Will a lack of fabric durability be their downfall? Impact of textile durability on the efficacy of three types of dual-active-ingredient long-lasting insecticidal nets: A secondary analysis on malaria prevalence and incidence from a cluster-randomized trial in north-west Tanzania

Will a lack of fabric durability be their downfall? Impact of textile durability on the efficacy of three types of dual-active-ingredient long-lasting insecticidal nets: A secondary analysis on malaria prevalence and incidence from a cluster-randomized trial in north-west 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 Will a lack of fabric durability be their downfall? Impact of textile durability on the efficacy of three types of dual-active-ingredient long-lasting insecticidal nets: A secondary analysis on malaria prevalence and incidence from a cluster-randomized trial in north-west Tanzania Eliud Lukole, Jackie Cook, Jacklin F Mosha, Elizabeth Mallya, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3974056/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background The Dual-Active Ingredient long-lasting insecticidal nets (Dual-AI LLIN) have been developed to counteract the reduced efficacy of pyrethroid (PY)-only nets due to widespread pyrethroid insecticide resistance in malaria vector mosquitoes. They constitute half of the nets distributed in sub-Saharan Africa in the past two years. However, their effectiveness once they develop holes is unclear, particularly in pyrethroid-resistant settings. This study evaluates the textile integrity of three dual- AI LLINs compared to standard PY LLN, over 3 years of use in a community in Tanzania and the associated impact on malaria prevalence and incidence. Methods Between 2019 and 2022, we conducted a secondary analysis of data from a randomized controlled trial (RCT) in North-western Tanzania to evaluate the effectiveness of α-cypermethrin only; pyriproxyfen and α-cypermethrin (PPF-PY); chlorfenapyr and α-cypermethrin (chlorfenapyr-PY); and the synergist piperonyl butoxide and permethrin (PBO-PY) LLINs on malaria infection prevalence and case incidence. We assessed the association between the net textile condition and 1/malaria prevalence over 3 years of use, and 2/malaria case incidence in a cohort of children over 2 years of follow-up. Results There was no significant association between damaged (OR: 0.98, 95%CI: 0.71-1.37, p-value=0.6550) and too-torn (OR: 1.07, 95%CI: 0.77-1.47, p-value=0.6940) compared to intact nets on malaria prevalence for all net types. However, there were reduced rates of malaria case incidence in children sleeping under a net in good condition compared to extremely torn nets (incidence rate ratio (IRR) 0·76 [95%CI: 0.63-0.92], p=0.0047). Malaria incidence was also consistently lower in too-torn PBO-PY LLIN (IRR= 0.37 [95%CI: 0.19-0.72], p= 0.0033) and Chlorfenapyr-PY LLIN (IRR= 0.45 [95%CI: 0.33-0.97], p= 0.0525) compared to a intact PY-only LLIN during the first year of follow up. In year 2, the incidence was only significantly lower in intact Chlorfenapyr-PY LLIN (IRR= 0.49 [95%CI: 0.29-0.81], p= 0.0059) compared to intact PY LLIN. Conclusion Our study confirmed that sleeping under a Chlorfenapyr-PY LLIN or PBO-PY LLIN offered superior protection to pyrethroid-only nets even when torn. Preventing the development of holes is essential as they impact the level of protection offered against malaria infection. Trial registration ClinicalTrials.gov, number (NCT03554616) Background Malaria prevention has relied on mosquito nets treated with pyrethroid insecticides for decades. 1 Scaling up of long-lasting insecticidal nets (LLINs) has averted an estimated 2 billion cases and 12 million deaths between 2000 and 2021. 1 Due to the emergence and spread of pyrethroid insecticide resistance in malaria vector mosquitoes, new classes of LLINs combining a pyrethroid and a second insecticide with a different mode of action, 2, 3 or a pyrethroid and synergist piperonyl butoxide (PBO) 4 have been developed as alternatives to pyrethroid only LLINs. 5 The addition of these classes of LLINs to the market of malaria vector control products is vital to help mitigate further development of insecticide resistance. 1 Several randomized controlled trials (RCT) have shown the superior efficacy of the combination of pyrethroid and PBO (trade names: Olyset Plus and Permanet 3), 6, 7 pyrethroid- chlorfenapyr insecticides (Interceptor G2), 8, 9 and some nets treated with pyrethroid-pyriproxyfen insecticides (Olyset Duo 10 ), compared to standard pyrethroid-only LLIN. Based on the evidence generated by these RCTs, the new net classes are now being rolled out on a large scale. In sub-Saharan Africa, around 350 million have already been distributed since 2018, and half of the nets distributed in the past two years were PBO-pyrethroid nets or dual active ingredient nets, with these numbers set to increase 11 as these nets are gradually replacing pyrethroid-only nets in areas of pyrethroid resistance. However, the longer-term effectiveness of a net is impacted by its functional survival in field conditions. 12 Several studies have reported reduced effectiveness of holed LLINs in areas with pyrethroid resistance; however, these studies tend to be laboratory-based 13 , experimental-hut trials 14–16 , and assessing pyrethroid-only treated LLINs. 17–19 The present study reports on a secondary analysis of a large randomized controlled trial in Tanzania that evaluated the effectiveness of dual-AI LLINs. 20 In our first report, we showed that combining pyrethroids with either chlorfenapyr or PBO provides further protection against malaria infection prevalence, malaria incidence, and entomological indices over one or two years of use compared to standard LLIN. 8 Here, we report on the textile integrity of three dual-AI LLINs; Chlorfenapyr-PY LLIN, Pyriproxyfen-PY LLIN, and PBO-PY LLIN, over time and examine the relationship of net fabric quality with malaria prevalence and incidence. Methods Study design and settings The study took place in 17 wards (72 villages) on the southern border of Lake Victoria, Misungwi district (latitude 2°51'00.0"S, longitude 33°04'60.0"E), Mwanza region, in northwestern Tanzania. This is a secondary analysis of a four-arm, double-blinded cluster randomized trial (CRT) that assessed the effectiveness of dual-AI LLINs on malaria outcomes. 8, 20 The following treatments were randomly allocated to 21 clusters each (Additional file 1): Interceptor (alpha-cypermethrin, [control] arm), Interceptor G2 (Chlorfenapyr-PY LLIN (alpha-cypermethrin + chlorfenapyr), Royal Guard (Pyriproxyfen-PY LLIN (alpha-cypermethrin + pyriproxyfen), and Olyset Plus (permethrin + piperonyl butoxide (PBO)). In September/October 2021 (33 months post net distribution), the Tanzanian National Malaria Control Program (NMCP) distributed 40,000 Olyset Plus in the study area via the school net program (SNP). Participants Malaria infection prevalence was measured during repeated cross-sectional surveys at 12 months (t12; January/February 2020), 18 months (t18; July/August 2020), 24 months (t24; January/February 2021), 30 months (t30; July/August 2021), and 36 months (t36; January/February 2022) post-intervention. Two children aged between 6 months and 14 years from each of 45 randomly selected households per cluster were tested for malaria infection using rapid diagnostic tests (RDT) (CareStart malaria HRP2 [pf], DiaSys, Wokingham, UK). In each cluster, the textile integrity of study LLINs was assessed in at least 13 randomly selected houses (out of 45) at t12, t24, and t30 and in at least 16 households (to account for fewer nets remaining in the households) at the t36 months survey. Due to the COVID-19 pandemic, holes in the nets were not assessed at t18 to adhere to safety protocols. This secondary analysis is restricted to children in households selected for net textile integrity assessment. A cohort of 2940 children (35 children per cluster on average) aged 6 months to 10 years was recruited after net distribution in February 2019 and followed for one year until January 2020 to assess malaria case incidence. A second cohort of 3360 (40 children per cluster) was recruited one year after net distribution in February 2020 and followed up for one year until January 2021. Procedures Between January 26th and 28th, 2019, the four types of nets were distributed to study arms as allocated and detailed elsewhere. 8 In each household selected for fabric integrity, a maximum of 3 study LLINs used the previous night were randomly selected for hole assessment, with priority given to the net used by the selected children for malaria infection prevalence testing. In the cohort, malaria parasitaemia was measured bi-weekly at a central meeting point. Children with fever (tympanic temperature ≥ 37·5°C) or a history of fever in the past 48 h were tested for malaria parasites by rapid diagnostic test (CareStart malaria HRP2/pLDH [pf/ pan] combo, DiaSys, Wokingham, UK). Children with a positive rapid diagnostic test or minor illness were treated by trained study nurses/clinicians as per national guidelines. At the end of each cohort year (last follow-up visit) from 12th December 2019 to 28th January 2020 for year 1, and from 1st December 2020 to 27th January 2021 for year 2, guardians/child caretakers of all cohort children were asked to bring the nets that a cohort child had been using for textile integrity assessment by trained field-workers. During these last cohort visits, alongside the net integrity assessment, malaria parasitaemia was measured in all children regardless of whether they had a fever or a history of fever. These data provide a direct link between the net condition and malaria infection status of the net’s user since the cohort child slept under the same net throughout the previous year. The number and size of holes, hole location on the net, and type of holes were recorded for each selected study net. The size was classified into four categories per WHO guidelines: size 1 = 0·5–1·99 cm, size 2 = 2–9·99 cm, size 3 = 10–25 cm, and size 4 > 25 cm. The size of the holes was estimated by superimposing transparent plastic with illustrations of hole sizes. The hole surface area (HSA) for each net was then calculated as the number of holes counted multiplied by the size category weights as per WHO guidelines 21 as follows: HSA= (1·23 x no. of size1 holes) + (28·28 x no. of size2 holes) + (240·56 x no. of size3 holes) + (706·95 x no. size4 holes). Based on the HSA, each net was then categorized as good (HSA: ≤ 79 cm 2 ), damaged (HAS: 80–789 cm 2 ), or extremely-torn (HSA: > 789 cm 2 ). Hole types included: holes at the hanging points, holes caused by tears, holes caused by burns, holes caused by rodents, and holes caused by sharp objects. Data collection was done on smartphones using the Open-Data-Kit (ODK) software. Data from each field team was directly uploaded to a secure database at the London School of Hygiene and Tropical Medicine (LSHTM). After completion of the surveys, datasets were transferred to STATA release 15 (StataCorp, College Station, TX, USA) for further aggregation, cleaning, and preparation for analysis. Outcomes The study outcomes were malaria prevalence in children aged 6 months − 14 years and incidence in children aged 6 months − 10 years using dual-AI LLINs compared with standard PY LLIN with different textile conditions. Statistical analysis The analysis for this study was restricted to study nets distributed in January 2019. The cross-sectional data collected at t30 were excluded from analysis due to seasonality (collected during the dry season while the rest of the surveys were in the rainy season). Household social and economic wealth indices were constructed and analysed by Principal component analysis (PCA) and were subdivided into wealth tertiles. Wald tests of multiple comparisons of means were used to compare hole surface area differences between study LLINs. For cross-sectional data, the association between net physical condition and malaria infection prevalence was assessed using mixed-effects logistic regression. The association between net physical condition and cumulative incidence of malaria infection in cohort study was analysed by mixed-effects Poisson regression with individual follow-up time specified as an offset and cluster set as a random effect. Furthermore, each dual-AI LLIN in different physical condition were compared to good PY LLIN on malaria infection to assess their superiority in protection. Interactions between net type and net physical condition, survey timepoint and net type were examined. Results A total of 4876 households were selected for textile durability assessment over the four cross-sectional surveys between 07th January 2020 and 10th February 2022. Of these, 67% (n = 3284) consented to participate in the study. From the consenting households, 5817 children were tested for malaria infection, and 5060 study LLINs (1464 PY-LLIN, 1500 Chlorfenapyr-PY LLIN, 1181 Pyriproxyfen-PY LLIN, and 915 PBO-PY LLIN) were assessed for fabric integrity. At baseline (October 2018), malaria prevalence measured in children aged 6 months to 14 years was 44% (1948/4403), balanced across study arms. 8, 20 Ownership of any net (at least 1 net per household) remained high over the study period, from 99.7% 3 months after net distribution to 96.2% (1036/1077) at t36. Ownership of study net (≥ 1 study LLIN per house) declined over the three years of the study from a high of 92% (697/755 houses) after t12 in January 2020 to 62% (672/1077) in January 2022 (Table 1 ). Reported study net use recorded during cross-sectional surveys also declined over the three years of the study from 72% (3155/4373) three months after the mass distribution in January 2019 8 to 23% (2068/9044) in January 2022 at t36 (Table 1 ). The lowest study net use was in the PBO-PY group at the t36 timepoint (19% (286/1469)). Between t30 and t36, the ownership of other PBO-PY LLIN in the study area (in all arms) increased from 13% (229/1723) to 33% (1076/3263) due to the local government-led top-up campaigns through the School Net program (SNP) (Additional file 6). Table 1 Household, socioeconomic, and net characteristics of participating households in the cross-sectional surveys Covariates Cross-sectional survey Cross-sectional survey timepoint 12 months 24 months 30 months 36 months Mean number of people per household (sd), N 7.1 (3.0), 755 8.1 (3.4), 803 8.0 (3.6), 649 8.4 (3.8), 1077 Mean number of children (< 15 years) per household (sd), N * 3.6 (1.9), 755 4.2 (2.1), 803 4.0 (2.2), 649 4.2 (2.2), 1077 Mean number of sleeping spaces used last night (sd), N 2.9 (1.4), 755 3.2 (1.6), 803 3.2 (1.5), 649 3.5 (1.7), 1077 Households characteristics : % electricity (95%CI), N 24.5 (21.6–27.7) 27.3 (24.3–30.5) 36.1 (32.5–39.8) 37.7 (34.9–40.6) % open eaves: (95%CI), N 32.1 (28.8–35.5) 34.1 (30.9–37.5) 34.9 (31.4–38.7) 31.57 (28.9–34.4) Main housing materials % floor: earth/sand (95%CI), N 64.8 (61.3–68.1) 67.6 (64.3–70.8) 58.6 (54.7–62.3) 61.8 (58.8–64.6) % roof: tin (95%CI), N 71.9 (68.6–75.0) 72.7 (69.5–75.7) 77.2 (73.8–80.3) 74.5 (71.8–77.0) % walls: unburnt bricks or mud (95%CI), N 79.3 (76.3–82.1) 78.5 (75.5–81.2) 76.4 (73.0-79.5) 76.9 (74.3–79.3) % no ceiling (95%CI), N 97.5 (96.1–98.4) 97.9 (96.6–98.7) 96.5 (94.7–97.6) 96.8 (95.5–97.7) % plastered walls 67.3 (63.9–70.5) 63.0 (59.6–66.3) 67.5 (63.8–71.0) 67.3 (64.5–70.1) Mean number of mosquito nets owned per household (sd), N Any LLIN 3.8 (1.8), 755 3.1 (1.6), 803 2.7 (1.6), 649 3.0 (1.8), 1077 Study LLIN 2.5 (1.5), 755 1.6 (1.2), 803 1.2 (1.1), 649 1.1 (1.1), 1077 Mean number of nets used last night per household (sd), N Any LLIN 2.4 (1.3), 755 2.4 (1.3), 803 2.0 (1.3), 649 2.3 (1.5), 1077 Study LLIN 1.6 (1.2), 755 1.2 (1.1), 803 0.9 (1.0), 649 0.8 (0.9), 1077 Proportion of households with at least 1 net % (n/N) Any LLIN 100 (755/755) 