Interventions and Practical Approaches to Reduce the Burden of Malaria on School-Aged Children

Abstract

Robust evidence indicates school-aged children are particularly vulnerable to malaria and need special measures to protect them. Calls are widespread for better diagnostic approaches and innovative programs that benefit children, because current levels of malaria-related morbidity and mortality are so high. Problematically, most national malaria control programs do not specifically target school-aged children; although the literature describes options for child-focused strategies, there is no consensus on the optimal intervention; and where a strategy is advocated, it is almost always one identified through systematic review. While understandably the scientific “gold standard,” such reviews exclude many potentially useful and valid approaches, because reports describing them do not meet the inclusion criteria of being randomized controlled trials. Such trials are inevitably limited in number due to cost and complexity, and many excluded reports describe locally developed innovation based on World Health Organization diagnostic and therapeutic guidelines with the potential to benefit children. This chapter frames how practical interventions such as these can be put in place by school communities, and in parallel, how approaches advocated by the WHO and Lancet Commission to promote health literacy and access to essential health services can create ways to reduce the burden of malaria on school-aged children.

1. Introduction

Malaria exemplifies how health inequity negatively impacts children’s lives and their ability to benefit from education. While global investment in recent years to fight malaria has led to millions of malaria deaths being averted, and this progress has certainly benefited young children [1], bold decisions are still needed to control the disease [2], and especially to meet the longstanding calls for specific interventions to reduce the burden of disease in school-age children [3, 4, 5, 6]. Overall, policies to address the high prevalence of malaria infection in this age group are lacking, and school-age children continue to attract little attention as a group in need of special measures to protect them [4, 7].

Although leading authors have recommended that malaria should be included as a key component of school health programs, the clear ideas and defined approaches required to effectively improve malaria control among school-age children remain unforthcoming [5]. Even a recent Lancet commentary largely echoed prior (unheeded) calls for interventions specifically targeting this age group by reporting more trials which had failed to define a universally applicable intervention, and offering the potential cost of programs and lack of policy support as continuing barriers to progress [3]. However, effective school-based approaches do exist that can positively impact morbidity. Importantly they include elements that are simple and broadly applicable, and will improve health and wellbeing and in doing so increase the capacity of children to learn [1, 7, 8]. Many also have the ability to benefit the broader community beyond the school in the context of malaria.

In a prior review (2020), Macnab described the global impact of malaria on school children, and outlined the principal school-based strategies tried as a way to reduce the adverse effects of infection on the health of children, their ability to attend school and on their long-term academic potential [7]. Such strategies continue to include seasonal chemoprophylaxis, intermittent protective treatment and antimalarial therapy linked to mass drug administration for neglected tropical diseases. This review also emphasized the global need for children to be educated about malaria at school so that they understand how it is caused, how it can be prevented, and the importance of early diagnosis and prompt treatment. This is a fundamental need in addition to being a necessary component that must be provided in parallel with any preventive or therapeutic strategy if it is to be fully effective.

Expanded and innovative strategies are needed to regain momentum over malaria control, including new and better diagnostic approaches to address malaria in children because of the current levels of morbidity and mortality [9]. The WHO estimates widespread deployment of insecticide-treated bed nets, vector control programs, rapid diagnostic testing, new treatments and prophylactic strategies have averted 7·6 million deaths since 2000. But recently stated global targets to reduce case incidence and mortality rates by at least 90% by 2030 are now at risk, and emphasize again that a disproportionate disease burden falls on children [10].

Schools are important in the fight against malaria on several levels. Simple and inexpensive additions to the curriculum can increase children’s knowledge and improve their health, and where teachers are engaged and taught the necessary skills schools can provide their pupils with timely diagnosis and treatment. School-based programs that educate children broadly on the causation and prevention of malaria and what care is required, reduce child morbidity. But health promotion in schools is also known to benefit the broader community, as where children receive appropriate guidance they can act as agents for change both within and beyond the school and spread the knowledge they acquire to their families and beyond [3, 11, 12]. This willingness and ability to share learned concepts and practices also indicates that children educated in this way acquire higher levels of health literacy [13].

As early as 2005 Afenyadu et al. proposed improving access to treatment for children with malaria by engaging teachers in care [14]. But the first endorsement of this approach came from the International Pediatric Association (IPA) following a 2-year trial in rural Uganda of a community participatory intervention model where teachers were taught to screen all sick children using rapid point-of-care diagnostic testing (RDT) and treat those testing positive promptly [15]. The IPA identified this model as applicable worldwide in areas where malaria is endemic, because it significantly reduced morbidity from malaria in school-aged children, and the diagnostic and treatment components were based on the approaches recommended by the World Health organization (WHO) [16].

