Implementing mass campaigns during a pandemic: What we learnt from supporting seasonal malaria chemoprevention during COVID-19 - SMC
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MALARIA CONSORTIUM
LEARNINGPAPER
Implementing mass
campaigns during a
pandemic:
What we learnt from supporting
seasonal malaria chemoprevention
during COVID-19
Contents Key learnings 6
Low risk perception and
4 Introduction In 2020, the COVID-19 pandemic presented exposure to misinformation
novel challenges to implementing community-
among SMC stakeholders,
5 Our seasonal malaria chemoprevention programme
based malaria control interventions. During this
time, Malaria Consortium supported seasonal
implementers and
communities pose a
3
malaria chemoprevention (SMC) in Burkina Faso,
challenge. It is essential to
6 COVID-19 and seasonal malaria chemoprevention Chad, Nigeria, Togo and Mozambique, reaching
more than 12 million children 3–59 months. The clearly and consistently
pandemic posed a significant risk of transmission provide the rationale for
6 Methods to SMC implementers. To minimise the risk of SMC implementers IPC guidelines and promote
infection and maintain essential malaria services, require COVID-19-related adherence. Different target
7 Our learnings 2020 SMC campaigns were implemented using
strict infection prevention and control (IPC)
commodities, such as face
masks, hand sanitiser and
audiences will require
different communication
7 Planning
measures based on Malaria Consortium and disinfectant, which are and engagement strategies.
national IPC guidelines. Key learnings from necessary for adherence to
implementing this life-saving intervention during the IPC guidelines.
9 Procurement and supply management a pandemic include the following:
7
11 Community engagement
1
13
4
Training
IPC measures are
14 SPAQ administration most effective when
Sound IPC measures Early agreement on IPC explained clearly to SMC
15 Supervision are central to the safe implementers, practised
guidelines for SMC, quality
implementation of SMC. standards of COVID-19- during training sessions
and reinforced through
17 Seasonal malaria chemoprevention in 2021 They need to be based on
scientific evidence, as well as
related commodities and
supervision.
usage protocols helps
national and international inform SMC planning and
18 References guidelines and IPC protocols. procurement.
8
2 5 SMC can be a useful
community platform
to share public health
Minimising risk for everyone Strong commitment to information among target
involved in SMC requires enforcing IPC guidelines populations. Community
adaptations to all SMC from national malaria distributors should be
activities, especially planning, programmes, along with trained on communicating
procurement, community an inclusive approach basic information on
engagement, training, involving government and COVID-19 prevention
SPAQ administration and implementing partners, is and transmission to
supervision. crucial. communities.
1 2
Introduction
Significant progress in reducing the global burden of malaria has been made since the start of the
millennium. The unprecedented expansion of malaria interventions in the twenty-first century has led
to a considerable impact on malaria incidence and mortality. By the end of 2019, an estimated 1.5 billion
malaria cases and 7.6 million deaths had been averted in this 20-year period.[1] However, progress has
levelled off, making it essential to ensure that proven malaria prevention and control strategies reach all
who can benefit from these interventions.
In Africa, malaria persists as a leading cause of morbidity and mortality in young children, with an
estimated 275,000 children under five having died from malaria in 2019.[1] In 2020, the SARS-CoV-2 novel
coronavirus (COVID-19) pandemic emerged as an additional challenge, and there were fears that the
disruption to malaria services could result in a substantial increase in malaria deaths.[2]
In the Sahel region, most childhood malaria infections and deaths occur during the rainy season,
which generally lasts between three and five months. In 2012, the World Health Organisation (WHO)
recommended SMC, the administration of a monthly course of sulfadoxine-pyrimethamine (SP) plus
amodiaquine (AQ), or ‘SPAQ’, to children 3–59 months during the peak malaria transmission season,
as an impactful approach to malaria prevention. SMC is mainly delivered door-to-door by trained
community distributors. A full course of SPAQ is given over three consecutive days. On the day of the
community distributor’s visit to a household, one tablet of SP and one tablet of AQ, dispersed in water, are
administered under the supervision of a community distributor. This is called directly observed treatment
(DOT). Community distributors give the remaining two doses of AQ to the caregiver to disperse and
administer daily over the next two days. Each full course of SPAQ confers a high degree of protection from
malaria infection for approximately 28 days.
The distribution of these effective antimalarials at monthly intervals during the rainy season in the
Sahel region has been shown to be 75 percent protective against uncomplicated and severe malaria in
children under five.[3] Case-control studies from five countries have shown that SMC was associated with
a protective effectiveness against clinical malaria of 88 percent and a reduction in the number of malaria
deaths in hospital.[4] SMC has the potential to avert millions of cases and thousands of deaths among
children living in areas of highly seasonal malaria transmission.[5] It has also been found to be a cost-
effective intervention that significantly reduces malaria diagnostic and treatment costs.[6] SMC has been
successfully scaled up, reaching over 21 million children in 13 countries in 2019.[1]
Caregiver administers SMC medication to child, Mozambique
3 4
Our seasonal malaria chemoprevention Methods
programme Supporting the implementation of SMC during partners to provide feedback on their approval for this exercise from an independent
the COVID-19 pandemic and applying strict IPC experience of implementing SMC during review board was not obtained.
