Remark:

• Post-discharge malaria chemoprevention (PDMC) should be given to children following admission with severe anaemia [156] that is not due to blood loss following trauma, surgery, malignancy or a bleeding disorder.
• PDMC implementation should be tailored to admissions of children with severe anaemia and consider the duration of protection of the selected antimalarial, and the feasibility and affordability of delivering each additional PDMC course (see “Practical info”).
• Moderate to high perennial malaria transmission settings are defined as areas with a P. falciparum parasite prevalence greater than 10% or an annual parasite incidence greater than 250 per 1000 [29]. These thresholds are indicative and should not be regarded as absolute for determining applicability of the PDMC recommendation.

Practical info Antimalarial medicine Medicines used for PDMC can be the same as the first-line malaria treatment, but an alternative medicine is preferred. SP, AL and DHAP were used in three trials and all regimens were found to be effective for PDMC (Phiri et al unpublished evidence). Age group Local data on the age distribution of severe anaemia should be referenced when determining the target age group for PDMC. Two studies evaluated PDMC doses in children under 59 months [157][158], and one study evaluated doses in children aged 3 months to 9 years [159]. Dosage Children on PDMC should receive a complete course of antimalarials at the recommended treatment dose. The drug dosage should be determined by the child’s weight wherever possible, with dosing according to age only in situations where the child’s weight is unknown or cannot be determined. Frequency The frequency of PDMC administration should be informed by the length of protective efficacy of the selected drug, the duration of the transmission season, and the feasibility of delivering each additional PDMC treatment. Two of the three trials providing evidence for this recommendation provided three PDMC treatments. One trial administered SP monthly starting seven days post-discharge until the end of the transmission season [159]; another trial administered AL at discharge then twice at four and eight weeks post-discharge [157]; and the third trial administered AL at discharge and then DHAP three times starting 14 days post-discharge and then monthly [158]. Delivery Two delivery approaches for PDMC were evaluated in one effectiveness study: community-based and facility-based delivery strategies. For community-based delivery, caregivers received all courses of PDMC on discharge, whereas for facility-based delivery, the caregiver had to collect the PDMC drugs from a health facility each month. Community-based delivery was preferred by caregivers and associated with increased adherence compared to facility-based strategies (community:70.6% vs. facility: 52.0%, p = 0.006) [160]. Caregivers felt that the instructions on PDMC administration written on the child’s health card were sufficient without reminders via text message or from community health workers (CHWs). There was no statistical evidence that SMS reminders resulted in greater adherence (incidence rate ratio: 1.03; 95% CI:

• 0.88–1.21; p = 0.68) [161]. Drug resistance The impact of drug resistance on the protection provided by PDMC is currently unclear. A relatively small proportion of the population is eligible for PDMC compared to other malaria chemoprevention interventions such as SMC, PMC or IPTp. Hence, the selective pressure exerted by PDMC on the parasite population, and consequent risk of PDMC increasing resistance to antimalarials across the population, is likely to be small. Contraindications Individuals should not receive both PDMC and other forms of malaria chemoprevention (e.g. SMC, PMC or MDA). If other malaria chemoprevention programmes are unable to effectively screen and exclude individuals receiving PDMC, then PDMC should not be administered during periods when SMC, PMC or MDA are being provided. Children with sickle cell disease should be included in PDMC, unless they are already receiving regular chemoprevention due to sickle cell disease. PDMC is not recommended in children who develop severe acute illness following discharge, those who are unable to take oral medication, children who during the last 30 days received a dose of any of the drugs being used for PDMC, or those allergic to any of the drugs being used for PDMC. PDMC-SP should not be given to individuals receiving a sulfa-based medication as treatment or prophylaxis, including co-trimoxazole (trimethoprim–sulfamethoxazole) for HIV. Other considerations Information about PDMC should be fully accessible to caregivers. As with all health interventions, consent should be obtained from the caregiver on behalf of the child prior to administration of PDMC.