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MALARIA IN PREGNANCY: CURRENT APPROACH TO MANAGEMENT

MALARIA IN PREGNANCY: CURRENT APPROACH TO MANAGEMENT. BY. AY ISAH SENIOR LECTURER / CONSULTANT UNIVERSITY OF ABUJA TEACHING HOSPITAL ABUJA, NIGERIA. Outline . Introduction The life cycle and the drugs Effects of Pregnancy on Malaria Current approach to the use (IPTs & case Mgt)

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MALARIA IN PREGNANCY: CURRENT APPROACH TO MANAGEMENT

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  1. MALARIA IN PREGNANCY:CURRENT APPROACH TO MANAGEMENT BY AY ISAH SENIOR LECTURER / CONSULTANT UNIVERSITY OF ABUJA TEACHING HOSPITAL ABUJA, NIGERIA

  2. Outline • Introduction • The life cycle and the drugs • Effects of Pregnancy on Malaria • Current approach to the use (IPTs & case Mgt) • Challenges in Management (Nets, IPT & Drugs) • Research questions! • Conclusion N/BUSSA, CME 08/13

  3. Introduction • 300 million malaria cases each year worldwide • 9 out of 10 cases occur in Africa • An African dies of malaria every 10 seconds • Affects 5 times as many as TB, AIDS, measles and leprosy combined N/BUSSA, CME 08/13

  4. Significance of malaria in pregnancy • 30 million African women are pregnant yearly • Malaria is more frequent and severe during pregnancy • Women in 1st or 2nd pregnancy more at risk N/BUSSA, CME 08/13

  5. Introduction Contd • WHO recommends package of interventions 1 • ITNs • IPTp – SP • Effective case management • Niger state ITNs Corvarage - 70% • growing ineffectiveness of SP for IPTp • Global Mal program (ERG, WHO)2 • Malaria Policy AdvComm (MPAC) for MoH N/BUSSA, CME 08/13

  6. Oocyst Sporozoites Mosquito Salivary Gland Zygote Gametocytes Red Blood Cell Cycle Malaria Parasite Life Cycle & Drugs Liver stage N/BUSSA, CME 08/13

  7. Effects of Pregnancy on Malaria • More common. • Immuno suppression and loss of acquired immunity to malaria. • More atypical. • due to the hormonal , immunological and haematological changes of pregnancy. • More severe. • parasitemia tends to be 10 times higher. N/BUSSA, CME 08/13

  8. Effects of Pregnancy on Malaria • More fatal • mortality is also double (13 % Vs 6.5%). • Selective treatment • Some drugs are contra indicated in pregnancy . • Other problems • Management of complications of malaria may be difficult due to the various physiological changes of pregnancy. N/BUSSA, CME 08/13

  9. The Update - WHO Recommendations(IPTp with SP*) • Evidence Reviewed • series of Published Literatures 2– 12 • esultsfrom effectiveness monitoring studies (BKMMUZ) 11 . Kayentaoet al. Effect on low birth weight of monthly dosing versus the standard two- dose regimen of IPT with SP for the control of malaria in pregnancy in sub-Saharan Africa: a systematic review and meta-analysis of 5969 pregnancies in seven randomized trials. JAMA 2013 ;309(6):594-604. N/BUSSA, CME 08/13

  10. WHO Recommendations(IPTp with SP*) • IPTp with SP remain effective & should still be administered • Is recommended for all pregnant women AT EACH SCHEDULE ANC in Areas of stable transmission (moderate - high). 11, 12 N/BUSSA, CME 08/13

  11. WHO Recommendations – IPTp with SP* • Currently, no established threshold level of malaria transmission below which SP is no longer cost effective • Insufficient data for general recommendation for the use of SP outside Africa • Contn monitoring of effectiveness is essential N/BUSSA, CME 08/13

  12. WHO Recommendations – IPTp with SP* • Particular issues on above • 1st adm as early as possible in 2ndTM (13weeks) • At least 1 month apart • Can be adm late after 36 wks without safety concern (up to delivery) • Should be as DOT N/BUSSA, CME 08/13

  13. WHO Recommendations – IPTp with SP* • Can be given on empty stomach • F/Acid > 5mg should not be given concomitantly • SP is C/I in women on septrin prophylaxis * Malaria Policy Advisory Committee Meeting 11-13 September 2012, WHO HQ Session 4 N/BUSSA, CME 08/13

