Assessment of community-level effects of intermittent preventive treatment for malaria in schoolchildren in Jinja, Uganda (START-IPT trial): a cluster-randomised trial

Abstract

SummaryBackgroundIntermittent preventive treatment (IPT) is a well established malaria control intervention. Evidence that delivering IPT to schoolchildren could provide community-level benefits is limited. We did a cluster-randomised controlled trial to assess the effect of IPT of primary schoolchildren with dihydroartemisinin-piperaquine (DP) on indicators of malaria transmission in the community, in Jinja, Uganda.MethodsWe included 84 clusters, each comprising one primary school and the 100 closest available households. The clusters were randomly assigned 1:1 to receive IPT with DP or standard care (control) by restricted randomisation to ensure balance by geography and school type. Children in intervention schools received IPT monthly for up to six rounds (June to December, 2014). We did cross-sectional community surveys in randomly selected households at baseline and in January to April, 2015, during which we measured participants' temperatures and obtained finger-prick blood smears for measurement of parasite prevalence by microscopy. We also did entomological surveys 1 night per month in households from 20 randomly selected IPT and 20 control clusters. The primary trial outcome was parasite prevalence in the final community survey. The primary entomological survey outcome was the annual entomological inoculation rate (aEIR) from July, 2014, to April, 2015. This trial is registered at ClinicalTrials.gov, number NCT02009215.FindingsAmong 23 280 students registered in the 42 intervention schools, 10 079 (43%) aged 5–20 years were enrolled and received at least one dose of DP. 9286 (92%) of 10 079 received at least one full course of DP (three doses). Community-level parasite prevalence was lower in the intervention clusters than in the control clusters (19% vs 23%, adjusted risk ratio 0·85, 95% CI 0·73–1·00, p=0·05). The aEIR was lower in the intervention group than in the control group, but not significantly so (10·1 vs 15·2 infective bites per person, adjusted incidence rate ratio 0·80, 95% CI 0·36–1·80, p=0·59).InterpretationIPT of schoolchildren with DP might have a positive effect on community-level malaria indicators and be operationally feasible. Studies with greater IPT coverage are needed.FundingUK Medical Research Council, UK Department for International Development, and Wellcome Trust.

Prevalence of malaria parasitaemia in school-aged children and pregnant women in endemic settings of sub-Saharan Africa: A systematic review and meta-analysis

“…Malaria infection in school-aged children is mostly asymptomatic ( Walldorf et al, 2015 ; Nankabirwa et al, 2014 ; Nankabirwa et al, 2013 ; Yeka et al, 2015 ) making them reservoirs for transmission within their communities, at the cost of increased malaria related morbidities such as anaemia and impaired cognitive development ( Nankabirwa et al, 2014 ; Clarke et al, 2008 ; Nankabirwa et al, 2013 ; Maccario et al, 2017 ) in this age group. Given the high correlation shown ( r = 93%), targeted interventions such as (IPT) need to be expanded to school-aged children (IPTsc) since they are more likely to harbour malaria parasites compared to under-fives and pregnant women ( Walldorf et al, 2015 ; Staedke et al, 2018 ). This would likely reduce the parasite burden in children and boost the effectiveness of other control programs including IPTp and SMC ( Staedke et al, 2018 ).…”

“…Given the high correlation shown ( r = 93%), targeted interventions such as (IPT) need to be expanded to school-aged children (IPTsc) since they are more likely to harbour malaria parasites compared to under-fives and pregnant women ( Walldorf et al, 2015 ; Staedke et al, 2018 ). This would likely reduce the parasite burden in children and boost the effectiveness of other control programs including IPTp and SMC ( Staedke et al, 2018 ). Recent evidence in Uganda demonstrated that with high coverage, implementation of IPTsc using Dihydroartemisinin-Piperaquine (DP) was effective in reducing community parasite prevalence and entomological inoculation rates ( Staedke et al, 2018 ).…”

“…This would likely reduce the parasite burden in children and boost the effectiveness of other control programs including IPTp and SMC ( Staedke et al, 2018 ). Recent evidence in Uganda demonstrated that with high coverage, implementation of IPTsc using Dihydroartemisinin-Piperaquine (DP) was effective in reducing community parasite prevalence and entomological inoculation rates ( Staedke et al, 2018 ). Implementation of IPT can reduce undetected asymptomatic and sub-microscopic infections that are hampering control efforts.…”

“…Malaria control interventions often target vulnerable populations, pregnant women and children under-fives ( Walldorf et al, 2015 ). However, the burden of malaria in terms of detectable parasitaemia, asymptomatic and submicroscopic infections in school-aged children (5–14 years) remain underappreciated ( Staedke et al, 2018 ). A previous systematic review ( Nankabirwa et al, 2014 ) reported, a prevalence of malaria parasitaemia among school-aged children ranging from 18 to 83% at different time points across sixteen high transmission settings in sub-Saharan countries.…”

“…Yet, limited interventions are targeting control malaria in school-aged children despite their high burden of malaria infection. Strategies targeting this population could impact malaria transmission and infection control in the community ( Staedke et al, 2018 ).…”