Malaria Matters

May 23, 2015

Verifying Malaria Medicines on Your Mobile

Filed under: Drug Quality,Private Sector,Treatment — Bill Brieger @ 6:00 pm

On their website Sproxil says that, “Sproxil actively supports Nigeria’s National Agency for Food and Drug Administration and Control (NAFDAC) in the fight against counterfeiting by pioneering Nigeria’s first Mobile Authentication Service.” They note further that …

“On February 2, 2010, NAFDAC launched the NAFDAC MAS, putting the power of product verification right in the hands of the consumer. MAS is powered by Sproxil’s award-winning cloud-based Mobile Product Authentication™ technology, and remains the world’s largest nation-wide implementation of consumer-facing SMS anti-counterfeiting technology in the world.”

Below are two malaria medicine packets recently purchased. After scratching the small label (see it circled, we got the SMS messages as posted.  The NAFDAC registration number alone is not enough to ascertain the validity. This is a smart procedure, even without a smart phone. Of course one still needs to read the expiry dates!

P-Alaxin front scratch off1. OK Genuine P-Alaxin Tablet. Your PIN:949769012921 NRN:04-9495 Problem? Call 08039012929 NAFDAC & Bliss Care Sproxil SMS

Lonart DS back PIN2. OK Original Lonart DS tabs NRN:04-9927 Use mosquito nets to help avoid malaria Problem? Call 08039012929 NAFDAC & GREENLIFE CARE Sproxil Solution

May 6, 2015

Lessons Learned from a Supervisory Visit to a Medicine Shop

Filed under: Private Sector,Treatment — Bill Brieger @ 1:16 pm

DSCN2943In this posting Hajara Moses John of the Bauchi State Agency for the Control of HIV/AIDS, TBL and Malaria [BACATMA] shares lessons learned in supervising medicine sellers.

Our team had planned supervisory visit last week to patent medicine vendors (PMVs) where shop owners have been taught the correct management of childhood illnesses. Our experience one particular shop pulled together so many lessons about training and supervision, and we are sharing this here. In the first shop we visited that day we found a boy aged 12 behind the counter. I took on the role of a mystery client, and mentioned some symptoms to the boy. “My 5-year old son is at home with catarrh. His nose is really running and his breathing is fast. What do you recommend I give him?”

The boy mentioned a local brand of antihistamine. I asked if there was anything else we should do, and the boy said that should work fine.

Next I said my two-year old daughter was also unwell. She was having fever, shivers with aches and pains. Did he have any suggestions for her? His prompt answer was “Ampiclox.”

I then asked him where the owner of the shop was. He said, “Oh my father has traveled.” I asked what class the boy was in school, to which he said the first class of junior secondary school.

Word of our visit must have spread in the area, because then a woman rushed in who it turned out to be the boy’s mother and asked how she could help us.

We explained that we were from the Ministry and were going around to help medicine shop owners improve the quality of their services. The mother happily reported that she had received training “in malaria and those other small small diseases of pickin,” from the Minsirty fo health and again from a NGO.

I went back to case of the child with a respiratory infection and pointed out the breath counting beads on the table. She said it was her husband who had done the training where the beads were explained but never taught her how to use them. We then spent some time explaining to the mother and her son about the beads and demonstrated how to use them, and also explained about management of fever.

Finally I asked the mother why she was not in the shop since her husband had traveled. She said she was in the kitchen preparing lunch for the children, and as the oldest, the 12-year old was assumed capable of running the shop. We encouraged her to discuss as a family how they could share what they have learned about managing child illness and always ensure that a competent person is available in the shop.

Training of PMVs is not a simple matter. The person trained may not always be in the shop nor share what he/she learned with other salespeople. Supervision is necessary in order to reinforce what was learned during training and provides an opportunity to teach others on-the-job. PMVs provide a large portion of the services in many African communities, and we must ensure that they can focus on quality.

April 27, 2015

Invest in Using Preventive Services: an Update from the 2014-15 Uganda Malaria Information Survey

Filed under: IPTp,ITNs,Monitoring — Bill Brieger @ 7:22 pm

MIS Uganda 2014-15The Demographic and Health Survey people have just released the preliminary MIS results for Uganda. From the viewpoint to the Millennium Development Goals (MDGs), there are cautiously positive signs.

