Implementation of the intermittent preventive treatment of malaria in school-aged children (IPTsc) in moderate and high endemic areas in Tanzania: a policy brief

Summary

In high-transmission settings, up to 70% of school-aged children (SAC; 5–15 years) harbour malaria parasites, mostly asymptomatically. This contributes significantly to school absenteeism (13–50%) and anaemia (61%), impairing cognitive development and academic performance. Despite this burden, SAC are often excluded from malaria-targeted interventions and act as a key reservoir for transmission. Intermittent Preventive Treatment for school-aged children (IPTsc), recommended by the World Health Organization (WHO), involves administering a full antimalarial treatment course at regular intervals to prevent infection. This policy brief follows a successful clinical trial and large-scale implementation research in Tanzania that demonstrated IPTsc's operational feasibility and effectiveness. Administering Dihydroartemisinin–Piperaquine (DP) through school-based delivery proved safe, cost-effective, acceptable to communities, and led to significant reductions in malaria prevalence. These findings support IPTsc as a complementary malaria control strategy in endemic areas with moderate to high transmission. Countries with similar epidemiological profiles are encouraged to adopt IPTsc as part of their national malaria control strategies.

Funding

The Global Fund, via the Ministry of Health, Tanzania (implementation research pilot of IPTsc), and Flemish Interuniversity Council (VLIR-UOS), Belgium, TEAM initiative, grant TZ2017TEA451A102 (clinical trial).

Introduction

In 2024, the WHO African region, which mostly comprises the sub-Saharan Africa (SSA), was home to 94% of malaria cases and 95% of malaria deaths globally. Tanzania, along with Nigeria, the Democratic Republic of Congo, and Niger, are among the four African countries accounting for over half of all malaria deaths worldwide.¹ However, Tanzania has made significant progress despite these reported figures. According to the National Malaria Control Programme (NMCP), malaria prevalence in Tanzania has declined substantially from 18.1% in 2008 (meso-endemic level) to 8.1% in 2022 (hypo-endemic level). This prevalence varied by region, ranging from less than 1% in the highlands of Arusha to 15% in the Southern Zone and as high as 24% along the Lake and Western zones.² The observed heterogeneity has necessitated sub-national stratification to optimise the cost-effective implementation of interventions adapted to local epidemiology. The stratification revealed distinct variations in malaria decline across and within regions and councils^2,3 Yet, the updated 2024 council-level stratification shows that 94 councils (51%) are categorized as moderate (n = 70) or high endemic (n = 24), indicating that existing malaria control tools remain suboptimal.^2,4,5 Detailed analyses at the council level indicate that in moderate to high endemic councils, school aged children (SAC) (aged 5–15 years) are the most affected age group.⁶

In these high-transmission settings, up to 70% of SAC harbour malaria parasites, mostly asymptomatic, accounting for 13–50% of all school absenteeism and 61% of anaemia,^4,5 which adversely affects cognitive development and academic performance. Currently, there are limited or no malaria-targeted interventions for SAC, who therefore contribute significantly as a reservoir for onward malaria transmission.^1,7 Main interventions, including insecticide-treated nets (ITNs), indoor residual spraying (IRS), larval source management (LSM, prompt diagnostic testing and effective antimalarial treatment, and health education have proven less effective among SAC.⁸ Targeted malaria control primarily focuses on pregnant women receiving multiple doses of Sulfadoxine–Pyrimethamine (SP) as Intermittent Preventive Treatment during pregnancy (IPTp-SP) alongside a limited school-based bed net distribution program (SNP) where SAC help increase household net coverage. Recent data also show persistent geographic and demographic disparities in malaria prevalence among schoolchildren, emphasising the urgent need to scale-up tailored interventions such as intermittent preventive treatment in schoolchildren (IPTsc) to address this critical reservoir.

