Malaria Control during pregnancy in the WHO African Region

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Malaria Control during pregnancy in the WHO
African Region
Dr Magda RobaloWHO/AFRO
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Outline of the presentation

• RBM Goal
• RBM technical strategies
• Abuja targets
• Burden of malaria in pregnancy
• Available interventions for malaria control
  during pregnancy
• What is IPT
• IPT possible regimens
• IPT current programme status
• ITNs and pregnancy
• Partnerships for ANC enhancement
• Improvement of maternal and child health
• Challenges
• Conclusion

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RBM Goal_____________________
1.4
Annual deaths from malaria (millions)
1.2
1
0.8
0.6
0.4
0.2
0
1970
1980
1990
2000
2010
4
RBM technical strategies_____________________

• Promote access to prompt treatment with effective
  drugs
• Ensure multiple prevention by improving access to
  insecticide treated materials (ITMs) and other
  vector control methods
• Control and prevention of malaria in pregnancy
• Preparedness and response to emergencies,
  including epidemics

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Abuja targets (1)_____________________

• By the year 2005
• At least 60 of those at risk, particularly
  children under the age of five years will benefit
  of a prompt access to effective antimalarial
  treatment, within 24 hours of onset of symptoms

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Abuja targets (2)_____________________

• By the year 2005
• At least 60 of those at risk of malaria,
  particularly pregnant women and children under
  five years of age, will benefit from the most
  suitable combination of personal and community
  protective measures such as ITNs and other
  interventions which are accessible and affordable
  to prevent infection and suffering

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Abuja targets (3)______________________

• By the year 2005
• At least 60 of all pregnant women who are at
  risk of malaria, especially those in their first
  pregnancies, will have access to chemoprophylaxis
  or intermittent presumptive treatment

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Women, Poverty and Pregnancy

• Several studies around the world have shown that
  women are the poorest of the poor, particularly
  in Africa financial vulnerability of African
  women
• Biological vulnerability during pregnancy
  increases the risk of disease and poverty among
  African women
• Pregnant women in malarious areas in Africa are
  highly vulnerable

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Burden of Malaria in Pregnancy (1)

• The epidemiology of malaria in pregnancy has not
  been fully defined (what we know is little,
  compared to what we dont know)
• Programmatic effectiveness of recommended policy
  (weekly prophylaxis) has not been achieved
• Limited understanding and promotion of the policy
  at all levels (national, district and local)
• Malaria infection is largely asymptomatic,
  particularly in highly endemic areas
• Shortages of antimalarial drugs at health
  facilities
• Poor compliance of the pregnant women
• Cultural barriers related to pregnancy in Africa
• Development and spread of drug resistant P.
  falciparum across Africa

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Burden of Malaria in Pregnancy (2)

• 24 million pregnancies in malaria-endemic areas
• Malaria contributes to negative health impact of
  both mothers and infants
• Mothers
• 3-15 of severe anaemia
• up to 10,000 deaths by anaemia related to malaria
  per year
• Infants
• 8-14 of all low birth weight
• 30 of preventable low birth weight
• 3-8 of infant mortality

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Malaria in Pregnancy

• Pregnancy makes women more vulnerable to
• malaria, resulting in high morbidity and
  mortality
• Malaria infection can lead to acute disease and
  anaemia
• Malaria parasites accumulate in the placenta
• Anaemia and placental malaria are associated
  with low birth weight (IUGR or prematurity)
• Low birth weight is the single greatest risk
  factor for neonatal death

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Malaria in Pregnancy
Malaria
Pregnant Women
parasitemiaspleen ratesmorbidity anemia
fever illness cerebral malaria
hypoglycemia puerperal sepsis
mortality severe disease hemorrhage
Fetus
abortionsstillbirthscongenital infection
Newborn
low birth weightprematurityIUGRmalaria
illnessmortality
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• Malaria in Pregnancy
• Low Transmission Areas

Acquired Immunity - Low

• All pregnancies

Clinical Illness

• Recognition and case management

Severe Disease
Risk to Mother
Risk to Fetus
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• Malaria in Pregnancy
• High Transmission Areas

