Malaria in Pregnancy

Malaria in Pregnancy

Prevention and Control of Malaria in Pregnancy A Workshop for Health Care Providers This publication is adapted from the Prevention and Control of Malaria in Pregnancy Learning Resource Package made possible through support by United States Agency for International Development (USAID) under terms of Award No. HRN-A-00-98-00043-00/Maternal and Neonatal Health Program, and by the Maternal and Child Health Division, Office of Health, Infectious Diseases and Nutrition, Bureau for Global Health, under the terms of the Leader with Associates Cooperative Agreement GHS-A-00-04-00002-00/ACCESS Program. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID or the United States Government. USAID did not contribute to the information in or funding of the 2015 edition or to the 2018 update. 2 Malaria in Pregnancy: Workshop Purpose This workshop is designed to provide

learners with the knowledge and skills they need to prevent, recognize, and treat malaria in pregnancy (MIP) in areas of moderate to high malaria transmission. Antenatal care (ANC) is recommended as the platform for integration of evidencebased services for pregnant women, including services to prevent and treat MIP. 3 MIP: Workshop Purpose (continued) The 2016 WHO recommendations on ANC state, ANC provides a platform for important healthcare functions, including health promotion, screening and diagnosis, and disease prevention. It has been established that by implementing timely and appropriate evidence-based practices,

ANC can save lives. Crucially, ANC also provides the opportunity to communicate with and support women, families and communities at a critical time in the course of a womans life (WHO 2016). They support the WHO 2012 policy recommendation for intermittent preventive treatment of malaria in pregnancy with 4 Workshop Specifics Note to facilitators: Please complete this slide with information about your workshop schedule. Include relevant statistics about MIP in your country and/or region.

5 Introduction: Facts about Malaria Over 3 billion people live in 106 countries and territories that are at risk of malaria transmission (CDC 2016). There were an estimated 214 million cases of malaria worldwide in 2015, which resulted in an estimated 438,000 deaths. 90% of the malaria deaths occur in sub-Saharan Africa (WHO 2015d). Pregnant women and young children are most at risk. Recent data indicate that up to 20% of stillbirths

in 6 Facts about Malaria and Pregnancy 25 million30 million pregnant African women in malarious areas each year are at risk of contracting malaria (Falade et al. 2010; Dellicour et al. 2010). Malaria is more frequent and more complicated during pregnancy. 10,000 maternal deaths occur annually from malaria-related anemia, and many more are likely to be directly or indirectly due to malaria infections (Dellicour et al. 2010).

7 Endemicity: Plasmodium falciparum: global map (2010) Source: Gething, P.W. et al. 2010 8 Facts: Global Response to Malaria Control Roll Back Malaria (RBM) was launched by WHO, UNICEF, the United Nations Development Programme, and the World Bank in 1998 to provide a coordinated global approach to fight malaria. RBM comprises more than 500 partners:

governments, private groups, research organizations, civil society, and media. Vision: By 2015, the malaria-related Millennium Development Goals 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. 9 Global Response to Malaria Control (continued) Priority: Prevent poor outcomes caused by MIP. RBM Summit in Yaound in 2005: Strategic plan was aimed at assisting vulnerable groups. Target: 80% of pregnant women in areas of stable

transmission to receive IPTp by 2010. The US Presidents Malaria Initiative (PMI), also launched in 2005, aims to reduce malaria-related deaths by 50% in 19 high-burden countries. PMI set a target for use of insecticide-treated nets (ITNs) and IPTp by pregnant women at 85%. Free advocacy resources and tools: http://rollbackmalaria.com/ 10 Global Response to Malaria Control (continued) Developed by the RBM Partnership, the first Global Malaria Action Plan for a Malaria-Free World 20082015 was endorsed by world leaders and the malaria community during the 2008

Millennium Development Goals Malaria Summit in New York. It is a valuable advocacy tool, road map for progress, and evidence-based strategy for delivering effective prevention and treatment. Action and Investment to Defeat Malaria 2016 2030 builds on the success of the first Global Malaria Action Plan, serving as both a clarion call and a guide for collective action (WHO 2015a). 11 Global Response to Malaria Control (continued) The Global Technical Strategy for Malaria 20162030 was adopted by the World Health Assembly in May 2015:

Sets the target of reducing global malaria incidence and mortality rates by at least 90% by 2030. Emphasizes the need for universal coverage of core malaria interventions for all populations at risk and highlights the importance of using high-quality surveillance data for decision-making (WHO 2015c). 12 Global Response to Malaria Control (continued) In April 2015, RBMs Global Call to Action to

Increase National Coverage of Intermittent Preventive Treatment of Malaria in Pregnancy for Immediate Impact: By 2030, achieve at least 90% coverage with three or more doses of IPTp in areas of stable malaria transmission for all malaria endemic countries. 13 Global Response to Malaria Control (continued) Transforming Intermittent Preventive Treatment of Malaria in Pregnancy for Optimal Pregnancy, funded by

Unitaid, 20172022: The introduction of IPTp in the early 2000s increased opportunities for pregnant women to protect themselves and their unborn babies from the detrimental consequences of MIP. IPTp uptake has fallen short of set targets in most sub-Saharan African countries. In 2014, a global call to action to increase IPTp uptake was launched and engendered great momentum at global and country levels to reprioritize MIP programming and address 14 shortfalls in IPTp uptake. Prevention and Control of MIP

Module 1: ANC 15 ANC: Module 1 Learning Objectives Define ANC and list the main goals of ANC. Describe WHOs three-pronged approach to MIP. Discuss the timing of ANC contacts. Describe the essential elements of a birth preparedness/complication readiness plan. Describe health system factors to support recordkeeping for ANC. 16

Group Education in ANC Clinic in Ghana Antenatal care: Ghana Photo by: William Brieger/Jhpiego 17 Improving the Experience of ANC: The 2016 WHO Recommendations 18 Background: Revised WHO Recommendations for ANC The purpose of the 2016 WHO

recommendations is to: Place the woman at the center of care. Promote innovative, evidence-based approaches to ANC. Enhance the womans experience of pregnancy and ensure that babies have the best possible start in life. Align with the Sustainable Development Goals to expand care beyond survival, prioritizing

person-centered health and well-being, not only the prevention of death and morbidity. 19 Content of the 2016 WHO Recommendations for ANC Divided into five categories and contains 39 recommendations. Specific recommendations will be cited in this workshop as they pertain to routine ANC and prevention and treatment of MIP.

