mosquito blood feeding. Data were collected for seven nights, with a one-night airing period between rounds to reduce any chance of any residual effects before introducing the next treatment. During the study, the volunteers adhered to a predetermined roster as they sequentially rotated among the huts. They entered their assigned huts at 19:00 hours (hrs) and slept under the nets until 06:00 hrs the following morning. At 06:00 hrs, mosquitoes were collected from 1) inside the nets, 2) the floor, walls, ceiling, and 3) exit traps using aspirators. Subsequently, the collected mosquitoes were sorted and categorised based on their location, and status (dead and fed, dead and unfed, alive and fed, and alive and unfed). These mosquitoes were then held in a temperature-controlled room for 24-hr with access to a 10% sugar solution at 21.5\u0026ndash;33.5\u0026deg;C temperature and 32.5\u0026ndash;82.7% relative humidity, to assess mortality at 24 hr after capturing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eProcedures for experimental hut trial quality checks: bioefficacy and chemical analysis\u003c/h2\u003e \u003cp\u003ePrior to the experimental hut trial, pre-test quality checks were conducted to assess the bioefficacy (\u0026ge;\u0026thinsp;95% KD60 / \u0026ge; 80% M24) using cone bioassay and nets were stored for chemical analysis of the insecticide on the net at time 0, the day before the first wash. Bioefficacy and storage of samples for chemical analysis tests were again carried out after completing the necessary 20 field washes. Post-experimental checks were conducted at the end of the hut trial using the nets evaluated in the huts (both unwashed and 20x washed) against susceptible \u003cem\u003eAn. gambiae sensu stricto\u003c/em\u003e (s.s) (Ifakara strain), and strongly pyrethroid-resistant \u003cem\u003eAn. arabiensis\u003c/em\u003e (Kingani strain) exposed to nets using cone bioassay according to the WHO procedures [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], while samples for chemical content were shipped to IIBAT for insecticide chemical analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was conducted using STATA 16 software [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Descriptive analysis was conducted for cone bioassays for the primary outcomes, knockdown at 60 minutes (KD60) and 24-hr mortality for quality checks. Results were presented as arithmetic mean percentages with 95% Confidence Intervals (CI).\u003c/p\u003e \u003cp\u003eOutcomes (both proportion of 24-hour mortality and blood feeding) in the experimental hut trial were analysed using binomial logistic regression. For the non-inferiority analyses, unwashed Yorkool\u0026reg; G3 nets were compared with unwashed Olyset\u0026reg; Plus nets, 20\u0026times; washed Yorkool\u0026reg; G3 nets were compared with 20\u0026times; washed Olyset\u0026reg; Plus nets, and a separate comparison of the average value of the outcomes for unwashed and 20x washed nets was conducted. The delta to assess the non-inferiority for 24-hour mortality was estimated using: \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\frac{x-7}{100-(x-7)}/\\frac{x}{100-x}\\)\u003c/span\u003e\u003c/span\u003e, where x was the 24-hour mortality of mosquitoes captured in the huts with the comparator pyrethroid-PBO nets, Olyset\u0026reg; Plus. The delta for blood feeding was estimated using: \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\frac{x+7}{100-(x+7)}/\\frac{x}{100-x}\\)\u003c/span\u003e\u003c/span\u003e, where x was the proportion of blood feeding of mosquitoes captured from the huts with Olyset\u0026reg; Plus net. Non-inferiority was established when the lower confidence interval model-estimated odds ratio (OR) of Yorkool\u0026reg; G3 nets compared to Olyset\u0026reg; Plus nets was not lower than the delta of the proportion of mosquito mortality, and when the upper confidence interval of the OR of the Yorkool\u0026reg; G3 nets in comparison to Olyset\u0026reg; Plus nets was not higher than the delta of the proportion of mosquito blood feeding.\u003c/p\u003e \u003cp\u003eFor the superiority analysis, the following comparisons were made for each of the study outcomes: unwashed Yorkool\u0026reg; G3 and unwashed Olyset\u0026reg; Plus nets compared to unwashed PermaNet\u0026reg; 2.0 nets; 20\u0026times; washed Yorkool\u0026reg; G3 and 20\u0026times; washed Olyset\u0026reg; Plus nets compared to 20\u0026times; PermaNet\u0026reg; 2.0 nets; and the average value of the study outcomes for unwashed and 20x washed pyrethroid-PBO nets against pyrethroid nets. The pyrethroid-PBO products were deemed superior when the OR for proportion of 24-hour mortality was higher than 1.00 and the p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05, and the OR was lower than 1.00 and the p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for proportion of mosquitoes\u0026rsquo; blood feeding.\u003c/p\u003e \u003cp\u003eIn these model analyses, fixed effects included the treatment, hut, volunteer, and day of sleeping in the huts. For the analysis performed on the average of the outcomes, the wash status (unwashed and 20x washed) of net was added as a fixed effect.\u003c/p\u003e \u003cp\u003eA post hoc simulation was conducted to check the power of the study following the new guideline [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The new guidelines detailed the change of the threshold of non-inferiority from 0.7 OR to 7% difference in proportion of mosquito mortality. This was done by simulating a generalised linear mixed model a thousand times, with treatment, volunteer, hut and day adjusted as fixed effect using R software [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Actual estimates of the study were used in the simulation: median number of 26 mosquitoes per hut, overall study variation of 93%, and 40% dispersion of mosquitoes following a negative binomial distribution and a non-inferiority margin of 7% difference in the proportion of mosquito mortality. For unwashed condition, 53% mortality from Yorkool\u0026reg; G3 and 44% for Olyset\u0026reg; Plus, and for 20x washes, 49% mortality from Yorkool\u0026reg; G3 and 35% mortality for Olyset\u0026reg; Plus nets were used in the simulation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eExperimental hut study power\u003c/h2\u003e \u003cp\u003eBefore the experimental hut trial, power of the study was estimated to be 97% for unwashed nets and 82% for 20x washed nets. Following the latest guideline, the post hoc study power was 98.4% for unwashed nets and 99.9% for 20x washed nets.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eExperimental hut trial\u003c/h2\u003e \u003cp\u003eNight-time temperature ranged between 21.0\u0026ndash;32.3\u0026deg;C and relative humidity was between 45\u0026ndash;85% in Lupiro during the study period. Nets were stored at room temperature (\u0026lt;\u0026thinsp;32\u0026deg;C) throughout the trial. The experimental trial started four days after the last wash (washing ended on the 29th of August 2020 and the trial started on the 2nd of September 2020). A total number of 21,974 \u003cem\u003eAn. arabiensis\u003c/em\u003e mosquitoes were collected over 49 nights of data collection. Median number of mosquitoes captured per night per hut was 26 (Interquartile range (IQR):14\u0026ndash;43), but was heterogeneous and varied by product (Fig.\u0026nbsp;3).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 3. Violin plot of the distribution of numbers of female\u003c/b\u003e \u003cb\u003eAnopheles arabiensis\u003c/b\u003e \u003cb\u003emosquitoes collected per hut-night.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eFilled violins: Unwashed nets; unfilled violins: 20x washed nets. Green: pyrethroid only nets, orange: first-in-class pyrethroid-PBO nets, blue: pyrethroid-PBO candidate nets.