MALARIA IN PREGNANCY

1. MALARIA IN PREGNANCY Dr S. Zinyowera NMRL Coordinator, AMR Coordinator

2. Why is MIP Important? • Each year, more than 30 million women in Africa become pregnant in malaria-endemic areas • Malaria and pregnancy are mutually aggravating conditions. The physiological changes of pregnancy and the pathological changes due to malaria have a synergistic effect on the course of each other • Women are four times as likely to get sick from malaria if they are pregnant and twice as likely to die from the disease.

3. Effects of Pregnancy on Malaria • Reduced immunity especially in primigravidae increases risk of malaria infection and development of severe disease • Increased circulating volume leads to haemodilution and anaemia • Increased demand on haematinic stores in the body especially Fe worsens both haemodilutional and malarial anaemia

4. EFFECT OF MIP ON MATERNAL, NEWBORN, INFANT AND CHILD HEALTH Source: Meghna Desai et al: Lancet Series Vol 7 2007

5. MALARIA IN PREGNANCY STRATEGY • Strategy aimed at improving pregnancy outcome for both mother and developing baby • Uses five pronged approach to reach pregnant women • Quality Focused Antenatal Care • Appropriate Health Promotion • Intermittent Preventive Treatment with SP using a DOT approach • The use of LLINs during pregnancy • Good case management for malaria disease in pregnancy In areas of stable (high and moderate) transmission all five interventions In areas of unstable/epidemic prone (low) transmission LLINs, Quality FANC and malaria case management recommended. • Delivery of MIP strategy should be coordinated efforts of both malaria and Reproductive Health Units through ANC

6. Intermittent Preventive Treatment (IPTp) • Based on an assumption that every pregnant woman in a malaria-endemic area is infected with malaria and has malaria parasites in the blood or in the placenta • The pregnant woman with malaria parasites in her blood may not have symptoms of malaria, but the parasites can still affect her health and that of the unborn baby. • IPTp is based on the use of anti malarial medicines given in treatment doses at pre defined intervals after quickening • IPTp was recommended by the WHO Expert Committee on Malaria in 2000 • In Zimbabwe the policy was recommended by case management subcommittee meeting of 26 May 2004 • Policy operationalized on 1st June 2004 • New policy from 2014

7. Intermittent Preventive Therapy in Pregnancy (IPTp) Old Policy: • Use of Sulphadoxine/Pyrimethamine (SP) only as follows: • 3 tablets at booking (after quickening), then at 26 -28 & finally 34-36 wks • Was aiming for at least 2 doses of IPTp New Policy: • First dose after quickening (around 16 weeks) • 3 SP tablets at each of the 4 Focused ANC visits- including at delivery stage (very safe). aims for at least 3 doses NB: 1. Doses should not be less than four weeks apart 2. Women on Cotrimoxazole prophylaxis should not get SP, due to higher risk of adverse effects

8. Intermittent Preventive Treatment (IPTp) • Sulphadoxine-Pyrimethamine (SP) currently considered the most effective medicine for IPTp: • Good efficacy in most areas • Good safety profile in pregnancy • Good Programme feasibility

9. IPTp Policy in Zimbabwe • Relevance of IPTp has to be review as the epidemiological patterns of malaria changes – Note IPTp districts and tendency to move to IST

10. Case Management • Diagnostic: MIP often misdiagnosed ( eclampsia if convulsions, absence of fever, anaemia) Importance of LMP in all women of child bearing age at history taking • Confirmation of diagnosis important

11. Case Mx for uncomplicated MIP ACTs are not recommended in the 1st trimester • ONLY in the absence of an available alternative and presence of a life threatening condition can they be used in the 1st trimester.

12. Malaria In Pregnancy and HIV • Number of studies shown and some currently on-going to show relationship between Malaria and HIV • Malaria has been shown to increase Mother to Child HIV transmission • HIV has been shown to reduce response to IPTp • Two doses are not be adequate in HIV pregnant women • Both HIV and malaria contribute to maternal anaemia, IUGR, possible foetal wastage and increased infant mortality

13. LLINs use In pregnancy • Delivery methods to pregnant women and children under five; • Preferably at no cost to end user for rapid scale up of LLINs. • Highly subsidised channels at ANC and Child health Clinics • Private sector support at cost or subsidised • Encourage behaviour change through appropriate IEC • Monitor use at each ANC visit • Encourage patient caregiver discussion to increase compliance on LLINs use and other methods of malaria prevention and treatment

14. Programmatic issues • Need for close partnership with RH programmes • Capturing IPTp and LLIN information in ANC services • Routine distribution of nets in ANC • Maintaining IPTp coverage at same levels as ANC coverage • Pharmacovigilance issues • Community based delivery of IPTp (where ANC coverage is low not easily accessible) • Availability of SP

15. Conclusion • Malaria preventive package includes: • Intermittent preventive treatment during antenatal clinic visits • Use of LLINs throughout pregnancy and in the postpartum period • Prevention must be complemented by effective case management of malaria illnessfor all women of reproductive age.

16. THANK YOU Muchas gracias Merci beacoup Tatenda chose Siyabonga