Acquired immunity - high
Asymptomatic infection

• 1st 2nd pregnancies

Placental Sequestration

• Effect of HIV infection

Altered Placental Integrity
Anaemia
Less Nutrient Transport
Low Birth Weight
Excess Infant Mortality
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LBW and Premature Delivery

• Malaria infection of the Placenta is a major
  contributor along with anemia to low birth weight
  and premature delivery
• Even if an infected mother has no symptoms, the
  baby is still at risk

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Increased Risk of Severe Malaria

• Pregnancy reduces a womans immunity to malaria,
  making her more susceptible to severe malaria
  than other adults
• Treatment of severe malaria is more complicated
  in Pregnancy

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Core Impact Indicator 2a Proportion of deaths
attributed to malaria among under 5 and targets
groups in HF surveyed in selected countries in
2001
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Core Impact Indicator 2c Malaria case fatality
rates in under 5 and other target groups in HFs
surveyed in selected countries in 2000
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Core Outcome Indicator 4 Pregnant women taking
some chemoprophylaxis/intermittent preventive
treatment according to national policy in
selected countries in 2001
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Core Outcome Indicator 5 Use of Mosquito Nets in
selected countries in 2001
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Core Outcome Indicator 5 (Contd) Use of
Mosquito Nets in selected countries in 2001
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Core Impact Indicator 3a Morbidity attributed to
malaria in under 5 and target groups in HFs
surveyed in selected countries in 2001
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Available interventions

• Case management
• ITNs
• IPT
• Data provided by studies in Malawi and Kenya
  provided the scientific base for initiation of a
  policy dialogue on the IPT strategy

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Malaria Control during PregnancyImplementation
Package(s)
ANC Community
IPT
ITNs
ANC Community
ANC Community
CM
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What is Intermittent Preventive Treatment (IPT) ?

• A prevention strategy that consists of a
  therapeutic dose of an effective antimalarial
  (currently sulfadoxine-pyrimethamine)
  administered during routine clinic/community
  visits, aiming at reducing the adverse
  consequences of placental malaria infection,
  maternal malaria and associated anemia during
  pregnancy

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Intermittent Preventive Treatment- possible
regimens -

• Sulfadoxine-pyrimethamine (S-P) at least two
  treatment doses (3 tablets) at the second
  trimester (after quickening) and at the beginning
  of the third trimester
• for areas with CQ-resistant P. falciparum
• Chloroquine (CQ) at least two treatment doses at
  monthly visits beginning after quickening
• for areas with CQ-sensitive P. falciparum and/or
  other malaria species

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IPT in Malawi

• Two doses of SP compared to single dose in
  
• pregnancy result in reduction in incidence of
  
• LBW
• from 33.9to 13.5 in primigravidae
• from 13.9 to 6.5 in multigravidae
  (Verhoeff et al, 1998)
• Women taking two or more doses of SP
  
• deliver babies 195g heavier than those among
  
• women not taking SP (Rogerson et al, 2000)

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IPT prevents severe anemia
The more recent randomized control trials of 2
intermittent courses of SP suggest that the
incidence of severe anemia can be reduced by up
to 48 in primigravidae and secundigravidae
(Parise and all, 1998)
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IPT Cost effectiveness in Malawi(Schultz et al,
1995)

• Using data and costs from Malawi studies in
  decision-analysis model
• In 10,000 women
• Two dose SP prevent 205 cases LBW at a cost of
  9.66 per case prevented
• One dose SP followed by weekly CQ prevent 59
  cases LBW at cost of 62 per case prevented
• CQ treatment weekly prophylaxis prevents 30
  cases LBW at cost of 113 per case

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• Intermittent Preventive Therapy
• - the two dose strategy-

• Dose 1
• 24-28 wks

Dose 2 30-36 wks
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30
10
Quickening
Conception
Birth
Weeks of gestation
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Intermittent Preventive Treatment -
modifications for HIV infection -

• HIV-positive women have higher prevalences and
  densities of peripheral and placental parasitemia
• Drug efficacy compromised more S/P doses
  required to achieve similar effect
• If gt10 seroprevalence of HIV among pregnant
  women, recommendation is to give more frequent
  doses of SP