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eMortality\u003c/h2\u003e \u003cp\u003eYorkool\u0026reg; G3 nets induced significantly higher mortality at 24-hr [50.9% (95% confidence interval (CI): 47.5\u0026ndash;54.3)] than all other ITNs: Olyset\u0026reg; Plus [39.2% (95% CI: 36.1\u0026ndash;42.3)], PermaNet\u0026reg; 2.0 [27.2% (95% CI: 24.7\u0026ndash;29.7)] and untreated net [11.1% (95% CI: 8.1\u0026ndash;14.1)] (Fig.\u0026nbsp;4). Based on the WHO non-inferiority margin of 7% difference in mosquito mortality, Yorkool\u0026reg; G3 was non-inferior to Olyset\u0026reg; Plus nets [odds ratio (OR): 1.78 (95% CI: \u003cb\u003e1.65\u0026ndash;1\u003c/b\u003e.92)], as the lower confidence interval value was greater than delta (δ\u0026thinsp;=\u0026thinsp;0.74), with the direction of effect being higher for both the unwashed and 20x washed Yorkool\u0026reg; G3 nets over Olyset\u0026reg; Plus nets (Fig.\u0026nbsp;5 and Table\u0026nbsp;1). Furthermore, a superiority analysis demonstrated that pyrethroid-PBO ITNs had a higher killing effect than pyrethroid only ITNs of all wash conditions (Table\u0026nbsp;2). This was also seen for ITNs over untreated nets (the negative control) (Table\u0026nbsp;2). Additional results are in supplementary file 3.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 4. Proportion of female\u003c/b\u003e \u003cb\u003eAnopheles arabiensis\u003c/b\u003e \u003cb\u003emosquitoes dying at 24 hours (95% CI) after collection from experimental huts. Circles represent unwashed, hollow circles 20x-washed and triangles unwashed and 20x-washed combined.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 5. Mortality (95% CI) of female\u003c/b\u003e \u003cb\u003eAnopheles arabiensis\u003c/b\u003e \u003cb\u003emosquitoes at 24 hours after collection from experimental huts demonstrating non-inferiority of Yorkool\u0026reg; G3 compared to Olyset\u0026reg; Plus nets. Circles represent unwashed, hollow circles 20x-washed and triangles unwashed and 20x-washed combined. Pink semi-circle represents the non-inferiority margin, that estimates must not fall within to be deemed non-inferior.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;1 Non inferiority analysis of pyrethroid-PBO nets: Yorkool\u0026reg; G3 compared to Olyset\u0026reg; Plus\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eBlood Feeding\u003c/h2\u003e \u003cp\u003eThe proportions of mosquito blood feeding were substantially lower for all treated nets than those of the untreated nets, with all ITNs inducing more than 90% feeding inhibition (Fig.\u0026nbsp;6). The lowest proportions of blood feeding were seen for Olyset\u0026reg; Plus nets (Fig.\u0026nbsp;6). Yorkool\u0026reg; G3 nets were non-inferior [OR 1.87 (95% CI: 1.46\u0026ndash;2\u003cb\u003e.39\u003c/b\u003e)] to Olyset\u0026reg; Plus nets; the upper confidence interval value was lower than the delta (δ\u0026thinsp;=\u0026thinsp;4.85) (Table\u0026nbsp;1, Fig.\u0026nbsp;7). As was seen for mortality in the superiority analysis, pyrethroid-PBO ITNs reduced blood feeding significantly more than the pyrethroid only ITNs (Table\u0026nbsp;2), indicating the additional benefit of the PBO synergist. Likewise, all ITNs significantly reduced \u003cem\u003eAn. arabiensis\u003c/em\u003e blood feeding compared to untreated net (Table\u0026nbsp;2). Additional results are in supplementary file 3.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 6. Proportion of female\u003c/b\u003e \u003cb\u003eAnopheles arabiensis\u003c/b\u003e \u003cb\u003emosquitoes that blood-fed (95%) after collection.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 7. Blood feeding (95% CI) of female\u003c/b\u003e \u003cb\u003eAnopheles arabiensis\u003c/b\u003e \u003cb\u003emosquitoes after collection from experimental huts demonstrating non-inferiority of Yorkool\u0026reg; G3 compared to Olyset\u0026reg; Plus nets. Circles represent unwashed, hollow circles 20x-washed and triangles unwashed and 20x-washed combined. Pink semi-circle represents the non-inferiority margin, that estimates must not fall within to be deemed non-inferior.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;2 Superiority analysis of pyrethroid-PBO products\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eQuality assurance bioefficacy\u003c/h2\u003e \u003cp\u003eAll the pieces of both unwashed and 20x-washed Yorkool\u0026reg; G3 ITNs which were tested before (15 out of 15 samples) and after (10 out of 10 samples) the experimental hut trial met acceptable quality performances of \u0026ge;\u0026thinsp;95% mosquito knockdown after 60 minutes or \u0026ge;\u0026thinsp;80% mosquito mortality at 24 hours after exposure (WHO criterion for bioefficacy [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]) of the laboratory-reared resistant \u003cem\u003eAn. arabiensis\u003c/em\u003e and susceptible \u003cem\u003eAn. gambiae\u003c/em\u003e mosquitoes. This was also seen for the pyrethroid only ITNs before and after the trial on susceptible \u003cem\u003eAn. gambiae\u003c/em\u003e mosquitoes. However, for the pyrethroid-PBO positive control, Olyset\u0026reg; Plus ITNs, quality assurance was met based on proportion of knock down (KD60) for unwashed condition only, and not on 20x-washed condition, indicating that Olyset\u0026reg; Plus was not as wash resistant, Table\u0026nbsp;3.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;3 Cone test data before washing, after washing 20 times, and after experimental hut trial with pyrethroid susceptible Anopheles gambiae (Ifakara strain) and pyrethroid resistant Anopheles arabiensis (Kingani strain). Number of mosquitoes exposed (No.), number (No.), percent (%) knockdown at 60 minutes (KD60), % 24-hour (24hr) mortality (adjusted for control).\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eChemical content\u003c/h2\u003e \u003cp\u003eThe chemical content of all the nets tested before washing were within the 25% +/- of target dose as per WHO guidelines [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, after washing, only Yorkool\u0026reg; G3 nets, both the deltamethrin and PBO content, were within the target dose, while the pyrethroid and PBO AI target doses of none of the other positive controls were within the range. Although all the nets had high (\u0026gt;\u0026thinsp;95%) wash resistance indices, washing resulted in lower concentration of the active ingredients with Yorkool\u0026reg; nets retaining 94% and 76% of deltamethrin and PBO, respectively, Olyset\u0026reg; Plus 69% of permethrin and 57% of PBO, and PermaNet\u0026reg; 2.0 61% of deltamethrin. The greater retainment of the pyrethroid compared to PBO indicates that the PBO is lost more quickly after 20 washes (Table\u0026nbsp;4).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;4 Insecticidal content of nets by wash: Number of samples tested (N), active ingredient (AI) content (g/kg) with standard deviation (SD), % of nets within 25% +/- of target dose, AI within net spatial variation (% RSD), and wash retention index of Yorkool\u0026reg; G3, Olyset\u0026reg; Plus and PermaNet\u0026reg; 2.0 net samples before and after 20 washes.\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eYorkool\u0026reg; G3 nets, treated with deltamethrin and PBO are considered a new product under the second class of nets described by WHO, \u0026lsquo;ITNs designed to kill host-seeking insecticide-resistant mosquitoes\u0026rsquo;, and that provide greater protection than pyrethroid-only nets [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. For prequalification of this product by WHO, we investigated the wash interval of Yorkool\u0026reg; G3 nets in the laboratory following 2013 WHO guidelines [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and entomological efficacy in experimental huts in Tanzania according to WHO prequalification guidance [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and the non-inferiority guidelines of Global Malaria Programme (GMP) at WHO [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] with a conservative budget to fulfil both of their requirements.