98.5 (791/803) 95.5 (620/649) 96.2 (1036/1077) Study LLIN 92.3 (697/755) 78.3 (629/803) 66.6 (432/649) 62.4 (672/1077) Proportion of participants reporting using a net the night before % (n/N) Any LLIN 81.3 (4306/5294) 75.4 (4899/6502) 62.3 (3220/5170) 67.8 (6128/9041) Study LLIN 51.6 (2805/5435) 37.4 (2432/6502) 27.8 (1439/5171) 22.9 (2068/9044) Varieties of nets available in the household N = 3010 N = 2513 N = 1723 N = 3263 % Pyrethroid (PY) LLIN (n) 16.5 (498) 14.0 (352) 14.2 (245) 11.3 (369) % Chlorfenapyr-PY LLIN (n) 18.5 (557) 13.7 (345) 12.6 (217) 11.7 (318) % PBO-PY LLIN (n) 13.4 (403) 8.6 (215) 8.1 (139) 4.8 (158) % Pyriproxyfen-PY LLIN (n) 15.2 (458) 13.0 (327) 10.3 (178) 6.7 (218) % Permanet 2.0 (n) 17.4 (525) 19.2 (482) 20.3 (349) 16.6 (543) % Olyset net (n) 13.9 (419) 23.8 (597) 18.6 (312) 13.7 (447) % Olyset Plus (distributed by NMCP) (n) 0.3 ( 9 ) 6.37 (160) 13.3 (229) 33.0 (1076) % Others nets (n) 1.3 (141) 0.6 ( 35 ) 1.2 (45) 1.0 (71) Number of children tested for malaria (n/N) 1275/1374 1476/1534 1146/1227 1920/2026 % Malaria infection in 6 months-14 years children (95%CI) 18.7 (16.6–20.9) 38.4 (35.9–40.9) 45.6 (42.7–48.5) 31.1 (29.1–33.2) sd: standard deviation; CI: confidence intervals; N: total number of observations, NMCP: National Malaria Control Program In the nets collected during cross-sectional surveys, overall, at t12, 54% (597/1110) of the study nets had at least one hole of any size (53% (152/285)-pyrethroid (PY) LLIN, 48% (162/341)-Chlorfenapyr-PY LLIN, 52% (125/241)-Pyriproxyfen-PY LLIN, and 65% (158/243)-PBO-PY LLIN), and this increased to 82% (830/1007) (84% (274/326)-PY-LLIN, 81% (280/346)-Chlorfenapyr-PY LLIN, 81% (162/200)-Pyriproxyfen-PY LLIN and 84% (114/135)-PBO-PY LLIN) at t36. Similarly, the mean Hole Surface Area (HSA) increased from 340 cm² to 1242 cm² in Pyrethroid-PY, 355 cm² to 1325 cm² in Chlorfenapyr-PY LLIN, 526 cm² to 1301 cm² in Pyriproxyfen-PY LLIN and 990 cm² to 2060 cm² in PBO-PY LLIN between t12 and t36 (Additional file 3). There were no significant differences in mean HSA between PY-LLIN, Chlorfenapyr-PY LLIN, and Pyriproxyfen-PY LLIN at any survey time point, while PBO-PY LLIN had substantially higher HSA at each time point than any other study net (Additional file 3). The overall percentage of extremely torn nets in the cross-sectional surveys increased from 17% (189/1110) at t12 to 35% (372/1055) at t24 and stabilised between 44% (311/700) at t30 and 43% (432/575) at t36 (Additional file 2). In all net brands, the lower part of the nets (bottom zone) was more damaged than the rest of the zones (Additional file 4). All new nets had similar dimensions (height: 180cm); however, after three years of field use, the height decreased disproportionately between net brands to 170cm for PY-LLIN, 174 cm for Chlorfenapyr-PY LLIN, 157cm for Pyriproxyfen-PY LLIN, and 158cm for PBO-PY LLIN (Additional file 5). There was no significant association between malaria prevalence and net condition: damaged (OR: 0.98, 95%CI: 0.71–1.37, p-value = 0.6550) and too-torn (OR: 1.07, 95%CI: 0.77–1.47, p-value = 0.6940) compared to good nets (Table 2 ; Additional file 10). Malaria infection was also significantly lower for children living in clusters that received Chlorfenapyr-PY LLINs compared to those living in clusters that received PY LLINs regardless of the physical condition (Table 2 ). Children from houses with more than 50% of the sleeping spaces covered by the study nets had lower odds of malaria (OR: 0.61, 95%CI: 0.42–0.87, p-value = 0.006) than households with fewer sleeping spaces covered. The odds of malaria in all arms increased with time since the net distribution, however, was lower at t36 compared to t24, and this was likely related to the distribution of PBO-PY LLIN in all arms in October 2021 (four months before t36 survey) in the study area via the school-net program (SNP). Moreover, children sleeping under nets had lower odds of malaria infection than children not using any nets (Additional file 7). In the surveyed households, the majority of households reported closing the main doors at night, getting inside houses, and sleeping time between 21h and 22h (Additional file 9). Table 2 Association between net physical condition and malaria prevalence in children aged 6 months to 14 years Covariate %Infection (n/N) Adjusted OR 95% CI p-value Net condition Good 24.6 (180/733) 1 (Ref) Damaged 25.4 (109/429) 0.98 0.71–1.37 0.6550 Too-torn 28.3 (146/516) 1.07 0.77–1.47 0.6940 Study arm Pyrethroid (PY) LLIN 33.7 (168/498) 1 (Ref) Chlorfenapyr-PY LLIN 17.7 (90/508) 0.40 0.23–0.69 0.001 Pyriproxyfen-PY LLIN 28.4 (101/356) 0.80 0.47–1.38 0.430 PBO-PY LLIN 24.1 (76/316) 0.62 0.35–1.08 0.091 Cross-sectional survey 12 months post-intervention 17.0 (103/607) 1 (Ref) 24 months post-intervention 36.1 (210/582) 2.93 2.15–3.99 < 0.001 36 months post-intervention 25.0 (122/489) 1.72 1.22–2.43 0.002 Children age 0–4 years 14.8 (97/656) 1 (Ref) 5–10 years 30.5 (213/699) 2.86 2.13–3.85 < 0.001 11–14 years 38.7 (125/323) 4.62 3.25–6.58 < 0.001 SES Lowest 27.5 (156/567) 1 (Ref) Middle 27.2 (155/571) 0.92 0.68–1.26 0.622 Highest 23.0 (124/540) 0.66 0.46–0.93 0.018 Eaves Yes 30.7 (167/544) 1 (Ref) No 23.6 (268/1134) 0.78 0.59–1.04 0.096 Household study net coverage* Too few ( = 50%) 27.4 (1775) 0.61 0.42–0.87 0.006 *Household study net coverage: is the proportion of sleeping spaces in the household used last night covered by study net; There was no evidence of interaction between net physical condition and net type, p-value = 0.9814. There was no evidence of interaction between net type and survey timepoint, p-value = 0.5010. In the cohort, 5019 children (2256 in year 1 and 2763 in year 2) were assessed alongside the study nets they used at the last cohort visit. Of these children, 2239 (99%) in year 1 and 2403 (87%) in year 2 declared to own study nets. These nets were brought for physical condition assessment. Overall, the mean HSA in the cohort nets was 786 cm² for year 1 and 1047 cm² for year 2. Over the two years of cohort study, the overall percentage of extremely torn nets increased from 19% (430/2234) at t12 to 33% (801/2397) at t24 (Additional file 2). There were increased rates of malaria cases in children sleeping under too-torn nets (IRR 1.33 [95% CI 1.12–1.57], p = 0.0012) compared to sleeping under good nets (Table 3 ). Lower rates of malaria cases were associated with living in houses with the highest social-economic status (IRR 0·77 [95% CI 0.63–0.96], p = 0.0189), using Chlorfenapyr-PY LLIN (IRR 0·49 [95% CI 0.31–0.79], p = 0·0035). Higher rates were associated with using study nets that were two years old (IRR 1·41 [95% CI 1.19–1.67], p = 0.0001). Older children and living in a house with open eaves were not associated with a higher incidence of malaria. Table 3 Association between net physical condition and malaria case incidence in children aged 6 months to 10 years Covariate Number of clinical episodes Follow-up time child years Incidence per child per year Adjusted Rate ratio 95%CI p-value Study net condition Good 573 2268.4 0.25 1 (ref) Damaged 258 902.9 0.29 1.18 0.97–1.43 0.0936 Too-torn 379 1184.7 0.32 1.33 1.12–1.57 0.0012 Study arm Pyrethroid (PY) LLIN 392 1114.7 0.35 1 (ref) Chlorfenapyr-PY LLIN 174 1120.4 0.16 0.49 0.31–0.79 0.0035 Pyriproxyfen-PY LLIN 363 1124.4 0.32 1.00 0.64–1.58 0.9844 PBO-PY LLIN 281 996.5 0.28 0.83 0.52–1.32 0.4334 Cohort year year1 434 1931.4 0.22 1 (ref) year2 776 2424.6 0.32 1.41 1.19–1.67 0.0001 Children age group 0–4 years 512 1879.7 0.27 1 (ref) 5–10 years 698 2476.3 0.28 1.08 0.92–1.27 0.3604 Socio-economic status Lowest 296 899.6 0.33 1 (ref) Middle 273 897.2 0.30 0.96 0.79–1.16 0.6542 Highest 217 874.0 0.25 0.77 0.63–0.96 0.0189 Eaves No 829 3061.1 0.27 1 (ref) Yes 381 1294.8 0.29 1.00 0.82–1.21 0.9768 In order to assess if the dual-AI LLINs were superior to PY LLINs against incidence regardless of their textile conditions, we compared each net type and condition to a PY LLIN in good condition. During the first year of follow-up, the protective effect of extremely-torn dual-AI LLINs compared to good (HSA: ≤ 79 cm 2 ) PY LLIN against malaria case incidence was strongest for (HSA: > 789 cm 2 ) PBO-PY LLIN (IRR 0·37 [95% CI 0·19 − 0·72], p = 0·0033), borderline for chlorfenapyr-PY LLIN (IRR: 0·45 [95% CI 0·33 − 0·97], p = 0·0525) and no additional protection was given by pyriproxyfen-PY LLIN (IRR 1·15 [95% CI 0·61 − 2·17], p = 0·6596). Sleeping under a good PBO-PY LLIN or a good chlorfenapyr-PY LLIN was more protective than sleeping under a good PY LLIN against malaria case incidence. For children using pyriproxyfen-PY LLIN, however, there was a slight decrease in malaria incidence in children sleeping under damaged nets (0.26 cases per child/year) or good nets (0.24 cases per child/year); however, those differences were not significant compared to good PY LLIN (IRR = 0.74 [95% 0.38–1.46], p = 0.3856) -for damaged pyriproxyfen-PY LLIN and (IRR = 0.78 [95% 0.46–1.34], p = 0.3688) for good pyriproxyfen-PY LLIN (Table 4 a). Table 4 a: Association between net physical condition and malaria case incidence in children aged 6 months to 10 years in year 1 LLIN type and condition Number of clinical episodes Follow-up time child years Incidence per child per year Adjusted Rate ratio 95%CI p-value Pyrethroid (PY) LLIN Good 104 313.48 0.33 1 Damaged 36 95.67 0.38 0.90 0.57–1.43 0.6538 Too-torn 30 81.17 0.37 0.93 0.56–1.54 0.7778 Pyriproxyfen-PY LLIN Good 83 342.67 0.24 0.78 0.46–1.34 0.3688 Damaged 22 84.64 0.26 0.74 0.38–1.46 0.3856 Too-torn 34 84.41 0.40 1.15 0.61–2.17 0.6596 PBO-PY LLIN Good 33 199.70 0.17 0.43 0.23–0.80 0.0076 Damaged 12 70.58 0.17 0.61 0.28–1.33 0.2128 Too-torn 22 174.74 0.13 0.37 0.19–0.72 0.0033 Chlorfenapyr-PY LLIN Good 34 309.56 0.11 0.35 0.28–0.71 0.0006 Damaged 15 96.40 0.16 0.51 0.38–1.03 0.0675 Too-torn 10 79.30 0.13 0.45 0.33–0.97 0.0525 In year 2, compared to those sleeping under good PY-LLIN, only children sleeping under chlorfenapyr-PY LLIN in good condition had a significant and more substantial protective effect (IRR = 0.49 [95% CI 0.52–1.37], p = 0.0059) against malaria case incidence (Table 4 b). There was no reduced risk of infection associated with sleeping under too-torn PBO-PY LLIN (IRR = 1.36 [95% 0.86–2.16], p = 0.1858) and too-torn Pyriproxyfen-PY LLIN (IRR = 1.46 [95% CI 0.89–2.37], p = 0.1305) in year 2 compared to PY-LLIN in good condition. Table 4 b: Association between net physical condition and malaria case incidence in children aged 6 months to 10 years in year 2 LLIN type and condition Number of clinical episodes Follow-up time child years Incidence per child per year Rate ratio 95%CI p-value Pyrethroid (PY) LLIN Good 107 312.18 0.34 1 Damaged 62 159.22 0.39 1.19 0.83–1.70 0.3533 Too-torn 53 152.95 0.35 1.07 0.74–1.56 0.7125 Pyriproxyfen-PY LLIN Good 80 299.81 0.27 0.85 0.52–1.37 0.4949 Damaged 57 133.47 0.43 1.37 0.82–2.28 0.2308 Too-torn 87 179.46 0.48 1.46 0.89–2.37 0.1305 PBO-PY LLIN Good 67 181.21 0.37 1.18 0.72–1.94 0.5144 Damaged 26 91.19 0.29 0.98 0.54–1.77 0.9505 Too-torn 119 275.63 0.43 1.36 0.86–2.16 0.1858 Chlorfenapyr-PY LLIN Good 50 317.19 0.16 0.49 0.29–0.81 0.0059 Damaged 36 169.21 0.21 0.67 0.39–1.16 0.1499 Too-torn 30 153.87 0.19 0.64 0.36–1.14 0.1286 Discussion As part of a cluster randomised trial of dual-active ingredient malaria vector control interventions, we assessed the textile conditions of the dual-AI LLINs [namely: Chlorfenapyr-PY LLIN, Pyriproxyfen-PY LLIN, and a PBO-PY LLIN] after three years of use in the community. 8 We then explored the associations between net conditions and malaria prevalence (from repeated cross-sectional surveys) and incidence (from a cohort study) in Mwanza region, Tanzania. In this study, based on the cross-sectional survey data, there was no evidence indicating that the condition of the net was associated with malaria prevalence. Indeed, it was observed that good, damaged, and too-torn study nets appeared to offer similar levels of personal protection against malaria infection prevalence after adjusting for several covariates, such as net age, child age, presence of eaves in the house, socio-economic status, and household level net coverage. The strong protection provided by high household coverage of nets (> 50%) highlights the importance of promoting high levels of ownership and retention of nets in all households. Additionally, from the repeated cross-sectional measures, we also observed that study nets offered protection to those sleeping under them against malaria infection, and that sleeping under any net with holes provided more protection than sleeping without a net at all, similar to studies undertaken in Malawi 17, 18, 22 , and Equatorial Guinea. 18 LLINs, as the principal form of malaria vector control in the study area, reduced malaria infection by 54%, regardless of the net type and whether they had holes, compared to not using a net at all. Notably, even users of pyrethroid-only LLINs were far more protected than non-net users. This finding supports existing evidence that pyrethroid-only LLINs still provide protection compared to sleeping without a net, even in insecticide-resistant settings. 17, 22, 23 Several studies have reported on the association between increased levels of damage of pyrethroid-only nets and increased malaria infection, 18, 24 while others reported no association. 25, 26 However, while we saw no impact of differences in net integrity on malaria prevalence, in our cohort study, there was a strong association between net textile condition and malaria case incidence, unlike the cohort study in Malawi. 22 In the first year, when the insecticides were in suitable 8 concentrations, torn Chlorfenapyr-PY LLIN and PBO-PY LLIN were better than good PY-LLIN. However, in the second year, only good Chlorfenapyr-PY LLIN was better than good PY-LLIN; this may be explained by waning insecticide concentrations in the dual-AI LLINs over time 8 . Torn pyriproxyfen-PY LLINs (in the first and second year) and torn PBO-PY LLINs (during the second year) of use did not provide superior protection against malaria case incidence compared to good PY LLINs. This is consistent with results generated recently in Tanzania 8 and Benin 9 , where Pyriproxyfen-PY LLINs and PBO-PY LLIN did not perform well during the second year. This study supports and adds weight to previous studies that suggested the impaired effectiveness of these two products is likely related to poor fabric integrity, leading to an unexpected decline in community coverage. However, a systematic review of 22 published studies reported that wear and tear were not identified as a reason for not using mosquito nets when they are the only nets available. 27 In this study, ownership, usage, and textile conditions of all nets declined swiftly over the three years after net distribution. The decline was more marked in the PBO-PY LLIN arm followed by pyriproxyfen-PY LLINs, consistent with the results generated recently in Tanzania in a prospective net cohort study done with the same net. 28 It is fairly standard to see a reduction in usage and ownership in places with no continuous distribution of nets. 18 However, through the continuous distribution of nets in antenatal care (ANC) clinics and the expanded program on immunization (EPI) and school-based programs coverage of other nets in the study area was kept high. 29 In all nets, the damage was most severe in the bottom part. 12, 30 This part has been reported to have limited contribution to mosquito prevention 30 as it is always tucked under a mat or mattress. However, improper tucking of the bed net is not uncommon practice 31 32 33 , and net tucking is very challenging without a proper bed frame; in this study, more than half of the sleeping spaces in surveyed households had no bed frames. For untucked or partially tucked nets, the bottom part will still allow mosquitoes to penetrate. Enhancing the bottom part might remedy nets from early hole development and further enlargement, although other studies have shown that dense knitting in this part of the net did not necessarily make it more durable. 