Seasonal Malaria Chemoprevention (SMC) is a critical strategy for programs and policymakers in areas where malaria follows a seasonal pattern. As global health advocacy for expanded scale-up and use grows, so too is the attention given to SMCs at the global level. This article reviews the international movement for SMC, highlighting achievements, challenges, and concerted efforts to bring this intervention into broader malaria control programs.
Understanding Seasonal Malaria Chemoprevention (SMC)
Seasonal Malaria Chemoprevention consists of administering antimalarial drugs to a population, especially children, at a time of year when there is the highest malaria transmission risk. This type of pre-emptive treatment is usually delivered in the form of a series of doses over a defined period – typically the malarial season – to lower the likelihood of malaria or severe disease.
In areas with seasonal transmission of malaria – where the risk of infection peaks at certain times of the year –ORS is the optimal preparation because SMC, the provision of preventive treatment over high-risk periods, typically takes place over these peak seasons. SMC has proven to be an extremely effective tool for reducing malaria morbidity and mortality while avoiding further strain on healthcare systems.
The Rationale Behind SMC
Seasonal Transmission Patterns
Since malaria transmission is seasonal, associated with characteristic seasonal changes in environmental factors such as rainfall and temperature that provide ideal conditions for mosquito breeding, it made sense to administer SMC during the season of peak transmission to prevent infections that had not yet happened.
High Efficacy
Data shows that SMC is very effective at reducing episodes of malaria and hospitalizations of children under five years of age who are particularly susceptible to severe malaria. Field operational studies and clinical trials have shown that SMC can reduce incidence by up to 75 percent during the treatment period.
Public Health Impact
SMC prevents malaria illnesses, which in turn relieves pressure on health facilities, lowers treatment costs improves health outcomes in the community, and contributes to the broader objectives of malaria control, such as reducing transmission and mortality rates.
Key Milestones in the Global Advocacy for SMC
The Evidence Base
This evidence began to build to a critical mass in support of SMC, and in the late 2000s reached the point where there was sufficient robust empirical evidence to demonstrate that SMC works. Researchers conducted trials in Mali, Niger, and Nigeria that show SMC reduces malaria illness, hospital admissions, and deaths in children during the high transmission season.
Global Health Organizations’ Support
International health organizations have played a crucial role in promoting SMC:
- World Health Organization (WHO): The WHO issued its recommendation for SMC in a 2011 report endorsing SMC as a key component of national malaria-control policies in areas where transmission is seasonal. WHO also offers guidance and recommendations on how to implement an SMC program.
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria: The Global Fund has helped to scale up SMC interventions by providing funding and technical assistance to countries to expand their prevention programs and improve access to antimalarial medicines.
- Roll Back Malaria Partnership (RBM): RBM has aggressively championed SMC, organized meetings, and coordinated knowledge-sharing activities to speed up the implementation of SMC around the world.
National and Regional Initiatives
Several countries have successfully implemented SMC programs, demonstrating its feasibility and impact:
Nigeria: Nigeria has been leading the SMC vanguard, implementing a national program to cut malaria prevalence substantially in targeted areas, but also providing an example for countries following behind.
Mali and Niger: Both countries have incorporated SMC into their national malaria control strategies and both have reported significant reductions in malaria cases and hospitalizations over the last few years. These successes will inform the scale-up of SMC in other endemic areas.
International Conferences and Forums
Notably, international conferences and forums have played a critical role in promoting the SMC agenda. The biannual Malaria World Congress, ASTMH meetings, and similar conferences have served as a platform for unveiling new research findings, discussing implementation challenges, and also mobilizing support for SMC.
Success Stories and Impact
Case Study: Nigeria
SMC has significantly reduced malaria incidence in children under five in Nigeria, where the government and international partners have worked to scale up coverage by establishing an efficient distribution system and community outreach. Severe malaria and attendant hospitalizations in the areas with SMC and neighboring regions have shown a substantial decline since the country embarked on this strategy in 2014.
Case Study: Mali
In Mali, high coverage rates have reduced both malaria cases and mortality, thanks to a well-coordinated national program involving government ministries, traditional local health workers, and international partners. Indeed, Mali’s success demonstrates the vital role that strong health systems and community engagement can play in any national program of SMC.
Case Study: Niger
Niger’s SMC program demonstrated the scalability of preventive interventions in the resource-poor setting by combining community distribution with intensive coverage campaigns. The positive outcomes in Niger and other parts of the continent today justify the strategic use of seasonal chemoprevention beyond any existing mass drug administration programs.
Challenges and Barriers
Supply Chain Management
Ensuring a consistent supply of antimalarial drugs is one of the main challenges of SMC programs; being unable to secure a steady and reliable supply, or without effective supply chain management, not only will children fail to receive the full recommended doses of antimalarial drugs, but populations might even miss out on full coverage during malaria season as a whole.
Healthcare Infrastructure
SMC requires a strong health infrastructure to hire and train staff and distribute the medication effectively. Because health systems vary greatly, in places with weak systems it might be a greater challenge to scale up SMC. This could require additional investments or capacity building.
Community Acceptance
These programs need community buy-in, and they can fail if their SMC activities are not widely known or practiced by the communities involved. Wilkinson argues that the first hurdle to SMC achieving adequate coverage rates is addressing misconceptions about malaria in target populations.
Monitoring and Evaluation
Monitoring and evaluating the efficacy of SMC programs are also very important. One of the reasons why we continue to have bednets in homes is because this method of malaria control is consistently monitored and evaluated to make sure we are making the best use of the resource and changing course as new information becomes available. Monitoring and evaluation frameworks for SMC initiatives are not easy to establish, let alone implement, but they are important for success and sustainability.
Future Directions and Recommendations
Expanding Coverage
Also, more work is required to improve SMC coverage in populations at the highest risk of malaria, not only geographically, but also in ethnic minority populations with historically high malaria incidence or limited access to services. Overall, by scaling up SMC programs and incorporating them into national plans for malaria control, novel SMC interventions can be of benefit at larger scales and help to achieve global malaria targets for elimination.
Strengthening Health Systems
It’s also crucial to build and bolster health facilities, supply chains, and distribution networks because SMC programs rely on having a robust healthcare infrastructure in a region to supply medicines to patients. In addition, investing in that same infrastructure – such as health facilities and healthcare workers – can help bolster the capacity to deliver SMC, as well as other malaria interventions.
Enhancing Community Engagement
Building trust through community education and outreach can play a role in advances in the field of SMC – like community involvement in the planning and implementation of SMC programs.
Advancing Research
There is still much work to be done to further study SMC – particularly its long-term impact and cost-effectiveness – and to refine strategies for optimizing the use of resources. Research can also guide the development of new antimalarial drugs and approaches to improving SMC delivery.
Promoting Global Advocacy
Global advocacy needs to be sustained to ensure continued support for SMC, raise funds, build on successes, address challenges, and ensure international coordination among actors.
The SMC advocacy movement brings relevance to the potential of new malaria prevention initiatives such as SMC by demonstrating that we can achieve strong growth by adhering to evidence-based principles, by working together with our international and national partners, and by overcoming the challenges that come our way. In short, if we can follow these principles, SMC and other malaria-prevention initiatives can measurably reduce malaria incidence, increase public health, and move us dramatically forward in the fight to achieve global malaria control and elimination goals.
