Lives at Risk: Malaria in pregnancy Malaria Epidemiology Branch, Division of Parasitic Diseases U.S....
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![Page 1: Lives at Risk: Malaria in pregnancy Malaria Epidemiology Branch, Division of Parasitic Diseases U.S. Centers for Disease Control and Prevention.](https://reader030.fdocuments.in/reader030/viewer/2022032709/56649ec65503460f94bd10c1/html5/thumbnails/1.jpg)
Lives at Risk: Malaria in pregnancy
Malaria Epidemiology Branch, Division of Parasitic DiseasesU.S. Centers for Disease Control and Prevention
![Page 2: Lives at Risk: Malaria in pregnancy Malaria Epidemiology Branch, Division of Parasitic Diseases U.S. Centers for Disease Control and Prevention.](https://reader030.fdocuments.in/reader030/viewer/2022032709/56649ec65503460f94bd10c1/html5/thumbnails/2.jpg)
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
![Page 3: Lives at Risk: Malaria in pregnancy Malaria Epidemiology Branch, Division of Parasitic Diseases U.S. Centers for Disease Control and Prevention.](https://reader030.fdocuments.in/reader030/viewer/2022032709/56649ec65503460f94bd10c1/html5/thumbnails/3.jpg)
![Page 4: Lives at Risk: Malaria in pregnancy Malaria Epidemiology Branch, Division of Parasitic Diseases U.S. Centers for Disease Control and Prevention.](https://reader030.fdocuments.in/reader030/viewer/2022032709/56649ec65503460f94bd10c1/html5/thumbnails/4.jpg)
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
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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
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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
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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
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Low birth weight
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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
![Page 10: Lives at Risk: Malaria in pregnancy Malaria Epidemiology Branch, Division of Parasitic Diseases U.S. Centers for Disease Control and Prevention.](https://reader030.fdocuments.in/reader030/viewer/2022032709/56649ec65503460f94bd10c1/html5/thumbnails/10.jpg)
Factors Contributing to Low Birth Weight – that are amenable to intervention during pregnancy
Low caloric intake or wt gain
Malaria
General morbidity
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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
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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
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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
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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
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• Preventive intermittent treatment (PIT)
• Insecticide treated nets (ITN)
• Treatment and Care of acute cases of malaria during pregnancy
Interventions to addressmalaria in pregnancy
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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)
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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
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Insecticide Treated Materials
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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
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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
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Interventions to address malaria in pregnancy
Intermittent preventive treatment
Insecticide-treated materials
Case management
UNICEF/C-55-10/Watson
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Malaria in Mothers and Infants
Non-pregnantNon-pregnant PregnancyPregnancy Post-partumPost-partum
InfancyInfancy
Insecticide-treated nets
IPT
Case management
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Malaria Control during PregnancyImplementation Package(s)
IPTIPT ITNsITNs
CMCM
ANCANCANCANCPrivatePrivateSectorSector
FacilitiesFacilitiesCommunityCommunity
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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