1. The Global Impact of Malaria
An Informational Session for Clinicians
Genevien Simpson-Griffiths, MPH student
Walden University
PUBH
Instructor: Dr. Raymond W. Thron
Fall Quarter, 2009 .
Good Afternoon ladies and thank you for taking the time today to participate in this very important informational session. My name is Genevien Simpson-Griffiths and I will be spending the next half hour talking to you about Malaria as a general overview to start and then transition into specifics concerning the risks associated with pregnant women and infants. I will also go on to discuss malaria illness prevention strategies.

2. Malaria is Preventable!!
The Good news is that Malaria is a curable illness and most importantly is preventable. Prevention and control of malaria is the area I will be focusing my session on today and the benefits of focused antenatal care for the women and infants in the community. This target population requires extreme focus as “Pregnant women and children under five years of age are at the highest risk of malaria-associated death and morbidity” (US aid, n.d).
As a public health professional we like to use the old adage “prevention is better than cure” to guide our practice What I hope you also come away with today is best practices to help you better serve the women of your community.
Malaria is Preventable!!

3. What is Malaria? Infectious parasite called Plasmodium
Anopheles mosquito is the vector that transmits infection to humans when they take a blood meal
Some symptoms of malaria include: fever, headache, vomiting, fatigue, cough, abdominal pain, myalgia of the limbs and back which usually appear between 10 and 15 days after the mosquito bite.
I know all of you know what Malaria is as you live the harsh reality of its affects everyday in your practice. However, I am just going to provide a general overview to give my presentation some context. Malaria is a tropical disease that is caused by a parasite called Plasmodium, which is transmitted to humans via the bites of infected mosquitoes. In the human body, the parasites multiply in the liver, and then ev infect red blood cells.
Symptoms of malaria generally include fever, headache, and vomiting, and usually appear between 10 and 15 days after the mosquito bite. Depending on the parasite that individual is infected with symptoms can be more severe like an enlarged spleen or jaundice. However, later in the presentation I will discuss some of the more severe risk factors specific to pregnant women (WHO, n.d)
Lastly as we know If not treated, malaria can quickly become life-threatening with the last result being disrupting the blood supply to vital organs eventually causing certain and painful death.
World Health Organization. (n.d). Malaria. Retrieved from

4. 4 Types of Human Malaria Plasmodium falciparum Plasmodium vivax
(Most Common & Most Deadly)
Plasmodium vivax
(Most Common)
Plasmodium malariae
Plasmodium ovale
Parasite from species PLASMODIUM
There are four types of human malaria from the parasite species called Plasmodium
Plasmodium vivax
Plasmodium malariae
Plasmodium ovale.
Plasmodium falciparum and Plasmodium vivax are the most common. Plasmodium falciparum is the most deadly. This strain of the species is also the most dangerous for pregnant women.
(malaria) n.d
4 Types of Human Malaria

5. QUICK FACTS ABOUT MALARIA
There were 247 million cases of malaria in 2006
In 2006 nearly one million deaths, mostly among African children
A child dies of malaria every 30 seconds
Approximately half of the world's population is at risk of malaria, particularly those living in lower-income countries.
Travellers from malaria-free areas to disease "hot spots" are especially vulnerable to the disease
World Health Organization. (n.d). Retrieved from

6. Most cases and deaths are in sub-Saharan Africa
Most cases and deaths are in sub-Saharan Africa. although, Asia, Latin America, the Middle East and parts of Europe are also affected
Malaria is responsible for a 1.3% growth penalty per year in some African countries, due to loss in productivity
Malaria costs Africa more than $12 billion in lost Gross domestic product (GDP) every year
Just to explain those last 2 points a little further what it means is that many African countries suffer a decrease in economic productivity by 1.3% due to unfortunate loss of human life or due to human illness as a result of Malaria. Therefore the amount of loss work days severely impacts a country by crippling their ability to efficiently produce across all sectors.
GDP is a measure of a country's economic performance and is the market value of all final goods and services made within the borders of a country in a year. It is a fundamental measurement of production (wikipedia, n.d).
In areas of Africa with high malaria transmission, an estimated 990,000 people died of malaria in 1995 – over 2700 deaths per day
Sadly the true numbers of death and disease caused by malaria are likely much higher because not all people go to hospitals when they are sick or having a baby, and many die at home.
Quick Facts Cont’d

7. Severe malaria occurs most frequently in:
persons who have no immunity
Persons whose immunity has been decreased
young children and pregnant women in areas with high transmission. tm
The third bullet regarding pregnant women and infants is where I will focus my discussion as I mentioned earlier since this is very vulnerable population.

