Scaling Up Malaria in Pregnancy Services in Tanzania

1
Scaling Up Malaria in Pregnancy Services in
Tanzania

• Patricia P. Gomez
• Clinical Specialist, ACCESS Program/JHPIEGO

2
Acknowledgments

• The ACCESS/Tanzania team
• Maryjane Lacoste
• Muthoni Magu-Kariuki
• Gaudiosa Tibaijuka
• The ACCESS/Baltimore team
• Natalie Hendler
• Nancy Caiola
• Barbara Rawlins
• Sarla Chand
• Steve Bruno

3
Overview

• What is the ACCESS Program?
• Why is MIP important to address?
• What are Tanzanias health indicators?
• Why scale up MIP services?
• How are MIP services being scaled up?
• What has the program accomplished and learned,
  and where does it go from here?

4
The ACCESS Program

• Access to clinical and community maternal,
  neonatal and womens health services
• 5-year, 75 million USAID flagship maternal and
  newborn health program
• Partners JHPIEGO, Save the Children-US,
  Constella Futures, Academy for Educational
  Development, American College of Nurse-Midwives,
  IMA World Health
• Goals advocacy and policy in maternal/newborn
  health issues at the global level scale up known
  cost-effective evidence-based interventions to
  reduce maternal and newborn mortality

5
The ACCESS Program (2)

• Currently working in 25 countries
• Collaborate with Ministries of Health
  international bodies (WHO, UNICEF, UNFPA, PMNCH,
  CDC, etc.) and USAID-funded global and bi-lateral
  programs
• Special Initiatives
• Prevention of postpartum hemorrhage
• Newborn survival - KMC
• Prevention and treatment of malaria in pregnancy
• Pre-service education
• Safe Birth Africa Initiative, Rwanda
• Based on household-hospital continuum of care

6
Household-to-Hospital Continuum of Care Model
7
Presidents Malaria Initiative Launched 2005
Funding Levels and Coverage
Year Anticipated Funding Level Coverage
2006 30 million 3 countries
2007 135 million 7 countries
2008 300 million 15 countries
2009 300 million 15 countries
2010 500 million 15 countries
TOTAL 1.265 billion
Possible plus-up of 25 million
8
PMI Goal and Targets

• Goal
• To reduce malaria-related mortality by 50 in 15
  selected countries
• Targets
• To achieve 85 coverage of vulnerable groups with
  four key interventions

9
PMI Interventions

• Artemisinin-based combination therapy (ACTs)
• Insecticide-treated bed nets (ITNs)
• Intermittent preventive treatment in pregnancy
  (IPTp)
• Indoor residual spraying (IRS) (where appropriate)

10
Addressing MIP

• 90 of all malaria illness and death in the world
  occurs in sub-Saharan Africa
• 50 million women who live in malaria-endemic
  regions become pregnant each year over 50 of
  them live in sub-Saharan Africa
• Most common and virulent species of the malaria
  parasite is Plasmodium falciparum
• Infection with P. falciparum may result in
• maternal anemia (2 15)
• fetal loss, IUGR (13 70), and low birth
  weight (8 36)

11
Why should MIP be addressed? (2)

• Malaria is usually asymptomatic but leads to
  severe maternal anemia and low birthweight
• Up to 200,000 infant deaths/year could be
  prevented by control of MIP
• HIV increases risk of contracting malaria and
  worsens the disease reduces antimalarial
  efficacy

12
Characteristics of Malaria Transmission

• Stable areas, e.g. Tanzania
• People are frequently bitten by infective
  mosquitoes
• Levels of acquired immunity are high (pregnant
  women are semi-immune to malaria)
• Low peripheral parasitemia
• Heavy placental infection

• Unstable areas, e.g. South Africa
• People are infrequently exposed to malaria
• Levels of acquired immunity are low (pregnant
  women are not immune)
• Heavy peripheral parasitemia
• Low or undetectable placental infection