Malaria Consortium is a leading implementer international SMC community to guidelines resulted in invaluable insight that can COVID-19 (42 people in total)
of SMC. Along with other partners, we have build the evidence base for SMC,
planning and enumeration inform not only the implementation of SMC Feedback from the participants focused on
• a validation exercise to substantiate the
demonstrated how SMC can be delivered safely and contribute to SMC policy going forward, but also that of community- planning, procurement and supply management,
and effectively at scale and easily adapted to and practice. Our support procurement and supply management based mass campaigns during a pandemic more
findings with key Malaria Consortium staff.
community engagement, training, SPAQ
diverse settings: multi-country evaluations of spans all the components generally. To consolidate and synthesise the administration and supervision. We have
For the purpose of this exercise, we defined
the Achieving Catalytic Expansion of SMC in that together make up SMC (Figure 1). community engagement lessons we learnt in 2020, Malaria Consortium
a lesson as any insight gained during
organised our lessons learnt under those themes.
the Sahel (ACCESS-SMC) project, which was led conducted the following activities after the end
implementation of an intervention that can be
by Malaria Consortium, showed that SMC at In 2020, our SMC programme reached over training of the annual SMC rounds in December 2020 and
usefully applied to future or other interventions,
Malaria Consortium also conducted mixed-
scale was effective in preventing morbidity and 12 million children through the efforts of over January 2021: methods research on IPC compliance among
including reflections on what went better
mortality from malaria, with few serious adverse 100,000 individuals.[7] While we have supported community distributors during SMC in 2020,
SMC in Burkina Faso, Chad and Nigeria for
SPAQ administration • a review of 21 SMC and COVID-19-related
than expected and what did not work well. All
including structured observations.[17] The
reactions reported.[4]
participants were informed about the purpose
a number of years, 2020 saw the internal and external documents, including preliminary results suggest mixed adherence to
SMC campaigns are implemented under the expansion of our support to Togo and case management and pharmacovigilance safety and IPC protocols, training tools and
of the exercise and consented to their feedback
the COVID-19 measures. Results will be published
being used anonymously in written outputs,
leadership of national malaria programmes Mozambique.[8] For a more detailed job aids in mid-2021 and are not included in this learning
including this learning paper. As the information
and through countries’ existing health system description of Malaria Consortium’s SMC supervision • semi-structured conversations with Malaria requested related directly to respondents’
paper.
structures. Malaria Consortium provides programme — which is supported mostly by
Consortium staff and malaria programme professional role in SMC implementation, ethical
technical and logistical support to ensure high philanthropic, as well as other, funding sources — monitoring and evaluation
coverage and quality of SMC implementation. refer to our 2020 philanthropy report.[9]
We also conduct research and engage with the Figure 1: As a community-based public health
intervention, SMC comprises several key components.
COVID-19 and seasonal malaria
chemoprevention
The WHO declared the SARS-CoV-2 novel and deaths among children under five — which • disinfection of surfaces and frequently
coronavirus outbreak a global pandemic on would put additional strain on health systems touched items
11th March 2020.[10] The first case of COVID-19 already under pressure because of the need to
• assessment of temperature and symptoms
on the African continent was confirmed in address COVID-19.[14] We led the development
Egypt on 14th February 2020[11] — within three of global operational guidance on adapting SMC • preventing implementers with symptoms
months, it had spread throughout Africa, where to minimise risk, which was published by the Roll of COVID-19 from participating in the
most countries were experiencing community Back Malaria (RBM) Partnership to End Malaria.[15] campaign.
transmission.[12] The pandemic presented a host We also developed enhanced safety protocols for
of new challenges for the safe implementation SPAQ administration that would apply to areas We subsequently discussed this internal guidance
of SMC campaigns, which were due to begin where we supported SMC implementation in with government and implementing partners to
in July in most of the countries where we 2020.[16] Our internal guidance was based on the determine how it could be applied appropriately
support SMC. Given that SMC is a time-bound, following principles of IPC: at a country level, for example by including IPC
seasonal intervention, there was urgency for measures in training materials and including
decision-making to limit the risk of transmission • limiting in-person contact COVID-19 messages in communications
of COVID-19 during SMC delivery. In line with plans. Our aim was to ensure that SMC could
• physical distancing of at least two metres
WHO recommendations,[13] we advocated for continue to be effective at preventing malaria SMC launch event, Mozambique
SMC to be recognised as an essential health • use of face masks and respiratory hygiene while simultaneously protecting communities,
service and asserted that its discontinuation community distributors and other implementers,
• regular hand hygiene
would risk a substantial increase in malaria cases staff and stakeholders.
5 6
LESSONS
Planning transmission in sub-Saharan Africa at the time.
Therefore, we aligned our internal IPC guidance
In some instances, there was tension between
national COVID-19 guidance and our internal IPC “Adding the COVID measures cost a lot.
