By implementing seasonal malaria chemoprevention we are one step closer to eradicating malaria in the Sahel
Malaria Consortium's Programme Manager for the Burkina Faso country office, Dr. Victor Nana, discusses the recent SMC distributions in Burkina Faso, citing the challenges faced and highlighting the importance of implementing this intervention at scale.
What is SMC?
SMC is a strategy endorsed by the World Health Organisation to prevent malaria in children aged three to 59 months living in the Sahel. In this region, more than 60% of malaria cases occur during the rainy season, which often lasts for approximately four months.
The SMC intervention consists of giving preventive malaria treatments (sulphadoxine-pyrimethamine and amodiaquine, SP+AQ) to children each month of the rainy season. Each month there are three doses that are given over three days. The first is supervised and administered by a Community Health Worker (CHW) and the following two doses are given by parents on the subsequent days.
How is SMC administered to eligible children?
In Burkina Faso, due to the rural nature of the districts identified by the NMCP for SMC distribution, we decided to carry out door-to-door distribution of SMC for the duration of the campaign. In order to ensure that the eligible children receive this treatment, teams of CHWs conduct household visits, going wherever they think they may find eligible children. There are over 8,000 CHWs working to administer the SMC preventive treatment to 649,694 children across the country. Prior to roll out, all of these CHWs were trained to administer the medication. Their training also included how to communicate with parents and how to highlight the key messages so that the administration of the second and third dose is properly carried out at home.
The children eligible to receive SMC are those aged three - 59 months. How was this target age range chosen?
Malaria is a serious parasitic disease that is transmitted by mosquitoes. How vulnerable a person is to this disease depends on the age and general health of the individual. In countries where malaria is endemic, children aged three to 59 months are the most vulnerable faced with malaria because their bodies have not yet acquired the necessary immunity to fight the parasite. This means that today, over 90% of malaria related deaths are seen in children under five. By giving these children SMC, we can prevent up to 75% of cases and reduce related mortality by 75 %. We do not give children under three months the SMC treatment, because we consider that children born in endemic zones are already protected by the antibodies passed on by their mothers in the first three months of their lives.
What happens when a Community Health Worker arrives at a home where SMC eligible children are living?
When the CHW arrives, he/she greets the family and explains the nature of his/her visit, telling the family that malaria can be prevented in their children under five, by taking the SMC drugs. The family is often already aware that the SMC campaign is taking place, thanks to social mobilisation activities that have taken place before the launch of the distributions; however the CHW takes time to explain the purpose of SMC. In addition, the CHW must ask a series of questions in order to establish whether or not the child is eligible to receive the first dose of SP+ AQ:
- Does the child have any allergies?
- Has the child had amodiaquine and/or sulphadoxine-pyrimethamine before?
- Has the child ever had a reaction to amodiaquine and/or sulphadoxine-pyrimethamine, such as a rash, swelling or difficulty breathing?
- Has the child ever had a reaction to medication containing cotrimoxazole such as a rash, swelling or difficulty breathing?
- Is the child sick now? Does he/she have a fever? Has the child taken any medicines in the last four weeks?
- Did this medicine contain amodiaquine and/or sulphadoxine-pyrimethamine?
Once the child has been confirmed as eligible to receive the first dose of SP+AQ, the CHW proceeds to prepare and administer the mixture. Once the child has taken their first dose, the CHW spends 30 minutes with the family in order to ensure that there is no immediate adverse reaction to the medication. During this time, he/she then explains to the family that the remaining two doses should be given on the two consecutive days, following administration of the first dose.
How does the CHW obtain the drugs?
Every morning and evening the CHWs go to the Community Health Centre (Centre de Santé et Promotion Sanitaire) where they are given the required amount of SP+AQ for the day. In the evening, they report back to the CHC, provide their summary of the day’s distributions and return any remaining drugs. The following morning they return and the whole process starts again.
In some instances, if heavy rains are feared overnight, the CHWs will be given the medication the night before in order to ensure that, even if the CHWs cannot access the CHC because of flooding, they are able to administer the drugs to the eligible children in their designated villages.
What has been your role in the preparation of the first round of SMC distributions?
As Malaria Consortium's Programmes Manager for the ACCESS SMC project in Burkina Faso, my role is to organize and coordinate the planning and implementation of the project across the 11 districts: SMC is being implemented in 17 districts across the country in total and Malaria Consortium is working with the National Malaria Control Program (NMCP) in 11 of these districts. Malaria Consortium is the technical and financial partner of the Ministry of Health through its collaboration with the NMCP, which supports the roll out at scale of this intervention.
What were some of the main difficulties that you encountered in the preparation and roll out of this intervention?
SMC is not a new intervention in Burkina Faso, but this is the first time that SMC has been implemented at such scale. The transition to implementing SMC at scale has required rigorous planning, good coordination, communication and an inclusive approach, involving all stakeholders. There have, of course, been challenges along the way; notably in terms of coordinating all the actors involved. Now that the project is being rolled out in the districts, there are other challenges that we need to overcome. In doing door to door distributions, we are always going to encounter certain difficulties. One of the main difficulties is the accessibility of the villages. For the CHWs and the supervision teams, it is not always easy to reach the identified villages because of poor road conditions and is made worse by heavy rains and the flooding that ensues.
What should we do to improve the implementation of this intervention?
In order to succeed in the implementation of an SMC campaign, it is crucial that sufficient time is factored in for planning and that deadlines are respected. Before starting to plan, it is key to have a good understanding of the context in which the campaign will be rolled out, to consider the strengths and weaknesses of the environment in which we are working and to be aware of the socio-economic context and the resources available. The implementation of this intervention requires commitment and motivation from all players involved.
To improve the implementation of the SMC campaign, it is important that we continue to ensure thorough planning and that we work to make sure that resources are received on time in the different relevant structures so that the actors involved in their distribution can better plan the roll out of the intervention.
Why is it important that we continue the implementation of SMC in the Sahel?
It is crucial that we continue to implement SMC in eligible countries across the Sahel. According to research, this preventive treatment reduces morbidity and mortality related to malaria by 75%. By implementing SMC, we are one step closer to eradicating malaria in the Sahel.?
If rolled out at scale, this intervention would have a positive effect at community, district and national level. By reducing the number of cases of malaria, the associated economic cost would also be reduced, freeing up funds to be invested elsewhere. For many families, this intervention will mean the difference between life and death.
If you had five minutes to convince a donor that SMC should be made available to all eligible children across the Sahel, what would you say?
Malaria is a disease that we can beat. We know how to prevent it; we just need to convince the right people to support us in rolling out and scaling up the interventions that work, such as SMC. So, if I had five minutes with a donor, I would say…
Malaria is a serious parasitic disease transmitted by mosquitoes. It is endemic with high seasonal transmission in countries across the Sahel, killing many children aged between three to 59 months. Millions of children born in these countries never celebrate their fifth birthday because of malaria.
- Malaria is a preventable disease and SMC is an example of an effective, evidence based, intervention to prevent malaria in children
- SMC, recommended by WHO in 2012, is a cost-effective intervention that if implemented at scale could prevent 75% of malaria cases.
- By supporting SMC, we guarantee healthy lives; we also give national economies a breath of fresh air, relieving the pressure of the economic burden of malaria.
It’s simple; I would say that this is an intervention that will protect the most vulnerable children when they are most at risk from malaria.