Insecticide treated bednet ownership by households has reached 90%. Equity appears to have been achieved with the households in the lowest, second and third wealth quintiles registering 92%, 94% and 93% ownership. The highest and next highest quintiles had 85% and 88% ownership respectively. Those in the higher wealth quintiles often have better quality housing that of itself offers preventive benefits.

An interesting number is that over 86% of households obtained their nets through campaigns. It appears that the catch up phase of net distribution is repeating itself and the more sustainable keep up phase where nets are provided through routine services has not taken effect.

Household ownership of at least one net translates into use by only 69% of residents generally, and still only 74% in homes that actually own a net. Net use by ‘vulnerable groups’ was a bit better: 74% for children below five years of age and 75& for pregnant women. Thus we can see that household ownership does not guarantee that we meet the 2010 target of 80% coverage/use.

We have moved from recommending two doses of sulfadoxine-pyrimethamine as intermittent preventive treatment for malaria in pregnancy to three or more. The MIS does not report on increased doses but even for two contacts, only 25% of recently pregnant women in Uganda were covered.

The results show that malaria prevention is still an elusive goal. Thirty per cent of children given malaria rapid diagnostic tests during the survey had malaria parasite antigens. We must invest more in ensuring that preventive interventions are routinely available and are actually used before our attention is diverted from the MDGs to the SDGs.

April 25, 2015

Huambo: Thinking ahead toward investing in malaria elimination

Filed under: Elimination,Invest in Malaria Control — Bill Brieger @ 4:47 pm

wmd2015logoEight members of the Southern African Development Community are strategizing toward the pre-elimination phase of malaria.  The four frontline states are Namibia, South Africa, Swaziland and Botswana.  The second tier includes Angola, Zambia, Zimbabwe and Mozambique.

Huambo circled Pf_mean_2010_AGOMalaria prevalence varies by province in Angola with greater burden in the north (see map on right). Huambo in the central highlands is the second most populous province at 2 million and in some of the 11 municipalities malaria transmission is low.  This has led provincial health authorities to strategize how to invest in pre-elimination efforts where appropriate while maintaining full prevention interventions where needed.

An analysis of routine health information system (HIS) data is a first step. Rapid Diagnostic tests are part of the basic protocol for case management in all health centers. Data for 2014 was summarized by municipality. Test positivity rates for each municipality are shown in the map to the left. These range from a low of 2% in Katchiungo in the east to 54% Bailundo in the north.

Huambo Municipalities Malaria Test PositivityMore detailed geospatial analysis will be needed looking at variations within municipalities by health center catchment area, but a broad picture emerges that three municipalities in the northern part of the province have higher RDT positivity rates, and require sustained interventions like long lasting insecticide-treated nets and intermittent preventive treatment for pregnant women.

Reactive case detection such as being practiced in Swaziland might be considered in the remaining 8 municipalities after some initial pilot testing. Community based surveys using RDTs and more precise tests like polymerase chain reaction (PCR) could also be tried in order to supplement current HIS data and provide better targeting of interventions.

Hopefully government and partners will invest in helping Huambo test these processes. Huambo could then provide a good model for approaching malaria elimination for the rest if the country and the region.

April 23, 2015

Burkina Faso: Defeating Malaria by Investing in Expanding Intermittent Preventive Treatment in Pregnancy

Filed under: IPTp,Malaria in Pregnancy — Bill Brieger @ 9:10 am

WMD15_6b_Facebook_FinalIn Burkina Faso, Antenatal Care (ANC) is a national platform for malaria in pregnancy prevention and control. The 2010 Demographic and Health Survey showed a good initial ANC registration rate (95%), but over 56% of pregnant women in rural areas do not register until their second or third trimester. Thus they may have missed the full regimen of ANC services including Long Lasting Insecticide-treated nets and intermittent preventive treatment of malaria in pregnancy (IPTp).

In 2010 only 10.6% of pregnant women nationally and 8.4% in rural areas received two doses of IPTp. Now WHO recommends more doses. This had improved by the time the 2014 Malaria Information Survey was completed to 68% for one dose, 48% for two and 22% for three doses.

Jhpiego’s USAID-supported Improving Malaria Care (IMC) project in Burkina Faso has been providing technical assistance and training to health districts and their ANC staff on implementing updated (2012) WHO IPTp guidelines. The recommended provision of IPTp at every ANC visit from the 13th week of pregnancy onward leads to the possibility of 3 or more doses per woman. The new guidance was incorporated into the update of Burkina Faso’s malaria strategy and has been disseminated since September 2014.

