Prevention and Control of Malaria in Pregnancy

A Workshop for Health Care Providers

Facts about Malaria

 300 million cases each year worldwide

 9 of 10 cases occur in Africa
 A person in Africa dies of malaria every 10 seconds
 Women and young children are most at risk
 Affects five times as many people as AIDS, leprosy,
measles and tuberculosis combined

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Facts about Malaria and Pregnancy

 25 million pregnant African women in malarious areas

yearly
 Malaria is more frequent and complicated during
pregnancy
 In malaria-endemic areas, malaria during pregnancy may
account for:
 Up to 15% of maternal anemia
 8–14% of low birthweight
 30% of “preventable” low birth weight
 3–8% of infant death

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Roll Back Malaria Partnership

 Worldwide partnership launched by WHO, UNICEF,

UNDP in 1998 to provide a coordinated global approach
to fighting malaria
 Partners: governments, private groups, research
organizations, civil society, media
 Vision: By 2015 the malaria-related Millennium
Development Goals (MDGs) are achieved. Malaria is no
longer a major cause of mortality and no longer a barrier
to social and economic development and growth
anywhere in the world.

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RBM Partnership

 Priority: Prevent poor outcomes caused by malaria in

pregnancy
 RBM Summit 2005 Yaoundé:
 Strategic plan aimed at vulnerable groups
 Target: 80% of pregnant women in areas of stable
transmission receive IPTp by 2010
 Free advocacy resources and tools:
http://www.rbm.who.int

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Malaria Prevention and
Treatment in Pregnancy

WHO strategy:
 Use of insecticide-treated nets (ITNs)
 Intermittent preventive treatment (IPTp)
 Case management of women with symptoms and signs of
malaria

Platform for these services: focused antenatal care with

health education about malaria

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Prevention and Control of Malaria in Pregnancy

Chapter One: Focused Antenatal Care

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Focused Antenatal Care:
Chapter Objectives

 Explain the differences between basic, additional and

initial specialized care
 Describe the four main goals of focused ANC
 Describe the essential elements of a birth and
complication readiness plan
 Discuss the frequency and timing of focused
ANC visits
 Describe components of record keeping for focused ANC

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Traditional Antenatal Care

 Emphasizes:
 Ritualistic, “routine” care
• Actions are often not evidence-based or goal-directed
 Frequent visits
 Does not emphasize individual
clients’ needs
 Often based on risk approach

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Focused Antenatal Care

An approach to ANC that emphasizes:

 Evidence-based, goal-directed actions
 Individualized, woman-centered care
 Quality vs. quantity of visits
 Care by skilled providers

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Evidence-Based, Goal-Directed Actions

 Address most prevalent health issues affecting women

and newborns
 Adjusted for specific populations/regions
 Appropriate to gestational age
 Based on firm rationale

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Individualized, Woman-Centered Care

Based on each woman’s:

 Specific needs and concerns
 Circumstances
 History, physical examination, testing
 Available resources

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Quality vs. Quantity of ANC Visits

 WHO multi-center study:

 Number of visits reduced without affecting outcome for
mother or baby
 Recommendations:
 Content and quality vs. number of visits
 Goal-oriented care
 Minimum of four visits

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No Longer Recommended

 Numerous, routine visits:

 Burden to women and health care system
 Routine measurements and examinations:
 Maternal height and weight
 Ankle edema
 Fetal position before 36 weeks
 Care based on risk assessment

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Risk Approach

Not an effective ANC strategy because:

 Complications cannot be predicted—all pregnant women
are at risk for developing complications
 Risk factors are usually not direct cause of complications

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Risk Approach (cont.)

 Many “low risk” women develop complications:

 Have false sense of security
 Do not know how to recognize/respond to problems
 Most “high risk” women give birth without
complications:
 Inefficient use of scarce resources

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Care by a Skilled Provider

 Has formal training and experience

 Has knowledge, skills and qualifications to deliver safe,
effective maternal and newborn health care
 Practices in home, hospital, health center
 May be a midwife, nurse, doctor, clinical officer, etc.

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Scope of Focused ANC

 The scope of antenatal services includes:

 Basic care
 Care for additional needs
 Initial specialized care

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Basic Care for ALL women
Services all women should receive to ensure, support and maintain a normal
childbearing cycle:

 Early detection of complications, chronic conditions and

other problems/potential problems
 Health promotion to facilitate healthy practices
 Nutritional support
 Birth preparedness/complication readiness
 Testing/counseling for HIV (unless client
“opts out”)
 Immunizations and other preventive measures

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Additional Care for SOME women

 To address concerns such as common discomforts in

pregnancy or special needs
 Special needs: conditions or personal/social factors to
consider when planning and implementing care
 Examples of additional care:
 Counseling on specific health topics
 Addressing the needs of pregnant adolescents
 Caring for women who are HIV-infected

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Initial Specialized Care
for a FEW women

 A few pregnant women will need initial specialized care for

more serious problems or complications including additional
ANC visits and/or referral
 Examples: life-threatening complications, e.g., severe malaria,
anemia or antenatal hemorrhage
 Does not include management of the problem, but stabilization
and preparation for referral to a higher level of care