20 Focused ANC versus Current WHO Recommendations Until the release of the 2016 WHO recommendations for ANC, the most commonly used approach was focused ANC, which centered on a womans needs but relied on fewer visits. The new recommendations call for a minimum of eight contacts during pregnancy to improve perinatal outcomes and maternal satisfaction. Timing of ANC Contacts A minimum of eight

ANC contacts is recommended to reduce perinatal mortality and improve womens experience of care. The word visit is replaced with contact to imply active engagement between the pregnant woman and her health care provider. 22

Settings for ANC Contact can be adapted to local contexts through community outreach programs and lay health worker involvement. 23 Components of ANC The components of ANC include: Risk identification Prevention and management of

pregnancy-related or concurrent diseases Health education and health promotion 24 Risk Identification ANC promotes targeted assessment, during which the health care provider interviews, examines, and tests the woman to determine her risk of developing pregnancyrelated complications and conditions that are common in the population being served. 25

Prevention and Management of PregnancyRelated or Concurrent Diseases The following antenatal complications are major causes of maternal and newborn mortality: Hemorrhage Fetal malposition/malpresentation Pre-eclampsia/eclampsia Sepsis/infection Malaria HIV/AIDS 26 Prevention and Management of PregnancyRelated or Concurrent Diseases (continued) Targeted assessment includes detection of signs and symptoms of pregnancy-related complications (such as placental abruption)

and/or pre-existing diseases (such as diabetes). The health care provider also manages these complications or provides initial management and stabilization, including lifesaving measures as needed. Facilitating management or referral to a higher level of care is an important role of the ANC provider. 27 Health Education and Health Promotion ANC promotes setting aside time during each contact to discuss important health issues. The health care provider should ensure that the woman and her family have the

information they need to make healthy decisions during pregnancy, childbirth, and the postpartum/newborn period, and sufficient guidance in applying that information in their particular situation. 28 Health Education and Health Promotion (continued) Important aspects to include in each ANC contact are:

Healthy eating Care for common discomforts Avoiding use of potentially harmful substances (alcohol and tobacco, and drugs not prescribed by the provider) Handwashing and personal hygiene Physical activity and rest Sexual relations and safer sex Early and exclusive breastfeeding Family planning/healthy timing and spacing of 29

Health Education and Health Promotion (continued) Birth preparedness and complication readiness is an intervention included by WHO as an essential element of the ANC package (WHO 2015d). If a woman is well prepared for normal childbirth and possible complications, she is more likely to receive the timely care from a provider that is needed to protect her overall health, and possibly save her life and the life of her newborn. The birth plan helps to ensure that necessary preparations for normal childbirth are made well in advance of the estimated delivery date. Since every woman and her family must be prepared to

respond appropriately in an emergency, the birth30 Health Education and Health Promotion (continued) Major components of the birth plan include: Choosing a health care provider to attend the birth

Place of birth Transportation for normal birth and in case of emergencies/referrals Funds for normal birth and complications/emergencies Decision-making Support during birth and at home after the birth Identifying a blood donor Items for a clean and safe birth 31 Health Education and Health Promotion (continued) Danger signs in pregnancy

Vaginal bleeding Difficulty breathing Fever Severe abdominal pain Severe headache/blurred vision Convulsions/loss of consciousness Persistent cough, night sweats, blood-tinged

sputum Labor pains/loss of amniotic fluid before 37 weeks 32 Health Promotion Messages Specific to MIP In areas with a malaria risk, pregnant women and their families should receive the following health care, messages, and counseling: IPTp-SP (in areas of moderate to high transmission) works to protect against malaria and its complications. Women should be counseled about the importance of returning for continued ANC contacts. The 20122013 WHO recommendations for pregnant women, including the following: As early as possible during the second trimester (13

weeks and after), give IPTp-SP, three tablets at one time (each tablet contains sulfadoxine 500 mg/pyrimethamine 25 mg), using directly observed therapy. IPTp-SP should be given at each scheduled ANC contact, at least 1 month apart. 33 Health Promotion Messages Specific to MIP (continued) SP can be given on an empty stomach or with food. Folic acid at a daily dose equal to or above 5 mg should not be given with SP because it counteracts SPs efficacy as an antimalarial. A daily dose of iron and folic acid supplementation in pregnant

women at the dose of 3060 mg of elemental iron and 0.4 mg of folic acid is recommended. Combined, the two will help reduce the risk of low-birthweight infants, maternal anemia, and iron deficiency at term. SP should not be administered to women living with HIV who are receiving co-trimoxazole prophylaxis. 34 Health Promotion Messages Specific to MIP (continued) Provide info on ITNs, such as:

Where to find them How to use them effectively How they work Their benefits and safety for the pregnant woman and fetus in malaria risk areas ITNs should be provided to women as early in the pregnancy as possible. Ideally, all women should sleep under ITNs so they are protected even before they become pregnant. 35 Health Promotion Messages Specific to MIP

(continued) Women with suspected malaria must go immediately to a health facility, and compliance with the treatment regime must be ensured (see Appendix B for WHO/USAID/MCSP Implementing Malaria in Pregnancy Programs in the Context of World Health Organization Recommendations on Antenatal Care for a Positive Pregnancy Experience). Malaria prevention: What the woman and her family can do to minimize mosquito bites. 36 Other Vital Components of ANC Prevention of tetanus and anemia:

Tetanus toxoid immunization Daily oral iron and folic acid supplementation with 3060 mg of elemental iron and 0.4 mg of folic acid Preventive treatment for hookworm infection in endemic areas, after the first trimester 37 Other Vital Components of ANC (continued) Prevention of mother-to-child transmission of

HIV (PMTCT): In high-prevalence settings (less than 5% HIV prevalence in the population that is being tested), provider-initiated testing and counseling for HIV should be done routinely in all ANC settings. In low-prevalence settings, provider-initiated testing and counseling can be considered for pregnant women in ANC settings as a key component in the effort to eliminate mother-to-child transmission of HIV.

Integrate HIV testing with syphilis, as relevant to the setting. Strengthen the underlying maternal and child health systems. 38 Other Vital Components of ANC (continued) Many men are uncertain about how they can contribute to a healthy outcome for their partners and their babies. Depending on the womans preference and cultural norms, a man can be encouraged to:

Support and encourage the woman throughout pregnancy. Ensure adequate rest and healthy eating. Provide financial support for normal birth, complications, and care of the newborn. Help the woman make a birth and complication readiness plan. 39 Other Vital Components of ANC (continued)

Encourage the woman to attend the antenatal clinic as early as possible in pregnancy and then as recommended thereafter. Encourage the woman to take her SP under provider supervision. Make sure the woman has an ITN and sleeps under it every night before, during, and after pregnancy. Use condoms consistently and correctly to prevent sexually transmitted infections/HIV. Accompany his partner to the health facility and during childbirth. 40

Scheduling and Timing of Antenatal Contacts Appropriate scheduling depends on the womans gestational age and individual needs. For women whose pregnancies are progressing normally, WHO now recommends a minimum of eight ANC contacts (WHO 2016c). 41 Scheduling and Timing of Antenatal Contacts (continued) These contacts may take place at or around the times listed:

First contact: Ideally, this contact should take place in the first trimester (by 12 weeks). Second and third contacts: Two contacts should take place in the second trimester, ideally at 20 and 26 weeks. Fourth through eighth contacts: These should take place at about 30, 34, 36, 38, and 40 weeks. If the woman has not given birth by 41 weeks, she should be referred for delivery.

42 Scheduling and Timing of Antenatal Contacts (continued) WHO recommends that, in areas of moderate to high malaria transmission in Africa, IPTp-SP should be given to all pregnant women at each scheduled ANC contact, starting as early as possible in the second trimester, provided that the doses of SP are given at least 1 month apart. WHO recommends a package of interventions for preventing MIP, which includes promotion of ITNs and IPTp-SP. To ensure that pregnant women in endemic areas start SP as early as possible in the second trimester, policymakers should ensure health system contact with women at 13 weeks

43 gestation. Nigerian Federal Ministry of Health Poster Example of one countrys plan: Three ways to prevent malaria during pregnancy: 1. 2. 3. ITNs IPTp-SP Case management,

for women with malaria symptoms Photo courtesy of Nigeria Federal Ministry of Health 44 Scheduling and Timing of Antenatal Contacts (continued) Please see the reference manual, Table 1. 2016 ANC contact schedule with timelines for implementation of malaria in pregnancy interventions for thorough review of the eight recommended ANC contacts and MIP-related interventions.

