Abstract
Improving the health of school-aged children can yield substantial benefits for cognitive development and educational achievement. However, there is limited experimental evidence of the benefits of alternative school-based malaria interventions or how the impacts of interventions vary according to intensity of malaria transmission. We investigated the effect of intermittent screening and treatment (IST) for malaria on the health and education of school children in an area of low to moderate malaria transmission. A cluster randomised trial was implemented with 5,233 children in 101 government primary schools on the south coast of Kenya in 2010-2012. The intervention was delivered to children randomly selected from classes 1 and 5 who were followed up for 24 months. Once a school term, children were screened by public health workers using malaria rapid diagnostic tests (RDTs), and children (with or without malaria symptoms) found to be RDT-positive were treated with a six dose regimen of artemether-lumefantrine (AL). Given the nature of the intervention, the trial was not blinded. The primary outcomes were anaemia and sustained attention. Secondary outcomes were malaria parasitaemia and educational achievement. Data were analysed on an intention-to-treat basis. During the intervention period, an average of 88.3% children in intervention schools were screened at each round, of whom 17.5% were RDT-positive. 80.3% of children in the control and 80.2% in the intervention group were followed-up at 24 months. No impact of the malaria IST intervention was observed for prevalence of anaemia at either 12 or 24 months (adjusted risk ratio [Adj.RR]: 1.03, 95% CI 0.93-1.13, p = 0.621 and Adj.RR: 1.00, 95% CI 0.90-1.11, p = 0.953) respectively, or on prevalence of P. falciparum infection or scores of classroom attention. No effect of IST was observed on educational achievement in the older class, but an apparent negative effect was seen on spelling scores in the younger class at 9 and 24 months and on arithmetic scores at 24 months. In this setting in Kenya, IST as implemented in this study is not effective in improving the health or education of school children. Possible reasons for the absence of an impact are the marked geographical heterogeneity in transmission, the rapid rate of reinfection following AL treatment, the variable reliability of RDTs, and the relative contribution of malaria to the aetiology of anaemia in this setting. www.ClinicalTrials.gov NCT00878007.
Highlights
In many malaria endemic countries, successful control programmes have recently reduced the level of malaria transmission [1,2,3], and as a consequence, immunity to malaria is acquired more slowly and the burden of clinical malaria is shifting from the very young to older children [4,5]
There remains a lack of consistent policy and technical guidance [23] on which interventions can reduce the burden of malaria among school children and which can cost-effectively be delivered through existing school systems
7,337 children aged between 5 and 20 years were randomly selected in January 2010 of which 5,772 (78.7%) parents consented, with no real differences found between groups in terms of percentage of parents refusing and not attending the meetings
Summary
In many malaria endemic countries, successful control programmes have recently reduced the level of malaria transmission [1,2,3], and as a consequence, immunity to malaria is acquired more slowly and the burden of clinical malaria is shifting from the very young to older children [4,5]. Infection rates are typically highest among school-aged children [7,8], who, due to recent improvements in primary school access, are increasingly enrolled in school [9,10]. Tackling such parasitaemia, whether or not it results in clinical disease, is important for two reasons. Improving the health of school-aged children can yield substantial benefits for cognitive development and educational achievement. We investigated the effect of intermittent screening and treatment (IST) for malaria on the health and education of school children in an area of low to moderate malaria transmission. In 2008, the Partnership launched its Global Malaria Action Plan, which aims to control malaria to reduce the current burden, to eliminate malaria over time country by country, and, to eradicate malaria
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