School-based health care delivery has the potential to benefit more than 1 billion children worldwide [17]. The WHO ‘Health Promoting School’ (HPS) model is one potential way to initiate school health programs [18]. The model is based on simple concepts and is flexible. The aim is to generate life-long learning through additions to the curriculum that enable children to acquire both relevant health ‘knowledge’ and practical ‘skills’ with the overarching objective of positively influencing social determinants of health [19]. Many schools initiate basic health promotion programs independently, others require varying levels of teacher training, resource provision and ongoing support [20]. The WHO now endorses school programs as a way to address specific health challenges worldwide.

Effective engagement of schools in health promotion and care delivery is most readily achieved where policies to do so are in place and practical support is provided [17, 21]. Currently there are calls to improve the overall health of children as a way to promote their learning and enable them to achieve their full potential [7]. This has come about because of the growing recognition that good health at school improves educational outcomes, which in turn builds human capital: “the sum of a population’s health, skills knowledge and experience that is central to a country’s economic growth” [3]. Importantly, addressing malaria in school-age children is now an element in this goal to build human capital.

There is growing evidence of ‘what works and why’ in the context of health promotion in school settings. Gaps remain in our understanding of the optimal intervention and programing needed in the context of malaria, and ongoing efforts to conduct research to identify effective programs is essential, and ideally followed by the conduct of randomized controlled trials [7]. Cohee has described school health as “the key to unlocking the potential of the world’s children,” and that “schools offer a uniquely sustainable platform for health delivery in low resource settings, while at the same time influencing community change through their education role” [3].

Importantly, the literature describes several approaches employed successfully to address malaria in school-aged children, and while many have significant limitations in terms of being broadly applicable, these too may still be the right approach in defined circumstances. New strategies are also being proposed; many are innovative modifications of prior approaches, some are specific refinements to address challenges like emerging drug resistance, and of course the new recommendation for the first malaria vaccine to be rolled out on a large scale now has to be factored into national programs to fight malaria [22, 23]. The aim must be to find broadly applicable, socially acceptable, cost effective, interventions to reduce mortality and morbidity in school children. Such programs in turn will ensure that malaria does not negatively impact the ability of participating children to achieve their academic potential by minimizing the risk of short- and long-term cognitive impairment, and that the broader community becomes better informed about the challenge of malaria and ways to address it, through the ‘trickle down’ effect of pupils sharing knowledge and skills learned with their families [24]. Where programs successfully reduce the incidence of infection in children, the broader community also benefits through the overall local reduction in the reservoir of malaria transmission [8].

2. Therapeutic and interventional approaches

Despite being preventable, detectable and curable, malaria remains one of the main causes of mortality and significant morbidity due to infectious disease [9]. Trialed approaches to reduce morbidity in school-age children include prophylaxis, intermittent protective treatment (IPT), mass drug administration (MDA) and combination of rapid diagnosis and treatment. Preventive treatment to protect school-aged children significantly decreases P. falciparum prevalence, malaria-related anemia, and also the risk of subsequent clinical infection across transmission settings. Hence the logic of policies to make therapeutic intervention strategies broadly available to protect this age group; this approach could also provide benefit by decreasing transmission, and thereby advance the goal of malaria elimination [8].

2.1 Prophylaxis

In areas where malaria is endemic prophylaxis is generally not recommended for children due to poor adherence to prescribed regimens, limited compliance due to cost, side effects over time, and the risk of emergence and drug resistance [25].

2.2 Intermittent protective treatment (IPT)

IPT involves periodic drug administration at defined intervals of a full therapeutic dose of a single drug, or drugs in combination, to those at high risk regardless of their infection status. Trials have involved two main approaches, seasonal malaria chemoprevention and intermittent parasite clearance. An example of IPT delivery through schools is described by Fernando et al. from Sri Lanka [26]. In a randomized double-blind placebo-controlled trial school children aged 6–12 years were given weekly chloroquine or placebo for 9 months. The incidence of malaria fell in the treated group, and a significant difference in absence from school and a marked improvement in school performance was found between them and those pupils receiving a placebo. Evidence from several African countries has shown that seasonal malaria chemoprevention measures can be highly effective, with most severe malaria eradicated, and a reduction in P. falciparum prevalence, the incidence of clinical uncomplicated malaria, and malaria-related anemia [27].

Trials data generally indicate that IPT regimens benefit school-age children by reducing rates of infection, improving health, decreasing absence from school, enhancing academic achievement, and protecting cognitive ability [28, 29]. There is consensus that IPT is a safe and simple strategy that offers remarkable protection in school-aged children in high-malarial-transmission settings, and preferable to prophylaxis. Effective strategies are seen as a potentially valuable addition to school health programs [30]. Evidence from several African countries has also shown that SMC using SP-AQ is highly effective, eradicating most severe malaria, and leading to strong reduction in P. falciparum prevalence, the incidence of clinical uncomplicated malaria, and malaria anemia; two systematic reviews and meta-analyses on efficacy and safety summarize the pros and cons of specific drug regimens [31, 32].

