As 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 foundationâ€™s money, while crucial, could have ‘far-reaching, largely unintended consequences,'”Â 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.Â 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.Â 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.
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.
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.
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.
Although 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.