Sound IPC measures are central to the safe
implementation of SMC and need to be based
with global standards and based these on the guidelines, which were sometimes perceived as The amount of resources needed to on scientific evidence as well as national and
Planning usually begins several international guidelines and IPC protocols. If in
best available evidence at the time. Concurrently, too cautious. On this point, many respondents implement SMC increased, things like
months before the start of the doubt, err on the side of caution.
we discussed our IPC guidance with government felt that it was key to discuss the IPC measures PPE came at an extra cost. All of the
first SMC cycle. This involves
and implementing partners to ensure they were with country stakeholders to promote inclusivity materials, manuals had to be updated,
determining where and
reflected in national SMC guidelines. In Nigeria, of views, agreement and ownership, all while printed, which incurred additional Control of a pandemic requires collaboration
when exactly SMC will be
meetings were held at both the national and prioritising SMC implementers’ safety. expense. More human resources were between stakeholders at all levels. Task forces
implemented, enumerating the
state level with recently appointed COVID-19 needed. An assessment was conducted need to be established to discuss IPC guidelines
“Developing
target population of children
state task forces to micro-plan the approach to the guidance happened in a to identify [staff at high risk], which and mitigating measures. To ensure buy-in
3–59 months and recruiting
implementing SMC while ensuring adherence short period of time. It was not lateral, ended up being around 20 percent among stakeholders, this process should
community distributors and
to Malaria Consortium IPC guidance, and to nor straightforward. It was, rather, a of our [Malaria Consortium] staff so be inclusive, involving government and
supervisors. implementing partners. Strong commitment to
determine how to tailor this to the context of web of activities in which every relevant more people had to be recruited to
cover their absence. Exposed cases enforcing IPC guidelines from national malaria
In view of the risks that each state. person carried along…even though
also had to be isolated and withdrawn programmes is crucial.
there was fear and a diversity of views,
“[As
the pandemic posed, we
for the] development of the the guidance found a common ground. from fieldwork for two weeks and
put in place measures to
guidance plan, we looked at it at the A lesson was that the incorporation of replacements found; sacrifices had to
”
prevent the transmission of Minimising risk for everyone involved in SMC
NMEP [National Malaria Elimination stakeholders into implementation was be made. requires adaptations to all SMC activities,
COVID-19 among Malaria
Our learnings
Programme] level, with other partners, key; they were invited to observe and (Malaria Consortium staff) especially planning, procurement, community
Consortium staff, partners
engagement, training, SPAQ administration and
“There
and integrated all of these measures then provided their technical advice on
”
and implementers. Measures was a negative impact on
as part of the Nigerian CDC [Centre how to improve. supervision. IPC guidelines need to be reflected
included office closures, remote the budget, and more costs like in and applied to SMC protocols, tools and
working and restrictions on for Disease Control]. Also at the state (Malaria Consortium staff).
procuring PPE and supporting routine materials.
national and international [level], at the beginning of pandemic,
Due to the addition of COVID-19 IPC measures implementation with hand sanitiser,
there were massive mobilisation efforts
”
travel, as well as asking staff to face masks. Less people in a [training]
at all levels. that were necessary for implementing SMC
voluntarily and confidentially IPC guidelines and SMC protocols need to be
safely during the pandemic, SMC budgets had class means having to pay more
report personal health risk (Ministry of Health staff) agreed as early as possible, so they can inform
to be adjusted. This increased the cost of SMC technical allowance training days to the
”
levels using pre-defined risk SMC planning and procurement.
implementation, despite savings gained from consultant.
categories that informed (Malaria Consortium staff)
cancelled travel and some in-person training.
mitigation measures at work. Where possible, adherence to IPC measures,
The latter still took place as much as possible;
This meant that most in-person Some respondents commented that workload benefits, barriers and the impact of COVID-19
however, in order to adhere to the COVID-19
meetings and communication and time pressure during the planning stage were on quality and effectiveness of SMC should
guidance on the maximum number of people
about SMC planning shifted to so high that there was insufficient time to put be evaluated through research and M&E
allowed to gather in one location, the number of
online platforms, email, telephone in place a system for monitoring the potential — including routine household surveys —
trainings required increased, which augmented
calls and electronic sharing of impact of SMC campaigns on COVID-19 recognising that these activities themselves need
the cost. The cost of SMC also increased due to be conducted in a COVID-19-safe manner.
documents, with any planned transmission, or to think about how routine
to the additional human resources needed to
international travel cancelled. monitoring and evaluation (M&E) and research
respond to the pandemic. Another significant
would need to be adapted. A system should be in place to monitor if
cost factor was the need to procure COVID-
As planning for the 2020 SMC delivery has any effects on community
19-related commodities (often referred to by
SMC campaign in most of the transmission of COVID-19. This is likely to
respondents as ‘PPE’ — personal protective
implementing countries was already involve monitoring both official COVID-19 data
equipment). One respondent was of the opinion
underway when the pandemic and anecdotal reports.
that urgency around the need for COVID-19-
began, we had to quickly determine
related commodities during global shortages
appropriate COVID-19 IPC measures
meant that suppliers increased their prices Safe implementation of SMC during a pandemic
and adapt the SMC activities to
due to the surge in rapid demand. The cost of comes at a cost. Commitment for increased
minimise risk for everyone involved.
procuring COVID-19-related commodities for funding needs to be secured from donors and
Decision-making on what constituted stakeholders early during the planning and
SMC, including freight, constituted around seven
safe IPC measures was fraught with procurement phase of the campaign.
percent of the annual SMC budget in 2020.
