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Archive for "IPTi"



IPTi &Treatment Bill Brieger | 11 Jul 2008

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 Bill Brieger | 15 May 2008

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.

IPTi &Partnership Bill Brieger | 20 Feb 2008

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.

IPTi &Nutrition Bill Brieger | 08 Dec 2007

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.

IPTi &IPTp Bill Brieger | 07 Oct 2007

Ghana Health Leader Advocates IPTi for Malaria Control

For the past several years a consortium has been investigating whether intermittent preventive treatment with sulfadoxine-pyrimethamine (SP) for infants (IPTi) could be as effective a malaria control tool as its counterpart for pregnant women (IPTp). According to Ghanaweb.com on Friday, “Professor John Gyapong, Director of the Health Research Unit of the GHS (Ghana Health Service, noted that IPTi with SP had been found to be very efficacious, safe and cost effective.” Reductions in malaria and related factors found in the Ghana research are seen in the attached graph.
results-of-ghana-ipti-trial.jpgAlthough Prof. Gyapong appeared to advocate for quick adoption of IPTi in Ghana, he also did note that WHO has yet to endorse the practice. In fact some would say that a verdict on IPTi is overdue considering the volume of research generated so far and available for review on the IPTi Consortium website. This delay may not be surprising based on the reluctance of WHO’s Global Malaria Program to embrace IPTp even though evidence of its effectiveness persists.

Of course, there are some legitimate concerns about expanding IPT, which need to be addressed, even based on the data generated in Ghana. Among these issues are the following:

  • resistance of parasites to SP
  • appropriateness of EPI as a delivery mechanism for IPTi
  • equity of access to IPTi
  • timing of IPTi dosages
  • concerns about seasonality of transmission

These issues are explored in detail in the various journal articles available for free download at the IPTi website. Fortunately, Dr. Andrea Egan from IPTi Consortium has assured that, “a comprehensive research and implementation agenda had been developed to resolve any outstanding scientific questions on whether IPTi was safe and effective to use as a malaria control intervention and move the intervention into policy and practice.”

Clearly IPTi would not be implemented as a stand alone intervention, but would and should be integrated with other control measures including ITNs and prompt case management with ACTs. There is always benefit to having another strategy to add to a comprehensive malaria program in order to outwit mosquitoes and parasites.

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