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Impact of a malaria intervention package in schools on Plasmodium infection, anaemia and cognitive function in schoolchildren in Mali: a pragmatic cluster-randomised trial
  1. Siân E Clarke1,
  2. Saba Rouhani1,2,
  3. Seybou Diarra2,
  4. Renion Saye3,
  5. Modibo Bamadio2,
  6. Rebecca Jones1,
  7. Diahara Traore4,
  8. Klenon Traore4,
  9. Matthew CH Jukes5,
  10. Josselin Thuilliez6,
  11. Simon Brooker1,
  12. Natalie Roschnik2,
  13. Moussa Sacko3
  1. 1Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
  2. 2Save the Children, Bamako, Mali
  3. 3Ministry of Health, Institut National de Recherche en Santé Publique, Bamako, Mali
  4. 4Ministry of Health, Programme National de Lutte contre le Paludisme, Bamako, Mali
  5. 5RTI International, Research Triangle Park, North Carolina, USA
  6. 6CNRS (Centre National de la Recherche Scientifique) - Centre d'Économie de la Sorbonne, Paris, France
  1. Correspondence to Dr Siân E Clarke; sian.clarke{at}


Background School-aged children are rarely targeted by malaria control programmes, yet the prevalence of Plasmodium infection in primary school children often exceeds that seen in younger children and could affect haemoglobin concentration and school performance.

Methods A cluster-randomised trial was carried out in 80 primary schools in southern Mali to evaluate the impact of a school-based malaria intervention package. Intervention schools received two interventions sequentially: (1) teacher-led participatory malaria prevention education, combined with distribution of long-lasting insecticidal nets (LLINs), followed 7 months later at the end of the transmission season by (2) mass delivery of artesunate and sulfadoxine-pyrimethamine administered by teachers, termed intermittent parasite clearance in schools (IPCs). Control schools received LLINs as part of the national universal net distribution programme. The impact of the interventions on malaria and anaemia was evaluated over 20 months using cross-sectional surveys in a random subset of 38 schools(all classes), with a range of cognitive measures (sustained attention, visual search, numeracy, vocabulary and writing) assessed in a longitudinal cohort of children aged 9–12 years in all 80 schools.

Results Delivery of a single round of IPCs was associated with dramatic reductions in malaria parasitaemia (OR 0.005, 95% CI 0.002 to 0.011, p<0.001) and gametocyte carriage (OR 0.02, 95% CI 0.00 to 0.17, p<0.001) in intervention compared with control schools. This effect was sustained for 6 months until the beginning of the next transmission season. IPCs was also associated with a significant decrease in anaemia (OR 0.56, 95% CI 0.40 to 0.78, p=0.001), and increase in sustained attention (difference +0.23, 95% CI 0.10 to 0.36, p<0.001). There was no evidence of impact on other cognitive measures.

Conclusion The combination of malaria prevention education, LLINs and IPCs can reduce anaemia and improve sustained attention of school children in areas of highly seasonal transmission. These findings highlight the impact of asymptomatic malaria infection on cognitive performance in schoolchildren and the benefit of IPCs in reducing this burden. Additionally, malaria control in schools can help diminish the infectious reservoir that sustains Plasmodium transmission.

  • malaria
  • anaemia
  • cognition
  • schoolchildren
  • schools
  • insecticide-treated nets
  • ITNs. LLINs
  • intermittent preventive treatment
  • IPT
  • intermittent parasite clearance
  • IPC
  • asymptomatic
  • gametocytes
  • Mali

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  • Contributors The study was conceived by NR, MS, SB, SD, MB and SEC, with additional technical guidance provided by the National Malaria Control Programme (DT and KT). All authors contributed to the design and implementation of the trial. RJ analysed the data, and SEC and SR wrote the manuscript. All authors commented on the manuscript and approved the final draft.

  • Competing interests None declared.

  • Ethics approval Ethical Committee of the National Institute of Public Health Research, Ministry of Health, Mali.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The published data are available from the authors on request.

  • Correction notice This paper has been amended since it was published Online First. Owing to a scripting error, some of the publisher names in the references were replaced with 'BMJ Publishing Group'. This only affected the full text version, not the PDF. We have since corrected these errors and the correct publishers have been inserted into the references.

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