uncertainty, due to limited evidence on
the severity of COVID-19 and the degree of
7 8
LESSONS
Procurement should be changed. Figure 2 shows the COVID-19
related commodities Malaria Consortium Medical face masks Bleach Disposable cups and SMC implementers should be given COVID-19-
related commodities, such as face masks, hand
and supply procured and how they were used. To be worn during training and SPAQ For making bleach solutions to clean hard surfaces
spoons sanitiser and disinfectant, which are necessary
for them to adhere to the IPC guidelines.
management administration by SMC implementers at training venues and health facilities, and to
For SPAQ administration, where caregivers could
1,700,773
We sourced COVID-19-related commodities clean SMC tools during SPAQ administration
not provide clean cups
31,824 litres
locally wherever quality and price allowed, to Early definition of specifications and
Malaria Consortium directly sources and
617,457
reduce item and transportation costs, as well quantification of COVID-19-related
delivers SPAQ from a quality-assured
as transit delays, especially as some shipments commodities is important to ensure the right
manufacturer to central medical stores in the
were subjected to quarantine periods. However, quality and quantities are sourced and made
countries where we implement SMC. From
in some cases, sourcing internationally could available on time. This includes agreeing to
there, we support national health supply
facilitate better quality and prices. quality standards and usage protocols between
chains to distribute the SPAQ and other SMC
Soap stakeholders prior to procurement.
commodities to regional, district, health facility
and community levels. “ We also had to worry about quality — For hand washing at training venues and health Rubber gloves Digital thermometers
there were some dodgy suppliers out facilities To be worn while cleaning with bleach Low-quality or poorly specified fabric facemasks
there. The majority of items were locally To take SMC implementers’ temperature at the
69,878 bars 59,863
For the SMC campaigns in 2020, we not only and hand-cleaning products can significantly
sourced but we did buy some things beginning of each day
had to obtain COVID-19-related commodities increase the risk of transmission of COVID-19
3,082
to prevent the spread of the virus, but we also
internationally. We procured things during the SMC campaign.
needed to rapidly specify, quantify, quality
nationally and locally. For example, for
check, procure and distribute these items,
items needed in Chad, we ordered from
which included face masks, hand sanitiser and
Burkina Faso and ordered them to be
sent to Chad, telling the supplier that
disinfectant. Moreover, we had to do so at short
we would only pay once the shipment Buckets with tap and Spray bottles
”
notice and in the face of rising global demand,
shortages, a flooding of the markets with poor
quality supplies and broader supply chain
actually arrived in Chad.
(Malaria Consortium staff)
basin For applying bleach solution to hard surfaces and
SMC tools
Waste disposal bags
For hand washing at venues and health facilities To collect discarded face masks and used paper
58,550
interruptions. Malaria Consortium staff explained
Previous relationships with suppliers proved to without access to running water towels during SPAQ administration
the importance of linking the procurement of
be beneficial at a time when many consumers
these items with national procurement and
mobilisation efforts, while also balancing the
prioritisation and supply chain management
were competing for the same commodities. For
example, the same supplier of SPAQ medicines 2,652 250,410
in China also produced face masks, which helped
of other essential items. Another lesson was to
with timely procurement of those items.
define and clearly articulate the standards for
each commodity with partners — for instance, Paper towels
the type of face mask, e.g. reusable cloth versus
disposable medical, and the type and percentage
Hand sanitiser For wiping down hard surfaces and SMC tools
where bleach solution was used
For disinfecting, hands during SPAQ
2,399,316
of alcohol in hand sanitiser — and check the
quality provided by the supplier against agreed administration
91,492 litres
specifications for large volumes over dozens of
locations across multiple countries.
We also had to decide and agree on the
quantification of COVID-19-related commodities
for SMC activities, which required close
collaboration between programme and
operations colleagues, as these decisions had
significant implementation and cost implications.
For example, how often hands should be
sanitised, which would inform how much hand Figure 2: Essential commodities we
procured with philanthropic funding
sanitiser would be needed per community in 2020 to help prevent COVID-19
distributor per day, or how often face masks transmission
9 10
LESSONS
Community COVID-19, and the symptoms are similar to other
‘familiar’ diseases like the flu or common cold. “Where SMC had not been implemented
Low risk perception and exposure to
misinformation among SMC stakeholders,
engagement A few respondents also referred to community before [Mozambique], we were worried
about coverage and acceptability. There
implementers and communities pose
a challenge. It is essential to clearly and
perceptions that COVID-19 only affects people
To ensure that communities understand was also the issue of the acceptability consistently provide the rationale for IPC
living in cities or rich people. One respondent
the rationale for SMC and support its of the COVID guidelines by caregivers measures, promote adherence and explain
noted that some people believe that heat, being
— what would they think about adaptations to how the intervention is delivered.
implementation, we typically conduct African and one’s religion are all protective against Different target audiences will require different
sensitisation meetings with local leaders and the virus. handwashing and masks? Would that
communication and engagement strategies.
community members, broadcast radio spots affect their acceptability of SMC in the
and enlist town announcers to disseminate
information during the campaign.
“Inthevillages, people do not believe that community? ”
(Malaria Consortium staff) Community engagement is a crucial component
disease exists because they don’t
know anyone with the disease among of SMC, but even more so during a pandemic.