2.3 Mass drug administration (MDA)

MDA is a WHO endorsed strategy to control 7 of a group of 13 major, disabling and ‘neglected’ tropical diseases (NTDs) (ascariasis, trachoma, trichuriasis, hookworm, schistosomiasis, lymphatic filariasis, and onchocerciasis) [33]. MDA has been combined with the delivery of other care entities in school-based settings. In Ghana, combining IPT for malaria with MDA to control intestinal soil-transmitted helminths benefited measures of anemia, sustained attention and recall [34]. And, in Malawi the approach was found to be well-tolerated, safe for teachers to administer, beneficial, and well-received by parents; all findings of obvious practical importance [35]. Adding malaria IPT to already established NTD control programs also increases the cost-effectiveness of both interventions, particularly where teachers are trained to be part of program delivery.

2.4 Combined rapid diagnosis and treatment

Diagnosis and treatment in combination employs the use of rapid diagnostic test kits (RDT) and treatment of those testing positive with artemisinin combination therapy (ACT). This has primarily been a clinic-based strategy, and is an approach endorsed by the WHO as the first-line of treatment in areas where malaria is endemic [7, 16]. In order to increase access to this standard of care, several countries have reported expanding the role of pharmacists by training them how to do RDTs [36]. Reports have also followed of successful ‘downstream’ expansion through school-based programs where appropriately trained volunteer teachers administer RDT to all children who are sick at school, and administer ACT promptly to those testing positive [15, 37].

RDTs are an inexpensive diagnostic approach, reliably estimate infection in low and high prevalence categories, and have the major advantage that they make immediate treatment feasible [38]. The sensitivity and specificity of RDTs are good enough for them to replace conventional testing for malaria. The positive impact of RDTs on malaria management has been widely demonstrated, and effective roll-out and sustained use on a national scale has been achieved through well planned implementation [39]. Basic training in their use also enables teachers and other providers without a healthcare background to use them reliably [40]. When employed for school-based diagnosis it has been shown that practical aids in the form of step-by-step usage guides can improve performance. Like any technology, refinement will likely be needed over time to keep to keep RDTs a cutting edge diagnostic entity.

ACTs are a unique class of antimalarial drugs. Developed from plant-based peroxides they kill young intraerythrocytic malaria parasites before they can develop into more harmful mature forms; this achieves a robust parasitological response which results in rapid clinical improvement [41]. More than 20 years ago the WHO recommended ACT as the first-line treatment for P. falciparum malaria in all countries with endemic disease [42]. The benefits of genuine ACTs are considerable, and include their fast action, high efficiency, minimal adverse effects, low cost, and the potential to lower the rate at which resistance emerges and spreads [43]. However, care must be taken over the choice of the preparation used, because sub-standard and counterfeit products with little or no efficacy pose severe threats to human health, and there is increasing concern over the emergence of resistance to this class of drugs [44].

Where the efficacy of ACTs is high, more could be achieved through increasing their availability. But in spite of the large body of evidence for both the efficacy and safety of ACTs this drug class is not being used as widely or as comprehensively as it should be [45]. An additional concern is that even when they are available, the way ACTs are used does not always conform to international guidelines [46]. There are of course many practical challenges to making ACTs more available globally, including cost, and finding effective ways to distribute and administer ACTs to a greater number of children, who are arguably the population who needs them most [47]. Continuing to search for innovative ways to increase ACT availability and promote their appropriate use are two essential components for improving malaria control in school-aged children. Approaches to date with promise include: a community case management approach, where a variety of trained providers are used to deliver ACTs [48], distribution through agents in drug stores, pharmacies and private medical clinics [49], and of course via teachers in school health programs [15, 37].

Importantly, the use of RDT and ACT is endorsed by the WHO, and arguably, increasing access to this combined diagnostic and treatment approach is one of the simplest and potentially most cost-effective ways to reduce malaria morbidity among school-aged children. This is especially true in countries that are already using RDT and ACT in government hospitals and clinics, as expansion of bulk purchasing and scale up of distribution offer a more economic proposition than developing new programs which will potentially require other drugs and alternative infrastructure. The use of RDT and ACT in non-traditional outlets is particularly applicable in rural areas where distance limits ready access to hospital and clinic facilities.

2.5 Multiple first line therapies

Use of multiple first-line therapies (MFT) is an emerging strategy where several ACTs are prescribed together rather than a single first-line ACT. Because antimalarial treatment currently depends so heavily on artemisinins, the evolution of resistance to ACTs in some parts of the world seriously threatens the overall effectiveness of antimalarial treatment [50]. The emergence of resistance is compounded by use of these drugs in some of the poorest countries in the world, where the dosage used is often incorrect, ineffective counterfeit products are widespread, poor quality drugs are commonly purchased due to their lower cost, and a complete course of treatment is not taken as some is held back to use with future illness [44].