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Scope of Focused ANC

Majority of pregnant
women need these services
only

Some pregnant women require

these services also

Fewer pregnant women require

these services

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Goal of Focused Antenatal Care

To promote maternal and newborn health and survival through:

 Identification and treatment of existing

health problems
 Early detection of complications and/or diseases arising
during pregnancy
 Birth preparedness and complication readiness
 Health promotion and disease prevention

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Identification and Treatment of Existing Health
Problems

 Early detection and treatment of problems that can complicate

the woman’s pregnancy
 Targeted assessment:
 Provider interviews, examines and tests the woman to
detect signs/symptoms of conditions that are common in
the population being served as well as pregnancy-related
complications.
 Providing (or facilitating) appropriate treatment

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Identification and Treatment of Existing Health
Problems (cont.)

 Malaria—history and physical exam:

 Does the woman live in an area of stable or unstable malaria
transmission?
 Fever and accompanying signs/symptoms
 Uncomplicated vs. severe cases
 Severe anemia—physical exam, testing
 Hypertension—B/P measurement
 HIV testing and counseling
 Sexually transmitted infections:
 Including syphilis (RPR) and other appropriate screening

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Early Detection of Complications and/or Diseases

 Another component of targeted assessment

 Detecting signs and symptoms of maternal complications,
for example:
 Hemorrhage
 Pre-eclampsia/eclampsia
 Prolonged/obstructed labor
 Sepsis/infection

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Early Detection of Complications and/or Diseases
(cont.)

 Management of complications or initial management and

stabilization, including life-saving measures as needed
 Facilitating management or referral to a higher level of
care

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Birth Preparedness and
Complication Readiness

 Develop birth plan—for normal birth and possible

complications:
 Arrangements made in advance by woman and family
(with help of skilled provider)
 Usually not a written document
 Reviewed/revised at every visit
 Minimize disorganization at time of birth or in an
emergency
 Ensure timely and appropriate care

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Essential Elements of a Birth Plan

 Facility or Place of Birth: Home or health facility for birth,

appropriate facility for emergencies
 Skilled Provider: To attend birth
 Provider/Facility: Contact information
 Transportation: Reliable, accessible, especially for odd hours
 Funds: Personal savings, emergency funds
 Decision-Making: Who will make decisions, especially in an
emergency

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Essential Elements of a Birth Plan (cont.)

 Family and Community Support: Care for family in

woman’s absence and birth companion during labor
 Blood Donor: In case of emergency
 Needed Items: For clean and safe birth and for newborn
care
 Knowledge of: Danger signs/signs of advanced labor

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Danger Signs of Pregnancy

 Vaginal bleeding
 Difficulty breathing
 Fever
 Severe abdominal pain
 Severe headache/blurred vision
 Convulsions/loss of consciousness
 Labor pains before 37 weeks

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Health Promotion and
Disease Prevention

 Inform and educate the woman with health messages

and counseling appropriate to:
 Individual needs, concerns, circumstances
 Gestational age
 Most prevalent health issues
 Support the woman in making decisions and solving
actual or anticipated problems
 Involve partner and family in supporting/adopting healthy
practices

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Health Promotion and
Disease Prevention (cont.)

 Prevention of malaria:
 Intermittent preventive treatment (IPTp)
 Use of insecticide-treated nets (ITNs)
 What family can do to minimize mosquito breeding/bites
 Other important issues to be discussed include:
 Nutrition
 Care for common discomforts
 Use of potentially harmful substances
 Hygiene
 Rest and activity

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Health Promotion Topics

 Sexual relations and safer sex

 Early and exclusive breastfeeding
 Testing/counseling for HIV infection:
 Unless she “opts out”
 Family planning/healthy timing and spacing of
pregnancies

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Disease Prevention

 Along with health messages, another important aspect

of health promotion is the provision of safe and cost-
effective interventions to prevent certain conditions

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Disease Prevention (cont.)

 Prevention of malaria:
 Intermittent preventive treatment (IPTp)
 Use of insecticide-treated nets (ITNs), including long- lasting
insecticide-treated nets (LLINs)
• Where to access them
 What the family can do to minimize mosquito breeding/bites
 Prevention of mother-to-child transmission of HIV (PMTCT)
if applicable:
 Follow local guidelines

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Disease Prevention (cont.)

Preventing other endemic diseases/deficiencies:

 Anemia:
 Iron/folate supplements and nutrition counseling
 Presumptive treatment for hookworm infection
 Tetanus:
 Tetanus toxoid immunization
 Vitamin A supplements (per country guidelines):
 Helps prevent night blindness and supports fetal growth
and development

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Disease Prevention (cont.)

 Iodine supplements (per country guidelines):

 Iodine deficiency is the main cause of preventable mental
retardation and brain damageespecially in the developing
fetus and young children. During pregnancy, it also
increases the chance of spontaneous abortion and stillbirth.