In the context of the pandemic, many of these Examples from a few countries highlighted Messaging around the prevention of COVID-19
the people they know. The educated
activities had to be cancelled or adapted; for the importance of consistent messaging and needs to be aligned with national social and
people believe in the disease but it’s a
example, instead of a larger meeting held at the awareness-raising activities on COVID-19 behaviour change communication strategies.
minority. It’s a new disease so it’s hard
provincial level, several smaller meetings were prevention measures to counter low risk
to manage. At the beginning, there was
held at the district level to reduce participant perception and to promote acceptability and
a stigma around the disease; people Cultural and contextual issues need to be
numbers. SMC implementers and community compliance, drawing on lessons from the Ebola
thought it was like Ebola. Now people considered, without compromising the scientific
distributors wore face masks and practised IPC outbreak.
are reassured. People do not follow soundness of the IPC guidelines.
measures such as physical distancing, using hand
“Evidence
the measures. They still greet each
sanitiser and disinfecting items. These were not informed the guidance, and
other with handshakes. In the general
perceived as fitting in with local customs in some examples from the past were drawn SMC can be a useful community platform to
population, the fear of the disease is
upon; for example, the measures share public health information among target
locations, where shaking hands and close personal gone and people have the same life as
” followed during the Ebola outbreak populations. Community distributors should
greetings indicate familiarity and goodwill; such before. A caregiver in a Fulani settlement in Sokoto state, Nigeria, administers SPAQ to her child under the supervision of
with the messaging being similar ‘stop community distributors. This is known as DOT. be trained on communicating basic COVID-19
actions help not only to build trust within the (Malaria Consortium staff) prevention and transmission information to
community, but also to promote acceptability of people from dying’, push that message.
Several respondents from Nigeria described how Related to this observation, in Nigeria, a study communities.
SMC. In Mozambique, where SMC had not been The guidance was evidence based
and open to everyone. This has to be SMC implementation facilitated opportunities to on COVID-19 knowledge, beliefs, prevention
implemented before, there were concerns
“The community distributors find it
very difficult to keep social distancing.
about how the COVID-19 IPC measures would
affect community uptake and acceptability.
translated into different languages
and very specific, reiterated at the
enhance national COVID-19-prevention efforts,
such as mass media campaigns and spreading
behaviours and misinformation found that
receiving information from community
A rumour management strategy would help to
mitigate the effect of negative rumours about
end of each cycle. It was important messages at the household level. distributors during the campaign was significantly SMC.
Everybody in the community knows However, according to Malaria Consortium
to disseminate COVID-19 health associated with a higher likelihood of caregiver
them and if they don’t greet people
[with handshakes], culturally it is seen
staff in country, during SMC implementation,
acceptance and coverage were perceived as messaging at all levels. ” “Because of SMC and the COVID knowledge of COVID-19 prevention behaviours.
” (Malaria Consortium staff)
measures, all workers were This demonstrates the important role SMC can
as rude. high. Several respondents suggested this was
trained on COVID and they raised play in sharing information about COVID-19
(Malaria Consortium staff) because adhering to and accepting COVID-19 IPC
awareness about COVID-19 in every among communities.[18]
measures had been normalised over time, prior
At the community level, particularly in rural household; the SMC implementation
to the implementation of SMC in Mozambique.
areas and villages, respondents commented complemented COVID awareness and Despite initial concerns about negative
Implementation in the country began
that the general public, and even community prevention. [Malaria Consortium] community perceptions of SMC, demand and
concurrently with the rainy season, in November
distributors, may not believe COVID-19 exists provided face masks and hand wash; uptake for SPAQ were reported as high across
2020, whereas campaigns in other countries
or may be sceptical about the disease’s severity. this complemented state and country the implementation countries — as were
mostly began in July 2020.
Several respondents noted that in urban areas or efforts. Other services adhere to community distributors’ use of face masks and
capital cities, the public may be better informed handwashing and immunisation — their adherence to IPC guidance during the
now the health workers have face pandemic. Nevertheless, several staff commented
”
about COVID-19 and more aware of the risks.
Respondents suggested a range of reasons for masks. on the necessity of establishing a response plan
low risk perception, including: that reported (Malaria Consortium staff) to address negative rumours. Most respondents
COVID-19 cases in the implementing countries considered community awareness raising and
were relatively low, community members may not engagement on SMC and COVID-19 even more
know anyone personally who had fallen ill with important in the pandemic context to promote
continued acceptance and support.
11 12LESSONS LESSONS
Training “Another major adaptation was the
While feasible at the national and state level,
remote trainings are not practical at lower SPAQ distancing guidelines at all times. This contrasted
with a comment from a national malaria
While COVID-19 IPC measures did not affect
SMC coverage, the impact on quality of SMC
Prior to the start of the first SMC cycle, all
training itself and that rollout. Training
the number of health workers and
levels of the health system. In-person training
will continue to be required, but suitable IPC
administration programme staff member who thought that implementation needs more consideration;
for example, with regard to observing DOT.
trainers, health facility workers, community quality was not affected by the change.
community health workers annually measures need to be applied. Community distributors go door-to-door to Research could help in obtaining a better
“don’t
distributors and supervisors attend training understanding of how IPC measures may affect
is huge. There are 20,000 community deliver SPAQ. Each monthly course of SPAQ SMC is a well-accepted intervention; I
on SMC. Typically, this starts at the national quality of SMC implementation and how
distributors on an annual basis…how It is important to train SMC implementers on involves one single dose of SP and three daily think the measures have had an
level with a training-of-trainers; training is then operational challenges could be addressed. This
do you manage that huge number?! IPC measures and any required adaptations to doses of AQ. Caregivers administer the first effect on quality. Caregivers are used
cascaded down the health system levels. needs to take into account the perspectives of
So all trainings, national and state the SMC protocol. This should include practical dose of SP and AQ under the supervision of the to giving medicine to their children so SMC implementers and the need to be mindful
level, became virtual. It took us into demonstrations and opportunities for SMC community distributor, and give the remaining what community distributors observed of cultural and contextual barriers.
