Seasonal malaria chemoprevention in an area of extended seasonal transmission in Ashanti, Ghana: an individually randomised clinical trial

Abstract

ObjectiveTo investigate the effectiveness of seasonal malaria chemoprevention (SMC) and community case management with long‐acting artemisinin‐based combination therapies (ACTs) for the control of malaria in areas of extended seasonal malaria transmission.MethodIndividually randomised, placebo‐controlled trial in the Ashanti Region of Ghana. A total of 2400 children aged 3–59 months received either: (i) a short‐acting ACT for case management of malaria (artemether‐lumefantrine, AL) plus placebo SMC, or (ii) a long‐acting ACT (dihydroartemisinin‐piperaquine, DP) for case management plus placebo SMC or (iii) AL for case management plus active SMC with sulphadoxine‐pyrimethamine and amodiaquine. SMC or placebo was delivered on five occasions during the rainy season. Malaria cases were managed by community health workers, who used rapid diagnostic tests to confirm infection prior to treatment.ResultsThe incidence of malaria was lower in children given SMC during the rainy season. Compared to those given placebo SMC and AL for case management, the adjusted hazard ratio (aHR) was 0.62 (95% CI: 0.41, 0.93), P = 0.020 by intention to treat and 0.53 (95% CI: 0.29, 0.95), P = 0.033 among children given five SMC courses. There were no major differences between groups given different ACTs for case management (aHR DP vs. AL 1.18 (95% CI 0.83, 1.67), P = 0.356).Conclusion SMC may have an important public health impact in areas with a longer transmission season, but further optimisation of SMC schedules is needed to maximise its impact in such settings.

Impact of an Irrigation Dam on the Transmission and Diversity of Plasmodium falciparum in a Seasonal Malaria Transmission Area of Northern Ghana

“…Moreover, the Ghana Government, through its one-village-one-dam policy [24], aims to create additional dams especially in the northern part of the country to sustain agriculture and livestock breeding during the dry season. e seasonal malaria control strategy focuses on chemotherapy during the wet season [23,25], and the current data, in agreement with a previous finding [22], identify a potential loophole in this control strategy, especially in communities that have very large dams. Our data therefore highlight the need to factor the presence of such water bodies into malaria control efforts.…”

“…Generally high prevalence of submicroscopic P. falciparum parasites during both wet and dry seasons at the two study sites indicates the potential for transmission to occur throughout the year or at least have parasites persist throughout the dry season and be ready for transmission when vector breeding commences in the wet season. Currently, in Northern Ghana, there is an on-going seasonal malaria control programme that administers antimalarial drugs during the wet season only [23] in an effort to reduce parasite burden.…”

Facilitators and Barriers to Uptake of an Extended Seasonal Malaria Chemoprevention Programme in Ghana: A Qualitative Study of Caregivers and Community Health Workers

“…CHWs proposed an extended seven month period to accommodate children in rural areas with no HCF, suggesting May through November (CHW2). This proposal was also supported in the trial, with evidence that SMC started too late in 2012 relative to the start of the long transmission season [11]. …”

“…Whilst caregivers reported the 3-day per month regimen was also acceptable, in practice the full dose was not always consumed as evidenced by CHWs during home visits. The complexity of the regimen may have influenced uptake and subsequent efficacy of the SMC [11]. It was widely recognised that a one day regimen would be preferable for SMC and would reduce the burden of drug administration on caregivers.…”

“…In response, we undertook a trial of monthly SMC over five months in an area of extended malaria transmission, in the Ashanti Region of Ghana [clinicaltrials.gov identifier: NCT01651416], a predominantly rural area with moderately high malaria transmission throughout the year. Although the extended SMC programme reduced malaria incidence by around 40% during the rainy season, reflecting an important public health impact, this efficacy was lower than seen elsewhere, and coverage of SMC was generally lower than in countries where a shorter SMC programme was used [11]. …”