Footnotes for "IPTi for malaria: a promising intervention with likely room to scale"

[1] “Although the effect size varied over time and between drugs, overall IPTi impacts on the incidence of clinical malaria overall, with a 30% reduction (rate ratio 0.70, 0.62 to 0.80; 10 studies, 10,602 participants).” Esu, Oringanje, and Meremikwu 2021, "Main results."

[2] "WHO is now recommending a new intervention against Plasmodium falciparum malaria: Intermittent Preventive Treatment for infants (IPTi). Intermittent Preventive Treatment in infancy with SP (SP-IPTi) is the administration of a full therapeutic course of SP delivered through the Expanded Program on Immunization (EPI) at defined intervals corresponding to routine vaccination schedules – usually at 10 weeks, 14 weeks, and ∼9 months of age – to infants at risk of malaria." WHO, Policy recommendation on Intermittent Preventive Treatment during infancy with sulphadoxine-pyrimethamine (SP-IPTi) for Plasmodium falciparum malaria control in Africa, 2010, p. 1

[3] “However, to date, only Sierra Leone has implemented IPTi at a national scale. The country adopted the intervention in 2016, piloting it in two then four districts before national roll-out in 2018.” WHO, Technical consultation to review the role of drugs in malaria prevention for people living in endemic settings: meeting report, 2020, p. 10

[4] "At the central level, there is support to decrease the burden of malaria in infants, and implementation through routine immunization should ensure access for the target population. Integration of IPTi into immunization services, including outreach sessions, adds a preventive intervention and could increase coverage of both interventions in communities. However, careful coordination is required for training, supply and time management. As with IPTp, coordination is required between the established delivery platform, i.e., the routine immunization services, and the national malaria programme. The success of an IPTi programme will depend on strong leadership within the national and subnational EPI teams.” WHO, Technical consultation to review the role of drugs in malaria prevention for people living in endemic settings: meeting report, 2020, p. 11

[5] “The recommendation that IPTi should not be implemented in areas with high prevalence of molecular markers of SP resistance was seen as the primary barrier to its implementation for two reasons. First, the requirement for countries to measure molecular markers to determine the applicability of IPTi in their setting may be a barrier, as markers of SP resistance are no longer routinely monitored. Second, the prevalence of molecular markers of drug resistance may not correlate with the effectiveness of chemoprevention, as has been acknowledged with IPTp. However, caution is required in extrapolating findings from semi-immune pregnant women to nonimmune infants.” WHO, Technical consultation to review the role of drugs in malaria prevention for people living in endemic settings: meeting report, 2020, p. 11

[6] “Paediatric drug formulation: The pilot implementation studies found that, although it was possible to cut and crush SP tablets for administration to young infants, this was a cumbersome process. A paediatric formulation has been developed for SMC, which would make for much easier administration. The importance of ensuring adequate dosing and of understanding the pharmacokinetics in the target age group was recognized.” WHO, Technical consultation to review the role of drugs in malaria prevention for people living in endemic settings: meeting report, 2020, p. 12

In April 2021, a dispersible SP tablet at the appropriate dosage for infants was added to WHO's list of prequalified medicinal products. See the second bullet and accompanying footnotes under "The intervention" on our grant page.

[7] See our program review on IPTi, "What is the problem?": "Malaria is the fourth largest cause of death for children under 5 in sub-Saharan Africa, accounting for 12% of deaths."

[8] As of early 2022, we are primarily looking to recommend grants that we estimate are 8 or more times as cost-effective as GiveDirectly's unconditional cash transfer program, and are willing to consider recommending a limited amount of funding to grants that are between 5 and 8 times as cost-effective as GiveDirectly. For examples of the cost-effectiveness of our recommendations, see here.

[9] ICAP, a research group at Columbia University, has supported the scale-up of IPTi in Sierra Leone in the past, and other organizations have been funded to implement small-scale IPTi pilot programs for research purposes. See here for more details.