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Scheduling and Timing of
ANC Visits

 First visit: By 16 weeks or when woman first thinks she is

pregnant
 Second visit: At 24–28 weeks or at least once in
2nd trimester
 Third visit: At 32 weeks
 Fourth visit: At 36 weeks
 Other visits: If complication occurs, follow-up or referral is
needed, woman wants to see provider,
or provider changes frequency based on findings or local
policy

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Record-Keeping for ANC Visits

Necessary to:
 Adequately monitor woman’s condition
 Provide continuity of care
 Communicate effectively among health care providers or
among health care sites (if referred)

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Record-Keeping Responsibilities

 Health facility:
 Establishes and maintains a record for every woman and
newborn who receives care
 Provider:
 Gathers information, records it, refers to it and updates it at
the time of each visit
 Ensures that information is accurate and
clearly written

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Record-Keeping
Record all information on the ANC chart and
clinic card:

 First ANC visit:

 History
 Physical examination
 Testing as appropriate (e.g., malaria, HIV)
 Care provision, including IPTp, TT, iron/folate
 Health messages discussed, including birth plan, malaria
prevention (use of ITNs) and danger signs
 Date of next ANC visit

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Record-Keeping (cont.)

Subsequent ANC visits:

 Interim history
 Targeted physical examination, testing
 Care provision, including IPTp if appropriate
 Health messages (including review/revision of birth plan)
 Counseling/testing for HIV if not done previously or woman
requests it
 Date of next ANC visit

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Prevention and Control of Malaria in Pregnancy

Chapter Two: Transmission of Malaria

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Malaria Transmission:
Chapter Objectives

 Define malaria and how it is transmitted

 Describe the extent of malaria in Africa in general and in your
own country
 Compare the effects of malaria in areas of stable and unstable
transmission
 List the effects of malaria on pregnant women and their
unborn babies
 Describe the effects of malaria on pregnant women with
HIV/AIDS

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Malaria Transmission

Caused by Plasmodium parasites:

 Plasmodium falciparum:
 The most common type in much of Africa
 Causes the most severe disease
 Plasmodium vivax
 Plasmodium ovale
 Plasmodium malaria

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Malaria Transmission (cont.)

 Spread by female Anopheles mosquitoes infected with

parasites
 Anopheles mosquitoes are usually active
at night
 Infected mosquito bites a person
 Malaria parasites reproduce in human blood
 Mosquito bites infected person, and goes on to bite and
infect another person

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Anopheles Mosquito

Anopheles mosquitoes differ from other mosquitoes in the way

their body is positioned. The body of the Anopheles points up in the
air in one line, but in other mosquitoes, the rear end is bent and
points down.

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Factors Affecting Transmission

 Breeding sites
 Parasites
 Climate
 Population

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Breeding Sites

Stagnant or slow-flowing bodies of water:

 Small ponds, ditches, pits, and canals
 Swamps, reservoirs, and rice fields
 Pools of water after rain
 Uncovered water tanks
 Streams with slow-flowing water along banks
 Water-filled animal hoof prints
 Objects that collect water: empty tins, containers

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Parasites and Climate

 Enough parasites must exist in the human population

to infect the mosquito
 Temperature must average at least
18–20 C and humidity stay above 60% for the mosquito
to survive and the parasite to develop
 The warmer the weather, the faster the development of
the parasite

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Population

 In Africa, Anopheles mosquitoes do not fly further than

about 1–2 km from their breeding sites
 People must be near or within a short distance from these
breeding sites in order to be bitten by the infected
mosquito

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Populations Most Affected
by Malaria

 Children under 5 years of age:

 About 70% of malaria deaths
 Pregnant women:
 More likely to become infected compared to non-
pregnant women
 Women in first or second pregnancies more at risk
 Unborn babies
 Immigrants from low-transmission areas
 HIV-infected persons

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Transmission Levels -
Stable Transmission

 Places where populations are continuously exposed to a fairly

constant rate of malaria
 Immunity is developed during childhood
 Adolescents and adults are partially immune, although they may
have a few parasites in their blood
 Immunity is reduced in pregnancy and can be lost when persons
move out of the high transmission area for a long time
 Children and pregnant women in areas of stable transmission have
the highest risk of becoming ill
from malaria

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Stable Transmission

Acquired Immunity – high  In absence of HIV infection, 1st

and 2nd pregnancies are at
higher risk
Asymptomatic infection
Placental sequestration
Anaemia Altered placental integrity

Less nutrient transport

Maternal Morbidity Low Birth Weight Higher Infant Mortality

WHO 2004

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Transmission Levels–
Unstable Transmission

 Population is not exposed to malaria

very often
 Malaria can sometimes be seasonal in these areas
(e.g., rainy season)
 Population develops little or no immunity
 Children, adults, pregnant and non-pregnant women are
equally susceptible

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Transmission Levels–
Unstable Transmission (cont.)

