Implementation research of a cluster randomized trial evaluating the implementation and effectiveness of intermittent preventive treatment for malaria using dihydroartemisinin-piperaquine on reducing malaria burden in school-aged children in Tanzania: methodology, challenges, and mitigation

Abstract

Background It has been more than 20 years since the malaria epidemiologic shift to school-aged children was noted. In the meantime, school-aged children (5–15 years) have become increasingly more vulnerable with asymptomatic malaria prevalence reaching up to 70%, making them reservoirs for subsequent transmission of malaria in the endemic communities. Intermittent Preventive Treatment of malaria in schoolchildren (IPTsc) has proven to be an effective tool to shrink this reservoir. As of 3rd June 2022, the World Health Organization recommends IPTsc in moderate and high endemic areas. Even so, for decision-makers, the adoption of scientific research recommendations has been stifled by real-world implementation challenges. This study presents methodology, challenges faced, and mitigations used in the evaluation of the implementation of IPTsc using dihydroartemisinin-piperaquine (DP) in three councils (Handeni District Council (DC), Handeni Town Council (TC) and Kilindi DC) of Tanga Region, Tanzania so as to understand the operational feasibility and effectiveness of IPTsc on malaria parasitaemia and clinical malaria incidence. Methods The study deployed an effectiveness-implementation hybrid design to assess feasibility and effectiveness of IPTsc using DP, the interventional drug, against standard of care (control). Wards in the three study councils were the randomization unit (clusters). Each ward was randomized to implement IPTsc or not (control). In all wards in the IPTsc arm, DP was given to schoolchildren three times a year in four-month intervals. In each council, 24 randomly selected wards (12 per study arm, one school per ward) were chosen as representatives for intervention impact evaluation. Mixed design methods were used to assess the feasibility and acceptability of implementing IPTsc as part of a more comprehensive health package for schoolchildren. The study reimagined an existing school health programme for Neglected Tropical Diseases (NTD) control include IPTsc implementation. Results The study shows IPTsc can feasibly be implemented by integrating it into existing school health and education systems, paving the way for sustainable programme adoption in a cost-effective manner. Conclusions Through this article other interested countries may realise a feasible plan for IPTsc implementation. Mitigation to any challenge can be customized based on local circumstances without jeopardising the gains expected from an IPTsc programme. Trial registration clinicaltrials.gov, NCT04245033. Registered 28 January 2020, https://clinicaltrials.gov/ct2/show/NCT04245033

Prevalence and risk factors associated with malaria infections at a micro-geographic level in three villages of Muheza district, north-eastern Tanzania

“…Studies conducted in different countries reported a decline in the prevalence of malaria infections in under-fives while the prevalence in school children either increased or had a slight decline between 2000 and 2023 [50,51]. These findings showing a high prevalence of malaria in school children are consistent with those of other studies that were conducted in Tanzania and Uganda and reported a high prevalence of malaria in this group [52][53][54]. This provides evidence to NMCP to support targeting school children with specific interventions aimed at shrinking the transmission reservoir in this group where most infections are asymptomatic, as the country makes progress towards malaria elimination by 2030.…”

“…Based on the findings of high malaria burden in school children and a decline of malaria prevalence in under-fives, different countries are targeting these groups differently with malaria interventions. For instance, in Tanzania, school children’s interventions include biannual parasitological surveys and free bed nets through the school net programme [55], while a plan is underway to launch intermittent preventive treatment (IPTsc) [52] to reduce the malaria burden in this group and prevent them from sustaining and perpetuating transmission. For under-fives, the government still implements the scheme of providing bed nets through the ANC clinics and also free health care that covers case management services, focusing on prompt diagnosis using RDTs and effective treatment for malaria using ACTs [56].…”

Exploring activities and behaviours potentially increases school-age children’s vulnerability to malaria infections in south-eastern Tanzania

“…The average malaria prevalence among school-age children stands at 21.6% nationally, this figure is estimated to be 14% higher than the under-five [ 14 ]. Several initiatives designed to interrupt and reduce malaria infection in this group including a school net distribution programme [ 12 , 15 – 17 ]. The use of Insecticide-treated bed nets is the main malaria vector control in Tanzania.…”