Prevention and Control of Malaria during Pregnancy

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

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 Prevention and Control of Malaria during Pregnancy

3. Populations Most Affected by Malaria • Children under 5 years of age • Pregnant women • Unborn babies • Immigrants from low-transmission areas • HIV-infected persons Prevention and Control of Malaria during Pregnancy

4. 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 Prevention and Control of Malaria during Pregnancy

5. Malaria in pregnant women • >50 million pregnant women exposed to malaria each year • ~3.5 million pregnant women infected Poor birth outcomes Poor maternal outcomes Prevention and Control of Malaria during Pregnancy

6. Placental malaria • Parasites accumulate and thrive in the placenta • Only affects primigravidae in areas of high transmission Prevention and Control of Malaria during Pregnancy

7. 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 Prevention and Control of Malaria during Pregnancy

8. 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 Prevention and Control of Malaria during Pregnancy

9. 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 Prevention and Control of Malaria during Pregnancy

10. 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 Prevention and Control of Malaria during Pregnancy

11. Maternal mortality • Responsible for 0.5 – 23% of maternal deaths in Africa • Malaria causes severe anemia and  platelets can predispose to death from hemorrhage Prevention and Control of Malaria during Pregnancy

12. 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 Prevention and Control of Malaria during Pregnancy

13. 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 Prevention and Control of Malaria during Pregnancy

14. 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 Prevention and Control of Malaria during Pregnancy

15. Intermittent Preventive Treatment Although a pregnant woman with malaria may have no symptoms, malaria can still affect her and her unborn child Prevention and Control of Malaria during Pregnancy

16. 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) Prevention and Control of Malaria during Pregnancy

17. 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 Prevention and Control of Malaria during Pregnancy

18. 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 Prevention and Control of Malaria during Pregnancy

19. Dose Chloroquine Timing 150 mg 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 Chemoprophylaxis with Chloroquine: For Women Allergic to Sulfa Drugs* *If chloroquine resistance rates in the country are high, chemoprophylaxis with chloroquine is not recommended. Prevention and Control of Malaria during Pregnancy

20. Detecting Malaria • Symptoms • Fever • Chills • Headaches • Muscle/joint pains • Lab exam of blood from a finger prick Prevention and Control of Malaria during Pregnancy

21. Types of Malaria • Uncomplicated • Most common • Complicated • Life threatening, can affect brain • Pregnant women more likely to get complicated malaria than non-pregnant women Prevention and Control of Malaria during Pregnancy

22. 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 Recognizing Malaria in Pregnant Women Prevention and Control of Malaria during Pregnancy

23. 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) Prevention and Control of Malaria during Pregnancy

24. 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 Prevention and Control of Malaria during Pregnancy

25. 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 Prevention and Control of Malaria during Pregnancy

26. 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 Prevention and Control of Malaria during Pregnancy

27. Primaquine (PQ) use in P. vivax and P. ovaleinfections • 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 Prevention and Control of Malaria during Pregnancy

28. 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 Prevention and Control of Malaria during Pregnancy

29. 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 Prevention and Control of Malaria during Pregnancy

30. Malaria TreatmentPlasmodium falciparum infections • Acquired in CQ-sensitive areas • Chloroquine alone • Acquired in CQ-resistant areas • Quinine + tetracycline • Quinine + sulfadoxine/pyrimethamine Prevention and Control of Malaria during Pregnancy

31. 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 Prevention and Control of Malaria during Pregnancy