Impact of Pyrethroid Plus Piperonyl Butoxide Synergist-Treated Nets on Malaria Incidence 24 Months after a National Distribution Campaign in Rwanda.

Malaria remains a public health priority in Rwanda. The use of insecticide-treated nets (ITNs) is a key malaria prevention tool. However, expanding pyrethroid resistance threatens the gains made in malaria control. In 2018, the Rwandan malaria program strategic approach included the use of newer types of ITNs such as pyrethroid plus piperonyl butoxide (PBO) synergist-treated nets to counter pyrethroid resistance. In February 2020, 5,892,280 ITNs were distributed countrywide; 1,085,517 of these were PBO nets distributed in five districts. This study was a pragmatic observational study that leveraged the 2020 net distribution and routinely collected confirmed malaria cases to determine the impact of PBO nets 1 and 2 years after ITN distribution. No differences were observed in the average net coverage between the PBO and standard net districts. A significant reduction in malaria incidence was reported in both the PBO (P = 0.019) and two control districts that received standard nets (P = 0.008) 1 year after ITN distribution. However, 2 years after, this reduction was sustained only in the PBO (P = 0.013) and not in the standard net districts (P = 0.685). One year after net distribution, all districts had a significant reduction in malaria incidence rate (incidence rate ratio < 1). In the second year, incidence in districts with PBO nets continued to decrease, whereas in districts with standard nets, incidences were similar to predistribution levels. The results indicate that PBO nets are a promising tool to combat pyrethroid resistance in Rwanda, with protective effects of up to 2 years post distribution.