This component of the intervention required
another round of training materials implementers to practise. two doses of AQ over the following two days. — they give them instructions and
”
significant adaptations to provide training in an
adaptation; how do we deliver online If a child is very sick, or has an allergy or a fever, monitor. No quality issues.
IPC-compliant way. In many locations, due to
to still maintain quality and be able to the child is referred to the health facility to be (Ministry of Health staff) No single IPC measure will provide full
travel restrictions, the training-of-trainers shifted It is also important to clearly communicate and protection from transmission of airborne
certify people being trained as having evaluated.
from the trainer being physically present to explain the rationale behind the IPC measures infections. Full adherence to all IPC measures
completed it and understood what For SMC community distributors, physical
virtual facilitation. This new mode of working and and adaptations to the SMC protocol during by all SMC implementers is not always practical
they were trained on? Health facility SMC training. Due to the COVID-19 pandemic, the SPAQ distancing and disinfecting items presented
learning posed several challenges, particularly the and cannot be assumed. Consequently, effective
health workers were also trained online administration procedure was adapted to comply cultural challenges that hindered adherence to
need for all participants, including the trainer, to protection requires a mix of complementary IPC
but for community health workers, with the IPC guidance, while maintaining DOT. IPC guidelines during SPAQ distribution.
measures, including physical distancing, hand
learn an entirely new platform (such as Microsoft
because of the challenge with them Rather than community distributors preparing
“very
Teams or Zoom). Other issues included internet hygiene and wearing of face masks.
not being familiar with the technology, the first dose of SPAQ and giving it to the child, Using disinfectant on surfaces is
connectivity, poor bandwidth and background
we conducted their training at the they were asked to place the medication blister odd in the community where
noise issues, which were perceived as disruptive;
community level, still face-to-face packs on a table or mat and instruct the caregiver people don’t even own furniture and
language barriers, especially in Mozambique The unanimous perception among respondents
but maintained physical distancing, to prepare and administer the medications. place items on the floor. Often, the
where training was being delivered for the first was that SMC coverage had not been affected by
reduced number of people in a class, it Community distributors stood two metres away disinfectant stayed in storage at the
time; and the absence of certain participatory complying with the IPC guidance. Administrative
was done outside in the shade, not in and wore masks. health facilities, where staff did use
adult training techniques, for example, in-person
demonstrations, role plays and trainer observation
an enclosed space. This was to ensure
that SMC still happens because people Respondents’ perceptions varied on whether
it.”
(Malaria Consortium staff)
coverage data as well as household surveys
conducted in 2020 showed generally high
”
of trainees completing tasks. Because of limited coverage and no substantial difference compared
still needed to receive these services. caregiver drug administration facilitated or
access to internet and IT equipment and support, A few respondents mentioned the importance with previous years.[19] To date, there is no
(Malaria Consortium staff) hindered a child accepting the medications. Some
trainings at the lower health system levels of context in deciding which COVID-19-related indication that SMC implementation may have
felt that because caregivers know their children
remained in-person. However, strict IPC measures commodities would be most appropriate to contributed to the transmission of SARS-CoV-2 in
better than community distributors do, children
were applied; for example, limiting participant provide. For instance, hand sanitiser is more the implementation settings.
would be more likely to accept the medicines
numbers per training. Moreover, job aids and appreciated in locations where water is scarce,
from a caregiver. They, therefore, felt this should
training tools needed to be adapted to comply and it would be difficult to utilise bars of soap
be a permanent change to the way that SPAQ
with COVID-19 IPC guidance, and to be user- and buckets for hand hygiene.
is administered in SMC campaigns, beyond the
friendly in different languages and contexts.
context of the pandemic. Other respondents
Several factors reportedly facilitated compliance,
“We believed that because community distributors are
didn’t know we could implement including: the protection of self and communities;
more experienced at preparing and administering
not in-person meetings, trainings, but frequent reminders; support and supervision;
the medication, the change to caregiver
we can. Short videos of each training provision of requisite COVID-19-related
administration of SPAQ on day one might hinder
module are helpful. It is best to send commodities, which was perceived to create a
uptake.
information to WhatsApp as a way of compliance-friendly environment; knowledge
refreshing; videos are a good way to and understanding of SARS-CoV-2 transmission
A few respondents expressed concerns that, to
refresh knowledge. Virtual meetings are and the COVID-19 disease; and the general
minimise contact, community distributors may
too long, and people leave sometimes. embeddedness of national COVID-19 measures
deliver SPAQ blister packs to caregivers without
It is important still for high-level prior to the start of the SMC campaign.
