Module 6 Version 2

1. Applying Community-Directed Intervention (CDI) to Intermittent Preventive Treatment in Pregnancy (IPTp) Module 6 Version 2

2. Overview • Malaria in pregnancy (MiP) control has three major components: • Sleeping inside insecticide-treated bed nets or long-lasting insecticidal nets (ITNs/LLINs) • IPTp • Prompt and appropriate case management • This module will focus mainly on IPTp

3. Learning objectives • By the end of this module, learners will be able to: • Describe their country’s specific malaria data • Describe the basis for IPTp and the use of sulfadoxine-pyrimethamine (SP) for IPTp • Identify special IPTp target groups • State the difference between chemoprophylaxis and IPTp • Describe the benefits of IPTp • Identify who should be given IPTp • Identify who should NOT be given IPTp • Describe when and how to give IPTp

4. MiP in Africa is responsible for... • 3%‒15% of maternal anemia (Steketee et al. 2001) • 5%‒14% of low birthweight (LBW) in newborns • 30% of “preventable” LBW in newborns • 7%‒10% of congenital malaria in newborns (Mosha et al. 2010) • 20% of stillbirths (Lawn et al. 2016) • 200,000 newborn deaths per year (Dellicour et al. 2010)

5. Why is MiP important in your country? • Each year, more than ___ women in your country become pregnant in malaria-endemic areas • At any given time, nearly ___% of pregnant women in your countrymay have malaria parasites in their blood

6. IPTp • IPTp is a prevention strategy for areas of high, stable malaria transmission • In these areas, pregnant women may have malaria, especially infection of the placenta, and not always show any signs such as fever • A full course of malaria treatment can clear these malaria parasites The more stable malaria transmission an area has, the darker red it appears on this map. Source: United States Agency for International Development (USAID). 2011. The President’s Malaria Initiative: Fifth Annual Report to Congress; Executive Summary. Washington, DC; USAID. https://www.pmi.gov/docs/default-source/default-document-library/pmi-reports/pmi_annual_execsum11.pdf?sfvrsn=15. Accessed September 26, 2018.

7. IPTp is based on... ...the assumption that every pregnant woman living in an area of moderate to high malaria transmission has malaria parasites in her blood or placenta, whether or not she has symptoms or signs of malaria Photo by Karen Kasmauski

8. IPTp: Special target groups • We target all pregnant women in areas of high, stable transmission, but especially: • Women in their first or second pregnancies • Women with HIV • Adolescents (10‒19 years of age) • Women with sickle cell disease • All pregnant women with unexplained anemia

9. IPTp: World Health Organization (WHO) recommendations • All pregnant women should receive at least three doses of IPTp (IPTp3), during routinely scheduled antenatal care (ANC) visits: • No more frequently than monthly starting from the 13th week of gestation • Under the health care provider’s direct observation (directly observed therapy, or DOT) • The WHO recommends a schedule of at least eight patient contacts in the clinic or at home.

10. IPTp: World Health Organization (WHO) recommendations, cont. • IPTp with SP continues to be highly effective in preventing the adverse consequences of MiP. • Pregnant women who are already receiving co-trimoxazole prophylaxis should not receive IPTp with SP. Taking both drugs will increase the risk of adverse effects from SP.

11. The use of SP for IPTp • Remember that IPTp is based on the assumption that every pregnant woman living in an area of moderate to high malaria transmission has malaria parasites in her blood or placenta, whether or not she has symptoms of malaria: • A pregnant woman with malaria may have no symptoms, but malaria can still affect her and her unborn child • IPTp with SP reduces: • Severe antenatal anemia in the mother • LBW • Perinatal deaths (to a lesser extent) • These beneficial effects are most pronounced in women in their first or second pregnancies

12. The use of SP for IPTp, cont. • IPTp with SP continues to be highly effective in preventing the adverse consequences of MiP • All pregnant women should receive at least three treatment doses of SP after quickening (baby has started moving in the womb), and at intervals of at least 4 weeks • HIV-positive pregnant women not taking co-trimozaxole should receive at least three treatment doses of SP after quickening (baby has started moving in the womb), and at intervals of at least 4 weeks

13. Clearing parasites • The majority of fetal growth occurs between 24 and 36 weeks of gestation • So, if the woman receives the minimum of three recommended doses beginning as early as possible in the second trimester (e.g., at 13 weeks): • The parasites will be cleared from the placenta, reducing anemia for mother and fostering intrauterine fetal growth • Note that it is safe to give SP up to the time of delivery because clearing placental malaria can help prevent postpartum hemorrhage and congenital malaria in the newborn

14. Timing of monthly IPTp doses in relation to fetal growth velocity when gestational age is known IPTp4 IPTp3 IPTp with SP should be given before and during the period of rapid growth of the baby starting from 13 weeks! Fetal growth velocity IPTp2 IPTp1 Quickening 13 wks. 13 16 20 30 36 Birth Conception Weeks of pregnancy

15. Timing of monthly IPTp doses in relation to fetal growth velocity where exact fetal gestational age cannot be determined (use experience of quickening) IPTp3 IPTp4 Where the exact gestational age is unknown, IPTp may start after experience of quickening! IPTp2 Fetal growth velocity IPTp1 Quickening 10 16 20 30 36 Birth Conception Weeks of pregnancy