CoverageAnnual data from the Health Management and information System for 2014 from three districts (Batie, Po and Ouargaye) and 61 health clinics where IMC has been working were collected and summarized. A total of 26,909 women registered for ANC our of the estimated 35,420 in the Three districts.

The chart at the left shows coverage of ANC visits and IPTp provision based on the estimated 2014 population of pregnant women in the districts. Eleven (17.7%) clinics had not started the updated IPTp guidance. The Ministry of Health also experienced stock-outs of sulfadoxine-pyrimethamine.

Being new IPTp3+ poses challenges and needs greater investment. The IMC project in collaboration with the National Malaria Control Program is examining ways to invest in stronger antenatal malaria prevention including capacity building for ANC staff and provision of IPTp by the existing network of volunteer community health workers.

April 22, 2015

World Malaria Day 2015 Blog Postings Help #DefeatMalaria

wmd2015logoA special World Malaria Day 2015 Blog has been established. So far nine postings are available at http://www.worldmalariaday.org/blog. Please read and share with colleagues.

1. “Investing in integrated health services to defeat malaria”BY ELAINE ROMAN, MCSP Malaria Team Lead.

2. “Fake antimalarials: how big is the problem?”

BY DÉBORA MIRANDA, Technical Communications Officer, ACT Consortium (UK).

3. “Why antimalarial medicines matter”WMD15_7_Facebook_Final

BY PROFESSOR PAUL NEWTON AND ANDREA STEWART, Worldwide Antimalarial Resistance Network and Laos Oxford University Mahosot Hospital Wellcome Trust Research Unit.

4. “Malaria as an entry point for addressing other conditions”

BY HELEN COUNIHAN, Senior Public Health Specialist, Community Health Systems.

5. “Bridging the Care-Seeking Gap with ProAct”

BY MATT McLAUGHLIN, Program Manager of Peace Corps Stomping Out Malaria in Africa initiative.

WMD15_6a_Facebook_Final6. “Defeating Malaria in Pregnancy”

BY CATHERINE NDUNGU, ELAINE ROMAN AND AUGUSTINE NGINDU, Jhpiego.

7. “Intermittent Preventive Treatment, a Key Tool to Prevent and Control Malaria in Pregnancy”

BY CLARA MENÉNDEZ, Director of ISGlobal’s Maternal Child and Reproductive Health Initiative.

8. “Widespread artemisinin resistance could wipe out a decade of malaria investment”

BY TIM FRANCE, Asia Pacific Leaders Malaria Alliance.

9. “The long walk to a malaria-free world”

BY DAVID REDDY, CEO Medicines for Malaria Venture.

April 15, 2015

Investing in Antenatal Care to Defeat Malaria

Filed under: Invest in Malaria Control,IRS,Malaria in Pregnancy — Bill Brieger @ 6:51 am

For many years malaria in pregnancy (MIP) was the proverbial neglected step-child of malaria control programs. Partly this was due to structural problems – the challenge of coordination between different units and departments within a ministry of health – malaria programs and reproductive health programs in separate and parallel divisions.

Another reason for neglect may lie in the fact that it is been difficult to achieve the MDG 5 as outlined in the United Nations’ 2014 Millennium Development Goals Report. One still finds that worldwide, almost 300,000 women died in 2013 from causes related to pregnancy and childbirth. Maternal death is mostly preventable and much more needs to be done to provide care to pregnant women.

Maternal death prevention includes providing pregnant women 3 or more doses of sulphadoxine-pyrimethamine (SP) for intermittent preventive treatment in pregnancy (IPTp) and ensuring women have AND sleep under insecticide treated bednets (ITNs) during antenatal care (ANC). Unfortunately recent Demographic and Health Surveys (DHS) and Malaria Information Surveys (MIS) from endemic countries show slow or stagnating progress in reaching Roll Back Malaria goals of 80% coverage of pregnant women with these interventions. Recent DHS/MIS have found that only 15% of recently pregnant women got two doses of IPTp in Nigeria, with only slightly better coverage in Burkina Faso (46%). Now that targets have shifted to three or more doses, the coverage challenge is even greater.

