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 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 is old and familiar Malaria has been in this area shown for millenia Communities and families know malaria Often it goes unnoticed, or at least unresponded to

High Transmission Areas 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

Neonatal Mortality Rates by Birthweight Mangochi, Malawi -- September 1987 - June 1989 1000 800 800 600 Deaths per 1000 Live Births 400 300 200 49 26 <1500 1500-1999 200-2499 ³ 2500 Relative Risk 31 11.7 2.4 1.0

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

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

Low birth weight

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

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

*Neonatal Mortality Rate Contribution of Prematurity and IUGR to Low Birth Weight Mangochi, 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.

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

Malaria in Pregnancy Opportunities 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

Antenatal care in Africa Proportion of Pregnant Women Seeking Antenatal Clinic Care Demographic and Health Surveys

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

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

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

Insecticide Treated Materials

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

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 In summary, this study involving 2754 pregnant women of all gravidae groups living in an areas of intense malaria transmission showed that women in their first 4 pregnancies in bednet villages, and this is data I have not been able to show you, had less malaria and particulary severe malaria associated anemia during pregnancy, defined as a Hb < 8 g/dl in the presence of any parasitaemia. The the mean birth weights and gestational ages were higher, and the risk of any adverse outcome, including LBW and fetal loss was reduced by 25%. The data also clearly does not support the hypothesis of a trend towards decreasing efficacy with increasing transmission pressure.

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

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

Malaria Control during Pregnancy Implementation Package(s) Private Sector IPT ITNs ANC Facilities Community CM

The effect of malaria during pregnancy on morbidity and mortality is: 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