For years, malaria has ruled mercilessly in certain regions of the world. Especially in Africa. Yet over the past decade, despite the absence of a malaria vaccine, one anti-malarial strategy sought to make a difference: more than 700 million doses of Seasonal Malaria Chemoprevention (SMC) were distributed to young children, globally. 

The evidence is now clear: SMC has helped to save hundreds of thousands of their lives. So much so, that more countries have now begun to implement SMC, which involves the intermittent administration of a curative dose of antimalarial medicine to children at high risk of severe malaria living in areas with seasonal transmission, regardless of whether they are infected with malaria.

As we mark the International Day of the African Child on 16 June, it’s important to recall how far we’ve come. At the dawn of the new millennium, malaria was infecting several hundred million people every year – and killing almost 900,000, annually. Although gains have been made to rein in its lethal impact, malaria continues to kill at an alarming rate: it took 619,000 lives in 2021, according to the World Health Organization (WHO) and its World Malaria Report 2022.

 Tragically, it’s children under the age of five who constitute the vast majority of malaria-related deaths; therefore, they are most in need of protection from this deadly disease. Their immune systems are not fully developed to fight off malaria parasites, which makes them easy prey.

Averting millions of cases

So how did this SMC intervention avert millions of malaria cases and so many needless deaths?

The idea behind it was simple: Let’s protect children with existing drugs during the malaria season, commencing just before cases start to climb. The implementation was more complicated, though, as it required strong technical and financial partnerships – which continue to deliver, up through today.

The intervention started out slowly. National health authorities had to be convinced of SMC effectiveness. A considerable, consistent supply had to be acquired of Sulfadoxine-Pyrimethamine Amodiaquine (popularly known as SPAQ), which is the antimalarial combination therapy administered in SMC campaigns.

A child-friendly formulation also had to be developed, with the drugs then distributed. Healthcare workers had to be trained in its administration. Parents had to be persuaded that three, four even five doses of the drug would protect their children for the entire malaria season.

In response, African researchers played a pivotal leadership role in the rapid SMC policy adoption, then its large-scale implementation. From 2002-2008, researchers in Senegal, Gambia, Mali and Ghana ensured that the results of landmark SMC studies were widely disseminated, and then they designed and implemented new research that provided additional evidence of SMC effectiveness. Their efforts led to the initial WHO recommendation, in 2012.

As for partnerships, together with Roll Back Malaria, an SMC working group was created to help countries fast-track policy adoption. This working group eventually became the SMC Alliance.

Meanwhile, Unitaid has also been a key player: it funded the ACCESS SMC project, which demonstrated the feasibility of scaling up and dramatically expanding SMC, by evaluating its effectiveness and cost.

Effective and inexpensive

As supportive evidence mounted, SMC uptake rapidly increased. Today, 15 countries in the Sahel region of Western Africa are on board, implementing regular SMC campaigns during malaria season. In 2021 alone, despite Covid-related delivery challenges, 45 million children received SMC. Then in 2022, 48 million kids received it. This protected them during the rainy season, when deadly female Anopheles mosquitoes lurk in the shadows, ready to pounce on their next blood meal. 

As if saving lives were not enough, SMC has also proved to be highly cost-effective. A 2021 analysis revealed that SMC had so far saved participating health systems as much as $66 million.

 An additional tool to protect young children appeared in 2021 with the arrival of the RTS, S/AS01 malaria vaccine, Mosquirix, which also received a WHO recommendation. A study last year showed that SMC, when combined with this vaccine, provided significantly greater protection than either intervention alone.

 SMC has shown such remarkable efficacy in the Sahel region of West Africa, other parts of the continent are now beginning adopt it: This year, Mozambique became the first country in southern Africa to pilot SMC; while in East Africa, Uganda, Tanzania and South Sudan are engaged in early SMC efforts.

And it doesn’t stop there. From 2009 onwards, researchers in Senegal began to explore whether SMC could benefit older children; they confirmed it could also protect children aged 5 to 10 years old. This led the WHO to review the guidelines in June 2022 to allow SMC to extend beyond the Sahel and reach children older than 5. This potentially protects millions more.

All this is excellent news for the donors who have invested in SMC. It is equally welcome news for those national health systems in Africa that experience seasonal malaria transmission, as they are keen to save the lives of future citizens and are attracted to SMC’s cost-effectiveness. However, despite its rapid rise in popularity, SMC brings challenges of its own: mainly, how to secure uninterrupted supplies of SPAQ and develop new drugs to respond to resistance.

African manufacturing boost

Indeed, reaching older children requires more supplies of WHO-approved SPAQ. To resolve this problem, international partners, including MMV, are supporting the local African production of SPAQ. By the end of 2023, SPAQ will be manufactured for the first time in Africa to WHO-quality standards – another landmark worth celebrating.

Meanwhile, as more countries outside the Sahel region are keen to roll out SMC, unfortunately, in parts of eastern Africa, there are signs of drug resistance to Sulfadoxine Pyrimethamine. Undeterred, researchers and national malaria teams in these countries are exploring alternative drug combinations for SMC regimens, in case resistance renders SPAQ completely ineffective. The spectre of drug resistance always looms.

So far, though, given the determination of countries’ malaria programs and the malaria community, no problem has been insurmountable. Yet a major barrier remains: sustainable funding. Stagnant funding for malaria, especially malaria-drug research, might not only slow the development of new antimalarials but place millions of young lives at risk. We cannot allow this to happen.

We, in the malaria community, are confident that these 10 years of success in protecting and saving countless young African children is all the evidence we need to continue supporting SMC until no child or family ever suffers from this disease.

Prof Jean Louis Ndiaye is a Professor of Parasitology and Head of the Research and Innovation Division at the University Iba Der Thiam of Thiès, in Senegal. He is co-chair of the SMC Alliance research sub-group.

Dr André Marie Tchouatieu is the Director of Chemoprevention Access and Product Management at MMV and General Secretary of the SMC Alliance.

Image Credits: UNICEF USA , Damien Schumann / MMV.