Sierra Leone: A Lost Decade in Preventing Childhood Malaria in Sub-Saharan Africa

[This article has been originally published in Spanish in El País-Planeta Futuro]

On a quiet Friday morning, November 19, an event to mark the start of MULTIPLY activities takes place in the assembly hall of the Makeni Town Hall (Bombali, Northern Province of Sierra Leone). This is an implementation project whose objective is to expand the protection of the intermittent preventive treatment of childhood malaria (IPTi) until the second year of life, in Sierra Leone, and to introduce this intervention in two other countries: Mozambique and Togo.

The treatment recommended by WHO since 2010 to protect children against malaria has become a health policy in only one endemic country: Sierra Leone. We must continue to emphasize its potential and rethink strategies for its implementation.

The IPTi with sulfadoxine-pyrimethamine (SP) is an intervention evaluated and recommended by the WHO since 2010 to protect children against malaria. However, to date, it has only become health policy in a single malaria endemic country: Sierra Leone.

It is a paradox that the Ebola epidemic and the subsequent suspension of health services in the country, with the consequent increase in cases and deaths from childhood malaria, was the trigger for the implementation of this strategy, led by Dr. Sam Smith, then responsible for the malaria program in the African country.

But this fact constitutes an exception. Despite being an intervention that has been shown to be safe and effective in reducing clinical malaria, anemia, and hospital admissions, in addition to being very cost-effective (due to the low cost of the SP drug), accepted by the affected population and feasible in its implementation (when administered in routine vaccination visits), it is not, to date, applied in the rest of the countries. If it were, it could help reduce mortality and illness caused by malaria, especially in the first year of life, when more deaths occur.

Anna Lucas/ISGlobal.

The IPTi is a clear example of the winding paths that scientific knowledge often follows from the moment evidence is generated to its application. In the present case, various factors may have contributed to this.

The IPTi is a clear example of the winding paths that scientific knowledge often follows from the moment evidence is generated to its application

How can the ambitious goals of the 2030 Agenda be achieved if interventions that can have the most impact, such as IPTi , are not prioritized? Various elements conspire against its fulfillment. From the disconnect between the ambitious goals in child health, malaria or universal health coverage and the priorities of research and development donors, to biased perceptions that continue to influence decision-making. All this, coupled with the lack of political will or leadership in endemic countries, and the weak voice of disadvantaged populations including young children.

The recent WHO recommendation regarding the childhood malaria vaccine is excellent news: we will have another safe, equitable preventive tool –administered through the vaccination programme– that can reduce malaria episodes by 40%. As is often noted, progress in malaria control requires a combination of tools. For this reason, the new vaccine does not make the implementation of the IPTi, which has an efficacy of 30%, less necessary. On the contrary, it highlights the need to deploy and combine both strategies to protect the largest number of children from malaria in a more effective, durable and equitable manner.

The new vaccine does not make the implementation of IPTi any less necessary. On the contrary, it highlights the need to deploy and combine both strategies to better and more equitably protect the largest number of children.

The current context of stagnation in the fight against malaria and the COVID-19 pandemic force us to rethink our strategies more than a decade after WHO’s the recommendation of IPTi, The renewed interest of some donors and policy makers represents a new opportunity to help this intervention reach its ultimate recipients, who are not the publishers of scientific publications in some high-income country, but children from malariaendemic areas in sub-Saharan Africa.

Clara Menéndez, MULTIPLY project director at the launch of the project in Sierra Leone in November 2021. 

Children under five years of age account for the majority of cases and deaths from malaria (274,000 deaths each year). Thus, the cost of inaction in this lost decade is estimated at around one million infant deaths that could have been prevented.

Together with the rest of the community dealing with childhood malaria, we are working to help change this. How? By promoting the IPTi among health authorities and donors with updated data, evidence and strategic information, and advocating so that mortality from this disease has the visibility it deserves and becomes a priority on their agendas. Also, through technical collaboration with the countries and other actors, providing training and support for its implementation in the countries, and involving the affected communities in the process. All this to ensure that the application of this powerful prevention tool for childhood malaria reaches its full potential and gets closer to becoming a reality in national malaria control programmes in sub-Saharan Africa.

The MULTIPLY consortium is coordinated by the Barcelona Institute for Global Health (ISGlobal) and includes Fundação Manhiça (FM)- Centro de Investigação em Saúde de Manhiça (CISM, Mozambique), College of Medicine and Allied Health Sciences (COMAHS, Sierra Leone), Université de Lomé (UL, Togo), L'Institut de recherche pour le développement (IRD, France), and Medicines for Malaria Venture (MMV, Switzerland). MULTIPLY is a project part of the EDCTP2 programme funded by the European Union. MULTIPLY is ongoing in Sierra Leone within the framework of the ICARIA project, funded by the Gates Foundation and the la Caixa Foundation. In Mozambique, the project is developed with the support of the AECID.