MIM2013: IPTp policy in Zanzibar towards pre-elimination of malaria: results from a study of placental parasitemia

maisha 1Mwinyi Issa Ramadhan Khamis, Elaine Roman, Raz Stevenson, Chonge Kitojo, Julie Msellem, Marya Plotkin, Khadija Said; Natalie Hendler; Asma Gutman, and Peter McElroy developed this presentation for the MIM2013 6th Pan-African Conference on Malaria in Durban. They represent the Zanzibar National Malaria Control Programme, Zanzibar Ministry of Health, Jhpiego Tanzania, Jhpiego Baltimore, United States Agency for International Development, US Centers for Disease Control and Prevention and the US President’s Malaria Initiative and were involved in the bilateral Maisha Project.

Due to scale up of malaria prevention and treatment by the Zanzibar Malaria Control Programme (ZMCP) of the Ministry of Health (MOH), Zanzibar is in the pre-elimination phase of malaria control P. falciparum prevalence in the general population is currently less than 0.5% [1], and the diagnostic positivity rate among febrile patients was 1.2% in 2011 [2]
Control of Malaria in Pregnancy (MIP) follows the 3 pronged approach recommended by WHO:

  • Intermittent preventive treatment for pregnant women (IPTp) with sulfadoxine-pyrimethamine (SP) distributed through antenatal care (ANC) services
  • Long lasting insecticide treated nets
  • Case management of malaria in pregnancy

IPTp-SP was implemented in 2004 when malaria prevalence exceeded 20%. Coverage among pregnant women remains low. In their last pregnancy:

  • 69% women reported taking any SP
  • 43% women reported taking 2+ doses of SP [3]

The MOH of Zanzibar is reconsidering provision of IPTp through ANC services in light of very low malaria prevalence. ZMCP has introduced screening for malaria in ANC services. In 2011 and 2012, 0.2% of ANC clients tested positive for malaria using mRDT (19,724 malaria tests were performed in 2011 and in 27,186 performed in 2012) [4]

Placental 1aThe Placental Parasitemia Study was a prospective observational study was conducted in selected health facilities in Zanzibar with the objective of measuring placental parasitemia rates among pregnant women who did not receive IPTp. The study addressed the Policy question: Is IPTp useful at current level of transmission in preventing maternal and neonatal morbidity?

A Convenience sample of pregnant women enrolled at six hospitals in Zanzibar on day of delivery was recruited from September 2011 – April 2012. Client card checked for documentation of provision of IPTp (eligible= no doses of SP, resident of Zanzibar). Informed consent obtained from eligible clients.

Samples were taken from maternal side of placenta by labor ward midwives. Dried blood spots (DBS) on filter paper were prepared from placental blood specimens DBS were analyzed via polymerase chain reaction indicating active Plasmodium infection (all species).

1,423 deliveries were enrolled from Pemba (52%) and Unguja (48%), representing 6% of the total deliveries at the six facilities.  The Average age of women was 26.9 years and 376 (32%) were primigravidae.
In 9 of 1,349 (0.8%, 95% confidence interval 0.2–3.3%) placental specimens were PCR positive. Only P. falciparum detected. Six (66%) of the nine placental infections were from Unguja deliveries. Eight placental infections were accompanied by a normal birth weight delivery (? 2500 g). Placental infections were not more common during the seasonal transmission increases of 2011-12.

In Conclusion, Malaria infection among pregnant women who have not had IPTp is extraordinarily low (0.8%). Given the low prevalence of placental malaria infection among women who had not had IPTp, in combination with the overall low prevalence of malaria on the islands, a policy shift away from IPTp is not an unreasonable option, if this is done with expanded surveillance of MIP and strengthening of detection and case management of women with MIP.

We Recommend Enhanced surveillance of MIP through expansion of the existing surveillance system, MEEDS, to capture symptomatic pregnant women diagnosed at ANC and ensure that pregnancy status is recorded for women diagnosed at the outpatient department. Case management of MIP should be strengthened and continued high ownership and use of ITNs should be ensured, particularly among women of reproductive age.

A internal review of costs and findings from surveillance to inform on whether the cost of screening every pregnant woman in antenatal care is justified

References

  1. Bhattarai A, Ali AS, Kachur SP. Impact of artemisinin-based combination therapy and insecticide-treated nets on malaria burden in Zanzibar. PloS Med 4(11): e309.
  2. Zanzibar Malaria Control Programme. Zanzibar Malaria Epidemic Early Detection System Biannual Report, Mid-Year 2011; Vol. 3,  (No.1); 2011.
  3. Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS) 2011-12.
  4. Zanzibar Malaria Control Programme. Unpublished 2012 National surveillance data.

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