The WHO has also identified that the dosage recommendations for a number of antimalarials used in children have not always been optimal. This is largely evident where schedules are derived from adult dosing regimens [46]. This too creates increased selection pressure for the emergence and spread of resistance. However, while there is growing concern that resistance to ACTs could spread rapidly, modeling predicts that using MFT rather than a single first-line ACT will reduce the number of treatment failure in the long term, and prolong the effective life of this important class of drugs [51].

3. School-based community teacher-driven intervention models

3.1 History

As early as the 1920’s it was recognized that use of malaria suppressive drugs for special groups might be beneficial. Quinine was tried in Ghana (Gold Coast) in 1925 with little success. In the 1950’s several school-based trials of the synthetic antimalarial pyrimethamine were conducted in sub-Saharan Africa; these showed that malaria could be successfully controlled, and treated children were found to have significantly better general health and average weight gain compared to untreated children [7].

In 1955 Colbourne reported using a combination of amodiaquine and pyrimethamine to suppress malaria in 7-year-old children in a school in Accra, Ghana. In the regimen used, children received amodiaquine at the beginning of each term to clear parasitemia followed by pyrimethamine weekly to provide suppression. A control group received comparable placebo. In treated children a 50% reduction in absenteeism resulted; the first use of this measure as a surrogate for morbidity from malaria [52].

3.2 Teacher administered RDT and ACT

This community participation teacher-driven model was first implemented in 4 low resource communities in Uganda where sick children were usually just sent home for parents to manage, and teachers had identified the burden malaria was taking on the health and academic potential of their pupils [15]. In order to ensure that the resources and will of the community were behind any program implemented, the principles of respectful engagement were followed by engaging in dialog with community leaders, teachers and parents and exploring a range of possible interventions. The plan the community chose as the best, locally achievable approach was for two volunteer teachers in the each of the schools to be trained how to use RDT kits to test for malaria in all the children falling sick at school on a daily basis, and administer ACT promptly to all those testing positive.

In order to evaluate the effect, the schools were taught to formally record their regular daily census of which pupils were present or absent at school, and how to document numeric and descriptive data on the children requiring the planned intervention. The daily census data documenting when and how long any child was absent were then recorded for a full year prior to testing and treatment beginning. During that time a local clinic ran training days to teach all required skills and safety procedures to the teachers [53], orient the schools on data collection, screening and treatment, and set up delivery of the RDT kits and ACT supplies. The same data collection on absenteeism was then continued during the following year; the consecutive 2 year timeline was to ensure no bias from seasonal variations in malarial infection. In addition, the number of children found to be sick each day, tested using RDT, found to be RDT positive for malaria, and who received ACT was documented. A brief clinical history for each child treated also noted the time line for their return to class. A single dose ACT preparation was used to ensure a full course of treatment was completed.

Results: In the pre-intervention (year 1) 953 of 1764 pupils were sent home due to presumed infectious illness. At home, parental management only approached WHO standards for accurate diagnosis and prompt treatment of malaria in 1:4 children, and the mean duration of absence from school was 6.5 school days (SD: 3.17). During school-based teacher-administered RDT/ACT (year 2) 1066 of 1774 pupils were identified as sick, 765 of these had a positive RDT and received ACT, and their duration of absence fell to 0.6 (SD: 0.64) days p < 0.001. Many of the children felt well enough to return to class within hours of being treated; this was presumed due their malaria being diagnosed early in its evolution, and the prompt treatment with ACT being effective.

Overall, absence from school was reduced by 60.8% during this intervention. If the same percentage of children sent home in year one had malaria as were diagnosed using RDTs in year two, this would equate to 1358 cases in 1775 children over the 2 years - a malaria incidence rate of 79% across the 4 schools. The significant decrease in the duration of absence due to malaria from 6.5 school days to <1 day was maintained in the subsequent 3 years when the schools themselves sustained this teacher-driven program. Of interest, these outcome data are directly comparable to Colbourne’s initial estimate that 5–6 school days were saved per child with malaria suppression, in her landmark studies 60 years earlier [52]. Importantly, delivery of care using this model was readily implemented and sustained, teachers participated willingly, pupils reported health benefits, and their parents also saw the intervention as positive [7].

A similar approach was successfully trialed subsequently in primary schools in Malawi and was comparably effective. Absence from school was again decreased and the trained teachers were identified to be trusted providers of malaria care [37]. The authors of both studies concluded that training teachers to “test and treat” was well received, supported national health and education policies and was seen to be a worthwhile intervention by the community. Importantly, teachers were enthusiastic about taking part and sustainability was demonstrated by ongoing data from Uganda; the target schools independently continued RDT/ACT post intervention (until the school closures necessitated by the Covid-19 pandemic) and the significant reduction in malaria morbidity (reduction in absenteeism) was sustained; there is also robust evidence of greater knowledge about many aspects of malaria among the school-children and in the broader community.

