Seasonal Malaria Chemoprevention in Guinea in 2021: coverage survey results.

SMC gives children a high level of personal protection from malaria. Evaluation of SMC programmes by the ACCESS-SMC project showed substantial reductions in malaria cases and malaria deaths in children, associated with introduction of SMC. High coverage of monthly cycles is needed during the malaria season to maximise the impact of this intervention. The WHO recommendation previously limited SMC to four monthly cycles, and to children under 5 years of age. Updated WHO guidelines published in June 2022 (who.int) recognize that more than 4 cycles may be needed in some areas, and that the age range may need to be adapted, to reflect the ages at risk of severe malaria. Seasonal Malaria Chemoprevention (SMC) was introduced in Guinea in 2015 for children aged 3 months to 5 years, in 6 prefectures, scaling up to 8 prefectures in 2016, 10 in 2017, 13 in 2018, and 17 prefecture from 2020. Household surveys have been conducted at the end of each year to monitor SMC uptake and use of LLINs. The average coverage per cycle was 71.6% in 2018, 71.5% in 2019, and 78.2% in 2020. LLIN coverage in children was 30.2% in 2018, 85.7% in 2019 and 66.3% in 2020. SMC coverage has been consistently low in the prefecture of Siguiri, the largest prefecture. In 2019 the PNLP undertook research to determine barriers to SMC uptake in Siguiri and in 2020 piloted a modified delivery approach to address these barriers. In 2020 and 2021 steps were taken to ensure safe delivery of SMC delivery during the COVID-19 pandemic, and in 2021, SMC distribution teams were trained to document referral of children who were unwell, screen and refer children for malnutrition, check vaccination records and refer under-vaccinated children, check receipt of a LLIN (long-lasting insecticide-treated bednet) in the last campaign, promote antenatal attendance for pregnant women including referral of women who had not received IPTi or an LLIN. In one prefecture, the use of a fifth SMC cycle was piloted, and in three health centres digital recording of SMC treatments was piloted alongside the usual recording in registers. In 2021, four cycles of SMC were delivered in the prefectures of Gaoual, Koundara, Mali, Lelouma, Labe, Koubia, Tougué and Dinguiraye, with support from PMI, and in Siguiri, Mandiana, Kouroussa, Kankan, Pita, Dalaba, Mamou and Faranah prefectures, supported by the Global Fund, in July, August, September and October, and in Dabola, five cycles were piloted, supported by the Global Fund and KOICA, four cycles taking place at approximately the same time as in the other prefectures, and the additional cycle before these, in June. A total of 4.48million treatments were delivered to 1.1million children. Survey methods and objectives: This survey to assess coverage of SMC in 2021, was conducted in January 2022 (but is referred to here as the 2021 survey). A total of one hundred communities were selected with probability proportional to population. The survey aimed to assess uptake of SMC, and use of bednets by children and by all other household members. In 2021, SMC campaigns included documented referral of children who were unwell, screening and referral for malnutrition, checking vaccination records and referral of under-vaccinated children, and promotion of antenatal attendance for pregnant women. Questions related to implementation of these additional activities were included in the survey. In Dabola, where a fifth cycle of SMC was piloted, a higher sampling fraction was used in order to be able to estimate coverage of 5 cycles reliably. Area sampling was used to select households. Each selected community was divided into segments, one segment chosen at random, and all eligible children within the chosen segment were included in the survey. A total of 2,772 children eligible to receive 4 treatments (July-October) were surveyed in 100 clusters. A total of 1806/1924 households agreed to participate, a response rate of 93.9%. This included, in Dabola, 484 households and 260 children eligible for 5 cycles (June-October). Use of LLINs was assessed for a total of 8,938 household members. Caregivers were interviewed about SMC treatments, dates of treatments were recorded from the SMC card, and SMC registers were checked to verify SMC treatments. In addition, all persons who slept in the household the night before the survey were listed, all bednets owned by the household were also listed and inspected, and for each person, the net they slept under, if any, was noted. SMC coverage in 2021: In this report, coverage is reported for cycles 1-4 (July-October) for all prefectures (the ‘primary’ 4 cycles), and for ‘cycle 0’ (June) in Dabola only. Overall, the percentage of eligible children who received SMC was 56.1% in cycle 1, 52.7% in cycle2, 49.4% in cycle3, and 45.9% in cycle 4. Coverage varied by prefecture. The largest prefecture in terms of population had the lowest coverage, and the four prefectures with the lowest coverage accounted for 37% of the total target population. Efforts to improve SMC delivery should be focussed on these areas. Most children who received SMC in the first cycle, received SMC in the subsequent cycles. But children who were missed at the first cycle were unlikely to receive SMC in later cycles: 95% of those missed at the first cycle, received no SMC. It is therefore important to ensure children are reached in the first cycle. Coverage of the first cycle was less than 70% in four prefectures. A total of 41.5% of eligible children did not receive any of the primary 4 cycles in 2021, 43.3% received all four monthly treatments, and 58.5% received SMC at least once. Equitability of SMC uptake: SMC uptake was equitable with respect to sex (similar coverage in boys and girls) and according to caregiver wealth ranking based on household assets, but SMC uptake was much lower in children who were not using a LLIN than in children who were using a LLIN. A total of 35% of SMC-eligible children slept under an LLIN the night before the survey. Among these children, 87% received SMC in the first cycle and 72% received four SMC treatments. But 65% of children eligible for SMC did not sleep under an LLIN, and of these children, only 39% received SMC in the first cycle and only 28% received four SMC treatments. Timing of SMC cycles: The interval between cycles should be 28 days. After this time, SMC efficacy declines rapidly. Based on dates recorded on SMC cards, 90% of intervals between cycles were 32 days or less but few children received treatments at 28 day intervals. These intervals should be reduced to 28 days. Cases will increase in the 5th week as protection wanes rapidly after 4 weeks. Delivery of 5 cycles of SMC: In the prefecture of Dabola where SMC over 5 cycles was piloted, 82.8% of children eligible to receive 5 cycles received cycle 0, 81.1% cycle 1, 79.1% cycle 2, 76.3% cycle 3 and 66.7% cycle 4. A total of 66.3% received all 5 cycles. 