Impact of a malaria intervention package in schools onPlasmodiuminfection, anaemia and cognitive function in schoolchildren in Mali: a pragmatic cluster-randomised trial

Abstract

BackgroundSchool-aged children are rarely targeted by malaria control programmes, yet the prevalence of Plasmodium infection in primary school children often exceeds that seen in younger children and could affect haemoglobin concentration and school performance.MethodsA cluster-randomised trial was carried out in 80 primary schools in southern Mali to evaluate the impact of a school-based malaria intervention package. Intervention schools received two interventions sequentially: (1) teacher-led participatory malaria prevention education, combined with distribution of long-lasting insecticidal nets (LLINs), followed 7 months later at the end of the transmission season by (2) mass delivery of artesunate and sulfadoxine-pyrimethamine administered by teachers, termed intermittent parasite clearance in schools (IPCs). Control schools received LLINs as part of the national universal net distribution programme. The impact of the interventions on malaria and anaemia was evaluated over 20 months using cross-sectional surveys in a random subset of 38 schools(all classes), with a range of cognitive measures (sustained attention, visual search, numeracy, vocabulary and writing) assessed in a longitudinal cohort of children aged 9–12 years in all 80 schools.ResultsDelivery of a single round of IPCs was associated with dramatic reductions in malaria parasitaemia (OR 0.005, 95% CI 0.002 to 0.011, p<0.001) and gametocyte carriage (OR 0.02, 95% CI 0.00 to 0.17, p<0.001) in intervention compared with control schools. This effect was sustained for 6 months until the beginning of the next transmission season. IPCs was also associated with a significant decrease in anaemia (OR 0.56, 95% CI 0.40 to 0.78, p=0.001), and increase in sustained attention (difference +0.23, 95% CI 0.10 to 0.36, p<0.001). There was no evidence of impact on other cognitive measures.ConclusionThe combination of malaria prevention education, LLINs and IPCs can reduce anaemia and improve sustained attention of school children in areas of highly seasonal transmission. These findings highlight the impact of asymptomatic malaria infection on cognitive performance in schoolchildren and the benefit of IPCs in reducing this burden. Additionally, malaria control in schools can help diminish the infectious reservoir that sustains Plasmodium transmission.

Impact of school-based malaria case management on school attendance, health and education outcomes: a cluster randomised trial in southern Malawi

“…The overall impact may have been masked by lack of effect for the children in the intervention group who did not directly benefit from the intervention, highlighting the increasingly cited issue of trial design for an intervention where a benefit is only required, sought or gained by a limited proportion of the intervention population 46 47. The nature of the intervention (treatment of symptomatic children) is such that there are no immediate benefits in terms of reduced transmission for the wider group, of one individual taking up the intervention, such as there might be with an intervention such as intermittent screening and treatment or intermittent preventive treatment 18. The increased absenteeism attributed to illness observed in the intervention group during spot checks was unexpected but could potentially be explained by factors related to the intervention design.…”

“…A 2017 review described a range of strategies aimed at reducing the burden of malaria among school-aged children,15 16 including using antimalarial drugs for prevention, as well as case management within the school context 7 17 18. Case management evaluations in Ghana, Malawi and Tanzania demonstrated teachers can effectively deliver presumptive malaria treatment in schools 19–21.…”

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

“…The malaria burden in school-aged children has been underappreciated, 6 but a wealth of evidence from Uganda and elsewhere suggests that IPT of malaria in schoolchildren provides substantial health benefits and might improve cognitive function. 7 , 8 , 9 , 10 Additionally, parasite prevalence is typically highest in school-aged children (although age ranges vary with transmission intensity), who serve as reservoirs of infection for the onward transmission of malaria to mosquitoes. 11 Targeted use of chemoprevention in school-aged children will benefit individual children 7 and might decrease malaria transmission by reducing the infectious reservoir, which would benefit the community.…”

Pilot Study of the Addition of Mass Treatment for Malaria to Existing School-Based Programs to Treat Neglected Tropical Diseases

“…In settings with highly seasonal malaria transmission, treatment at the end of the transmission season leads to prolonged parasite free time making the timing of the distribution critical. 21 In Malawi, annual NTD MDA occurs in April, which is also the end of the malaria high transmission season. However, on-going transmission throughout the year may make this timing less critical than the frequency of distributions.…”

“… 13 – 15 Clinical trials have shown benefits of school-based mass treatment of malaria, including decreased Plasmodium falciparum prevalence, incidence of clinical malaria, and prevalence of anemia. 8 , 16 – 21 …”