 Malaria in pregnancy can be very serious; complications

may occur in a short time
 Pregnant women usually present with clinical
signs/symptoms and sometimes severe malaria, which is
life-threatening
 Common outcomes of malaria infection in unstable areas:
Abortions, stillbirths and low birth weight

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Unstable Transmission

Acquired Immunity – low or none

Clinical Illness

 All pregnancies are at risk

Severe Disease
 Key intervention strategies: disease
recognition and case management

Risk to Mother Risk to Fetus

WHO 2004

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Transmission Levels–
Mixed Transmission

 Different levels of transmission can occur within a country

or region
 Within a malarious region (such as in Southern Africa) there
can also be malaria-free areas
 Factors affecting transmission include temperature, humidity
and altitude:
 The lifespan of the mosquito is increased with high humidity, while
cold weather (below 16° C) slows the development of the malaria
parasite

59
Effects of Malaria on
Pregnant Women

 All pregnant women in malaria-endemic areas are at risk

 Parasites attack and destroy red blood cells
 Malaria causes up to 15% of anemia in pregnancy
 Malaria can cause severe anemia
 In Africa, anemia due to malaria causes up to 10,000 maternal
deaths per year

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Effects of Malaria on
Pregnant Women (cont.)

 Effects range from mild to severe, depending on the

level of malaria transmission in a particular setting
and the pregnant woman’s level of immunity
 The level of immunity depends on
several factors:
 Intensity of malaria transmission
 Number of previous pregnancies
 Presence of other conditions, such as HIV, which can lower
immune response during pregnancy

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HIV/AIDS during Pregnancy

 Reduces a woman’s resistance to malaria

 Increases likelihood of developing clinical malaria
 Causes malaria treatment to be less effective
 Increases risk of malaria-related problems
in pregnancy
 Increases risk of intrauterine growth restriction
 Increases the risk of preterm birth
 Increases the risk of maternal anemia

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HIV/AIDS and Malaria

 Pregnant women who are co-infected

with HIV and malaria are at a very high
risk for anemia and malaria infection of
the placenta
 Their newborns are therefore more
likely to have low birth weight and die during infancy

63
Integrating Malaria and HIV Services:
WHO Recommendations

 Protection by ITNs is of high priority

 HIV-infected women with malaria risk should receive either IPTp with SP
(at least 3 doses or according to country guidelines) or daily cotrimoxazole
prophylaxis:
 DO NOT give SP to clients on daily cotrimoxazole
 Collaboration of reproductive health programs with HIV and malaria
control programs should occur to ensure integrated service delivery:
 Counseling and care directed at preventing/treating both malaria
and HIV
 Appropriate diagnostic tools for both diseases, antiretrovirals, and antimalarials
available at all levels of health care system

64
Malaria and Sickle Cell

 Persons with sickle cell trait have some resistance to

falciparum malaria, especially in early childhood
 Though they may have protection, it is still important that
those with sickle cell trait receive ITPp and use ITNs and
other preventive measures

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Effects of Malaria on
Unborn Babies

 During pregnancy, malaria parasites hide in the placenta

 This interferes with transfer of oxygen and nutrients to
the baby, increasing risk of:
 Spontaneous abortion
 Preterm birth
 Low birth weight—single greatest risk factor for death
during first month of life
 Stillbirth

66
Effects of Malaria on Communities
 Causes sick individuals to miss work (and wages)
 Causes sick children to miss school
 May cause chronic anemia in children, inhibiting growth and
intellectual developmentaffecting future productivity
 Uses scarce resources
 Puts strain on financial resources (treatment is more costly than
prevention)
 Drugs (cost)
 Causes preventable deaths, especially among children and pregnant
women

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Summary of Main Points

 Malaria is transmitted through

mosquito bites
 Pregnant women and children are particularly at risk for
malaria
 Pregnant women infected with malaria may have no
symptoms
 Women with HIV/AIDS have a higher risk of malaria
infection

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Summary of Main Points (cont.)

 Malaria can lead to severe anemia, spontaneous

abortion and low birth weight newborns
 Malaria is preventable
 Malaria is treatable

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Prevention and Control of Malaria in Pregnancy

Chapter Three: Prevention of Malaria

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Preventing Malaria:
Chapter Objectives

 List the three elements of malaria prevention and control

according to the WHO malaria in pregnancy (MIP) strategy
 List the elements of counseling women about the use of
insecticide-treated nets (ITNs), intermittent preventive
treatment during pregnancy (IPTp) and other means of malaria
prevention
 Describe the use of sulfadoxine-pyrimethamine (SP) for IPTp,
including dosage, timing and contraindications

71
WHO/AFRO Malaria
Prevention Strategy

 Designed to be appropriate for most African settings with

guidance on adapting it to local situations
 Based on fact that most sub-Saharan Africans live in
areas of stable transmission

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WHO/AFRO Malaria
Prevention Strategy (cont.)

 Insecticide-treated nets (ITNs)

 Intermittent preventive treatment in pregnancy (IPTp)
 Case management of malaria illness
and anemia

73
Insecticide-Treated Nets

 Very effective because mosquitoes bite at night when the

pregnant woman is asleep
 Reduce human contact with
mosquitoes by:
 Killing them if they land on the net, or
 Repelling them, thus driving them away from where people
are sleeping

74
Insecticide-Treated Nets (cont.)

 Prevent physical contact with mosquitoes

 Kill or repel other insects:
 Lice
 Ticks
 Bedbugs

75
Insecticide-Treated Nets (cont.)

Untreated Nets Insecticide-Treated Nets

 Provide a high level of  Provide some protection
protection against malaria against malaria
 Kill or repel mosquitoes that  Do not kill or repel mosquitoes
touch the net that touch net
 Reduce number of mosquitoes  Do not reduce number of
in/outside net mosquitoes
 Kill other insects such as lice  Do not kill other insects like
and bedbugs lice and bedbugs
 Are safe for pregnant women,  Are safe for pregnant women,
young children young children
and infants and infants

