PMI Impact Malaria is the flagship global service delivery project of the U.S. President's Malaria Initiative (PMI), providing global technical leadership to fight malaria and save lives. PMI Impact Malaria supports countries in their efforts to strengthen malaria diagnosis, treatment, and drug-based prevention in health facility and community settings through implementation and technical support, as well as operational research.
In four (Burkina Faso, Cameroon, Mali, Niger) of the 18 partner countries that PMI Impact Malaria supports, we work with the Ministries of Health and the National Malaria Programs (NMPs) to plan and execute malaria prevention campaigns known as seasonal malaria chemoprevention (SMC). SMC campaigns are an effective measure in preventing malaria in children which consist of a 3-day course of anti-malarial medications provided each month for the duration of the annual rainy season, when malaria transmission is highest. These campaigns are conducted by thousands of health workers to spread awareness and information about the campaigns, deliver supplies, and to provide the lifesaving medicine to caretakers and their young children. Adherence to the anti-malarial medicine is critical for SMC campaigns to be effective.
During the 2020 SMC campaign in Niger, PMI Impact Malaria set out to understand adherence to these anti-malarial medicines and the attitudes and practices of caregivers providing them to their young children. PMI Impact Malaria published those findings in Malaria Journal to contribute best practices and lessons learned to global knowledge and future efforts. We recently spoke with PMI Impact Malaria's Chief of Party in Niger and publication author, Dr. Daniel Koko (right), to learn more about the study his team led and how the findings have informed their support of the national Ministry of Health and National Malaria Control Program in SMC campaigns (the interview has been edited for clarity):
What is the significance of the findings in this publication?
Seasonal malaria chemoprevention (SMC) is recognized by the World Health Organization (WHO) as an effective intervention to reduce episodes of uncomplicated and severe malaria in children by approximately 75%  and so far, 15 countries in sub-Saharan Africa have been implementing SMC campaigns with about 180 million treatment doses delivered to 45 million children in 2021 (World Malaria report 2022).
However, SMC intervention cannot reach their full potential in mass campaign i.e., reducing morbidity in children, without the engagement of community distributors and caregivers to adhere to the administration of medicines according to SMC guidelines.
This publication is significant because it provides us, as public health experts (research institutions, implementing agencies, donors, etc.), with key elements from field implementation. This includes the adherence of community distributors and caregivers to SMC guidelines and the attitudes and practices of caregivers about the administration of medicines at home without any support or follow-up on the second and third day.
What did you learn through these findings?
Through these findings, we are pleased to confirm the acceptability of the SMC intervention by caregivers and their good adherence to the full 3-day course. This study found that 99.1% of children received their first dose of SMC medicines on day 1, 90% on day 2 and 84% day 3. This could be explained by caregivers’ knowledge of SMC as a malaria intervention, as well as by the positive effect of SMC on the health of children treated during previous campaigns. We are also delighted to see that SMC medicines are well tolerated by children with only a few minor adverse drug reactions reported. This contributed to strengthening caregivers’ trust in the SMC campaigns.
Our study also revealed that many community distributors did not comply with the Niger SMC guidelines, notably that more than 50% of the first dose was given to children by their caregivers without direct observation from the distributor. In many cases, the distributor left full packets of anti-malarial medicine for the caregiver to administer to the child at a later time. These same practices were noted in other countries as well. Finally, due to the demands of farming work during SMC period, discontinuation of SMC regimen were observed in a few caregivers. The main reasons were “forgetting”, “not having time”, and “the mother’s absence”. These discrepancies and challenges reveal important information for planning future campaigns.
What problems might these findings help solve and how might this help communities prevent malaria through SMC?
These findings help to look definitively at implementation to proactively raise challenges that need to be addressed to make SMC campaigns more effective in the future. For example, through this study it appears that community distributor trainings should be redesigned to focus on interpersonal communication and associated tools such as memory aids (one example is that flipcharts with images could be provided to improve home visits). Supervision, including direct observation of distributors, during the encounter with caregivers could reinforce distributor practices. Further, these findings suggest the need to develop behavioral interventions to strengthen the caregivers’ adherence on subsequent days at home. These interventions could include the involvement of other family members and neighbors and other social support, such as community outreach to maximize the timely and appropriate dosing of children.
How have these lessons been applied/changed how your team supports the NMCP and Ministry of Health to conduct SMC in Niger?
These findings will help the Ministry of Health of Niger to improve, update, and revise the national SMC guidelines. They will also inform the National Malaria Control Program, donors, and implementing partners in the planning, budgeting, implementation, and evaluation phases of future SMC campaigns.
What inspires you about continuing this work to end malaria in your country?
What inspires me and has driven me throughout my career is the need to serve the underprivileged and most vulnerable people by helping government and civil societies to eliminate or at least reduce inequities. Growing up in Sub-Saharan Côte d’Ivoire, I experienced personally what it means to be vulnerable. I suffered from infectious diseases many times and one of which could have taken my life because of lack of access to basic public health facilities. I am so fortunate, I survived. This is not the case for many of my friends. Now, I would like to take advantage of my position in public health sector to help those most in need in my country and around the world.
PMI Impact Malaria is funded and technically assisted by the U.S. President's Malaria Initiative (PMI) and is led by Population Services International (PSI) in partnership with Jhpiego, Medical Care Development International (MCDI), and the Malaria Elimination Initiative (MEI) at the University of California San Francisco.