34 Similarities in physical properties (fibers, denier, and integrity) between some nets [chlorfenapyr-PY LLIN and PY-LLIN], but differences in protective efficacy against malaria infection emphasize the pivotal role of non-pyrethroid insecticide and synergists (chlorfenapyr and PBO 35 ) in malaria vector control. In addition, this study demonstrates that the resilient physical integrity of the nets on its own is not enough to provide sustained protection to users of nets in good conditions against bites of malaria-transmitting mosquitoes even in settings of high net coverage, as it was in the cohort children where we observed > 80% use. This is contrary to the review by Okumu (2020), 36 which suggested that physically durable nets could serve a similar purpose as insecticidal nets. Limitations In this study, we only assessed net condition at the end of the year against cumulative incidence over the year; likely, the nets were not in that condition for the whole year. However, when we assessed the association between malaria prevalence and net condition in cohort children during their last visits, it showed similar results. The number of study nets to be assessed decreased over time due decline in coverage, leading to a small number of cross-sectional nets assessed towards the end. However, a better and direct comparison of the protective effect of nets was attained with the cohort nets, which had high access and usage across the study. Net users in the cross-sectional survey tend to replace lightly damaged nets with readily available new ones, likely, the majority of the nets evaluated towards the end of the study were still new or put into usage a few months previously. Conclusion Our results provide evidence that sleeping under extremely-torn chlorfenapyr-PY LLIN and PBO-PY LLIN offered superior protection compared to sleeping under good standard net, and, the protective effect of PBO-PY LLIN diminishes as PBO-treated nets age. The results also show that, when assessing net integrity independent of the protective effect against malaria, chlorfenapyr-PY LLIN nets are physically more durable than PBO-PY LLIN but relatively similar to pyriproxyfen-PY LLIN. The future strategies for control programs reliant on the dual-AI LLINs, therefore, not only seek to provide new nets to households that do not have nets but also instigate strategies to inform the population that even a torn dual-AI LLIN is better than an intact standard net or sleeping without a net; small holes in nets should not motivate households to discard the nets. Furthermore, there should be an emphasis on proper net care and repair practices among users, as well as the necessity for manufacturers to develop physically durable LLINs. Abbreviations LLIN Long-lasting insecticidal net AI Active ingredient PY pyrethroid PBO piperonyl butoxide PPF pyriproxyfen RCT Randomised controlled trial mRDT malaria rapid diagnostic test IRR incidence rate ratio SNP school net program Table 1: Household, socioeconomic, and net characteristics of participating households in the cross sectional surveys Declarations Ethics approval Ethical approval for the RCT was obtained from the institutional review boards of the Tanzanian National Institute for Medical Research (reference number: NIMR/HQ/R.8a/Vol.IX/2743), Kilimanjaro Christian Medical University College (2267), London School of Hygiene and Tropical Medicine (14952), and University of Ottawa (H-05-19-4411). Informed consent to participate in the study should be obtained from parent or guardian or any adult present in the house. Consent for publication Not applicable Availability of data The datasets generated and/or analysed during the current study are not publicly available due strict laws in Tanzania that restrict data to be shared outside the country without a Data Transfer agreement (DTA.pdf (nimr.or.tz)). A DTA process will need to be completed by interested researchers. Competing interests The authors declare that they have no competing interests Funding Department for International Development, UK Medical Research Council, Wellcome Trust, and Department of Health and Social Care (#MR/R006040/1). The Bill and Melinda Gates Foundation via the Innovative Vector Control Consortium (IVCC). The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication. Authors’ contributions EL, JC and NP conceived and designed the study. EL, TA, and JFM led the data collection in the field. EM developed data collection tools and managed the data. EL did statistical analysis with inputs form JC, MAK, IK, and NP. EL wrote the first draft of the manuscript with inputs from JC, and NP. EL and NP had full access and verified the data and had final responsibility for the decision to submit for publication. All authors have reviewed, read, and approved the final version of the manuscript. Acknowledgements We thank colleagues and staff at Pan-African Malaria Vector Research Consortium (PAMVERC) in Misungwi-Mwanza who were involved in the project. We acknowledge the assistance provided by government leaders at the Misungwi District council (district, ward, village and hamlet level). We thank Hon. Juma Sweda (Former Misungwi District Commissioner) and Dr. Thomas Rutachunzibwa (Mwanza Regional Medical Officer) for their immense support for creating friendly atmosphere for running the project. Finally, we thank all the participating households for their cooperation. References WHO. World malaria report 2022. 2022. WHO. Specifications and evaluations for public health pesticides: alpha-cypermethrin + chlorfenapyr. 2019. WHO. WHO specifications and evaluations for public health pesticides alpha-cypermethrin + pyriproxyfen: long-lasting (incorporated into filaments) insecticidal net. 2018. WHO. WHO specifications and evaluations for public health pesticides: deltamethrin + piperonyl butoxide long-lasting (incorporated into filaments) insecticidal net. 2017. WHO. WHO Guidelines for malaria. 2023 14-03-2023. Report No. Protopopoff N, Mosha JF, Lukole E, Charlwood JD, Wright A, Mwalimu CD, et al. Effectiveness 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 factorial design trial. Lancet. 2018;391(10130):1577–88. Rugnao S, Gonahasa S, Maiteki-Sebuguzi C, Opigo J, Yeka A, Katureebe A, et al. LLIN Evaluation in Uganda Project (LLINEUP): factors associated with childhood parasitaemia and anaemia 3 years after a national long-lasting insecticidal net distribution campaign: a cross-sectional survey. Malar J. 2019;18(1):207. Mosha JFKM, Lukole E, Matowo NS, Pitt C, Messenger LA, Mallya E, Jumanne M, Aziz T, Kaaya R, Shirima BA, Isaya G, Taljaard M, Martin J, Hashim R, Thickstun C, Manjurano A, Kleinschmidt I, Mosha FW, Rowland M, Protopopoff N. Effectiveness 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. Lancet 2022;399(10331):1227–1241 2022. Accrombessi M, Cook J, Dangbenon E, Yovogan B, Akpovi H, Sovi A, et al. Efficacy of pyriproxyfen-pyrethroid long-lasting insecticidal nets (LLINs) and chlorfenapyr-pyrethroid LLINs compared with pyrethroid-only LLINs for malaria control in Benin: a cluster-randomised, superiority trial. Lancet. 2023;401(10375):435–46. Tiono AB, Ouedraogo A, Ouattara D, Bougouma EC, Coulibaly S, Diarra A, et al. Efficacy of Olyset Duo, a bednet containing pyriproxyfen and permethrin, versus a permethrin-only net against clinical malaria in an area with highly pyrethroid-resistant vectors in rural Burkina Faso: a cluster-randomised controlled trial. Lancet. 2018;392(10147):569–80. Net mapping project. The elliance for malaria prevention [Internet]. 2021 [cited 08/12/2023]. Available from: https://allianceformalariaprevention.com . Lukole E, Cook J, Mosha JF, Messenger LA, Rowland M, Kleinschmidt I, et al. Protective efficacy of holed and aging PBO-pyrethroid synergist-treated nets on malaria infection prevalence in north-western Tanzania. PLOS Glob Public Health. 2022;2(10):e0000453. Ochomo EO, Bayoh NM, Walker ED, Abongo BO, Ombok MO, Ouma C, et al. The efficacy of long-lasting nets with declining physical integrity may be compromised in areas with high levels of pyrethroid resistance. Malar J. 2013;12:368. Ngufor C, N'Guessan R, Boko P, Odjo A, Vigninou E, Asidi A, et al. Combining indoor residual spraying with chlorfenapyr and long-lasting insecticidal bed nets for improved control of pyrethroid-resistant Anopheles gambiae: an experimental hut trial in Benin. Malar J. 2011;10:343. N'Guessan R, Corbel V, Akogbeto M, Rowland M. Reduced efficacy of insecticide-treated nets and indoor residual spraying for malaria control in pyrethroid resistance area, Benin. Emerg Infect Dis. 2007;13(2):199–206. Irish S, N'Guessan R, Boko P, Metonnou C, Odjo A, Akogbeto M, et al. Loss of protection with insecticide-treated nets against pyrethroid-resistant Culex quinquefasciatus mosquitoes once nets become holed: an experimental hut study. Parasit Vectors. 2008;1(1):17. Lindblade KA, Mwandama D, Mzilahowa T, Steinhardt L, Gimnig J, Shah M, et al. A cohort study of the effectiveness of insecticide-treated bed nets to prevent malaria in an area of moderate pyrethroid resistance, Malawi. Malar J. 2015;14:31. Rehman AM, Coleman M, Schwabe C, Baltazar G, Matias A, Gomes IR, et al. How much does malaria vector control quality matter: the epidemiological impact of holed nets and inadequate indoor residual spraying. PLoS ONE. 2011;6(4):e19205. Bradley J, Ogouyemi-Hounto A, Cornelie S, Fassinou J, de Tove YSS, Adeothy AA, et al. Insecticide-treated nets provide protection against malaria to children in an area of insecticide resistance in Southern Benin. Malar J. 2017;16(1):225. Jacklin F, Mosha MAK, Louisa A, Messenger M, Rowland N, Matowo C, Pitt E, Lukole. Monica Taljaard,Charles Thickstun, Alphaxard Manjurano, Franklin W. Mosha, Immo Kleinschmidt, Natacha Protopopoff. Protocol for a four parallel-arm, singleblind, cluster-randomised trial to assess the effectiveness of three types of dual active ingredient treated nets compared to pyrethroid-only long-lasting insecticidal nets to prevent malaria transmitted by pyrethroid insecticideresistant vector mosquitoes in Tanzania. 2021. WHO/WHOPES. Guidelines for laboratory and field-testing of long-lasting insecticidal nets: Control of neglected tropical diseases WHO pesticide evaluation scheme. 2013. Shah MP, Steinhardt LC, Mwandama D, Mzilahowa T, Gimnig JE, Bauleni A, et al. The effectiveness of older insecticide-treated bed nets (ITNs) to prevent malaria infection in an area of moderate pyrethroid resistance: results from a cohort study in Malawi. Malar J. 2020;19(1):24. Kleinschmidt I, Bradley J, Knox TB, Mnzava AP, Kafy HT, Mbogo C, et al. Implications of insecticide resistance for malaria vector control with long-lasting insecticidal nets: a WHO-coordinated, prospective, international, observational cohort study. Lancet Infect Dis. 2018;18(6):640–9. Mejia P, Teklehaimanot HD, Tesfaye Y, Teklehaimanot A. Physical condition of Olyset(R) nets after five years of utilization in rural western Kenya. Malar J. 2013;12:158. Minta AA, Landman KZ, Mwandama DA, Shah MP, Eng JLV, Sutcliffe JF, et al. The effect of holes in long-lasting insecticidal nets on malaria in Malawi: results from a case-control study. Malar J. 2017;16(1):394. Obala AA, Mangeni JN, Platt A, Aswa D, Abel L, Namae J, et al. What Is Threatening the Effectiveness of Insecticide-Treated Bednets? A Case-Control Study of Environmental, Behavioral, and Physical Factors Associated with Prevention Failure. PLoS ONE. 2015;10(7):e0132778. Pulford J, Hetzel MW, Bryant M, Siba PM, Mueller I. Reported reasons for not using a mosquito net when one is available: a review of the published literature. Malar J. 2011;10:83. Jackline Martin EL, Louisa A, Messenger T, Aziz E, Mallya E, Bernard NS, Matowo, Jacklin F, Mosha M, Rowland FW, Mosha. Alphaxard Manjurano and Natacha Protopopoff. Monitoring of Fabric Integrity and Attrition Rate of Dual-Active Ingredient Long-Lasting Insecticidal Nets in Tanzania: A Prospective Cohort Study Nested in a Cluster Randomized Controlled Trial. 2024. WHO-GMP. Achieving and maintaining universal coverage with long-lasting insecticidal nets for malaria control: Recommendations. 2017. Lorenz LM, Bradley J, Yukich J, Massue DJ, Mageni Mboma Z, Pigeon O, et al. Comparative functional survival and equivalent annual cost of 3 long-lasting insecticidal net (LLIN) products in Tanzania: A randomised trial with 3-year follow up. PLoS Med. 2020;17(9):e1003248. Msellemu D, Shemdoe A, Makungu C, Mlacha Y, Kannady K, Dongus S, et al. The underlying reasons for very high levels of bed net use, and higher malaria infection prevalence among bed net users than non-users in the Tanzanian city of Dar es Salaam: a qualitative study. Malar J. 2017;16(1):423. Teklemariam Z, Awoke A, Dessie Y, Weldegebreal F. Ownership and utilization of insecticide-treated nets (ITNs) for malaria control in Harari National Regional State, Eastern Ethiopia. Pan Afr Med J. 2015;21:52. Pooseesod K, Parker DM, Meemon N, Lawpoolsri S, Singhasivanon P, Sattabongkot J, et al. Ownership and utilization of bed nets and reasons for use or non-use of bed nets among community members at risk of malaria along the Thai-Myanmar border. Malar J. 2021;20(1):305. Skovmand O, Bosselmann R. Strength of bed nets as function of denier, knitting pattern, texturizing and polymer. Malar J. 2011;10:87. Martin JL, Mosha FW, Lukole E, Rowland M, Todd J, Charlwood JD, et al. Personal protection with PBO-pyrethroid synergist-treated nets after 2 years of household use against pyrethroid-resistant Anopheles in Tanzania. Parasit Vectors. 