SPAQ (sulfadoxine-pyrimethamine + amodiaquine) for Seasonal Malaria Chemoprevention (SMC)

P. falciparum is a major cause of childhood death across the sub-Sahel region. Most of the malaria mortality and morbidity occurs during the rainy season. Giving effective malaria chemoprevention during this period has been shown to prevent illness and death from malaria in children.

Seasonal malaria chemoprevention (SMC) is defined as the intermittent administration of full treatment courses of an antimalarial medicine during the malaria season to prevent malarial illness by maintaining drug concentrations in the blood throughout the period of greatest transmission.1 

In March 2012, WHO recommended SMC using a complete treatment of sulfadoxine-pyrimethamine and amodiaquine (SPAQ) once a month for 4 months during the malaria transmission season for children aged between 3 and 59 months. MMV has been supporting this recommendation and working to enhance the reach of this treatment to populations that need it. 

WHO cites the following expected benefits from SMC1

  • Prevents approximately 75% of all malaria episodes 

  • Prevents approximately 75% of severe malaria episodes 

  • May result in a decrease in child mortality of around 1 in 1,000 

  • Probably reduces the incidence of moderately-severe anaemia 

Published estimates indicate that “in areas suitable for seasonal malaria chemoprevention, there are 39 million children under 5 years of age, who experience 33.7 million malaria episodes and 152,000 childhood deaths from malaria each year. The majority of this burden occurs in the Sahelian or sub-Sahelian regions of Africa. [This] data suggest that seasonal malaria chemoprevention has the potential to avert several million malaria cases and tens of thousands of childhood deaths each year if successfully delivered to the populations at risk.” 2

  • Access in Action

    • In 2012-2013, MMV worked with Guilin Pharma, a Fosun Pharma company, supporting the company’s efforts to obtain WHO prequalification for a co-blistered combination of SPAQ. WHO prequalification was granted in 2014.

    • MMV was a partner in ACCESS-SMC, a Unitaid-funded project led by Malaria Consortium supporting National Malaria Control Programmes in seven countries in the Sahel region to roll out SMC. Thanks to this project, access to SPAQ has increased from around three million children covered in 2015 to more than 6.5 million in 2016, with consequent reduction of malaria cases during the transmission period. MMV’s role in this effort focuses primarily on strengthening and diversifying the supply-side response to the increasing demand for SPAQ. 

    • As part of that work, MMV has supported the manufacturer S Kant Healthcare in developing a second, dispersable and child-friendly formulation of SPAQ, Supyra®, to improve drug availability. This work is now completed, and the dossier was submitted to the WHO prequalification programme in July 2018, then subsequently to the Global Fund Expert Review Panel (ERP) in September 2018. The ERP panel gave a positive opinion in Febuary 2019 and allowed Supyra to be purchased using international donor funds for a period of one year while its prequalification review is ongoing.

    • MMV is continuing to roll out an interactive forecasting tool to improve stock management of SMC drugs. The forecasting tool tracks implementation of SMC campaigns from one year to the next and captures the following information: 

      • Number of eligible children planned and covered
      • Number of SPAQ treatments required and distributed per country
      • Funding partners

    • MMV has spearheaded scientific and stakeholder input about desired attributes of next generation SMC drugs as future alternatives to SPAQ. As part of this consultative process, between September and December 2015, MMV undertook surveys in Burkina Faso and the Gambia to define the attributes of next-generation SMC drugs. In January 2016, MMV convened a high-level meeting to review these results and to refine further scientific input. The data and perspectives gathered via this multi-phased process helped to inform a new MMV target product profile (TPP) for chemoprevention. This work led to the choice of atovaquone-proguanil and amodiaquine in combination to be investigated as a potential alternative to SPAQ in areas eligible for SMC with SP resistance. A safety study in healthy volunteers for this new combination began in early 2019.

    • MMV supported the RBM West and Central African Regional Networks with effective SMC planning, including development of an SMC Tool Kit that addresses planning, training, as well as monitoring and evaluation needs.

    • Together with Médecins Sans Frontières (MSF) and Guilin Pharma, MMV has also developed user-friendly packaging and SMC administration cards to support correct dispensing by healthcare workers and proper use by parents or caregivers

    • In its role as the secretariat of the SMC Working Group, MMV has supported the convening of all SMC countries for planning and review meetings after each SMC season. This provides a unique platform where country progress and challenges in SMC implementation can be discussed with all SMC stakeholders. Discussions on the positioning of this working group inside the RBM mechanisms will be a key focus in the following months.

     

    • Following the successful implementation of SMC, MMV has designed a programme called the SEAMACE (Seasonal Malaria Chemoprevention Extension) continuum looking at how SMC can be extended on several fronts. This continuum is designed around 4 pillars:

     

      • Improving coverage of the current eligible target population of children between 3 and 59 months and ensuring sustainability where SMC has been implemented for the last 4-5 years.

     

      • Extending the eligibility age bracket to pre-adolescent children and extending the campaign duration to align with the transmission duration in certain areas of the Sahel region where malaria transmission can last for 5 to 6 month.

     

      • Helping prepare for possible geographic extension of SMC to eligible areas of Southern and Eastern Africa; this will involve development of a new drug combination that is being tested currently for safety and tolerability in healthy volunteers. 

     

    • MMV believes that SMC, when used in association with other interventions, can support the path to malaria elimination in highly seasonal transmission areas.  


    Past and current partners:

    Guilin Pharma, a Fosun Pharma company; Médecins Sans Frontières (MSF); Unitaid; National Malaria Control Programmes (NMCPs); S Kant Healthcare; SMC Working Group; Malaria Consortium, Catholic Relief Services, London School of Hygiene and Tropical Medicine (LSHTM).  


    1. WHO Policy Recommendation: Seasonal malaria chemoprevention (SMC) for Plasmodium falciparum malaria control in highly seasonal transmission areas of the Sahel sub-region in Africa 

    2. Estimating the potential public health impact of seasonal malaria chemoprevention in African children", M. Cairns et al. Nature Communications. 2012 Jun 6;3:881. doi: 10.1038/ncomms1879

     

    Updated January 2019