lives at risk: malaria in pregnancy malaria epidemiology branch, division of parasitic diseases u.s....
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Lives at Risk: Malaria in pregnancy
Malaria Epidemiology Branch, Division of Parasitic DiseasesU.S. Centers for Disease Control and Prevention
The burden of malaria in pregnancy
45 million pregnancies in malarious areas; 23 million in sub-Saharan Africa
Estimated 200,000 Low Birth Weight pregnancies/year
Placental infection contributes to: 15% of maternal anemia 8-14% of all low birth weight 30% of preventable low birth weight 3-8% of infant mortality
Malaria in Pregnancy Malaria in Pregnancy High Transmission AreasHigh Transmission Areas
Altered Placental Integrity
Less Nutrient Transport
Placental Sequestration
Low Birth Weight Excess Infant Mortality
Asymptomatic infection
Anaemia
Acquired immunity - high
1st & 2nd pregnancies
HIV infection extends this to all pregnancies, and makes it worse
Neonatal Mortality Rates by BirthweightMangochi, Malawi -- September 1987 - June 1989
0
200
400
600
800
1000
<1500 1500-1999 200-2499 2500
Death
s p
er
1000 L
ive B
irth
s
800
300
49 26
31 11.7 2.4 1.0Relative Risk
Placental parasitemia by pregnancy number, Kisumu, Kenya, 1996-98
0
5
10
15
20
25
30
1st 2nd 3rd or greater
1-999 1000-9999 >10,000
Parasite density/mm3
% parasitemic
772 402 479
Pregnancy number
Placental parasitemia by HIV status and pregnancy number, Kisumu, Kenya, 1996-98
0
5
10
15
20
25
30
35
40
G1 G2 G3 G1 G2 G3
1-999 1000-9999 >10,000
Parasite density/mm3
% parasitemic
HIV (+) HIV (-)
231 159 197 772 402 479
Total n = 2263Summary RR = 1.63 (1.41-1.89), p<0.001
Low birth weight
Factors Contributing to Low Birth Weight - Developing Countries
Nonwhite race
Low caloric intake or wt gain
Low prepregnancy wt
Short stature
Malaria
Female sex
Primiparity
Maternal LBW/History LBW
General morbidity
Small paternal size/other
Factors Contributing to Low Birth Weight – that are amenable to intervention during pregnancy
Low caloric intake or wt gain
Malaria
General morbidity
Contribution of Prematurity and IUGR to Low Birth Weight
Mangochi, Malawi
Adapted from Steketee et al.
82%
8
18
Normal Birthweight
Low Birthweight
PrematurityNMR* 245/1000
IUGRNMR* 52/1000
18%
All InfantsN=1,618
Low BirthweightN=297
*Neonatal Mortality Rate
Frequency of Low Birth Weight by placental malaria infection,
Malawi 1988-91
0
5
10
15
20
25
30
35
Grav 1 Grav 2 Grav 3+
Placental +
Placental -
% Low Birth weight
Malaria in PregnancyMalaria in PregnancyOpportunities for InterventionOpportunities for Intervention
Program opportunity in areas of Africa with greatest LBW > 60% women
attend ANC Drugs
Intermittent Preventive Treatment (IPT)Case Management
Insecticide Treated Nets (ITN) Treatment of anemia
Iron/folateNutritional counseling
Antenatal care in AfricaAntenatal care in AfricaProportion of Pregnant Women Seeking Antenatal Clinic CareProportion of Pregnant Women Seeking Antenatal Clinic Care
0
10
20
30
40
50
60
70
80
90
100
Countries
Zambia-96Rwanda-92Zimbabwe-94Botswana-88Kenya-98Uganda-95Malawi-92Tanzania-96Ghana-98Namibia-92Comoros-96Cote d'Ivoire-94Senegal-97Liberia-86Togo-98Benin-96Cameroon-98Madagascar-97Guinea-99Sudan-90Mozambique-97CAR-94Burkina Faso-99Nigeria-90Eritrea-95Mali-96Niger-98Chad-97
Demographic and Health Surveys
• Preventive intermittent treatment (PIT)
• Insecticide treated nets (ITN)
• Treatment and Care of acute cases of malaria during pregnancy
Interventions to addressmalaria in pregnancy
Providing antimalarial treatment dose at scheduled antenatal clinic visits
• Shown to:
• Substantial improvement in maternal anemia
• >50% reduction in placental malaria rates
• 20-25% reduction in low birth weight rates
Preventive intermittent treatment (PIT)
Intermittent Preventive TherapyIntermittent Preventive Therapy- the monthly clinic dosing strategy-- the monthly clinic dosing strategy-
Weeks of gestationConception Birth
20 3010Quickening
Rx Rx Rx Rx
Insecticide Treated Materials
Bednets: Birth OutcomeBednets: Birth OutcomeGravidae 1-4
0
5
10
15
20
25
30
35
Stillb
irth/
aborti
on
Prete
rm d
eliv
ery
SGA
Low b
irth w
eigh
t
LBW o
r PTD o
r SG
A
Any ad
vers
e ou
tcom
e
Pre
vale
nce
(%
)
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Pre
vale
nce
rat
io
control
bednet
PR (95% CI)
ter Kuile 2001Kenya
Impact of ITNs on maternal and infant health, western Kenya
• During pregnancy 38% reduction in peripheral parasitemia 21% reduction in all cause anemia (Hb < 11 g/dl) 47% reduction in severe malarial anemia
At delivery 23% reduction in placental malaria 28% reduction in LBW 25% reduction in any adverse birth outcome
Interventions to address malaria in pregnancy
Intermittent preventive treatment
Insecticide-treated materials
Case management
UNICEF/C-55-10/Watson
Malaria in Mothers and Infants
Non-pregnantNon-pregnant PregnancyPregnancy Post-partumPost-partum
InfancyInfancy
Insecticide-treated nets
IPT
Case management
Malaria Control during PregnancyImplementation Package(s)
IPTIPT ITNsITNs
CMCM
ANCANCANCANCPrivatePrivateSectorSector
FacilitiesFacilitiesCommunityCommunity
Summary The effect of malaria during pregnancy on morbidity and mortality is: documented; consistent across
studies; amenable to interventions applied during the current pregnancy
The malaria effect is linked with anemia & HIV
Today, the tragedy rests in the failure to apply existing effective control measures