RDT and ACT are widely employed, but their use by trained teachers in a school-based initiative to address the health related consequences of malaria on absenteeism had not previously been implemented. Training teachers is an approach that reflects government policy in many countries to promote RDT use by non-medical personnel [36, 49]. The intervention incorporates diagnostic and treatment entities advocated by WHO [16, 38, 42]. The model is now endorsed by the International Pediatric Association as a community-based approach applicable worldwide where morbidity from malaria is high. Integrating ‘test and treat’ strategies for malaria control into larger health, nutrition and education platforms that schools can offer, is a pathway that would also help in achieving the current health-related UN sustainable development goals [54].

4. School-based approaches to reduce morbidity

There are a range of practical measures not directly related to formal additions to the curriculum or the introduction of school-based therapeutic options that can be put in place by school communities to reduce the burden of malaria on their school-aged children. The most applicable ones are those that individual schools develop themselves in response to local needs that their community identifies, or which grow out of collaborative activities to achieve a defined public health or educational goal. In any given community local needs and resources will differ, so individual initiatives need to be tailored accordingly, and, for instance, accommodate differences between urban and rural settings. Ideally each initiative will be broad and multifaceted enough to leverage as many components of the malaria education/prevention/treatment equation as are required to comprehensively meet the needs of the target school community.

Centering malaria programs on children in schools is an example of the type of innovative, content specific intervention called for by the WHO Commission on Social Determinants of Health to support health behaviors, and empower young people to take control of their lives [55]. Such ‘task shifting’ to school-based programs has already increased the delivery of other essential health services for children [23]. Hence, a particularly effective way to develop the measures an individual school or larger community requires, is to use the strategic approaches advocated by the WHO Commission and the Lancet Commission on the future of health in sub-Saharan Africa to improve health literacy and achieve health equity through action [55, 56].

Six of the WHO/Lancet Commission approaches relevant to enabling school communities to reduce the burden of malaria on children are:

• Community empowerment

• People-centered strategies

• Innovative education

• Novel and improved tools

• Training to respond to local needs

• Use of non-traditional avenues and outlets

4.1 Community empowerment

There are multiple health benefits to be gained through community empowerment and this approach is needed to promote health in all sections of society [57, 58]. Campaigns that inform, consult, involve, collaborate and empower for example can be used to engage stakeholders in sub-populations at particular risk from malaria. Parents need to be engaged in particular, as care for sick children obviously generally devolves to them. The central problem parents need help with is that many lack the knowledge and/or resources necessary to provide what their child needs when she/he becomes sick and may have malaria. There is evidence that the current lack of understanding about the approach required to diagnose and treat malaria means that only around 25% of children with early malarial infection receive accurate diagnosis and prompt, effective treatment within 24 hours of the onset of illness, as advocated by WHO [1, 7, 15].

The widespread practice of teachers generally sending home children found to be sick at school compounds this problem, as the end result is that appropriate diagnosis and treatment often do not occur, or at best, the required interventions are delayed [7, 59]. In many communities most febrile illnesses are treated empirically without any diagnostic procedure [44]. Also, dependence on care by traditional healers or trust in prayer often dictates the care a child receives, and there is strong reliance on non-specific medication for fever; preference for such entities contributes to morbidity [60].

Second-order ramifications of malaria morbidity are also compounded in this way. These include loss of schooling due to repeated or prolonged absence, malaise following sub-optimal treatment that prevents full attention and participation in class, and loss of cognitive ability and fine motor skills where a child is left with neurological sequalae. These all negatively impact a child’s ability to learn and ultimately rob many of the ability to achieve their long term academic potential [28, 61, 62].

School communities in endemic areas are generally aware of the immediate impact malaria takes on children of school age, but often do not equate infection with impairment of academic performance over time. Parents can be empowered by learning about this association and, in turn, be guided to learn more about the many ways in which they can protect their children against malaria. For example, through the use of insecticide-treated bed nets, indoor spraying, reduction of breeding sites, and other methods for vector control [63, 64].

Communities should be encouraged to see their schools as platforms for the basic education required to inform children adequately about malaria in endemic areas, and be encouraged to lobby for ‘test and treat’ capacity in schools where the local mindset and/or infrastructure do not make WHO levels of diagnosis and treatment available for children.

4.2 People-centered strategies

Where low public confidence exists in health care services people-centered strategies can improve low public confidence [56]. Constructive solutions are best arrived at through listening and respectful dialog. What needs to be identified is where the real issues lie, and where distrust is based on misconceptions or misinformation. Practical training in social listening and the use of role-play helps caregivers to respond in a non-judgmental manner.

Where there is a lack of knowledge or practical skills, the best people-centered programs are ones that are flexible, so as to allow the people they are for to get as much benefit from them as their abilities or circumstances allow. If misinformation is an issue, small group discussion will be preferable for many older parents, while internet and social media-generated dissemination of appropriate facts can be used to engage younger segments of the population.

