A pioneering malaria prevention method trialled in Mali is dramatically reducing seasonal malaria among children, according to a mass pilot launched by NGO Médecins Sans Frontières (MSF) in August 2012.
In Koutiala District in the southeast, 170,000 children were given a three-day course of anti-parasite medicine amodiaquine and sulfadoxine/ pyrimethamine (branded as Fansidar) on a monthly basis during the high transmission period of the disease between July and October.
MSF teams witnessed a 75 percent decline of uncomplicated malaria cases and a more than 60 percent decline in disease-related hospitalizations in the week following the distribution of the medication.
“The effects happened overnight,” Johannes Sekkenes, head of the MSF mission in Mali, told IRIN.
“In the district hospital in Koutiala, as soon as the treatment started to take effect, the number of hospitalized children dropped. Today, the hospital has 120-150 children hospitalized, whereas this time last year there was around 300, 70 percent of whom had severe malaria,” she said.
Most of the hospitalized children in Koutiala are malnourished with complicating factors, usually malaria or diarrhoeal diseases.
Nurses and community health workers orally administer the first dose via directly observed treatment (DOT) at fixed distribution sites or door-to-door in smaller villages. During this visit, the mother is taught how to administer the remaining two doses for that month.
“The mothers know that malaria is a killer and this really keeps kids alive. Consequently, the population has adhered to the strategy in a very positive way,” said Sekkenes.
“This is not so much a wonder drug as a highly effective strategy which is targeted at the peak period of risk when over 80 percent of malaria attacks occur in countries like Mali, Senegal, Chad and other parts of the Sahel,” said Sian Clarke, a malaria expert at the London School of Hygiene and Tropical Medicine.
Health workers and MSF doctors stressed that such interventions must go hand in hand with other prevention activities to have a wide-scale, long-term impact.
“To really have a global impact you have to implement the programme in all the health districts, as well as to ensure you use other malaria-fighting strategies such as mosquito nets and insecticide spraying,” said Sekkenes.
Resistance and side-effects
Fansidar, the registered trademark for sulfadoxine /pyrimethamine was once widely used to treat malaria throughout Africa but has been phased out and replaced by artemesinin combination therapies (ACT) partly because resistance to Fansidar had built up.
There is a possibility that this resistance could also build up in West Africa. However, following studies in 2011 the World Health Organization (WHO) has recommended that the drug can be used for prevention as long as it is used in “multi-therapy” alongside other drugs like amodiaquine (an anti-malarial linked to chloroquine), and only for 3-4 months a year in areas with seasonal malaria.
“A number of research papers have been written analysing this question of resistance. So far, there has been no evidence to suggest that build-up of resistance could be a problem,” said Clarke.
Another concern, specific to malaria, is the way prevention therapies may hamper natural immunity, which is acquired slowly and relies on repeat exposure to infection. Delaying the build-up of this natural immunity could lead to an increased risk of dangerous malaria attacks in adulthood, noted Clarke.
“It was precisely these concerns that have held back implementation of preventive strategies in the past,” she said.
Other concerns related to the potential side-effects - amodiaquine can lead to vomiting in a child and sulfadoxine/pyrimethamine can in rare cases spark off allergic reactions, calling for strict ongoing surveillance, notes MSF.
Though obstacles and concerns remain, the Malian Ministry of Health plans to run the programme in five regions - Koutiala, Kita, Kolokani, Bankass and San - in 2013 and roll out the programme across the rest of the country by 2014, said Klénon Traoré, director of the National Programme to Fight Malaria (PNLP).
Although the drug is relatively cheap (50 US cents per child per month) and generic forms are available on the market, it is a costly drug to administer in terms of training healthcare workers, door-to-door visits in isolated areas, and educating mothers on how to give the final two doses every month.
“We have the funding for the programme, but we are not sure if it will be available in the future,” said Traoré. International donors have withdrawn most direct aid to the Malian government following the March coup, and pending democratic elections, which are not expected to take place anytime soon.
The takeover of the north is also a handicap, he said, in implementing the programme as planned in July 2013.
The drug has also been rolled out to 10,000 children in Chad, which also experienced a sharp decline in malaria cases just after treatment.
Over 650,000 people die from malaria every year and 90 percent of these fatalities occur in sub-Saharan Africa, most of them young children.