45 Scheduling and Timing of Antenatal Contacts (continued) The period between 13 and 20 weeks is a critical period for irreversible negative consequences of MIP, when parasite densities are highest and major benefit can be achieved from malaria prevention. For effective MIP programming, a contact with the provider early during the second trimester (between 13 and 16 weeks) is critical to ensuring timely access to the first dose of IPTp-SP for maximal impact. While the practice in many countries is to give the first dose of

IPTp-SP at quickening (womans first awareness of fetal movement), this can leave the pregnant woman and fetus unprotected for several weeks, depending on variations in womens perception of quickening 46 (WHO 2017). Scheduling and Timing of Antenatal Contacts (continued) A Toolkit to Improve Early and Sustained Intermittent Preventive Treatment in Pregnancy (IPTp) Uptake has been developed to assist providers in assessing gestational age in the second trimester (USAID and MCSP 2017). An important component of the toolkit is the

job aid, Prevention of Malaria during Pregnancy: Administer IPTp-SP Starting at 13 Weeks, which can be found in Appendix B of the reference manual. 47 Scheduling and Timing of Antenatal Contacts (continued) Also see the reference manual, Table 2. Components of antenatal care contacts (for pregnant women in moderate- to high-transmission areas), for a full description of ANC interventions by trimester and ANC contact. 48

Recordkeeping for Antenatal Contacts and Malaria Prevention Activities The following are necessary: Adequate monitoring of the womans condition Continuity of care Effective communication among health care providers and among health care sites (if referred) 49 Recordkeeping 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 contact. Ensures that information is accurate and clearly written. Woman:

Should be encouraged to keep her ANC card or booklet in a safe place. She should bring it to every contact and to the facility for labor and birth. 50 Recordkeeping Procedure Record all information on the ANC card and clinic card: First ANC contact:

History Physical examination Testing/screening as appropriate (e.g., malaria, HIV, TB) Provision of care, including IPTp, tetanus toxoid, and iron/folate Discussion of health messages, including birth plan, malaria prevention (use of ITNs), and danger signs 51 Recordkeeping Procedure (continued)

Subsequent ANC contacts: Interim history Targeted physical examination, testing Provision of care, including IPTp-SP, if appropriate Discussion of health messages (including review/revision of birth plan) Counseling/testing for HIV, if not done previously or if woman requests it

Date set for next ANC contact 52 Maintaining antenatal care records in Nigeria Photo by: William Brieger/Jhpiego 53 Respectful Maternity Care One of the major reasons that women do not attend ANC or give birth in facilities is the perceived lack of respectful treatment by providers. The White Ribbon Alliance worked with global organizations to formulate the Respectful Maternity Care: Universal Rights of

Childbearing Women (2011) charter, which includes: Freedom from harm Right to information, informed consent and refusal, and respect for choices and preferences, including companionship during maternity care 54 Respectful Maternity Care (continued)

Dignity, respect Equality, freedom from discrimination, and equitable care Right to timely health care and to the highest attainable level of health Liberty, autonomy, self-determination, and freedom from coercion 55 Respectful Maternity Care (continued) Respectful maternity care considers the woman to be an

active participant in her health, with rights and values that must be respected. It applies to assistance by a provider throughout the continuum of care, from ANC to labor, birth, and postnatal care. It includes the recognition of womens preferences and needs. Active steps must be taken to ensure and monitor for respectful maternity care, prevent disrespect and abuse, and take action to address them if they occur, ideally through facility-based quality improvement approaches. For further information on quality improvement, please refer to the WHOs Standards for Improving Quality of 56 Maternal and Newborn Care in Health Facilities. Respectful Maternity Care (continued)

Part of respectful maternity care is the use of positive interpersonal communication skills during every encounter with clients, including: Ensuring auditory and visual privacy during the ANC contact Speaking in a quiet, gentle tone of voice, using easily understood terms and language Listening to the woman/family and responding appropriately (active listening) Encouraging them to ask questions and

express concerns 57 Respectful Maternity Care (continued) Allowing them to demonstrate understanding of information provided Observing for unusual signs Explaining all procedures/actions and obtaining

permission before proceeding Showing respect for cultural beliefs and social norms Being empathetic and nonjudgmental Avoiding distractions while conducting the contact Thanking the client and reminding her when to come again 58 Respectful Maternity Care (continued) Remember: Respectful care is a lifesaving skill. The treatment of and care for each

client should result in her choosing to return to your facility Pregnant woman riding on bicycle to antenatal care contact. for care whenever Photo by: Peter Chisambiro needed. 59 Prevention and Control of Malaria in Pregnancy Module 2: Malaria Transmission 60 Malaria Transmission: Module 2 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, their unborn babies, and the community. Describe the effects of malaria on pregnant women living with HIV/AIDS. Discuss integration of MIP and PMTCT services into ANC. 61 Malaria Transmission: Background Caused by Plasmodium parasites: Plasmodium falciparum:

These are the most common type in much of Africa. Causes the most severe disease. Plasmodium vivax Plasmodium ovale Plasmodium malariae Plasmodium knowlesi (occurs naturally in

monkeys in Southeast Asia but is now known to cause disease in humans) 62 Malaria Transmission: Background (continued) Malaria is spread by female Anopheles mosquitoes infected with parasites. Anopheles mosquitoes are usually active at night. Malaria parasites reproduce in human blood. A mosquito bites an infected person, is infected with parasites, and then goes on to bite and infect another person. 63

Anopheles Mosquito Anopheles mosquitoes differ from other mosquitoes in the way their body is positioned. The body of the Anopheles mosquito points up in the air in one line, but the body of other mosquitoes is bent, and the rear end points down. Source: WHO 2004C. 64 Factors Affecting Transmission

Breeding sites Type of vector Parasites Climate Population 65 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 Holes in tree trunks

66 Types of Vector The principal vector is the Anopheles mosquito. Different Anopheles species exist in different parts of the world. Some Anopheles species are more efficient in transmitting malaria than others. 67 Parasites and Climate Enough parasites must exist in the human population to infect the mosquito.

The environmental temperature must average at least 1820C and humidity must stay above 60% for the mosquito to survive and the parasite to develop. The warmer the weather, the faster the development of the parasite. 68 Population In Africa, Anopheles mosquitoes do not fly farther than about 12 km from their breeding sites unless they are aided by wind. People must be near or within a short distance of these breeding sites to be

bitten by the infected mosquito. 69 Populations Most Affected by Malaria Pregnant women: Are more likely than nonpregnant women to become infected and develop signs and symptoms. Women in first or second pregnancies are more at risk. Children under 5 years of age:

About 90% of malaria deaths occur in Africa, and the majority are among children under 5 years old (WHO 2014b). Unborn babies Immigrants from low-transmission areas HIV-infected people 70 Transmission Levels: Stable Transmission Areas Stable transmission areas are places where populations are continuously exposed to a fairly constant rate of malaria infection. Immunity develops 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 if someone moves out of the hightransmission area for a long time. Pregnant women and children in areas of stable transmission have the highest risk of becoming ill from malaria. 71 Stable Transmission Possible outcomes of a malaria infection A small proportion develop signs and symptoms A large proportion are immune and have no signs

and symptoms Disease with signs and symptoms Asymptomatic infection Severe disease Placental sequestration Altered placental integrity Spontaneou s abortion

