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Long-Lasting Insecticidal Nets: Supply Update Long-lasting Insecticidal Nets: Supply Update UNICEF Supply Division March 2020 0 Long-lasting Insecticidal Nets - Supply Update March 2020 This update reports on UNICEF’s historical and projected long-lasting insecticidal nets supply, demand, and market developments. UNICEF launched its last tender in 2018, concluding with long- term arrangements for 2019-2020 to ten suppliers with products now listed under the World Health Organization’s prequalification team for vector control. 1. Summary • Long-lasting insecticidal net (LLIN) procurement volumes can vary substantially from year-to-year in accordance with country requirements.1 In general, countries procure new and replacement LLINs for distribution in mass campaigns on a two- to three-year cycle. In 2017 and 2018, UNICEF procured 23 and 13 million nets respectively on behalf of approximately 30 countries, compared to 41.3 million nets in 2016. UNICEF procured 47.4 million nets in 2019 and anticipates procuring an estimated 25 million nets in 2020. • Overall aggregate supply remains stable. UNICEF estimates the total global LLIN production capacity to be 400 million nets annually, against global LLIN deliveries reaching approximately 250 million in 2019, representing over half of the reported requirements. • The weighted average price (WAP) for LLINs secured through UNICEF continues to decline, having decreased by more than 55 per cent over the past eight years from USD 4.20 in 2011 to reach USD 1.88 in 2019, realizing further cost savings for country programmes and partners. • UNICEF concluded its last LLIN tender towards the end of 2018 and issued ten manufacturers long-term arrangements (LTAs) to secure access to LLINs over its 2019-2020 tender period, including to new and innovative products. Through its engagement with industry, UNICEF is applying supply chain cost and sustainability considerations to its LLIN procurement strategy to address some of the programmatic and supply chain challenges undermining environmental sustainability and the risks associated with LLIN shipments and packaging. • Currently, the World Health Organization (WHO) lists 20 different prequalified LLINs from 12 different manufacturers, including new LLIN technologies that could help stem the rise in insecticide resistance. WHO has transitioned its pesticide evaluation scheme (WHOPES), used to promote and coordinate the testing and evaluation of pesticide product safety, efficacy, and operational acceptability of public health pesticides, to a prequalification team for vector control (PQT-VC). It is now able to harmonize its evaluation processes and product assessment streams for diagnostics, medicines, vaccines, and vector control. It reflects the growing prominence and broader array of vector control interventions beyond the use of pesticides to cover a wider range of vector-borne diseases including Chagas disease, Chikungunya, dengue fever, and Zika virus disease, amongst many others. 2. Brief Background and Procurement History Malaria is a preventable and curable life-threatening parasitic disease transmitted to people through the bites of infected female Anopheles mosquitoes. There are more than 400 species of Anopheles mosquito,2 of which five are known to cause malaria in humans.3 In 2017, WHO reported that malaria parasites caused an estimated 219 million cases of the disease in 87 countries and an estimated 435,000 deaths, of which 61 per cent were children under five years of age.4 Africa accounts for 92 per cent of the estimated disease burden globally, and 93 per cent of malaria mortality. Five countries account globally for nearly half of all malaria cases, of which Nigeria (25 per cent), the Democratic Republic of the Congo (11 per cent), 1 UNICEF articulates supply trends as either number of nets procured, or number of nets delivered. Substantial differences in supply data can occur between annually reported LLIN procurement and LLIN deliveries due to long-lead delivery times for shipments by sea, which can be between two to eight weeks depending on the volume, and their subsequent transit to community distribution points. 2 World Health Organization, Malaria Fact Sheet, WHO, Geneva, March 2019. 3 Zoonotic Plasmodium causing malaria in humans: P. falciparum, P. malariae, P. ovale, P. vivax, and P. knowlesi, the latter normally infecting animals. There is no known human to human transmission. 4 WHO, Malaria Fact Sheet. 