The research, published in The Lancet, demonstrates the impact of Seasonal Malaria Chemoprevention (SMC), a combination of sulfadoxine-pyrimethamine antimalarials with amodiaquine, given as tablets once a month, during the four-month rainy season, community health workers.
SMC had already shown that it significantly reduced malaria cases among children, but this new study is “the first proof of the impact on malaria deaths in children”, so the authors call for broad administration across West Africa and Central.
The study “Achieving the catalytic expansion of SMC in the Sahel” (ACCESS-SMC), now published, evaluated the safety and effectiveness of SMC in terms of scale, delivery costs, cost-effectiveness and the effects on drug resistance between 2015 and 2016 in seven countries: Burkina Faso, Chad, Gambia, Guinea, Mali, Niger and Nigeria.
Low levels of resistance to seasonal treatments have been identified, but the authors consider continuous molecular monitoring necessary to provide an early warning of loss of efficacy.
In 2019, malaria caused 643,000 deaths worldwide and more than half (356,000) were children under the age of 5, the vast majority in West and Central Africa.
In the sub-Sahel region of Africa (from southern Senegal and northern Guinea to Chad and northern Cameroon), SMC is given monthly to children during the rainy season.
The tablets are administered over three days: two on the first day, one on the second and another on the third.
Some clinical trials have pointed to a 75% reduction in malaria, including severe malaria.
For Paul Milligan, of the London School of Hygiene & Tropical Medicine (United Kingdom), one of the study’s authors, “this assessment of the increased implementation of SMC provides the first evidence of an impact in reducing malaria deaths in children”.
The project increased the demand for SMC drugs, which in turn encouraged drug manufacturers to increase capacity and develop child-friendly formulations.
There are now programs in 13 countries that reached around 22 million children in 2019. However, about eight million children living in areas suitable for SMC are being overlooked. Delivery needs to be optimized to ensure high levels of coverage in all regions, according to the publication.
During the period under review, SMC reduced malaria deaths in children during the rainy season by 42% in Burkina Faso and by 57% in Gambia.
The incidence of severe malaria was reduced by 55% in Gambia during 2015 and 2016 and by 27% in Burkina Faso in 2015. Data for 2016 were not available.
In all seven countries, outpatient malaria cases have declined, ranging from a 25% reduction in Nigeria in 2016 to 59% in Gambia in the same year.
Each monthly treatment demonstrated a high degree of personal protection for four weeks, reducing the incidence of malaria by more than 80% during this period.
Protection then falls quickly, with the drug reducing the incidence of malaria by 61% between the 29th and 42nd days after treatment.
For this reason, the authors say, treatments must have a strict interval of 28 days to maintain high levels of protection.
The study reports that more than 12 million monthly SMC treatments were administered in 2015 to a target population of more than 3.6 million children and 25 million SMC treatments in 2016 to a target population of 7.6 million children.
In 2015, 86% of children received at least one treatment, while 55% received all four treatments. On average, 76% of children received treatment every month. Similar numbers received treatment in 2016. In both years, coverage varied between the seven countries.
Door-to-door delivery has proven to be the most effective method of reaching children, especially in the poorest areas.
Safety control through the national pharmacovigilance system in each country has been improved to ensure that the drug remains safe when administered on a large scale.
Serious adverse reactions were uncommon, which was in line with previous clinical trials.
In 779 safety reports of individual cases related to the treatment of SMC that were available in the study, including cases of skin rashes and gastrointestinal disorders, 36 serious adverse drug reactions were recorded, but all of these children recovered and no cases of serious skin reactions was reported in the study.
Yacine Djibo, executive director of Speak Up Africa and author of the study, said: “Despite the challenges of delivering monthly treatments door to door, it is possible to achieve high coverage, reducing the unacceptable infant mortality rate associated with malaria.”
“These conclusions should support efforts to maintain high levels of SMC coverage and it is very encouraging to see that, since the end of ACCESS-SMC, project countries have successfully transitioned to other sources of funding and more countries have started seasonal chemoprevention programs malaria ”.
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