Adapted from WHO 2004c. Maternal and fetal death Anemia Less nutrient transport Low birthweight Maternal morbidity Higher infant

mortality 72 Transmission Levels: Unstable Transmission Areas Population is not exposed to malaria very often. Malaria is sometimes seasonal (e.g., rainy season). Population develops little or no immunity. Children and adults, including pregnant and nonpregnant women, are all equally susceptible to malaria. 73

Transmission Levels: Unstable Transmission Areas (continued) MIP can be very serious, and complications may occur in a short time. Pregnant women usually present with fever, clinical signs or symptoms, and sometimes severe malaria, which is life threatening. Common outcomes of malaria infection in unstable areas include:

Abortion Stillbirth 74 Unstable Transmission Acquired immunity: low or none Clinical illness Severe disease Risk to mother All pregnancies are at risk. Key intervention strategies: disease

recognition and case management Risk to fetus Source: WHO 2004. 75 Transmission Levels: Mixed Transmission Areas Different levels of transmission can occur within a country or region. Within a malarious region (such as southern Africa), there can also be malaria-free areas.

Factors affecting transmission include temperature, humidity, and altitude. The life span of the mosquito is increased with high humidity, while cold weather (below 16C) slows the development of the malaria parasite. 76 Effects of Malaria on Pregnant Women All pregnant women in malaria-endemic areas are at risk. The placenta becomes susceptible to malaria infection at the end of the first trimester (Walker et al. 2014). Parasites attack and destroy red blood cells.

Malaria causes up to 25% of anemia in pregnancy (Schantz-Dunn and Nour 2009). Malaria can cause severe anemia. In Africa, malaria-related anemia causes up to 10,000 maternal deaths per year (ALMA 2009). 77 Effects of Malaria on Pregnant Women (continued) Approximately 11% of newborn deaths in malariaendemic African countries are due to low birthweight resulting from P. falciparum infections during pregnancy. Effects range from mild to severe, depending on the level of malaria transmission in a particular setting

and the pregnant womans 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 a womans immune response during pregnancy 78 Co-Infections: HIV/AIDS during Pregnancy Reduces a womans resistance to malaria. Causes malaria treatment to be less effective.

Increases: Risk of malaria-related problems in pregnancy Likelihood of developing clinical malaria and death Risk of intrauterine growth restriction Risk of preterm birth Risk of maternal anemia 79

Co-Infections: HIV/AIDS during Pregnancy (continued) Pregnant women who are co-infected with HIV/AIDS 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 birthweight and die during infancy. 80 Integration of MIP and PMTCT Services into ANC Collaboration between reproductive health programs and HIV/AIDS and malaria control programs is essential so that prevention and

treatment of malaria and HIV/AIDS occur at every ANC contact. Appropriate diagnostic tools for diseases and for antiretrovirals and antimalarial medications should be available at all levels of the health care system. Additional research on interactions between antiretroviral and antimalarial drugs is urgently needed. 81 Integrating Malaria and HIV Services: WHO Recommendations Protection by ITNs is a high priority.

Ensure that HIV-infected women who are also at risk for malaria receive IPTp-SP as early as possible in the second trimester, if they are not already taking cotrimoxazole prophylaxis. Do not give SP to clients on daily co-trimoxazole. In adults living with HIV/AIDS, daily prophylaxis with co-trimoxazole has shown promise in preventing some infections, including malaria (Anglar et al. 1999; Suthar et al. 2012). Some programs are already using this approach. 82 Integrating Malaria and HIV Services: WHO

Recommendations (continued) Reproductive health programs should collaborate with HIV/AIDS and malaria control programs to ensure an integrated service delivery plan. Must ensure harmonization of national policies, guidelines, and training materials to avoid provider confusion and support coordinated implementation of services. Counsel and give care directed at preventing and treating HIV/AIDS and malaria. Appropriate diagnostic tools for both diseases, and antiretrovirals and antimalarials, should be

available at all levels of health care system. 83 Follow country guidelines. HIV/AIDS and Infant Feeding In 2016, WHO released Guideline: Updates on HIV and Infant Feeding (WHO 2016b), which includes the following recommendations: Women living with HIV/AIDS should breastfeed for at least 12 months and may continue breastfeeding for up to 24 months or longer (similar to the general population) while being fully supported for antiretroviral therapy adherence (see the WHO Consolidated Guidelines on the Use of Antiretroviral

Drugs for Treating and Preventing HIV Infection [WHO 2016a]). 84 HIV/AIDS and Infant Feeding (continued) In settings where health services provide and support lifelong antiretroviral therapy, including adherence counseling, and promote and support breastfeeding among women living with HIV/AIDS, the duration of breastfeeding should not be restricted. Women known to be living with HIV/AIDS (and whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first 6 months of life, introducing

appropriate complementary foods thereafter and continuing breastfeeding. Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided. 85 HIV/AIDS and Infant Feeding (continued) National and local health authorities should actively coordinate and implement services in health facilities and activities in workplaces,

communities, and homes to protect, promote, and support breastfeeding among women living with HIV/AIDS. Health care providers and women living with HIV can be reassured that antiretroviral therapy reduces the risk of postnatal HIV transmission in the context of mixed feeding. Although exclusive breastfeeding is recommended, practicing mixed feeding is not a reason to stop breastfeeding in the presence86 of antiretroviral drugs. HIV/AIDS and Infant Feeding (continued) Women who are not HIV-infected or whose HIV status is unknown should be:

Counseled to exclusively breastfeed their infants for the first 6 months. Counseled to introduce complementary foods while continuing breastfeeding for 24 months or beyond. Offered HIV testing if their HIV status is unknown. Counseled about ways to prevent HIV infection and about available services, such as family planning. In addition, health messages should be delivered

to the general population so optimal breastfeeding information is understood (WHO 87 2010a). Other Conditions in Pregnancy: Sickle Cell Trait According to the Centers for Disease Control and Preventions birth cohort studies, sickle cell trait provides 60% protection against overall mortality from malaria. Most of this protection occurs between the ages of 2 and 16 months, before the onset of clinical immunity in areas with intense transmission of malaria. Despite the fact that they have protection, it is still important for those with sickle cell trait to take IPTp-SP and use ITNs and other preventive

measures, such as indoor residual spraying (IRS), for malaria transmission control (World Health Assembly 2006). 88 Sickle Cell Disease People with sickle cell disease have two abnormal hemoglobin genes in their red blood cells. In general, women with sickle cell disease are at higher risk of pregnancy complications. Pregnancy can worsen sickle cell disease, and sickle cell disease can worsen pregnancy outcomes. Daily folic acid supplementation (with 1 mg or 5 mg orally) is often prescribed for women

with sickle cell disease before and during pregnancy to help them replenish stores lost 89 due to the hemolysis (destruction of red blood Sickle Cell Disease (continued) Unfortunately, global consensus does not exist regarding the optimal regimen for malaria prophylaxis or folic acid supplementation for pregnant women living with sickle cell disease in areas with moderate to high malaria transmission due to a lack of research evidence. Women with sickle cell disease must be encouraged to sleep under a long-lasting insecticide-treated net (LLIN) every night. As they are at higher risk of pregnancy complications,

efforts should be made to help them access specialty care in obstetrics and hematology, as available, so that specialists can make clinical decisions that consider the individual womans 90 Effects of Malaria on Fetus During pregnancy, malaria parasites hide in the placenta. This interferes with the transfer of oxygen and nutrients to the fetus, increasing the risk of:

