Discussion
malaria, infection, malaria infection
MALARIA, EVENT, SCHISTOSOMIASIS, INFECTION, MAY, WEST
This study has outlined an approach that can simplify introduction of IPTsc and possibly other various school health programmes in settings similar to Tanzania. It could also be useful for planning integration of various interventions to reduce the implementation cost, especially on drug delivery and supervision. To implement IPTsc, the study team had to understand how other programmes were implemented. It was noted that successful programme introduction has to consider the targeted population platform (meeting point) and schedule that routinely gather the targeted population and the intended outcome for the planned intervention. For example, the Intermittent Preventive Treatment in pregnancy (IPTp) was introduced under the platform of routine antenatal care (ANC) among women who were receiving antenatal care on monthly basis and has resulted into successful introduction of IPTp-using sulfadoxine pyrimethamine (SP) aiming at prevention of malaria infection during pregnancy and improving birth outcome. The same for IPT in infants (IPTi-SP, now termed as perennial malaria chemoprevention-[PMC]) has been implemented using the routine immunization programme; it also aimed at prevention of infection. A different approach has been used for the seasonal malaria chemoprevention (SMC) that is largely practiced in West Africa in the Sahel region; was designed to prevent infection in children under-five in a period of high season of malaria infection. In this, the gathering platform for children especially after completing the routine infant vaccination schedule was not available; they therefore made use of CHWs who would administer monthly anti-malarial medication (SPAQ) to children in their communities consecutively for 3–4 months. All these aspects have been successfully implemented [When it comes to school-aged children, the study team had to capitalize the fact that nowadays school enrolment in most African countries has significantly improved [There are other programmes that run through schools: the school MDA has been widely practiced in African schools [This study has laid out a proof of concept for operational ability of IPTsc in most endemic communities. The implementation approach and tools used in this study can be customized to fit the purpose in any community/country interested on IPTsc. The conduct of IPTsc was successful despite having some operational challenges that were well mitigated to bring a successful operation worthy adopting by any other nation. The first challenge was on school closure due to COVID-19 pandemic, which led the team to postpone the start of clinical and IPTsc administration visits from March to July–August, 2020, a time that was initially planned to be for round 2 of IPTsc. The shift did not affect the study since no clinical evaluation or drug administration had been conducted, so it was just a push on the plan forward. The monitoring following high rain season that normally starts March–May was then assessed following the third IPTsc round, so there was no strategic interruption on evaluation of IPTsc effectiveness.The other challenge was in reaching out the communities to explain the study. Since the community is huge and some would not attend briefing meetings, meetings were conducted on each school where parents committee inviting village leaders and key opinion leaders to help propel information in every gathering that they may hold internally. In addition, political leaders such as the District Commissioners were well engaged to the operation of IPTsc, they would deliver a massage on every community gathering they encounter in the event they visited interventional wards. Such involvement of community leaders and political leaders played an important role in the conduct of IPTsc. Issues like school food donation from parents/guardians were as well addressed on every meeting as a message encompassing successful IPTsc administration in their respective schools.The delivery of a three days anti-malarial regimen is indeed different from a one-day anthelminthic drug. Normally two teachers have been used to administer MDA against STH and schistosomiasis, the two would administer the drugs to all schoolchildren in a school, taking almost the whole day to finish. In this study, the study team invented the wheel by improving the number of teachers to be used per school. Seven teachers (one per class) was set as a default number, but basing on the fact that there are other schools with more schoolchildren enrolled, the number of teachers could reach to 17 per school for those with more than 1400 schoolchildren per school. This was done to enable a teacher to administer IPTsc drugs only for a short duration not disturbing the school curriculum. This made the operation effective since within an hour or two, the whole school would have finished drug administration. Incentive payment was made equally to all teachers involved, and was made once covering all 5 days set for drug dispensing (five covering those who would miss in any day). In addition, two CHWs were included in the list; these were helpful on finding or dosing those who missed school on day of administration. A similar arrangement can be made to access school-aged children who are not enrolled at schools, thus addressing equity concerns.