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CDC's Contributions to Preventing and Controlling Malaria During Pregnancy in Sub-Saharan Africa

In collaboration with many partners—other government agencies, international organizations, and African ministries of health—CDC has worked to

• Quantify the burden of adverse effects caused by malaria infection during pregnancy
• Evaluate the efficacy of novel strategies to prevent malaria during pregnancy
• Formulate strategies to deliver effective interventions to reduce malaria's ill effects on the health of pregnant women and their children
• Work with partners to scale up interventions to prevent and control malaria during pregnancy.

Specific Contributions

Reduction of low birth weight: Determined the risk of malaria-associated low birth weight and shown how this risk could be reduced through the delivery of efficacious antimalarial drugs as part of routine antenatal care.

Estimates of malaria burden: Updated estimates of the burden of anemia, low birth weight (due both preterm delivery and intrauterine growth retardation), and infant mortality associated with malaria infection during pregnancy [1]. With partners, have generated estimates of the burden of malaria during pregnancy in areas with limited data, including West Africa, areas of sub-Saharan Africa with low malaria transmission, and South/ South East Asia.

Rapid assessment methodology: Developed a methodology that can be used by ministries of health to estimate the burden of malaria during pregnancy and assess how best to incorporate antimalarial interventions into the existing antenatal care system [2]. To date, CDC has provided training for this methodology in Asia, Africa, and the Americas. (More about the rapid assessment methodology in our Malaria and Pregnancy spotlight.)

Intermittent preventive treatment in pregnancy (IPTp): With partners, developed the strategy of IPTp, and demonstrated that this intervention was effective in reducing maternal anemia and delivery of low birth-weight babies in different settings in sub-Saharan Africa [3, 4].

Interaction of Malaria and HIV: Demonstrated both the higher burden of malaria in HIV-seropositive (compared to HIV-seronegative) pregnant women and their impaired response to antimalarial treatment [5].

Insecticide-treated nets (ITNs): Demonstrated that the use of ITNs by pregnant women can reduce severe malarial anemia during pregnancy and reduce delivery of low birth-weight infants [6].

Issues Currently Under Study

Evaluation of new antimalarial drugs for pregnancy: In collaboration with international partners, CDC is working to evaluate the safety and efficacy of new antimalarial drugs and drug combinations for the treatment and prevention of malaria during pregnancy.

Evaluation of the combined benefit of IPTp and ITNs: CDC is working on novel mechanisms for increasing the percentage of pregnant women with access to IPTp and ITNs, and on measuring the combined impact of these interventions on preventing the adverse consequences of malaria during pregnancy.

Interaction of antimalarial drugs and folic acid: CDC is evaluating a possible interaction between IPTp with sulfadoxine-pyrimethamine and administration of folic acid during pregnancy. There has been a theoretical concern that these two beneficial antenatal interventions could interfere with one another in practice; this research will help to answer that question.

Development of a monitoring and evaluation system for malaria during pregnancy: In conjunction with WHO and other international partners, CDC has been developing a standardized system for monitoring the uptake of strategies to prevent malaria during pregnancy, as well as for demonstrating impact on preventing anemia and low birth weight.

Studying the efficacy of intermittent preventive treatment in infants (IPTi) for control of malaria and severe anemia in infancy: CDC is a member of the IPTi Consortium (www.ipti-malaria.org) and is conducting one of five large clinical trials that are currently under way in Africa to assess use of IPTi at time of routine vaccinations as a control strategy for prevention of malaria and anemia in infancy. (http://www.cdc.gov/malaria/cdcactivities/ipt_i.htm).

Review of the global burden of malaria in pregnancy and identifying gaps in knowledge: CDC is writing a review of the current knowledge and gaps in the burden of malaria in pregnancy. This is one of six state-of-the-art comprehensive reviews being undertaken by the MiP Consortium to develop a prioritized strategy defining the scope of future studies of malaria in pregnancy.

Citations

1. Steketee, R.W., B.L. Nahlen, et al., The burden of malaria in pregnancy in malaria-endemic areas. American Journal of Tropical Medicine & Hygiene, 2001. 64(1-2 Suppl): p. 28-35.

2. Parise, M.E., L.S. Lewis, et al., A rapid assessment approach for public health decision-making related to the prevention of malaria during pregnancy. Bull World Health Organ, 2003. 81(5): p. 316-23.

3. Kayentao, K., M. Kodio, et al., Comparison of Intermittent Preventive Treatment with Chemoprophylaxis for the Prevention of Malaria during Pregnancy in Mali. J Infect Dis, 2005. 191(1): p. 109-16.

4. Parise, M.E., J.G. Ayisi, et al., Efficacy of sulfadoxine-pyrimethamine for prevention of placental malaria in an area of Kenya with a high prevalence of malaria and human immunodeficiency virus infection. American Journal of Tropical Medicine & Hygiene, 1998. 59(5): p. 813-22.

5. ter Kuile, F.O., M.E. Parise, et al., The burden of co-infection with human immunodeficiency virus type 1 and malaria in pregnant women in sub-saharan Africa. Am J Trop Med Hyg, 2004. 71(2 Suppl): p. 41-54.

6. ter Kuile, F.O., D.J. Terlouw, et al., Reduction of malaria during pregnancy by permethrin-treated bed nets in an area of intense perennial malaria transmission in western Kenya. Am J Trop Med Hyg, 2003. 68(4 Suppl): p. 50-60.