Spontaneous abortion Preterm birth Low birthweightthe single greatest risk factor for death during the first month of life Stillbirth 91 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 and

affecting future productivity. Uses scarce resources. Puts strain on financial resources (treatment is more costly than prevention). Cost of drugs can be a burden on the community. Causes preventable deaths, especially among children and pregnant women. 92 Summary: Malaria Transmission Malaria is transmitted through female Anopheles mosquito bites. Pregnant women and children are particularly at risk of malaria. Adolescents are at higher risk of MIP. Pregnant women in malaria-endemic areas

infected with malaria may have no symptoms. Women living with HIV have a higher risk of malaria infection. Malaria can lead to severe anemia, spontaneous abortion, and low-birthweight newborns. Malaria is preventable and treatable. 93 Prevention and Control of Malaria in Pregnancy Module 3: Malaria Prevention 94 Malaria Prevention: Module 3 Objectives Describe the three-pronged approach to malaria prevention

and control according to the WHOs current MIP strategy (WHO 2013c). List the elements of counseling women about the use of ITNsspecifically LLINsfor IPTp and other means of malaria prevention. Describe the use of sulfadoxine-pyrimethamine (SP) for IPTp, including dosage, timing, and contraindications. Discuss IRS and other ways to prevent malaria. Assist the pregnant woman with preparing a birth preparedness and complication readiness plan. 95 WHO/AFRO Malaria Prevention Strategy Designed to be appropriate for most African settings, with guidance on adapting it to local

situations. Based on that fact that most sub-Saharan Africans live in areas of stable transmission. 96 WHO: Three-Pronged Approach ITNs IPTp-SP Confirmation of malaria and case management of malaria illness and anemia 97 Evidence for WHOs Three-Pronged Approach A meta-analysis of national survey datasets showed

exposure to IPTp-SP and ITNs to be associated with reductions of newborn mortality and low birthweight under routine program conditions (Eisele et al. 2012). The protective role of IPTp-SP in reducing newborn mortality under trial conditions and costeffectiveness of IPTp during routine ANC services have been demonstrated (Menendez et al. 2010; Sicuri et al. 2010). These studies highlight the critical importance of continuing IPTp and ITN use among pregnant women to prevent the adverse consequences of MIP. 98 Module Section 3.1 ITNs

99 Mother receiving insecticide-treated net in Angola Photo by: William Brieger/Jhpiego 100 ITNs ITNs, specifically LLINs, are very effective. Mosquitos generally bite at night, when people are asleep. ITNs reduce human contact with mosquitoes by:

Killing mosquitoes that land on the net Repelling them, thus driving them away from where people are sleeping 101 ITNs (continued) Prevent physical contact with mosquitoes. Kill or repel other insects:

Lice Ticks Bedbugs 102 Antenatal care nurse with an insecticide-treated net in Mozambique Photo by: William Brieger/Jhpiego 103 ITNs versus Untreated Nets ITNs

Untreated Nets Provide a high level of protection against malaria. Kill or repel mosquitoes that touch the net. Reduce number of mosquitoes inside and outside the net. Kill other insects, such as lice and bedbugs. Are safe for pregnant women, young children, and infants. Provide some protection

against malaria. Do not kill or repel mosquitoes that touch the net. Do not reduce the number of mosquitoes. Do not kill other insects, such as lice and bedbugs. Are safe for pregnant women, young children, and infants. 104 Mother and infant using a bed net in Akwa Ibom State, Nigeria

Photo by: William Brieger/Jhpiego 105 Benefits of ITNs Prevent mosquito bites. Protect against malaria, resulting in less: Anemia (maternal and newborn) Premature and low-birthweight infants Risk of maternal and newborn death Help people sleep better.

Promote growth and development of fetus and newborn. 106 Community Benefits of ITNs Cost less than treating malaria. Reduce the number of people getting sick (children and adults). Help children grow to be healthy and help working adults remain productive. Reduce number of deaths. 107

Where to Find ITNs ANC clinics General merchandise shops Drug shops/pharmacies Markets Public and private health facilities Community health workers

Nongovernmental organizations and community-based organizations 108 How to Use ITNs Hang net above bed or sleeping mat. Tuck edges under mattress or mat. Use every night, all year long. Use for everyone, if possible, but give priority to pregnant women, infants, and children.

109 ITNs ITN tucked under a bed ITN tucked under a mat 110 Caring for ITNs Handle net gently to avoid tears. Tie net up during day to avoid damage. Inspect regularly for holes and repair any holes found.

Retreat nets regularly if they are not longlasting so they will stay effective (retreating methods available on WHO website). Keep away from smoke, fire, and direct sunlight. The demand for LLINs has increased rapidly, from 5.6 million in 2004 to 145 million in 2010 (in sub-Saharan 111 Africa). LLINs A pre-treated, ready-to-use net that lasts between 3 and 5 years (depending on type) and does not require retreatment during that time Compared to regular ITNs, LLINs:

Usually have a one-time cost. Do not require additional treatments for 3 to 5 years. Save money because there are fewer additional costs associated with retreatment, retreatment campaigns, and additional insecticides. 112 LLINs (continued) Some studies have shown that for many reasons, LLINs may not last for the intended 3 to 5 years.

WHO thus recommends that each country conduct its own study to assess net attrition and physical integrity to better plan campaigns to resupply nets (WHO 2013b). 113 Module Section 3.2 IPTp-SP 114 ANC provision of IPTp-SP by DOT in Senegal

Photo by: Karim Seck/Jhpiego 115 IPTp-SP IPTp-SP is 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 might not have symptoms, malaria could nevertheless affect her and her fetus. Placental infection can begin by the end of the first trimester. Preventing parasites from attacking the placenta helps

the fetus develop normally and prevents low 116 birthweight. Expected Benefits of IPTp-SP per WHO Policy Brief on IPTp-SP (2013c) IPTp-SP prevents the adverse consequences of malaria on maternal and fetal outcomes, such as placental infection, clinical malaria, maternal anemia, fetal anemia, low birthweight, and newborn mortality. IPTp-SP has recently been shown to be highly costeffective for prevention of maternal malaria and reduction of newborn mortality in areas with moderate or high malaria transmission. Despite the spread of SP resistance, IPTp-SP continues to provide significant benefit, resulting in

protection against both newborn mortality (protective efficacy: 18%) and low birthweight (21% reduction) under routine program conditions. 117 Expected Benefits of IPTp-SP (continued) A recent study by Chico et al. (2017) found that pregnant women who received two or more doses of IPTp-SP were protected not only from adverse outcomes related to malaria but also some sexually transmitted/reproductive tract infections. 118

SP Resistance and IPTp-SP Evidence shows that SP prevents consequences of malaria in pregnant women who have already had a number of malaria infections and thus a certain level of immunity. It is thought that SP primarily works through a prophylactic effect. Recent evidence also demonstrates that SP is associated with higher mean birthweight and fewer low-birthweight births across a wide range of SP resistance levels. Even in areas where a high proportion of P. falciparum parasites carry these quintuple mutations, IPTp-SP remains effective in preventing the adverse consequences of malaria on maternal and fetal outcomes (WHO 2013c).