16. The difference between chemoprophylaxis and IPTp • IPTp is the use of antimalarial drugs given in treatment doses at predefined intervals beginning as early as possible in the second trimester to clear a presumed burden of parasites • IPTp is a curative dose of SP given at least three times during pregnancy • These curative doses clear the placenta of parasites at each dose

17. The difference between chemoprophylaxis and IPTp, cont. • IPTp works differently from chemoprophylaxis • Chemoprophylaxis requires a treatment dose, then subtherapeutic doses of the drug during and after pregnancy to prevent reinfection of the placenta

18. IPTp through community health workers (CHWs) CHW: • Informs community leader of readiness to begin distribution of drugs • Collects SP from the agreed point (usually from the health facility [HF])

19. IPTp through community health workers (CHWs), cont. • Gives health education to the women (home visits, women’s society meetings, marketplace, etc.) using the Interpersonal Communication for Prevention and Control of Malaria in Pregnancy: Community Health Workers’ Counseling Flip Chart • Identifies pregnant women eligible for IPTp dose

20. IPTp through community health workers (CHWs), cont. • Issues drug to eligible women and ensures they swallow full dose (DOT)* • Records the information about giving IPTp in CHW register • Refers pregnant woman to ANC for follow-up doses and ITN/LLIN if she has not already received one *Important note: In Madagascar and Mozambique, all pregnant women must receive the first dose of IPTp through ANC at the HF.

21. Health education by CHWs • Use the following methods to provide information: • Group talk to villagers • One-on-one counseling • Posters/flip charts • Storytelling and proverbs • CHWs should use the information, education, and communication materials supplied by the health service to give community members accurate information about malaria control measures

22. Sample counseling card for MiP Take a second dose of SP at least 4 weeks after the first Sleep under an insecticide-treated net Take a third dose of SP at least 4 weeks after the second Take three tablets (one dose) of SP after the 13th week of pregnancy Malaria is bad for your health and the health of your unborn child

23. Key health education messages • Provide general information about the: • Recognition of malaria • Causes of malaria • Prevention of malaria • Dangers of MiP • Explain that it is: • Very important to report any adverse events (e.g., rashes, red swollen painful tongue, diarrhea, nausea and vomiting) • Also important to take SP in the correct dosage and at the correct time • Explain the benefits of pregnant women registering early for ANC SP package insert. Image source: Medicines for Malaria Venture.

24. Benefits of IPTp Remind the pregnant woman that IPTp protects her from having malaria and thereby lowers the risk of: • Severe maternal anemia by 38% • LBW in the newborn by 43% • Perinatal mortality by 27% • Other malaria-related complications (abortions, stillbirths, preterm delivery, placental parasitemia) in pregnancy

25. How to give IPTp through CDI • Obtain quality-assured SP (500 mg/25 mg fixed ratio) from the facility-basedCDI focal person • Follow the procedure in the job aids (see Training in Community-Directed Intervention to Address Malaria in Pregnancy: Facilitators’ GuideAppendix F) to: • Determine whether the woman is eligible for SP • Administer dose if she is eligible • Document • Refer (for ANC, follow-up doses, etc.) • Plan follow-up visit

26. DOT for IPTp Women taking SP by DOT in a primary health center in Nigeria. Photo by Bright Orji, Jhpiego.

27. Folic acid (FA) • FA is usually given to pregnant women • SP is an antifolateand should not be given in combination with folates (e.g., FA) • Remind the pregnant woman not to take her FA for 7 days after taking SP IPTp1 IPTp2 IPTp3 IPTp4 | 4 wks. | 4 wks. | 4 wks. | 4 wks. *FA * = Stop FA for 7 days after taking SP

28. After giving IPTp • Advise the woman to visit the nearest HF for the comprehensive ANC that all pregnant women should receive • Advise her not to take FA for 1 week • Ask her to report to her community’s HF if she has: • Signs/symptoms of malaria: • Fever (hotness of the body) • Chill • Aches (headaches, body aches) • Joint pain or weakness • Nausea and vomiting • Loss of appetite • Or other complaints in pregnancy

29. Summary • Regular dosing of SP during pregnancy reduces the incidence of complications of malaria in pregnancy (e.g., maternal anemia, stillbirths, low birthweight, and neonatal deaths) • WHO recommends that all pregnant women in areas of high malaria transmission should receive at least 3 monthly doses of SP starting from as early as 13 weeks gestation • Trained health care workers and CHWs should follow the IPTp job aid to provide SP to eligible pregnant women with DOT

30. References • Dellicour S, Tatem AJ, Guerra CA, Snow RW, terKuile FO. 2010. Quantifying the number of pregnancies at risk of malaria in 2007: a demographic study. PLoS Med. 7(1):e1000221. doi: 10.1371/journal.pmed.1000221. • Lawn JE, Blencowe H, Waiswa P, et al. 2016. Stillbirths: rates, risk factors, and acceleration towards 2030. Lancet. 387(10018):587–603. doi: 10.1016/S0140-6736(15)00837-5. • Mosha TC, Ntarukimana D, John M. 2010. Prevalence of congenital malaria among neonates at Morogoro Regional Hospital, Morogoro, Tanzania. Tanzan J Health Res. 12(4):241–248. https://www.ajol.info/index.php/thrb/article/view/51792. Accessed October 19, 2018. • Steketee RW, Nahlen BL, Parise ME, Menendez C. 2001. The burden of malaria in pregnancy in malaria-endemic areas. Am J Trop Med Hyg. 64(1–2 Suppl):28–35.

31. Thank you! Any questions or comments?