London School of Hygiene & Tropical Medicine

Providing preventive treatment for malaria, given once per term, dramatically reduces rates of malaria infection and anaemia among schoolchildren, and significantly improves their cognitive ability, according to new research published today in The Lancet.

Malaria is a major cause of morbidity and mortality in early childhood, but its consequences during the school-age years are less widely acknowledged. By the time an African child enters school they have generally been repeatedly infected with malaria and have acquired immunity to the parasite making them less likely to die. However, malaria still accounts for up to 20% of deaths among schoolchildren, is an important cause of school absenteeism, and may hinder educational achievement. Additionally, many schoolchildren continue to harbour malaria parasites without displaying any symptoms of disease. These asymptomatic infections frequently go unrecognised and untreated, leading to anaemia and, as demonstrated for the first time in this study, impaired performance in school.

School-based health programs have been shown to work well in combating other diseases, such as worm infections, but less is known about their role in tackling malaria. Yet more children are now attending school than ever before and governments are increasingly recognising the importance of child health for educational achievement.

A multi-disciplinary team of Kenyan and British researchers investigated the impact of IPT, a new method of tackling malaria which involves the mass administration of a full course of an anti-malarial drug irrespective of whether children are infected. They assessed whether IPT could reduce the prevalence of anaemia, and improve classroom attention and educational achievement in schoolchildren. They carried out a randomised, placebo-controlled trial of IPT in 30 primary schools in a rural area of high malaria transmission in western Kenya. In total, 4916 children, aged 5-18 years, received three treatments (sulfadoxine-pyrimethamine combined with amodiaquine, or a dual placebo) at four-monthly intervals, once each school term. The impact of treatment was assessed through cross-sectional surveys 12 months later.

IPT dramatically reduced the occurrence of malaria infection in schoolchildren. The risk of anaemia was halved among those receiving IPT compared with the controls, and significant improvements were also seen in class-based tests of sustained attention among those receiving IPT. No impact was observed for educational achievement.

Dr Matthew Jukes, Assistant Professor of International Education at the Harvard Graduate School of Education, worked on the study and comments: 'Although it has long been suspected that malaria impairs school performance, this is the first study to provide evidence of a direct link between malaria and reduced attention in class. These results indicate that malaria infection may hinder learning and its prevention could be important to enhance the educational potential of schoolchildren.'

Dr Siân Clarke, a Lecturer in Malaria Research and Control at the London School of Hygiene & Tropical Medicine, comments: 'Our findings highlight the neglected burden of malaria in older children, and reveal that malaria infection in schoolchildren may have more profound consequences than previously appreciated. Preventing malaria could have important health and cognitive benefits for African schoolchildren and deserves more attention. These results show us that intermittent preventive treatment in schools is a novel and effective means to address this problem.'

The findings of the study have particular relevance for the global 'Education for All' initiative which aims to achieve universal school enrolment and enhance schooling.
The intervention could prove a valuable and affordable addition to realising 'Education for All' goals through school health and nutrition programmes which already provide treatments against worm infections. School-age children represent 26% of Africa's population where 94% of children go to school. Numerically, this represents up to191 million children who could benefit from a systematic approach to school-based malaria control, which could include IPT.

Dr Simon Brooker, a Reader in Tropical Epidemiology at the London School of Hygiene & Tropical Medicine adds: 'For a small financial investment the potential gains from the approach of IPT are extremely attractive. An important next step will be to work with government and development partners in Africa to investigate further the feasibility and cost- effectiveness of scaling up an IPT package within the context of school health programmes'.

The trial was funded by the Gates Malaria Partnership which is supported by a grant from the Bill & Melinda Gates Foundation. Additional funding was provided by the Norwegian Education Trust Fund and multi-donor Education Development Programme Fund of the World Bank; DBL Centre for Health Research and Development; and the Wellcome Trust.

• Effect of intermittent preventive treatment of malaria on health and education in schoolchildren: a cluster-randomised double-blind placebo-controlled trial. Siân E Clarke (London School of Hygiene & Tropical Medicine - LSHTM), Matthew CH Jukes (Harvard University, Cambridge, MA, USA), J Kiambo Njagi (Division of Malaria Control Ministry of Health, Nairobi, Kenya), Lincoln Khasakhala (African Mental Health Foundation, Nairobi, Kenya), Bonnie Cundill (LSHTM), Julius Otido (University of Nairobi Institute of Tropical and Infectious Diseases, Kenya (UNITID), Christopher Crudder (LSHTM), Benson BA Estambale (UNITID), Simon Brooker (LSHTM and KEMRI-Wellcome Collaborative Programme, Kenya).