3 trials of intermittent preventive treatment for malaria in children

Three randomized controlled trials published in this week's PLoS Medicine show that intermittent preventive treatment of malaria in children adds to the benefit of sleeping under bednets and that this public health intervention is best delivered by community-based, volunteer village health workers. Two randomized controlled trials (with over 3000 children in each study) carried out by a team of researchers led by Diadier Diallo from the London School of Hygiene & Tropical Medicine, London, UK, Amadou Konate from the Centre National de Recherche et de Formation sur le Paludisme, Ouagadougou and Alassane Dicko from the Malaria Research and Training Centre (University of Bamako), Bamako, Mali found that in the peak malarial transmission season in Burkina Faso and Mali, intermittent preventive treatment for malaria (using the antimalarial drugs sulphadoxine pyrimethamine and amodiaquine) provided substantial additional protection against episodes of clinical malaria, severe malaria, and all-cause hospital admissions in children sleeping under long-lasting insecticide treated bednets.

Intermittent preventive treatment (administration of anti-malarial drugs at defined time intervals to individuals, regardless of whether they are known to be infected with malaria) was initially recommended for pregnant women and has recently been extended to include infants and children. However, previous studies in children were carried out in countries where the use of insecticide treated bednets — an intervention that provides at least 50% protection against morbidity from malaria and is the main tool used for malaria control in most of sub-Saharan Africa — was relatively low. Therefore, the findings of these two trials are important as they demonstrate the additional benefit that intermittent preventive treatment can confer on standard malaria control practice.

The authors of the Burkino Faso study conclude: "There is now strong evidence to support the integration of [Intermittent preventive treatment for children] into malaria control strategies in areas of seasonal malaria transmission."

The authors of the study conducted in Mali arrive at a similar conclusion: "These findings indicate that [Intermittent preventive treatment for children] could make a valuable contribution to malaria control in areas of seasonal malaria transmission alongside other interventions."

However, for the scale up of intermittent preventive treatment for children to be successful, there needs to be an appropriate delivery system that can be generalized to most settings in Sub-Saharan Africa. A randomized controlled trial carried out by Kalifa Bojang from the Medical Research Council Laboratories, Banjul, The Gambia, and colleagues finds that in 26 rural areas of the Gambia (each with 400-500 children), delivery of intermittent preventive treatment to children by community-based, volunteer village health workers was more effective and less costly than delivery by reproductive and child health trekking teams (run by the Ministry of Health).

The authors found that delivery through the trained village volunteers was more effective because as these workers are resident in the community, drug administration was easier and more flexible since children were able to receive their medication on any day of the month. Therefore, delivery of the intervention is more convenient for parents and guardians.

The authors conclude: "Longer term experience will show whether the high level of coverage obtained in this study can be sustained but the results of this trial suggest that community volunteers can achieve high level coverage with this very effective malaria control intervention if they are supported to do so."

Source: Public Library of Science