Misinformation on malaria on the internet is not as prevalent as for other health issues such as vaccination or Covid-19 containment. But, it pays to identify and recommend sites with accurate facts and good resources. But, in parallel, reinforce the obvious, that not everything that people read online is true or reliable, and if there are important facts about malaria that anyone does not understand, someone that person trusts should be asked to explain what the key facts are.

Enabling people to understand the importance of controlling malaria and the need to protect children especially is not usually that difficult to achieve. However, strategic planning and dialog are particularly important to ensure understanding over issues that people will see as divisive. An example is the consideration being given to using gene drive approaches as part of future integrated strategies to combat malaria. Gene drive is an advanced form of genetic modification where a lab-created gene is introduced into an organism that targets and removes a specific natural gene. But, importantly this new gene can also automatically replicate itself in a way that ensures virtually all resulting offspring have the lab-created gene. This is in contrast to conventional genetic engineering where only about 50% of offspring are altered. Radical steps of this type are being considered because both the malaria mosquito and the malaria parasite are becoming increasingly resistant to current control methods. Gene drive technology is only authorized for laboratory research at present, but people are already concerned over its potential to impact species other than mosquitoes when it is used in the wild.

4.3 Innovative education

School-based programs that educate children broadly on the causation and prevention of malaria, and what care is required can reduce morbidity, and, in particular, increase access to timely diagnosis and treatment. The WHO health promoting school (HPS) model in particular lends itself to education on malaria, as a core concept is teaching children knowledge and practical skills through focused additions to the curriculum [17, 18]. Elements of the HPS model can be applied in various ways to either generate an overarching health ethos in the school or focus on a locally relevant health issue like malaria [18].

Award schemes should be explored as a way to foster HPS activity; a variety of support and recognition strategies can be put in place that will encourage individual schools, and create a spirit of competition between schools that is synergistic [21]. Although not evaluated specifically in the context of malaria education, the experience in African schools following the WHO HPS model is that health promotion activities benefit from local recognition and spread from one school to another through healthy rivalry between neighboring schools [65].

Innovative education can be used to address inequitable distribution of knowledge about malaria and promote understanding about the fundamentals of causation, preventive measures and timely diagnosis and treatment. Data on the use of insecticide-treated bed nets for instance suggest focused school-based education positively impacts their use; the need has also been identified for households to learn to make nets available for use by school-aged children [66]. Health promotion messaging should be tailored to address specific need such as this, and framed so that the message resonates with the age group being targeted. Sometimes non-traditional messengers prove to be particularly effective as communicators, for example, young people are drawn to celebrities endorsing health promotion through music videos and social media are an example [67].

In 2020 the World Economic Forum, UNICEF and the World Food Program announced an innovative approach to helping children achieve their full potential. The aim is to improve their health throughout the first 8000 days of life, and thereby build on current investment focused on improving health during the first 1000 days based on developmental origins of health and disease (DOHaD) science [68]. The mechanism proposed will be the development of integrated school programs that combine strategies that improve the health of school-age children. And the goal, to thereby promote their academic potential, achieve better educational outcomes and build human capital [3].

Clearly the education and school-based management strategies required for malaria will be part of this model in future. Integrated school health packages will be based on experience gained from a variety of successful school-based health interventions, and the expectation is that such integration will lead to synergistic effects where combined aims are met through delivery in a single program. Evidence already available from trials of combined health approaches in schools indicates that benefit will also accrue from shared costs, and the stronger health returns anticipated over programs where individual interventions are delivered alone [8, 69, 70].

Schools should also encourage teachers to create and share innovative educational approaches that engage their pupils. For example, clean-up programs can be initiated where children collect discarded plastic bottles, bags and bottle caps on their way to and from school. This approach is innovative as it provides evidence-based learning on how these items offer a breeding habitat for mosquito larvae, and an introduction to larval source management; a preventive approach with the dual benefit of reducing the numbers of house-entering mosquitoes and those that bite outdoors [64, 65]. Practical learning approaches like this can be complimented by in-class question and answer sessions, and the generation of visual aids for the classroom wall by the pupils that show other effective prevention practices and key facts about malaria.

4.4 Novel and improved tools

When the use of RDTs was introduced in community pharmacies this form of testing was not a new tool, but its application in this setting was novel, as was the later expansion of RDT kit use to include teachers in school-based programs [15, 48]. RDT use in both settings resulted in a significant improvement in the reach of this diagnostic tool, as it made testing more readily available and accessible to a larger proportion of the population. In school-based programs RDTs also provided a long called for way to improve care of the school-aged child, by providing an immediate and accurate diagnosis which then allows teachers to treat sick children promptly and with confidence [38].

ACTs continue to be the WHO endorsed first-line therapy in most parts of the world. However, the novel strategy of using multiple first-line therapies rather than a single ACT is a treatment innovation that will help counter emerging resistance to ACTs, and thereby allow this class of drug to remain therapeutically useful as antimalarial drugs for longer [50, 51].