\u003c/p\u003e \u003cp\u003eYorkool\u0026reg; G3 nets were found to be non-inferior to the first-in-class pyrethroid-PBO ITNs, Olyset\u0026reg; Plus, in terms of inducing mosquito mortality, and superiority over the first-in-class ITNs. Reasons to this finding could be the technique of dosing, as Yorkool\u0026reg; G3 nets utilise coating technique which allows the insecticide to be readily available on the surface of the net while for Olyset\u0026reg; Plus nets, the insecticide is incorporated into the fibres of the net which is gradually released overtime. The higher mortality seen with the Yorkool\u0026reg; G3 nets may also be attributed to the different pyrethroids used in each net. Olyset\u0026reg; Plus nets are treated with permethrin which is known to have high repellency effect [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. This may result in less contact with the net and therefore less time to pick up a lethal dose, compared to deltamethrin with less of a repellency effect. The lower blood-feeding inhibition of Yorkool\u0026reg; G3 nets compared to Olyset\u0026reg; Plus nets is consistent with a recent study comparing Olyset\u0026reg; Plus with another deltamethrin-PBO net, PermaNet\u0026reg; 3.0 [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], which was also attributed to the effect of the different pyrethroids used. For an ideal controlled experiment, products with identical chemicals should be used, however the availability of such products may be limited particularly if manufacturers are reluctant to provide their net for testing. For quality purposes, nets used in non-inferiority analyses should be sourced from the manufacturers directly.\u003c/p\u003e \u003cp\u003eEntomological efficacy of enhanced mortality and reduced blood feeding induced by the addition of PBO to pyrethroid ITNs to metabolic pyrethroid resistant malaria vectors was demonstrated in this study for both PBO products, confirming the utility of such nets for malaria control. Similar effects have been reported in previous experimental hut trials in northern Tanzania [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], Benin [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], Burkina Faso [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] and Ivory coast [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. However, the magnitude of the observed effects can vary depending on factors such as hut design, location, and the resistance intensity and mechanism of vector in different areas [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The current study was conducted in an area where \u003cem\u003eAn. arabiensis\u003c/em\u003e is the most dominant vector and which is metabolic resistance to all classes of pyrethroid [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe epidemiological efficacy of pyrethroid-PBO nets have been confirmed in large-scale cluster randomised-controlled trials in Tanzania and Uganda [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Given the comparable performance of Yorkool\u0026reg; G3 nets to the-first-in class pyrethroid-PBO ITN, Olyset\u0026reg; Plus, the net evaluated in these trials, it could be assumed that Yorkool\u0026reg; G3 nets would also be of public health value, however community durability studies are needed to ensure that the ITNs are durable such that they provide sustained protection and remain cost-effective over three years, usually the interval of ITN campaigns [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Durability in the field (the strength of the fabric and insecticide resistance to abrasion, wear and tears) of an ITN is not equal to the simulated \u0026lsquo;aging\u0026rsquo; of the nets through washing (20x-washes). Factors that affect net durability when used in the community, and not accounted for through laboratory or field washing, including how the nets are used and maintained (human behaviour) and environmental conditions that affect insecticide evaporation loss, washing, and abrasion, among many others [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne of the factors that makes a net \u0026ldquo;long lasting\u0026rdquo; is the ability of the net to consistently have sufficient chemical content available at its surface to induce high mortality of mosquitoes following contact. This was seen for Yorkool\u0026reg; G3 in the quality checks, 100% of the original chemical content was observed after 20x-washes. In bioefficacy evaluations before the hut trials, 67% of exposed insecticide resistant mosquitoes died, whilst mortality following the studies was 95%. This was not the case for the pyrethroid-PBO comparator net; none of the net pieces evaluated were within the target dose range for a chemical retention for the pyrethroid-PBO comparator, and poor mortality recorded in the cone bioassay experiment. This may be due to the difference in the treatment technique, as one utilised coating of the insecticide on the net surface and the other incorporated the insecticide within the fibres. Furthermore, different pyrethroids were compared, deltamethrin in the Yorkool\u0026reg; G3 nets and permethrin in the Olyset\u0026reg; Plus nets. As indicated before, the first-in-class product in this case differed in a number of aspects and may have been considered an inappropriate control in non-inferiority and superiority studies generally. One potential limitation of non-inferiority analyses where a first-in-class product has to be the standard comparator, is when the entomological efficacy in terms of mosquito mortality is lower than any other product to be compared. In this case second or third in class products may always appear non-inferior. Conversely, if the first-in-class product results in very high mosquito mortality, then future products that may still have public health value, may be shown to be inferior in many instances. This was taken into account by WHO and resulted in the non-inferiority margin being widened from 5\u0026ndash;7% [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven the current situation of increasing resistance in malaria-vectors, that contributes to the stalling or increase in malaria prevalence in certain malaria-endemic regions [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], rotation of pyrethroids has been suggested for management of insecticide resistance [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], however studies have shown no significant effect in the restoring of susceptibility of malaria vectors to pyrethroid insecticides [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. A promising strategy is to explore the rotation of classes of AI, such as using Yorkool\u0026reg; G3 ITNs in rotation with other limited classes of AI, instead of ignoring pyrethroid-PBO products due to the evidence of a superiority efficacy of a chlorfenapyr product over a pyrethroid-PBO product [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. In a nutshell, it is pertinent to encourage more classes of AI for development to ensure the swift feasibility of rotation of AI for insecticide resistance management.