agarwal_malaria in pregnancy and its contribution to anemia
TRANSCRIPT
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Malaria in Pregnancy and its
contribution to Anemia:
Sharing the PMI experience
Koki Agarwal,
Director, MCHIP/Jhpiego
Co-Chair RBM MIP WG
Global Nutrition Symposium
April 14, 2013
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Malaria in Pregnancy (MIP)
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MIP the basics
Stable Transmission Most of sub-Saharan Africa Pregnant women have some level of immunity 1st and 2nd pregnancies most at risk
MiP contributes each year to: 400,000 cases of severe anemia every year Maternal death: 10,000 Infant death: 200,000
11% of neonatal deaths in malaria endemic Africancountries are due to low birth weight resulting from P.falciparum infections in pregnancy
-WHO. A Strategic Framework for malaria Prevention and Control During Pregnancy in the African Region. 2004.-Guyatt HL, Snow RW. Malaria in pregnancy as an indirect cause of infant mortality in sub-Saharan Africa. Trans R. Soc Trop Med Hyg2001; 95: 569-76
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MIP the basics (2)
Unstable Transmission Pregnant women have little acquired immunity Similar risk across pregnancies MiP contributes to:
Severe malaria Anemia Stillbirths Abortions
Low Birth Weight Premature delivery, when infection occurs in 3rd
trimester
WHO. A Strategic Framework for malaria Prevention and Control During Pregnancy in the African Region. 2004.
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WHO Recommendations
WHO recommends a three-prongedapproach to prevent and treat MIP:1. Intermittent preventive treatment in pregnancy
(IPTp) with sulfadoxine-pyrimethamine (SP), in
areas of stable malaria transmission As early as possible in 2nd trimester During routine ANC One month apart SP can be given to a pregnant woman safely up until
the time of delivery2. Use of insecticide treated bed-net (ITN)3. Diagnosis and treatment of malaria case mgt.
Updated WHO Policy Recommendation (October 2012)- Intermittent Preventive Treatment of malaria inpregnancy using Sulfadoxine-Pyrimethamine (IPTp-SP)
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6Malaria during
Effect of Malaria on Pregnancy in
Stable Transmission Areas
Asymptomatic Infection
Altered Placental Integrity
Reduced Nutrient and Oxygen Transport
Placental Sequestration
Low Birth Weight (IUGR)
Risk of Newborn Mortality
Plasmodium falciparum malaria
Anemia
Source: WHO 2002.
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7Malaria during
Effect of Malaria on Pregnancy in
Unstable Transmission Areas
Acquired Immunity Low
Clinical Illness
Severe Disease
Risk to Mother Risk to Fetus
Source: WHO 2002.
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MiP and Neonatal Mortality (1)
Retrospective birth cohort from 32 national cross-sectional datasets in 25 African countries from 2000-2010
Among pregnant women in 1st or 2nd pregnancy,
who had taken at least 2 doses of IPTp-SP and/orhad ITN in household: 18% decrease in neonatal mortality (p
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MiP and Neonatal Mortality (2)
Randomized, placebo controlled trial of IPTp-SP in 1030pregnant Mozambican women found use of IPTp wasassociated with a 61.3% reduction in neonatal mortality. These results have not been replicated
The results of this trial showed that, maternal malaria mayhave a direct effect on neonatal mortality; prevention ofmalaria during pregnancy can reduce neonatal mortality
An increase in birth weight or gestational age is unlikely tobe the explanation
Presences of parasites in the placenta or in cord blood may
have had a negative effect on neonatal survival.
1. Clara Menndez, Azucena Bardaji, Betuel Sigauque, Sergi Sanz, John J. Aponte,Samuel Mabunda, Pedro L. Alonso. Malaria Prevention with IPTp during PregnancyReduces Neonatal Mortality. PLoS ONE; Feb 2010; Vol. 5, Issue 2.
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Cost Effectiveness of IPTp
Based on same study (Menedez et al), IPTp-SP was highly cost effective for bothprevention of maternal malaria and reduction
of neonatal mortality Incremental cost-effectiveness ratio of
US$1.02 per disability-adjusted life year
averted. Elisa Sicuri, Asucena Bardaji, Tacita Nhampossa, Maria Maixenchs, ArielNhacolo, Delino Nhalungo, Pedro L. Alonso, Clara Menndez. Cost-Effectiveness of Intermittent Preventive Treatment of Malaria in Pregnancy inSouthern Mozambique. PLoS ONE; Oct. 2010; Volume 5, Issue 10
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Malaria & Anemia
Anemia (clinical test or pallor) may be theonly sign that a woman has malaria
Women with anemia should be tested for
malaria
Women with anemia should be treated andreceive an integrated package of
interventions to address all its causes
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Needed: an integrated package
The impact of MiP is increased whencomplementary interventions are given toincrease intake of essential nutrients
For example, an integrated package ofinterventions is needed to address all thecauses of anemia
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Complementary interventions to
prevent & treat anemia
Iron-folic acid supplementation during pregnancy(currently 60 mg of iron/400 mcg of folic acid for 180days)additional IFA for anemia
Deworming during the second trimester and thirdtrimester (where prevalence is high)
Improving maternal diet to ensure adequate intake ofanemia-related micronutrients (e.g., iron, vitamin A)
Decrease work load Delayed cord clamping at birth
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Caveats for IPTp & IFA
supplementation
WHO recommends the administration of folic acid at adose of 0.4mg daily; this dose may be safely used inconjunction with SP- In countries with a combined IFApill (60 mg of iron & 0.4mg folic acid) no problem
Folic acid at a daily dose equal or above 5mg should notbe given together with SP as this counteracts its efficacyas an antimalarial.
Transition from the 5 mg dose to the combined IFA
When treating of anemia in pregnancy, providers shouldinclude testing of & treatment for malaria
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Results from ZambiaIndicator DHS
2001/2MIS
2006DHS
2007MIS
2008MIS
2010Attended 2+ ANC 91.4% N/A 94.3% N/A N/AAttended 4+ ANC 71.6% N/A 60.3% N/A N/AAttended first ANC at
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The road to effective programs
Strengthen the ANC platform to ensurecomprehensive services
Develop effective policies to support programs
Train providers to address all elements of FANC
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Commodities
Address Stock-outs ofSP & ITNs at ANC
Avoid inappropriate
use of SP Make ITNs free for
pregnant women andavailable through
ANC
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Quality Assurance
Ensure performancestandards in place
Drinking water for
DOTS available Routine supportive
supervision
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Community Involvement, Awareness
Engage community to raiseawareness of importance ofMIP and anemia Have women understand the
dangers Come in early for their first
visit
Explore community based
distribution of IPTp and IFA
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Monitoring and Evaluation
IPTp uptake to be recorded in registers forHMIS
Collect other data like % of women with
severe anemia
Collect information on ITN distributionthrough ANC
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