2021;14(1):150. Okumu F. The fabric of life: what if mosquito nets were durable and widely available but insecticide-free? Malar J. 2020;19(1):260. Additional Declarations No competing interests reported. Supplementary Files Additionalfiles.docx Additional files Additional file 1: Characteristics of the study nets distributed as part of the project in January 2029 Additional file 2: Study nets in good, damaged and too-torn condition (data from cross-sectional and cohort nets) Additional file 3: Multiple comparisons of the mean surface area of the holes in the study nets between nets types and age Additional file 4: Mean holes per study net per survey by zones (data from cross-sectional survey) Additional file 5: Mean height of the study net at t0, t30 and t36 Additional file 6: Source of nets in the study area Additional file 7: Association between sleeping under of different net physical condition and malaria prevalence in children aged 6 months to 14 years Additional file 8: Association between net physical condition and malaria prevalence in children aged 6 months to 10 years Additional file 9: Time people get inside the house and close the main doors Additional file 10: Interaction between net physical condition and net type Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 17 Apr, 2024 Reviews received at journal 03 Apr, 2024 Reviews received at journal 29 Mar, 2024 Reviews received at journal 25 Mar, 2024 Reviews received at journal 17 Mar, 2024 Reviewers agreed at journal 10 Mar, 2024 Reviewers agreed at journal 08 Mar, 2024 Reviewers agreed at journal 08 Mar, 2024 Reviewers agreed at journal 07 Mar, 2024 Reviewers invited by journal 06 Mar, 2024 Editor assigned by journal 21 Feb, 2024 Submission checks completed at journal 21 Feb, 2024 First submitted to journal 20 Feb, 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3974056","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":274016412,"identity":"b8138948-c3fe-4a2f-ba63-afe399e30fb3","order_by":0,"name":"Eliud Lukole","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYDACduYGhgcMcjz8IE5CATFamBkbGBIYjHkkG0BaDEjQwmBwAMQjRgs/M2ObRGKbgYzxjezEDw8MGOT5xQ7g1yLZDNHCY3Yjd7ME0GGGM2cn4NdicBis5Q9IywaQlgSD2wS02B+G2mI8I3fzD6K0GED9wmMgkbuNOFskDjM2WyScM+CROPN2m0WCgQRhv/C3Nx+88aHMwJ6/PXfzzR8VNvL80gS0AAGLBJgSAKuUIKgcBJg/QOw7QJTqUTAKRsEoGIEAAAwEPqGQev2OAAAAAElFTkSuQmCC","orcid":"","institution":"National Institute for Medical Research","correspondingAuthor":true,"prefix":"","firstName":"Eliud","middleName":"","lastName":"Lukole","suffix":""},{"id":274016413,"identity":"092c4b23-74cd-4d11-9256-cb99e3e8c1dd","order_by":1,"name":"Jackie Cook","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jackie","middleName":"","lastName":"Cook","suffix":""},{"id":274016414,"identity":"6ca94452-fe1a-4f66-99a5-89114950fe88","order_by":2,"name":"Jacklin F Mosha","email":"","orcid":"","institution":"National Institute for Medical Research","correspondingAuthor":false,"prefix":"","firstName":"Jacklin","middleName":"F","lastName":"Mosha","suffix":""},{"id":274016415,"identity":"c4340d5f-bad8-4c2e-93a8-52ad7c3a99e3","order_by":3,"name":"Elizabeth Mallya","email":"","orcid":"","institution":"Kilimanjaro Christian Medical University College","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"","lastName":"Mallya","suffix":""},{"id":274016416,"identity":"ddbba55e-d647-4207-8e8b-eff936cd9bea","order_by":4,"name":"Tatu Aziz","email":"","orcid":"","institution":"National Institute for Medical Research","correspondingAuthor":false,"prefix":"","firstName":"Tatu","middleName":"","lastName":"Aziz","suffix":""},{"id":274016417,"identity":"2beb4c2b-28ca-4626-8566-3809dd539477","order_by":5,"name":"Manisha A Kulkarni","email":"","orcid":"","institution":"University of Ottawa","correspondingAuthor":false,"prefix":"","firstName":"Manisha","middleName":"A","lastName":"Kulkarni","suffix":""},{"id":274016418,"identity":"ee9f0a24-91f3-4f07-8670-9aaf2cb7e992","order_by":6,"name":"Nancy S Matowo","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Nancy","middleName":"S","lastName":"Matowo","suffix":""},{"id":274016419,"identity":"deebaa10-f950-478e-a394-b558b4fd35d4","order_by":7,"name":"Jacklin Martin","email":"","orcid":"","institution":"Kilimanjaro Christian Medical University College","correspondingAuthor":false,"prefix":"","firstName":"Jacklin","middleName":"","lastName":"Martin","suffix":""},{"id":274016420,"identity":"f97db874-8036-4a8a-9805-eb28555606b0","order_by":8,"name":"Mark Rowland","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"","lastName":"Rowland","suffix":""},{"id":274016421,"identity":"e3e8e80b-0fa5-4def-8ba6-2edf38bf2e9b","order_by":9,"name":"Immo Kleinschmidt","email":"","orcid":"","institution":"University of the Witwatersrand","correspondingAuthor":false,"prefix":"","firstName":"Immo","middleName":"","lastName":"Kleinschmidt","suffix":""},{"id":274016422,"identity":"b2ff3012-c72e-4c87-b551-a06ab3b2e91a","order_by":10,"name":"Alphaxard Manjurano","email":"","orcid":"","institution":"National Institute for Medical Research","correspondingAuthor":false,"prefix":"","firstName":"Alphaxard","middleName":"","lastName":"Manjurano","suffix":""},{"id":274016423,"identity":"098f7ad1-3eba-43c6-a42a-89747e7d41df","order_by":11,"name":"Franklin W Mosha","email":"","orcid":"","institution":"Kilimanjaro Christian Medical University College","correspondingAuthor":false,"prefix":"","firstName":"Franklin","middleName":"W","lastName":"Mosha","suffix":""},{"id":274016424,"identity":"1b241472-f66f-49d1-9a2a-741c7e911a84","order_by":12,"name":"Natacha Protopopoff","email":"","orcid":"","institution":"London School of Hygiene \u0026 Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Natacha","middleName":"","lastName":"Protopopoff","suffix":""}],"badges":[],"createdAt":"2024-02-20 23:44:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3974056/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3974056/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51477665,"identity":"31dc25ef-7fd8-4b98-ac67-61ac217cdaef","added_by":"auto","created_at":"2024-02-22 09:52:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":690744,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3974056/v1/1b946540-bd6c-4ef4-9f94-d7f6659f559a.pdf"},{"id":51477052,"identity":"7f03f414-c2e3-444e-b429-31244fdc3d3d","added_by":"auto","created_at":"2024-02-22 09:44:11","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":209784,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional files\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdditional file 1: Characteristics of the study nets distributed as part of the project in January 2029\u003c/p\u003e\n\u003cp\u003eAdditional file 2: Study nets in good, damaged and too-torn condition (data from cross-sectional and cohort nets)\u003c/p\u003e\n\u003cp\u003eAdditional file 3: Multiple comparisons of the mean surface area of the holes in the study nets between nets types and age\u003c/p\u003e\n\u003cp\u003eAdditional file 4: Mean holes per study net per survey by zones (data from cross-sectional survey)\u003c/p\u003e\n\u003cp\u003eAdditional file 5: Mean height of the study net at t0, t30 and t36\u003c/p\u003e\n\u003cp\u003eAdditional file 6: Source of nets in the study area\u003c/p\u003e\n\u003cp\u003eAdditional file 7: Association between sleeping under of different net physical condition and malaria prevalence in children aged 6 months to 14 years\u003c/p\u003e\n\u003cp\u003eAdditional file 8: Association between net physical condition and malaria prevalence in children aged 6 months to 10 years\u003c/p\u003e\n\u003cp\u003eAdditional file 9: Time people get inside the house and close the main doors\u003c/p\u003e\n\u003cp\u003eAdditional file 10: Interaction between net physical condition and net type\u003c/p\u003e","description":"","filename":"Additionalfiles.docx","url":"https://assets-eu.researchsquare.com/files/rs-3974056/v1/677f817f0091d5416406115c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Will a lack of fabric durability be their downfall? Impact of textile durability on the efficacy of three types of dual-active-ingredient long-lasting insecticidal nets: A secondary analysis on malaria prevalence and incidence from a cluster-randomized trial in north-west Tanzania","fulltext":[{"header":"Background","content":"\u003cp\u003eMalaria prevention has relied on mosquito nets treated with pyrethroid insecticides for decades.\u003csup\u003e1\u003c/sup\u003e Scaling up of long-lasting insecticidal nets (LLINs) has averted an estimated 2\u0026nbsp;billion cases and 12\u0026nbsp;million deaths between 2000 and 2021.\u003csup\u003e1\u003c/sup\u003e Due to the emergence and spread of pyrethroid insecticide resistance in malaria vector mosquitoes, new classes of LLINs combining a pyrethroid and a second insecticide with a different mode of action,\u003csup\u003e2, 3\u003c/sup\u003e or a pyrethroid and synergist piperonyl butoxide (PBO)\u003csup\u003e4\u003c/sup\u003e have been developed as alternatives to pyrethroid only LLINs.\u003csup\u003e5\u003c/sup\u003e The addition of these classes of LLINs to the market of malaria vector control products is vital to help mitigate further development of insecticide resistance.\u003csup\u003e1\u003c/sup\u003e Several randomized controlled trials (RCT) have shown the superior efficacy of the combination of pyrethroid and PBO (trade names: Olyset Plus and Permanet 3),\u003csup\u003e6, 7\u003c/sup\u003e pyrethroid- chlorfenapyr insecticides (Interceptor G2),\u003csup\u003e8, 9\u003c/sup\u003e and some nets treated with pyrethroid-pyriproxyfen insecticides (Olyset Duo\u003csup\u003e10\u003c/sup\u003e), compared to standard pyrethroid-only LLIN.\u003c/p\u003e \u003cp\u003eBased on the evidence generated by these RCTs, the new net classes are now being rolled out on a large scale. In sub-Saharan Africa, around 350\u0026nbsp;million have already been distributed since 2018, and half of the nets distributed in the past two years were PBO-pyrethroid nets or dual active ingredient nets, with these numbers set to increase \u003csup\u003e11\u003c/sup\u003e as these nets are gradually replacing pyrethroid-only nets in areas of pyrethroid resistance. However, the longer-term effectiveness of a net is impacted by its functional survival in field conditions.\u003csup\u003e12\u003c/sup\u003e Several studies have reported reduced effectiveness of holed LLINs in areas with pyrethroid resistance; however, these studies tend to be laboratory-based\u003csup\u003e13\u003c/sup\u003e, experimental-hut trials\u003csup\u003e14\u0026ndash;16\u003c/sup\u003e, and assessing pyrethroid-only treated LLINs.\u003csup\u003e17\u0026ndash;19\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe present study reports on a secondary analysis of a large randomized controlled trial in Tanzania that evaluated the effectiveness of dual-AI LLINs.\u003csup\u003e20\u003c/sup\u003e In our first report, we showed that combining pyrethroids with either chlorfenapyr or PBO provides further protection against malaria infection prevalence, malaria incidence, and entomological indices over one or two years of use compared to standard LLIN.\u003csup\u003e8\u003c/sup\u003e Here, we report on the textile integrity of three dual-AI LLINs; Chlorfenapyr-PY LLIN, Pyriproxyfen-PY LLIN, and PBO-PY LLIN, over time and examine the relationship of net fabric quality with malaria prevalence and incidence.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and settings\u003c/h2\u003e \u003cp\u003eThe study took place in 17 wards (72 villages) on the southern border of Lake Victoria, Misungwi district (latitude 2\u0026deg;51'00.0\"S, longitude 33\u0026deg;04'60.0\"E), Mwanza region, in northwestern Tanzania. This is a secondary analysis of a four-arm, double-blinded cluster randomized trial (CRT) that assessed the effectiveness of dual-AI LLINs on malaria outcomes.\u003csup\u003e8, 20\u003c/sup\u003e The following treatments were randomly allocated to 21 clusters each (Additional file 1): Interceptor (alpha-cypermethrin, [control] arm), Interceptor G2 (Chlorfenapyr-PY LLIN (alpha-cypermethrin\u0026thinsp;+\u0026thinsp;chlorfenapyr), Royal Guard (Pyriproxyfen-PY LLIN (alpha-cypermethrin\u0026thinsp;+\u0026thinsp;pyriproxyfen), and Olyset Plus (permethrin\u0026thinsp;+\u0026thinsp;piperonyl butoxide (PBO)). In September/October 2021 (33 months post net distribution), the Tanzanian National Malaria Control Program (NMCP) distributed 40,000 Olyset Plus in the study area via the school net program (SNP).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eMalaria infection prevalence was measured during repeated cross-sectional surveys at 12 months (t12; January/February 2020), 18 months (t18; July/August 2020), 24 months (t24; January/February 2021), 30 months (t30; July/August 2021), and 36 months (t36; January/February 2022) post-intervention. Two children aged between 6 months and 14 years from each of 45 randomly selected households per cluster were tested for malaria infection using rapid diagnostic tests (RDT) (CareStart malaria HRP2 [pf], DiaSys, Wokingham, UK). In each cluster, the textile integrity of study LLINs was assessed in at least 13 randomly selected houses (out of 45) at t12, t24, and t30 and in at least 16 households (to account for fewer nets remaining in the households) at the t36 months survey. Due to the COVID-19 pandemic, holes in the nets were not assessed at t18 to adhere to safety protocols. This secondary analysis is restricted to children in households selected for net textile integrity assessment.\u003c/p\u003e \u003cp\u003eA cohort of 2940 children (35 children per cluster on average) aged 6 months to 10 years was recruited after net distribution in February 2019 and followed for one year until January 2020 to assess malaria case incidence. A second cohort of 3360 (40 children per cluster) was recruited one year after net distribution in February 2020 and followed up for one year until January 2021.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eProcedures\u003c/h2\u003e \u003cp\u003eBetween January 26th and 28th, 2019, the four types of nets were distributed to study arms as allocated and detailed elsewhere.\u003csup\u003e8\u003c/sup\u003e In each household selected for fabric integrity, a maximum of 3 study LLINs used the previous night were randomly selected for hole assessment, with priority given to the net used by the selected children for malaria infection prevalence testing.\u003c/p\u003e \u003cp\u003eIn the cohort, malaria parasitaemia was measured bi-weekly at a central meeting point. Children with fever (tympanic temperature\u0026thinsp;\u0026ge;\u0026thinsp;37\u0026middot;5\u0026deg;C) or a history of fever in the past 48 h were tested for malaria parasites by rapid diagnostic test (CareStart malaria HRP2/pLDH [pf/ pan] combo, DiaSys, Wokingham, UK). Children with a positive rapid diagnostic test or minor illness were treated by trained study nurses/clinicians as per national guidelines.\u003c/p\u003e \u003cp\u003eAt the end of each cohort year (last follow-up visit) from 12th December 2019 to 28th January 2020 for year 1, and from 1st December 2020 to 27th January 2021 for year 2, guardians/child caretakers of all cohort children were asked to bring the nets that a cohort child had been using for textile integrity assessment by trained field-workers. During these last cohort visits, alongside the net integrity assessment, malaria parasitaemia was measured in all children regardless of whether they had a fever or a history of fever. These data provide a direct link between the net condition and malaria infection status of the net\u0026rsquo;s user since the cohort child slept under the same net throughout the previous year.\u003c/p\u003e \u003cp\u003eThe number and size of holes, hole location on the net, and type of holes were recorded for each selected study net. The size was classified into four categories per WHO guidelines: size 1\u0026thinsp;=\u0026thinsp;0\u0026middot;5\u0026ndash;1\u0026middot;99 cm, size 2\u0026thinsp;=\u0026thinsp;2\u0026ndash;9\u0026middot;99 cm, size 3\u0026thinsp;=\u0026thinsp;10\u0026ndash;25 cm, and size 4\u0026thinsp;\u0026gt;\u0026thinsp;25 cm. The size of the holes was estimated by superimposing transparent plastic with illustrations of hole sizes. The hole surface area (HSA) for each net was then calculated as the number of holes counted multiplied by the size category weights as per WHO guidelines\u003csup\u003e21\u003c/sup\u003e as follows: HSA= (1\u0026middot;23 x no. of size1 holes) + (28\u0026middot;28 x no. of size2 holes) + (240\u0026middot;56 x no. of size3 holes) + (706\u0026middot;95 x no. size4 holes). Based on the HSA, each net was then categorized as good (HSA: \u0026le; 79 cm\u003csup\u003e2\u003c/sup\u003e), damaged (HAS: 80\u0026ndash;789 cm\u003csup\u003e2\u003c/sup\u003e), or extremely-torn (HSA: \u0026gt; 789 cm\u003csup\u003e2\u003c/sup\u003e). Hole types included: holes at the hanging points, holes caused by tears, holes caused by burns, holes caused by rodents, and holes caused by sharp objects.\u003c/p\u003e \u003cp\u003eData collection was done on smartphones using the Open-Data-Kit (ODK) software. Data from each field team was directly uploaded to a secure database at the London School of Hygiene and Tropical Medicine (LSHTM). After completion of the surveys, datasets were transferred to STATA release 15 (StataCorp, College Station, TX, USA) for further aggregation, cleaning, and preparation for analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eThe study outcomes were malaria prevalence in children aged 6 months \u0026minus;\u0026thinsp;14 years and incidence in children aged 6 months \u0026minus;\u0026thinsp;10 years using dual-AI LLINs compared with standard PY LLIN with different textile conditions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe analysis for this study was restricted to study nets distributed in January 2019. The cross-sectional data collected at t30 were excluded from analysis due to seasonality (collected during the dry season while the rest of the surveys were in the rainy season).