\u003c/p\u003e \u003cp\u003eOur studies fulfilled WHO recommended requirements for conducting non-inferiority studies in experimental huts [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] as follows: 1) selection of a study site where the primary vectors against which the nets are designed to target dominate, i.e. for pyrethroid-PBO nets the primary malaria vectors resistant to pyrethroids. In Lupiro, the dominant malaria vector is \u003cem\u003eAnopheles arabiensis\u003c/em\u003e and has been shown to be resistant to several pyrethroids. Studies of insecticide susceptibility at the time of the experiment demonstrated mortalities of 16%, 48% and 22% against permethrin, deltamethrin and alpha-cypermethrin, respectively (Supplementary Table\u0026nbsp;2)., 2) using recommended hut designs. Our studies were conducted in Ifakara experimental huts, one of the listed designs by WHO [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], 3) using a study design that reduces variability. Using a 7\u0026times;7 Latin Square design in fourteen huts, our study aimed to minimise variability as far as possible. With the use of many huts, multiple replicates could be undertaken in a short time period with minimal budget implications, 4) ensuring the study is of sufficient power, i.e. \u0026gt;80%, Using a thousand simulation of the model of the data analysis and accounting for estimates (using data from previous studies, the number of mosquitoes per night, % mortality of mosquitoes, and variation between huts, volunteers and day) it was estimated that the study had greater than 98% power. 5) using mortality as the primary outcome, assess non-inferiority and superiority of products using appropriate statistical analyses where the treatment, hut, volunteer and day are included in the model as fixed effects [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eYorkool\u0026reg; G3 ITNs were shown to be non-inferior to the first-in-class product within the pyrethroid-PBO ITN intervention class, Olyset\u0026reg; Plus, based on induced mosquito mortality and blood-feeding inhibition. Yorkool\u0026reg; G3 nets were also found to be superior to the standard pyrethroid-only ITN \u0026ndash; PermaNet\u0026reg; 2.0. Yorkool\u0026reg; G3 ITNs therefore meet the WHO\u0026rsquo;s criteria for being prequalified as an efficacious vector control tool to be used in areas with metabolic resistant malaria vectors. Our non-inferiority and superiority evaluations were easy to implement and could be feasibly conducted within the recommended time frame and to a reasonable cost, following the guidelines set by the prequalification team and GMP at WHO.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Active Ingredient\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAn\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cem\u003eAnopheles\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFIC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;First-in-Class\u003c/p\u003e\n\u003cp\u003eIHI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Ifakara health institute\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eITN\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Insecticide-treated net\u003c/p\u003e\n\u003cp\u003eM24\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mortality at 24 hours\u003c/p\u003e\n\u003cp\u003ePBO\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Piperonyl butoxide\u003c/p\u003e\n\u003cp\u003eRT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Regeneration time\u003c/p\u003e\n\u003cp\u003eSIC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Second-in-class\u003c/p\u003e\n\u003cp\u003eVCPTU\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Vector Control Product Testing Unit\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; World health organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHeartfelt appreciation goes to the entire team of VCPTU both based in Bagamoyo and Lupiro for their dedication and implementation of the study. A huge thanks to the people of Lupiro for their cooperation during the study. We extend our gratitude to Fu Haili, Yin Qing and the entire team of the Yorkool\u0026reg; International Trading Co., Ltd, China for the funding provided to implement the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOGO conceptualised and conducted the experimental hut trial, analysed all data and drafted the manuscript; MSM co-drafted the manuscript; EM substantially adviced on the implementation of the study and reviewed the manuscript; WN supervised the experimental hut trial and reviewed the manuscript; RP provided logistics support and reviewed the manuscript; SN, ABM, IM conducted all bioassays testing and reviewed the manuscript; HN and GL supervised volunteers, record observations and reviewed the manuscripts, JM adviced on the implementation of the study designs and reviewed the manuscript; YM and JS substantially reviewed the manuscript; and SJM was the principal investigator who conceptualised the study and substantially reviewed the manuscript. All authors approved the final draft of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTianjin Yorkool International Trading Co., Ltd, China provided fund for the testing of the products.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available in supplementary files. File 4 contains cone bioassay data on unwashed net pieces before experimental hut trial, file 5 contains cone bioassay data for 20x wash net pieces before experimental hut trial, file 6 contains cone bioassay data for unwashed and 20x washed net pieces after experimental hut trial, file 7 contains experimental hut trial data and file 8 contains chemical analysis data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the IHI Review Board with certificate number IHI/IRB/No: 29-2020 and the National Institute for Medical Research-Tanzania (NIMR) with a certificate number NIMR/HQ/R.8a/Vol.IX/3521.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePermission to publish was granted by\u0026nbsp;the National Institute for Medical Research-Tanzania (NIMR) referenced BD.242/437/01B/14.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOGO, MSM, JS, EM, KS, RP, SN, ABM, IM, HN, JM, and SJM test vector control products.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBhatt S, Weiss DJ, Cameron E, Bisanzio D, Mappin B, Dalrymple U, Battle KE, Moyes CL, Henry A, Eckhoff PA, et al: \u003cstrong\u003eThe effect of malaria control on \u003cem\u003ePlasmodium falciparum\u003c/em\u003e in Africa between 2000 and 2015.\u003c/strong\u003e \u003cem\u003eNature \u003c/em\u003e2015, \u003cstrong\u003e526:\u003c/strong\u003e207-+.\u003c/li\u003e\n\u003cli\u003eAbuelmaali SA, Elaagip AH, Basheer MA, Frah EA, Ahmed FT, Elhaj HF, Seidahmed OM, Weetman D, Mahdi Abdel Hamid M: \u003cstrong\u003eImpacts of agricultural practices on insecticide resistance in the malaria vector Anopheles arabiensis in Khartoum State, Sudan.\u003c/strong\u003e \u003cem\u003ePLoS One \u003c/em\u003e2013, \u003cstrong\u003e8:\u003c/strong\u003ee80549.\u003c/li\u003e\n\u003cli\u003eMatowo NS, Tanner M, Munhenga G, Mapua SA, Finda M, Utzinger J, Ngowi V, Okumu FO: \u003cstrong\u003ePatterns of pesticide usage in agriculture in rural Tanzania call for integrating agricultural and public health practices in managing insecticide-resistance in malaria vectors.\u003c/strong\u003e \u003cem\u003eMalar J \u003c/em\u003e2020, \u003cstrong\u003e19:\u003c/strong\u003e257.\u003c/li\u003e\n\u003cli\u003eRanson H, Lissenden N: \u003cstrong\u003eInsecticide Resistance in African Anopheles Mosquitoes: A Worsening Situation that Needs Urgent Action to Maintain Malaria Control.\u003c/strong\u003e \u003cem\u003eTrends Parasitol \u003c/em\u003e2016, \u003cstrong\u003e32:\u003c/strong\u003e187-196.\u003c/li\u003e\n\u003cli\u003eWHO: \u003cstrong\u003eGlobal report on insecticide resistance in malaria vectors: 2010\u0026ndash;2016.\u003c/strong\u003e Geneva: World Health Organization; 2018.\u003c/li\u003e\n\u003cli\u003eGleave K, Lissenden N, Chaplin M, Choi L, Ranson H: \u003cstrong\u003ePiperonyl butoxide (PBO) combined with pyrethroids in insecticidetreated nets to prevent malaria in Africa (Review).