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Low preva lenc e of plac ental malariainfec tion among pregnant women inZanzibar: policy implications for IPTp

Marya Plotkin1; Khadija Said2; Natalie Hendler1; Asma Ramadhan Khamis1; Mwinyi

Issa Msellem2; Abdul-wahid Al-mafazy2; Chonge Kitojo5,

Maryjane Lacoste1; Elaine Roman3, Veronica Ades4, Julie Gutman5,

Raz Stevenson6, Peter McElroy5

1Jhpiego Tanzania2Zanzibar National Malaria Control Programme, Zanzibar Ministry of Health3Jhpiego Baltimore4University of California San Francisco5Centers for Disease Control and Prevention and Presidents Malaria Initiative

6United States Agency for International Development

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Intermittent p reventive trea tment for p reg nantwomen (IPTp) with sulphadoxine-pyrimetha mine(SP) was imp lemented in 2004 when ma la riapreva lence in Zanziba r exc eeded 20%

Further sc a le-up of ma la ria inte rventions ha sbrought Zanziba r to the pre-elimina tion phase

P. fa lc ipa rumpreva lenc e in the genera l pop ula tionc urrently less than 0.5% [1], d iagnostic positivity rate

among feb rile pa tients 1.2% in 2011 [2]

Background

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Current IPTp c overage rema ins low: 69% reported

ta king any SP; 43% reported ta king 2+ doses of SP inlast pregnancy [3]

ZMCP has introduc ed sc reening for ma la ria a t ANCservic es [4]:

Year N Tested Positive (%)2011 19,724 40 (0.2%)

2012 11,336 18 (0.15%)

The va lue of IPTp in the c urrent low transmissionenvironment is uncerta in - few Afric an countriesha ve a ddressed IPTp sc a le-down

*data through June 2012

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The Plac enta l Parasitemia Study

A p rospec tive observa tiona l study was c onduc ted inselec ted hea lth fa c ilities in Zanziba r with theob jec tives of:

measuring p lac ental parasitem ia ra tes among

preg nant women who d id not rec eive IPTp

providing cost analyses to help inform polic ydec isions on the IPTp p rogram in Zanziba r

Policy questions: Is IPTp useful a t c urrent low leve l of transmission in

p reventing materna l and neonata l mo rb id ity?

Wha t a re the c osts and benefits of IPTp in Zanzibar?

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Figure 1. Fac ilities in the study with annual delivery volume

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MethodsFrom September 2011 - Ap ril 2012, a c onvenienc e samp le o fp regnant women were enrolled a t six hosp ita ls in Zanziba r on d ayof delivery

Client c ard c hec ked for doc umenta tion of p rovision of IPTp(e ligible= no doses of SP, resident o f Zanziba r)

Informed c onsent ob ta ined from elig ib le c lients

Samp le taken from ma terna l side of p lac enta by labor wardmidwives

Dried b lood spots (DBS) on filte r paper were p repared fromp lac enta l b lood spec imens

DBS were a na lyzed via polymerase c ha in reac tion ind ic a tingactive Plasmodiuminfec tion (a ll spec ies)

Informa tion on c lient, b irth we ight/ outc ome c ollec ted

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Facility Island Total

Chake Chake Hospital Pemba 401

Michiweni Cottage Hospital Pemba 70

Wete Hospital Pemba 175

Mnazi Mmoja Hospital Unguja 335

Kivunge Cottage Hospital Unguja 67

Mwembeladu Hospital Unguja 209

Total 1,258

Data collection has finished and last samples are being processed. Resultspresented for 1,258 samples: final results will include approximately 200 moresamples.

ResultsTable 1. Samples analyzed

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Results

1,258 samples have so far been p roc essed out o f1,489 collec ted

A shipment o f SP in November 2011 inc reasedava ilab ility of SP resulting in a d ramatic d rop in

elig ib le c lients by Janua ry 2012 Roughly 6% of the women d elivering in the fac ilities

were samp led into the stud y (range 4% - 14)

Average a ge of women w as 26.9 years

376 (32%) were primigravidas

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Figure 1. Timing of collection of samples

Rainy season: March - May, peak malaria transmission May June

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4 samples out of 1,258 were positive (0.3%,95% CI -0.12 0.81%)

Mwembeladu Hospita l (Oc tober 2011): 26 yea rold gravida 3, HIV neg a tive, 2.8 kg baby

Mnazi Mmoja Hospita l (Nov 2011): 35 year oldgravida 5 from Kilimahewa, HIV nega tive, 4.2 kgbaby

Michiweni Hea lth Center (April 10, 2012) A

gravida 1 HIV nega tive wom an, 2.5 kg baby. Michiweni Hea lth Center (April 11, 2012). A 25

year old , g ravida 3 of unknow n HIV sta tus,mac era ted stillb irth weighing 1.8 kg .

PCR Results and birth outc omes

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Table 2. Cost of IPTp program for 2011

Area Cost Source / Notes

SP $26,353 Includes the procurement cost for a shipment

of SP received in November 2011 as well as

storage and transport costs to facilities

Training $5,187 In-service training for ANC providers on focused

antenatal care (FANC)

Supervision $10,383 Costs of supervision for FANC which was

facilitated through MAISHA program

TOTAL $41,923

Costs associated for provision of IPTp for 2011 totaled approximately $42,000,which is relatively low for a national scale public health intevention

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Conclusions

Ma la ria infec tion a mong preg nant women whoha ve no t had IPTp is extraord inarily low (0.3%),ind ic a ting the level of risk among preg nant wom enis minima l

simila r results from ANC ma la ria sc reening and popula tionbased surveys (THMIS)

Cost of p rovision o f IPTp is rela tive ly inexpensive forthe ZMOH

Coverage o f IPTp among women g iving b irth in

fac ilities fluc tua tes ac c ord ing to c ommod itylog istics, but still shows c onsistent gaps

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Rec ommendations

Zanziba r is ad justing its strategy for ma la riaprevention and c ontrol to be a pprop ria te to thepre-elimina tion phase.

Weekly a c tive c ase detec tion from 2008 with Ma la ria

Ep idemic Early Detec tion System (MEEDS) [2] Ma la ria in pregnanc y polic y and stra tegy should

fo llow suit

ZMCP has a lready begun ac tive sc reening for

ma la ria pa rasitemia of ANC c lients. Need for more g uidanc e a nd more c onsistent rollout ,

inc lud ing guidelines and job a ides, stronger da tac ollec tion and ana lysis, inc lud ing stra tific a tions for first a ndrep ea t test

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References

1. Bha tta ra i A, Ali AS, Kac hur SP. Impac t o fa rtem isinin-based c ombination therapy a ndinsec tic ide-trea ted nets on ma la ria burden in

Zanzibar. PloS Med 4(11): e309.2. Zanziba r Ma la ria Control Programme. Zanzibar

Ma la ria Ep idemic Early Detec tion System Biannua lReport, Mid-Year 2011; Vo l. 3, (No.1); 2011.

3. Tanzania HIV/ AIDS and Ma la ria Ind ic a to r Survey(THMIS) 2011-12. Prelimina ry report.

4. Zanziba r Ma la ria Control Programme. 2012Nationa l surve illanc e da ta . Persona lc orrespondenc e, Mwinyi Msellem.