13
Effect of MIP in Stable Transmission Areas
Plasmodium falciparum malaria
Asymptomatic Infection
Placental Sequestration
Altered Placental Integrity
Reduced Nutrient and Oxygen Transport
Anemia
Low Birth Weight (IUGR)
Risk of Newborn Mortality
Source WHO 2002.
14
Effect of MIP Unstable Transmission Areas
Source WHO 2002.
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Effects on the Pregnant Woman
Effects Primigravidae in Stable areas All parities in Unstable areas
High fever (symptomatic) Placental infection Puerperal sepsis Complicated malaria Severe anemia Cerebral malaria Hypoglycemia Pulmonary edema Acute renal failure Increased maternal mortality - - - -
( Very Common, Common, Infrequent, --
Rare)
16
Effects on the Fetus and Newborn
Effects Primigravidae in stable malaria areas All parities in unstable malaria areas
Low birth weight IUGR Prematurity Abortion Stillbirth Congenital malaria Fetal anemia Infant mortality - - - ?
( Very Common, Common, Infrequent, --
Rare)
17
Placental Malaria
Prevalence of Placental Malaria in African Women
by Gravidity in Eight Studies
18
Low Birth Weight
Frequency of Low Birth Weight by Placental
Malaria Infection
Low Birth Weight
First Pregnancy
Second Pregnancy
Three or more pregnancies
Source Steketee 2001 Malawi 1988-1991
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Placental Parasitemia and HIV
Placental Parasitemia by HIV Status and Pregnancy
Number, Kenya, 1996-1998 (N 2263)
Parasite density/mm3
parasitemic
231
159
197
772
402
479
HIV ()
HIV (-)
Summary RR 1.63 (1.41-1.89), p lt0.001
Source van Eijk AM et al 2001.
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Intermittent Preventive Treatment in Pregnancy

• IPTp is an approach for effectively preventing
  and controlling malaria during pregnancy that
• Is based on an assumption that every pregnant
  woman in a malaria-endemic area is infected with
  malaria, and
• Recommends that every pregnant women receive at
  least two treatment doses of an effective
  antimalarial drug as a preventive measure
• Sulfadoxine-pyrimethamine (SP) currently
  considered the most effective drug for IPTp

21
IPTp with Sulfadoxine-Pyrimethamine

• SP is a combination of two different drugs. Each
  tablet of SP contains
• 500 mg of sulfadoxine, and
• 25 mg of pyrimethamine
• A single dose consists of three tablets taken at
  once, preferably under direct observation of the
  healthcare provider
• Fansidar is the most common brand name. Others
  include Falcidin, Laridox, Maladox, Orodar,
  Maloxine
• SP is generally more effective than chloroquine
  which is no longer effective in most countries
  because of parasite resistance

22
Effect of IPTp with SP

• Case management alone does not reduce effects of
  malaria in pregnancy as well as IPTp
• Not all women with malaria parasites have
  symptoms, and therefore would not receive
  treatment if we relied solely on case management
• IPTp produced better outcomes in terms of
  reducing
• Maternal and placental parasitemia
• Low birth weight
• IPTp is as effective as case management in terms
  of improving hemoglobin levels

23
Rationale for the Timing of the SP Doses
Fetal growth velocity ?
Rx
Rx
Last month
Quickening
20
30
10
16
Birth
Weeks of gestation
Conception
Source WHO 2002.
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Key Issues About Timing of Doses

• SP should be avoided during the first 16 weeks of
  pregnancy which is the period of initial
  development of the fetus
• It is best to clear the placenta of parasites
  during the period of maximum fetal growth
• IPTp allows the mother to recover from anemia by
  clearing peripheral parasitemia
• A note for the future SP resistance is growing,
  and at some point a new medicine for IPTp will be
  found

25
Steps for Providing IPTp with SP

• Determine quickening has occurred
• Inquire about history of severe skin rash from
  previous SP use
• Inquire about use of SP in last month
• Provide three tablets of SP with clean water in a
  clean cup
• Observe the patient swallowing all three tablets
  (Directly Observed Treatment or DOT strategy)
• DOT is one reason to ensure that IPTp is an
  essential component of an integrated ANC program
• Do not encourage women to undertake IPTp on their
  own

26
Steps for Providing IPTp with SP (2)

• Ask about side effects from previous dose before
  giving the next dose, which should not be less
  than 4 weeks from the last dose
• Record SP on the antenatal card and the clinic
  record
• Instruct client to return at next scheduled visit
  or earlier if she is feeling ill
• Drop-out is a major challenge for successful IPTp
  programs
• From 20-50 of women do not receive a second dose