TPI pregnancy-2The irony is that these same DHS reports show that a large proportion (>90%) of pregnant women in malaria endemic countries of Africa get registered for ANC. In order to achieve full coverage of IPTp pregnant women should attend ANC at least four times, but the recommended minimum of four ANC visits is difficult to achieve. According to WHO, “The proportion of pregnant women in developing countries who attended at least four antenatal care visit has increased from approximately 37% in 1990 to about 52% in 2012 but, in low-income countries, only 38% of pregnant women attended four times or more antenatal care during 2006-2013.”

In their article, “The quality–coverage gap in antenatal care: toward better measurement of effective coverage,” Stephen Hodgins and Alexis D’Agostino offer an explanation. They point out that it is not the number of ANC contacts alone that matters; it is the content of each visit that is equally important. They explain that a “coverage gap” exists when women who attended ANC four or more times did not receive the elements of basic package of services spelled out in the concept of Focused Antenatal Care (FANC).

Specific findings from Hodgins and D’Agostino’s DHS review showed that, “Blood pressure and tetanus toxoid performed best, with median quality–coverage gaps of 5% and 18%, respectively. The greatest gaps were for iron–folate supplementation (72%) and malaria prevention (86%).” Simply put, the lesson is that attending ANC does not equal receiving lifesaving maternal health services.

Many factors affect the quality of ANC services ranging from the major gaps in availability of trained health workers at the frontline in endemic countries to poor procurement and supply systems for even the cheapest drugs like SP. Even when health workers are in place, their understanding of and attitudes toward using SP for IPTp may be inadequate. These issues are where the gap between attending ANC and receiving needed services emerges. We will not be able to defeat malaria in pregnancy until we invest in strengthening the whole ANC system and pay better attention of women’s health.

April 13, 2015

Malaria Care: Investing in Infection Prevention to Save Health Workers’ Lives

Filed under: Diagnosis,Infection Prevention — Bill Brieger @ 5:45 am

wmdlogoThe recent World Malaria Day observances called on all partners to “Invest in the Future, Defeat Malaria.” The word ‘investments’ brings to mind huge supplies of insecticide treated nets and malaria medicines. The recent and ongoing Ebola crisis has shown how vulnerable health workers are when trying to diagnose and manage malaria when investments have not been made in safety equipment and training.

The Ebola epidemic in West Africa as well as its predecessors in Central Africa has taken a disproportionate toll on health workers. In the early stages of the outbreak, health workers regular front line clinics became infected when patients with Ebola, a disease which none had seen before, were initially thought to have malaria or other endemic febrile illnesses.

Health worker demonstrating RDT, using glovesContact with the various bodily fluids of these febrile patients during physical examination, including parasitological testing of blood for malaria diagnosis, combined with a lack of personal protection/infection prevention supplies and materials, resulted in many unnecessary health worker deaths. Many clinics closed, while those that remained open saw a drop in clients due to fears from beliefs that the unknown disease was emanating from the clinic.

It is necessary to ensure that health workers do not face such a fate again, nor be exposed to other blood borne pathogens like HIV and Hepatitis B. In addition attention is needed to protect others on the front line such as patent medicine shop workers and community health volunteers. A two-pronged approach is needed that combines education/training with a strong procurement and supply system for infection prevention and personal protection materials.

RDT Job AidWe should take advantage of World Health Organization guidance for infection prevention related to hemorrhagic fevers and within that has stressed the importance of general protection. Performing Rapid Diagnostic Tests (RDTs) for malaria is the time when most front line health workers could come into contact with a patient’s blood. Training materials and job aids as pictured here, stress the importance of hand washing and use of gloves, but the availability of regular water supplies and disposable gloves in many front line clinics is low or non-existent. The US Centers for Disease Control and Prevention (CDC) also offers the following guidance for malaria diagnosis and case management in countries where both Ebola and malaria are endemic. In addition to front line health staff, we have learned that community volunteers can safely practice infection prevention while performing RDTs by wearing gloves and correctly disposing the used materials.

Efforts to enable medicine shop workers to use RDTs have begun. They do become more vulnerable during Ebola outbreaks as public clinics may close due to health worker deaths. In Liberia medicine sellers who were taught to use RDTs were asked to stop the practice until safety could be assured.