\u003c/p\u003e \u003cp\u003eHousehold social and economic wealth indices were constructed and analysed by Principal component analysis (PCA) and were subdivided into wealth tertiles. Wald tests of multiple comparisons of means were used to compare hole surface area differences between study LLINs. For cross-sectional data, the association between net physical condition and malaria infection prevalence was assessed using mixed-effects logistic regression. The association between net physical condition and cumulative incidence of malaria infection in cohort study was analysed by mixed-effects Poisson regression with individual follow-up time specified as an offset and cluster set as a random effect. Furthermore, each dual-AI LLIN in different physical condition were compared to good PY LLIN on malaria infection to assess their superiority in protection. Interactions between net type and net physical condition, survey timepoint and net type were examined.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 4876 households were selected for textile durability assessment over the four cross-sectional surveys between 07th January 2020 and 10th February 2022. Of these, 67% (n\u0026thinsp;=\u0026thinsp;3284) consented to participate in the study. From the consenting households, 5817 children were tested for malaria infection, and 5060 study LLINs (1464 PY-LLIN, 1500 Chlorfenapyr-PY LLIN, 1181 Pyriproxyfen-PY LLIN, and 915 PBO-PY LLIN) were assessed for fabric integrity. At baseline (October 2018), malaria prevalence measured in children aged 6 months to 14 years was 44% (1948/4403), balanced across study arms.\u003csup\u003e8, 20\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOwnership of any net (at least 1 net per household) remained high over the study period, from 99.7% 3 months after net distribution to 96.2% (1036/1077) at t36. Ownership of study net (\u0026ge;\u0026thinsp;1 study LLIN per house) declined over the three years of the study from a high of 92% (697/755 houses) after t12 in January 2020 to 62% (672/1077) in January 2022 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Reported study net use recorded during cross-sectional surveys also declined over the three years of the study from 72% (3155/4373) three months after the mass distribution in January 2019\u003csup\u003e8\u003c/sup\u003e to 23% (2068/9044) in January 2022 at t36 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The lowest study net use was in the PBO-PY group at the t36 timepoint (19% (286/1469)). Between t30 and t36, the ownership of other PBO-PY LLIN in the study area (in all arms) increased from 13% (229/1723) to 33% (1076/3263) due to the local government-led top-up campaigns through the School Net program (SNP) (Additional file 6).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHousehold, socioeconomic, and net characteristics of participating households in the cross-sectional surveys\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCovariates\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eCross-sectional survey\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCross-sectional survey timepoint\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 months\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 months\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 months\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36 months\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean number of people per household (sd), N\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.1 (3.0), 755\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.1 (3.4), 803\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.0 (3.6), 649\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.4 (3.8), 1077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean number of children (\u0026lt;\u0026thinsp;15 years) per household (sd), N *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.6 (1.9), 755\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2 (2.1), 803\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.0 (2.2), 649\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.2 (2.2), 1077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean number of sleeping spaces used last night (sd), N\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9 (1.4), 755\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2 (1.6), 803\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.2 (1.5), 649\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.5 (1.7), 1077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHouseholds characteristics\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% electricity (95%CI), N\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.5 (21.6\u0026ndash;27.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.3 (24.3\u0026ndash;30.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.1 (32.5\u0026ndash;39.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.7 (34.9\u0026ndash;40.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% open eaves: (95%CI), N\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.1 (28.8\u0026ndash;35.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.1 (30.9\u0026ndash;37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.9 (31.4\u0026ndash;38.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31.57 (28.9\u0026ndash;34.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMain housing materials\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% floor: earth/sand (95%CI), N\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.8 (61.3\u0026ndash;68.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.6 (64.3\u0026ndash;70.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.6 (54.7\u0026ndash;62.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61.8 (58.8\u0026ndash;64.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% roof: tin (95%CI), N\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.9 (68.6\u0026ndash;75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.7 (69.5\u0026ndash;75.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77.2 (73.8\u0026ndash;80.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74.5 (71.8\u0026ndash;77.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% walls: unburnt bricks or mud (95%CI), N\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79.3 (76.3\u0026ndash;82.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.5 (75.5\u0026ndash;81.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76.4 (73.0-79.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e76.9 (74.3\u0026ndash;79.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% no ceiling (95%CI), N\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97.5 (96.1\u0026ndash;98.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97.9 (96.6\u0026ndash;98.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96.5 (94.7\u0026ndash;97.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96.8 (95.5\u0026ndash;97.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% plastered walls\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.3 (63.9\u0026ndash;70.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.0 (59.6\u0026ndash;66.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.5 (63.8\u0026ndash;71.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.3 (64.5\u0026ndash;70.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean number of mosquito nets owned per household (sd), N\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.8 (1.8), 755\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.1 (1.6), 803\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.7 (1.6), 649\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.0 (1.8), 1077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5 (1.5), 755\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.6 (1.2), 803\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.2 (1.1), 649\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.1 (1.1), 1077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean number of nets used last night per household (sd), N\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.4 (1.3), 755\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.4 (1.3), 803\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.0 (1.3), 649\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.3 (1.5), 1077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.6 (1.2), 755\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2 (1.1), 803\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9 (1.0), 649\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.8 (0.9), 1077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProportion of households with at least 1 net % (n/N)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 (755/755)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98.5 (791/803)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.5 (620/649)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e96.2 (1036/1077)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.3 (697/755)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.3 (629/803)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.6 (432/649)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e62.4 (672/1077)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProportion of participants reporting using a net the night before % (n/N)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.3 (4306/5294)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.4 (4899/6502)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62.3 (3220/5170)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e67.8 (6128/9041)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.6 (2805/5435)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.4 (2432/6502)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.8 (1439/5171)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.9 (2068/9044)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVarieties of nets available in the household\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;3010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2513\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1723\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;3263\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Pyrethroid (PY) LLIN (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.5 (498)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.0 (352)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.2 (245)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.3 (369)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Chlorfenapyr-PY LLIN (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.5 (557)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.7 (345)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.6 (217)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.7 (318)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% PBO-PY LLIN (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.4 (403)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.6 (215)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.1 (139)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.8 (158)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Pyriproxyfen-PY LLIN (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.2 (458)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.0 (327)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.3 (178)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.7 (218)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Permanet 2.0 (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.4 (525)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.2 (482)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.3 (349)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.6 (543)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Olyset net (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.9 (419)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.8 (597)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.6 (312)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.7 (447)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Olyset Plus (distributed by NMCP) (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.3 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.37 (160)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.3 (229)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33.0 (1076)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e% Others nets (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3 (141)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6 (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.2 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0 (71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of children tested for malaria (n/N)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1275/1374\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1476/1534\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1146/1227\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1920/2026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e% Malaria infection in 6 months-14 years children (95%CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.7 (16.6\u0026ndash;20.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.4 (35.9\u0026ndash;40.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.6 (42.7\u0026ndash;48.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31.1 (29.1\u0026ndash;33.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003esd: standard deviation; CI: confidence intervals; N: total number of observations, NMCP: National Malaria Control Program\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the nets collected during cross-sectional surveys, overall, at t12, 54% (597/1110) of the study nets had at least one hole of any size (53% (152/285)-pyrethroid (PY) LLIN, 48% (162/341)-Chlorfenapyr-PY LLIN, 52% (125/241)-Pyriproxyfen-PY LLIN, and 65% (158/243)-PBO-PY LLIN), and this increased to 82% (830/1007) (84% (274/326)-PY-LLIN, 81% (280/346)-Chlorfenapyr-PY LLIN, 81% (162/200)-Pyriproxyfen-PY LLIN and 84% (114/135)-PBO-PY LLIN) at t36. Similarly, the mean Hole Surface Area (HSA) increased from 340 cm\u0026sup2; to 1242 cm\u0026sup2; in Pyrethroid-PY, 355 cm\u0026sup2; to 1325 cm\u0026sup2; in Chlorfenapyr-PY LLIN, 526 cm\u0026sup2; to 1301 cm\u0026sup2; in Pyriproxyfen-PY LLIN and 990 cm\u0026sup2; to 2060 cm\u0026sup2; in PBO-PY LLIN between t12 and t36 (Additional file 3). There were no significant differences in mean HSA between PY-LLIN, Chlorfenapyr-PY LLIN, and Pyriproxyfen-PY LLIN at any survey time point, while PBO-PY LLIN had substantially higher HSA at each time point than any other study net (Additional file 3). The overall percentage of extremely torn nets in the cross-sectional surveys increased from 17% (189/1110) at t12 to 35% (372/1055) at t24 and stabilised between 44% (311/700) at t30 and 43% (432/575) at t36 (Additional file 2). In all net brands, the lower part of the nets (bottom zone) was more damaged than the rest of the zones (Additional file 4). All new nets had similar dimensions (height: 180cm); however, after three years of field use, the height decreased disproportionately between net brands to 170cm for PY-LLIN, 174 cm for Chlorfenapyr-PY LLIN, 157cm for Pyriproxyfen-PY LLIN, and 158cm for PBO-PY LLIN (Additional file 5).