119 Past Recommendations for IPTp-SP: Dose and Timing (WHO 2004) PREVIOUSLY All pregnant women were given at least two doses of SP during focused ANC visits, at least 1 month apart. The first dose was given no earlier than 16 weeks of pregnancy (or quickening). The recommended dose was and remains three tablets via directly observed therapy. 120 Current Recommendations for IPT-SP: Dose

and Timing (WHO 2013c) CURRENTLY As early as possible during the second trimester, all pregnant women are given IPTpSP (500 mg/25 mg), three tablets at one time via directly observed therapy. IPTp-SP should be given at each scheduled contact, at least 1 month apart, and only after

the first trimester. The last dose of IPTp-SP can be administered until the time of delivery without safety concerns. SP can be given on an empty stomach or with 121 food. Giving IPTp-SP in Mozambique Photo by: William Brieger/Jhpiego 122 Before Giving IPTp-SP Ensure that the woman is in the second trimester of

pregnancy (at least 13 weeks pregnant). Inquire about her use of SP within the last month (4 weeks). Ensure that she is not on co-trimoxazole or taking other sulfa drugs. Counsel that if she takes high doses of folic acid* ( 5 mg), she should suspend the folic acid for at least 2 weeks after each SP dose. Inquire about allergic reactions to SP or other sulfa drugs (especially severe rashes). Explain what you will do and address the womans questions. Provide a cup and clean water. * WHO recommends folic acid at a dose of 0.4 mg daily during 123 pregnancy.

Instructions for Giving IPTp-SP Directly observe the woman swallow three tablets of SP. Record the SP dose on ANC and clinic cards as directly observed therapy. Record the SP dose (IPTp-SP1, IPTp-SP2, IPTp-SP3, etc.) in the appropriate registers. Advise the woman to return: For her next scheduled contact If she has signs of malaria If she has other danger signs

Reinforce the importance of using ITNs yearround. 124 IPTp: Contraindications to SP Do not give SP during the first trimester. Be sure the woman is at least 13 weeks pregnant. Do not give SP to women with a reported allergy to SP or other sulfa drugs. Ask about sulfa drug allergies before giving SP. Do not give SP 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

125 IPTp-SP and Folic Acid WHO recommends folic acid at a dose of 0.4 mg daily during pregnancy (WHO 2013c). Some evidence suggests that high doses ( 5 mg) of folate supplementation may reduce the effectiveness of SP for treatment of malaria (Ouma et al. 2006; WHO 2013c). Use of recommended folic acid doses (0.4 mg) does not seem to reduce SP effectiveness. If folic acid doses 5 mg are used, instruct pregnant women not to take folic acid for at least 2 weeks (14 days) after receiving SP. Providers should understand and follow local

126 Determining Gestational Age The recent WHO policy on administration of IPTp-SP at 13 weeks of pregnancy may present a challenge to providers who are not accustomed to confirming early secondtrimester gestation. The following information can serve as a review. 127 Determining Gestational Age (continued) Take a history.

Ask about regularity of menstrual periods, current breastfeeding, and current or past use of contraception. Ask about the date of the first day of the last menstrual period and use a pregnancy wheel or calendar to determine weeks of pregnancy. Ask whether quickening has occurred. If it has, the woman is probably in the second trimester. If she has not noted fetal movement, she is still a candidate for IPTp-SP, if other findings

confirm that she is at least 13 weeks pregnant. Information obtained from the history must be 128 correlated with findings from the physical Determining Gestational Age (continued) Perform an abdominal exam. In the first trimester, the uterus grows from the size of a lemon to the size of a large orange

and cannot be palpated abdominally above the symphysis pubis. In the second trimester, the uterus grows to the size of a large mango or grapefruit and can be palpated abdominally about three fingerbreadths above the symphysis pubis. To palpate the uterus, make sure the woman has emptied her bladder. Explain what will be done (and why) before conducting the exam. 129 Determining Gestational Age (continued)

Ask her to lie on her back with support under her head, bend her knees, and keep her feet flat on the bed or exam table. Using a firm but gentle touch, place fingers on the pubic bone and walk them up the center of the abdomen until the top of her uterus (fundus) is palpated; it will feel like a hard ball. A uterine fundus palpated about three fingerbreadths above the pubic bone is compatible with pregnancy in the second trimester. 130

Determining Gestational Age (continued) Uterine size at 13 weeks on abdominal palpation (about two to three fingerbreadths above the symphysis pubis) 131 Determining Gestational Age (continued) Use other means of determining gestational age early in pregnancy.

Pregnancy tests, if available and affordable, can confirm pregnancy and be correlated with information from the history and physical exam. Ultrasound can be superior to dating by last menstrual period or physical examination, depending on clinical circumstances, but dating precision decreases with gestational age. WHO now recommends one obstetric ultrasound scan before 24 weeks gestation to 132 estimate gestational age and to identify Module Section 3.3

Health Education for Additional Prevention Methods 133 IRS The main purpose is to lower malaria transmission by reducing survival of mosquitoes entering houses or sleeping areas. IRS is an effective intervention when the following conditions are met: Adequate commitment and social acceptance Enough health system capacity to deliver quality, welltimed coverage to at least 80% of dwellings

Credible information about local vectors, especially their insecticide susceptibility, as well as indoor versus outdoor feeding and resting behaviors Providers should keep up to date about local IRS programs 134 More 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. This is 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. 135 Summary: Malaria Prevention There are many ways of preventing bites and reducing mosquito

breeding sites. Sleep inside ITNs (with edges tucked under mat or bedding). Where available, LLINs are preferable because they last longer and do not require continuous retreatment. Use of IPTp-SP prevents parasites from attacking the placenta. IPTp-SP helps prevent malaria and reduces the incidence of maternal anemia, spontaneous abortions, preterm birth, stillbirth, and low birthweight. IRS programs can be effective in reducing the number of mosquitoes that transmit malaria. They are not a replacement for ITNs and IPTp-SP, but they support and 136 enhance these efforts.

Prevention and Control of Malaria in Pregnancy Module 4: Diagnosis and Treatment of Malaria 137 Malaria Diagnosis and Treatment: Module 4 Objectives Explain why self-diagnosis and 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

MIP. Describe the treatment for uncomplicated MIP. Explain the steps to appropriately refer a pregnant woman who has severe malaria. 138 Malaria Diagnosis Usually based on the patients signs and symptoms, clinical history, physical examination, and laboratory confirmation of the malaria parasite, if available Prompt and accurate diagnosis leads to:

Improved differential diagnosis of febrile illness Improved management of nonmalarial illness Effective case management of malaria 139 Self-Diagnosis Clients who experience symptoms often rely on self-diagnosis and treatment. Because symptoms are similar to those of several other common ailments, misdiagnosis is possible. Prevalence of asymptomatic infections makes

self-diagnosis even more complex. Clients might take the wrong medicines, or might take the right medicines but not in the proper dosage or 140 Self-Diagnosis and Treatment If a client has self-treated and presents with malaria symptoms, or she reports that symptoms have worsened or recurred, it is possible that she: Has self-treated with the wrong drug or dosage. Has not completed the treatment. Has 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).