8. Women who are at High Risk
non-immune pregnant women
The illness can result in high rates of miscarriage and cause over 10% of maternal deaths (soaring to a 50% death rate in cases of severe disease) annually.
Semi-immune pregnant women risk severe anaemia and impaired fetal growth
HIV-infected pregnant women are also at increased risk.
(read after point # 3) even if these women show no signs of acute disease consequently, an estimated of their infants die annually as a result of malaria infection during pregnancy.
Women who are at High Risk

9. Malaria Infection During Pregnancy
Pregnant Women
Parasitaemia
Spleen rates
Febrile illness
Cerebral malaria
Hypoglycaemia
Puerperal sepsis
Severe disease
haemorrhage
Fetus
Abortion
Still birth
Congenital infection
New Born
Low Birth weight
Prematurity
Intrauterine growth retardation
Malaria illness
mortality
Malaria infection with plasmodium falicparum during pregnancy can result in a number of adverse consequences. The effect of the infection on the mother can range from negligible to severe. The severity of the effects depend on the level of immunity to malaria infection the mother has acquired prior to the pregnancy and the efficacy of the immune responses during pregnancy.
Factors affecting acquired antimalarial immunity depends on :
The intensity of the malaria transmission
Number of previous pregnancies
Presence of other conditions such a (HIV)
Malaria Infection During Pregnancy

10. Geography Pregnant women have little or no immunity
Women in Areas of low (unstable) Transmission
Pregnant women have little or no immunity
Pregnant women 2-3 times higher risk of developing severe disease from malaria than non pregnant women in same area
Maternal death may result directly from complications of severe malaria
stillbirth, spontaneous abortion, low birth weight (birth weight < 2.5kg), and neonatal death
WOMEN IN AREAS OF HIGH (STABLE) TRANSMISSION
Partial clinical immunity acquire during years of previous exposure prior to pregnancy does not prevent infection
Clinical malaria not predominant feature
Effects of infection are low birth rate and maternal anaemia
1995 estimated 400,000 cases of anaemia among pregnant African women
1995 estimated 100,000 infant deaths through low birth rate
Malaria symptoms manifest differently with the variable being geography or location. “Woman who live in areas of high transmission of malaria throughout their life develop and acquired immunity to malaria. Conversely, women who live in areas of low or unstable transmission of malaria have little or no acquired immunity” (Gikandi, Noor, Gitonga, Aianga & Snow, 2008).
(read after point #4 on left hand side) hypoglycaemia, cerebral malaria and pulmonary edema being particular problems.
Geography

11. Areas of High (stable) Transmission
Pictured here is a graphical description of the possible risks of a pregnant woman in an area of high transmission. “Stable transmissions predominates in Africa south of the Sahara and this region bears the greatest burden of malaria infections during pregnancy. Ill health affects in these areas are particularly apparent in the first and second malaria-exposed pregnancies” (WHO, 2004).
Ironically as noted above malaria infection in pregnant women is largely asymptomatic in areas of greatest burden, therefore requires a more rigorous preventative approach.
Source:

12. Areas of low (unstable) transmission
Conversely here is a graphical description of the health risk associated with women in low transmission areas.
Source:

13. So ladies and gentleman this is what we want pictured here
So ladies and gentleman this is what we want pictured here. We want to keep our patients and their families healthy and happy.
I will now discuss some ways in which you can help prevent and control malaria infections.
So How Do We Get Here?

14. Malaria Control Strategies
Insecticide-Treated bed nets (ITNs)
Intermittent preventative treatment (IPT)
Case Management
Since 2000, in order to help reduce the enormous burden and health impact associated with malaria the World Health Organization has recommended a package of intervention, a 3 pronged approach to prevent malaria during pregnancy. This includes the promotion of insecticide-treated bed nets (ITNs), intermittent preventive treatment in pregnancy (IPT), and effective case management of malarial illness when signs and symptoms become apparent (Abdunoor et al., 2008).
Kiwuwa, M., & Mufubenga, P. (2008). Use of antenatal care, maternity services, intermittent presumptive treatment and insecticide treated bed nets by pregnant women in Luwero district, Uganda. Malaria Journal, doi: /
Malaria Control Strategies

15. The incidence of women visiting antenatal clinics (ANC) during their pregnancy in many African countries is relatively high. These clinics have the most potential to influence women and affect change in promoting the increased use of the interventions I mentioned previously IPT and INT. “In areas of stable transmission such as this area, INT & IPT are the primary prevention approaches set out by the WHO guidelines. One study demonstrated that in rural Kenya overall 81% of pregnant women attended an ANC clinic at least once. ANC usage remained similar and high across all districts with 59% of women averaging at least three visits” (Omo-Aghoja, et. al, 2008)
Source:

16. Strategies for Improving Women’s Health (IPT)
IPT involves the administration of curative treatment dose of an effective antimalarial drug at predefined intervals during pregnancy. WHO recommends that every woman attending the antenatal clinic should receive at least two doses of SP sulfadoxine pyrimethamine after the first trimester for the prevention of malaria, and in cases of HIV-positive patients three doses is recommended. However, available evidence indicates that less than 15% of pregnant women attending antenatal clinics in Nigeria receive the first course of IPT, while only 10% receive the second course (Marchesini & Crawley, 2004).
“Other studies in Kenya and Malawi have shown that IPT with SP significantly reduces the prevalence of maternal anaemia and placental parasitaemia and the incidence of low birth weight” (Marchesini & Crawley, 2004).
Additionally it is important that “any women with severe anaemia from malaria-endemic areas must be treated with an effective antimalarial drug, whether or not peripheral parasitaemia is present and regardless if the woman has a history of fever or not” (Marchesini & Crawley, 2004).
Strategies for Improving Women’s Health (IPT)

