Impact of intermittent screening and treatment for malaria among school children in Kenya: a cluster randomised trial.
BACKGROUND
Improving the health of school-aged children can yield substantial benefits for cognitive development and educational achievement. However, there is limited experimental evidence of the benefits of alternative school-based malaria interventions or how the impacts of interventions vary according to intensity of malaria transmission. We investigated the effect of intermittent screening and treatment (IST) for malaria on the health and education of school children in an area of low to moderate malaria transmission.


RESULTS
A cluster randomised trial was implemented with 5,233 children in 101 government primary schools on the south coast of Kenya in 2010-2012. The intervention was delivered to children randomly selected from classes 1 and 5 who were followed up for 24 months. Once a school term, children were screened by public health workers using malaria rapid diagnostic tests (RDTs), and children (with or without malaria symptoms) found to be RDT-positive were treated with a six dose regimen of artemether-lumefantrine (AL). Given the nature of the intervention, the trial was not blinded. The primary outcomes were anaemia and sustained attention. Secondary outcomes were malaria parasitaemia and educational achievement. Data were analysed on an intention-to-treat basis. During the intervention period, an average of 88.3% children in intervention schools were screened at each round, of whom 17.5% were RDT-positive. 80.3% of children in the control and 80.2% in the intervention group were followed-up at 24 months. No impact of the malaria IST intervention was observed for prevalence of anaemia at either 12 or 24 months (adjusted risk ratio [Adj.RR]: 1.03, 95% CI 0.93-1.13, p = 0.621 and Adj.RR: 1.00, 95% CI 0.90-1.11, p = 0.953) respectively, or on prevalence of P. falciparum infection or scores of classroom attention. No effect of IST was observed on educational achievement in the older class, but an apparent negative effect was seen on spelling scores in the younger class at 9 and 24 months and on arithmetic scores at 24 months.


CONCLUSIONS
In this setting in Kenya, IST as implemented in this study is not effective in improving the health or education of school children. Possible reasons for the absence of an impact are the marked geographical heterogeneity in transmission, the rapid rate of reinfection following AL treatment, the variable reliability of RDTs, and the relative contribution of malaria to the aetiology of anaemia in this setting.


BACKGROUND
www.ClinicalTrials.gov NCT00878007.
Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom.
Katherine E
KE
Halliday
Health Systems and Social Science Research Group, Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya.
George
G
Okello
Department of Biostatistics and Bioinformatics and Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.
Elizabeth L
EL
Turner
Division of Malaria Control, Ministry of Public Health & Sanitation, Nairobi, Kenya.
Kiambo
K
Njagi
Health and Literacy Intervention Project, Ukunda, Kenya.
Carlos
C
Mcharo
Health and Literacy Intervention Project, Ukunda, Kenya.
Juddy
J
Kengo
Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.
Elizabeth
E
Allen
Department of Teacher Education, College of Charleston, South Carolina, United States of America.
Margaret M
MM
Dubeck
Graduate School of Education, Harvard University, Cambridge, Massachusetts, United States of America.
Matthew C H
MC
Jukes
Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom ; Malaria Public Health Department, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya.
Simon J
SJ
Brooker
D000293:Adolescent; D041923:Adolescent Development; D000740:Anemia / Q000175:diagnosis* / Q000453:epidemiology / Q000469:parasitology / Q000517:prevention & control*; D000962:Antimalarials / Q000627:therapeutic use; D002648:Child; D002657:Child Development; D002675:Child, Preschool; D016000:Cluster Analysis; D005260:Female; D006801:Humans; D007630:Kenya / Q000453:epidemiology; D016778:Malaria, Falciparum / Q000175:diagnosis* / Q000453:epidemiology / Q000469:parasitology / Q000517:prevention & control*; D008297:Male; D008403:Mass Screening; D018512:Parasitemia / Q000175:diagnosis / Q000453:epidemiology / Q000469:parasitology / Q000517:prevention & control; D010963:Plasmodium falciparum / Q000187:drug effects / Q000302:isolation & purification*; D015995:Prevalence; D013334:Students; D055815:Young Adult
D000962:Antimalarials