Does not have malaria. Often, clients can purchase drugswithout a prescription or verification of diagnosisat pharmacies, local shops, roadside kiosks, and other easily accessible locations. 141 Module Section 4.1 Diagnostic Tools and Testing 142 Diagnostic Testing: Advantages Parasitological diagnosis has several major

advantages, including: Prevention of wastage of drugs through unnecessary treatment, resulting in cost savings Improvement of care in parasite-positive patients due to greater certainty of malaria diagnosis Prevention of unnecessary exposure to malaria drugs

Confirmation of treatment failure 143 Methods: Diagnostic Testing The two methods of diagnostic testing for malaria are light microscopy and rapid diagnostic testing. After a woman presents with malaria symptoms and is tested, results should be available within a short time (less than 2 hours). If diagnostic testing is not possible, women must be treated on the basis of clinical diagnosis, but every effort should be made to conduct confirmatory testing. Source: WHO 2015d

144 Diagnostic Testing: Microscopy Microscopic examination: Remains the gold standard for laboratory confirmation of malaria. Involves examination of the clients blood, spread out as a thick or thin blood smear on a microscopic slide. Confirms the presence of malaria parasites and therefore the diagnosis of malaria. Is also useful when a client has vague symptoms. 145

Thin Film Is often preferred for routine examination of parasites. Makes organisms easier to see so the type of parasite can be identified. Is inadequate for detecting low parasite density. This Giemsa-stained slide depicts an example of properly prepared thick and thin film blood smears to be examined. Source: Courtesy of CDC Public Health Image Library: http://phil.cdc.gov/phil/home.asp 146 Thick Film

Concentrates the layers of red blood cells on the slide, using about two to three times more blood than the thin film. Is better than the thin film in detecting low levels of parasites, and estimating parasite density and reappearance of circulating parasites during relapses. Requires experienced technician because scanning for parasites among white blood cells and platelets can be difficult. 147 Rapid Diagnostic Testing

Developed to provide quick, accurate, and accessible malaria diagnosis without the need for laboratory facilities. Successful rapid diagnostic testing programs require: A cool chain for transport and storage Training for providers A clear policy on actions to take based on test results 148

Maintaining a Cool Chain Storage between 2C and 30C is recommended by rapid diagnostic test (RDT) manufacturers. Expiry dates are generally set according to these conditions. If storage temperatures exceed the recommended limits, it is likely that the shelf life of the RDTs will be reduced and sensitivity lost before the expiration date. 149 Maintaining a Cool Chain (continued) The cool chain starts before shipping from the manufacturer.

The shipper or air carrier is notified of temperature storage requirements, which are clearly marked on cartons and documents. Ground transportation: Attention must be given to outside temperatures while the vehicle is moving and parked during all stages of delivery. Storage:

Storage of RDTs at any stage before they reach the final destination should conform to manufacturersspecifications, which are usually 30C. 150 Indications for Diagnostic Testing For pregnant women, a parasitological diagnosis is recommended before 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.

Diagnostic testing is also used 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. Remember that counterfeit or poor-quality drugs may also cause treatment failure. 151 Module Section 4.2

Clinical Diagnosis 152 Types of Malaria Uncomplicated: Most common Severe: Life-threatening; can affect the brain Pregnant women more likely to get severe

malaria than nonpregnant women 153 Clinical Signs and Symptoms A diagnosis of malaria is based on the patient's symptoms and on physical findings at examination. First symptoms of malaria and physical findings often are not specific and are common to other diseases. 154 Uncomplicated Malaria: Signs and Symptoms The signs and symptoms of malaria are

nonspecific. Malaria is suspected clinically primarily on the basis of fever or a history of fever ( 37.5C axillary); anemia may also be present. There is no combination of signs or symptoms that reliably distinguishes malaria from other causes of fever. A diagnosis based only on clinical features has very low specificity and can result in overtreatment. 155 Severe Malaria: Diagnosis 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 must be confirmed by a laboratory test. 156 Severe Malaria: Signs and Symptoms One or more of the following clinical features in the presence of malaria parasitemia or positive RDT: Impaired consciousness/coma Prostration/generalized weakness Multiple convulsions (more than two in 24 hours) Deep breathing/respiratory distress Acute pulmonary edema Shock (systolic blood pressure < 80 mmHg) Acute kidney injury Clinical jaundice, evidence of other vital organ dysfunction

Significant bleeding 157 Pre-Referral Treatment for Severe Malaria in Pregnant Women Administer loading dose of appropriate antimalarial drug and refer the woman immediately if you suspect anything other than uncomplicated malaria. 158 Recommendations for Clinical Diagnosis

WHOs 2015 recommendations for clinical diagnosis/suspicion of uncomplicated malaria in different epidemiological settings: In malaria-endemic areas, malaria should be suspected in any patient presenting with a history of fever or temperature 37.5C and no other obvious cause. In settings where the incidence of malaria is very low, parasitological diagnosis of all cases of fever may result in considerable expenditure to detect only a few patients with malaria. Thus, patients should be identified who may have been exposed to malaria (e.g., have recently traveled to a malaria-endemic area without protective measures) and have fever or a history of fever with no other obvious cause before a parasitological test is conducted. 159

Recommendations for Clinical Diagnosis (continued) Signs and symptoms of malaria are nonspecific. Making a judgment or diagnosis based on clinical features alone has very low specificity, resulting in overtreatment for many. Other possible causes of fever and the need for alternative or additional treatment must be carefully considered. In all settings, clinical suspicion of malaria should be confirmed with a parasitological diagnosis. In settings where parasitological diagnosis is not possible, the decision to provide antimalarial treatment must be based on the prior probability of the illness being malaria. 160

Module Section 4.3 Caution: Presumptive Treatment 161 Definition: Presumptive Treatment (for Clients) Patients who suffer from a fever without an 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. 162

Problems: Presumptive Treatment In settings where parasitological diagnosis is not possible, a decision to provide antimalarial treatment must be based on the probability that the illness is malaria. Presumptive treatment can lead to incorrect diagnoses and unnecessary use of antimalarial drugs. Results in additional expense and increases the risk of selecting for drug-resistant parasites. For children and pregnant women, it may be

the best option when diagnostic testing is not 163 available. Fever during Pregnancy Temperature 37.5C axillary May be caused by malaria or: Bladder or kidney infection Pneumonia Typhoid, dengue fever, or yellow fever

Uterine infection Viral illnesses Careful history and a physical exam are needed to rule out other causes. 164 Fever during Pregnancy (continued) Ask the woman about or examine her for: Type, duration, and degree of fever Whether she has or has had:

Chills or rigors Episodes of a spiking fever Fits or convulsions Temperature, blood pressure, pulse, and respiration 165 Fever during Pregnancy: Other Things to Ask About Signs of severe malaria Signs of other infections: Chest pain/difficulty breathing Foul-smelling, watery vaginal discharge Tender/painful uterus or abdomen

Urinary frequency/urgency/pain on urination/flank pain Any fluid leaking from vagina/rupture of membranes Headache Muscle/joint pain Dry or productive cough Other danger signs 166

Recognizing Malaria in Pregnant Women Uncomplicated Malaria Signs and symptoms are nonspecific but can include fever 37.5C axillary, history of fever, and/or presence of anemia. Severe Malaria One or more of the following along with the presence of malaria parasitemia: Impaired consciousness/coma

Prostration/generalized weakness Multiple convulsions (more than two in 24 hours) Deep breathing/respiratory distress Acute pulmonary edema Shock (systolic blood pressure < 80 mmHg) Acute kidney injury Clinical jaundice, evidence of 167 other vital organ dysfunction Signs and Symptoms of Uncomplicated and Severe Malaria

