This paper presents the two-year-evaluation of intermittent preventive treatment for children (IPTc) combined with timely treatment at home for malaria control, targeting children aged 6 - 60 months old. The main finding at year-two-evaluation was a further reduction of about 66.6% (from 3.0% at year-one-evaluation to 1.0% at year-two-evaluation) in malaria prevalence in the study population compared to about 88.0% reduction reported between baseline and year-one-evaluation (25.0% at baseline and 3.0% at year-one-evaluation) . Compared to baseline (25.0%), year-two-evaluation shows a reduction of over 90.0% in parasite level in the study population. Several studies in IPT intervention measured clinical incidence rather than prevalence and found between 20% and 86.0% reduction with strong variations depending on transmission duration and intensity, target population and intervals between treatments [9–12, 15–18].
Anaemia in the children, defined as haemoglobin <10g/dl, further improved by 27.4% (from 16.8% at year-one evaluation to 12.2% at year-two evaluation). Compared to baseline, this was over 65.0% reduction in all cause anaemia prevalence in the study population. This compares well with a recent randomized trial in Tanzania, which showed that IPT given to infants at the time of childhood immunization reduced the incidence of the first episode of malaria and anaemia by more than 50.0% during the first year of life [11, 12]. However, the reduction in anaemia prevalence at year-two evaluation compared to year-one evaluation was not as dramatic as it was at year-one-evaluation compared to baseline. This could be attributable to the low level of parasitaemia observed after the year-one evaluation. Similar observation was also reported from The Gambia . Thus, at low prevalence, malaria may be contributing less to anaemia in children aged 6-60 months.
Malaria-related morbidity in the study population, expressed by the presence of fever and other malaria-related signs and symptoms reported, has reduced as captured either during prevalence surveys or IPTc administration. Timely treatment of febrile malaria cases in the community did not follow any pattern. However, it could be argued that the community assistants who were on hand to deliver effective treatment in a timely fashion have contributed to the marked reduction of parastaemia seen during evaluation surveys. A community randomized trial showed a slightly higher coverage in the community-based delivery arm compared to facility-based arm . This should encourage malaria control programmes to have confidence in community assistants to deliver timely treatment and possibly IPTc to children at community levels, once they are well trained by the programme, coupled with reference treatment card for easy and quick referencing when in doubt .
Findings reported here present a challenge to the existing practice, especially in most sub-Saharan African countries where malaria diagnosis is mostly based on presumption without confirmation. As community interventions or access to treatment increases, this may lead to fewer malaria infections, which may pose the danger of over diagnosis and treatment with expensive drugs for people who do not need them . Control programmes should therefore invest in rapid diagnostic test kits where microscopy is not possible. As reported by Zikusooka et al , this may lead to cost savings because artemisinin-based anti-malarial drugs are expensive. Goodman et al  also make this point, as rational use of anti-malarials will reduce the potential for emergence of resistance.
The use of IPTc combined with timely home treatment to control malaria was found to reduce malaria prevalence in children aged six to 60 months . Although this study cannot determine the contribution of IPTc or timely home treatment to the protection offered to the children because the two interventions were delivered concurrently, the two together in this study offered a major protection against malaria in children, reducing prevalence from 25.0% at baseline to 1.0% at year-two evaluation (twenty-four months of implementation). The question then is, at what point should the provision of IPTc stop? What techniques or methods could be used to mop-up the few parasites that may continue to sustain transmission, because the vector mosquito is highly efficient in malaria transmission?
At this point, it may be recommended to reduce the frequency of treatment from every four months to every six months or providing treatment at the beginning of each peak season (two peak seasons in southern Ghana). Either way, the timing must be related to the major peak season in the study area. At certain point it should be necessary to treat the general population at least once in a year to reduce the circulating parasites in the population such that mosquitoes will have very little or no parasite to transmit. Findings reported in this paper indicates that, with consistent efforts, malaria could be put under control such that it may no longer be a major public health problem, especially in sub-Sahara Africa where it is a threat to millions of people. Also, the study shows that it is possible to train community assistants to deliver IPTc together with home management of malaria on timely basis with very little supervision. However, additional training must be provided to enable community assistance to use RDT in the community so as to move away from presumptive treatment as malaria incidence continues to go down in communities.
One major limitation of the study was that rapid diagnostic test (RDT) was not used to confirm the presence of parasite before timely treatment was provided as a result of the ethical consideration not to allow field assistants to take blood from the children. Another weakness of the study is that there was no control group to compare the result so it was not possible to attribute all the reduction in parasite prevalence to the interventions. Also, the contribution of each of the intervention to the reduction of parasite prevalence in the study population was not measured. All these must be taken into consideration when designing s similar study in future.