Category Archives: IPTi

Country Updates on Global Call to Action to Increase Coverage of Intermittent Preventive Treatment in Pregnancy

Symposium 87 at the 65th Annual Meeting of the American Society of Tropical Medicine and Hygiene focused on the Global Call to Action to Increase Coverage of Intermittent Preventive Treatment in Pregnancy: Progress and Lessons Learned. The original Global Call was initiated at a previous ASTMH meeting. Elaine Roman of Jhpiego chaired the session. Panelists included Julie Gutman of the US CDC,  Frank Chacky of the NMCP in Tanzania, Yacouba Savadogo of the NMCP in Burkina Faso and Fannie Kachale of the Reproductive Health Directorate in the Malawi MOH.

symp-tanzania-1The symposium speakers reviewed country progress in sub-Saharan Africa (SSA) in increasing intermittent preventative treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP). They described how Ministries of Health and donors and partners are working to increase IPTp-SP coverage to address malaria in pregnancy (MiP).

Following the release of the World Health Organization’s (WHO) 2012 updated policy on IPTp-SP, a number of global stakeholders came together through the Roll Back Malaria-Malaria in Pregnancy Working Group, to elaborate the Global Call to Action: To Increase National Coverage with IPTp of MiP for Immediate Impact. The Call to Action calls upon countries and partners to immediately scale up IPTp-SP to improve health outcomes for mothers and their newborns. Scaling up IPTp-SP across most countries in sub-Saharan Africa remains a critical weapon to prevent the devastating consequences of MiP.

symp-ipt-update-malawi

IPTp3+ has been started in Malawi following WHO recommendations

However, the low proportion of eligible pregnant women receiving at least one dose of IPTp-SP (52%) and IPTp3-SP (17%) in 2014 is unacceptable. Despite growing parasite resistance to SP in some areas, IPTp-SP remains Tuesday a highly cost-effective, life-saving strategy to prevent the adverse effects of MiP in the vast majority of SSA.

Completion of the recommended three or more doses of IPTp-SP decreases the incidence of low birthweight (LBW) by 27%, severe maternal anemia by 40% and neonatal mortality by 38%. This symposium will feature presentations from WHO and the President’s Malaria Initiative on how they are prioritizing support to scale up MiP interventions including IPTp-SP across SSA.

Panelists from Burkina Faso, Malawi and Tanzania discussed how they were able to dramatically scale up IPTp-SP through a health systems approach that addresses MiP from community to district to national level.

symp-ipt-burkinaIn Burkina Faso, IPTp2-SP increased from 54.8% in 2013 to 82.3% nationally in 2015 and IPTp3-SP increased from 13.5% in 2014 to 41.2% nationally in 2015. Moving ahead Burkina Faso will Improve SP supply chain management, Pilot an IPTp distribution at the community level in three districts, Provide job aids throughout ANC clinics, and Provide support to district team for data review and analysis.

In Malawi, in targeted project sites across 15 districts, IPTp1 uptake increased from 44% in 2012 to 87% in 2015, while IPT2 increased from 16% to 61% over the same time period. Lessons learned from scale up include –

  • Consistent availability of SP for IPTp is critical to increasing coverage
  • A clear policy put in place to guide IPTp implementation is crucialsymp-building-blocks-malawi
  • A strong partnership between the Reproductive Health Directorate and National Malaria Control Programme is necessary
  • Intensification of information, education, and communication is crucial to increase uptake of ANC services
  • Strong collaboration, planning, and coordination between partners and other stakeholders improve ANC attendance
  • Antenatal clinics offers enormous opportunities for delivering the malaria prevention package, such as IPTp and insecticide-treated nets, to pregnant women

symp-ipt-tanzaniaIn Tanzania, IPTp2-SP increased from 34% in 2014 to 57% in 2015 and IPTp4-SP was reported at 22% in 225 facilities across 16 districts, in 2015. Program learning in Tanzania identified that consistent availability of commodities at facility level can complement Government’s and partners’ efforts to ensure provision of quality MiP services. Despite increased number of trained health care workers and regular supportive supervision and mentoring, increasing uptake of IPTp will continue to be a challenge unless malaria commodities such as mRDT and SP are available at health facilities. Redistribution of commodities among facilities could be crucial balancing the stock.