Continuous investment in RDTs themselves as well as the safety and protective supplies and treatment is needed. RDTs if performed properly can save lives of community members. Infection prevention steps and equipment can save the lives of the health workers who care for the community.

 —————————-

A longer version of this posting will appear in the May 2015 issue of Africa Health.

April 12, 2015

RBM Consensus: Continuous Distribution of Long-Lasting Insecticidal Nets in Africa through Antenatal and Immunization Services

Filed under: ITNs,Malaria in Pregnancy — Bill Brieger @ 1:36 pm

LLIN Statement HeadingThis statement is issued by the Roll Back Malaria (RBM) Partnership Working Groups on Malaria in Pregnancy and Vector Control, together with the Alliance for Malaria Prevention. Our aim is to appeal for more complete implementation of the WHO Recommendations for Achieving Universal Coverage With Long-Lasting Insecticidal Nets in Malaria Control (released September 2013, revised March 2014) [1]. In particular we wish to draw attention to this recommendation regarding long-lasting insecticidal nets (LLINs): “Continuous distribution channels should be functional before, during, and after the mass distribution campaigns to avoid any gaps in universal access to LLINs”.

Rationale

DSCN7129a pregnant women get ITNs when register for ANC RwandaIn most settings, pregnant women, infants and children under 5 years of age are at considerably higher risk of contracting malaria and developing severe disease than the general population. In sub- Saharan Africa, up to 90 percent of deaths due to malaria occur in infants and children under age 5. LLINs together with effective case management and intermittent preventive treatment in pregnancy (IPTp) are essential interventions for these vulnerable populations.

Antenatal care (ANC) and childhood vaccination clinics (i.e. those implementing the Expanded Program on Immunization, or EPI) offer effective channels for continuous distribution of LLINs since these provide a venue for structured visits targeting pregnant women, infants and young children. The use of ANC and EPI clinics for this purpose is further supported by the following considerations:

  • In most countries a large proportion of pregnant women attend ANC at least
  • EPI is one of the most equitable programs in child health, with high coverage globally.
  • Availability of LLINs in ANC and EPI sessions provides an incentive to attend and thus improves coverage of ANC and
  • Visits to ANC and immunization sessions are key opportunities for counseling pregnant women and mothers to promote the use of LLINs by pregnant women, infants and young

Other LLIN distribution channels may also offer good opportunities for achieving and maintaining universal coverage in addition to mass campaigns [1]. Each national malaria control program should develop its own LLIN distribution strategy that includes both mass distribution and continuous distribution channels, based on an analysis of the context of its local opportunities and constraints, and then document this in the national strategic plan. Program planning and implementation of continuous LLIN distribution should be conducted under the leadership of the national malaria control program, in conjunction with maternal health and EPI programs, as appropriate. Program implementers have an opportunity to reinforce counseling on the use of LLINs at ANC and immunization services.

Challenge

Some countries are faced with the challenge of insufficient LLIN stocks. Reports from several countries indicate that LLINs have been reallocated from ANC/EPI services to mass campaigns, as a means of compensating for shortfalls in stocks. However, we are concerned about this practice in the absence of an analysis of the impact on LLIN coverage of vulnerable groups. All possible efforts must be made to achieve or maintain universal coverage and, in the absence of sufficient LLINs, to avoid compromising coverage of vulnerable groups. Recognizing that intermittent mass campaigns are essential to maintaining high levels of coverage, and acknowledging that there may be disruption of routine systems during mass campaigns, every effort should be made to minimize these disruptions. The potential reallocation of LLINs from routine distribution channels to mass campaigns must be informed by local data indicating that this will not compromise protection of vulnerable groups such as pregnant women, infants and children under 5 years of age.

Action

The RBM Working Groups and the Alliance for Malaria Prevention therefore strongly urge national program managers responsible for malaria control, ANC and immunization services, and all health professionals concerned with these services, to heed and rapidly implement the WHO recommendations, which indicate that in addition to mass campaigns, a high priority should also be given to continuous distribution of LLINs during and after mass campaigns – such as through ANC, EPI services, and mother and child health weeks/months campaigns, as appropriate to the local context [1].