[10] See the proposal from PATH and Malaria Consortium here.

[11] "Twenty-nine countries accounted for 96% of malaria cases globally, and six countries – Nigeria (27%), the Democratic Republic of the Congo (12%), Uganda (5%), Mozambique (4%), Angola (3.4%) and Burkina Faso (3.4%) – accounted for about 55% of all cases globally." WHO, World Malaria Report 2021, p. xv

[12] The funding for this study was provided by an individual donor. For more information about the grant recommendation, see this page.

[13] We estimate about $34 million in potential room for more funding in Nigeria and $16 million in potential room for more funding in DRC. See our calculations here.

[14] See here in our preliminary cost-effectiveness analysis. This is substantially higher than the estimates we've seen in the academic literature on IPTi, which we believe may be underestimating costs; see footnote 36 in the cost-effectiveness section of our program review of IPTi.

[15] In 2020, GiveWell donors contributed over $240 million to our recommended charities. Of that total, about $69 million was directed to Malaria Consortium and about $61 million was directed to AMF. See the tables in the "Money Moved" section of our impact page.

[16] "Globally, malaria deaths reduced steadily over the period 2000–2019, from 896 000 in 2000 to 562 000 in 2015 and to 558 000 in 2019. In 2020, malaria deaths increased by 12% compared with 2019, to an estimated 627 000.

"The percentage of total malaria deaths in children aged under 5 years reduced from 87% in 2000 to 77% in 2020." WHO, World Malaria Report 2021, p. xvi.

[17] "There were an estimated 14 million more malaria cases and 47 000 more deaths in 2020 compared to 2019, due to disruptions to services during the pandemic. However, things could have been far worse if not for the efforts of malaria endemic countries to maintain services.

"Even before the pandemic, global progress against malaria had levelled off, and countries with a high burden of the disease were losing ground. Since 2015, the baseline of WHO’s global malaria strategy, 24 nations have registered increases in malaria mortality. Now, critical 2020 milestones of WHO’s global malaria strategy have been missed, and without immediate and dramatic action, the 2030 targets will not be met.

"Compounding the need for urgent action, this report also includes sobering new estimates of malaria’s toll on children under 5 years of age in sub-Saharan Africa, where a vast majority of malaria deaths occur each year. Using better data and more accurate methodology, it suggests the disease has claimed many more young lives over the past two decades than previously reported." WHO, World Malaria Report 2021, p. vi

[18] See our reviews of the evidence on AMF's program and Malaria Consortium's SMC program.

[19] See, for instance, the WHO guidelines to determine where SMC should be implemented in the "What is the program?" section of our review of SMC. See also a discussion of drug resistance in the "Possible negative/offsetting impacts" section of that page, and a discussion of insecticide resistance in the same section of our review of insecticide-treated nets.

[20] For example, WHO doesn't recommend that IPTi and SMC be administered in the same area. See the "What is the program?" section of our review of IPTi.

[21] For example, WHO recommends using a package of several interventions: "The World Health Organization (WHO) Global Technical Strategy for Malaria 2016–2030 (WHO-GTS) sets the goal of universal access to malaria prevention, treatment and diagnosis. This includes a core package of recommended interventions for reducing malaria-related morbidity and mortality: diagnosis and treatment of clinical and severe malaria, vector control with long-lasting insecticide-treated bed nets (LLINs) or indoor residual spraying (IRS) and chemoprevention for high-risk groups (infants, children in areas of seasonal transmission, pregnant women)." Winskill et al. 2019, p. 1

[22] These numbers refer to grants made in GiveWell's "metrics year" 2021, February 2021 through January 2022, not the calendar year 2021. They do not include another $7.5 million in donations earmarked by donors for AMF and Malaria Consortium, or donations made directly to these charities based on GiveWell's recommendation, for which we don't yet have data. We're drawing these numbers from our internal records, since we don't yet have a single, easily interpretable public source for them.

[23] See this spreadsheet for calculations.