Research Article: Intermittent Preventive Treatment of Malaria Provides Substantial Protection against Malaria in Children Already Protected by an Insecticide-Treated Bednet in Burkina Faso: A Randomised, Double-Blind, Placebo-Controlled Trial

Date Published: February 1, 2011

Publisher: Public Library of Science

Author(s): Amadou T. Konaté, Jean Baptiste Yaro, Amidou Z. Ouédraogo, Amidou Diarra, Adama Gansané, Issiaka Soulama, David T. Kangoyé, Youssouf Kaboré, Espérance Ouédraogo, Alphonse Ouédraogo, Alfred B. Tiono, Issa N. Ouédraogo, Daniel Chandramohan, Simon Cousens, Paul J. Milligan, Sodiomon B. Sirima, Brian Greenwood, Diadier A. Diallo, Stephen John Rogerson

Abstract: A randomized trial reported by Diadier Diallo and colleagues shows that intermittent preventive treatment for malaria in children who are protected from mosquitoes using insecticide-treated bednets provides substantial protection from malaria.

Partial Text: Significant efforts have been made in recent years to improve malaria control. However, malaria still remains a major public health problem in sub-Saharan Africa, responsible for about 800,000 deaths annually [1], and existing malaria control strategies provide only partial protection. The pressing need for new malaria control tools has led to evaluation of the strategy of intermittent preventive treatment (IPT) of malaria. IPT involves administration of antimalarial drugs at defined time intervals to individuals regardless of whether they are known to be infected with malaria to prevent morbidity and mortality from the infection [2]. IPT was initially recommended for pregnant women involving the administration of at least two doses of sulphadoxine pyrimethamine (SP) during antenatal visits after the first trimester of pregnancy. Recently the strategy was extended to infants (IPTi) with the administration of three doses of an antimalarial drug during the expanded programme of immunization (EPI) visits [3]. An Institute of Medicine report [4] indicated that IPTi is associated with a 30% (95% confidence interval [CI] 20%–39%) reduction in the incidence of clinical malaria. However in areas of seasonal malaria transmission, such as the Sahel and the sub-Sahelian regions of Africa, the main burden of malaria is in children under 5 y of age [5]. The strategy of IPT of malaria in children (IPTc) was designed for regions where malaria transmission is seasonal [6].

The protocol of the trial (Text S1), protocol amendment (Text S2), and CONSORT checklist (Text S3) are available as supporting information.

To the best of our knowledge, this is the first study to test if IPTc provides protection against malaria in children who are already protected by an ITN. Our results show conclusively that IPTc does provide substantial protection against clinical malaria episodes, severe malaria, and all-cause hospital admissions in children using an ITN. The primary role of ITNs is to prevent mosquito bites, thus reducing the risk of malaria infection, whereas IPTc clears existing infections and has a prophylactic effect preventing new blood stage infections. The high PE of IPTc in children using ITNs may partly reflect protection from infections acquired because of exposure to mosquitoes at night outside sleeping hours. Coverage of ITNs was low among older children and adults in the study area; the absolute reduction in malaria incidence due to IPTc may have been less if coverage of ITNs in the population as a whole had been higher. A similar additional effect of combining chemoprevention with ITNs was observed in a community randomised study of ITNs and chemoprophylaxis with Maloprim (dapsone-pyrimethamine) given every 2 wk in Sierra Leone [23]. In this study, ITNs and chemoprophylaxis alone were associated with 49% and 42% protection against malaria, respectively, whereas the combined effect of the two interventions was 72% (95% CI 67%–76%). Consistent findings have also been reported from The Gambia, where seasonal chemoprophylaxis with Maloprim protected children from malaria attacks in villages where ITNs were being used [24].



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