Reference

1.   WHO recommendations for achieving universal coverage with long-lasting insecticidal nets in malaria control. Geneva: World Health Organization, Global Malaria Programme; 2013 (revised March 2014). Available from: http://www.who.int/malaria/publications/atoz/who_recommendation_coverage_llin/en/

This statement was developed among the following Partners:

LLIN partners

April 11, 2015

RBM Consensus Statement on Folic Acid Supplementation During Pregnancy

Filed under: IPTp,Malaria in Pregnancy — Bill Brieger @ 1:53 pm

1_FOLIC ACID_ENThe Roll Back Malaria (RBM) Partnership Malaria in Pregnancy Working Group supports the following for all pregnant women living in sub-Saharan Africa:

In malaria-endemic areas, intermittent preventive treatment using sulfadoxine-pyrimethamine (IPTp-SP) should be provided to pregnant women at each scheduled antenatal care (ANC) visit for protection against malaria. This should start early in the second trimester and continue until the time of delivery, with the doses given at least one month apart [1].

  • IPTp-SP has been shown to reduce maternal anemia, antenatal maternal parasitemia, low birthweight infants and neonatal deaths.
  • Co-trimoxazole provides some protection through its antimalarial activity; however, IPTp-SP should NOT be given to women who are taking daily co-trimoxazole prophylaxis (i.e. mainly those living with HIV) as this increases the risk of adverse event

Daily oral supplementation of 30–60 mg elemental iron and 400 µg (0.4 mg) folic acid should be provided as early as possible in pregnancy to meet iron and folic acid requirements [2]. In cases where a combined folic acid–iron tablet is not available, a daily dose of 400 µg (0.4 mg) folic acid can be used separately.

There is evidence that high doses of folic acid (i.e. 5,000 µg or more) may interfere with the efficacy of sulfadoxine-pyrimethamine as an antimalarial [3]. The higher 5,000 µg (5 mg) dose for pregnant women should be restricted for use in very specific clinical cases.

High doses of folic acid are not needed during low-risk pregnancies and may counteract the efficacy of both sulfadoxine-pyrimethamine and co-trimoxazole as antimalarials [4]. The RBM Malaria in Pregnancy Working Group strongly advises that countries currently prioritize the procurement and distribution of the available combined dose of 400 µg (0.4 mg) folic acid plus 30–60 mg elemental iron (The current iron and folic acid preparation is 400 ?g (0.4 mg) of folic acid plus 60 mg of elemental iron) as part of routine ANC. It also recommends that countries substantially reduce current stores and supplies of folic acid at a dose of 5,000 µg (5 mg) or higher at all facilities, as this dose should only be used for specific medical conditions as outlined by the World Health Organization (WHO) [2]

References:

  1. Policy brief for the implementation of intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP). Geneva: World Health Organization; 20
  2. Guideline: daily iron and folic acid supplementation in pregnant w Geneva: World Health Organization; 2012.
  3. Peters PJ, Thigpen MC, Parise ME, Newman RD. Safety and toxicity of sulfadoxine-pyrimethamine: implications for malaria prevention in pregnancy using intermittent preventive Drug Saf. 2007 June; 30(6):481–501.
  4. Cotrimoxazole (Septrin) [Internet]. NAM Aidsmap; 2015. Available from: http://www.aidsmap.com/Cotrimoxazole-iSeptrini/page/1731332/

Partners involved in this statement include …

Partners

Frequently asked questions about iron and folic acid during pregnancy

1. What daily dose of iron and folic acid supplementation does WHO recommend during pregnancy?

Folate requirements are increased in pregnancy because of the rapidly dividing cells in the fetus and elevated urinary losses. Increased iron is needed to meet the demands for iron of the developing fetus and cell mass expansion. WHO recommends iron and folic acid supplementation for pregnant women, starting early in pregnancy and at a daily dose of 30–60 mg of elemental iron plus 400 µg (0.4 mg) of folic acid, as this has been shown to reduce the risk of low birthweight, maternal anemia and iron deficiency [2]. In settings where anemia in pregnant women is a severe public health problem (i.e. 40 percent or higher) a daily dose of 60 mg of elemental iron is preferred over a lower dose. If a woman is diagnosed with anemia, WHO recommends daily treatment with 120 mg of elemental iron and 400 µg (0.4 mg) of folic acid until her hemoglobin concentration rises to a normal level [5,6].

