Seasonal Malaria Chemoprevention: 10 years down the line where are we?

By Dr André Tchouatieu

In March 2012, the World Health Organization published a policy recommendation to prevent malaria in children under 5 in medium to high endemic areas where malaria transmission is seasonal, associated with an annual rainy season lasting 3 to 4 months. In Africa, these transmission patterns are found mainly in the Sahel region across West and Central Africa, and a region across southern and eastern Africa.

For 10 years, Seasonal Malaria Chemoprevention (SMC) has been protecting children, positively impacting multiple malaria indicators. This strategy consists of giving all eligible children a combination of antimalarial drugs (sulfadoxine-pyrimethamine and amodiaquine – SPAQ) from the start of the rainy season (the transmission period) every month through the end of the period. It has been shown in clinical trials to be able to reduce the incidence of malaria by a range of 75 to 85% of cases.

To date, the countries’ embrace of this strategy has been growing significantly. In 2014, the first year that most countries started to adopt the strategy, approximately 2.4 million children were protected. In 2021, more than 43 million children received SMC in 13 countries across the Sahel region – from Senegal to Cameroon. This is one of the fastest-growing interventions in malaria control and prevention, receiving support from both endemic countries and their financial and implementing partners.  Remarkably, some countries have even taken on financial loans to implement SMC, believing that this is an investment that, in all senses, will pay off.  On the supply side, there has been significant involvement and adaptation from the manufacturers to fulfil the constantly growing demand by providing quality products; since the initial product launch, a newer child-friendly and taste-masked formulation of SPAQ has been developed, responding to the needs of the target population to be protected.

Expansion opportunities

This finding is now being confirmed in other countries with similar malaria epidemiology.  And, in areas initially excluded from SMC because of known resistance to Sulfadoxine, some initial trials have shown positive outcomes. Should preventive efficacy of SPAQ be confirmed in those areas (mainly in south-eastern Africa), SMC expansion may be considered.

Funding for sustainability

About 90 per cent of the funding directed to SMC today is provided by international donor money, and funding will be a major limiting factor for SMC expansion.  More investments are needed to support SMC expansion. In parallel, ongoing efforts to seek greater cost efficiency in SMC campaigns will be critical. The campaign mode which is currently used to distribute SMC is highly effective but engenders high costs for logistics, supervision, and collateral activities. SMC implementing countries and all malaria-endemic countries in Africa have been looking at how they could involve their local private sector, since more countries see SMC as an intervention with a good “return on investment,” to use the language the private sector understands the most.  Governments are called upon to increase their contribution to such interventions with recognized potential for saving lives.

First-hand experience of the impact of SMC

During a visit to the district of Dabola in Guinea during their first year of SMC implementation in 2018, I had the opportunity to speak with the head of the local hospital about the impact of SMC He took me to the wards and showed me empty beds, saying that during the same period the previous year, the same ward was full of patients. He confessed to me that their rate of blood transfusion was considerably low compared to the previous year. These were considered direct effects of SMC. The pride of this peripheral health authority was so contagious that when reviewing the details of malaria transmission in that area, we decided with the National Malaria control program to pilot adding one more cycle of SMC earlier in the year to better cover the transmission period which seemed to be slightly longer than the proposed 4 months. The trial is ongoing and the preliminary results after the first year of implementation are promising.

SMC alongside other malaria interventions is a credible tool that needs to be further promoted for sustainability; it can continue to move us one step closer to the goal of malaria elimination while saving many lives along the way.

Dr André Tchouatieu is a medical doctor with specialist training in malaria, health economics, and health systems. Currently, he is the Director of Access and Product Management at Medicines for Malaria Venture (MMV), a product development partnership based in Geneva, where he leads the chemoprevention strategy looking at how best antimalarial medicines can be used preventatively to protect people in endemic countries.
Prior to MMV, he spent several years with Sanofi as country manager in Burundi, Medical Advisor for Eastern Africa based in Nairobi, and Global Malaria Senior Medical Manager in Paris. Prior to Sanofi, André had served as a field physician with Médecins Sans Frontières in East Africa.