Introduction to malaria in pregnancy

Epidemiology and control of
malaria during pregnancy in
sub-Saharan Africa

Mary Hamel, M.D.
Malaria Branch, CDC

Objectives

 Discuss the epidemiology of malaria during
pregnancy (MIP) in sub-Saharan Africa
 Describe intervention strategies, challenges
and successes
 Discuss MIP and HIV interactions and
strategies

Malaria during pregnancy

 50 million women in malaria endemic areas become
pregnant each year

 MIP estimated to account for:
• 400,000 cases of severe anemia in pregnant
women

Post-partum hemorrhage is a leading cause of maternal
mortality
• ~ 35% of preventable low birth weight (LBW)

LBW is risk for infant mortality
• 3-8% of infant mortality
• 75,000 - 200,000 infant deaths annually

Risks for MIP

 Primi- or secundi- gravida
• 1st or 2nd pregnancy, have not developed
pregnancy-specific acquired immunity
 HIV-positive women
• Eliminates gravidity-specific pattern
 Young maternal age (ex. adolescents)

Current strategies, challenges
and successes

Major strategies for malaria control
during pregnancy
 Drugs
• Intermittent preventive treatment during
pregnancy (IPTp)
• Febrile case management
 Insecticide Treated Nets (ITNs)

Intermittent Preventive
Treatment for pregnancy (IPTp)

IPTp to prevent MIP
 Rationale for IPTp

Prevents placental malaria (or clears established
placental infection), during period of rapid fetal growth
 Most commonly used regimen:
• Sulfadoxine-pyrimethamine (SP)
• At least 2 treatment doses (3 tablets) but best to have 3 or
more doses starting after quickening (~16 weeks
gestation), provided at least 4 weeks apart

Can be given monthly

Can be given until end of pregnancy
• HIV infected need at least 3 doses for benefit

None if taking daily septrin

IPTp to prevent MIP
 SP works for IPTp despite high SP resistance and
malaria treatment failures in young children
• Acquired immunity
• prevention vs. treatment
• Confusing for policy makers and health workers (HWs)
 Easily deliverable (single dose)
 Can be provided under directly observed therapy
(DOT) at clinic
 Well-tolerated, inexpensive
• Very few side effects
• Rarely Stevens Johnson Syndrome (SJS) if allergy

If mucosal lesions, rash, stop SP and see doctor

Why is IPTp implementable?
 In most African countries women attend
antenatal clinic (ANC)
 Typically begin ANC in 2nd trimester
 On average make 3-4 ANC visits during
pregnancy
 Ample time to provide at least 2 doses
 WHO recommendation to provide IPTp ~
1999

IPTp implementation
 In most countries, less than 20% of
pregnant women living at risk for
malaria receive at least 2 doses of SP
IPTp

Challenges in implementation:
IPTp Malawi
 IPTp adopted into policy ~ 1999
 2002: 21% recently pregnant women
presenting to deliver at the major
hospital in the capital city had received
2 doses IPTp

IPTp Malawi– Exploring poor uptake
Health worker survey
 Health workers (HW) reported:
• Women arrive at ANC late in pregnancy
• Women do not come to ANC
• Women refuse IPTp
• Women afraid to take IPTp on an empty
stomach
• SP out of stock or reserved for treatment

Women told to cut grass around compound
• No water in the clinic for IPTp DOT

Household survey
 90% of women visited ANC
 Women come to ANC beginning in 2nd
trimester
 Average number of visits = 4
 Women reported they go to ANC to get SP
and iron

Health facility survey
 SP in stock
 Nonetheless, women at clinic on day of
survey who were due for IPTp did not
receive IPTp

Health worker observation
 HWs confused about when IPTp should be
provided
• Old WHO recommendations confusing

Administer treatment dose of SP in 2nd and 3rd
trimester, not last 4 weeks of pregnancy
• HWs could not accurately estimate trimesters
• HWs could not determine last 4 weeks of
pregnancy

Not necessary, theoretical risk of kinicterus not
founded


Current WHO
recommendations for IPTp
 Beginning after quickening, provide at
least 2 doses of SP as IPTp no less
than 4 weeks apart

New IPTp policy in Malawi
 Memo circulated from MOH with new
guidelines, instructing HWs to follow them
 No change in SP supply, water supply,
community mobilization or information for
pregnant women
 6 months after new guidelines, HF survey
showed 71% of pregnant women had
received SP IPTp

IPTp in Kenya
 IPTp adopted 1998, and new guidelines
adopted in 2006
 Malaria Indicator Survey (MIS) 2007
• 13% of women received 2 doses of SP IPTp
 Similar results in western Kenya despite
HW re-training and community mobilization
 Similar memo circulated to health facilities
 Household survey: 41% of recently
pregnant women received 2 doses IPTp

MI NSTRY OF HEALTH
RefXX/YY/ZZ 10, December, 2010

To: District Medical Officer of Health

-X District

-Y District

-Z District

Medical Superintendant

- X District Hospital

-Y District Hospital

-Z District Hospital

Re: Scale up of Intermittent Preventive Treatment for Malaria in Pregnancy (IPTp)

The Malaria Indicator Survey of 2007 showed that despite good antenatal clinic attendance, only 21% of
women received the second dose of SP for IPTp. This is a commendable achievement from as low as 7%,
but needs to be increased to achieve internationally set targets of 80%.

