Protecting Children: 10 Years of Seasonal Malaria Chemoprevention Inside View 16/06/2022 • Andre-Marie Tchouatieu & Abena Poku-Awuku Share this:Click to share on Twitter (Opens in new window)Click to share on LinkedIn (Opens in new window)Click to share on Facebook (Opens in new window)Click to email this to a friend (Opens in new window)Click to print (Opens in new window) A health worker explains her child’s symptoms to a mother in a Guinea health centre On the Day of the African Child, Medicines for Malaria Venture (MMV) reflects on what 10 years of seasonal malaria chemoprevention has meant for young children in the Sahel, and how to protect more children going forward. Malaria, a disease that is both a cause and consequence of poverty, has plagued endemic-country health systems, economies and people — especially children — for millennia. The Day of the African Child is an opportunity to celebrate 10 years of seasonal malaria chemoprevention (SMC) and to draw attention to the fact that, despite the progress made against the disease, children in sub-Saharan Africa still bear the majority of the global burden. The World Health Organization (WHO) first recommended SMC in 2012 to protect eligible children in Africa’s Sahel region, where malaria transmission is at its highest during the rainy season. The importance of this is underscored by the fact that six out of 10 countries targeted by WHO’s ‘high burden to high impact’ initiative are located in this region. When administered to this population of children in this geographic region, the intervention has been shown to be highly effective, providing up to 88% protection against malaria within the first 28 days after its administration and reducing hospital admissions by up to 39%. Modelling estimates also suggest that the intervention could curb roughly 21 million malaria cases and prevent 100,000 child deaths each year, if successfully delivered to at-risk populations. National malaria control programmes (NMCPs) have therefore been quick to include SMC in their strategic plans and deliver it year-on-year. To administer SMC, children aged three to 59 months receive one dose of sulfadoxine-pyrimethamine with three doses of amodiaquine (SPAQ) 3 days a month. Previously, this was recommended for up to four months; however, WHO’s new guidelines recommend SMC for the “peak malaria transmission season”, regardless of length. SMC use has expanded rapidly since its introduction. In 2012, several thousand children in two countries received SMC. In 2021, about 44 million children in 13 countries benefited. The growing number of children receiving SMC required greater supply security and more pharmaceutical suppliers. Fosun Pharma’s subsidiary, Guilin Pharmaceuticals, with MMV’s support, developed a SPAQ tablet that was prequalified by WHO in 2014. Results from the first SMC trials showed that the intervention would be more effective if the medicines were palatable and easily dissolved in water, reducing the likelihood that children would spit them out. Consequently, Guilin developed a child-friendly version of SPAQ that was prequalified by WHO in 2018. MMV and S-Kant, funded by UNITAID, developed another dispersible version of SPAQ that was WHO prequalified in 2021. Since 2014, over 700 million treatment courses of SPAQ have been distributed. Relieving pressure on health systems and economies A local health center during coronavirus. Currently, the malaria burden in sub-Saharan Africa is an impediment to reaching Sustainable Development Goal 3 (Ensure healthy lives and promote well-being for all at all ages), and more specifically, Target 3.3 (End the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases). SMC is a low-cost intervention that contributes to reducing the burden on health systems in terms of cost of malaria diagnosis, treatment and in-patient admissions. In fact, a 2021 analysis in seven countries revealed that implementing SMC saved health systems approximately USD 66 million and increased economic productivity by USD 43 million, contributing to Goal 8 (Decent work and economic growth). This is also significant for families who pay out of pocket for malaria diagnosis and treatment: 13% of the global malaria budget came from out-of-pocket expenditure; much higher than with other priority diseases in sub-Saharan Africa such as HIV/AIDS, where out-of-pocket expenditure represented just under 5% of global spend. Integrating SMC and other health interventions Seasonal malaria chemoprevention has saved thousands of lives of children under the age of five. Combining SMC with interventions such as malaria community case management (CCM), long-lasting insecticidal net distribution and malnutrition interventions has enabled