76
Benefits of
Insecticide-Treated Nets

 Prevent mosquito bites

 Protect against malaria, resulting in less:
 Anemia
 Prematurity and low birth weight
 Risk of maternal and newborn death
 Help people sleep better
 Promote growth and development of fetus and newborn

77
Benefits of
Insecticide-Treated Nets: Community

 Cost less than treating malaria

 Reduce number of sick children and adults (helping
children grow to be healthy and helping working adults
remain productive)
 Reduce number of deaths

78
Where to Find
Insecticide-Treated Nets

 General merchandise shops

 Drug shops/pharmacies
 Markets
 Public and private health facilities
 Community health workers
 NGOs, community-based organizations

79
How to Use
Insecticide-Treated Nets

 Hang above bed or sleeping mat

 Tuck under mattress or mat
 Use every night, all year long
 Use for everyone, if possible, but
give priority to pregnant women, infants and children

80
Insecticide-Treated Nets

ITN tucked under a bed ITN tucked under a mat

81
Caring for
Insecticide-Treated Nets

 Handle gently to avoid tears

 Tie net up during day to avoid damage
 Regularly inspect for holes, repair if found
 Re-treat regularly so they stay effective
 Keep away from smoke, fire, direct sunlight

82
Long-Lasting
Insecticide-Treated Nets (LLINs)

 A pre-treated, ready-to-use net that lasts between

3 and 5 years (depending on type) and does not require
re-treatment during that time
 Compared to ITNs, long-lasting nets:
 Usually have a one-time cost
 Do not require additional treatments
 Save money as there are no additional costs associated with

re-treatment, re-treatment campaigns or additional

insecticides

83
Intermittent Preventive Treatment (IPTp)

Based on the assumption that every pregnant woman

living in an area of high malaria transmission has malaria
parasites in her blood or placenta, whether or not she has
symptoms of malaria
Although a pregnant woman with malaria may have no
symptoms, malaria can still affect her and her unborn child.

84
Intermittent Preventive Treatment: Use

WHO 2004:
 All pregnant women should be given at least two doses of
sulfadoxine-pyrimethamine (SP) during ANC visits
 Give the first dose after quickening and no earlier than 16
weeks of pregnancy
 Give the 2nd dose at least 1 month (4 weeks) later

Preventing parasites from attacking the

placenta helps the fetus develop normally and
avoid low birth weight

85
Intermittent Preventive Treatment:
Dose and Timing

 A single dose is three tablets of sulfadoxine 500 mg +

pyrimethamine 25 mg
 Health care provider should dispense dose and directly
observe client taking dose

86
Before Giving Intermittent
Preventive Treatment

 Ensure woman is at least 16 weeks pregnant and that

quickening has occurred
 Inquire about use of SP in last 4 weeks
 Inquire about allergies to SP or other sulfa drugs
(especially severe rashes)
 Explain what you will do; address the woman’s questions
 Provide cup and clean water

87
Instructions for Giving IPTp

 Directly observe woman swallow three tablets of SP

 Record SP dose on ANC and clinic card
 Advise the woman when to return:
 For her next scheduled visit
 If she has signs of malaria
 If she has other danger signs
 Reinforce the importance of using ITNs

88
IPTp: Contraindications to SP

 Do NOT give during first trimester: Be sure quickening

has occurred and woman is at least 16 weeks pregnant
 Do NOT give to women with reported allergy to SP or
other sulfa drugs: Ask about sulfa drug allergies before
giving SP
 Do NOT give to women taking cotrimoxazole or other
sulfa-containing drugs: Ask about use of these medicines
before giving SP
 Do not give SP more frequently than monthly: Be sure at
least 1 month has passed since the last dose of SP

89
Indoor Residual Spraying (IRS)

 Main purpose: to lower malaria transmission by reducing

survival of mosquitoes entering houses or sleeping areas
 An effective intervention when these conditions
are met:
 A large number of the structures in an area have adequate
sprayable surfaces
 A majority of the vector population rests indoors
• Most malaria vectors in Africa are indoor-resting
 The vector is susceptible to the insecticide in use
 Providers should keep updated about any local IRS
programs in their areas and educate clients accordingly

90
Other Ways to Prevent Malaria

 Cover doors and windows with wire or nylon mesh/ nets to

prevent mosquitoes from entering the house
 Avoid going outside after dark; when out in evenings:
 Wear protective clothing covering arms and legs
 Apply chemical mosquito repellent cream on exposed
skin surfaces
 Use mosquito coils that release smoke; the smoke keeps
mosquitoes away or kills them when they fly through it
 Spray rooms with insecticide before going to bed:
 Only effective for a few hours, so spray in combination with other
measures, such as screening doors and windows
 Physically kill mosquitoes indoors by swatting them