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• Intermittent Preventive Therapy
• - the monthly clinic dosing strategy-

Rx
Rx
Rx
Rx
20
30
10
Quickening
Conception
Birth
Weeks of gestation
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IPT and folic acid

• There is evidence that folic acid, administered
  concurrently with SP can antagonize the action of
  sulfadoxine
• It is therefore suggested that folic acid
  supplements should be delayed for one week after
  SP treatment, to avoid an inhibitory effect on
  antimalarial efficacy
• However, there are as yet no clinical data to
  substantiate this. Pharmacodynamic interactions
  of folate and SP need to be monitored

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Intermittent Preventive TreatmentCurrent
Programming Status

• Malawi
• IPT with SP (2 doses) implemented 1993
• Effectiveness demonstrated
• Need to increase coverage
• Countries where IPT is or will be policy
• Kenya Nigeria?
• Tanzania Mali?
• Uganda
• Zambia?
• Mozambique?
• Senegal?

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Insecticide Treated Nets (ITN)

• Decrease peripheral parasitemia, anemia,
  placental malaria, pre-term delivery, and
  increase in mean birth weight
• 25 decrease in infants who were premature or SGA
  among women sleeping under ITN

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Bednets Birth Outcome
Gravidae 1-4
ter Kuile 2001 Kenya
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ITNs and Pregnant Women

• Among Gravidae 1-4 bednets associated with
• During pregnancy
• 38 (17-54) reduction in peripheral parasitemia
• 21 (4-35) reduction in all cause anemia (Hb lt 11
  g/dl)
• 47 (6-71) reduction in severe malarial anemia
• At delivery
• 23 (6-37) reduction in placental malaria
• 28 (2-47) reduction in LBW
• 25 (13-35) reduction in any adverse birth
  outcome

ter Kuile 2001 Kenya
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Partnership for Antenatal Care EnhancementPartne
r Interventions in ANC

• MPS Essential ANC package, health services
  strengthening
• RBM IPT ITNs, with case management
• EPI tetanus toxoid
• HIV/AIDS-MTCT HIV screening and counseling with
  ARV therapy
• FP Post-partum post abortion counseling
• Nutrition Fe, folate, Vit. A

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Improvement of maternal and child health
MPS
FP
RBM
Antenatal Care
Nutrition
HIV/AIDS MTCT
EPI
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Antenatal care in AfricaProportion of Pregnant
Women Seeking Antenatal Clinic Care
Demographic and Health Surveys
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Partnership for Antenatal Care Enhancement

• IPT ITNs for women in 2nd and 3rd trimesters
• ITNs for reproductive age women
• Case management, including management of anemia

• Provision of commodities and logistics
• Education, sensitization
• Investments in integrated personnel training and
  supportive supervision
• Operational research
• Commitment to excellence in Monitoring and
  Evaluation

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Challenges

• Responsiveness to national interests
• Deployment and use of IPT
• Useful therapeutic life of CQ and SP
• Limited armamentarium of malaria drugs with both
  demonstrated efficacy and safety during pregnancy
• As of yet, little or no information on the safety
  and efficacy of combination therapy in pregnant
  women
• Scaling up the use of ITNs
• Potential impact of the combined package IPTITNs
• Need for carefully planned operational studies as
  part of the implementation process
• Social and cultural determinants of women using
  antenatal care services

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Conclusion

• Malaria in pregnancy is a significant health
  problem in Africa
• MoH alone are not able to implement the necessary
  interventions to tackle the problem
• There is a need to advocate for strong
  partnerships with all stakeholders in order to
  implement cost-effective interventions that are
  technically appropriate, logistically feasible
  and culturally acceptable

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RBM hope for the future
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(No Transcript)
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Currently available antimalarial drugs

• CQ (where resistance levels are not high)
• SP
• Mefloquine (expensive, adverse effects)
• Proguanil (compliance, altered pharmacokinetics
  during pregnancy, higher maintenance doses
  required)
• Maloprim (pyrimethaminedapsone) compliance,
  resistance to pyrimethamine develops rapidly
• Amodiaquine (large scale use needs to be
  monitored, adverse effects)