While it is well recognized that the malaria targets for the Millennium Development Goals for 2015 were achieved even though the tools used and the ways in which they were applied were often imperfect [71], it is important that the search continues for better tools for all aspects of malaria control. But in parallel, ways should be explored to expand access to the tools we have that work well, ensure that they are used optimally, and find innovative ways in which they can be modified to meet a new need or counter the very real risk of emergence of drug resistance.

In 2021, the WHO made the historic announcement that a long awaited vaccine for malaria was now recommended for the prevention of P. falciparum malaria in children living in regions with moderate to high transmission [22]. A vaccine against malaria has long been sought, but has proved elusive, in part due to the complexity of the parasite and its numerous immune evasion mechanisms [72]. The RTS,S/AS01 vaccine (RTS,S) is designed to induce antibodies against the sporozoite phase of the lifecycle; this blocks infection of the liver, where the parasite would normally mature and multiply before re-entering the bloodstream to further infect erythrocytes.

RTS,S is the first parasite vaccine to obtain regulatory approval, and there are caveats regarding its current place in malaria control, particularly related to the dosing strategy required, the period of protection provided and partial efficacy, all of which leave room for improvement [73]. Currently the vaccine requires 4 doses from 5 months of age, and for the foreseeable future, vaccinated children will also require some form of chemoprophylaxis in addition, in order to achieve optimum vaccine efficacy. Because of the target age group, programs to immunize will obviously not be school-based [74], but awareness that child vaccination is now an option should be incorporated into school-based health education. This investment will mean that the next generation of young parents will know that this form of prevention is available for their children.

Modifications in dose and schedule have contributed to improved vaccine performance, and further variations may follow [75]. But, as important and historic as vaccine use will be, WHO is calling for the introduction of this novel tool to be used to reinvigorate the fight against malaria in parallel with vaccine rollout programs [22]. This is an important opportunity to respond more effectively than in the past to the repeated calls to scale up and improve malaria control in school-age children [23].

National policies will need to be established and strategies developed to promote local programs that incorporate child vaccination. Creating and implementing the programs required will require both inspired leadership and inter-sectorial collaboration, funding, and support in order for communities to ‘buy into’ the concept and participate successfully. In addition to the public education and engagement needed regarding the vaccine, clear direction and recommendations are also necessary at the same time on how to deliver and sustain the components of the scaled up malaria control programs for children called for by the WHO to accompany introduction of the vaccine [23].

Meanwhile, several other malaria vaccines with different modes of action are under development. Pre-erythrocytic forms continue to be some of the most promising; pre-erythrocytic agents target antigens from the Plasmodium sporozoite and liver stages when infection is in its earliest stages following inoculation and clinically silent. Induction of antibodies and T cell responses clear sporozoites or block their invasion of hepatocytes [73]. Circumsporozoite protein is a specific target in ongoing research; this is the major antigen on the surface of sporozoites. Various approaches are being applied to develop RTS,S derivatives that improve immunogenicity; recent trials indicate that the R21/MM vaccine appears safe and very immunogenic in African children, and promises high-level efficacy [72].

Novel use of technology can also impact vector control and improve the logistics of delivering supplies needed to test and treat malaria in rural areas. The deployment of drones is an example. Use of this technology in Zanzibar has made it possible to map difficult to find water pools which enables breeding sites to be targeted before larvae turn into adult mosquitoes, and it was learned during the Covid-19 pandemic that drones can be employed effectively to deliver urgently needed supplies when vaccines required in remote areas were provided in this way.

4.5 Training personnel to respond to local needs

The majority of teachers understand the toll malaria takes on their pupil’s health, but many need training to fully understand how they and their school can contribute to strategies to reduce the impact the disease can have on their pupils. For instance, not all recognize that repeated absence from class or a pupil dropping out of school altogether can be due to the cumulative effects of malaria. Also, full realization of the negative impact that severe or repeated infection can have often only comes when the beneficial effects of a school-based diagnostic and treatment program become evident through the school’s improved performance in national exams.

It is well documented in the literature that the duration of malaria-related absence, frequency of absence due to repeated infection, residual malaise from sub-optimal treatment and transient neurological complications due to malaria can all compromise a child’s potential to learn. In this context, it is important that teachers and parents learn about the negative neurologic effects malaria can cause, and that repeated infection can have detrimental effects that are cumulative, and lead to permanent loss of cognition and learning ability [28, 30, 62]. While the exact mechanisms underlying long-term detriment are debated, a clear relationship exists between the severity of infection and the magnitude of the adverse cognitive effect. An excellent schematic that helps in teaching how adverse effects probably come about and their importance was published in 2010 based on a series of studies examining cognitive function and school performance in children after infection with P. falciparum and P. vivax malaria [62].

