Recommendation 1	In some scenarios, it may be possible that mass drug administration will drive the evolution of drug resistance more strongly when compared to no MDA. This risk exists when all three of the following are present after the MDA program: (A) a very small number of parasite-positive individuals, (B) regular importation of drug-resistant genotypes in the focal MDA area, and (C) continued use of first-line therapy that selects for these newly imported drug-resistant genotypes.
Recommendation 2	In the present modeling analysis, detrimental drug-resistance outcomes–if they occur–typically appear several years after the MDA. If a risk of higher drug resistance is identified, a course correction should be planned as soon as possible.
Recommendation 3	If one of A, B, or C (from Recommendation 1) is missing, MDA is projected to have a neutral or mitigating effect on drug-resistant alleles, and high-coverage MDA can be pursued without concern that drug-resistance will undermine the intended public health goals.
Recommendation 4	The regional epidemiological and genetic characteristics of P. falciparum transmission should be well understood before initiating MDA activities. If the MDA is targeted at a group of highly connected population, all of which have high drug-resistance levels, an MDA should be conducted for the entire region or not at all. If MDA implementation is only possible in some regions among a highly connected group, the regions with highest resistance levels should be chosen for MDA assuming prevalence levels are sufficiently low.
Recommendation 5	According to our modeling analysis, the level of MDA coverage has a weak effect on drug-resistance evolution. Therefore investment in community outreach, public communication, and staffing to lift MDA participation rates to the highest possible levels would likely increase the chances of local elimination without risking adverse drug-resistance outcomes.
Recommendation 6	The most direct approach to avoiding drug-resistance risks after several rounds of MDA is to drive parasite numbers to zero while the number of parasite-carrying individuals is still low. An economic analysis based on the allowable costs and projected benefits of post-MDA improvements in case management could help make the case that these additional interventions are potentially highly cost effective.
Recommendation 7	After an MDA program has completed, future malaria prevalence is more predictable than future drug-resistance evolution. The low-prevalence period after an MDA is an opportune period to drive parasite numbers to zero, and additional public health resources should be committed to this activity.