Abstract
ABSTRACT.Sulfadoxine-pyrimethamine plus amodiaquine is delivered to children aged 3–59 months as seasonal malaria chemoprevention (SMC) in areas where transmission is highly seasonal such as Chad and other Sahelian countries. Although clinical trials show a 75% reduction in malaria cases, evidence of SMC’s impact at scale remains limited. Using data from the Chadian National Health Management Information System, we analyzed associations between SMC implementation during July–October and monthly district-level malaria incidence (suspected and confirmed outpatient cases) among children aged 0–59 months at health facilities in 23 health districts with SMC implementation during 2013–2018. Generalized additive models were fitted with separate cyclic cubic spline terms for each district to adjust for seasonality in cases. SMC implementation in Chad was associated, compared with no implementation, with lower monthly counts of both suspected (rate ratio [RR]: 0.82, 95% CI: 0.72–0.94. P = 0.006) and confirmed malaria cases (RR: 0.81, 95% CI: 0.71–0.93, P = 0.003), representing around 20% reduction in malaria incidence. Sensitivity analyses showed effect sizes of up to 28% after modifying model assumptions. Caution should be exercised in interpreting our findings, which may not be comparable with other studies, and may over- or underestimate impact of SMC; not all malaria cases present at health facilities, not all suspected cases are tested, and not all facilities report cases consistently. This study’s approach presents a solution for employing readily available routine data to evaluate the impact of health interventions at scale without extensive covariate data. Further efforts are needed to improve the quality of routine data in Chad and elsewhere.
Highlights
IntroductionSeasonal malaria chemoprevention (SMC) through administration of sulfadoxine-pyrimethamine (SP) in combination with amodiaquine (AQ) at monthly intervals to children aged 3–59 months is recommended as an intervention against Plasmodium falciparum malaria during the annual high-transmission season in regions where the majority (. 60%) of clinical malaria cases occur during a period of 4 months, the clinical attack rate of malaria is greater than 0.1 attack per transmission season in the target age group, and SP plus AQ (SPAQ) remains efficacious.[1]Seasonal malaria chemoprevention is considered a costeffective intervention,[2,3,4,5] with annual cost of delivery per child in Chad in 2016 estimated at US$3.86, and costs of US$10.26 and US$39.20 per malaria case and disability-adjusted life year averted among eligible children.[4]It has been found to be a highly efficacious intervention in terms of reduction of malaria morbidity, prevalence of malaria parasitemia, malaria-related hospital admissions, and mortality.[6,7,8,9,10,11,12] A number of randomized controlled trials have been conducted to assess the protective efficacy of seasonal malaria chemoprevention (SMC) against malaria cases in eligible children
Sulfadoxine-pyrimethamine plus amodiaquine is delivered to children aged 3–59 months as seasonal malaria chemoprevention (SMC) in areas where transmission is highly seasonal such as Chad and other Sahelian countries
Seasonal malaria chemoprevention (SMC) through administration of sulfadoxine-pyrimethamine (SP) in combination with amodiaquine (AQ) at monthly intervals to children aged 3–59 months is recommended as an intervention against Plasmodium falciparum malaria during the annual high-transmission season in regions where the majority (. 60%) of clinical malaria cases occur during a period of 4 months, the clinical attack rate of malaria is greater than 0.1 attack per transmission season in the target age group, and SP plus AQ (SPAQ) remains efficacious.[1]
Summary
Seasonal malaria chemoprevention (SMC) through administration of sulfadoxine-pyrimethamine (SP) in combination with amodiaquine (AQ) at monthly intervals to children aged 3–59 months is recommended as an intervention against Plasmodium falciparum malaria during the annual high-transmission season in regions where the majority (. 60%) of clinical malaria cases occur during a period of 4 months, the clinical attack rate of malaria is greater than 0.1 attack per transmission season in the target age group, and SP plus AQ (SPAQ) remains efficacious.[1]Seasonal malaria chemoprevention is considered a costeffective intervention,[2,3,4,5] with annual cost of delivery per child in Chad in 2016 estimated at US$3.86, and costs of US$10.26 and US$39.20 per malaria case and disability-adjusted life year averted among eligible children.[4]It has been found to be a highly efficacious intervention in terms of reduction of malaria morbidity, prevalence of malaria parasitemia, malaria-related hospital admissions, and mortality.[6,7,8,9,10,11,12] A number of randomized controlled trials have been conducted to assess the protective efficacy of SMC against malaria cases in eligible children. Seasonal malaria chemoprevention (SMC) through administration of sulfadoxine-pyrimethamine (SP) in combination with amodiaquine (AQ) at monthly intervals to children aged 3–59 months is recommended as an intervention against Plasmodium falciparum malaria during the annual high-transmission season in regions where the majority A metaanalysis of SMC studies with monthly administration of SPAQ to children aged less than five years during the peak malaria transmission season showed an 83% (95% CI: 72–89) reduction in the incidence of clinical attacks of malaria and a similar reduction in incidence of severe malaria.[13] Among these studies, a trial in Senegal conducted by Cisse et al.[14] found that the prevalence ratio of P. falciparum parasitemia diagnosed using rapid diagnostic tests (RDT) was 68% lower (95% CI: 35–85, P 5 0.002) among children aged 3–59
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