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Lives at Risk: Malaria in pregnancy

Lives at Risk: Malaria in pregnancy. Malaria Epidemiology Branch, Division of Parasitic Diseases U.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

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Lives at Risk: Malaria in pregnancy

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  1. Lives at Risk: Malaria in pregnancy Malaria Epidemiology Branch, Division of Parasitic Diseases U.S. Centers for Disease Control and Prevention

  2. 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

  3. Malaria in Pregnancy High Transmission Areas Acquired immunity - high Asymptomatic infection • 1st & 2nd pregnancies Placental Sequestration • HIV infection extends this to all pregnancies, and makes it worse Anaemia Altered Placental Integrity Less Nutrient Transport Low Birth Weight Excess Infant Mortality

  4. ³2500 <1500 1500-1999 200-2499 Neonatal Mortality Rates by BirthweightMangochi, Malawi -- September 1987 - June 1989 1000 800 800 600 Deaths per 1000 Live Births 400 300 200 49 26 0 1.0 Relative Risk 31 11.7 2.4

  5. Placental parasitemia by pregnancy number, Kisumu, Kenya, 1996-98 Parasite density/mm3 % parasitemic 772 402 479 Pregnancy number

  6. Placental parasitemia by HIV status and pregnancy number, Kisumu, Kenya, 1996-98 Parasite density/mm3 % parasitemic 231 159 197 772 402 479 HIV (+) HIV (-) Total n = 2263 Summary RR = 1.63 (1.41-1.89), p<0.001

  7. Low birth weight

  8. Factors Contributing to Low Birth Weight - Developing Countries Short stature Nonwhite race Malaria Maternal LBW/History LBW Small paternal size/other General morbidity Low prepregnancy wt Female sex Primiparity Low caloric intake or wt gain

  9. Factors Contributing to Low Birth Weight – that are amenable to intervention during pregnancy General morbidity Malaria Low caloric intake or wt gain

  10. Contribution of Prematurity and IUGR to Low Birth WeightMangochi, Malawi Normal Birthweight Prematurity NMR* 245/1000 8 82% 18% Low Birthweight IUGR NMR* 52/1000 18 All Infants N=1,618 Low Birthweight N=297 *Neonatal Mortality Rate Adapted from Steketee et al.

  11. Frequency of Low Birth Weight by placental malaria infection,Malawi 1988-91 % Low Birth weight 35 30 25 20 Placental + 15 Placental - 10 5 0 Grav 1 Grav 2 Grav 3+

  12. Malaria in PregnancyOpportunities 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/folate • Nutritional counseling

  13. Antenatal care in AfricaProportion of Pregnant Women Seeking Antenatal Clinic Care Demographic and Health Surveys

  14. Interventions to addressmalaria in pregnancy • Preventive intermittent treatment (PIT) • Insecticide treated nets (ITN) • Treatment and Care of acute cases of malaria during pregnancy

  15. Preventive intermittent treatment (PIT) 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

  16. Intermittent Preventive Therapy - the monthly clinic dosing strategy- Rx Rx Rx Rx 20 10 30 Quickening Conception Birth Weeks of gestation

  17. Insecticide Treated Materials

  18. Bednets: Birth Outcome Gravidae 1-4 ter Kuile 2001 Kenya

  19. 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

  20. Interventions to address malaria in pregnancy • Intermittent preventive treatment • Insecticide-treated materials • Case management UNICEF/C-55-10/Watson

  21. Malaria in Mothers and Infants Insecticide-treated nets IPT Non-pregnant Pregnancy Post-partum Infancy Case management

  22. Malaria Control during PregnancyImplementation Package(s) ANC Private Sector IPT ITNs ANC Facilities Community CM

  23. 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

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