\u003c/strong\u003e \u003cem\u003eCochrane Database of Systematic Reviews \u003c/em\u003e2021.\u003c/li\u003e\n\u003cli\u003eDadzie SK, Chabi J, Asafu-Adjaye A, Owusu-Akrofi O, Baffoe-Wilmot A, Malm K, Bart-Plange C, Coleman S, Appawu MA, Boakye DA: \u003cstrong\u003eEvaluation of piperonyl butoxide in enhancing the efficacy of pyrethroid insecticides against resistant Anopheles gambiae s.l. in Ghana.\u003c/strong\u003e \u003cem\u003eMalaria Journal \u003c/em\u003e2017, \u003cstrong\u003e16\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eProtopopoff N, Mosha JF, Lukole E, Charlwood JD, Wright A, Mwalimu CD, Manjurano A, Mosha FW, Kisinza W, Kleinschmidt I, Rowland M: \u003cstrong\u003eEffectiveness of a long-lasting piperonyl butoxide-treated insecticidal net and indoor residual spray interventions, separately and together, against malaria transmitted by pyrethroid-resistant mosquitoes: a cluster, randomised controlled, two-by-two fact.\u003c/strong\u003e \u003cem\u003eThe Lancet \u003c/em\u003e2018, \u003cstrong\u003e391:\u003c/strong\u003e1577-1588.\u003c/li\u003e\n\u003cli\u003eWHO:\u003cstrong\u003e List of WHO prequalifed vector control products.\u003c/strong\u003e vol. 2023. 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Mallya E, Jumanne M, Aziz T, Kaaya R, et al: \u003cstrong\u003eEffectiveness and cost-effectiveness against malaria of three types of dual-active-ingredient long-lasting insecticidal nets (LLINs) compared with pyrethroid-only LLINs in Tanzania: a four-arm, cluster-randomised trial.\u003c/strong\u003e \u003cem\u003eLancet \u003c/em\u003e2022, \u003cstrong\u003e399:\u003c/strong\u003e1227-1241.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1 Non inferiority analysis of pyrethroid-PBO nets: Yorkool\u0026reg; G3 compared to Olyset\u0026reg; Plus\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.587628865979383%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003e\u003cstrong\u003eProduct\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCondition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDelta for 7% difference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.61855670103093%\"\u003e\n \u003cp\u003eOR (95%CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003eTest outcome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.587628865979383%\" rowspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003eMortality at 24 hrs\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Primary Outcome)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" rowspan=\"2\"\u003e\n \u003cp\u003ePooled*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.61855670103093%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.76923076923077%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.46153846153846%\"\u003e\n \u003cp\u003e1.78 (\u003cstrong\u003e1.65\u003c/strong\u003e \u0026ndash; 1.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-inferior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.512820512820515%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"2\"\u003e\n \u003cp\u003eUnwashed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.512820512820515%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.76923076923077%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.46153846153846%\"\u003e\n \u003cp\u003e1.69 (\u003cstrong\u003e1.51\u003c/strong\u003e \u0026ndash; 1.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-inferior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.512820512820515%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"2\"\u003e\n \u003cp\u003e20x washed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.512820512820515%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.76923076923077%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.46153846153846%\"\u003e\n \u003cp\u003e1.85 (\u003cstrong\u003e1.68\u003c/strong\u003e \u0026ndash; 2.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-inferior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.587628865979383%\" rowspan=\"6\"\u003e\n \u003cp\u003eBlood feeding (Secondary outcome)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" rowspan=\"2\"\u003e\n \u003cp\u003ePooled*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" rowspan=\"2\"\u003e\n \u003cp\u003e4.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.61855670103093%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.76923076923077%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.46153846153846%\"\u003e\n \u003cp\u003e1.87 (1.46 \u0026ndash; \u003cstrong\u003e2.39\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-inferior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.512820512820515%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"2\"\u003e\n \u003cp\u003eUnwashed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"2\"\u003e\n \u003cp\u003e4.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.512820512820515%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.76923076923077%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.46153846153846%\"\u003e\n \u003cp\u003e2.55 (1.73 \u0026ndash; \u003cstrong\u003e3.75\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-inferior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"20.512820512820515%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"2\"\u003e\n \u003cp\u003e20x washed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" rowspan=\"2\"\u003e\n \u003cp\u003e4.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.641025641025642%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.512820512820515%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.76923076923077%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.46153846153846%\"\u003e\n \u003cp\u003e1.49 (1.08 \u0026ndash; \u003cstrong\u003e2.05\u003c/strong\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.76923076923077%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-inferior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e*unwashed and washed nets combined.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOdds ratio for the effect of Yorkool\u0026reg; G3 ITNs compared to the pyrethroid-PBO positive control, Olyset\u0026reg; Plus, estimated using logistic regression adjusting for the effect of volunteer, day, and hut as fixed effects. For the pooled analysis, wash condition was adjusted for as a fixed effect. For 24-hr mortality, lower margin of the confidence interval must be higher than delta. For blood feeding, upper margin of the confidence interval must be lower than delta.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eTable 2 Superiority analysis of pyrethroid-PBO products\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003e\u003cstrong\u003eProduct\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCondition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95%CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003eTest outcome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.402061855670103%\" rowspan=\"18\"\u003e\n \u003cp\u003eOdds ratio for the effect of pyrethroid-PBO ITNs compared to the pyrethroid positive control, PermaNet\u0026reg; 2.0,\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" rowspan=\"9\"\u003e\n \u003cp\u003e\u003cstrong\u003eMortality at 24 hrs\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Primary Outcome)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003ePermaNet\u0026reg; 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" rowspan=\"3\"\u003e\n \u003cp\u003ePooled*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.63 (1.52 \u0026ndash; 1.76)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.91 (2.69 \u0026ndash; 3.14)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.535211267605632%\"\u003e\n \u003cp\u003ePermaNet\u0026reg; 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.309859154929576%\" rowspan=\"3\"\u003e\n \u003cp\u003eUnwashed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.35211267605634%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.084507042253522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.16 (1.93 \u0026ndash; 2.43)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.66 (3.24 \u0026ndash; 4.13)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.535211267605632%\"\u003e\n \u003cp\u003ePermaNet\u0026reg; 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.309859154929576%\" rowspan=\"3\"\u003e\n \u003cp\u003e20x washed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.35211267605634%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.084507042253522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.33 (1.20 \u0026ndash; 1.47)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.46 (2.23 \u0026ndash; 2.72)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.476190476190476%\" rowspan=\"9\"\u003e\n \u003cp\u003eBlood feeding (Secondary outcome)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\"\u003e\n \u003cp\u003ePermaNet\u0026reg; 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.476190476190476%\" rowspan=\"3\"\u003e\n \u003cp\u003ePooled*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.428571428571427%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.904761904761905%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.36 (0.29 \u0026ndash; 0.45)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.68 (0.55 \u0026ndash; 0.83)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.535211267605632%\"\u003e\n \u003cp\u003ePermaNet\u0026reg; 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.309859154929576%\" rowspan=\"3\"\u003e\n \u003cp\u003eUnwashed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.35211267605634%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.084507042253522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.28 (0.19 \u0026ndash; 0.40)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.71 (0.52 \u0026ndash; 0.96)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.027\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.535211267605632%\"\u003e\n \u003cp\u003ePermaNet\u0026reg; 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.309859154929576%\" rowspan=\"3\"\u003e\n \u003cp\u003e20x washed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.35211267605634%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.084507042253522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.44 (0.33 \u0026ndash; 0.58)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.65 (0.50 \u0026ndash; 0.86)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.402061855670103%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003e\u003cstrong\u003eProduct\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCondition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95%CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003eTest outcome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.402061855670103%\" rowspan=\"20\"\u003e\n \u003cp\u003eOdds ratio for the effect of ITNs compared to the negative control, SafiNet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\" rowspan=\"10\"\u003e\n \u003cp\u003e\u003cstrong\u003eMortality at 24 hrs\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Primary Outcome)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUntreated net\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.402061855670103%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.556701030927837%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.309278350515465%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.43298969072165%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.535211267605632%\"\u003e\n \u003cp\u003ePermaNet\u0026reg; 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.309859154929576%\" rowspan=\"3\"\u003e\n \u003cp\u003ePooled*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.35211267605634%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.80 (3.14 \u0026ndash; 4.60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.084507042253522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e6.21 (5.15 \u0026ndash; 7.50)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e11.05 (9.13 \u0026ndash; 13.37)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.535211267605632%\"\u003e\n \u003cp\u003ePermaNet\u0026reg; 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.309859154929576%\" rowspan=\"3\"\u003e\n \u003cp\u003eUnwashed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.35211267605634%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.17 (2.60 \u0026ndash; 3.87)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.084507042253522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e6.85 (5.65 \u0026ndash; 8.31)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e11.59 (9.51 \u0026ndash; 14.13)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.535211267605632%\"\u003e\n \u003cp\u003ePermaNet\u0026reg; 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.309859154929576%\" rowspan=\"3\"\u003e\n \u003cp\u003e20x washed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.35211267605634%\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.12 (2.57 \u0026ndash; 3.78)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.084507042253522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.14 (3.42 \u0026ndash; 5.01)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e7.68 (6.34 \u0026ndash; 9.30)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.476190476190476%\" rowspan=\"10\"\u003e\n \u003cp\u003eBlood feeding (Secondary outcome)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.047619047619047%\"\u003e\n \u003cp\u003eUntreated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.476190476190476%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.428571428571427%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.904761904761905%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.535211267605632%\"\u003e\n \u003cp\u003ePermaNet\u0026reg; 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.309859154929576%\" rowspan=\"3\"\u003e\n \u003cp\u003ePooled*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.35211267605634%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.38 (0.30 \u0026ndash; 0.49)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.084507042253522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.14 (0.10 \u0026ndash; 0.18)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.26 (0.20 \u0026ndash; 0.34)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.535211267605632%\"\u003e\n \u003cp\u003ePermaNet\u0026reg; 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.309859154929576%\" rowspan=\"3\"\u003e\n \u003cp\u003eUnwashed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.35211267605634%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.40 (0.30 \u0026ndash; 0.52)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.084507042253522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.11 (0.08 \u0026ndash; 0.16)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.28 (0.21 \u0026ndash; 0.38)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.535211267605632%\"\u003e\n \u003cp\u003ePermaNet\u0026reg; 2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.309859154929576%\" rowspan=\"3\"\u003e\n \u003cp\u003e20x washed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.35211267605634%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.35 (0.27 \u0026ndash; 0.44)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.084507042253522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.718309859154928%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eOlyset\u0026reg; Plus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.15 (0.11 \u0026ndash; 0.20)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.586206896551722%\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.03448275862069%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.23 (0.17 \u0026ndash; 0.30)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.24137931034483%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.137931034482758%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuperior\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*unwashed and washed nets combined\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote: Estimations were done using logistic regression adjusting for the effect of volunteer, day, and hut as fixed effects. For the pooled analysis, wash condition was adjusted for fixed effect. For superiority on mortality, OR must be higher than 1.00 and p-value\u0026lt;0.05, and for blood feeding, OR must be lower than 1.00 and p-value \u0026lt;0.05.