symp-tanzania-by-regionMoving forward Tanzania plans to use alternative funding to procure malaria commodities at health facility (e.g., Community Health Fund, National Health Insurance Fund, basket fund). Other efforts will include conducting onsite mentorship and coaching, data collection and interpretation, selecting sentinel sites for collecting IPTp3, working with Ministry of Health HMIS to revise HMIS tools when opportunity arises, and training Community Health Workers (CHWs) on maternal, neonatal and child health interventions including early booking of ANC services.

These three country examples demonstrate that progress is challenging but possible. The call to action for increased IPTp access and use is stronger today.

Improving IPTp uptake and mitigating Stock-outs in Bungoma County, Kenya

A poster entitled “Improving Pregnancy Outcomes: Alleviating Stock-Outs of Sulfadoxine-Pyrimethamine in Bungoma, Kenya” was presented by Augustine Ngindu, Gathari Ndirangu, Waqo Ejersa, David Omoit, and Mildred Mudany from Jhpiego’s Kenya Team at the 65th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The abstract follows …

policyWHO recommends intermittent preventive treatment of malaria in pregnancy using sulfadoxine pyrimethamine (IPTp-SP) to be provided at antenatal care (ANC) clinic. The Malaria Policy in Kenya requires that All pregnant women in malaria-endemic areas receive free intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP), have access to free malaria diagnosis and treatment when presenting with fever, and have access to long-lasting insecticidal nets.

Kenya’s Strategic Direction between 2014–2018 was revised to reflect the following:

  • All pregnant women in the 14 malaria-endemic counties shall receive at least three doses of IPTp-SP
  • Annual quantification of SP based on consumption to ensure adequate supplies
  • Training, retraining and supervision of health care workers
  • Dissemination of appropriate IPTp messages and materials

coverageMinistry of Health (MOH) used to procure SP until 2013 when health services were devolved to counties and procurement of became the responsibility of county governments. This presented a major challenge as counties had not factored SP in their budgets. Consequently, counties experienced SP stock-outs from October 2014. In Bungoma County the number of pregnant women receiving IPTp dropped by 51% from 7,845 in October 2014 to 3,865 in February 2015.

To alleviate the situation (MOH) at national level requested counties to procure SP. Advocacy efforts with Bungoma County by the Maternal and Child Survival Program focused on prioritization of SP procurement at least once every quarter. As a result of this intervention, Bungoma County procured SP from February to July 2015.

core-indicatorsThe county advised health facilities to procure additional SP doses if the supplied stocks ran out. The procurement led to a 117% increase in the number of pregnant women receiving IPTp; from 3,865 in February to 8,404 in July 2015.

The fiscal year ended in June 2015 and no funds were available to procure additional SP until October 2015. This contributed to a 33% decrease in the number of pregnant women receiving IPTp from 8,404 in July to 5,672 in October 2015. As a response to support counties, MOH at national level procured 2.24 million SP doses in November/December for 14 MIP-focus counties which were received at health facilities in February 2016.

In conclusion, Bungoma County applied feasible mitigation measures including county level procurement of SP, supplemented by additional procurement at health facility and national levels. This is a practice which is replicable in other counties to ensure continued availability of SP to protect pregnant women from effects of malaria in pregnancy.

Community Directed Interventions to Enhance PHC and MCH

William Brieger of the Department of International Health, JHU Bloomberg School of Public Health, delivered the keynote address to the Community Based Primary Health Care Working Group at the 2015 American Public Health Association in Chicago. The focus was on Community Directed Interventions (CDI) as a way to enhance implementation of primary health care and maternal and child health. Some excerpt from the talk follow.