91
Summary of Main Points

 There are many ways of preventing bites and reducing

mosquito breeding sites
 Sleep under ITNs; where available, LLINs are preferred as
they last longer and do not require re-treatment
 Use of IPTp prevents parasites from attacking the placenta
 IPTp helps prevent malaria and reduces the incidence of
maternal anemia, spontaneous abortions, preterm birth,
stillbirth and low birth weight
 IRS programs can be effective in reducing number of
mosquitoes that transmit malaria; they are not a replacement
for ITNs and IPTp, but support and enhance these efforts

92
Prevention and Control of Malaria in Pregnancy

Chapter Four: Diagnosis and Treatment of Malaria

93
Malaria Diagnosis and Treatment: Chapter
Objectives

 Explain why self-diagnosis/treatment may lead to treatment

failure or recurring infection
 Describe the types of diagnostic tests available for malaria and
their advantages and disadvantages
 Identify other causes of fever during pregnancy
 List the signs and symptoms of uncomplicated and severe
malaria during pregnancy
 Describe the treatment for uncomplicated malaria
in pregnancy
 Explain the steps to appropriately refer a pregnant woman who
has severe malaria

94
Malaria Diagnosis

 Usually based on signs and symptoms of the patient,

clinical history and physical examination and/or
laboratory confirmation of the malaria parasite, if
available.
 Prompt and accurate diagnosis leads to:
 Improved differential diagnosis of febrile illness
 Improved management of non-malarial illness
 Effective case management of malaria

95
Self-Diagnosis

 Clients who experience symptoms often rely on self-diagnosis

and treatment
 Because symptoms are similar to those of several other
common ailments, mis-diagnosis is possible
 Prevalence of asymptomatic infections makes self-diagnosis
even more complex
 Client may take the wrong medicines, or the right medicines
but not in the proper dosage or for the recommended duration

96
Self-Diagnosis and Treatment

 When a client has self-treated and presents with

malaria symptoms or reports that symptoms have
worsened/recurred, it is possible that she:
 Has self-treated with the wrong drug or dosage
 Has not completed the treatment
 May have been given incorrect treatment instructions (or did not understand
instructions)
 Has received a poor-quality or counterfeit drug (this can happen even at
health facilities)

Often clients can purchase drugs without a prescription or

verification of diagnosis at pharmacies, local shops, roadside
kiosks and other easily accessible locations.

97
Diagnostic Testing

 Parasitological diagnosis has several major advantages

including:
 Prevents wastage of drugs through unnecessary treatment,
resulting in cost savings
 Improves care in parasite-positive patients due to greater
certainty of malaria diagnosis
 Prevents unnecessary exposure to malaria drugs
 Confirms treatment failure

98
Methods of Diagnostic Testing

 The two methods of diagnostic testing for malaria are

light microscopy and rapid diagnostic testing (RDT).
 Once the woman presents with malaria symptoms and is
tested, results should be available within a short time
(< 2 hours). When this is not possible, she must be treated
on the basis of clinical diagnosis (WHO 2006).

99
Diagnostic Testing: Microscopy

 “Gold standard” for laboratory confirmation of malaria

 Examination of the client’s blood, spread out as a thick or
thin “blood smear” on a microscopic slide
 Confirms the presence of malaria parasite and therefore
the diagnosis of malaria
 Also useful when a client has vague symptoms

100
Thin Film

 Often preferred for routine estimation of parasites

because organisms are easier to see and count
 Inadequate for detecting low parasite density

101
Thick Film

 Concentrates the layers of red blood cells on the slide,

using about 2 to 3 times more blood than the thin film
 Better than the thin film in detecting low levels of
parasites and reappearance of circulating parasites during
relapses
 Requires experienced technician because scanning for
parasites among white blood cells and platelets can be
difficult

102
Diagnostic Testing

If facilities for blood testing are not available or negative

lab results are received, malaria is considered the most
likely diagnosis in a pregnant woman who has recently been
exposed to mosquito bites and has symptoms of malaria.

103
Rapid Diagnostic Testing (RDT)

 Developed to provide quick, accurate and accessible

malaria diagnosis without the need for laboratory
facilities
 Successful RDT programs require:
 A “cool chain” for transport and storage
 Training for providers
 A clear policy on actions to take based on test results

104
Potential Uses for RDT

 Diagnosis by health care workers without access to

microscopy services
 Remote diagnosis for organized workforces in malaria-
endemic areas:
 e.g., military or mining companies
 Outbreak investigation and malaria prevalence surveys
 Self-diagnosis by trained individuals or groups
 “After-hours” diagnosis in hospital labs or clinics
 Diagnosis in suspected drug-resistant or
unresponsive malaria

105
Interpreting RDT Results

 When using RDTs, remember that a negative result

does not always exclude malaria because:
 There may be insufficient parasites to register a positive
result
 The RDT may have been damaged, reducing its sensitivity
 Illness may be caused by another species of malaria
parasite that the RDT is not designed
to detect

106
Interpreting RDT Results (cont.)

 A positive result does not always signify malaria

illness because:
 The antigen may sometimes be detected after the parasites
have died (i.e., after treatment) or due to the persistence of
malaria gametocytes that do not cause illness
 Presence of other substances in the blood may sometimes
produce a false-positive result
 Presence of parasites does not always signify malaria in
persons with high immunity as there may be other causes of
fever

107
Maintaining a “Cool Chain”

 Storage between 2° C and 30° C is recommended by

RDT manufacturers.
 Expiry dates are generally set according to these
conditions.
 If storage temperatures exceed these recommended limits,
it is likely that the shelf life of the RDTs will be reduced
and sensitivity lost before the expiration date.