27
Use ITNs/LLINs

• The use of ITNs/LLINs have been shown to result
  in reduction of low birth weight or prematurity
• ITNs reduce transmission by physically preventing
  vector mosquitoes from landing on sleeping persons

28
ITN/LLIN Benefits

• Repel and kill mosquitoes that come in contact
  with the net
• Kill other insects like cockroaches, lice, ticks
  and bed bugs
• Should be used by pregnant women as early during
  pregnancy as possible and use should be
  encouraged throughout pregnancy and in the
  postpartum period

29
ITN Impact on Fetal Growth and Duration of
Gestation

• Pregnant women protected by insecticide-treated
  nets were less likely
• To deliver prematurely or
• To have small-for-gestational-age newborns
• Compared to control groups who were not protected
  by the nets
• This finding holds true irrespective of the
  womans parity, except for the incidence of
  small-for-gestational-age babies born to women
  with 4 or more pregnancies

Source ter Kuile et al 1999
30
ITN/LLIN Procurement and Management

• ITNs are often provided during childhood
  immunization campaigns
• It is less common to find ITNs allocated in
  adequate numbers to be an essential component of
  focused ANC
• The district health management team needs to meet
  and plan for adequate nets for children lt5 as
  well as pregnant women
• ITN/LLIN provision can be an important incentive
  to attend ANC
• A woman should get a net on her first ANC visit
  when it can offer the most protection during
  pregnancy
• Issues of subsidized v. free ITNs

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Lets take a trip to Tanzania!
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Health Indicators in Tanzania

• GENERAL
• Population 34.4 million
• Crude birth rate 43
• Crude death rate 14
• Total fertility rate 6.3
• Life expectancy 51 years
• MMR 578/100,000 live births
• NMR 32/1000 live births
• IMR 68/live births
• HIV prevalence 7

• MALARIA-RELATED
• Malaria illness accounts for 40 of all
  outpatient visits
• ITN ownership 23
• Use of ITN by pregnant women 16
• One ANC visit 94
• Four ANC visits 62
• 1st ANC visit by 16 weeks 14
• IPTp1 52
• IPTp2 22
• SBA 56

Source Tanzania DHS 2004-2005
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How to ensure MIP services

• WHO recommends four ANC visits for women
  experiencing normal pregnancy
• First visit should be before 16 weeks
• Using ANC as a platform women receive
• Basic ANC services iron/folate syphilis
  testing/treatment tetanus toxoid vaccination
  PMTCT health counseling nutrition, birth
  spacing, breastfeeding, etc.
• Counseling on use of ITNs
• ITNs or vouchers to buy them at subsidized price
• Intermittent preventive treatment (IPTp)
• Appropriate case management of malarial illness

34
How to ensure MIP services (2)

• Orientation package developed Focused
  ANC/Syphilis/Malaria in pregnancy (FANC/SIP/MIP)
• Providers (midwives) trained as clinical trainers
  at national, provincial, and district levels
• Module on quality improvement added and process
  integrated

35
Building the training system
Advanced Training Skills Workshop for FANC (One
2-week course) Participants ZPOs, ZTC
Counterparts and ZRCH Coordinators (45- 50 from
all 8 zones Zanzibar) Trainers ACCESS Staff
FANC orientation and Clinical Training Skills
Workshops/FANC TOTs (Multiple 2-week
courses) Participants Regional and District RCH
Coordinators ANC in-charges strong service
providers goal is 5 trainers/district, or 20
40 in each region Trainers National trainers
with support from ACCESS staff
Basic FANC Orientation Workshops (Multiple 6-day
courses) Participants all FANC providers from
hospitals, HCs and dispensaries Trainers all
FANC trainers
36
Issues in scaling up training

• Orientation package needs approval by MOH/MCH
  section as well as the NMCP and must incorporate
  new guidelines as they come out
• Districts had to commit funds to get providers
  trained at all levels of the system to health
  center and health post levels
• Tension between MOH desires for sustainable
  training framework and USG emphasis on numbers
  trained

37
Issues in scaling up (2)

• Monitoring of all facilities was difficult, so
  system of sentinel sites (30) was introduced, but
  each is at a different level of development
• Stockouts of SP more frequent than MOH admitted
  now reported through EPI system
• Zonal, regional, and district supervisors must be
  involved in monitoring and supervision so that
  providers can provide care they learned in
  training