IPTsc aims to treat and prevent malaria infections in SAC by administering a full treatment course of an antimalarial medicine at regular intervals to children old enough to attend school.⁹ This strategy clears both asymptomatic and symptomatic malaria infections and prevents malarial illness and its outcomes, such as anaemia, absenteeism, and cognitive impairment, in SAC who are at high risk of malaria.⁵ Evidence on the effectiveness and feasibility of IPTsc strategy is robust across many SSA countries including Tanzania.10, 11, 12 Currently, the WHO has recommends the rollout of IPTsc in moderate to high endemic areas.⁹ The addition of IPTsc to school health policy would be highly beneficial in improving the health and academic achievements of SAC.

Why IPTsc is needed?

School-aged children account for about 27% of the population in malaria-endemic areas and bear over 40% of the malaria-related burden in moderate to high transmission settings. Up to 70% of SAC harbour mostly asymptomatic malaria infections, which contribute to anaemia, poor cognitive development, and school absenteeism. Despite their vulnerability and acting as a key reservoir for transmission, SAC are not specifically targeted by current malaria control strategies. While pregnant women and infants benefit from IPTp and IPTi (now known as perennial malaria chemoprevention-PMC⁹), SAC remain largely unreached. Bed net use among SAC is also low (<40%)⁸ despite net availability. With the current malaria control interventions, these children have and will continue to be increasingly vulnerable compared to children under five years of age and pregnant women.^5,6 Country data show a stall in malaria control, with minimal change in national prevalence over the past seven years, highlighting the need for complementary malaria control strategies. Further evidence from national school malaria parasitological surveys (2015–2024), has consistently revealed high asymptomatic parasite carriage among SAC, underscoring the urgent need to focus on this group. In addition, access to healthcare is limited in most of rural areas of countries like Tanzania, which are also highly endemic to malaria. IPTsc offers an effective strategy to reach asymptomatic carriers in these communities, improving health outcomes and reducing transmission. Evidence shows that IPTsc provides additional community-level effect by decreasing local transmission.12, 13, 14 By treating otherwise untreated carriers and improving access to care, IPTsc fills a critical gap in malaria control efforts and supports health equity. Furthermore, IPTsc complements existing interventions by targeting the stage when parasites have bypassed physical barriers like bed nets and persist in the host, supported by immunomodulation in populations transitioning to immunity.⁵ Its implementation is essential to strengthen malaria interventions for this neglected age group. With evidence from pilot studies conducted in collaboration with the NMCP clearly demonstrating the impact of IPTsc,^10,11 alongside global calls to action⁷ and WHO recommendations,⁹ it is indeed the right time for national adoption.

Current evidence supporting IPTsc

IPTsc is recommended in areas with moderate to high malaria transmission.⁹ Globally, a systematic review¹² on IPTsc intervention has also shown the strategy is effective with average reduction of malaria parasitaemia by 72% (95% CI 57%–83%). In Tanzania, implementation research conducted by the National Institute for Medical Research (NIMR), in collaboration with the National Malaria Control Programme (NMCP), the President's Office Regional Administration and Local Government (PO-RALG), and the Ministry of Education (MoE), evaluated the feasibility and acceptability of delivering IPTsc using Dihydroartemisinin–Piperaquine (DP). This study, carried out across 127 primary schools in three highly endemic councils in Tanga Region (Handeni DC, Kilindi DC, and Handeni TC), involved over 73,000 schoolchildren.¹¹ Key findings included: Coverage defined as the proportion of SAC who completed three day course of therapeutic-dose DP out of the total number of children enrolled in a given school or ward within the IPTsc arm, exceeding 80% overall, with over 165,748 doses of DP successfully administered by schoolteachers, demonstrating high acceptability and feasibility of delivery through school teachers. The protective effectiveness of IPTsc for clinical malaria was 41% (95% CI: 31%–49%; p < 0.001) overall and 54% (95% CI: 44.2–62.6; p < 0.001) in high endemic strata (≥10% prevalence at baseline). Parasite prevalence decreased by 81% (95% CI: 56.3–100; p < 001) ranging from 58% (95% CI: 10.9–100; p = 0.18) in low strata to 83% (95% CI: 62.7–100; p < 0.001) in high endemic strata.¹⁰ IPTsc was also found to be cost-saving compared to treatment-based approaches.^11,15,16

