Malaria Evolution of intermittent screening and
treatment for malaria in pregnancy control Rapid diagnostic tests are improving all the time, with some scientists reporting greater sensitivity than microscopy. Couple this to their speed of result, and new effective measures for managing and preventing malaria become possible. Prof William Brieger reports
Intermittent preventive treatment of pregnant women (IPTp) with sulphadoxine-pyrimethamine (SP) for malaria has been a major,1
if not terribly well implemented, ma-
laria control strategy in countries with high and stable malaria transmission. Combined with the use of insec- ticide treated nets (ITNs) and appropriate case man- agement with artemisinin-based combination therapy (ACTs), IPTp offered an important third prong to protect this vulnerable population who in theory are reachable since most pregnant women in endemic countries at- tend antenatal care (ANC).2 The area benefiting from IPTp covers the bulk of
sub-Saharan Africa, but not countries on the periphery with unstable malaria transmission, like Namibia and Botswana,2
where transmission is seasonal or epidemic.
Here, as well as in countries that have made substantial progress in reducing the burden of malaria like Rwanda, ITNs themselves often carry the burden of protecting pregnant women since case management is dependent of treatment seeking in a variety of formal and non- formal care settings. IPTp as we know it is threatened.3
resistance of malaria parasites to sulphadoxine-pyri- methamine (SP), the drug of choice. The problem has been compounded by countries’ neglect in curbing the continued and unrecommended use of SP for treatment. Secondly, on a more positive note, as countries reduce their malaria burden and become more like those with low and unstable transmission, widespread IPTp does not make much sense as a strategy. Evidence suggests that ITNs alone are a better preventive measure than IPTp in areas with low transmission or growing parasite resistance to SP.3 This reduction in burden does not mean that preg-
nant women are no longer at risk in malaria endemic countries that are making progress. Although continued use of ITNs and other vector management interventions is recommended, the reality is that we are a long way from ensuring use of ITNs by pregnant women even when the household owns at least one net. For example, the Demographic and Health Survey of Liberia (2009) typifies the problem: 33% of all pregnant women slept
Professor William R Brieger is from the Department of International Health, The Johns Hopkins University Bloomberg School of Public Health; and is Senior Malaria Adviser for Jhpiego, an affiliate of the Johns Hopkins University.
July 2012
under an ITN the night before the survey, but in house- holds that possessed nets, still only 64% used them.4 Nets alone cannot protect pregnant women if they do not use them. We must therefore, step up the accu- racy of timely case detection and case management. A new study of malaria rapid diagnostic tests during
pregnancy in Tanzania sums up the current situation nicely:
‘Microscopy underestimated the real burden of malaria during pregnancy and RDTs performed better than microscopy in diagnosing PAM. In areas where intermittent preventive treatment during pregnancy may be abandoned due to low and decreasing malaria risk and instead replaced with active case management,
First is the growing
Bednets alone may not be enough to protect pregnant women
Africa Health 33
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