\u003c/p\u003e \u003cp\u003eThere was no significant association between malaria prevalence and net condition: damaged (OR: 0.98, 95%CI: 0.71\u0026ndash;1.37, p-value\u0026thinsp;=\u0026thinsp;0.6550) and too-torn (OR: 1.07, 95%CI: 0.77\u0026ndash;1.47, p-value\u0026thinsp;=\u0026thinsp;0.6940) compared to good nets (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e; Additional file 10). Malaria infection was also significantly lower for children living in clusters that received Chlorfenapyr-PY LLINs compared to those living in clusters that received PY LLINs regardless of the physical condition (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Children from houses with more than 50% of the sleeping spaces covered by the study nets had lower odds of malaria (OR: 0.61, 95%CI: 0.42\u0026ndash;0.87, p-value\u0026thinsp;=\u0026thinsp;0.006) than households with fewer sleeping spaces covered. The odds of malaria in all arms increased with time since the net distribution, however, was lower at t36 compared to t24, and this was likely related to the distribution of PBO-PY LLIN in all arms in October 2021 (four months before t36 survey) in the study area via the school-net program (SNP). Moreover, children sleeping under nets had lower odds of malaria infection than children not using any nets (Additional file 7). In the surveyed households, the majority of households reported closing the main doors at night, getting inside houses, and sleeping time between 21h and 22h (Additional file 9).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eAssociation between net physical condition and malaria prevalence in children aged 6 months to 14 years\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCovariate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%Infection (n/N)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eAdjusted OR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNet condition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.6 (180/733)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDamaged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.4 (109/429)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.71\u0026ndash;1.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.6550\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo-torn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.3 (146/516)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.77\u0026ndash;1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.6940\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStudy arm\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePyrethroid (PY) LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.7 (168/498)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChlorfenapyr-PY LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.7 (90/508)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.23\u0026ndash;0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePyriproxyfen-PY LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.4 (101/356)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.47\u0026ndash;1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.430\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePBO-PY LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.1 (76/316)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.35\u0026ndash;1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.091\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCross-sectional survey\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12 months post-intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.0 (103/607)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24 months post-intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.1 (210/582)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2.15\u0026ndash;3.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36 months post-intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.0 (122/489)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e1.22\u0026ndash;2.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChildren age\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;4 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.8 (97/656)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.5 (213/699)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2.13\u0026ndash;3.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;14 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.7 (125/323)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e3.25\u0026ndash;6.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSES\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLowest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.5 (156/567)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.2 (155/571)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.68\u0026ndash;1.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.622\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHighest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.0 (124/540)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.46\u0026ndash;0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEaves\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.7 (167/544)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.6 (268/1134)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.59\u0026ndash;1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.096\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousehold study net coverage*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo few (\u0026lt;\u0026thinsp;50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.6 (800)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate/high (\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.4 (1775)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.42\u0026ndash;0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Household study net coverage: is the proportion of sleeping spaces in the household used last night covered by study net; There was no evidence of interaction between net physical condition and net type, p-value\u0026thinsp;=\u0026thinsp;0.9814. There was no evidence of interaction between net type and survey timepoint, p-value\u0026thinsp;=\u0026thinsp;0.5010.\u003c/p\u003e \u003cp\u003eIn the cohort, 5019 children (2256 in year 1 and 2763 in year 2) were assessed alongside the study nets they used at the last cohort visit. Of these children, 2239 (99%) in year 1 and 2403 (87%) in year 2 declared to own study nets. These nets were brought for physical condition assessment. Overall, the mean HSA in the cohort nets was 786 cm\u0026sup2; for year 1 and 1047 cm\u0026sup2; for year 2. Over the two years of cohort study, the overall percentage of extremely torn nets increased from 19% (430/2234) at t12 to 33% (801/2397) at t24 (Additional file 2).\u003c/p\u003e \u003cp\u003eThere were increased rates of malaria cases in children sleeping under too-torn nets (IRR 1.33 [95% CI 1.12\u0026ndash;1.57], p\u0026thinsp;=\u0026thinsp;0.0012) compared to sleeping under good nets (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Lower rates of malaria cases were associated with living in houses with the highest social-economic status (IRR 0\u0026middot;77 [95% CI 0.63\u0026ndash;0.96], p\u0026thinsp;=\u0026thinsp;0.0189), using Chlorfenapyr-PY LLIN (IRR 0\u0026middot;49 [95% CI 0.31\u0026ndash;0.79], p\u0026thinsp;=\u0026thinsp;0\u0026middot;0035). Higher rates were associated with using study nets that were two years old (IRR 1\u0026middot;41 [95% CI 1.19\u0026ndash;1.67], p\u0026thinsp;=\u0026thinsp;0.0001). Older children and living in a house with open eaves were not associated with a higher incidence of malaria.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between net physical condition and malaria case incidence in children aged 6 months to 10 years\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCovariate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of clinical episodes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFollow-up time child years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIncidence per child per year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdjusted Rate ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy net condition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e573\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2268.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDamaged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e258\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e902.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.97\u0026ndash;1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0936\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo-torn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e379\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1184.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.12\u0026ndash;1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStudy arm\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePyrethroid (PY) LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1114.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChlorfenapyr-PY LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e174\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1120.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.31\u0026ndash;0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0035\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePyriproxyfen-PY LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e363\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1124.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.64\u0026ndash;1.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.9844\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePBO-PY LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e281\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e996.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.52\u0026ndash;1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.4334\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCohort year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eyear1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e434\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1931.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eyear2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e776\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2424.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.19\u0026ndash;1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChildren age group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;4 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e512\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1879.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e698\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2476.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.92\u0026ndash;1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.3604\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSocio-economic status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLowest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e296\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e899.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e273\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e897.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.79\u0026ndash;1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.6542\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHighest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e217\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e874.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.63\u0026ndash;0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0189\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEaves\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e829\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3061.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e381\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1294.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.82\u0026ndash;1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.9768\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn order to assess if the dual-AI LLINs were superior to PY LLINs against incidence regardless of their textile conditions, we compared each net type and condition to a PY LLIN in good condition. During the first year of follow-up, the protective effect of extremely-torn dual-AI LLINs compared to good (HSA: \u0026le; 79 cm\u003csup\u003e2\u003c/sup\u003e) PY LLIN against malaria case incidence was strongest for (HSA: \u0026gt; 789 cm\u003csup\u003e2\u003c/sup\u003e) PBO-PY LLIN (IRR 0\u0026middot;37 [95% CI 0\u0026middot;19\u0026thinsp;\u0026minus;\u0026thinsp;0\u0026middot;72], p\u0026thinsp;=\u0026thinsp;0\u0026middot;0033), borderline for chlorfenapyr-PY LLIN (IRR: 0\u0026middot;45 [95% CI 0\u0026middot;33\u0026thinsp;\u0026minus;\u0026thinsp;0\u0026middot;97], p\u0026thinsp;=\u0026thinsp;0\u0026middot;0525) and no additional protection was given by pyriproxyfen-PY LLIN (IRR 1\u0026middot;15 [95% CI 0\u0026middot;61\u0026thinsp;\u0026minus;\u0026thinsp;2\u0026middot;17], p\u0026thinsp;=\u0026thinsp;0\u0026middot;6596). Sleeping under a good PBO-PY LLIN or a good chlorfenapyr-PY LLIN was more protective than sleeping under a good PY LLIN against malaria case incidence. For children using pyriproxyfen-PY LLIN, however, there was a slight decrease in malaria incidence in children sleeping under damaged nets (0.26 cases per child/year) or good nets (0.24 cases per child/year); however, those differences were not significant compared to good PY LLIN (IRR\u0026thinsp;=\u0026thinsp;0.74 [95% 0.38\u0026ndash;1.46], p\u0026thinsp;=\u0026thinsp;0.3856) -for damaged pyriproxyfen-PY LLIN and (IRR\u0026thinsp;=\u0026thinsp;0.78 [95% 0.46\u0026ndash;1.34], p\u0026thinsp;=\u0026thinsp;0.3688) for good pyriproxyfen-PY LLIN (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003ea).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ea: Association between net physical condition and malaria case incidence in children aged 6 months to 10 years in year 1\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLLIN type and condition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of clinical episodes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFollow-up time child years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIncidence per child per year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdjusted\u003c/p\u003e \u003cp\u003eRate ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePyrethroid (PY) LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e313.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDamaged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.57\u0026ndash;1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.6538\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo-torn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.56\u0026ndash;1.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.7778\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePyriproxyfen-PY LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e342.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.46\u0026ndash;1.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.3688\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDamaged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.38\u0026ndash;1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.3856\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo-torn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.61\u0026ndash;2.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.6596\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePBO-PY LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e199.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.23\u0026ndash;0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0076\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDamaged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.28\u0026ndash;1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.2128\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo-torn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e174.