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eTable 3 Cone test data before washing, after washing 20 times, and after experimental hut trial with pyrethroid susceptible Anopheles gambiae (Ifakara strain) and pyrethroid resistant Anopheles arabiensis (Kingani strain). Number of mosquitoes exposed (No.), number (No.), percent (%) knockdown at 60 minutes (KD60), % 24-hour (24hr) mortality (adjusted for control).\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOlyset\u0026reg;\u0026reg; Plus\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eYorkool\u0026reg; G3\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePermaNet\u0026reg; 2.0\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStrain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment Arm\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNo. KD60\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e% KD60\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNo. mortality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e% 24hr mortality\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNo. KD60\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e% KD60\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNo. mortality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e% 24hr mortality\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNo. KD60\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e% KD60\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eNo. mortality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e% 24hr mortality\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eSusceptible \u003cem\u003eAn. gambiae\u003c/em\u003e s.s.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline quality check\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e206\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68.7\u003c/p\u003e\n \u003cp\u003e(62.2 \u0026ndash; 75.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e20x washed before hut\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17.3\u003c/p\u003e\n \u003cp\u003e(12.9-21.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.7\u003c/p\u003e\n \u003cp\u003e(5.3-12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eunwashed after hut\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e175\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e87.5\u003c/p\u003e\n \u003cp\u003e(79.3-95.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e186\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e93.0\u003c/p\u003e\n \u003cp\u003e(88.3 \u0026ndash; 97.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e20x washed after hut\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e181\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e90.5\u003c/p\u003e\n \u003cp\u003e(85.3\u0026ndash;95.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003cp\u003e(16.7-33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eResistant \u003cem\u003eAn. arabiensis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline quality check\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e206\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68.7\u003c/p\u003e\n \u003cp\u003e(63.7-73.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e20x washed before hut\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.0\u003c/p\u003e\n \u003cp\u003e(3.1\u0026ndash;8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.3\u003c/p\u003e\n \u003cp\u003e(7.5-17.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e201\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e67.0\u003c/p\u003e\n \u003cp\u003e(62.0-72.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eunwashed after hut\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48.0\u003c/p\u003e\n \u003cp\u003e(37.2-58.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e84.5\u003c/p\u003e\n \u003cp\u003e(79.4-89.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e20x washed after hut\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e71.5\u003c/p\u003e\n \u003cp\u003e(64.6-78.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15.0\u003c/p\u003e\n \u003cp\u003e(9.6-20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e189\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e94.5\u003c/p\u003e\n \u003cp\u003e(91.3-97.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 4 Insecticidal content of nets by wash: Number of samples tested (N), active ingredient (AI) content (g/kg) with standard deviation (SD), % of nets within 25% +/- of target dose, AI within net spatial variation (% RSD), and wash retention index of Yorkool\u0026reg; G3, Olyset\u0026reg; Plus and PermaNet\u0026reg; 2.0 net samples before and after 20 washes.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eTreatment Arm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAI content (g/kg) before trial\u003c/p\u003e\n \u003cp\u003eArithmetic Mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e% Within target dose range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAI Within Net Variation (% RSD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAI retained after 20 washes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eWash Resistance Index (%) (AI retained per wash)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAI Content (g/kg) after trial\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eArithmetic Mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 washes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20 washes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 washes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20 washes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 washes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20 washes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0 washes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20 washes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3 deltamethrin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.08\u003c/p\u003e\n \u003cp\u003e(0.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.91\u003c/p\u003e\n \u003cp\u003e(0.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e94.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e99.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.07\u003c/p\u003e\n \u003cp\u003e(0.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.91\u003c/p\u003e\n \u003cp\u003e(0.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYorkool\u0026reg; G3 PBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.26\u003c/p\u003e\n \u003cp\u003e(0.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.52\u003c/p\u003e\n \u003cp\u003e(0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e98.