1 Mozambique (5 per cent), and India and Uganda (with 4 per cent respectively). As part of WHO’s Global Malaria Technical Strategy 2016-2030 to reduce the burden of global malaria by 90 per cent by 2030,5 WHO recommends universal coverage with effective vector control including the use of indoor residual spraying (IRS) and insecticide-treated mosquito nets (ITN),6 particularly long-lasting insecticidal nets (LLINs), as core interventions for all populations at risk in all malaria-endemic settings. Sleeping under an LLIN is one of the most effective measures that can reduce the contact between mosquitoes and humans. It provides both a physical barrier and an insecticidal effect. There are two categories of ITN:7 Conventionally treated nets are treated with an insecticide that repels, disables, or kills mosquitoes that encounter the netting material through dipping in a diluent containing insecticide, post-production, either at the factory or post distribution. LLINs are considered far more effective as they are infused with a WHO-recommended insecticide during production using netting material with insecticide bound within or around the fibres at the factory, resulting in nets that retain their efficacy for much longer than conventionally treated nets (see 5.1 Durability). Pyrethroids are one of the oldest known insecticides, initially derived from pyrethrum, which comes from the dried and crushed flower heads of a genus of perennial flowering Asteraceae. However, as deriving it was expensive and in limited natural supply, pyrethroids have been adapted and synthesized since 1973. Synthetic pyrethroids are more stable to light, more toxic, and last longer in the environment than natural Pyrethrum.8 However, from their wide-spread use in ITNs and agriculture, WHO has been reporting an increasing emergence of insecticidal resistance to various insecticides, including pyrethroids, among Anopheles mosquitoes.9 An evaluation by WHO in 2018 of the effects of insecticide resistance on LLINs reaffirmed that LLINs nevertheless still provide significant protection against malaria, and that universal coverage of populations at risk with LLINs should continue. Nonetheless, the expansion of the current LLIN market to include new LLINs with increased efficacy against pyrethroid-resistant mosquitoes has become a specific priority within malaria vector control. Manufacturers are developing next-generation LLINs with active ingredients other than, or in addition to, pyrethroids, and include a new class of bed net with the chemical piperonyl butoxide (PBO).10 It is a chemical synergist that inhibits the enzymes in the natural defence mechanisms in insects, which prevents the detoxification of the pyrethroid. As a result, the pyrethroid in the LLIN remains potent against mosquitoes despite insecticidal resistance. Such PBO-pyrethroid-treated LLINs appear to have similar or better efficacy against resistant mosquitoes under controlled household conditions than standard LLINs that do not have PBO.11 Significant progress has been achieved since 2004 in malaria control, having reduced the number of global cases by 12 per cent and deaths from malaria by 45 per cent. Among children under five years of age, LLINs provide up to 55 per cent protective efficacy in preventing mortality attributed to malaria.12 These achievements are largely credited to the international efforts in scaling-up the core vector control interventions, particularly the use of LLINs. In 2017, about half of all people at risk of malaria in Africa were protected by an LLIN compared to 29 per cent in 2010. However, LLIN coverage only increased marginally over the course of 2015 to 2017,13 reflecting a wider stagnation in progress against malaria, leaving at least half of the population at risk uncovered. UNICEF procures LLINs on behalf of countries and partners in support of malaria control and prevention programmes, either with using programme funds or available country financing. UNICEF only procures LLINs that are prequalified by WHO. WHO currently lists 20 prequalified LLINs from 12 manufacturers (Table 1, next page). All vector control products that have been WHO prequalified, which includes IRS, insecticide treat net kits, larvicides, and space spray, can be accessed here:14 5 World Health Organization, Global Technical Strategy for Malaria 2016-2030, WHO, Geneva, May 2015, p. 3. 6 World Health Organization, Guidelines for Malaria Vector Control, WHO, Geneva, February 2019, p. 34. 7 Jaramillo, Gloria I, et al., Comparison of the Efficacy of Long-lasting Insecticidal Nets PermaNet® 2.0 and Olyset® Against Anopheles albimanus Under Laboratory Conditions, Scientific Electric Library Online, São Paulo, August 2011. 8 World Health Organization, Safety of Pyrethroids for Public Health Use, WHO, Geneva, 2005, p. 5. 9 World Health Organization, Insecticide Resistance, WHO, Geneva, 2019. 10 World Health Organization, Conditions for Deployment of Mosquito Nets Treated with a Pyrethroid and Piperonyl Butoxide, WHO, Geneva, December 2017. 11 Protopopoff, Natacha, et al., Effectiveness of a Long-lasting Piperonyl Butoxide-treated
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