In some parts of Africa, annual malaria cases are concentrated in the 4-month rainy season. Around 39 million African children under 5 years of age live in these regions and an estimated 152,000 die from malaria each year.3 Most of these children live in the Sahel and sub-Sahel regions of Africa where SMC with SP+AQ has been shown to be a cost-effective solution to prevent around 75% of malaria episodes: high-quality SMC drugs cost ~USD 1 per season, while inpatient care for a case of severe malaria is estimated to cost USD 12–75.1,2,3
In 2015, the ACCESS-SMC project reached 3 million children across the Sahel leading to reports of empty beds in malaria wards. In 2016, the goal is to reach 6.5 million children.
Prof. Jean Louis Ndiaye was involved in the early SMC pilot studies and its scale-up in Senegal. He explains how the challenges to realizing its maximum impact are being tackled.
1. What are the biggest challenges in the implementation of SMC?
The lack of a child formulation of SP+AQ is a big challenge. It means we must crush bitter tablets, making it very difficult to administer them to youngsters. Also, having enough medicines is challenging. Last year we didn’t get the quantity we needed to reach all the children.
Another challenge is the lack of a standardized approach to monitoring and evaluation to measure the public health impact of SMC and the prevalence of molecular markers for drug resistance. We know that pharmacovigilance systems are very weak in many countries, which makes it difficult to know the number of adverse events associated with SP+AQ, even if we know it is generally well tolerated.
2. How are these challenges being overcome?
Guilin has developed a dispersible tablet that was granted a favourable opinion by the Expert Review Panel for insertion on the Global Fund list of malaria products. This formulation can now be purchased by international funders for the 2016 campaign. It was also submitted to WHO prequalification and a verdict is expected in 2016.
Guilin is confident that there will be sufficient drugs available this year. Also, MMV has signed an agreement with a manufacturer, S Kant Healthcare, to develop a second child-friendly tablet. While ACCESS-SMC has developed a quantification tool to help forecasting.
The SMC working group is harmonizing training and ensuring all countries have the same tools. One day of the SMC training will be reserved to focus on pharmacovigilance. It is also conducting an impact and evaluation programme with donor funding in selected areas. However, the challenge remains to obtain and maintain funding for these activities in all areas that could benefit from them.
1 Cairns M et al. “Estimating the potential public health impact of seasonal malaria chemoprevention in African children.” Nat Commun. 3:881 (2012).
2 WHO/GMP Technical Expert Group On Preventive Chemotherapy, Geneva 4–6 May 2011. Report of the technical consultation on seasonal malaria chemoprevention: www.who.int/malaria/mpac/feb2012/ smc_teg_report.pdf
3 Lubell Y et al. “Cost-effectiveness of parenteral artesunate for treating children with severe malaria in sub-Saharan Africa.” Bull World Health Organ. 89(7):504-12 (2011).