SMC adherence collapses after day 1: only 20% of children complete the 3-day course

Seasonal malaria chemoprevention (SMC) requires children in the Sahel to take sulfadoxine-pyrimethamine plus a 3-day course of amodiaquine monthly during the 4-month rainy season. The first dose is observed by a community health worker, but the second and third daily doses are given to caregivers to administer at home. Studies in Niger found that only about 20% of children had complete adherence to all three doses. This matters because subtherapeutic drug levels from incomplete courses provide just enough drug pressure to select for resistant parasites without clearing the infection. The child remains partially protected at best, and each incomplete course is a resistance-breeding event at scale across millions of children. SMC reaches approximately 50 million children across the Sahel, so 80% non-adherence means roughly 40 million incomplete treatment courses per cycle, four times per season. The problem persists because caregivers in rural Sahel communities face competing demands: agricultural labor during rainy season peaks, caring for multiple children, and a lack of understanding that all three doses are critical. The bitter taste of amodiaquine causes vomiting in children, discouraging caregivers from administering subsequent doses. Nomadic populations in the Sahel are often missed entirely by door-to-door distribution campaigns.