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.19\u0026ndash;0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0033\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChlorfenapyr-PY LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e309.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.28\u0026ndash;0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDamaged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.38\u0026ndash;1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0675\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo-torn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.33\u0026ndash;0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0525\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn year 2, compared to those sleeping under good PY-LLIN, only children sleeping under chlorfenapyr-PY LLIN in good condition had a significant and more substantial protective effect (IRR\u0026thinsp;=\u0026thinsp;0.49 [95% CI 0.52\u0026ndash;1.37], p\u0026thinsp;=\u0026thinsp;0.0059) against malaria case incidence (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003eb). There was no reduced risk of infection associated with sleeping under too-torn PBO-PY LLIN (IRR\u0026thinsp;=\u0026thinsp;1.36 [95% 0.86\u0026ndash;2.16], p\u0026thinsp;=\u0026thinsp;0.1858) and too-torn Pyriproxyfen-PY LLIN (IRR\u0026thinsp;=\u0026thinsp;1.46 [95% CI 0.89\u0026ndash;2.37], p\u0026thinsp;=\u0026thinsp;0.1305) in year 2 compared to PY-LLIN in good condition.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eb: Association between net physical condition and malaria case incidence in children aged 6 months to 10 years in year 2\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLLIN type and condition\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of clinical episodes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFollow-up time child years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIncidence per child per year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRate ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePyrethroid (PY) LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e312.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDamaged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e159.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.83\u0026ndash;1.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.3533\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo-torn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e152.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.74\u0026ndash;1.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.7125\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePyriproxyfen-PY LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e299.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.52\u0026ndash;1.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.4949\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDamaged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e133.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.82\u0026ndash;2.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.2308\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo-torn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e179.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.89\u0026ndash;2.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.1305\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePBO-PY LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e181.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.72\u0026ndash;1.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.5144\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDamaged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.54\u0026ndash;1.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.9505\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo-torn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e275.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.86\u0026ndash;2.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.1858\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChlorfenapyr-PY LLIN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e317.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.29\u0026ndash;0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.0059\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDamaged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e169.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.39\u0026ndash;1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.1499\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo-torn\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e153.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.36\u0026ndash;1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.1286\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs part of a cluster randomised trial of dual-active ingredient malaria vector control interventions, we assessed the textile conditions of the dual-AI LLINs [namely: Chlorfenapyr-PY LLIN, Pyriproxyfen-PY LLIN, and a PBO-PY LLIN] after three years of use in the community. \u003csup\u003e8\u003c/sup\u003e We then explored the associations between net conditions and malaria prevalence (from repeated cross-sectional surveys) and incidence (from a cohort study) in Mwanza region, Tanzania.\u003c/p\u003e \u003cp\u003eIn this study, based on the cross-sectional survey data, there was no evidence indicating that the condition of the net was associated with malaria prevalence. Indeed, it was observed that good, damaged, and too-torn study nets appeared to offer similar levels of personal protection against malaria infection prevalence after adjusting for several covariates, such as net age, child age, presence of eaves in the house, socio-economic status, and household level net coverage. The strong protection provided by high household coverage of nets (\u0026gt; 50%) highlights the importance of promoting high levels of ownership and retention of nets in all households. Additionally, from the repeated cross-sectional measures, we also observed that study nets offered protection to those sleeping under them against malaria infection, and that sleeping under any net with holes provided more protection than sleeping without a net at all, similar to studies undertaken in Malawi\u003csup\u003e17, 18, 22\u003c/sup\u003e, and Equatorial Guinea.\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eLLINs, as the principal form of malaria vector control in the study area, reduced malaria infection by 54%, regardless of the net type and whether they had holes, compared to not using a net at all. Notably, even users of pyrethroid-only LLINs were far more protected than non-net users. This finding supports existing evidence that pyrethroid-only LLINs still provide protection compared to sleeping without a net, even in insecticide-resistant settings.\u003csup\u003e17, 22, 23\u003c/sup\u003e Several studies have reported on the association between increased levels of damage of pyrethroid-only nets and increased malaria infection,\u003csup\u003e18, 24\u003c/sup\u003e while others reported no association.\u003csup\u003e25, 26\u003c/sup\u003e However, while we saw no impact of differences in net integrity on malaria prevalence, in our cohort study, there was a strong association between net textile condition and malaria case incidence, unlike the cohort study in Malawi.\u003csup\u003e22\u003c/sup\u003e In the first year, when the insecticides were in suitable\u003csup\u003e8\u003c/sup\u003e concentrations, torn Chlorfenapyr-PY LLIN and PBO-PY LLIN were better than good PY-LLIN. However, in the second year, only good Chlorfenapyr-PY LLIN was better than good PY-LLIN; this may be explained by waning insecticide concentrations in the dual-AI LLINs over time\u003csup\u003e8\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTorn pyriproxyfen-PY LLINs (in the first and second year) and torn PBO-PY LLINs (during the second year) of use did not provide superior protection against malaria case incidence compared to good PY LLINs. This is consistent with results generated recently in Tanzania\u003csup\u003e8\u003c/sup\u003e and Benin\u003csup\u003e9\u003c/sup\u003e, where Pyriproxyfen-PY LLINs and PBO-PY LLIN did not perform well during the second year. This study supports and adds weight to previous studies that suggested the impaired effectiveness of these two products is likely related to poor fabric integrity, leading to an unexpected decline in community coverage. However, a systematic review of 22 published studies reported that wear and tear were not identified as a reason for not using mosquito nets when they are the only nets available.\u003csup\u003e27\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn this study, ownership, usage, and textile conditions of all nets declined swiftly over the three years after net distribution. The decline was more marked in the PBO-PY LLIN arm followed by pyriproxyfen-PY LLINs, consistent with the results generated recently in Tanzania in a prospective net cohort study done with the same net.\u003csup\u003e28\u003c/sup\u003e It is fairly standard to see a reduction in usage and ownership in places with no continuous distribution of nets.\u003csup\u003e18\u003c/sup\u003e However, through the continuous distribution of nets in antenatal care (ANC) clinics and the expanded program on immunization (EPI) and school-based programs coverage of other nets in the study area was kept high.\u003csup\u003e29\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn all nets, the damage was most severe in the bottom part.\u003csup\u003e12, 30\u003c/sup\u003e This part has been reported to have limited contribution to mosquito prevention\u003csup\u003e30\u003c/sup\u003e as it is always tucked under a mat or mattress. However, improper tucking of the bed net is not uncommon practice \u003csup\u003e31 32 33\u003c/sup\u003e, and net tucking is very challenging without a proper bed frame; in this study, more than half of the sleeping spaces in surveyed households had no bed frames. For untucked or partially tucked nets, the bottom part will still allow mosquitoes to penetrate. Enhancing the bottom part might remedy nets from early hole development and further enlargement, although other studies have shown that dense knitting in this part of the net did not necessarily make it more durable.\u003csup\u003e34\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSimilarities in physical properties (fibers, denier, and integrity) between some nets [chlorfenapyr-PY LLIN and PY-LLIN], but differences in protective efficacy against malaria infection emphasize the pivotal role of non-pyrethroid insecticide and synergists (chlorfenapyr and PBO\u003csup\u003e35\u003c/sup\u003e) in malaria vector control. In addition, this study demonstrates that the resilient physical integrity of the nets on its own is not enough to provide sustained protection to users of nets in good conditions against bites of malaria-transmitting mosquitoes even in settings of high net coverage, as it was in the cohort children where we observed \u0026gt; 80% use. This is contrary to the review by Okumu (2020),\u003csup\u003e36\u003c/sup\u003e which suggested that physically durable nets could serve a similar purpose as insecticidal nets.\u003c/p\u003e "},{"header":"Limitations","content":"\u003cp\u003eIn this study, we only assessed net condition at the end of the year against cumulative incidence over the year; likely, the nets were not in that condition for the whole year. However, when we assessed the association between malaria prevalence and net condition in cohort children during their last visits, it showed similar results. The number of study nets to be assessed decreased over time due decline in coverage, leading to a small number of cross-sectional nets assessed towards the end. However, a better and direct comparison of the protective effect of nets was attained with the cohort nets, which had high access and usage across the study. Net users in the cross-sectional survey tend to replace lightly damaged nets with readily available new ones, likely, the majority of the nets evaluated towards the end of the study were still new or put into usage a few months previously.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur results provide evidence that sleeping under extremely-torn chlorfenapyr-PY LLIN and PBO-PY LLIN offered superior protection compared to sleeping under good standard net, and, the protective effect of PBO-PY LLIN diminishes as PBO-treated nets age. The results also show that, when assessing net integrity independent of the protective effect against malaria, chlorfenapyr-PY LLIN nets are physically more durable than PBO-PY LLIN but relatively similar to pyriproxyfen-PY LLIN. The future strategies for control programs reliant on the dual-AI LLINs, therefore, not only seek to provide new nets to households that do not have nets but also instigate strategies to inform the population that even a torn dual-AI LLIN is better than an intact standard net or sleeping without a net; small holes in nets should not motivate households to discard the nets. Furthermore, there should be an emphasis on proper net care and repair practices among users, as well as the necessity for manufacturers to develop physically durable LLINs.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLLIN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLong-lasting insecticidal net\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eActive ingredient\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePY\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epyrethroid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePBO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epiperonyl butoxide\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePPF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epyriproxyfen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRandomised controlled trial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003emRDT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emalaria rapid diagnostic test\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIRR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eincidence rate ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSNP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eschool net program\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTable\u0026nbsp;1: Household, socioeconomic, and net characteristics of participating households in the cross\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esectional surveys\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the RCT was obtained from the institutional review boards of the Tanzanian National Institute for Medical Research (reference number: NIMR/HQ/R.8a/Vol.IX/2743), Kilimanjaro Christian Medical University College (2267), London School of Hygiene and Tropical Medicine (14952), and University of Ottawa (H-05-19-4411). Informed consent to participate in the study should be obtained from parent or guardian or any adult present in the house.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due strict laws in Tanzania that restrict data to be shared outside the country without a Data Transfer agreement (DTA.pdf (nimr.or.tz)). A DTA process will need to be completed by interested researchers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepartment for International Development, UK Medical Research Council, Wellcome Trust, and Department of Health and Social Care (#MR/R006040/1). The Bill and Melinda Gates Foundation via the Innovative Vector Control Consortium (IVCC). The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.