Numerous studies now show that it is beneficial to receive more than 2 doses of SP IPTp. All facilities in
your district should now follow the current national guidelines on IPTp, which are:

1. All pregnant women should receive a treatment dose of IPTp at every antenatal clinic visit
unless they have received SP in the prior four weeks.
2. Women who visit monthly for antenatal clinic should receive SP.
3. SP can be given in the last four weeks of pregnancy without risk to the mother or the baby.
4. Additional doses of SP IPTp, above two doses, reduces malaria in pregnancy and is beneficial to
the baby.

After this memo, there will be a national survey which will measure among other things, the number of
women who receive 2 or more doses of IPTp. At that time, we hope to find over 85% of recently
pregnant women received at least 2-3 doses of SP for IPTp.

Scaling up proven
interventions is challenging
 We may know what works, but finding out
how to implement/scale-up is a different
issue
 Barriers perceived by HWs, policy makers,
NGOs, not always true barriers
 “Obvious” solutions don’t always work
• Re-training, community mobilization/education
 Measuring whether efforts are effective is
essential

Insecticide treated bed nets
(ITNs)

ITNs to prevent malaria in pregnancy
 40% reduction in malaria parasitemia
 50% reduction in severe malaria
anemia
 35% reduction in placental malaria
 30% reduction in LBW
 ITNs are life-saving

ITN scale up for MIP
 WHO recommended ITNS for prevention of
MIP ~ 1996
 Initially promoted through “social marketing”
• Radio spots, billboards, drama
• Subsidized, ~8USD per ITN initially, later $0.70/
net in ANC
 By 2005, after nearly a decade of ITN
promotion, <20% of pregnant women slept
under ITN in most countries
 Cost was major barrier

ITN scale up for MIP
 Beginning 2005, national ITN distribution
campaigns in many countries
• Often paired with measles campaigns
• Highly successful
 In Kenya, resulted in increase from 4% of
pregnant women sleeping under an ITN
in 2003, to 40% in 2007
 In many places, ITNs now provided free
to pregnant women in ANC

Strategy for ITN scale up for MIP
 Best approach combines strategies
• Social marketing to build demand
• Mass distribution campaigns every 3
years
• Continuous supply through ANC for newly
pregnant mothers

An ITN for mother, is an ITN for infant
• Others?

Case management of malaria in
pregnancy
 If fever, test for malaria and treat
 However, due to acquired immunity, in
areas of high malaria transmission, mother
may not be sick
• Reason behind IPTp
 Some hospitals offer screening blood
smears and treatment at ANC
• Typically only first visit

Drugs used for malaria treatment during
pregnancy in sub-Saharan Africa

Used frequently Used with caution
 Quinine  Artemether lumefantrine
 SP (AL or coartem)
 Any artemisinin
combination

Antimalarials contra-indicated in
pregnancy

 Tetracycline
 Doxycycline
 Halofantrine
 Primaquine
 Tafenoquine

Malaria in Pregnancy and HIV
 In sub-Saharan Africa, 55% of HIV
infected adults are women of
reproductive age
 Malaria and HIV interact in ways that
are bad for both the mother and the
neonate

MIP and HIV Interaction
 HIV infected pregnant women have
increased
• Peripheral and placental parasitemia
• Malaria parasite densities
• Febrile illnesses
• Severe anemia
• Adverse birth outcomes

Low birth weight, preterm birth, IUGR
 Acquired immunity resulting in partial
protection to multigravidae lost

MIP and HIV Interaction
 Conflicting results regarding MIP and
HIV transmission to baby

HIV and Malaria Preventive
Strategies
 Prevention of Mother to Child
Transmission of HIV strategies
 Daily septrin for prevention of
opportunistic infections protects
against malaria in pregnancy
• IPTp with SP not required and
contraindicated – two sulfa drugs
 If unknown status in area of high HIV
prevalence, test, or provide at least 3
doses SP IPTp

Malaria in Pregnancy
Conclusions
 Although preventable, a serious public health
problem, associated with anemia, low birth
weight, and infant deaths

 A limited number of effective interventions exist
• ITNs, IPTp, case management, daily septrin for HIV
infected women

 Implementation and scale up is challenging
• Evaluation of efforts is essential to ensure gains are
made

Introduction to malaria in pregnancy

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