Anaemia is a persistent public health problem – most prevalent in low- and middle-income countries and in populations living in conditions of poverty and social exclusion. It is estimated that 40% of all children aged 6-59 months are impacted by anaemia,[1] which in severe cases can negatively affect mental, motor, and cognitive development. Children with severe anaemia are at increased risk of mortality and morbidity, and studies show that anaemia can account for up to 29% of childhood hospital admissions, and up to 10% of in-hospital mortality.[2] Children admitted to hospital with severe anaemia have a five times higher risk of death following discharge than children without anaemia, and a high risk of hospital readmission.[3] Progress toward global anaemia targets is slow.
Malaria is considered a main driver of childhood anaemia. Infants and children are amongst the most vulnerable to malaria transmission – of the 608,000 malaria deaths in 2022, 76% occurred in children under-5.[4] Similarly, progress towards the global malaria targets remains mostly slow, with millions continuing to miss out on the services they need to prevent, detect, and treat the disease.
In response to this health burden, WHO has highlighted malaria chemoprevention as a priority intervention to reduce anaemia prevalence,[5] and has included delivery of Post Discharge Malaria Chemoprevention (PDMC) in its malaria prevention guidelines since 2022.[6] PDMC is the administration of a full antimalarial treatment course at regular intervals to children who are discharged from hospital following a severe anaemia admission – regardless of malaria status – in settings with moderate-to-high malaria transmission. The purpose of PDMC is to prevent new malaria infections in vulnerable children after hospital discharge, a period when they are at highest risk of re-admission or death. The WHO recommendation is based on evidence that indicates that three months of PDMC is associated with a 77% reduction in mortality during the intervention period, and a 55% reduction in all-cause hospital readmissions six-months post-discharge.[7] Studies also show that PDMC strategies are less costly and more effective at increasing health-adjusted life expectancy than the standard of care.[8]
Although PDMC represents a potentially transformative intervention for highly vulnerable populations, country uptake has been slow, and key access barriers persist.
Despite the compelling evidence on the impact and cost-effectiveness of PDMC in trial settings, WHO has issued only a conditional recommendation due to numerous outstanding research gaps. Questions include optimal duration of the intervention in different geographical and transmission settings, impact in different risk groups, considerations related to drug selection, strategies for increasing patient adherence at-scale, feasibility of different delivery mechanisms, and cost of different approaches. Evidence that responds to these research gaps could inform planned implementation guidance from WHO.
Unlike other malaria chemoprevention strategies such as Seasonal Malaria Chemoprevention and Perennial Malaria Chemoprevention, there is no one existing platform that can be leveraged for PDMC delivery. Past pilots have utilized various delivery mechanisms (e.g. facility-based or community health workers) – but this has been largely left to the country programs to determine, and is not defined in the WHO recommendation. More guidance could help inform decisions on most effective delivery strategies within a local context.
There are questions on the most effective deployment approach for PDMC in the context of other malaria strategies, such as safety, feasibility and impact in parallel with other malaria chemoprevention interventions, as well as in the context of different case management approaches. Questions also exist on how to best optimize the strategy in the broader child health context – such as in combination with other anaemia-focused childhood interventions, in different age groups, and for hospital admissions beyond those for severe anaemia.
Demand and adoption barriers may also prevent scaled uptake of PDMC. In some cases, there are questions on cost and effectiveness in resource-constrained conditions given competing priorities. In addition to the general lack of awareness of PDMC, there is a need to ensure health system readiness – such as appropriate healthcare provider training, better resourcing for and linkages with community health workers, and supply chain requirements and drug availability. There are also barriers at the patient level, such as low adherence to dosing and caregiver hesitancy.
[2] Post-discharge morbidity and mortality in children admitted with severe anaemia and other health conditions in malaria-endemic settings in Africa: a systematic review and meta-analysis – PMC (nih.gov)
[3] Phiri KS, Calis JCJ, Faragher B, Nkhoma E, Ngoma K, Mangochi B, et al. Long term outcome of severe anaemia in Malawian children. PLoS One. 2008;3:e2903.
[4] World malaria report 2023. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO
[5] Accelerating anaemia reduction: a comprehensive framework for action. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO
[6] WHO guidelines for malaria, 16 October 2023. Geneva: World Health Organization; 2023 (WHO/UCN/GMP/ 2023.01 Rev.1). License: CC BY-NC-SA 3.0 IGO
[7] Phiri KS, Khairallah C, Kwambai TK, Bojang K, Dhabangi A, Opoka R, et al. Post-discharge malaria chemoprevention in children admitted with severe anaemia in malaria-endemic settings in Africa: a systematic review and individual patient data meta-analysis of randomised controlled trials. Lancet Global Health. 2023
[8] Economic evaluation of postdischarge malaria chemoprevention in preschool children treated for severe anaemia in Malawi, Kenya, and Uganda: A cost-effectiveness analysis – eClinicalMedicine (thelancet.com)
