Seasonal Malaria Chemoprevention
An Innovative Strategy to Reduce Malaria
Morbidity and Mortality

Dr Prudence Hamade, Malaria Consortium Senior Technical Advisor

Background Global shift from a ‘one size fits all’ approach to the targetingof malaria control strategies to specific populations and/orlocations for maximum effectiveness Based on accumulated evidence, in 2012, the World HealthOrganisation (WHO) issued a policy recommendation for a
new intervention against Plasmodium falciparum malaria,
Seasonal Malaria Chemoprevention (SMC), previously
referred to as Intermittent Preventive Treatment in children(IPTc)

What is Seasonal Malaria Chemoprevention?
 Intermittent administration offull treatment courses of an
antimalarial treatment
combination during themalaria season to prevent
malaria illness Drug combination of choice is atpresent
amodiaquine/sulfadoxinepyrimethamine (AQ/SP) Objective of SMC is maintaining
therapeutic antimalarial drugconcentrations in the blood
throughout the period ofgreatest risk

Research evidence to support effectiveness of SMC
Meta analysis and a Cochrane Review - potential impact: If all of the SMC suitable areas of Sahel and sub-Sahel wascovered; approximately 5 million malaria episodes and20,000 deaths could be averted*
Meremikwu M, Donegan S et al: Cochrane Review (2012)*Cairns M, Roca Felterer A et al: Nat Commun (2012) Intervention shown to be effective, cost effective, andfeasible
 Modelling of the cost effectiveness indicates it is highly costeffective even in low transmission areas
Ross A et al: PLOS ONE (2011)Malaria Consortium SMC project in Nigeria
An implementation trial to explore the feasibility,effectiveness, acceptability and costs of a communitybased delivery system for SMC in Katsina state,
Northern Nigeria

Project supported by Bill & Melinda Gates Foundation andthe Department for International Development/UKaid

Why Katsina State Katsina State is within the Sahel Region;
rainy season and peak malaria incidence
from July to October 2012 estimated population of 6,916,641


1,383,328 under-5 years

600,281 cases of malaria (2008)

4,103 malaria related deaths

 Katsina overall under-5 mortality rate 180
per 1,000 live births

Project objectives
Objective 1: To design in consultation with key local stakeholders,

community-based delivery systems for SMC which will review aspects
relating to feasibility, community acceptability, effectiveness and cost

Objective 2: To launch and execute SMC delivery in selected areasusing predetermined delivery systems and collect data on process
indicators including cost

Objective 3: To disseminate findings and share experiences withstakeholders to inform scale up and national plans for SMC

Objective 4: To evaluate community acceptability, costs andeffectiveness of the delivery system for SMC

Formative
research

Qualitative
reviewBaselinesurveyEndlinesurveyCase control
study
Routine M&E (HMIS)

Costing analysis

SMC delivery(2 LGAs)

SMC delivery(4 LGAs)

Baure (Yr 1)
Mashi (Yr 1)
Mai’adua (Yr 2)
Dutsi (Yr 2)

Intervention area 2013
Niger Republic In consultation withthe State MOH andSMCP, four LGAs werechosen Two forimplementation of
SMC and two forcontrol in 2013 Full implementation
in four LGAs in 2014

Process of implementation 1
Choice of location: LGAs jointly chosen with MoH at Central
and State levels during joint planning meetingsWidespread consultative process within State to obtainconsensus among health authorities, (State and LGA) political,traditional, religious and community leaders including nomadorganisations

Estimating the population to be covered

Mapping settlements including remote and mobile
populations and estimation of coverage population

Ordering of drugs (regulatory requirements, and importation)Ensuring the availability of AL, an ACT no containing AQ, andRDTs to test for malaria in all receiving health facilities

Community
Mobilisation
Activities

Household to household delivery

12 to 59 month blister
pack in Arabic

Fixed post delivery

Process of implementation 2

Logistics planning including supply chain managementDevelopment of training plan and tools in collaboration withstate health personnel based on formative research; e.g.,training materials, fixed-dose packaging and BCC materials



