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Monthly sulfadoxine/pyrimethamine-amodiaquine or dihydroartemisinin-piperaquine as malaria chemoprevention in young Kenyan children with sickle cell anemia: A randomized controlled trial.

Publication ,  Journal Article
Taylor, SM; Korwa, S; Wu, A; Green, CL; Freedman, B; Clapp, S; Kirui, JK; O'Meara, WP; Njuguna, FM
Published in: PLoS Med
October 2022

BACKGROUND: Children with sickle cell anemia (SCA) in areas of Africa with endemic malaria transmission are commonly prescribed malaria chemoprevention. Chemoprevention regimens vary between countries, and the comparative efficacy of prevention regimens is largely unknown. METHODS AND FINDINGS: We enrolled Kenyan children aged 1 to 10 years with homozygous hemoglobin S (HbSS) in a randomized, open-label trial conducted between January 23, 2018, and December 15, 2020, in Homa Bay, Kenya. Children were assigned 1:1:1 to daily Proguanil (the standard of care), monthly sulfadoxine/pyrimethamine-amodiaquine (SP-AQ), or monthly dihydroartemisinin-piperaquine (DP) and followed monthly for 12 months. The primary outcome was the cumulative incidence of clinical malaria at 12 months, and the main secondary outcome was the cumulative incidence of painful events by self-report. Secondary outcomes included other parasitologic, hematologic, and general events. Negative binomial models were used to estimate incidence rate ratios (IRRs) per patient-year (PPY) at risk relative to Proguanil. The primary analytic population was the As-Treated population. A total of 246 children were randomized to daily Proguanil (n = 81), monthly SP-AQ (n = 83), or monthly DP (n = 82). Overall, 53.3% (n = 131) were boys and the mean age was 4.6 ± 2.5 years. The clinical malaria incidence was 0.04 episodes/PPY; relative to the daily Proguanil group, incidence rates were not significantly different in the monthly SP-AQ (IRR: 3.05, 95% confidence interval [CI]: 0.36 to 26.14; p = 0.39) and DP (IRR: 1.36, 95% CI: 0.21 to 8.85; p = 0.90) groups. Among secondary outcomes, relative to the daily Proguanil group, the incidence of painful events was not significantly different in the monthly SP-AQ and DP groups, while monthly DP was associated with a reduced rate of dactylitis (IRR: 0.47; 95% CI: 0.23 to 0.96; p = 0.038). The incidence of Plasmodium falciparum infection relative to daily Proguanil was similar in the monthly SP-AQ group (IRR 0.46; 95% CI: 0.17 to 1.20; p = 0.13) but reduced with monthly DP (IRR 0.21; 95% CI: 0.08 to 0.56; p = 0.002). Serious adverse events were common and distributed between groups, although compared to daily Proguanil (n = 2), more children died receiving monthly SP-AQ (n = 7; hazard ratio [HR] 5.44; 95% CI: 0.92 to 32.11; p = 0.064) but not DP (n = 1; HR 0.61; 95% CI 0.04 to 9.22; p = 0.89), although differences did not reach statistical significance for either SP-AQ or DP. Study limitations include the unexpectedly limited transmission of P. falciparum in the study setting, the high use of hydroxyurea, and the enhanced supportive care for trial participants, which may limit generalizability to higher-transmission settings where routine sickle cell care is more limited. CONCLUSIONS: In this study with limited malaria transmission, malaria chemoprevention in Kenyan children with SCA with monthly SP-AQ or DP did not reduce clinical malaria, but DP was associated with reduced dactylitis and P. falciparum parasitization. Pragmatic studies of chemoprevention in higher malaria transmission settings are warranted. TRIAL REGISTRATION: clinicaltrials.gov (NCT03178643). Pan-African Clinical Trials Registry: PACTR201707002371165.

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Published In

PLoS Med

DOI

EISSN

1549-1676

Publication Date

October 2022

Volume

19

Issue

10

Start / End Page

e1004104

Location

United States

Related Subject Headings

  • Sulfadoxine
  • Pyrimethamine
  • Proguanil
  • Male
  • Malaria, Falciparum
  • Malaria
  • Kenya
  • Infant
  • Hydroxyurea
  • Humans
 

Citation

APA
Chicago
ICMJE
MLA
NLM
Taylor, S. M., Korwa, S., Wu, A., Green, C. L., Freedman, B., Clapp, S., … Njuguna, F. M. (2022). Monthly sulfadoxine/pyrimethamine-amodiaquine or dihydroartemisinin-piperaquine as malaria chemoprevention in young Kenyan children with sickle cell anemia: A randomized controlled trial. PLoS Med, 19(10), e1004104. https://doi.org/10.1371/journal.pmed.1004104
Taylor, Steve M., Sarah Korwa, Angie Wu, Cynthia L. Green, Betsy Freedman, Sheila Clapp, Joseph Kipkoech Kirui, Wendy P. O’Meara, and Festus M. Njuguna. “Monthly sulfadoxine/pyrimethamine-amodiaquine or dihydroartemisinin-piperaquine as malaria chemoprevention in young Kenyan children with sickle cell anemia: A randomized controlled trial.PLoS Med 19, no. 10 (October 2022): e1004104. https://doi.org/10.1371/journal.pmed.1004104.
Taylor SM, Korwa S, Wu A, Green CL, Freedman B, Clapp S, Kirui JK, O’Meara WP, Njuguna FM. Monthly sulfadoxine/pyrimethamine-amodiaquine or dihydroartemisinin-piperaquine as malaria chemoprevention in young Kenyan children with sickle cell anemia: A randomized controlled trial. PLoS Med. 2022 Oct;19(10):e1004104.

Published In

PLoS Med

DOI

EISSN

1549-1676

Publication Date

October 2022

Volume

19

Issue

10

Start / End Page

e1004104

Location

United States

Related Subject Headings

  • Sulfadoxine
  • Pyrimethamine
  • Proguanil
  • Male
  • Malaria, Falciparum
  • Malaria
  • Kenya
  • Infant
  • Hydroxyurea
  • Humans