A New Opportunity to Prevent Another Lost Decade in Reducing Malaria Burden in Young African Children

[This text has been originally published in Spanish in El País-Planeta Futuro. It has been written by Clara Menéndez, director of ISGlobal's Maternal, Child and Reproductive Health Initiative, and Anna Lucas, coordinator of ISGlobal's Maternal, Child and Reproductive Health Initiative]

African children under the age of two are the most at risk for malaria illness and death. Interventions like insecticide-treated bednets, indoor residual spraying, and artemisinin-based combination therapies have reduced infections and illnesses, but progress has stalled since 2017, and cases are rising in many areas in Sub-Saharan Africa. Two of the newest tools against this disease provide the opportunity to reach more children while strengthening fragile health systems: the Intermittent Preventive Treatment for infants (IPTi) and the recently recommended RTS,S/AS01 (RTS,S) malaria vaccine for children.

Intermittent Preventive Treatment for infants (IPTi) was develop more than 20 years ago and consists in the administration of a drug, sulfadoxine-pyrimethamine (SP) to infants when they get their core immunizations of diphtheria-tetanus-pertussis (DTP) and measles as part of the routine vaccination schedule of the Expanded Programme on Immunization (EPI). Studies have shown this approach reduces cases of malaria illness by 30%, hospital admissions by 23% and anemia by 21%.

Two of the newest tools against this disease provide the opportunity to reach more children while strengthening fragile health systems: the Intermittent Preventive Treatment for infants (IPTi) and the recently recommended RTS,S/AS01 (RTS,S) malaria vaccine for children

In October 2021 the world gleefully covered the announcement of the WHO recommendation for widespread use of the RTS,S/AS01 (RTS,S) malaria vaccine among children in sub-Saharan Africa. RTS,S is an important addition to the currently recommended interventions to prevent malaria. If introduced widely, the vaccine could save tens of thousands of lives of young children each year.

In 2010, WHO recommended that countries implement IPTi in sub-Saharan Africa through EPI and where SP resistance is not high. However, only one African country – Sierra Leone – has since put IPTi into policy and practice. What are the reasons behind this slow adoption? Probably it is a combination of factors: from the perception of part of the research community that IPTi with sulfadoxine–pyrimethamine had modest efficacy based on the unsubstantiated belief that molecular markers associated with reduced efficacy in treating clinical malaria would predict drug failure in preventing infections- , to the historical preference of the malaria community to operate through vertical programs rather than to integrate with other elements of the health system and the lack of political voice of the affected population: vulnerable children.

Only one African country – Sierra Leone – has since put IPTi into policy and practice

However, in recent years there are signs of change in the malaria landscape offering a new opportunity for the introduction and scale up of this lifesaving tool. Recent evidence shows that sulfadoxine–pyrimethamine continues to outperform all other antimalarials in preventing the consequences of malaria in pregnancy, and continues to be highly effective in combination for seasonal use.  

Moreover WHO’s recently updated recommendations for malaria chemoprevention among children – now called perennial malaria chemoprevention (PMC)- informed by the improved understanding of when and where chemoprevention can be most effective, encourage national malaria control programmes to expand access to IPTi /PMC, while tailoring the deployment to local contexts.

Sierra Leone hospital.

Following in the footsteps of Sierra Leone, Mozambique has recently announced the adoption of IPTi/PMC as a nationwide policy. Finally, major donors are funding several research projects investigating IPTi/PMC uptake and expansion in eight African countries aimed to understand the operational barriers so that more countries can implement this approach of health services integration and put IPTi/PMC into policy and practice. ISGlobal, who coordinates one of the ongoing efforts, is working with ministries of health in Mozambique, Sierra Leone and Togo and other research partners in the framework of the MULTIPLY project. MULTIPLY, funded by the EDCTP2 programme (which is supported by the European Unkion), aims to evaluate the impact of expanding IPTi/PMC during their second year of life in the protection of children against malaria while reducing anemia and overall mortality and morbidity.

The MULTIPLY project aims to evaluate the impact of expanding IPTi/PMC during their second year of life in the protection of children against malaria while reducing anemia and overall mortality and morbidity

Clearly, international donors and the malaria community are seeing the value of this strategy and the need to support country implementation. Both IPTi/PMC and the RTS,S/AS01 (RTS,S) are being delivered as part of the routine vaccination schedule of the Expanded Program on Immunisation (EPI). The EPI set up by WHO in 1974 to deliver multiple critical vaccines to all children through a simple schedule of child health visits has prevented millions of cases of diseases (measles, pneumonia, polio, …), contributing to significant declines in infant and child mortality since the 1990s. The EPI has also been used to successfully deliver non-vaccine products, such as Vitamin A, or bed net distribution.

Based on current trends, 31 million children under the age of five will die between 2018 and 2030. This is the most vulnerable group in the world to a host of diseases. To advance the child health agenda, the global health community must recognize that this fundamental platform be directly supported and reinforced as an integral part of the broader health system. It is time to overcome long-standing debates on health systems strengthening approaches. This is even more evident in the context of global crisis and COVID-19 where prioritization of investments and urgent action are needed to reverse not only negative impact of COVID-19 but also exacerbated pre-pandemic trends such as, stagnation of immunization coverage or malaria increased incidence and stalled decline in malaria deaths. A robust routine immunization program is a prerequisite to achieve and sustain ambitious goals such as disease elimination, increased immunization coverage, introduction of new vaccines, needed to achieve the Child health targets of reduced mortality and inequity set out in the Sustainable Development Goals.

A robust routine immunization program is a prerequisite to achieve and sustain ambitious goals such as disease elimination, increased immunization coverage, introduction of new vaccines

We have a safe, efficacious and cost-effective tool: IPTi/PMC, and a functioning delivery platform –the routine immunization platform-, in place in all malaria endemic countries. It’s time to get IPTi to more children and reduce the increasing cases of malaria illness and deaths. And it is time to ensure that the routine immunization platform receives the attention it requires to achieve its full potential to enable implementation of existing and new tools such as IPTi or the RTS,S vaccine. Let us try not to lose another decade in malaria prevention in the most vulnerable group for the infection.