Selection and training of 2,500 community caregivers (CCGs)
and supervisors to deliver the intervention and complete thenecessary forms

Training of health workers on use of pharmacovigilance forms
and management of breakthrough cases



Selection of sentinel sites and training for case control study

Multiple training materials for various participating groups

Community Caregiver job aid

Page 2 of the CCG Job Aid in English and HousaCommunity CareGivers (CCGs)
completing training

Health facility staff trained inuse of RDTs and treatmentof malaria cases

Monitoring and evaluation
Coverage: Registration

Efficacy: Case Control Study

Effectiveness: Post distribution survey to explore issues
such as adherence and confirmation of coverage

Resistance: Filter papers collected for PCR for resistancemarkers

Pharmacovigilance: register details minor side effects.
Data collection tools for severe adverse events in all healthfacilities and training of staff.

Acceptability: community dialogues post distributionResults
Round

TargetNumberreceiving
SMC

Coverage

Referred(%)

Vomiting(%)

1stAugust

141,842

131,227

94%

8,872 (7)913 (0.7)

2nd141,842

177,467127%

6,001(3.38)

1,644(0.9)

3rdOctober

141,842

176,659

126%

3,210(1.8)

1,052(0.5)

September

In wards near the border there were consistently higher numbers ofchildren than expected leading to a suspicion of cross border movements

Analysis of routine sentinel site facility data
Non-intervention LGA: Sandamu

Intervention LGA: Mashi

The reduction in expected malaria cases seen in health facilities wasaround 60% during the peak transmission season in September
A greater reduction might have been demonstrated if drug distribution
had been initiated in late July rather than late AugustScale up plan in Nigeria
 National Malaria Elimination Programme (NMEP): Inclusionof SMC strategy in policy revision and in the new National
Strategic Plan NMEP to write to drug regulatory agency (NAFDAC) on safety
profile of SP-AQ, inclusive of procedures forpharmacovigilance Technical expert group set up by the NMEP within the casemanagement sub committee Resource mobilisation drive: resources from DFID throughthe SuNMaP project to extend implementation to Jigawa
state on the back of lessons identified

Scale up – plans and possibilities
Sahel Region contains 24.2 million children under five years.
(Another 10 million in Southern Africa could also be targeted) In Nigeria in 2014 (9.2 million children) Malaria Consortium will
target 500,000 children in Katsina and Jigawa state (CHAI will
also implement in Kano state if funding can be obtained) Countries in the Sahel are planning to include SMC in Global
Fund new funding model proposals with support from WARNand CARN (RBM)
 Proposed UNITAID partnership: Malaria Consortium, CRS, MMV,MSH, Speak up Africa will cover 7.6 million children in 7
countries from 2015
 Internal resources within the countries could be mobilised
including government and private fundingOther issues for consideration
 Southern African countries need a different drug
combination
 Children under 10 years protected (as in Senegal)?
 How far can SMC be extended before it becomes mass drug
administration and what effect will SMC have ontransmission if it continues to be confined to children underfive ?
 How will the concentration on SMC affect the funding ofother more universal interventions such as mosquito net andcase management coverage?
 How long will the combination of AQ/SP last before drug
resistance develops?

The future Huge planning and funding gaps need to be filled if SMC is
to be implemented in a comprehensive manner which would
improve both effectiveness and cost effectiveness Attention needs to be paid to Monitoring and Evaluation(M&E) including maintaining high coverage,
pharmavcovigilance (safety) and efficacy (resistance) to makesure optimal results are continued over the years

Acknowledgements
Our thanks go to: Nigeria National Malaria Elimination Programme Katsina State Malaria Control Programme Katsina State Ministry of Health Bill & Melinda Gates Foundation
 Department for International Development/UKaid London School of Hygiene & Tropical Medicine
 Malaria Consortium National, Regional and Nigeria teams
 Political, religious and community leaders in Katsina State The communities

www.malariaconsortium.org
Thank you