introduction to malaria in pregnancy
DESCRIPTION
Powerpoint presentation from Dr. Mary Hamel's session on Malaria in Pregnancy during Stomping Out Malaria in Africa's Boot Camp III.TRANSCRIPT
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Epidemiology and control of malaria during pregnancy in
sub-Saharan Africa
Mary Hamel, M.D.
Malaria Branch, CDC
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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
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Epidemiology
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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
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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)
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Current strategies, challenges and successes
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Major strategies for malaria control during pregnancy
Drugs• Intermittent preventive treatment during
pregnancy (IPTp)• Febrile case management
Insecticide Treated Nets (ITNs)
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Intermittent Preventive Treatment for pregnancy (IPTp)
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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
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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
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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
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IPTp implementation
In most countries, less than 20% of pregnant women living at risk for malaria receive at least 2 doses of SP IPTp
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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
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IPTp Malawi– Exploring poor uptakeHealth 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
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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
IPTp Malawi– Exploring poor uptakeHousehold survey
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SP in stock Nonetheless, women at clinic on day of
survey who were due for IPTp did not receive IPTp
IPTp Malawi– Exploring poor uptakeHealth facility survey
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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
As result, WHO issued simplified guidelines
IPTp Malawi– Exploring poor uptakeHealth worker observation
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Current WHO recommendations for IPTp
Beginning after quickening, provide at least 2 doses of SP as IPTp no less than 4 weeks apart
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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
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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
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MINSTRY OF HEALTH
RefXX/YY/ZZ 10, December, 2010
To: District Medical Offi cer 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.
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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
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Insecticide treated bed nets (ITNs)
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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
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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
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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
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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?
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Case management of malaria
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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
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Drugs used for malaria treatment during pregnancy in sub-Saharan Africa
Used frequently Quinine SP
Used with caution Artemether lumefantrine
(AL or coartem) Any artemisinin
combination
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Antimalarials contra-indicated in pregnancy
Tetracycline Doxycycline Halofantrine Primaquine Tafenoquine
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Malaria in Pregnancy and HIV
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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
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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
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MIP and HIV Interaction
Conflicting results regarding MIP and HIV transmission to baby
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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
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Malaria in PregnancyConclusions
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