Tropical Health Matters

Anemia in pregnancy is responsible not only for threats to a woman’s health, but ultimately the survival of the child. Hotez and Molyneux in a PLoS Neglected Tropical Diseases editorial explain that …

“… most of the 7.5 million pregnant women infected with hookworm likely live in areas of sub-Saharan Africa that place them at risk for malaria. At the same time, malaria control and NTD control have each been shown to reduce anemia both in children and in pregnant women. Therefore, combining malaria and NTD control practices in a unified anemia framework affords one of the best opportunities to reduce the huge burden of morbidity and mortality that results from anemia in sub-Saharan Africa.”

Each disease presents its own challenges. Guyatt and Snow report that, “Although the vast majority of women with malaria infections during pregnancy remain asymptomatic, infection increases the risk of maternal anemia and delivering a low-birth-weight (LBW) baby.” Furthermore, “It is estimated that in areas where malaria is endemic, around 19% of infant LBWs are due to malaria and 6% of infant deaths are due to LBW caused by malaria. These estimates imply that around 100,000 infant deaths each year could be due to LBW caused by malaria during pregnancy in areas of malaria endemicity in Africa.”

Addressing hookworm during pregnancy in Peru, Larocque and colleagues found that pregnant women, “infected with moderate and heavy intensities of hookworm infection and those with moderate and heavy intensities of both hookworm and Trichuris infections were more likely to suffer from anemia than women having no or light intensities. These results support routine anthelminthic treatment within prenatal care programs in highly endemic areas.”

Positive experiences on anthelminthic control were also reported from Nepal in the Lancet. During prenatal care  “… women received albendazole twice during pregnancy. Women given albendazole in the second trimester of pregnancy had a lower rate of severe anaemia during the third trimester. Birthweight of infants of women who had received two doses of albendazole rose by 59 g , and infant mortality at 6 months fell by 41%. Antenatal anthelmintics could be effective in reducing maternal anaemia and improving birthweight and infant survival in hookworm-endemic regions.”

We reported from Mozambique that PMTCT and IPTp for malaria in pregnancy control are integrated into antenatal care in many clinics.  One can see metronidazole in addition to SP and AZT in the picture among the preventive medicines available for pregnant women. Countries can make their choices of anthelminthics, including albendazole, but the meassage that Hotez and Molyneux convey is the need to control NTDs like soil transmitted helminths should be an integral part of services for pregnant women.

Malaria is estimated to kill over 1 million people a year, mostly children, while the annual death toll from HIV/AIDS approaches 2 million. Where these diseases overlap, “Malaria contributes synergistically with HIV/AIDS to morbidity and mortality in areas where both infections are highly prevalent, such as in Africa south of the Sahara. In addition to providing immediate health benefits, prevention and treatment of malaria may lessen transient increases in HIV viral load during malaria episodes and thus help limit the progression,” according to the World Malaria Report.

With the clear public health links between the two diseases, one would have expected to see more reports about malaria in HIV within the XVII International AIDS Conference in Mexico. Search at the conference website on malaria as a key word turned up only four abstracts or session outlines that actually addressed malaria, not just presentations that happened to spell out the full title of the Global Fund, and thus inadvertently mentioned malaria.

An abstract by Imani et al. reported that, “HIV infection was significantly associated with cerebral malaria in children admitted to Mulago Hospital and the prevalence of HIV infection among those with cerebral malaria was 9%.
Recommendation: Malaria prevention should be an important component of education and counselling of HIV infected children and their caretakers. A large study is recommended to establish whether there is a correlation between the level of HIV immunosuppression and cerebral malaria.”

Oloo and colleagues presented on “Strengthening HIV/AIDS programs for transport sector workers through a regional trade union approach in East and Central Africa.” Among their recommendations was the importance of providing “integrated reproductive health, malaria and family planning services to transport workers through the resource centers.”

A workshop is being organized on, “Uniting and Empowering Civil Society on CCMs: How AIDS, TB, and Malaria Organizations Can Work Together on CCMs and in GFATM Advocacy,” and is crosscutting on the three diseases.

Finally, Raposo et al., presented the topic, “Counseling and testing in health: a public health approach to increase access to health promotion in Mozambique.”  They stressed the need for linkages with other health services. A model for better integrated services was described that included, “Additional counseling is provided for malaria prevention, environmental health, uptake of antenatal care during early pregnancy, and institutional delivery.”

Better integration of disease control and prevention efforts is needed to better serve those in endemic communities. Integration should also be evident in advocacy efforts such as international conferences. We can’t afford the medical model that looks at diseases only, not the people who suffer from multiple problems.

Infectious diseases during pregnancy put both the mother and the unborn child at risk.  According to WHO’s Global Malaria Program, co-infections with HIV and malaria put pregnant women at special risk. WHO is also concerned that opportunities to address infectious diseases like HIV and malaria are often missed during antenatal care (ANC).  WHO therefore recommends a minimum 4-visit focused ANC package as follows:

For antenatal care to be effective, all pregnant women need a minimum of four visits, at specific times and with evidence-based content. Care for women during pregnancy improves health by preventive measures, and by prompt detection and management of complications. Essential components of a focused antenatal-care package include screening for and treatment of disorders (such as anaemia, abnormal lie, hypertension, diabetes, syphilis, tuberculosis, and malaria); provision of preventive interventions (such as tetanus immunisation and insecticide-treated bednets); and counselling about diet, hygiene, HIV status, birth, emergency preparedness, and care and feeding of babies. Since antenatal care has good coverage, it provides a platform to increase the interventions provided during antenatal visits, including HIV care for the mother, prevention of maternal to child transmission (PMTCT) of HIV, and support for feeding choices. However, this opportunity must be weighed against the risk of overloading services that are already stretched.

It is encouraging to see that the Ministry of Health in Mozambique is taking the integration of malaria control and PMTCT into its antenatal care services.  The picture above shows an ANC nurse’s desk in one of the more that 500 health facilities that offer PMTCT. There is almost what one could call a one-stop-shop for pregnant women in terms of getting their preventive medicines – sulfadoxine-pyrimethamine (SP) for intermittent preventive treatment of malaria (IPT), and AZT and neviraprine for PMTCT prophylaxis, among others.

Some challenges to this integration remain.  The policy for IPT was adopted only in 2006 after pilot testing in two provinces, and needs to be disseminated more fully. PMTCT is presently offered in only about one-half to one-third of health facilities where ANC is offered. ITNs are not yet available in all routine service points, but there is a strong commitment to contiunue work toward integration.

The Round Six Global Fund application for Mozambique summarizes the vision of integration: “The HIV/AIDS component supports provision of comprehensive antenatal care (ANC) to pregnant women, consisting of provision of anaemia, syphilis and HIV tests; iron, folic acid and vitamin A supplementation; Intermittent Preventive Tretament (IPT) of malaria in pregnant women; de-worming, health education & counselling on breastfeeding , nutrition, HIV and hygiene. The delivery by the malaria component of ITNs through routine ANC will reinforce this comprehensive care. Early data from applying the model in Inhambane Province has also shown increased use of ANC when ITNs are made available; this will enhance uptake of the other services.”

We hope other countries take this as a model of ANC integration to emulate.