”
directly observing the drug administration, and
meetings to be face-to-face.
give little information about SMC and COVID-19
(Malaria Consortium staff)
to caregivers. Also, it may not be practical for
community distributors to adhere to physical
At an SMC launch event in Malema district in Mozambique, community members look
13 on as DOT is carried out. All community distributors and supervisors undergo essential 14
training prior to the start of the SMC campaign.LESSONS
Supervision Another respondent reflected that the COVID-19
pandemic expedited a shift from paper-based to
Supervision is an integral part of delivering high-
quality SMC campaigns. Despite the pandemic,
digital systems, which had a beneficial knock-on field presence of supervisors is required, but
During SPAQ distribution, trained facility- strict IPC guidelines have to be applied.
based health workers and supervisors oversee effect for reporting in Nigeria.
“We
the work of community distributors. Both
community distributors and supervisors collect
now avoid pieces of paper and Supervision is also an important mechanism for
administrative monitoring data and SPAQ
there has been a faster shift towards reinforcing adherence to IPC measures among
accountability data.
digitalisation. Which was happening community distributors. Supervisors need to
already, but COVID-19 has sped up this understand the rationale and practicalities
Given that IPC guidelines applied to both process. ”
(Malaria Consortium staff)
and they need to be present in the field to
provide constructive feedback to community
supervisors and community distributors, field
distributors.
supervision continued despite the pandemic.
However, travel restrictions and the physical
distancing guidelines led to some changes in the The pandemic has underlined the need to
presence and frequency of in-person supervision. increase the use of digital tools to strengthen
In Nigeria, a benefit to changes in supervision was SMC delivery.
that the supervisors of supervisors were required
to complete electronic forms — which had a
date and time stamp — to minimise contact with
paper-based items. This may have encouraged
their physical presence in the field. A separate
adaptation that provided supportive supervision
involved sending SMS messages to community
distributors to enhance adherence to COVID-19
IPC measures.
Compliance in Nigeria: Variation across states A community distributor maintains a two-metre
distance from a caregiver and child during SPAQ
administration in the 2020 SMC campaign in Nigeria.
“SMC is designed to be implemented
by community volunteers who are not
“For the first cycle in July, panic [about COVID-19 They were not as comfortable and made it hard
transmission] was high. The community to breathe, especially in the hot weather. The educated, and the design is to support
distributors and ad hoc staff were happy to have donor only approved cloth so they couldn’t them by a more closely oriented
support and comply. They were all provided afford the medical masks. In Katsina, we had supervisor. However, due to COVID, we
with masks and hand sanitiser and happy to to reinforce compliance. Here, there is an extra had to minimise supervision and there
practise the guidance. There was also strict level of supervisor as the state funds additional was less physical supervision. However,
supervision. They don’t see themselves as being supervisors. The LGAs [local government areas] at the same time, for the supervisors
forced to comply; they see it as a safety measure and communities enforce the use of face masks. of the supervisors, who now had to
and comply 100 percent. In Kano, there is the This is also included now in the processing fill out electronic forms on a device,
best adherence, it is not difficult. This was checklist for supervisors, and there is a feedback as opposed to the pre-COVID paper-
the epicentre, so awareness was everywhere. loop for compliance. based manual forms that digitally
The community distributors are aware of the recorded a time and location stamp,
harm and risk. They saw masks as a way to Engagement included targeted advocacy as perhaps this pushed them more to the
protect themselves. At the state level, there was COVID-19 measures may impact acceptability. field than in previous times because
training on COVID-19 and mask use became Traditional rulers were engaged, and the radio their actions were being recorded, so a
a norm. In Yobe, this was the second best for house broadcast messages. People demand SPAQ positive effect. ”
(Malaria Consortium staff)
compliance, and it was more difficult. The face coverage.”
masks were cloth and reusable, not surgical.
(Malaria Consortium staff)
A blister pack containing SPAQ medication. A full course of SPAQ confers a high degree of protection from malaria infection for
approximately 28 days.
15 16Seasonal malaria References
1. WHO. World Malaria Report 2020: 20 years of global progress and challenges. Geneva: WHO; 2020.
chemoprevention in 2021 2.
3.
WHO. The potential impact of health service disruptions on the burden of malaria: A modelling analysis for countries in sub-Saharan Africa. Geneva: WHO;
2020.
Meremikwu MM, Donegan S, Sinclair D, Esu E, Oringanje C. Intermittent preventive treatment for malaria in children living in areas with seasonal
transmission. Cochrane Database of Systematic Reviews CD003756. https://doi.org/10.1002/14651858.CD003756.pub4. Also: WHO. Seasonal malaria
chemoprevention (SMC). [2017 May 01; cited 2019 Jan 25]. Available from: https://www.who.int/malaria/areas/preventive_therapies/children/en/.
4. ACCESS-SMC Partnership. Effectiveness of seasonal malaria chemoprevention at scale in west and central Africa: An observational study. The Lancet. 2020;
396(10265): 1829–40.
