Intermittent Preventive Treatment of Malaria in Pregnancy (IPTp) as part of antenatal care (ANC) is a key malaria control strategy in areas of stable falciparum transmission.Â Growing resistance of parasites to the drug used for IPTp, sulfadoxine-pyrimethamine (SP) have led malaria program managers to wonder whether they should stop IPTp.Â Information presented at the Roll Back Malaria (RBM) Partnershipâ€™s Malaria in Pregnancy Working Group meeting this week in Kigali, Rwanda, cautions about not throwing the baby out with the bathwater.
Peter Ouma of the Kenya Medical Research Institute/US Centers for Disease Control & Prevention and a member of the Malaria in Pregnancy Research Consortium shared research that showed continued value of SP for IPTp. Peter shared data on the importance of three doses of IPTp on reducing placental parasitemia, the condition that causes inter-uterine growth retardation and is especially helpful for primi- and secundi-gravidae.
Three IPTp doses is within the context of the recommended â€œat least twoâ€ doses recommended for pregnant women after quickening in stable transmission areas. In fact some countries like Ghana already recommend three.
Peter also advocated for more attention to SP drug quality. Most of the donors focus attention on quality approval processes for the treatment drugs – artemisinin-based combination therapy (ACT) – but many countries buy their own SP from various sources. Thus continued use of IPTp with SP should be linked with drug quality control to achieve maximum effectiveness.
Of course people recognize that SP will eventually need to be replaced.Â Various individual and combination drugs are being tested. Richa Chandra of Pfizer presented information on one such preventive treatment – Azithromycin and Chloroquine FDC (AZCQ).Â Most interestingly, AZCQ was found to be synergistically effective even with parasite strains that were resistant to chloroquine.
Should research favor roll out of AZCQ, practical planning and costing issues would need to be addressed. Like other drugs being tested, this combination would need to be given for three days unlike the one-time-only treatment dose of SP. Richa stressed the importance of community engagement if adherence to this 3-day regiment is to be achieved.
There was fear from the programmatic side that early cessation of IPTp within ANC would create a programming gap, such that when a replacement drug or combination comes along, it would be difficult to reintroduce IPTp into the ANC routine.Â But continued IPTp with SP is more than a placeholder; scale up and maintain IPTp programs in our high transmission countries will still save lives.