Abstract
BackgroundSeasonal malaria chemoprevention (SMC) is a new strategy recommended by WHO in areas of highly seasonal transmission in March 2012. Although randomized controlled trials (RCTs) have shown SMC to be highly effective, evidence and experience from routine implementation of SMC are limited.MethodsA non-randomized pragmatic trial with pre-post design was used, with one intervention district (Kita), where four rounds of SMC with sulfadoxine + amodiaquine (SP + AQ) took place in August–November 2014, and one comparison district (Bafoulabe). The primary aims were to evaluate SMC coverage and reductions in prevalence of malaria and anaemia when SMC is delivered through routine programmes using existing community health workers. Children aged 3–59 months from 15 selected localities per district, sampled with probability proportional to size, were surveyed and blood samples collected for malaria blood smears, haemoglobin (Hb) measurement, and molecular markers of drug resistance in two cross-sectional surveys, one before SMC (July 2014) and one after SMC (December 2014). Difference-in-differences regression models were used to assess and compare changes in malaria and anaemia in the intervention and comparison districts. Adherence and tolerability of SMC were assessed by cross-sectional surveys 4–7 days after each SMC round. Coverage of SMC was assessed in the post-SMC survey.ResultsDuring round 1, 84% of targeted children received at least the first SMC dose, but coverage declined to 67% by round 4. Across the four treatment rounds, 54% of children received four complete SMC courses. Prevalence of parasitaemia was similar in intervention and comparison districts prior to SMC (23.4 vs 29.5%, p = 0.34) as was the prevalence of malaria illness (2.4 vs 1.9%, p = 0.75). After SMC, parasitaemia prevalence fell to 18% in the intervention district and increased to 46% in the comparison district [difference-in-differences (DD) OR = 0.35; 95% CI 0.20–0.60]. Prevalence of malaria illness fell to a greater degree in the intervention district versus the comparison district (DD OR = 0.20; 95% CI 0.04–0.94) and the same for moderate anaemia (Hb < 8 g/dL) (DD OR = 0.26, 95% CI 0.11–0.65). The frequency of the quintuple mutation (dhfr N51I, C59R and S108N + dhps A437G and K540E) remained low (5%) before and after intervention in both districts.ConclusionsRoutine implementation of SMC in Mali substantially reduced malaria and anaemia, with reductions of similar magnitude to those seen in previous RCTs. Improving coverage could further strengthen SMC impact.Trial registration clinical trial registration number NCT02894294
Highlights
Seasonal malaria chemoprevention (SMC) is a new strategy recommended by World Health Organization (WHO) in areas of highly seasonal transmission in March 2012
The region is disproportionally affected by malaria, with 88% of the estimated 214 million malaria cases and 90% of 438,000 malaria deaths worldwide occurring in this region in 2015, according to recent World Health Organization (WHO) estimates
This study aims to evaluate SMC coverage and reductions in malaria and anemia when SMC is delivered through routine programmes by existing community health workers
Summary
Seasonal malaria chemoprevention (SMC) is a new strategy recommended by WHO in areas of highly seasonal transmission in March 2012. Malaria remains a major cause of morbidity and mortality in sub-Saharan Africa. More than two-thirds (70%) of all malaria deaths occur in children under 5 years of age [1]. As in many countries in sub-Saharan Africa, malaria is the primary cause of morbidity and mortality in Mali, among children under 5 years old. In 2015, the national health information system reported 2.4 million clinical cases of malaria in health facilities, accounting for 34% of all outpatient visits for all age groups. According to the 2015 Malaria Indicator Survey (MIS) [2] conducted during the high transmission period, the prevalence of parasitaemia among children 6–59 months of age was 32%
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