School-based Treatment with ACT to Reduce Transmission: Evaluation of the community impact of intermittent preventive treatment for malaria in Uganda

Despite global commitment to malaria control and substantial increases in funding, the burden of malaria in Africa remains high. Currently, malaria control is targeted at children under five years and pregnant women. School-aged children remain relatively uncovered leaving them at risk for illness and death, and with the potential to transmit malaria to other members of the community. Intermittent preventive treatment (IPT), administering antimalarial treatment at predefined intervals regardless of infection status, has been shown to benefit pregnant women, infants, and young children, and has become an important malaria control strategy. Initial studies conducted in Uganda and elsewhere in Africa suggest that school-aged children also benefit from IPT, but the community benefits of IPT and impact on malaria transmission are unproven.

We propose to evaluate the impact of IPT for malaria in Ugandan schoolchildren on indicators of health and malaria transmission in the community. We will select 36 primary schools in Kanungu district to participate in the study; 18 schools will be randomly assigned to receive the IPT intervention, and 18 will be assigned to standard care (no intervention). Dihydroartemisinin-piperaquine (DP), a highly effective and long-acting, artemisinin-based combination therapy (ACT) will be provided to eligible children attending intervention schools once a term (3 times per year) for one year. In addition, all children in both the intervention and standard care schools will receive annual deworming, according to national guidelines.

Outcomes will be measured using surveys of communities, schoolchildren, and mosquito vectors.
Community and school surveys will be conducted at baseline and approximately two months after the third (and final) round of treatment. The community surveys will consist of a household questionnaire and a laboratory evaluation of all household members; 180 residents from randomly selected households from each of the 36 clusters will be included. For the school surveys, 64 randomly selected children from each of the 36 schools will be included. In both community and school surveys, a finger-prick blood sample will be obtained to evaluate for malaria parasites and to measure blood counts (haemoglobin). Mosquitos will also be collected from eight randomly selected households from each of the 36 clusters. Each house will be sampled once a month for the duration of the study.

The primary outcomes for the trial will be the proportion of people that are infected with malaria parasites and the entomologic inoculation rate (estimated number of infective mosquito bites per person per year) in the community. We will also determine the proportion of schoolchildren that are infected with malaria parasites.

A qualitative study will run alongside the main trial to investigate perceptions of the IPT intervention, and the potential feasibility of integrating the intervention into health service and school systems in Uganda. Results from this work will help to inform the design of future Information, Education, and Communication programmes if the intervention was taken to scale. We will also conduct mathematical modelling to determine the potential impact of the intervention in other epidemiological settings.

Given the potential contribution by school-aged children to malaria transmission in the community, and the likelihood of operational success and sustainability of school-based interventions, the question of whether IPT targeted to schoolchildren could reduce malaria transmission at a population level is highly relevant. This trial will address that question, and includes health service research and modelling to help guide future research and implementation of the intervention, and help shape policies in Uganda and elsewhere in Africa.

We propose to evaluate the impact of intermittent preventive treatment (IPT) for malaria in Ugandan schoolchildren on indicators of health and malaria transmission in the community, using a cluster randomised design. The unit of randomisation for the trial will be a primary school. A cluster will be defined as the school plus surrounding catchment area, including households located within a 500m radius. We will select 36 primary schools in Kanungu district to participate in the study; 18 schools will be randomly assigned to receive the IPT intervention, and 18 will be assigned to standard care (no intervention). Dihydroartemisinin-piperaquine (DP), a highly effective artemisinin-based combination therapy (ACT) will be provided to eligible children attending intervention schools once a term (3 times per year) for one year. In addition, all children in the intervention and standard care schools will receive annual deworming, according to national guidelines. Outcomes will be measured using surveys of communities, schoolchildren, and mosquito vectors. Community and school surveys will be conducted at baseline and approximately two months after the third (and final) round of treatment.

The primary objective of the study is to evaluate the impact of IPT for malaria, as compared with the current standard of care, on community-level indicators of malaria transmission. We will test the hypothesis that malaria transmission, as measured by the prevalence of asexual parasitaemia and the entomological inoculation rate (EIR), will be lower in communities surrounding the intervention schools, than those surrounding the standard care schools.

To guide future research and implementation of the intervention, our proposal includes health service research to evaluate perceptions of the intervention and the potential feasibility of taking the programme to scale, and mathematical modelling to determine the potential impact of the intervention in other epidemiological settings.

Introduction

Malaria remains one of the most important global health challenges. The economic and social burden of malaria is great, and malaria and poverty are closely linked. Malaria control efforts typically target children under five years and pregnant women. However, malaria remains a problem in older children, contributing to poor school performance, and putting school-aged children at risk for illness and death. Older children also serve as a reservoir for parasites, with the potential to transmit malaria to other members of the community.

Intermittent preventive treatment (IPT), providing antimalarial treatment at predefined intervals regardless of infection status, is becoming an important malaria control strategy. In this study, we propose to evaluate the impact of IPT for malaria in Ugandan schoolchildren on community-level indicators of malaria transmission. Treatment with dihydroartemisinin-piperaquine, a highly effective and long-acting, artemisinin-based combination therapy (ACT) will be provided to eligible children attending intervention schools once a term, for a total of three treatments over one year. If the intervention is successful, it will decrease malaria transmission in the community, as well as improve health of schoolchildren. To guide future research and implementation of the intervention, our proposal also includes health service research to evaluate perceptions of the intervention and the potential feasibility of taking the programme to scale, and mathematical modelling to determine the potential impact of the intervention in other epidemiological settings.


Who might benefit from this research?

This research will directly benefit those involved in with the study, including schoolchildren, teachers, and primary schools. Others associated with the study, including members of the students' households, and members of the communities surrounding the participating schools, also stand to benefit. Local, district, and national officials involved in health and education, Uganda's National Malaria Control Programme, and other organizations such as non-governmental organizations (NGOs) that are involved in malaria research and control, are also expected to benefit from this research, in Uganda, elsewhere in Africa, and globally. The study proposed here is designed to evaluate the efficacy of the IPT intervention in a controlled setting, delivered by research study staff. We envision that future studies could assess the effectiveness of the intervention in programmatic settings, with the intervention delivered by teachers or school nurses, informed by the implementation research and modelling incorporated in this study. The impact of future studies that lead on from our research could be far reaching, with national, international and global impact.


How might they benefit from this research?

Anticipated economic and social impacts of this research include increased health and well-being, increased school performance, improved effectiveness of primary schools, improved economic prosperity, enhanced quality of life, strengthened links between the education and health sectors, and opportunities for evidence based policy making. Schoolchildren participating in the study are expected to benefit directly through improved health and well-being, and increased school performance. If the intervention decreases malaria transmission, the health of other community members also stands to improve. Increased school attendance and student performance may enhance the effectiveness of primary schools. Decreasing the burden of malaria could contribute to economic prosperity and enhanced quality of life for the community. This research aims to build the links between education and health sectors, and stands to provide evidence to guide future policy decision making, which would benefit officials involved in health and education, and organizations involved in malaria research and control.