IPT – Not just for pregnant women anymore

Global Health Council Research Associate Lillian Benjamin is at the 5^th MIM Pan-African Malaria Conference in Nairobi, Kenya. This is the first of her posts from the conference.

NAIROBI, Kenya — Intermittent Preventive Treatment (IPT), the administration of a full course of an antimalarial drug as a therapeutic dose,  has widely been accepted as a  protective measure added to antenatal care for women in malaria endemic countries.  The use of IPT is believed to treat pregnant women from possible malaria infection in hopes of reducing maternal anemia, which can lead to complications during childbirth as well as problems for her fetus. While this practice has been prescribed by the World Health Organization for pregnant women, in the past two days there has been discussion on the use of IPT for other at-risk groups, infants and children.

Intermittent Preventive Treatment for infants (ITPi)  is the delivery of a full course of antimalarials at the time of the Expanded Program for Immunization (EPI) vaccines in the first year of life. Infants would be given IPT at the time of their vaccinations: DTP2 (two months), DTP3 (three months), and measles and yellow fever (nine months). A recent article in the Lancet — Aponte John J, Schellenberg David, Egan Andrea, et al. “Efficacy and safety of intermittent preventive treatment with sulfadoxine-pyrimethamine for malaria in African infants: a pooled analysis of six randomised, placebo-controlled trials.” (2009; 374: 1533–42) —  highlights the findings from a meta-analysis of six different study sites within Africa. The study shows that IPTi with antimalarial medication sulphadoxine-pyrimethamine (SP) was 30.3 percent protective against clinical malaria  during the first year of life.

David Schellenberg also presented results from on the feasibility and community effects of large scale IPTi implementation in southern Tanzania. This study found that when IPTi-SP was administered along with EPI there was a 59 percent reduction in the incidence of clinical malaria and a 50 percent reduction in the incidence of severe anemia in the first year of life.  Alexandra de Sousa discussed the implementation of such programs in six African countries. Her findings showed that even when health care workers were reluctant to participate in the program because of the belief that it would add to an increase in work load, the intervention was welcomed because of the potential benefits.  It also was believed that IPTi would increase EPI adherence as parents welcomed ITPi and wanted their children to participate, thereby coming back for vaccinations.

Dr. Robert Newman, director of the of the Global Malaria Programme, informed the audience that WHO has just released a policy recommendation for ITPi, stating that SP-ITPi, delivered through EPI, is a recommend as an addition to malaria control interventions in countries in Africa when EIR is beyond 10 and parasite resistance to SP is not high. However,  ITPi is not recommended to be given to infants that are being treated for HIV infection.

Research also was presented from the Intermitted Preventative Treatment of Malaria in Children (IPTc) Taskforce. Diallo Didder, Konate Amadou and Dicko Alassane presented research on a trial of IPTc in children, when controlling for use of ITNs (insecticide treated bed nets). The purpose of the study was to see if IPTc adds to the protection provided by ITNs. Researchers enrolled two cohorts of children in Mali and Burkina Faso, the groups were divided by the intervention– administration of IPTc. Researchers were able to control for the use of ITNs by giving all children enrolled in the study ITNs and monitoring the use of ITNs through home visits during the study. The use of ITNss during the study period was more than 90 percent. The children ranged in age from three months to 59 months. They were given three doses of an antimalarial drug in one month during their country’s malaria season. There were no severe adverse effects; however, there was a significant  increase in vomiting and fever for the intervention group.

Although the study has yet to be released and the authors are still reviewing the results, preliminary findings showed that ITPc had a protective effect of 75 percent reduction in clinical malaria, 81 percent reduction in severe malaria, and a 77 percent reduction in hospital admissions. Other presenters examined the logistics and cost effectiveness of the intervention.

Both sessions provided scientific evidence that would merit the uptake of IPT for infants and children, but it is important to note that only ITPi has gone been reviewed by a WHO task force and warranted WHO policy recommendation.  Further research  is still needed on the efficacy of ITPc before it is recommended by the WHO.