Prior to the implementation study, a clinical trial in Muheza District, Tanga, tested IPTsc using both Artesunate–Amodiaquine (ASAQ) and DP.¹⁵ The results showed a protective efficacy against parasitaemia of 64% (95% CI: 39–79, p < 0.001) for DP, and 52% (95% CI: 23–70, p < 0.002) for ASAQ.¹⁵

Operational costs and cost effectiveness

Operationalisation costs for administering three rounds of IPTsc in a year were estimated at approximately 1.5USD per child (excluding cost of drugs). Assuming a patient is treated at a public health facility, this represents cost savings compared to over 15USD for treating a single episode of non-severe malaria, approximately 29USD for anaemia treatment, and between 30USD and 72USD, for treatment of a severe malaria case. In the cost effectiveness analysis, the main drivers for the implementation cost were drug costs and the initial start-up expenses, which included intensive training and community sensitisations.¹⁶ However, these costs are expected to decrease as IPTsc becomes a routine and well-established intervention. Drug costs can also decline if more countries adopt the intervention, enabling pooled procurement mechanisms similar to those used for seasonal malaria chemoprevention (SMC). This collective purchasing power can reduce prices and improve accessibility for all participating countries.

Drug choices

The drug choices can be routinely reviewed following experience built on the already implemented drug choices i.e. DP,¹¹ and any new to come from ongoing drug developments. The government and its stakeholders (international and local partners) can look for other possibilities to fund and or contribute to the implementation costs, especially at the beginning/introductory phase of the intervention.

Basing on a systematic review¹² and on the experience in Tanzania,¹¹ the suggested drug for IPTsc use is DP, due to its proven effectiveness and long half-life compared to other combinations.^12,15 DP is listed as an alternative first-line in the malaria diagnostic, treatment and preventive therapies guideline in Tanzania. The ideal drug characteristics for this purpose include combination therapies with well-matched half-lives, drugs with competing resistance mechanisms from first-line treatment drugs, or a rotation of drugs.

It is expected that IPTsc delivery through directly observed therapy (DOT) by school teachers will ensure high adherence, as the full course of DP-a three day regimen with one supervised dose per day, - is relatively infrequent, being administered approximately three times per year, depending on seasonality. This intermittent use is a precautionary approach that may maintain a balance in parasite and drug pressure, minimising the chance for parasites to develop resistance to the chemoprevention drug, especially since children would still receive first-line treatment if infected. Our clinical trial assessments of IPTsc with DP or ASAQ did not indicate any impact on resistance development in the study population.¹⁷ Thus, routine and comprehensive surveillance of antimalarial drug resistance will be essential to preserve drug efficacy and guide timely policy adjustments.

IPTsc implementation consideration

Given the effective school enrolment reaching almost 100% in Tanzania, schools remain the most appropriate platform for reaching SAC. However, for equity reasons, eligible children who are not enrolled at schools and some who may not even be at home, can be reached through the social welfare department, which can help access children residing in orphanage homes and street children. This will require collaboration with the community health workers (CHWs), who can assist teachers in locating children who missed a dose or were absent on dosing days, including street children and those in orphanages.

For safety monitoring, the Tanzania Medicines and Medical Devices Authority (TMDA) should be involved in collection and evaluation of adverse drug reactions (ADRs) using the existing ADR reporting system. TMDA should be engaged from the commencement of IPTsc for team training and supervision. Other programmes, such as school MDA for helminthic control, have been widely practiced in African schools, and are mostly delivered by school teachers. These teachers can be trained to deliver IPTsc, as was done in Tanga Region.¹¹ Incentive payments should be made equally to all teachers involved, covering all dosing (dispensing) days (e.g., three days for the full course of DP), with provision for up to a week to reach students who miss a scheduled dose.

The IPTsc delivery schedule should mimic malaria seasonality in the targeted communities, three times a year in areas with bimodal rainfall seasons, and twice a year in areas with unimodal rainfall seasons. Frequency can be added depending feasibility and appropriateness. Continuous monitoring of drug safety, malaria prevalence trends, and markers of drug resistance should accompany the implementation of the IPTsc strategy.