A combined dose of 60 mg of elemental iron and 400 µg (0.4 mg) of folic acid is included on the WHO Model List of Essential Medicines [7] and is provided by the United Nations Children’s Fund (UNICEF). Using this preparation to treat anemia would provide 800 µg (0.8 mg) of folic acid daily, which would not interfere with sulfadoxine-pyrimethamine as an antimalarial [8]. A trial conducted on pregnant women in Gambia using a 1,500 µg (1.5 mg) daily dose of folic acid showed no reduction in sulfadoxine-pyrimethamine efficacy [9]. However, to date, no data are available on sulfadoxine- pyrimethamine efficacy when administered with daily folic acid doses between 1,500 µg (1.5 mg) and less than 5,000 µg (5 mg) in pregnant women.

Women should be counseled when they receive iron and folic acid supplements to inform them why these supplements are needed, how to take them and for what duration. They should also receive information about how to manage the possible side effects of iron supplementation (mainly mild gastrointestinal symptoms), which may occur in some women.

2. What are the clinical indications for higher dose folic acid during pregnancy?

Folic acid insufficiency is associated with an increased risk of neural tube defects, a debilitating congenital anomaly in which the neural tube does not close properly. This occurs in 0.5–6.5 out of every 1,000 pregnancies. The neural tube forms in the first month after conception, with closure by about 28 days; thus, in order to prevent neural tube defects maternal intake of folic acid should begin before conception and continue through early pregnancy.

There are limited cases (e.g. for prevention of recurrent cases of neural tube defects [10] and for women on anticonvulsant treatment, diabetics and women with sickle cell anemia) where it is recommended that pregnant women take folic acid at a daily dose of 5,000 µg (5 mg).

In particular, women who have had a previous pregnancy resulting in a baby with neural tube defects are at higher risk of having another baby with neural tube defects. These women should receive folic acid at a dose of 5,000 µg (5 mg) a day starting at least one month – though preferably two to three months – before they conceive, and continuing until 12 weeks of gestation, while increasing their dietary folate intake. Given the need for supplementation prior to conception, fortification of staple foods with folic acid should also be considered as a cost-effective public health measure to reduce the incidence of neural tube defects [11].

3. How does folic acid interfere with the efficacy of sulfadoxine- pyrimethamine against malaria?

Folic acid is an essential nutrient for all organisms. Humans get folate from food or dietary supplements. Other organisms, such as the malaria parasite, synthesize folic acid de novo, or endogenously. Both sulfadoxine-pyrimethamine and co-trimoxazole are anti-folates and prevent malaria by blocking the synthesis of folic acid. Without folic acid, the parasite cannot complete its lifecycle. However, if blood folate concentrations are high enough, the malaria parasite can use this folate instead of making its own, allowing the infection to continue unchecked.

Additional References

5. World Health Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations University (UNU). Iron deficiency anaemia assessment, prevention, and control: a guide for programme Geneva: WHO; 2001

6. Iron and folate Integrated Management of Pregnancy and Childbirth (IMPAC). In: Standards for maternal and neonatal care, 1.8. Geneva: World Health Organization; 2007.

7. WHO model list of essential medicines, 18th Geneva: World Health Organization; 2013. Available from: http://apps.who.int/iris/bitstream/10665/93142/1/EML_18_eng.pdf

8. Ouma P, Parise ME, Hamel MJ, et Randomized controlled trial of folate supplementation when treating malaria in pregnancy with sulfadoxine-pyrimethamine. PLoS Clin Trials. 2006 Oct 20; 1:e28. Available from: http://journals.plos.org/plosclinicaltrials/article?id=10.1371/journal.pctr.0010028

9. Mbaye A, Richardson K, Balajo B, et Lack of inhibition of the anti-malarial action of sulfadoxine-pyrimethamine by folic acid supplementation when used for intermittent preventive treatment in Gambian primigravidae. Am J Trop Med Hyg. 2006 Jun; 74(6):960–4. Available from: http://www.ajtmh.org/ content/74/6/960.long

10. Prevention of neural tube Integrated Management of Pregnancy and Childbirth (IMPAC). In: Standards for maternal and neonatal care, 1.5. Geneva: World Health Organization; 2007.

11. World Health Organization (WHO), Food and Agriculture Organization (FAO). Guidelines on food fortification with micr Geneva: WHO; 2006.

Suggested citation: Roll Back Malaria Partnership Malaria in Pregnancy Working Group: Consensus Statement on folic acid supplementation during pregnancy. Geneva; 2015.

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