Ivermectin coverageThe origins of the CDI Approach are based in Onchocerciasis Control and the implementation research done by the Tropical Disease Research (TDR) Program of WHO and collaborating agencies to help establish the foundational guidance of the African Program for Onchocerciasis Control in 1995. Since then we have seen an expansion of CDI into other health issues

We should start discussion with an understanding of ‘community’ which Rifkin et al. (1988) defined as a group of people living in the same defined area sharing basic values, organization, and interests. White (1982) proposed that community is an informally organized social entity which is characterized by a sense of identity. Manderson et al. (1992) in their work for TDR defined community as a population which is geographically focused but which also exists as a discrete social entity, with a local collective identity and corporate purpose.

Communities are people sharing values and institutions. Community is based on locality (geographic), interdependent social groups, interpersonal relationships expressed through social networks and built on s culture that includes values, norms, and attachments to the community as a whole as well as to its parts. Prior to developing any community intervention we must understand the boundaries, composition and structure of a community from the perspectives of its own members, as their local knowledge and participation are central to success.

community systemsCommunity Systems Strengthening has been taken up by the Global Fund in order to enhance coverage of various health interventions such as HIV drugs and bednets to prevent malaria. Community systems are community?led structures and mechanisms used by communities through which community members and community based organizations and groups interact, coordinate and deliver their responses to the challenges and needs affecting their communities. Many community systems are small?scale and/or informal. Others are more extensive – they may be networked between several organizations and involve various sub?systems. For example, a large care and support system may have distinct sub?systems for comprehensive home?based care, providing nutritional support, counselling, advocacy, legal support, and referrals for access to services and follow?up.

Efficacy, Social Control and Cohesion are important characteristics of communities that enable them to take on project and solve problems. Collective Efficacy is a perceived ability to work together. Social control provides evidence that communities are able to enforce their norms. Cohesion describes social interaction that brings people together. A strong sense of identity and a sense of belonging describe communities that can get things done. These characteristics lead to community competency to collaborate effectively in identifying the problems/needs of the community, achieve a working consensus on goals and priorities, agree on ways and means to implement the agreed-upon goals, and collaborate effectively in the required actions.

Communities chooseIt is important to distinguish between Community Based Intervention (CBI) and Community Directed Intervention. CBI takes place in the community but a Health/Development agency exercises authority over decisions on project design and implementation. Project activities (e.g., service delivery dates and procedures) are designed by the agency. Activities simply happen in the community.

With CDI the community exercises authority over decisions and decides on acceptable method to implement projects. This ensures sensitivity to local decision-making structures and social life. Activities happen both in and by the community; the community is in control.

CDI was pioneered for Onchocerciasis (River Blindness) Control as community directed treatment with ivermectin (CDTI). When communities are in charge, coverage is better than when ivermectin distribution is centrally organized by a health agency. The original 1995 CDI field testing showed better ivermectin coverage when the community was in charge of distribution. Since the beginning of CDTI, over 200,000 villages in 18 African countries have been distributing ivermectin annually through their own efforts. Lessons learned over the years are that CDI works best when 1) the smallest level of an organized community is the basis of action (e.g. a hamlet, a clan/kin group) and 2) communities are encouraged to choose as many CDDs as they think they need to get the job done. This means that the community is in charge, not individual volunteers who can be replaced anytime the community finds the need.

With CDI for onchocerciasis or any other health program, Communities plan and chose how to deliver services. This may be house-to-house, central place distribution or a combination. Health workers provide training and supervision to volunteer village health workers called community directed distributors (CDDs).

CDI study 2008TDR observed that CDI naturally expanded to include other services wanted by the community such as immunization, community development, water and sanitation, agriculture and forestry, HIV-AIDS, family planning, guinea worm, Vitamin A. TDR and APOC then decided that CDI with other service components should be systematically tested. The project sites added in a systematic manner other interventions to existing CDTI programs including home management of malaria, ITN distribution & promotion, TB DOTS, Vitamin A in addition to continued ivermectin distribution. These services varied in complexity and communities responded by dividing the work among several different volunteers.