When implementing IPTsc, the Ministry of Health (MoH) should collaborate with PO-RALG and MoE. The MoH would provide policy direction and supervise the process in collaboration with TMDA (pharmacovigilance), while the PO-RALG would be responsible for implementation, working with MoE on curriculum and scheduling matters. Integration with other ongoing school health programmes such as routine school mass drug administration (MDA) for deworming, and nutritional supplementation, can be facilitated if delivered by the same implementer.

Since IPTsc can result in almost 50% reduction in malaria cases in the communities, it is recommended that, funding for procurement and distribution of drugs be sourced from the central government budget for essential medicines (without limiting partners) and integrated into the supply chain management system, channelled to specified moderate to high endemic councils.

Regarding community engagement, some members may not attend briefing meetings. Therefore, parents committee meetings should be conducted inviting village leaders and key opinion leaders to help disseminate information at every community gathering. Additionally, political and administrative leaders should be engaged from the very beginning of IPTsc operations for sensitisation and administrative support. They will help address critical needs for successful IPTsc implementation, such as securing school food donations from parents or guardians, providing drinking water, and other necessities.

Recommended policy actions

This policy brief is recommending the following actions:

• •Add IPTsc as a complementary malaria control strategy targeting SAC in areas of moderate to high transmission.
• •Recognize IPTsc as effective, cost-saving, safe, acceptable, and feasible for malaria prevention among SAC
• •Implement IPTsc operationally through schoolteachers as a practical delivery channel.
• •Include explicit strategies to reach out-of-school children through community-based delivery platforms, leveraging community health workers, local leaders, and informal gathering points to ensure equitable access.
• •
  Integrate IPTsc delivery with other school health programs to enhance efficiency and impact, including:

  • o
    Nutritional supplement initiatives addressing broader child health and development needs.
  • o
    Menstrual hygiene management programs to support adolescent girls' health, school attendance, and wellbeing.
  • o
    Neglected tropical disease (NTD) routine MDA.
  • o
    Eye and ear screening programs.
  • o
    Adolescent vaccination campaigns.
• •Leverage integrated delivery to reduce implementation costs and increase cost-effectiveness.
• •Strengthen monitoring, evaluation, and community engagement to optimise intervention uptake and impact.

Table 1 provides a further description of the prioritization of policy actions:

Table 1.

Prioritization and timeframe of IPTsc policy actions.

Priority	Timeframe	Policy actions
Essential	Short-term	•Implement IPTsc delivery through existing school systems targeting enrolled children to achieve rapid impact. •Integrate IPTsc with ongoing school health initiatives such as nutritional supplementation, deworming, and menstrual hygiene programs to leverage existing structures and minimise incremental costs. •Develop and pilot a complimentary community-based delivery mechanisms for reaching out-of-school children to promote equity. •Strengthen monitoring, evaluation, and community engagement activities to ensure data-driven program adjustments.
	Long-term	•Scale up complimentary community-based IPTsc delivery platforms to achieve comprehensive coverage, ensuring equity across in-school and out-of-school children. •Institutionalise integration of IPTsc with a broader package of school and adolescent health services (e.g., immunisation, deworming, eye/ear screening). •Build capacity within health and education sectors for sustained implementation and coordination.
Optional	Short-term	•Introduce additional school-based health interventions aligned with IPTsc, such as mental health or physical fitness programs, depending on local priorities. •Conduct operational research to refine integrated delivery models and cost-effectiveness analyses.
	Long-term	•Expand IPTsc integration into wider community health platforms targeting other vulnerable populations beyond SAC. •Advocate for policy adaptations supporting multisectoral collaboration beyond health and education sectors.

Contributors

GM writing—original draft. VB,DTR, MC, MDS, BPM, AL, FC,SA, AD, AM, SL, FM, HB, JPVg, and JPAL provided technical comments to improve the manuscript, GM, VB,DTR, FC, MC, MDS, and BPM accessed and verified the underlying data. All authors reviewed & edited the manuscript. All authors read and approved the final manuscript.

Declaration of interests

All authors declare no conflict of interest.