Investigating the feasibility and effectiveness of integrating helminth control with seasonal malaria chemoprevention (SMC) in West African children

Malaria and worms commonly affect children in poor countries in Africa. Both infections can cause anaemia which can, acting alone or together, lead to preventable deaths. Given natural co-existence of the two infections in many African children, holistic approach to treatment has potential to improve child survival and development. Previous efforts on mass deworming reached only a third of the children, leaving out school-aged children who form substantial proportions of the population-at-risk, whereas, a malaria prevention platform called seasonal malaria chemoprevention (SMC) successfully implemented in Sahel region, has a very high coverage and significantly reduced malaria death. The approved deworming and SMC drugs work well with minimal side-effects when used separately. Though, combined use of the two drugs are not known to have significant reactions; they have not been previously used together in clinical studies.

This fellowship therefore aims to explore the feasibility and effectiveness of an integrated treatment approach for malaria and worms using existing SMC platform to deliver deworming medications. A three-stage study is designed to achieve this goal. First, a systematic literature review on the burden of malaria and worm co-infections in African children will be conducted. Findings of this review would strengthen the rationale for evaluating innovative platforms for integrated management of malaria-helminth co-infections in vulnerable populations.

This will be followed by a survey to determine the magnitude of burden of malaria-helminth co-infections among pre-school and school-age children in Senegal. Senegal is the first country in Sahel region which has successfully implemented SMC in school-aged children. South-eastern Senegal is also known to harbour substantial proportions of children at high risk of malaria-helminth co-infections; the effects of which have contributed to school absenteeism, poor cognitive function and poor academic performance.

Finger-prick blood samples will be collected from eligible children for malaria microscopy and specialised molecular tests for species determination. An improved diagnostic performance of the circulating antigen assay by parallel testing for circulating anodic and cathodic antigens in serum and urine will be used in the detection and quantification of Schistosomes. Furthermore, stool samples will be collected to detect intestinal helminths using a highly specific multiplex real-time polymerase chain reaction which targets several intestinal helminths including schistosomes

Information generated from the second stage will serve as baseline data and will be used to develop a follow-up study that will investigate the feasibility and effectiveness of integrating SMC with helminth control in the pre-school and school-aged children. As SMC drugs are given monthly for three-to-four cycles during malaria seasons, antihelminth drugs will be co-administered with the first course of SMC in all study children. Adverse symptoms will be collected using augmented passive surveillance system following administration of SMC and anti-helminthic drugs. Haemoglobin concentration and parasite density will be determined at the end of SMC course. Also, stool and urine samples will be collected to determine the effectiveness of the anti-helminthic drugs. Cognitive skills of the study children will also be assessed.

As feasibility may include acceptability, qualitative interviews will be conducted among parents of the study children on their perceptions about effectiveness, practicalities, acceptability and barrier to using the integrated treatment approach. Also, key informant interviews will be held among SMC providers to further explore these factors. To enhance the capabilities of the applicant to become an independent researcher in malaria and NTDs, capacity building on molecular detection of malaria-helminth species and cognitive skills assessment will be included

The studies proposed in this fellowship application will make impact by achieving the following benefits:

Improved policy making: Clear evidence on the feasibility and effectiveness of integrated malaria-helminth control will be made available to policymakers at country and international levels. This will enable them to make evidence-based decisions about the implementation and sustainability of the integrated programme. Findings of the studies will provide better understanding of challenges and prospects encountered in the course of implementing the integrated malaria-helminth control and how the challenges can be addressed and optimized the programme for delivery of combined prophylactic treatment for malaria and helminth infections using an existing seasonal malaria chemoprevention (SMC) platform.

Improved policy implementation and programmatic management: National, sub-national and international policy makers will appreciate better the synergistic effects of integrated SMC and deworming programmes on child survival and development as well as the rationale driving the change from single disease control programme to the integrated control programme. This will assist them in strengthening the delivery of the control programme. Through active stakeholder engagements, this fellowship will provide evidence-based information which will ultimately increase awareness amongst national and international decision makers on the crucial need to reinforce existing malaria prevention control programme with helminth control.

Improved school-based health programmes: Findings of these studies will inform the implementation of improved school-based health programmes where school-age children who are largely left out of SMC programme can benefit improved health when they receive combined SMC and deworming drugs. This will translate to improved school attendance, improved cognition and better academic performance which ultimately will contribute to improvement in human capital development which serves as a boost to national and global economy growth.

Improved knowledge base: Findings of this study will expand the knowledge base that supports evidence-based informed decision and policy making on integrated malaria-helminth control in Africa. The study will provide evidence on how two important prevention control programmes targeting vulnerable African children are delivered through integrated approach; how challenges are addressed and structures within the health systems are utilized for optimal integrated delivery of the control programmes. This will contribute to the development of more evidence-informed and context-relevant programmes; and to the development of robust methods for implementation of integrated malaria-helminth control programmes. In addition, the study will provide evidence on newer diagnostic tools for helminth infections and this will likely inform further studies to gather more evidence that may lead to policy change in diagnosis of helminth infections in endemic countries

Improved capacity within the national control programmes: The study will support capacity development within national control programmes in monitoring and evaluation of implementation and effectiveness of integrated malaria-helminth control. This will enable them to identify in real-time challenges inherent in implementation such as supply chain, community acceptance, drug adherence etc and proffer evidence-based solutions to strengthen the operations.