health systems to optimize staff time and reach children who otherwise may not have been reached. Even with limited resources, through CCM, countries have trained and supported community health workers who provide services for multiple illnesses such as malaria, pneumonia and diarrhoea for sick children and families with limited access to case management at health facilities. In 2021, WHO approved the RTS,S vaccine for children in areas with moderate to high Plasmodium falciparum malaria. While the vaccine is a useful addition to the malaria control toolbox, its efficacy (around 36%) falls short of being a silver bullet. Encouragingly, recently reported studies have shown that when the vaccine is combined with SMC, the efficacy in preventing malaria is significantly greater for each intervention alone – providing a belt-and-braces approach to better protect young children at risk of malaria. The introduction of innovations like digital tools, which are replacing paper-based data collection and management systems in SMC campaigns in Benin, the Gambia, Ghana and Nigeria, has also helped better manage and improve data quality. Enhancing the integration of digital systems will contribute to stronger data management systems that can provide evidence for informing policy decisions and boosting programme effectiveness. Initiatives such as the European & Developing Countries Clinical Trials Partnership-funded OPT-SMC project are also building NMCP staff’s capacity to better implement SMC and improve data monitoring, evaluation and management in all 13 implementing countries. Overcoming new challenges and finding ways forward Boys drink water from rehabilitated wells by AMISOM in EL-Ma’an, Bal’ad District of HirShabelle State. Now that protection of children under 5 in the Sahel is improving, there is evidence of seasonal malaria shifting to older children. Projects in Senegal have shown that SMC is effective in five- to 10-year-olds. Consequently, the SMC-Impact project, financed by the Korea International Cooperation Agency’s Global Disease Eradication Fund, will pilot expanding SMC to older children in the Gambia and Niger. While the numerous benefits of SMC for communities and economies are evident, children in parts of Southern and East Africa with seasonal malaria are not yet benefiting from the intervention due to anticipated lack of efficacy due to high levels of resistance to SP and AQ, which have precluded large-scale implementation. However, preliminary results from pilots conducted with SPAQ in Eastern and Southern Africa show positive results. Additionally, the updated WHO guidelines for malaria chemoprevention suggest that any antimalarial combination that is different from those used for first-line treatment can be used for SMC. Thus, larger-scale implementation of SMC can be anticipated in Africa in the coming years. Despite proven benefits, the future of SMC is uncertain, as malaria budgets continue to be under threat due to growing health and national security challenges facing both donor and SMC-implementing countries. Africa’s growing population, which is expected to triple by 2100, will require protection against malaria. In addition to saving lives, protection against life-threatening diseases like malaria will bring significant productivity and economic benefits. Increased financing and national stewardship for SMC are non-negotiable if countries want to keep populations healthy and generate national economic savings. Although there are challenges to reaching all at-risk children, it is important not to overlook the work that has been — and continues to be — undertaken by NMCPs, researchers, healthcare workers and caregivers to save children’s lives over the past 10 years. The impact of SMC has been remarkable, and in the decade ahead, it will likely increase the impact it can deliver as restrictions on geography and targeted age ranges are relaxed. Dr Abena Poku-Awuku is an Advocacy Manager at Medicines for Malaria Venture. Dr André-Marie Tchouatieu is a Director of Access and Product Management at Medicines for Malaria Venture. Image Credits: Medicines for Malaria Venture, USAID. Share this:Click to share on Twitter (Opens in new window)Click to share on LinkedIn (Opens in new window)Click to share on Facebook (Opens in new window)Click to email this to a friend (Opens in new window)Click to print (Opens in new window) Combat the infodemic in health information and support health policy reporting from the global South. Our growing network of journalists in Africa, Asia, Geneva and New York connect the dots between regional realities and the big global debates, with evidence-based, open access news and analysis. 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