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.21\u003c/p\u003e\n \u003cp\u003e(0.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.53\u003c/p\u003e\n \u003cp\u003e(0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOlyset\u0026reg;\u0026reg;Plus permethrin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19.26\u003c/p\u003e\n \u003cp\u003e(0.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.28\u003c/p\u003e\n \u003cp\u003e(0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e69.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e98.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19.35\u003c/p\u003e\n \u003cp\u003e(0.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.22\u003c/p\u003e\n \u003cp\u003e(0.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOlyset\u0026reg;\u0026reg;Plus\u003c/p\u003e\n \u003cp\u003ePBO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.84\u003c/p\u003e\n \u003cp\u003e(0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.58\u003c/p\u003e\n \u003cp\u003e(0.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e97.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.87\u003c/p\u003e\n \u003cp\u003e(0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.49\u003c/p\u003e\n \u003cp\u003e(0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePermaNet\u0026reg; 2.0 deltamethrin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.43\u003c/p\u003e\n \u003cp\u003e(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003cp\u003e(0.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e97.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.44\u003c/p\u003e\n \u003cp\u003e(0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003cp\u003e(0.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Supplementary File","content":"\u003cp\u003eSupplementary File 7 is not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"malaria-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"malj","sideBox":"Learn more about [Malaria Journal](http://malariajournal.biomedcentral.com/)","snPcode":"12936","submissionUrl":"https://submission.nature.com/new-submission/12936/3","title":"Malaria Journal","twitterHandle":"@malariajournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"ITN, non-inferiority, insecticide resistance, pyrethroid, PBO, Yorkool® G3, mosquito, malaria, experimental hut, Tanzania","lastPublishedDoi":"10.21203/rs.3.rs-4510891/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4510891/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eNon-inferiority trials are recommended by the World Health Organization (WHO) to demonstrate that health products show comparable efficacy. As part of the WHO Global Malaria Programme (GMP) process of assessment of malaria vector control products, a second-in-class insecticide treated net (ITN) must be shown to be non-inferior to a first-in-class product based on mosquito mortality. The public health impact of the first-in-class pyrethroid-piperonyl butoxide (PBO) ITN, Olyset\u0026reg; Plus, has been demonstrated in epidemiological trials in areas with insecticide-resistant mosquitoes, but there is need to determine the efficacy of other pyrethroid-PBO nets to ensure timely market availability of nets and so to increase access to ITNs. The non-inferiority of a deltamethrin-PBO ITN Yorkool\u0026reg; G3 was evaluated entomologically against Olyset\u0026reg; Plus in experimental huts in Tanzania, following WHO guidelines for non-inferiority trials.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThe trial of the two pyrethroid-PBO ITNs was conducted in experimental huts in Lupiro, Tanzania, using a randomised double-blind 7 x 7 Latin Square block design. The study ran for 49 nights in 14 huts assessing the mosquito mortality and blood feeding of wild free-flying resistant \u003cem\u003eAnopheles arabiensis\u003c/em\u003e. Using the non-inferiority approach, the efficacy (mosquito mortality at 24 hours and blood feeding) of unwashed and 20 times field-washed pyrethroid-PBO Yorkool\u0026reg; G3 ITNs, were compared with the first-in-class product Olyset\u0026reg; Plus and against a pyrethroid-only ITN, PermaNet\u0026reg; 2.0 ITNs, as a standard comparator.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe experimental hut trial demonstrated the non-inferiority of Yorkool\u0026reg; G3 to Olyset\u0026reg; Plus based on mortality [51% vs 39%, respectively, OR 1.68 (95% CI: \u003cb\u003e1.50\u0026ndash;1\u003c/b\u003e.88)], given that lower 95% CI exceeded 0.74 (delta of 39%). Blood feeding inhibition was high for all treated ITNs (\u0026gt;\u0026thinsp;90%). The pyrethroid-PBO ITNs were superior to the pyrethroid-only net, PermaNet\u0026reg; 2.0, as determined by both the proportion of mortality and blood feeding of mosquitoes (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eYorkool\u0026reg; G3 ITNs demonstrated non-inferiority to the first-in-class Olyset Plus and superiority over the standard pyrethroid-only ITN, PermaNet\u0026reg; 2.0 as measured by mortality and blood feeding inhibition of wild insecticide resistant \u003cem\u003eAn. arabiensis\u003c/em\u003e mosquitoes. Yorkool\u0026reg; G3 ITNs are therefore potential tools for the control of metabolic insecticide resistant malaria vectors.\u003c/p\u003e","manuscriptTitle":"The non-inferiority efficacy of Piperonyl-butoxide Yorkool® G3 Insecticide treated nets in the experimental huts in Tanzania","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-15 12:27:27","doi":"10.21203/rs.3.rs-4510891/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-18T14:37:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-06T14:22:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-18T07:09:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-17T21:41:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"39727390428395724242948454763725915186","date":"2024-06-30T11:04:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"24936210526498663212610987603296027096","date":"2024-06-26T15:38:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"68336449623765450429608105681829396324","date":"2024-06-26T08:31:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"67737842988910860219840540007340917987","date":"2024-06-26T04:18:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"39733753249895164263232065520677722655","date":"2024-06-25T06:36:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-24T03:41:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-01T07:41:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-01T07:41:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"Malaria Journal","date":"2024-05-31T19:43:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"malaria-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"malj","sideBox":"Learn more about [Malaria Journal](http://malariajournal.biomedcentral.com/)","snPcode":"12936","submissionUrl":"https://submission.nature.com/new-submission/12936/3","title":"Malaria Journal","twitterHandle":"@malariajournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5c8e9658-9abf-47b2-8dd1-499f3f3be1a2","owner":[],"postedDate":"June 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-21T16:02:32+00:00","versionOfRecord":{"articleIdentity":"rs-4510891","link":"https://doi.org/10.1186/s12936-024-05130-7","journal":{"identity":"malaria-journal","isVorOnly":false,"title":"Malaria Journal"},"publishedOn":"2024-10-16 15:57:38","publishedOnDateReadable":"October 16th, 2024"},"versionCreatedAt":"2024-06-15 12:27:27","video":"","vorDoi":"10.1186/s12936-024-05130-7","vorDoiUrl":"https://doi.org/10.1186/s12936-024-05130-7","workflowStages":[]},"version":"v1","identity":"rs-4510891","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4510891","identity":"rs-4510891","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}