\u0026nbsp;The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEL, JC and NP conceived and designed the study. EL, TA, and JFM led the data collection in the field. EM developed data collection tools and managed the data. EL did statistical analysis \u0026nbsp;with inputs form JC, MAK, IK, and NP. EL wrote the first draft of the manuscript with inputs from JC, and NP. EL and NP had full access and verified the data and had final responsibility for the decision to submit for publication. All authors have reviewed, read, and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank colleagues and staff at Pan-African Malaria Vector Research Consortium (PAMVERC) in Misungwi-Mwanza who were involved in the project. We acknowledge the assistance provided by government leaders at the Misungwi District council (district, ward, village and hamlet level). We thank Hon. Juma Sweda (Former Misungwi District Commissioner) and Dr. Thomas Rutachunzibwa (Mwanza Regional Medical Officer) for their immense support for creating friendly atmosphere for running the project. Finally, we thank all the participating households for their cooperation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO. World malaria report 2022. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Specifications and evaluations for public health pesticides: alpha-cypermethrin\u0026thinsp;+\u0026thinsp;chlorfenapyr. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. WHO specifications and evaluations for public health pesticides alpha-cypermethrin\u0026thinsp;+\u0026thinsp;pyriproxyfen: long-lasting (incorporated into filaments) insecticidal net. 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. WHO specifications and evaluations for public health pesticides: deltamethrin\u0026thinsp;+\u0026thinsp;piperonyl butoxide long-lasting (incorporated into filaments) insecticidal net. 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. WHO Guidelines for malaria. 2023 14-03-2023. Report No.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProtopopoff N, Mosha JF, Lukole E, Charlwood JD, Wright A, Mwalimu CD, et al. Effectiveness 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 factorial design trial. Lancet. 2018;391(10130):1577\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRugnao S, Gonahasa S, Maiteki-Sebuguzi C, Opigo J, Yeka A, Katureebe A, et al. LLIN Evaluation in Uganda Project (LLINEUP): factors associated with childhood parasitaemia and anaemia 3 years after a national long-lasting insecticidal net distribution campaign: a cross-sectional survey. Malar J. 2019;18(1):207.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMosha JFKM, Lukole E, Matowo NS, Pitt C, Messenger LA, Mallya E, Jumanne M, Aziz T, Kaaya R, Shirima BA, Isaya G, Taljaard M, Martin J, Hashim R, Thickstun C, Manjurano A, Kleinschmidt I, Mosha FW, Rowland M, Protopopoff N. Effectiveness 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. Lancet 2022;399(10331):1227\u0026ndash;1241 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAccrombessi M, Cook J, Dangbenon E, Yovogan B, Akpovi H, Sovi A, et al. Efficacy of pyriproxyfen-pyrethroid long-lasting insecticidal nets (LLINs) and chlorfenapyr-pyrethroid LLINs compared with pyrethroid-only LLINs for malaria control in Benin: a cluster-randomised, superiority trial. Lancet. 2023;401(10375):435\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTiono AB, Ouedraogo A, Ouattara D, Bougouma EC, Coulibaly S, Diarra A, et al. Efficacy of Olyset Duo, a bednet containing pyriproxyfen and permethrin, versus a permethrin-only net against clinical malaria in an area with highly pyrethroid-resistant vectors in rural Burkina Faso: a cluster-randomised controlled trial. Lancet. 2018;392(10147):569\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNet mapping project. The elliance for malaria prevention [Internet]. 2021 [cited 08/12/2023]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://allianceformalariaprevention.com\u003c/span\u003e\u003cspan address=\"https://allianceformalariaprevention.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLukole E, Cook J, Mosha JF, Messenger LA, Rowland M, Kleinschmidt I, et al. Protective efficacy of holed and aging PBO-pyrethroid synergist-treated nets on malaria infection prevalence in north-western Tanzania. PLOS Glob Public Health. 2022;2(10):e0000453.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOchomo EO, Bayoh NM, Walker ED, Abongo BO, Ombok MO, Ouma C, et al. The efficacy of long-lasting nets with declining physical integrity may be compromised in areas with high levels of pyrethroid resistance. Malar J. 2013;12:368.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNgufor C, N'Guessan R, Boko P, Odjo A, Vigninou E, Asidi A, et al. Combining indoor residual spraying with chlorfenapyr and long-lasting insecticidal bed nets for improved control of pyrethroid-resistant Anopheles gambiae: an experimental hut trial in Benin. Malar J. 2011;10:343.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eN'Guessan R, Corbel V, Akogbeto M, Rowland M. Reduced efficacy of insecticide-treated nets and indoor residual spraying for malaria control in pyrethroid resistance area, Benin. Emerg Infect Dis. 2007;13(2):199\u0026ndash;206.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIrish S, N'Guessan R, Boko P, Metonnou C, Odjo A, Akogbeto M, et al. Loss of protection with insecticide-treated nets against pyrethroid-resistant Culex quinquefasciatus mosquitoes once nets become holed: an experimental hut study. Parasit Vectors. 2008;1(1):17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindblade KA, Mwandama D, Mzilahowa T, Steinhardt L, Gimnig J, Shah M, et al. A cohort study of the effectiveness of insecticide-treated bed nets to prevent malaria in an area of moderate pyrethroid resistance, Malawi. Malar J. 2015;14:31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRehman AM, Coleman M, Schwabe C, Baltazar G, Matias A, Gomes IR, et al. How much does malaria vector control quality matter: the epidemiological impact of holed nets and inadequate indoor residual spraying. PLoS ONE. 2011;6(4):e19205.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBradley J, Ogouyemi-Hounto A, Cornelie S, Fassinou J, de Tove YSS, Adeothy AA, et al. Insecticide-treated nets provide protection against malaria to children in an area of insecticide resistance in Southern Benin. Malar J. 2017;16(1):225.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJacklin F, Mosha MAK, Louisa A, Messenger M, Rowland N, Matowo C, Pitt E, Lukole. Monica Taljaard,Charles Thickstun, Alphaxard Manjurano, Franklin W. Mosha, Immo Kleinschmidt, Natacha Protopopoff. Protocol for a four parallel-arm, singleblind, cluster-randomised trial to assess the effectiveness of three types of dual active ingredient treated nets compared to pyrethroid-only long-lasting insecticidal nets to prevent malaria transmitted by pyrethroid insecticideresistant vector mosquitoes in Tanzania. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO/WHOPES. Guidelines for laboratory and field-testing of long-lasting insecticidal nets: Control of neglected tropical diseases WHO pesticide evaluation scheme. 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShah MP, Steinhardt LC, Mwandama D, Mzilahowa T, Gimnig JE, Bauleni A, et al. The effectiveness of older insecticide-treated bed nets (ITNs) to prevent malaria infection in an area of moderate pyrethroid resistance: results from a cohort study in Malawi. Malar J. 2020;19(1):24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKleinschmidt I, Bradley J, Knox TB, Mnzava AP, Kafy HT, Mbogo C, et al. Implications of insecticide resistance for malaria vector control with long-lasting insecticidal nets: a WHO-coordinated, prospective, international, observational cohort study. Lancet Infect Dis. 2018;18(6):640\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMejia P, Teklehaimanot HD, Tesfaye Y, Teklehaimanot A. Physical condition of Olyset(R) nets after five years of utilization in rural western Kenya. Malar J. 2013;12:158.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinta AA, Landman KZ, Mwandama DA, Shah MP, Eng JLV, Sutcliffe JF, et al. The effect of holes in long-lasting insecticidal nets on malaria in Malawi: results from a case-control study. Malar J. 2017;16(1):394.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eObala AA, Mangeni JN, Platt A, Aswa D, Abel L, Namae J, et al. What Is Threatening the Effectiveness of Insecticide-Treated Bednets? A Case-Control Study of Environmental, Behavioral, and Physical Factors Associated with Prevention Failure. PLoS ONE. 2015;10(7):e0132778.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePulford J, Hetzel MW, Bryant M, Siba PM, Mueller I. Reported reasons for not using a mosquito net when one is available: a review of the published literature. Malar J. 2011;10:83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJackline Martin EL, Louisa A, Messenger T, Aziz E, Mallya E, Bernard NS, Matowo, Jacklin F, Mosha M, Rowland FW, Mosha. Alphaxard Manjurano and Natacha Protopopoff. Monitoring of Fabric Integrity and Attrition Rate of Dual-Active Ingredient Long-Lasting Insecticidal Nets in Tanzania: A Prospective Cohort Study Nested in a Cluster Randomized Controlled Trial. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO-GMP. Achieving and maintaining universal coverage with long-lasting insecticidal nets for malaria control: Recommendations. 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLorenz LM, Bradley J, Yukich J, Massue DJ, Mageni Mboma Z, Pigeon O, et al. Comparative functional survival and equivalent annual cost of 3 long-lasting insecticidal net (LLIN) products in Tanzania: A randomised trial with 3-year follow up. PLoS Med. 2020;17(9):e1003248.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMsellemu D, Shemdoe A, Makungu C, Mlacha Y, Kannady K, Dongus S, et al. The underlying reasons for very high levels of bed net use, and higher malaria infection prevalence among bed net users than non-users in the Tanzanian city of Dar es Salaam: a qualitative study. Malar J. 2017;16(1):423.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTeklemariam Z, Awoke A, Dessie Y, Weldegebreal F. Ownership and utilization of insecticide-treated nets (ITNs) for malaria control in Harari National Regional State, Eastern Ethiopia. Pan Afr Med J. 2015;21:52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePooseesod K, Parker DM, Meemon N, Lawpoolsri S, Singhasivanon P, Sattabongkot J, et al. Ownership and utilization of bed nets and reasons for use or non-use of bed nets among community members at risk of malaria along the Thai-Myanmar border. Malar J. 2021;20(1):305.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkovmand O, Bosselmann R. Strength of bed nets as function of denier, knitting pattern, texturizing and polymer. Malar J. 2011;10:87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin JL, Mosha FW, Lukole E, Rowland M, Todd J, Charlwood JD, et al. Personal protection with PBO-pyrethroid synergist-treated nets after 2 years of household use against pyrethroid-resistant Anopheles in Tanzania. Parasit Vectors. 2021;14(1):150.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkumu F. The fabric of life: what if mosquito nets were durable and widely available but insecticide-free? Malar J. 2020;19(1):260.\u003c/span\u003e\u003c/li\u003e\u003c/ol\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":"","lastPublishedDoi":"10.21203/rs.3.rs-3974056/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3974056/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Dual-Active Ingredient long-lasting insecticidal nets (Dual-AI LLIN) have been developed to counteract the reduced efficacy of pyrethroid (PY)-only nets due to widespread pyrethroid insecticide resistance in malaria vector mosquitoes. They constitute half of the nets distributed in sub-Saharan Africa in the past two years. However, their effectiveness once they develop holes is unclear, particularly in pyrethroid-resistant settings. This study evaluates the textile integrity of three dual- AI LLINs compared to standard PY LLN, over 3 years of use in a community in Tanzania and the associated impact on malaria prevalence and incidence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBetween 2019 and 2022, we conducted a secondary analysis of data from a randomized controlled trial (RCT) in North-western Tanzania to evaluate the effectiveness of α-cypermethrin only; pyriproxyfen and α-cypermethrin (PPF-PY); chlorfenapyr and α-cypermethrin (chlorfenapyr-PY); and the synergist piperonyl butoxide and permethrin (PBO-PY) LLINs on malaria infection prevalence and case incidence. We assessed the association between the net textile condition and 1/malaria prevalence over 3 years of use, and 2/malaria case incidence in a cohort of children over 2 years of follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no significant association between damaged (OR: 0.98, 95%CI: 0.71-1.37, p-value=0.6550) and too-torn (OR: 1.07, 95%CI: 0.77-1.47, p-value=0.6940) compared to intact nets on malaria prevalence for all net types. However, there were reduced rates of malaria case incidence in children sleeping under a net in good condition compared to extremely torn nets (incidence rate ratio (IRR) 0·76 [95%CI: 0.63-0.92], p=0.0047). Malaria incidence was also consistently lower in too-torn PBO-PY LLIN (IRR= 0.37 [95%CI: 0.19-0.72], p= 0.0033) and Chlorfenapyr-PY LLIN (IRR= 0.45 [95%CI: 0.33-0.97], p= 0.0525) compared to a intact PY-only LLIN during the first year of follow up. In year 2, the incidence was only significantly lower in intact Chlorfenapyr-PY LLIN (IRR= 0.49 [95%CI: 0.29-0.81], p= 0.0059) compared to intact PY LLIN.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study confirmed that sleeping under a Chlorfenapyr-PY LLIN or PBO-PY LLIN offered superior protection to pyrethroid-only nets even when torn. Preventing the development of holes is essential as they impact the level of protection offered against malaria infection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinicalTrials.gov, number (NCT03554616)\u003c/p\u003e","manuscriptTitle":"Will a lack of fabric durability be their downfall? Impact of textile durability on the efficacy of three types of dual-active-ingredient long-lasting insecticidal nets: A secondary analysis on malaria prevalence and incidence from a cluster-randomized trial in north-west Tanzania","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-22 09:44:06","doi":"10.21203/rs.3.rs-3974056/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-18T01:59:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-03T09:20:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-29T08:02:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-25T12:19:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-17T14:16:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"139c2358-f8e5-46d0-b340-d5133e60ee5a","date":"2024-03-10T19:56:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"af9d3a26-5331-4744-9e0c-265cf74e15ae","date":"2024-03-08T08:26:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51f1ed7e-c6d2-4fab-ab31-a7dc3b16edb2","date":"2024-03-08T08:05:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"013f3db6-6f35-4c4c-9f77-9e1253273ca6","date":"2024-03-07T07:05:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-07T04:20:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-21T05:30:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-21T05:30:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Malaria Journal","date":"2024-02-20T23:42:27+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":"4976b1d0-89b5-4b76-9e14-c1b8de39b599","owner":[],"postedDate":"February 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-06-20T15:31:31+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-22 09:44:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3974056","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3974056","identity":"rs-3974056","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}