Comparing the un-comparable: Olyset Plus and Olyset, different malaria impact

In a recent article in The Lancet, Protopopoff et al. stated that insecticide resistance must be tackled and concluded that adding the insecticide synergist piperonyl butoxide (PBO) to a bed net with a pyrethroid as principal insecticide might be a part of the response.

The study in Tanzania compares malaria prevalence between users of two different nets with the principal insecticide permethrin: Olyset and Olyset Plus (Olyset+), the latter also holding the synergist molecule PBO, the first not. The article is based on randomized cluster trial of very high quality, but Olyset+ exposes much more permethrin at the surface so the higher efficacy may not be because of the added PBO.

Data published by the World Health Organization (WHO) when evaluating Olyset+ as well of the study of Protopopoff et al. showed that much more permethrin is available on the surface of Olyset+ than on the surface of Olyset and the relatively small and rapidly dwindling dosage of PBO may have nothing to do with the superior effect of Olyset+. The WHO should not change politics for "PBO nets" based on this study alone.