Academic journal article Bulletin of the World Health Organization

Intermittent Preventive Treatment for Malaria in Infants: A Decision-Support Tool for Sub-Saharan Africa/Traitements Preventifs Intermittents De la Malaria Pour Les Nourrissons: Un Outil D'aide a la Prise De Decision Pour l'Afrique Subsaharienne/ Tratamiento Preventivo Intermitente De la Malaria En Lactantes: Una Herramienta De Apoyo a Las Decisiones Para El Africa Subsahariana

Academic journal article Bulletin of the World Health Organization

Intermittent Preventive Treatment for Malaria in Infants: A Decision-Support Tool for Sub-Saharan Africa/Traitements Preventifs Intermittents De la Malaria Pour Les Nourrissons: Un Outil D'aide a la Prise De Decision Pour l'Afrique Subsaharienne/ Tratamiento Preventivo Intermitente De la Malaria En Lactantes: Una Herramienta De Apoyo a Las Decisiones Para El Africa Subsahariana

Article excerpt

Introduction

The burden of severe forms of Plasmodium falciparum malaria is concentrated in young children and a recent pooled analysis showed that this is even more pronounced for malaria leading to death than for less severe forms of the disease. (1) The targeted provision of insecticide-treated nets to pregnant women (2) and children under 5 years of age (3) has helped protect those at an increased risk. Measures that target the very young may provide a useful additional strategy for malaria control.

Intermittent preventive treatment involves the administration of a therapeutic dose of an antimalarial drug at predefined times regardless of an individual's infection status. The effect of administering intermittent preventive treatment in infants (IPTi) at the time of routine vaccination delivered through the Expanded Programme on Immunization (EPI) has been evaluated in several randomized controlled trials. (4-10) A pooled analysis of the results of the first six trials of sulphadoxine-pyrimethamine (4-9) showed an overall protective efficacy of 30% (95% confidence interval, CI: 20-39) against clinical malaria, 38% (95% CI: 13-56) against hospital admission for infection with malaria parasites, 23% (95% CI: 10-34) against all-cause hospital admission and 21% (95% CI: 8-33) against anaemia in the first year of life. (11) One trial in an area of very high drug resistance to sulphadoxine--pyrimethamine showed that such treatment had no effect, although the long-acting drug mefloquine had a protective efficacy of 38% against clinical malaria. (10) The strategy of administering IPTi using an efficacious, long-acting antimalarial drug therefore has merit. A recent World Health Organization (WHO) consultation document recommended that IPTi with sulphadoxine--pyrimethamine (IPTi-SP) be considered under certain epidemiological conditions in which the drug combination is effective. (12)

There has been some debate about where IPTi should be introduced because the burden of clinical malaria extends beyond infancy and, in some settings, infection is concentrated in only a few months of the year. (13-15) It is not feasible to carry out large-scale randomized controlled trials to determine the effectiveness of IPTi against severe outcomes in a wide range of different settings. Alternative methods are therefore needed to determine where IPTi is likely to be most beneficial. In this study, we attempted to solve this problem using two approaches: a secondary analysis of existing research data and a stochastic mathematical model.

As the epidemiology of malaria is complex and heterogeneous and even varies over small distances, it is difficult to develop a universal malaria control policy that is appropriate to all situations in a given country. Nevertheless, to simplify logistics, malaria control programme managers plan their activities at a national or subnational level, taking into account local variations in malaria epidemiology where possible.

Here we present evidence from our research into the applicability of IPTi under a range of epidemiological conditions. These findings have been developed as a decision-support tool (available at: http://ipti.lshtm.ac.uk) to help policy-makers decide where to implement IPTi.

Methods

Age pattern analysis A pooled analysis of available data on the age pattern of outcomes of P. falciparum malaria was undertaken and has been described elsewhere. (1) In brief, a systematic literature review was used to determine the age distribution of patients with clinical malaria, of those admitted to hospital with malaria parasites (i.e. those in whom malaria infection was confirmed after hospital admission for severe symptoms) and of those whose death was diagnosed as due to malaria by verbal autopsy. Data were collected in 21 sub-Saharan African countries from a total of 61 research sites. Each site was categorized as having a low, medium or high intensity of malaria transmission according to whether the entomological inoculation rate (EIR) was < 10, 10-100 or > 100 infective bites per person per year, respectively, as determined from temporally matched and georeferenced data, or whether the georeferenced prevalence of malaria parasites in children aged under 5 years was < 25%, 25-60% or > 60%, respectively. …

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