Prevention and Control of Malaria during Pregnancy Dr.M.Davarpanah.

Prevention and Control of Malaria during Pregnancy

Dr.M.Davarpanah

Prevention and Control of Malaria during Pregnancy 2

Facts about Malaria

300 million cases each year worldwide 9 of 10 cases occur in Africa A person in Africa dies of malaria every 10

seconds Women and young children are most at risk Affects five times as many people as AIDS,

leprosy, measles, and tuberculosis combined


Populations Most Affected by Malaria

Children under 5 years of age Pregnant women Unborn babies Immigrants from low-transmission areas HIV-infected persons


Effects of Malaria on Pregnant Women

All pregnant women in malaria-endemic areas are at risk

Parasites attack and destroy red blood cells Malaria causes up to 15% of anemia in

pregnancy Can cause severe anemia In Africa, anemia due to malaria causes up to

10,000 maternal deaths per year


Malaria in pregnant women

>50 million pregnant women exposed to malaria each year

~3.5 million pregnant women infectedPoor birth outcomesPoor maternal outcomes


Placental malaria

Parasites accumulate and thrive in the placenta

Only affects primigravidae in areas of high transmission


Effects on Unborn Babies

Parasites hide in placenta Interferes with transfer of oxygen and

nutrients to the baby, increasing risk of: Spontaneous abortion Preterm birth Low birthweight—single greatest risk factor for

death during first month of life Stillbirth


Pathologenesis of malaria in pregnancy

During normal pregnancy, the cellular immune response (Th1) is suppressed to prevent fetal rejection

Malaria stimulates the Th1 response intrauterine growth retardation

Malaria stimulates expression of an HIV co-receptor (CCR5) in the placenta


Gravidity and malaria

Primigravidae have no pre-existing immunity to placental parasites and are highly susceptible

In high transmission areas, primigravidae develop immunity to placental parasites and are protected in subsequent pregnancies

In low transmission areas, multigravidae are unexposed and unprotected


Effects of malaria on pregnant women

Poor birth outcomes Low birth weight due to preterm delivery (PTD)

and intrauterine growth retardation (IUGR) abortions, stillbirths

Maternal outcomes Anemia, maternal mortality


Maternal mortality

Responsible for 0.5 – 23% of maternal deaths in Africa

Malaria causes severe anemia and platelets can predispose to death from hemorrhage


HIV/AIDS and Malaria during Pregnancy

HIV/AIDS reduces a woman’s resistance to malaria

Intermittent preventive treatment (IPT) given 3 times during pregnancy is effective for women with HIV/AIDS


Malaria Prevention and Treatment during Pregnancy

Focused antenatal care (ANC) with health education about malaria

Use of insecticide-treated nets (ITNs) Intermittent preventive treatment (IPT) Case management of women with symptoms

and signs of malaria


Intermittent Preventive Treatment

Based on the assumption that every pregnant woman living in an area of high malaria transmission has malaria parasites in her blood or placenta, whether or not she has symptoms of malaria


Intermittent Preventive Treatment

Although a pregnant woman with malaria may have no symptoms, malaria can still affect her and her unborn child


Intermittent Preventive Therapy (IPT)

Areas of high transmission Therapeutic doses of SP given periodically to

all pregnant women or infants at risk Takes advantage of

High utilization by pregnant women of antenatal clinics

High coverage of infants for EPI vaccination visits (2, 3, 9 mos)


Intermittent Preventive Treatment: Dose and Timing

A single dose is three tablets of sulfadoxine 500 mg + pyrimethamine 25 mg

Healthcare provider should dispense dose and directly observe client taking dose


Intermittent Preventive Treatment: Contraindications to Using SP

Do NOT give during first trimester: Be sure quickening has occurred and woman is at least 16 weeks pregnant

Do NOT give to women with reported allergy to SP or other sulfa drugs: Ask about sulfa drug allergies before giving SP

Do NOT give to women taking co-trimoxazole, or other sulfa-containing drugs: Ask about use of these medicines before giving SP

Do not give SP more frequently than monthly: Be sure at least 1 month has passed since the last dose of SP


Chemoprophylaxis with Chloroquine: For Women Allergic to Sulfa Drugs*

Dose Chloroquine 150 mg

Timing

1 4 tablets First ANC visit after 16 weeks

2 4 tablets Second day after first dose

3 2 tablets Third day after first dose

Weekly 2 tablets Every week during pregnancy

*If chloroquine resistance rates in the country are high, chemoprophylaxis with chloroquine is not recommended.