18.1% did not receive SMC. These results indicate that it is feasible to achieve high coverage of SMC over 5 cycles. The median interval between cycles was 30 days between cycle 0 and cycle 1, and 31 days between cycle 1 and 2, and between cycle 2 and 3, and 32 days between cycle 3 and 4. Cycle dates should be chosen to ensure that children are treated at intervals of about 28 days. 5 cycles are then sufficient to protect for about 5x28=140 days or 20 weeks. Checking of vaccination status: Among children who received SMC at least once, the percentage of children whose vaccination status was checked, according to the caregiver, was 59.3%, and of these 34.9% were referred for immunisation, and 41.7% of those attended for vaccination, according to caregivers. Nutritional screening: 10.1% of children had MUAC measured according to the caregiver and of these 25.8% were referred for treatment. Bednet use: Bednet use has decreased sharply since the last LLIN campaign in 2019. In the 2021 survey, 37% of individuals surveyed (of all ages) slept under an LLIN the night before the survey, compared with 66% in 2020 and 86% in 2019. Prefectures with low coverage of SMC also had low coverage of LLIN use. Children who did not receive SMC were less likely to use an LLIN than children who received SMC. LLIN use varied by age group, and was lowest in children aged 5-9yrs. 35.5% of SMC-eligible children, and 37.4% of all ages, slept under a LLIN the night before the survey. Only 27.5% of the 5-9 age group slept under a LLIN. 29.2% of the population had access to a LLIN, 42.0% of households owned a LLIN, but only 13.3% of households had one LLIN for every two members. Recommendations: SMC has been successfully scaled-up in Guinea, achieving consistently high coverage. In 2021, to take advantage of the SMC platform, SMC distribution teams were trained to document referral of children who were unwell, screen and refer children for malnutrition, check vaccination records and refer under-vaccinated children, check receipt of a LLIN (long-lasting insecticide-treated bednet) in the last campaign, promote antenatal attendance for pregnant women including referral of women who had not received IPTi or an LLIN. In one prefecture, the use of a fifth SMC cycle was piloted, and in three health centres digital recording of SMC treatments was piloted alongside the usual recording in registers. In total, 4.48million treatments were administered to 1.1million children in 17 prefectures. 1. While high SMC coverage was maintained in many areas, coverage was very low in the largest prefecture, Siguiri, and was less than 70% at cycle 1 in three other prefectures. These four prefectures with the lowest coverage accounted for 37% of the target population. Reasons for this need to be explored, including the possible impact of the additional tasks SMC teams performed in 2021. 2. In Siguiri, SMC uptake has been consistently low. The reasons have been investigated by the PNLP. Key barriers were a lack of trust, drug distributors and supervisors who lived far from distribution areas, and distributors who had insufficient time, lacked adequate training, and found families often away from home. Strategies to address the barriers were then developed through a participatory approach and piloted. These strategies included reducing workload by increasing the number of distributors, selecting those who would be available throughout the season, ensuring each distributor pair includes one from the local community and one who is literate, strengthening community mobilisation by recruiting a resident advocate for SMC in each community and starting mobilisation 5 days in advance of each cycle. The use of local advocates was found to be highly effective in strengthening social mobilization, and increasing the number of distributors increased costs, but made it possible to reach areas that could not be covered previously. These strategies should be implemented in Siguiri prefecture during the next campaign and evaluated through the next coverage survey. 3. Children who are not reached in the first SMC cycle of the year, are very unlikely to receive SMC in later cycles. The same children that do not receive SMC, are much less likely to use a LLIN. The reasons for this should be explored and efforts made to ensure that all households are reached in the first cycle. SMC teams can check and promote LLIN use but this will be less effective if SMC teams fail to visit households with poorest access to LLINs. 4. There has been a sharp drop in LLIN coverage since the last campaign in 2019. A gradual reduction in net use after a campaign is to be expected but the reduction since the 2019 campaign is surprisingly large. Operational research is needed to explore when and why households decide to discard nets, and to develop health messaging to improve retention of LLINs. 5. Children aged 5 to 9 yrs are much less likely to use a LLIN than children under 5 and than older children and adults. The lowest coverage was in 5-6yr-olds. These children are vulnerable because they have recently stopped receiving the protection of SMC. SMC teams should be trained to emphasise the importance of using a LLIN, especially for children who have reached 5 yrs and stop receiving SMC, and operational research should be undertaken to develop strategies to promote LLIN use in this age group. 6. Results for Dabola prefecture shows feasibility of achieving high uptake of SMC over 5 cycles. These data should support introduction of a 5th cycle in other prefectures. 7. Results on integration of nutritional screening, promotion of immunisation, LLIN use, and antenatal care, indicate that checking of vaccination status was undertaken widely, nutritional screening was more limited. More information about where and how these strategies are being implemented would allow the survey teams to plan more effective evaluation. The possible impact of the extra workload on SMC coverage and the need to strengthening of SMC teams, should be investigated. Children who are referred for treatment as a result of MUAC screening, should be tracked to determine if they are able to access treatment, and caregivers consulted to understand how to make treatment accessible. 8. Future surveys should ideally be conducted within one month of the last SMC cycle, to minimise recall bias.