108
Maintaining a “Cool Chain” (cont.)

 The “cool chain” starts before shipping from the manufacturer:

 The shipper or air carrier is notified of temperature storage
requirements and in clear markings on cartons, documents
 Ground transportation:
 Attention to outside temperatures while the vehicle is moving
and parked during all stages of delivery
 Storage:
 Storage at any stage before reaching final destination
should conform to manufacturers’ specifications, which is
usually ≤30° C

109
Indications for
Diagnostic Testing

 For pregnant women, a parasitological diagnosis is

recommended prior to starting treatment:
 Those who live in or have come from areas of unstable transmission
are the most likely candidates for severe malaria, which can be life-
threatening
 As a test of cure in clients who have been treated for malaria
but still have symptoms:
 If treatment was adequate, clients may have been reinfected or have
another problem causing similar symptoms
 Counterfeit or poor quality drugs may also be a the cause of treatment
failure

110
Clinical Diagnosis

 Based on the patient's symptoms and on physical

findings at examination
 The first symptoms of malaria and physical findings are
often not specific and are common to other diseases

111
Malaria Symptoms

The most common symptoms of malaria are:

 Fever
 Chills
 Headaches
 Muscle or joint pains

112
Severe Malaria

 In severe malaria (caused by Plasmodium falciparum),

clinical findings are more striking and may increase the
suspicion of malaria.
 Thus, in most cases the early clinical findings in malaria
are not typical and may need to be confirmed by a
laboratory test.

113
Signs/Symptoms of Severe Malaria

 Confusion
 Coma
 Neurologic focal signs
 Severe anemia
 Respiratory difficulties

114
Recommendations for
Clinical Diagnosis

 Where the risk of malaria is low, clinical diagnosis of

uncomplicated malaria should be based on the degree of
exposure to malaria and a history of fever in the previous
3 days with no features of other severe diseases.

115
Recommendations for
Clinical Diagnosis (cont.)

 In areas where the risk of malaria is high, clinical

diagnosis should be based on a history of fever in the
previous 24 hours and/or the presence of anemia.

116
Definition of
Presumptive Treatment

 Patients who suffer from a fever that does not have any
obvious cause are presumed to have malaria and are
treated for that disease, based only on clinical suspicion,
and without the benefit of laboratory confirmation.

117
Definition of
Presumptive Treatment (cont.)

 Dictated by practical considerations

and allows the treatment of a potentially fatal disease
 Can often lead to incorrect diagnoses and unnecessary use
of antimalarial drugs:
 Results in additional expenses and increases the risk of
selecting for drug-resistant parasites
 For children and pregnant women, may be the best option
when diagnostic testing is not available

118
Fever during Pregnancy

 Temperature of 38° C or higher

 May be caused by malaria, but also by:
 Bladder or kidney infection
 Pneumonia
 Typhoid, dengue fever, yellow fever
 Uterine infection
 Careful history and physical exam are required to rule out
other causes

119
Fever during Pregnancy (cont.)

 Ask about or examine for:

 Type, duration, degree of fever
 Whether she has or has had:
 Chills/rigors
 Episodes of a spiking fever
 Fits/convulsions
 Take the client’s temperature

120
Also Ask about:

 Signs of severe malaria

 Signs of other infections:
 Chest pain/difficulty breathing
 Foul-smelling watery vaginal discharge
 Tender/painful uterus or abdomen
 Frequency/urgency/pain in urinating/flank pain
 Any fluid leaking from vagina/rupture of membranes
 Headache
 Muscle/joint pain
 Dry or productive cough
 Chest pain and/or difficulty breathing
 Other danger signs

121
Types of Malaria

 Uncomplicated:
 Most common
 Severe:
 Life-threatening, can affect brain
 Pregnant women more likely to get severe malaria than
non-pregnant women

122
Recognizing Malaria in
Pregnant Women
Uncomplicated Malaria
 Fever
 Shivering/chills/rigors
 Headaches
 Muscle/joint pains
 Nausea/vomiting
 False labor pains
Severe Malaria
Signs of uncomplicated malaria PLUS one or more of the following:
 Confusion/drowsiness/coma
 Fast breathing, breathlessness,
dyspnea
 Vomiting every meal/unable
to eat
 Pale inner eyelids, inside of
mouth, tongue, and palms
 Jaundice
123
Recognizing Malaria in
Pregnant Women (cont.)