Detecting Malaria

Symptoms Fever Chills Headaches Muscle/joint pains

Lab exam of blood from a finger prick


Types of Malaria

Uncomplicated Most common

Complicated Life threatening, can affect brain Pregnant women more likely to get

complicated malaria than non-pregnant women


Recognizing Malaria in Pregnant Women

Uncomplicated Malaria Fever Shivering/chills/rigors Headaches Muscle/joint pains Nausea/vomiting False labor pains

Complicated Malaria Signs of uncomplicated

malaria PLUS one or more of the following:

Dizziness Breathlessness/difficulty

breathing Sleepy/drowsy Confusion/coma Sometimes fits,

jaundice, severe dehydration


Drugs Used to Treat Malaria

Chloroquine (Aralen, Dawaquine) Amodiaquine (Camoquine) Quinine and Quinidine Sulfa combination drugs (Fansidar, Metakelfin) Mefloquine (Lariam) Halofantrine (Halfan) Atovaquone-proguanil (Malarone) Atemisinin derivatives (Paluther)


Case Management: Drugs

First-line drug therapy is indicated for uncomplicated malaria

Second-line drug therapy is indicated for uncomplicated malaria that has failed to respond to first-line drug

In almost all countries, quinine is the drug of choice for complicated malaria


Malaria Treatmentnon-falciparum infections

Chloroquine (CQ) is the drug of choice Some CQ-resistant P. vivax has been reported

from Oceania and South America Mefloquine or quinine for proven resistant cases Primaquine to eradicate liver phase in P. vivax

and P. ovale infections


CQ-resistant P. vivax

Emerged in Southeast Asia Indonesia, Papua New Guinea, Birma

Also documented in Latin America Guyana

Also documented in South Asia India

CQ therapy still recommended Quinine after documented treatment failure


Primaquine (PQ) use in P. vivax and P. ovale infections

Use to achieve radical cure and prevent relapses Check glucose-6-phosphate dehydrogenase (G6PD) level

first PQ can cause hemolysis in G6PD-deficient patients If mildly deficient, consider weekly PQ dosing instead of

daily Partial resistance in Oceania and Southeast Asia

Double usual dose if exposed in these areas Contraindicated in pregnancy

Pregnant women and newborns use prophylactic CQ weekly until delivery or until end of breast-feeding

Then use primaquine


Primaquine 8-aminoquinoline acts on gametocytes, hypnozoites; weak against

asexual blood stage parasites primarily used as post-exposure prophylaxis and

radical cure for P. vivax and P. ovale contraindicated in G6PD deficiency and

pregnancy decreased activity against some P. vivax


Second-Line Drug

Most clients will respond to malaria treatment and begin to feel better within 48 hours

However, if the client’s condition does not improve or worsens, give second-line treatment for uncomplicated malaria


Malaria TreatmentPlasmodium falciparum infections

Acquired in CQ-sensitive areas Chloroquine alone

Acquired in CQ-resistant areas Quinine + tetracycline Quinine + sulfadoxine/pyrimethamine


Multidrug-resistant P. falciparum

Focus in Southeast Asia Border areas, forest transmission Recommendations

Prophylaxis: Doxycycline Treatment:

• Quinine combinations, longer duration of therapy

• High-dose MQ,artemisinin combinations Identifying and documenting treatment

failure is critical

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Prevention and Control of Malaria during Pregnancy Dr.M.Davarpanah.

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