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Malaria in Pregnancy and its

contribution to Anemia:

Sharing the PMI experience

Koki Agarwal,

Director, MCHIP/Jhpiego

Co-Chair RBM MIP WG

Global Nutrition Symposium

April 14, 2013

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Malaria in Pregnancy (MIP)

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MIP the basics

Stable Transmission Most of sub-Saharan Africa Pregnant women have some level of immunity 1st and 2nd pregnancies most at risk

MiP contributes each year to: 400,000 cases of severe anemia every year Maternal death: 10,000 Infant death: 200,000

11% of neonatal deaths in malaria endemic Africancountries are due to low birth weight resulting from P.falciparum infections in pregnancy

-WHO. A Strategic Framework for malaria Prevention and Control During Pregnancy in the African Region. 2004.-Guyatt HL, Snow RW. Malaria in pregnancy as an indirect cause of infant mortality in sub-Saharan Africa. Trans R. Soc Trop Med Hyg2001; 95: 569-76

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MIP the basics (2)

Unstable Transmission Pregnant women have little acquired immunity Similar risk across pregnancies MiP contributes to:

Severe malaria Anemia Stillbirths Abortions

Low Birth Weight Premature delivery, when infection occurs in 3rd

trimester

WHO. A Strategic Framework for malaria Prevention and Control During Pregnancy in the African Region. 2004.

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WHO Recommendations

WHO recommends a three-prongedapproach to prevent and treat MIP:1. Intermittent preventive treatment in pregnancy

(IPTp) with sulfadoxine-pyrimethamine (SP), in

areas of stable malaria transmission As early as possible in 2nd trimester During routine ANC One month apart SP can be given to a pregnant woman safely up until

the time of delivery2. Use of insecticide treated bed-net (ITN)3. Diagnosis and treatment of malaria case mgt.

Updated WHO Policy Recommendation (October 2012)- Intermittent Preventive Treatment of malaria inpregnancy using Sulfadoxine-Pyrimethamine (IPTp-SP)

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6Malaria during

Effect of Malaria on Pregnancy in

Stable Transmission Areas

Asymptomatic Infection

Altered Placental Integrity

Reduced Nutrient and Oxygen Transport

Placental Sequestration

Low Birth Weight (IUGR)

Risk of Newborn Mortality

Plasmodium falciparum malaria

Anemia

Source: WHO 2002.

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7Malaria during

Effect of Malaria on Pregnancy in

Unstable Transmission Areas

Acquired Immunity Low

Clinical Illness

Severe Disease

Risk to Mother Risk to Fetus

Source: WHO 2002.

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MiP and Neonatal Mortality (1)

Retrospective birth cohort from 32 national cross-sectional datasets in 25 African countries from 2000-2010

Among pregnant women in 1st or 2nd pregnancy,

who had taken at least 2 doses of IPTp-SP and/orhad ITN in household: 18% decrease in neonatal mortality (p

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MiP and Neonatal Mortality (2)

Randomized, placebo controlled trial of IPTp-SP in 1030pregnant Mozambican women found use of IPTp wasassociated with a 61.3% reduction in neonatal mortality. These results have not been replicated

The results of this trial showed that, maternal malaria mayhave a direct effect on neonatal mortality; prevention ofmalaria during pregnancy can reduce neonatal mortality

An increase in birth weight or gestational age is unlikely tobe the explanation

Presences of parasites in the placenta or in cord blood may

have had a negative effect on neonatal survival.

1. Clara Menndez, Azucena Bardaji, Betuel Sigauque, Sergi Sanz, John J. Aponte,Samuel Mabunda, Pedro L. Alonso. Malaria Prevention with IPTp during PregnancyReduces Neonatal Mortality. PLoS ONE; Feb 2010; Vol. 5, Issue 2.

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Cost Effectiveness of IPTp

Based on same study (Menedez et al), IPTp-SP was highly cost effective for bothprevention of maternal malaria and reduction

of neonatal mortality Incremental cost-effectiveness ratio of

US$1.02 per disability-adjusted life year

averted. Elisa Sicuri, Asucena Bardaji, Tacita Nhampossa, Maria Maixenchs, ArielNhacolo, Delino Nhalungo, Pedro L. Alonso, Clara Menndez. Cost-Effectiveness of Intermittent Preventive Treatment of Malaria in Pregnancy inSouthern Mozambique. PLoS ONE; Oct. 2010; Volume 5, Issue 10

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Malaria & Anemia

Anemia (clinical test or pallor) may be theonly sign that a woman has malaria

Women with anemia should be tested for

malaria

Women with anemia should be treated andreceive an integrated package of

interventions to address all its causes

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Needed: an integrated package

The impact of MiP is increased whencomplementary interventions are given toincrease intake of essential nutrients

For example, an integrated package ofinterventions is needed to address all thecauses of anemia

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Complementary interventions to

prevent & treat anemia

Iron-folic acid supplementation during pregnancy(currently 60 mg of iron/400 mcg of folic acid for 180days)additional IFA for anemia

Deworming during the second trimester and thirdtrimester (where prevalence is high)

Improving maternal diet to ensure adequate intake ofanemia-related micronutrients (e.g., iron, vitamin A)

Decrease work load Delayed cord clamping at birth

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Caveats for IPTp & IFA

supplementation

WHO recommends the administration of folic acid at adose of 0.4mg daily; this dose may be safely used inconjunction with SP- In countries with a combined IFApill (60 mg of iron & 0.4mg folic acid) no problem

Folic acid at a daily dose equal or above 5mg should notbe given together with SP as this counteracts its efficacyas an antimalarial.

Transition from the 5 mg dose to the combined IFA

When treating of anemia in pregnancy, providers shouldinclude testing of & treatment for malaria

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Results from ZambiaIndicator DHS

2001/2MIS

2006DHS

2007MIS

2008MIS

2010Attended 2+ ANC 91.4% N/A 94.3% N/A N/AAttended 4+ ANC 71.6% N/A 60.3% N/A N/AAttended first ANC at

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The road to effective programs

Strengthen the ANC platform to ensurecomprehensive services

Develop effective policies to support programs

Train providers to address all elements of FANC

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Commodities

Address Stock-outs ofSP & ITNs at ANC

Avoid inappropriate

use of SP Make ITNs free for

pregnant women andavailable through

ANC

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Quality Assurance

Ensure performancestandards in place

Drinking water for

DOTS available Routine supportive

supervision

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Community Involvement, Awareness

Engage community to raiseawareness of importance ofMIP and anemia Have women understand the

dangers Come in early for their first

visit

Explore community based

distribution of IPTp and IFA

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Monitoring and Evaluation

IPTp uptake to be recorded in registers forHMIS

Collect other data like % of women with

severe anemia

Collect information on ITN distributionthrough ANC

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