Nutrition programs are the most widespread school-based initiatives to promote child health. When personnel are trained to implement them well, such programs can improve children’s learning ability and academic potential as well as their physical and mental well-being. Children who are well nourished are better positioned to recover from infectious illnesses, including malaria; significantly it is the most disadvantaged children who often benefit the most from school-based nutrition programs [76]. School garden projects can provide produce for lunch programs to feed children in need. Parents can be trained to collaborate and help run school gardens. A systematic review indicates that multiple life skills are learned and educational benefits accrued by pupils who are actively involved in tending gardens and the growing, harvesting and sale of produce [77].

Teachers in many low and middle income countries have been trained successfully to administer specific health programs in schools in response to identified local needs; examples include: the provision of intermittent anti-malarial therapy in Kenya [25, 78], prophylactic chloroquine in Sri Lanka [26], and nationwide anti-helminth treatment in India, Ghana and Uganda [34, 79]. Tetanus prophylaxis and now vaccination against human papilloma virus are also widely administered by individuals trained to deliver them through schools.

Training of staff in pharmacies to use RDT kits could provide sufficient additional capacity in some communities for this to be an alternative to setting up school-based testing and treatment. Programs developed to train non-medical personnel, including teachers, have been evaluated, and the knowledge and skills such training provides enables practitioners to be both safe and effective [53]. Integrating teachers trained to test and treat for malaria into larger health, nutrition and education platforms offered through schools would likely result in cost-benefit over providing individual health interventions singly, and also deliver combined benefits that would contribute towards achieving the sustainable development goals for health [54].

4.6 Non-traditional avenues and outlets

To be effective, any intervention that employs a non-traditional outlet or approach must be context-specific and tailored to meet the needs and available resources of the community that will implement and sustain it [3, 23]. The number, variety and scale of the problems communities in low-and-middle-income countries face regarding malaria requires ingenuity and creativity across society to seek out and trial non-traditional solutions that offer potential benefit. School-based health promotion is an example, and interventions with the potential to reduce malaria morbidity in children range from the provision of basic education about malaria through to ‘test and treat’ programs that implement WHO malaria management criteria.

Schools are still viewed as non-traditional outlets for health delivery, in spite of the many school-based programs that have been shown to provide benefits for the communities they serve. Importantly, evidence of program efficacy includes interventions to reduce the burden of malaria on school-aged children, including ones developed as a practical response to calls from teachers and community leaders. Unfortunately, not every country has a school system where teachers’ morale and motivation make teacher-driven health initiatives feasible [24, 65]. But in the majority, the small number of teachers in each school required to run a ‘test and treat’ program for malaria are likely to be forthcoming. Certainly, where teachers are aware of the impact malaria has and the improvements intervention can achieve, enough are likely to be willing and able to be taught how to screen children found to be sick at school, treat those testing positive promptly, and refer those children with severe or atypical disease to a conventional health outlet like a clinic or hospital.

From a practical standpoint, community participatory intervention models based in schools are also broadly applicable, and a low cost and flexible approach with considerable potential to meet the longstanding calls for interventions to reduce the burden of disease on school-age children [3, 4, 8]. In addition these models can comply fully with WHO-endorsed diagnostic and treatment principles, follow local government guidelines, and help achieve national goals for malaria control.

Importantly, integration of any avenues that can improve the delivery of health services in a community, or increase access by those needing care will impact the challenge of delay in the treatment of fever [44]. Waiting too long before seeking care for a child likely to have malaria, and failure to obtain an accurate diagnosis and prompt treatment are both major obstacles to achieving the goal of reducing malaria morbidity. Studies indicate that in sub-Saharan Africa <50% of sick, febrile children receive artemisinin combination therapy (ACT) within 24 hours [15, 45, 59, 80]. Approaches that remedy this situation would in themselves go a long way towards reducing the current burden of malaria on children.

5. Conclusion

Bold decisions are needed to control of malaria and particularly to improve the situation in school-aged children. The longstanding recognition that they are a large and especially vulnerable population has not been matched by clear strategies that can be broadly applied to reduce their burden of disease. School-based interventions to control malaria have obvious logic, as schools allow access to the relevant target population. Suitable initiatives exist that are applicable worldwide and have the potential to benefit millions of children. Education to provide a basic level of health literacy about malaria causation, prevention and management should be a universal component of the school curriculum where the disease is endemic. There is also evidence that school-based health care delivery, such as teacher-driven test and treat programs for malaria, offer a cost effective option alone, and especially if combined with other health interventions.

Acknowledgments

The delivery and evaluation of key school-based projects described was made possible through support from the Stellenbosch Institute for Advanced Study at Stellenbosch University in South Africa. Funding for the novel teacher-driven ‘test and treat’ program in Uganda was provided by a grant from the Hillman Medical Education Fund in Canada.

Conflict of interest

The author declares no conflict of interest.