17. Strategies for Improving Women’s Health (ITN)
Some of most successful models for subsidized net distribution include
ITNs distributed free during routine visits to antenatal clinics, health or immunization days, and other contacts with the health system
ITNs represent a powerful preventative approach for malaria infection. However, although “countries such as Kenya have achieved ITN coverage rates of up to 50%, many countries in the African region still have rates much below 10%” (Gikandi, Noor, Gitonga, Aianga & Snow, 2008). We want to ensure our region increases its ITN use and provides the support necessary to encourage more uptake of IPT. Additionally, there is decreased compliance to sleep under a mosquito net with women and children in the summer months but as clinicians you need to get the message across that this group of people are at risk all year round.
A 1996 cross section study in Ifakara, Tanzania revealed that 17% and 37% of households, respectively, owned at least one bed net This pro- portion increased markedly after intensive promotion of highly subsidized ITNs. In 2004, it was recorded that more than 80% of households in villages surrounding Ifakara owned a bed net and/or reported using bed nets. Moreover, the current district wide bed net coverage including an area of moderate ITN promotion activities stands at 78.4%. The increased bed net coverage made an important contribution to prevention of malaria illness and episodes among children less than five years (Abdunoor et al., 2008).
Insecticide-treated bednets (ITNs) are a highly effective way for individuals, families, and communities to protect themselves from malaria. Consistently sleeping under an ITN can decrease severe malaria by 45%, reduce premature births by 42%, and cut all-cause child mortality by 17% to 63%. When ITN coverage rates reach 80% or more in a community, those residents not sleeping under an ITN also obtain a protective benefit (US Aid, n.d)

18. Focused antenatal care is a proven evidence based approach
Allows the clinic to be central point of contact to deliver 3 major strategies
Delivery of full IPT regimen
Routine INT distribution
Opportunity to broaden community awareness and increase compliance
In conclusion, as clinicians working at an antenatal clinic you are in unique position to affect behaviour changes. As women come to the clinic for antenatal care you will start to forge a relationship with these ladies and you will have their trust. Its important to get the message out about prevention measures and through increased community awareness. Developing partnerships with other health units and community health programs will assist you in doing this. Additionally during case management it is also a critical time to discuss prevention measures therefore, helping to prevent these women from having re-occurring malaria illness. Incorporating the 3 pronged malaria control approach of using ITN’s, ITP and focused case management will enhance your ability to help your clients maintain better health and go along way in playing a part in the reduction of the malaria global endemic.
Benefits of ANC

19. Thank You for listening and for all that you do!
The discussion is now open for questions.

20. Preventing malaria in pregnancy through focused antenatal care: working with faith based organizations. (n.d). Retrieved from resources/saving-newborn-lives/publications/Preventing-Ma
Malaria. (n.d). WHO. Retrieved from
World Health Organization. (n.d). Malaria. Retrieved fromhttp:// ex.html
What is malaria (n.d). International Media corp. Retriev)ed from
Gross domestic product (n.d). Wikipedia retrieved from (n.d). Retrieved from
References

21. Malaria disease (n. d). Centre for disease control and prevention
Malaria disease (n.d). Centre for disease control and prevention. Retrieved from
A strategic framework for malaria prevention and control during pregnancy in the African region (2004). WHO retrieved from alaria_pregnancy_str_framework.pdf
Gikandi, P., Noor, A., Gitonga, C., Ajanga, A., & Snow, R. (2008). Access and barriers to measures targeted to prevent malaria in pregnancy in rural Kenya. Tropical Medicine & International Health, 13(2), doi: /j x (1995)
References cont’d

22. Kabanywanyi, A. , MacArthur, J. , Stolk, W. , Habbema, J. , Mshinda, H
Kabanywanyi, A., MacArthur, J., Stolk, W., Habbema, J., Mshinda, H., Bloland, P., et al. (2008). Malaria in pregnant women in an area with sustained high coverage of insecticide-treated bed nets. Malaria Journal, doi: /
Omo-Aghoja, L., Abe, E., Feyi-Waboso, P., & Okonofua, F. (2008). The challenges of diagnosis and treatment of malaria in pregnancy in low resource settings. Acta Obstetricia & Gynecologica Scandinavica, 87(7), doi: /
References Cont’d

23. Marchesini, P. & Crawley, J. (2004)
Marchesini, P. & Crawley, J. (2004). Reducing the burden of malaria in pregnancy. Retrieved from /MeraJan2003.pdf
References Cont’d