Seasonal Malaria Chemoprevention: An Evolving Research Paradigm

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In this issue, Paul Milligan and colleagues [1] provide evidence of the dramatic impact on the incidence of malaria of seasonal malaria chemoprevention (SMC) among children aged older than five years, the current recommended upper age limit for SMC.Research on drugs to prevent malaria in Africa among nonpregnant populations has a long history with surprisingly little sustainable policy impact.The last five years of SMC research signal an important stage in drug-based policy for malaria based on evolving field science. Antimalarial Drugs to Prevent Malaria in AfricaThe use of antimalarial drugs to prevent malaria in Africa is not new [2,3].At the turn of the last century, quininisation was widely promoted among residents of colonial administrative centres.During the "eradication" projects of the 1950s and 1960s, when indoor residual spraying failed to reach expected targets, mass drug administration (MDA) was included, resulting in huge reductions in infection incidence but never quite reaching elimination.The seasonal use of "chemoprophylaxis" was undertaken as part of pilot trials or elimination campaigns in Kenya, Burkina Faso, Senegal, Reunion, and Tunisia, again with dramatic impacts on parasite transmission and disease incidence [2,3].Approaches to the seasonal use of drugs to prevent infection were resurrected during the 1980s with trials of fortnightly distribution by village health workers of pyrimethamine-dapsone to young children in The Gambia, resulting in an 80% reduction in clinical events and a 34% reduction in all-cause childhood mortality [4].Trials during the early 2000s of intermittent presumptive sulphadoxine-pyrimethamine (SP) treatment of infants (IPTi) attending routine vaccine visits showed on average a 30% protection against morbid events due to malaria [5].However, with the exception of the presumptive SP treatment of malaria in pregnancy, throughout the history of malaria control in Africa, drug-based interventions have received less attention compared to vector control.All commentators, since the earliest use of quinine and chloroquine prophylaxis, have highlighted concerns related to adherence, adequate coverage, sustainability, delayed acquisition of immunity, and resistance, concerns relevant to both vector-and drug-based control.

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