Refer the woman

immediately
if you suspect anything
other than
uncomplicated malaria

124
Case Management

 Despite preventive measures, some pregnant women

will still become infected with malaria
 The goal of malaria treatment during pregnancy:
To completely eliminate the infection because any
amount of parasites in the blood can affect the mother or
fetus

125
Case Management (cont.)

 Determine whether malaria is uncomplicated or

severe
 Uncomplicated: Manage according to local protocol
 Severe: Refer immediately to higher level of care;
consider giving pre-referral treatment or first dose
of antimalarial if available and provider is familiar with
its use

126
Case Management: Drugs

 Selection of treatment is based on:

 The gestational age of the pregnancy
 Available drugs:
 Drugs that are approved for malaria treatment in
accordance with national guidelines

127
Combination Therapy

 Plasmodium falciparum has become resistant to single-

drug therapy, resulting in ineffective treatment and
increased morbidity and mortality
 WHO now recommends that countries use a combination
of drugs to fight malaria
 Drug resistance is far less likely with combination
therapy than with single-drug treatments

128
Types of Combination Therapy

Artemisinin-based Combination Therapy (ACT):

 The simultaneous use of drugs that includes a derivative
of artemisinin along with another anti-malarial drug
 This combination is currently the most effective treatment
for malaria
 For second and third trimesters, ACTs should be the first-
line treatment if available and in line with local protocol

129
Types of Combination Therapy (cont.)
Non-Artemisinin-based Combination Therapy:
 Sulfadoxine-pyrimethamine with chloroquine (SP + CQ) OR
Amodiaquine (SP + AQ)
 Due to the high levels of CQ resistance, the SP + CQ
combination is not recommended
 If more effective ACTs are not available, and both SP and AQ
are effective (efficacy is greater than 80%), then SP + AQ can
be used as an interim measure (WHO 2006)
 Clients receiving non-ACTs containing SP for treatment
of malaria:
 May continue to take IPTp but should wait at least 1 month after
completing treatment to take next dose of IPTp; refer to local
guidelines for details

130
Selecting Treatment

 Follow local guidelines regarding which combination

therapies to use (if any) and how to use them
 For uncomplicated malaria in the 1st trimester and for
severe malaria in any trimester, quinine is the drug of
choice
 If ACTs are the only effective treatment available, they
can be used in the first trimester

131
Treating Uncomplicated Malaria

First trimester:
 Quinine 10 mg salt/kg body weight three times daily +
clindamycin 10 mg/kg body weight twice daily for 7 days
 If clindamycin is not available, use quinine only
 ACT can be used if it is the only effective treatment available
Second and third trimesters:
 Use the ACT known to be effective in the country/region, OR
 Artesunate + clindamycin (10 mg/kg body weight twice daily)
for 7 days, OR
 Quinine + clindamycin for 7 days

132
Treating Uncomplicated Malaria (cont.)

 Observe client taking anti-malarial drugs

 Advise client to:
 Complete course of drugs
 Return if no improvement in 48 hours
 Consume iron-rich foods
 Use ITNs and other preventive measures
 Follow country guidelines with regard to use of IPTp and
iron/folate during and after treatment of malaria

133
Treating Uncomplicated Malaria (cont.)

 Provide first-line anti-malarial drugs:

 Follow country guidelines
 Manage fever:
 Analgesics, tepid sponging
 Diagnose and treat anemia
 Provide fluids

134
Severe Malaria

Stabilize and refer the woman immediately

if she has any symptoms that suggest
severe malaria.

135
Convulsions or Fits

 If a pregnant woman presents with convulsions, it is

necessary to
determine whether they are due to
malaria or eclampsia
 Gather the following information to determine the cause
of convulsions/fits

136
Determining Causes of Convulsions

Signs/Symptoms Severe Malaria Eclampsia

Recent history of
Yes No
fever, chills
Temperature > 38° C < 38° C
Diastolic < Diastolic >
Blood pressure
90 mm Hg 90 mm Hg
Enlarged spleen Yes No

Jaundice Yes No

137
Treatment of Convulsions

 If eclampsia is suspected, stabilize and treat with

magnesium sulfate per national guidelines and refer
 If severe malaria is suspected, stabilize and treat with
quinine and diazepam or per country guidelines and refer

138
Severe Malaria:
Pre-Referral Treatment
 The risk of death from severe malaria is greatest in the
first 24 hours
 Delaying the start of appropriate antimalarial treatment can
result in worsening of the woman’s condition or even death
 If possible, start treatment immediately and give pregnant
women the full dose of parenteral antimalarials before referral
 First trimester:
 Quinine is the drug of choice, but artesunate is also an option
 Second and third trimesters:
 IM or IV artesunate is the first and artemether the second option
 Rectal administration of artesunate or artemether may be given if
injections are not possible

WHO 2006

139
Referral Preparation

 Explain situation to the client and her family

 Give pre-referral treatment if possible
 Help arrange transport to other facility, if possible
 Accompany the woman during transport, if possible, and be
sure to have sufficient medication available
 Record information on ANC card and clinic record

140
Referral Note

 Include the following information in your

referral note:
 Brief history of client’s condition
 Details of any treatment provided
 Reason for referral
 Any significant findings from history, physical exam or
lab tests
 Highlights of any important details of current pregnancy
 Copy of client’s ANC record, if possible
 Contact information in case the referral facility or provider has any
questions

141
Summary of Main Points

 Uncomplicated malaria can be easily treated if

recognized early, but it is very important to finish the
course of treatment to be effective
 Because severe malaria requires specialized management,
women with severe malaria should be referred
immediately to avoid complications and death

142