Uncomplicated Malaria: One or more of the following clinical features in the presence of malaria parasitemia or positive rapid diagnostic test: Axillary temperature 37.5C, and/or history of recent fever, and/or presence of

anemia Severe Malaria: One or more of the following clinical features or laboratory findings in the presence of malaria parasitemia or positive rapid diagnostic test: Clinical Features: Impaired c onsciousness/c oma Prostration/ generalized weakness

Deep breathing/respiratory distress Multiple c onvulsions (>two within 24 hours) Laboratory Findings: Hypoglyc emia (blood gluc ose < 2.2 millimoles per L or <40 mg per deciliter) Metabolic acidosis (plasma bicarbonate <15 millimoles per L); hyperlactatemia (lactate > 5 millimoles per L)

C irc ulatory collapse/shoc k (systolic blood pressure < 80 millimeters of mercury) Severe normocytic anemia (hemoglobin < 7 g per deciliter, pac ked c ell volume < 20%) Ac ute kidney injury

Hemoglobinuria Signific ant bleeding Pulmonary edema (radiologic ) Ac ute pulmonary edema

C linical jaundic e and evidenc e of other vital organ dysfunc tion Hyperparasitemia* Renal impairment (serum c reatinine > 265 micromoles per L) Plasma or serum bilirubin > 50 micromoles per L (3 mg per dec iliter) with a parasite c ount >100,000 per microliter) 168 Module Section 4.4 Case Management of Malaria during Pregnancy

169 Case Management Goals: Malaria during Pregnancy Despite preventive measures, some pregnant women will still become infected with malaria. The goal of malaria treatment during pregnancy is to completely eliminate the infection because having any parasites in her blood can affect the mother and her fetus. 170 Case Management Goals: Malaria during

Pregnancy (continued) Determine whether malaria is uncomplicated or severe: Uncomplicated: Manage according to the case management job aid. Severe: After administering loading dose of appropriate antimalarial drug, refer immediately to higher level of care. 171 Case Management: Drugs

Selection of treatment is based on: The trimester of pregnancy Available drugs Approved drugs for malaria treatment in accordance with national guidelines 172 Case Management: 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. 173 ACTs: Types of Combination Therapy Artemisinin-based combination therapies (ACTs): The simultaneous use of a drug that includes a derivative of artemisinin along with another antimalarial drug Currently the most effective treatment for

malaria Should be the first-line treatment in the second and third trimesters 174 Module Section 4.5 Treatment for Uncomplicated Malaria 175 WHO 2015 Recommendations for ACT in Pregnancy 176

Treating Uncomplicated Malaria Observe the client taking the first dose of her antimalarial drugs (directly observed therapy) and record the dosages. Advise the client to: Complete the course of drugs. Return in 48 hours for follow-up, or sooner if condition worsens. Consume iron-rich foods.

Use ITNs and other preventive measures. Follow country guidelines with regard to use of IPTp-SP and iron/folic acid during and after treatment of malaria. 177 Treating Uncomplicated Malaria (continued) Provide first-line antimalarial drugs. Refer to case management job aid. Manage fever 38C axillary.

Tepid sponging; paracetamol 500 mg, two tablets every 6 hours as needed Diagnose and treat anemia. Provide fluids. 178 Module Section 4.6 Management of Severe Malaria 179 Severe Malaria: Convulsions or Fits

If a pregnant woman presents with convulsions, determine whether they are due to malaria or eclampsia. Gather information from the following chart to determine the cause of convulsions or fits. 180 Determining Causes of Convulsions Signs/ Symptoms Recent history of fever, chills Temperature Blood pressure Proteinuria

Enlarged spleen Jaundice Severe Malaria Eclampsia Yes No > 37.5 C < 38 C Diastolic

< 90 mmHg Diastolic > 90 mmHg No Yes Possibly No Yes No

181 Other Considerations (CDC 2013) If eclampsia is suspected, stabilize and treat with magnesium sulfate per national guidelines, then refer. If severe malaria is suspected, stabilize and treat with appropriate antimalarial drug and diazepam, then refer. Oral antimalarial drugs are not recommended for the initial treatment of severe malaria. If severe malaria is strongly suspected but a laboratory diagnosis cannot be made, collect blood for diagnostic testing. Parenteral

182 Severe Malaria: Pre-Referral Treatment (WHO 2015d) In the case of antimalarial treatment for severe malaria, the main objective is to prevent death. 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 a womans condition or even death. If possible, start treatment immediately by giving the pregnant woman a loading dose of a parenteral antimalarial before referral:

parenteral artesunate, 2.4 mg/kg, IV bolus 183 Stabilize Severe Malaria Stabilize by providing a loading dose of the appropriate antimalarial drug and refer the woman immediately if she has any symptoms that suggest severe malaria. 184 Stabilization and Pre-Referral Treatment for Severe Malaria

All Trimester/ Nonpregnant Adults First-Line Drug Parenteral artesunate 2.4 mg per kilogram IV bolus (push) injection or IM injec tion as loading dose. Second-Line Drug If artesunate is unavailable, intramuscular artemether should be given, and if this is unavailable, then parenteral quinine should be started immediately until artesunate is obtained.c To view the entire job aid for Treatment of Uncomplicated Malaria Among Women of Reproductive Age, please see the reference manual, Figure 11.

185 Referral Preparation Explain the situation to the client and her family. Give her pre-referral treatment, if possible. Help arrange transport to a higher-level facility, if possible. Accompany the woman during transport, if possible, and be sure to have sufficient medication available. Record the referral information on the ANC card. 186

Referral Notes Include the following in your referral note: Brief history of clients 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 clients ANC record, if possible Contact information in case the referral facility or provider has any questions Source: Adapted from WHO 2015d. 187 Recognizing and Reporting Potential Adverse Effects Health care providers should understand the potential adverse effects of all medications they administer. This includes those used to treat MIP, although these drugs are generally well tolerated and have no or only mild side effects, if used as directed.

Women need to know about adverse effects that they might experience and what to do if they occur. Potential adverse effects are summarized in the next slide. 188 Recognizing and Reporting Potential Adverse Effects (continued) Artemether/lumefantrine: Weakness, headache, dizziness Artesunate/amodiaquine: Weakness (mild or severe) headache or dizziness Quinine: Buzzing or ringing in the ears or hypoglycemia (when given parenterally) Artemisinin: Dizziness, headache, vomiting,

diarrhea 189 Recognizing and Reporting Potential Adverse Effects (continued) Providers should be aware of the pharmacovigilance (drug safety) system in their countries, to which they can report: Adverse effects Other concerns about the medications they administer

190 Summary: Malaria Diagnosis and Treatment Diagnostic testing should be performed to confirm malaria illness. Uncomplicated malaria can be easily treated if it is 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 given a loading dose of the appropriate antimalarial drug and referred immediately to avoid complications and death.

191 Module Section 4.7 Health Education 192 Keeping Up to Date This malaria workshop and training materials should bring participants up to date on current policies and practices. Malaria control is a dynamic field with new discoveries in the area of medicines, insecticides, and other interventions. To maintain best practices, health workers

need to update themselves through selflearning. 193 Free Journals/Magazines 194 The Internet: Crucial for Continued Self-Learning Free online journals Africa Health: http://www.africa-health.com/ Malaria Journal: http://www.malariajournal.com/

Twitter If you have a twitter account, search for the latest information using: #malaria Listserv Sign up for malaria mailings: http://knowledge-gateway.org/malaria 195 References and Resources For all references, see reference manual.

196

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