Dr André-Marie Tchouatieu tells us about the progress and challenges of implementing SMC, and MMV’s future plans to increase its impact.
Since the WHO issued its SMC recommendation in 2012, what kind of impact has it had on the Sahel region of Africa?
In most countries that have implemented SMC, malaria incidence initially reduced by 25–60%, and malaria related mortality by 40–45%. The intervention is therefore having a significant protective effect against uncomplicated and severe malaria. This is great news, but we will have to confirm these reductions over the coming years, and during the 2020 COVID-19 pandemic in particular. Senegal, Burkina Faso and Ghana are among the countries that have seen the most signifi cant benefi ts from SMC so far, and we hope that other countries in the region will benefit as we look to increase SMC coverage. It’s really important that we apply robust and consistent methodology to assess the impact of SMC on the burden of malaria in the Sahel region, and evaluate its benefits continuously.
How are countries mobilizing national resources to increase uptake of SMC?
Some countries are seeking financial support from the World Bank and other regional banks to complement the funding they receive through multinational mechanisms such as the Global Fund and the US President’s Malaria Initiative. In addition, governments in some countries, such as Mali and Ghana, are increasingly contributing towards SMC campaigns and allocating more of their malaria funds towards SMC. However, the proportion of resources that comes from national sources is still negligible, and most countries are largely dependent on international donor funding.
What are the logistical challenges associated with implementing an SMC campaign?
In the early days of implementation, forecasting the supply of SMC was a major challenge as it was based on census data that were often old and inaccurate. With updates to census data, countries are now much better able to predict their SMC supply needs. Social and political migration in some countries also makes forecasting difficult. Countries generally have an extra 10% stock of SPAQ as a buffer to cover any additional needs, but thanks to improved coordination between countries, rapid movement of stock from areas of low to high demand is now possible.
Compliance to SMC is also a challenge. The first dose of SPAQ is administered by a healthcare worker, but ensuring adherence to the second and third doses of AQ alone, which are usually given by caregivers (parents or guardians), is challenging. Supervised administration of the full course of SMC would be beneficial but would also increase costs. Several countries are currently exploring this option.
How has MMV helped to diversify the supplier base for SPAQ?
Only one WHO-prequalified, child-friendly SPAQ product is currently available, and so MMV is supporting a second supplier, S Kant Healthcare, to bring forward a new child-friendly, dispersible formulation. However, demand for SMC is likely to increase in the coming years due to the extension of the age range to include children up to 10 years of age, and an increased duration of coverage (up to 5 months based on changing epidemiological patterns). Ensuring a steady supply of SPAQ will therefore be crucial.
What is MMV’s mid- to long-term strategy for SMC?
Should the efficacy of SPAQ be compromised by resistance, new medicines will be needed. To increase the options for SMC, MMV is looking at new molecules, as well as repurposing existing antimalarial medicines. While exploring possible alternatives to SPAQ, we are keeping a close eye on the cost of a potential new product and trying to keep it within a similar price range as the currently approved medicines. Last year, we tested a new co-formulation of atovaquone-proguanil and amodiaquine in a drug-drug interaction study, which has the potential to achieve the same preventive efficacy as SPAQ. Unfortunately, this combination presented an unacceptable safety risk in healthy volunteers and the study was stopped.
SMC is classified as a protective intervention aimed at decreasing the number of malaria cases and deaths. However, in the long run, MMV would like to complement SMC with transmission-blocking interventions that can be administered either before or at the same time as SMC, thus contributing to an overall reduction in malaria in the community. One possible avenue could include the addition of endectocides (e.g. ivermectin), which kill mosquitoes, in combination with SPAQ; another approach could be to add a low dose of primaquine to kill gametocytes (the parasite stage that causes transmission from infected humans to mosquitoes). These approaches could help reduce rates of reinfection significantly in areas of high transmission.