  14. WHO Recommendations – IPTp with SP* • Determinants & Potential confounders of reduced effectiveness • Maternal • Compliance with ANC • HIV infection • Age • Gravidity N/BUSSA, CME 08/13

  15. WHO Recommendations – IPTp with SP* • Health system • Quality / Ascess to care • DOT • SP quality • High concomitant dosage of FA N/BUSSA, CME 08/13

  16. WHO Recommendations – IPTp with SP* • Others • Malaria transmission intensity (The higher, the more effective) • No of timing of SP doses Vs Gestational age • SP resistance • ITNs use • Pharmacokinetic changes in pregnancy N/BUSSA, CME 08/13

  17. WHO Recommendations – Case Management • It is preferable that treatment for malaria should not be initiated until the diagnosis has been established by laboratory investigations. "Presumptive treatment" without the benefit of laboratory confirmation should be reserved for extreme circumstances (strong clinical suspicion, severe disease, impossibility of obtaining prompt laboratory diagnosis)*. * CDC treatment guide lines, April 2011 N/BUSSA, CME 08/13

  18. WHO Recommendations – Case Management • Establish the diagnosis • Safety issues of drugs in various trimesters • Gestational Age / Severity (Current position) • Available evidence (Severity, 2012) • simple Vs Severe N/BUSSA, CME 08/13

  19. Case Management (Evidence based) • Simple Malaria in Pregnancy (In all trimesters) • Arthemeter/Lumefantrine(Coartem) • Mefloquine(CDC recommendation, SEPT 2011.) FDA recatigorisation – B Similar to gen. Population • Quinine Sulphate + Clindamycin • Artesunate+ Amodiquine N/BUSSA, CME 08/13

  20. Case Management (Evidence based) • Complex Malaria in Pregnancy • All trimesters! • Quinine. Loading / maintenance • Artesunate(CDC 2011) Parenteral, then Orals - Artesunate 2.4 mg/kg IV at hour 0, 12 and 24 - oral artesunate 2 mg/kg/dose, for 7 days and clindamycin 5 mg/kg • Succ treatment with ACT (AM J Trop Med 2012; 86:3. • A case Report! N/BUSSA, CME 08/13

  21. Awareness & Utilization of ITNs in Nigeria Challenges in Management – ITNS • South –Western Nigeria • - 51.4% Vs 2.1 (Abiona, Ife,2005) • - 20 .0% Vs 2.1% (Sebanjo,Ife- 2006) • - 41.1% Vs 10.2% (Adeyemi, Osogbo 2007) • South –Eastern Nigeria • - 7% Vs 0.1% (NETMARK Survey, 2000) • North –Western Nigeria • - 74.4% Vs 13.2% (Isah,Nwobodo 2008) • Niger state (Availability - 70%. Reduce MIP?) N/BUSSA, CME 08/13

  22. Challenges in Management – IPTs, Drugs • IPTs • Hardly, DOT • Rapidly developing resistance • Drugs • Quinine – Fear & Prejudice! • Fake & Adulterated brands • Over the counter Abuse N/BUSSA, CME 08/13

  23. Anti Malaria Vaccine • WHY THE NEED FOR VACCINE? • Cost of current anti-malaria drugs • Cost of Environmental preventive measures • Drugs and Insecticides resistance • Poor compliance N/BUSSA, CME 08/13

  24. Anti Malaria Vaccine • No significant Progress till date • PfEMP 1 protein (James Beeson, Australia Sept 2012) • Progress is Expected (How soon?) N/BUSSA, CME 08/13

  25. Research Key Areas • Safety of SP when given > 5 during Pregnancy • Interactions between Antimalarial & ARVs • Malaria intensity level & SP effectiveness • Monitoring Protocols for SP effectiveness • Innovative community strategies to increase Sp uptake N/BUSSA, CME 08/13

  26. Research Key Areas • Operational ways to improve delivery & use of ITNs by Women before they concieve • Production, Availability and ascess to Parenteral ACTs • Funding of Vaccine development in Africa • How long should we expect effective vaccine? N/BUSSA, CME 08/13

  27. Conclusion • SP remain effective Preventive measure but must be complimented with Vector control and effective case management • Could be administered at least, on monthly bases • Avoid 1st TM but safe up till delivery • ACTs are safe throughout pregnancy • Parenteral Artesunate can be used in place of Quinine • Effective Vaccine is still under way • Doctors mayrespond to Research ?s to add quality! N/BUSSA, CME 08/13

  28. Outcome should be like this! THANK YOU!!!

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