Appropriate malaria treatment CDI studyCoverage of interventions like malaria case management, ITN promotion and Vitamin A distribution was higher in the intervention areas compared to the delivery of these services through the routine health system. TB DOTS presented the only challenge because of the social stigma associated with the disease. The study concluded that CDI can effectively incorporate high impact, evidence based interventions while at the same time maintaining and increasing ivermectin coverage. Since CDI does not rely on one volunteer but whole community effort, the problem of overburdening on community health worker did not arise. Other incterventions ould benefit from CDI such as Misoprostol, Intermittent Preventive Treatment, Deworming, Oral Rehydration solution, Zinc, Cotrimoxazole, Amoxicillin, Soap for handwashing and WaterGuard treatment kits.

MIPJhpiego an NGO affiliate of the Johns Hopkins University used CDI to deliver malaria in pregnancy (MIP) prevention services in Nigeria including Intermittent Preventive Treatment and Insecticide Treated Nets. Contrary to fears that CDI would detract from antenatal care attendance, the work of CDDs actually ensured that ANC attendance increased over time. Through CDI IPTp coverage increased compared to control communities and more pregnant women slept under ITNs regularly.

Community-Clinic modelJhpiego next expanded CDI for MIP into integrated Community Case Management (iCCM), thus taking community case management beyond community based care. Giving communities responsibility for organizing and managing their services using the CDI approach meant greater access to services whenever people need them. Using the CDI approach to iCCM CDDs reached 7,504 clients who presented signs and symptoms of malaria. CDDs successfully conducted malaria diagnosis using the rapid diagnostic test (RDT) kits. Overall, 47.8% tested positive while 52.2% tested negative. CDDs adhered to guidelines and all the 3,587 clients with positive RDT results received appropriate anti-malarial medicines. As appropriate 21.0% were treated for diarrhoea, 11.0% for pneumonia (of whom 68.0% were referred to the health facility)

CDDsA Supervisory Checklist and Performance Standards were developed and used for Assessing CDD performance. The results were discussed at monthly CDD meetings at their nearest health facilities. This led to further improvements in History taking, Examination, Conducting RDTs for Malaria and Illness Management.

TDR has done further scoping to learn if CDI would be acceptable by health workers and community members in Urban, Nomadic and Underserved Rural Communities. CDI was favorable received. In conclusion we have learned over the years that CDI can involve women, families and communities in meeting their own health needs.

Malaria and the Rains of Africa

The World Health Organization is guiding countries across the Sahel of Africa to begin piloting ‘seasonal malaria chemoprevention” or SMC. We recently featured this in the May 2013 issue of Africa Health. WHO explains that “Seasonal malaria chemoprevention is defined as the intermittent administration of full treatment courses of an antimalarial medicine to children during the malaria season in areas of highly seasonal transmission.” This is an outgrowth of several years of research into intermittent preventive treatment for infants (IPTi) and children.

dscn8811a.jpgMalaria program managers wanted a more focused application of IPTi where it would be likely to make a major impact on disease control. Researchers found that areas meeting malaria seasonality definition of 60% of annual incidence within 4 consecutive months were observed more frequently in the Sahel and sub-Sahel than in other parts of Africa, and thus could provide an ideal focus for intervention.

What makes transmission more intense in those four months is the rainy season.  Ironically we have recently seen a more intense rainy season in the Sahel with serious flooding. IRIN reports that, “The African Centre of Meteorological Applications for Development (ACMAD) in a seasonal weather outlook says near-average or above-average rainfall is likely over the western Sahel, which stretches across Mauritania, Senegal and western and central Niger. These regions are ‘expected to be the area with the highest risk of above average number of extreme precipitating events that may lead to flash floods’.”

