SMC+ ? Prudence Hamade and Sylvia Meek ACCESS-SMC Partners’ Meeting, January 2016, Kampala

Increasing the value of SMC  SMC is highly effective for reducing morbidity from malaria in children under five years  It is also highly cost-effective  What more could be done to make it an even more attractive investment for governments and their partners?  What strategies could make it more sustainable?  What are the options for integrating preventive interventions, which may:  Reduce the cost of delivering SMC  Increase the effectiveness of SMC  Reduce the cost / increase effectiveness of the other interventions

Other important causes of morbidity and mortality in <5yrs children in the Sahel  Pneumonia  Diarrhoea  Malnutrition (includes acute and chronic malnutrition and micronutrient deficiencies especially anaemia and zinc deficiency )

Interventions to consider for integration with SMC for children under five years Other malaria interventions:  SMC + seasonal malaria vaccine booster  LLIN top-ups – enhancing continuous distribution Interventions for other health problems  Nutrition (peak malaria season and hunger season overlap in Sahel)  EPI Interventions for malaria and others  Integrated Community Case Management iCCM for pneumonia, diarrhoea and malaria  Role of RDTs – access to diagnosis and treatment of common diseases could significantly reduce the referral challenges for sick children identified during SMC

Pneumonia Preventive activities  Vaccination PCV7/13, Pertussis (EPI) and HIB. Needs at least three doses, needs cold chain and someone trained to give injections (regulatory approval to train CHWS to give injections )  Health education on infection control, handwashing and smoke avoidance  Zinc distribution  Including an antibiotic: Azithromycin used in trachoma prevention produced big reduction (50%) in all cause mortality in children and large reductions in morbidity from pneumonia and diarrhoea Curative activities  CHWs trained in ICCM for early case management

Diarrhoea Preventive activities  Vaccination rotavirus  Health education related to hygiene and handwashing Treatment  Use of ORS  ICCM for early case detection and treatment

Malnutrition – intervention options to consider Prevention  Distribute food supplements to all children under five ( LNS or biscuits )  Join with WFP to distribute family rations to all families  Distribute sprinkles to each child to put on morning porridge to correct micro-nutrient deficiencies  Distribute iron/folate supplements to children and pregnant women Treatment  Screen all children under five and refer to reinforced Nutrition programmes for management (Could argue this would improve malaria outcomes in a better nourished child )

Potential for integration of SMC and nutrition interventions Integrate nutrition screening and referral of identified cases of acute malnutrition as part of the SMC outreach o Important to ensure that the points of referral are able to provide an adequate response At present we see this approach as more sustainable and with less risk of undermining SMC coverage than direct distribution of food supplements during SMC o Risks related to different age ranges, reduced uptake of SMC if food supplies are not guaranteed, multiple attendances with food as motivator o Logistic challenges

Using the SMC platform to reach other target groups As SMC brings health workers in contact with remote communities, are there opportunities from this contact beyond protection of children alone? – especially at a challenging time of year 1.Protection of pregnant women, who bring the children they already have for SMC ◦IPTp ◦Health education to improve ANC attendance ◦Tetanus vaccination, deworming (once only in pregnancy) 3 days mebendazole ◦Iron folate supplements, zinc and iodine 2.Neglected Tropical Diseases Mass Drug Administration (addresses whole community) ◦Trachoma, Lymphatic Filariasis, Onchocerciasis, Schistosomiasis, Soil Transmitted Helminths ◦Azithromycin, ivermectin, praziquantel, albendazole

Other possible interventions to integrate with SMC  Community disease surveillance  M-health support  Targeted health education while in the home

Questions  Would any given intervention increase/decrease cost of SMC?  Would any given intervention reduce the effectiveness or coverage of SMC?  Would any given intervention increase the effectiveness and coverage of SMC?  Drug and vaccine interactions Do we know enough?  Could CHW cope with multiple tasks and would the addition of tasks reduce the quality of their SMC delivery?  What are the risks of seriously undermining SMC implementation?

To Discuss  Are any of these options worth considering for the 2016 season? How feasible?  How could we measure the efficiencies from integration?  What are the major risks?  How many SMC-eligible areas have adopted iCCM with same or different CHWs? ◦Is this something to promote?