38
How are MIP services being scaled up?

• A total of 441 in-service trainers have been
  trained since 2004
• 415 from facilities in 21 regions
• 26 are Zonal and Regional RCH Coordinators from
  all 8 zones
• 2,431 providers (41 of those offering FANC) have
  been trained since 2004
• 25 of facilities (1,199) offering FANC have
  trained providers

39
How are MIP services being scaled up? (3)

• Tutors and preceptors trained from all 51 nursing
  and midwifery schools (includes FBOs)
• 28 diploma level
• 23 certificate level
• This year 1600 students will graduate from these
  programs, exposed to FANC/MIP/SIP

40
Scaling up with FBOs

• About 42 of health care in Tanzania is provided
  by faith-based organizations
• 21 providers from 15 FBO facilities trained in
  Mwanza region
• Advocacy meetings targeting religious leaders
  carried out to increase dissemination of health
  messages to men and women

41
Scaling up through demand creation

• Communities must be aware of the importance of
  FANC and must demand the services
• Partnership formed with media groups to formulate
  radio messages
• Advocacy to religious leaders
• Some training of community workers and good
  support through the White Ribbon Alliance

42
How are MIP services being scaled up? (4)

• Thus in sentinel sites coverage is
• IPT1 59 (52 DHS)
• IPT2 41 (22 DHS)
• ITN voucher distribution 93 (75 TDHS)
• Challenges include
• Stock outs of SP
• Data reporting/collecting
• Supervision

Source TDHS 2004/5
43
How are MIP services being scaled up? (5)

• Quality improvement process using performance
  standards is incorporated into provider training

44
ANC QI Assessment Tool
PERFOMANCE STANDARDS The health care provider properly conducts individualized care based on national guidelines and according to findings VERIFICATION CRITERIA PROVIDE ROUTINE CARE TAKE ACTION Gives on DOT 3 tablets of sulfadoxinepyrimethamine according to the national guidelines Explains that in case she vomits within 30 minutes, the dose should be repeated Provides ferrous sulfate and folic acid or FEFOL in enough amounts to last until next visit Provides mebendazole tablets 500 mg DOT once by mouth after first trimester Give tetanus toxoid (TT) based on womans need according to standard guidelines Y,N, NA ____ ____ ____ ____ ____ COMMENTS
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Assessed Sections in the ANC QI
SECTIONS TOTAL PERFORMANCE STANDARDS ACHIEVED PERFORMANCE STANDARDS ACHIEVED
1. FOCUSED ANTENTAL CARE 17 12 71
2. INFORMATION, EDUCATION AND COMUNICATION (IEC) 5 4 80
3. INFECTION PREVENTION 4 3 75
4. MANAGEMENT SYSTEM 7 4 57
5. HUMAN, PHARMACY AND LABORATORY RESOURCES 10 5 50
TOTAL 43 28
Type of assessment Baseline 58
-------------------------- Internal Assessment
-------------------- External Assessment
------------------------------------ Date
--------------------------------------------------
------ ACHIEVED ACHIEVED STANDARDS /
ASSESSED STANDARDS x 100 N.B. ALL STANDARDS
HAVE TO BE ASSESSED THROUGH OBSERVATION,
INTERVIEW OR RECORD REVIEW
46
Lessons Learned

• Scale up coverage systems strengthening FANC
  must be platform for integration of services
• Training systems must be sustainable and should
  include both in-service and pre-service systems
• Quality improvement processes should be built in
  but must be supported at the outset
• Link with faith-based and private sectors
• ME paramount to guide understanding of program
  results and next steps

47
Conclusions

• MIP coverage improves through interventions that
• Strengthen the service provision platform of ANC
• Mobilize community acceptance
• Coverage is remarkable in districts/provinces
  where technical support has been offered
• Effective training with simple messages
• A comprehensive approach leads to improved
  coverage and must be adapted to country needs

48
Thank you!

• Contacts
• pgomez_at_jhpiego.net
• www.accesstohealth.org
• www.rollbackmalaria.org
• www.fightingmalaria.gov

49
Provoking thought

• What is the role of community-based distribution
  in meeting the PMI goal of 85 coverage of IPTp2?
• Should ITNs be given free to all pregnant women
  or should they have to pay a fee through social
  marketing?