What does this flooding mean for SMC?  While breeding mosquitoes obviously need the pools that rainwater creates, too much rain may have an opposite effect with flash floods washing out breeding sites (let alone homes and possessions). When flooding results in larger and longer collections of standing water, mosquito breeding may be enhanced, but this will make logistical support for training, supervision, and drug supplies extremely difficult in the region.

dscn8824a.jpgThe Sahel is one of the areas in Africa where we might hope for some early progress toward malaria elimination. With global climate changes affecting the region we can only wonder whether the weather will cooperate and allow timely implementation of new interventions.  As IRIN implies – contingency planning is extremely important.

Time to Give IPTi a Chance

logo_ipti.jpgEight years ago researchers in Tanzania discovered that giving a full dose of sulphadoxine-pyrimethamine (SP) to infants as intermittent preventive treatment (IPT) has similar positive effects of reduced malaria and anemia as the same process had already shown in pregnant women.  This led to the formation of the IPTi Consortium whose aim was to amass the evidence needed so that international bodies could accept and develop guidelines for this life saving intervention.

Although a variety of studies across Africa with support from UNICEF, the Gates Foundation and others have confirmed the benefits of IPTi, there has been reluctance by WHO to endorse this intervention.  This may have been based on fears of rising parasite resistance to SP.

Today the Lancet has published a meta or pooled analysis of these IPTi Confortium sponsored studies from trials that were conducted in Mozambique, Gabon, Tanzania and Ghana. IPTi Consortium reports that, “SP has a protective efficacy of 30·3% (95% Confidence Intervals 19·8–39·4, p<0·0001) against clinical malaria, in areas of low to moderate resistance to SP during the first year of life.”

Researchers from the Consortium are realistic: “IPTi is not a ‘not a magic bullet‘ and noted that SP resistance has spread to several parts of Africa, which could limit the effectiveness of the IPTi using this drug. But the intervention could prevent 6 million cases of malaria each year among those most vulnerable to the disease.”

IPTi with SP has been proven not only efficacious, but relatively easy to deliver through infant immunization campaigns and routine immunization services. IPTi has also been shown to be acceptable to the community and parents of these infants. Also IPTi is cheap – about US $0.13-0.23 per dose.

While research will continue to find replacements for SP, there is no reason not to act now using this proven intervention to save lives.  It is time for malaria partners and endemic country control programs to come together and operationalize these findings and begin saving lives until such time as a replacement medicine can be found of good efficacy and reasonable cost.

Countries must also remove SP from the shelves of shops and pharmacies where it is sold for treatment so that what remains of its efficacy can be protected until a replacement is found.

The IPTi Consortium is right that there is no magic bullet – this includes nets and treatment drugs, too. All possible and affordable strategies need to be employed to meet the 2015 Millennium Development Goals – saving children’s lives.

IPTi and EPI – healthy links

Recently we highlighted some lessons that malaria control efforts could learn from immunization program management, and observed that this was important because malaria control interventions such as ITN distribution have often been linked with immunization campaigns.  Another link is use of the Expanded Program for Immunization (EPI) services as a delivery mechanism for intermittent preventive treatment for infants (IPTi).

Pool and colleagues have reported on the acceptability of EPI as a channel for IPTi delivery in Tanzania. The researchers concluded that, “In this setting, IPTi delivered together with EPI was generally acceptable. Acceptability was related to prior routinization of EPI [emphasis added] and resonance with traditional practices. Non-adherence was due largely to practical, social and  structural factors, many of which could easily be overcome.”

eritrea-polio-immu.jpgFor example, mothers would have preferred drops instead of tablets for their infants. As with vaccines, mothers knowledge about the whole process was vague and generally consisted of an understanding that the process promoted health rather than controlled specific diseases. Structural factors related to poverty. Despite potential limitations, EPI appears to be a good platform for IPTi delivery.

