Intermittent Preventive Treatment of malaria in pregnancy (IPTp) using sulfadoxine-pyrimethamine (SP) has been a long standing intervention to protect pregnant women and their unborn children from the dangerous effects of malaria in stable transmission settings. Placental malaria deprives the fetus of nutrients leading to low birth weight, still birth and miscarriages. The mother herself suffers anemia and potentially, death.
There had always been a challenge to getting pregnant women to obtain at least two doses of IPTp-SP due to a variety of factors ranging from health system lapses to late antenatal care attendance by mothers. This phenomenon of dropping out of multi-contact interventions is not uncommon and seen equally in programs such as childhood immunization. Therefore when the World Health Organization raised the bar and recommended IPTp starting in the 13th week of pregnancy and monthly thereafter, the challenge of providing three or more doses arose.
The Malaria Indicator Surveys (MIS) and the Demographic and Health Surveys (DHS) are an ideal was to trace the progress of malaria intervention over multiple years. With the release of the preliminary results of 2017 Tanzania MIS it is now possible to track this service from over a decade. The Attached chart, using MIS/DHS reports shows that so far Tanzania has not come near achieving 80% coverage of this indicator. While there had been major increases over recent years, reports of IPTp coverage in 2017 show only 56% of recently pregnant women received at least two doses, and only 26% received three or more.
It should be noted that countries are beginning to stratify their interventions according to available transmission data. Therefore as noted in the US President’s Malaria Initiative Malaria Operations Plan for 2018, Zanzibar where transmission is low, has stopped IPTp and focuses on prompt and appropriate case management, while the mainland of Tanzania continues with all MIP interventions. Of interest is the most recent child prevalence map found in the 2017 MIS results that shows other parts of the mainland may also be approaching very low transmission.
Moving forward it will be useful if Tanzania and other endemic countries not only gather epidemiological data to help stratify appropriate interventions (as suggested in the WHO malaria elimination framework), but go further to focus reporting by strata. That said, the health system and community difficulties in achieving high IPTp coverage wherever it is appropriate will remain a challenge if services remain based in static health facilities. Community roles must be explored.
Dr. Anthony Laku who is currently the Immunization Program Officer in the South Sudan Ministry of Health presented the status of efforts to eliminate maternal and neonatal tetanus (MNT) in South Sudan at the fourth meeting of the WHO Regional Immunization Technical Advisory Group held 5-7 December 2017 in Johannesburg, South Africa. A summary of key challenges is shared below.
General Challenges to health delivery in South Sudan include a Maternal Mortality Ratio of 2054 per 100,000 live births. Also ~56% of population are not reached by Health Facilities; 60% of roads not accessible for half of the year; 45% of people live without access to safe water; and 86% of women have no formal education.
Delivery of immunization is hampered by persistent insecurity and inaccessibility. As of 31st August 2017, 7.5 million people are affected, and 3.9 million people are displaced, of which 2 million are in neighboring countries. The health services have varying degrees of difficulty in reaching the displaced people with immunization services.
Key strategies to eliminate MNT are as follows:
- Three doses to all Women of Reproductive Age (WRA) using supplementary immunization activities (SIAs)
- Provision of at least two doses of tetanus containing vaccines (TT) to all pregnant women and in high-risk areas
- Promotion of clean delivery services for all pregnant women, and
- Effective surveillance for MNT
So far the results have been below the targets for elimination. For example, 61% of 80 counties had less than 80% coverage in the third Round of Tetanus Containing Vaccines SIAs with 27/80 counties not reached at all. There was low estimated routine immunization (Penta3) coverage of only 26% in 2016. A limited number of skilled staff were available to ensure clean cord delivery (5% skilled delivery) with challenging implication on MNT elimination validation.
The protracted civil crisis in the country creates an uphill task for reaching key global targets including MNT elimination. Weak economic status in the country has had a ripple effect on staff motivation and commitment (e.g. delayed salaries).
Additional strategies were adopted for coverage improvement in 2017. A “Hit and Run” strategy was developed for insecure areas. Periodic Intensification of Routine Immunization was used in areas of intermittent crisis and or with high buildup of unimmunized populations. Overall the MNT elimination strategic plan was updated for 2018–2022.
Funding gaps exist for this new strategic plan with only 21% of needed finance is pledged. One approach to funding is aligning MNT elimination with funding in related areas such as the RMNCAH and Nutrition strategy and the Human Resource for Health Strategy. Despite these challenges South Sudan is persisting in efforts to eliminate MNT.