From evidence to policy: how the MULTIPLY study is transforming malaria prevention in young children

The MULTIPLY project provides strong, real-world evidence that perennial malaria chemoprevention (PMC) can be effectively delivered through routine immunisation services to reduce malaria burden in young children. Designed as a multi-country implementation study embedded within national health systems, MULTIPLY evaluated the delivery of sulfadoxine–pyrimethamine (SP) during routine Expanded Programme on Immunisation (EPI) contacts in Sierra Leone, Mozambique, and Togo.

Over two years, approximately 45,000 children under two years old were targeted across 67 health facilities. The study adapted PMC delivery to fit national contexts, expanding to six doses in Sierra Leone and Mozambique and introducing a four-dose schedule in Togo. Ministries of Health and national malaria and immunisation programmes were closely involved in implementation, ensuring alignment with existing systems and policies.

Findings show that PMC delivery through routine EPI platforms is feasible, acceptable, and capable of achieving substantial coverage. More than 55% of children received at least three doses; however, full dosing schedules remained below 50%, highlighting operational challenges in sustaining extended regimens. Evidence from cohort studies and routine data indicates reductions in malaria infection and clinical episodes, with additional benefits for anaemia and hospital admissions in some settings. The intervention was well accepted by caregivers and healthcare workers, who valued its integration into routine services. Cost-effectiveness analyses suggest that PMC can be delivered at relatively low additional cost by leveraging existing infrastructure, offering good value for money in high-burden settings. Importantly, molecular surveillance found no significant increase in key SP resistance markers after two years of implementation, supporting the safety of expanded PMC use while emphasising the need for ongoing monitoring.

MULTIPLY has already influenced national policy. Sierra Leone is preparing to expand its PMC schedule to six doses, Togo has adopted a four-dose strategy in high-transmission areas, and Mozambique has incorporated PMC into its national malaria strategy. At the global level, the findings are informing WHO discussions on malaria chemoprevention and its integration with evolving immunisation schedules.

By embedding PMC research within routine systems and maintaining strong policy engagement, MULTIPLY demonstrates how implementation research can accelerate the uptake of life-saving interventions. The project provides a scalable model for integrating malaria prevention into child health systems and advancing progress towards reduced child mortality in high-burden settings.