A review of the Demographic and Health Survey for Tanzania shows that the country has maintained a full immunization coverage rate of around 70% over the past 4 surveys (12 years), but that in the most recent survey (2004) at least 90% of infants had at last one EPI contact. This again speaks well for incorporating IPTi into an existing system that reaches most infants.

The DHS does show some other factors in EPI coverage that would also affect IPTi and reinforces structural factors as a concern. There was lower rural than urban immunization coverage.  More educated and wealthier parents were more likely to get their infants immunized that less educated and poorer ones. DPT3 coverage in 2004 was only 75% for those in the lowest wealth quintile compared to 96% among those in the highest quintile.

These wealth/access disparities are no reason to dissociate IPTi from EPI, but they do emphasize the need for overall health reform so that disease prevention interventions equitably reach all children and families.

Preventive Treatment for School Children

Providing malaria treatment once a term to Kenyan pupils offers important benefits according to this headline: “Malaria prevention in schools reduces anaemia and improves educational potential in Kenyan school children.” In fact lower rates of anemia and improved classroom attention were achieved. Children do not have to be observably sick from malaria to be affected by the disease – the prevalence of P. falciparum was around 40% in these children at baseline.

The study which is fully described in The Lancet, was “A stratified, cluster-randomised, double-blind, placebo-controlled trial of IPT in 30 primary schools in western Kenya. Schools were randomly assigned to treatment (sulfadoxine-pyrimethamine [SP] in combination with amodiaquine or dual placebo) by use of a computer-generated list. Children aged 5–18 years received three treatments at 4-month intervals (IPT n=3535, placebo n=3223). The primary endpoint was the prevalence of anaemia, defined as a haemoglobin concentration below 110 g/L. This outcome was assessed through cross-sectional surveys 12 months post-intervention.”

school-under-the-mangoes-sm.jpgHere is an example where Millennium Development Goals for health and education goals can be achieved through a common intervention.

Of course the benefits of a school-based health program are based on the levels of school attendance, and as reported, “School-age children represent 26% of Africa’s population where 94% of children go to school.”  It should be stressed that this figure is for primary school students.

Interestingly the average age of the study pupils was almost 14 years, likely reflecting late start for education possibly due to family financial problems. The implication for community level malaria control is that there may be a large number of 5-8 year old children who are not yet in school, but are hopefully protected by ITNs at home.

While WHO’s Global Malaria Program (GMP) acknowledges the existence of a now quite extensive body of research on intermittent preventive treatment for infants, it has yet to endorse the practice. The fact that the current study on school children was “funded by the Gates Malaria Partnership which is supported by a grant from the Bill & Melinda Gates Foundation (with) additional funding … provided by the Norwegian Education Trust Fund and multi-donor Education Development Programme Fund of the World Bank; DBL Centre for Health Research and Development; and the Wellcome Trust,” is unlikely to sway opinion at GMP, which has been critical of Gates’ involvement in malaria control and research.

While some may question the use of SP as part of the IPT regimen for these children, the overall concept of IPT for primary school pupils is valuable. One cannot assume that because they don’t look sick that these children are in fact healthy and are not part of the malaria transmission process – it would be a mistake to neglect school children. Partners need to work together to increase available interventions that can reach this group so that endemic countries will ultimately benefit not only from their improved educational attainments, but also from their enhanced economic potential as adults.

IPTi still in limbo, doubts remain

Even after several years of intensive, multi-site research on intermittent preventive treatment for infants (IPTi) with sulfadoxine-pryimethamine (SP) we still seem no closer to making IPTi a public health intervention to strengthen our malaria control arsenal. In 2006 WHO’s Global Malaria Program indicated that, “Intermittent preventive treatment in infants (IPTi) is a new promising strategy under WHO evaluation.” Two years later, this evaluation period appears to continue.

img_3667_lowsm.jpgCochrane Reviews has published this month an update on IPT and chemoprophylaxis. The authors conclude that the “long-term deleterious effects, including the possibility that it may interfere with the development of children’s immunity to malaria, are unknown for either regimen. Further trials with long-term follow up are needed.” Interestingly they do quote one study from 2005 that reported: “Intermittent treatment produced a sustained reduction in the risk of clinical malaria extending well beyond the duration of the pharmacological effects of the drugs, excluding a so-called rebound effect and suggesting that such treatment could facilitate development of immunity against Plasmodium falciparum.”