This learning exercise served to document how taking into account emerging evidence. Malaria We welcome the opportunity to work with
5. WHO. World Malaria Report 2019. Geneva: WHO; 2019.
a multi-country community-based intervention Consortium and its partners are well prepared for our partners to shape and improve the SMC
6. Gilmartin C, Nonvignon J, Cairns M, Milligan P, Bocoum F, Winskill P, et al. Seasonal malaria chemoprevention in the Sahel subregion of Africa: A cost-
at scale was adapted during a global pandemic, this and we plan to expand the SMC programme campaign, disseminate learning across the public effectiveness and cost-savings analysis. The Lancet Global Health, 2021; 9 (2). Available from: https://doi.org/10.1016/S2214-109X(20)30475-7.
as well as what worked well and what could in 2021 to reach 16 million children under the health community, and ensure that the campaign 7. Malaria Consortium. Seasonal malaria chemoprevention: Protecting children under five from malaria during peak transmission season. Project brief. London:
be improved, for organisational learning and age of five in Burkina Faso, Chad, Nigeria, Togo, is implemented safely with the full support of the Malaria Consortium; 2020. Available from: https://www.malariaconsortium.org/resources/publications/1366/seasonal-malaria-chemoprevention-protecting-
dissemination among the wider SMC, malaria and Mozambique and — starting in 2021 — global SMC community. We believe that children-under-five-from-malaria-during-peak-transmission-season.
global health community. Uganda. it is more important than ever to build 8. Malaria Consortium. Assessing the feasibility, acceptability and impact of seasonal malaria chemoprevention in Mozambique. Synopsis. London: Malaria
on the learnings and successes of 2020 Consortium; 2020. Available from: https://www.malariaconsortium.org/resources/publications/1372/assessing-the-feasibility-acceptability-and-impact-of-
seasonal-malaria-chemoprevention-in-mozambique.
There are positive signs and the global to make the 2021 SMC campaign the
9. Malaria Consortium. Malaria Consortium’s seasonal malaria chemoprevention program: Philanthropy report 2020. London: Malaria Consortium; 2021.
community is making significant strides in most extensive and beneficial to date. Available from: https://www.malariaconsortium.org/resources/publications/1430/malaria-consortium--s-seasonal-malaria-chemoprevention-program-
the fight against COVID-19; however, viral philanthropy-report-2020.
transmission, morbidity and mortality of the 10. WHO. Listings of WHO’s response to COVID-19. [2020 Jun 29]. Available from: https://www.who.int/news/item/29-06-2020-covidtimeline.
disease remain threats globally in 2021. We are 11. Prevent Epidemics. Update on COVID-19 in Africa. 2020 Aug 26. Available from: https://preventepidemics.org/covid19/science/insights/update-on-covid-19-
determined to continue our work with national in-africa/.
malaria control and elimination programmes and 12. Akinwotu E. Experts sound alarm over lack of Covid-19 test kits in Africa. The Guardian [online]. 2020 May 29. [Retrieved 2020 May 29]. Available from:
implementing partners to deliver the campaign https://web.archive.org/web/20200529155322/https:/www.theguardian.com/global-development/2020/may/26/africa-concerned-over-lack-of-coronavirus-
testing-kits.
safely, drawing on our technical expertise and
13. WHO. Tailoring malaria interventions in the COVID-19 response. Geneva: WHO; 2020.
experience, and our lessons learnt in 2020, while
14. Malaria Consortium [internet]. Our statement on COVID-19 and SMC; 2020. [Cited 2021 Mar 5]. Available from: https://www.malariaconsortium.org/blog/
our-statement-on-covid-19-and-smc/#_edn1.
15. RBM Partnership to End Malaria. Adapting seasonal malaria chemoprevention in the context of COVID-19: Operational guidance. 2020. Available from:
https://www.malariaconsortium.org/resources/publications/1336/adapting-seasonal-malaria-chemoprevention-in-the-context-of-covid-19-operational-
guidance.
16. Malaria Consortium. Steps for using infection prevention and control to deliver SMC during COVID-19 pandemic. London: Malaria Consortium; 2020.
Available from: https://www.malariaconsortium.org/gallery-file/06170924-10-smc_covid19jobaid.pdf.
17. Malaria Consortium. Assessing adherence to infection prevention and control measures for seasonal malaria chemoprevention during COVID-19. 2020.
London: Malaria Consortium; 2020. Available from: https://www.malariaconsortium.org/resources/publications/1383/assessing-adherence-to-infection-
prevention-and-control-measures-for-seasonal-malaria-chemoprevention-during-covid-19.
18. Richardson S, Ibinaiye T, Nikau J, Oresanya O, Marasciulo M, Roca-Feltrer A, et al. COVID-19 knowledge, beliefs, prevention behaviours and misinformation in
the context of an adapted seasonal malaria chemoprevention campaign in six northern Nigerian States. Tropical Medicine and Health, 2020; 48(101): https://
doi.org/10.1186/s41182-020-00288-7.
19. Malaria Consortium. Quantitative report on seasonal malaria chemoprevention supported by Malaria Consortium in 2020: Coverage and quality in Burkina
Faso, Chad, Nigeria and Togo. London: Malaria Consortium; 2021. Available from: https://www.malariaconsortium.org/resources/publications/1429/
quantitative-report-on-seasonal-malaria-chemoprevention-supported-by-malaria-consortium-in-2020-coverage-and-quality-in-burkina-faso-chad-nigeria-
-and-togo.
© Malaria Consortium / April 2021
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Community distributors in Mozambique, where the SMC campaign was implemented for the first time in 2020.
Contact: info@malariaconsortium.org
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