More recently these researchers addressed interventions including IPTi and found evidence, “… that each of these measures may permit attenuated P. falciparum blood-stage infections, which do not cause clinical malaria but can act as an effective blood-stage ‘vaccine’.” This paints a more positive picture than the Cochrane review, though the need for more research looking specifically at immunity would be valuable.

IPT is what the name says – intermittent. It would be given possibly three times a year coinciding with immunization contacts. There would therefore still be opportunities for ‘attenuated infections’ as mentioned above that could actually boost immunity.

It is time that decisions are made concerning IPTi. If more research is needed, malaria partners need to say so and fund it now. If more study is not needed, it is time to roll out another life saving malaria control intervention.

When elephants fight

dscn3097sm.JPGAs the saying goes, when elephants fight, the grass suffers. The New York Times has reported on just such a fight between elephants – titans in the malaria world, The WHO Global Malaria Program (GMP) and the Bill and Melinda Gates Foundation. According to the article GMP has voiced concern that, “the foundation’s money, while crucial, could have ‘far-reaching, largely unintended consequences,'”  and that Gates funded research might subvert the agenda and role of WHO. The Gates Foundation countered by saying that, “the foundation did not second-guess or ‘hold captive’ scientists or research partnerships that it backed,” and values external review.

A key point of contention is the issue of Intermittent Preventive Treatment for Infants (IPTi). GMP’s current position is that sulfadoxine-pyrimethamine (SP) used in IPT may be dangerous given to children in regular doses and that anyway there is increasing resistance to the drug by malaria parasites.  In contrast, research managed by the IPTi Consortium has produced promising results in many countries. The Times quotes scientists on both sides of the debate.

To make the situation more challenging, UNICEF, another key malaria partner, has invested in IPTi and found its effects to be positive: “Research shows that intermittent preventive treatment for infants (IPTi) may be effective in reducing anaemia and clinical malaria in young children, and may soon be provided as part of their routine immunization visits. UNICEF is a member of the IPTi Consortium, which is currently conducting research into the feasibility of introducing this additional intervention in Africa.” UNICEF is stuck in the unenviable middle of the storm.

In the meantime while the elephants fight, infants and small children are the grass that suffers.  While we do have ACTs and LLINs and IRS, we do not have the yet crucial mix of interventions that can permanently rid children from the threat of malaria. We need dialog and partnership in the malaria community, not fighting at the expense of children.
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ps – The baby elephants pictured above are not fighting anyone. While they don’t need IPTi, they do need help. They are residents of the Baby Elephant Orphanage near Nairobi.

Better Nutritional Status through Malaria Prevention

Researchers in Senegal studied the effect of intermittent preventive treatment (IPT) of malaria for children during the malaria transmission season in that country and found that, “The prevention of malaria would improve child nutritional status in areas with seasonal transmission.” In particular mean weight gain was significantly better for those receiving IPT.

These researchers also note that similar positive results have been observed in other malaria prevention research efforts in the Gambia and Tanzania. The Tanzania work included ITNs in addition to IPT.

A basic child health monitoring tool, the Road to Health Chart, comes to mind. The guidance with the charts was usually to suspect illness, such as diarrhoeal diseases and TB should a child’s weight remain static or decrease between clinic visits. It is encouraging to know that we can also improve overall child nutritional status through malaria prevention. More work is needed to document these effects of preventive interventions in areas with year-round malaria transmission. Such results also add to the economic benefits arguments for malaria control as children with better nutritional status will hopefully grow into more productive adults.