Malaria Prevention in Pregnancy: When Will the Prevention Programme Respond to the Science
Steketee, Richard W., Journal of Health Population and Nutrition
The article by Okoko and colleagues (1) in this issue of the Journal presents an interesting scenario. By its title, the article draws attention to the comparison with seminal work done between 1966 and 1972 when Sir Ian McGregor and colleagues monitored malaria infection at delivery and birth outcomes in more than 6,000 women in urban and rural parts of western Gambia (2). In a much smaller sample of women delivering during the rainy season in eastern Gambia in 1997, Okoko and colleagues observed very similar findings. In essence, nothing has changed in the 30 intervening years.
The article by McGregor and colleagues, in combination with similar reports by others (3), led to discussions of the importance and appropriate approaches to the prevention of malaria in pregnancy. The World Health Organization (WHO) published recommendations for antimalarial chemoprophylaxis in pregnancy in 1986 (4) and noted the importance of an initial treatment dose, because many asymptomatic women were infected at the time of their first antenatal clinic visit. Studies elsewhere in Africa in the 1980s and 1990s showed the benefit of various treatment and or chemoprophylaxis regimens on the reduction of malaria, maternal anaemia, low birth-weight, and premature delivery (5,6). Work by others in the Gambia contributed to the growing recognition that effective interventions, including the use of antimalarial drugs (7,8) and insecticide-treated bednets (9), could be applied and could markedly reduce the adverse effects from malaria. Yet, good scientific inquiry and published articles have not led directly to changes in national policy and implementation of these policies at the local level. Okoko and colleagues note in their introduction that "the use of antimalarial chemoprophylaxis is still not uniformly practised in the Gambia," and they conclude that "a workable policy needs to be put in place."
Recent studies in African settings have addressed the issue of a 'workable policy.' With the recognition that health systems have difficulty in delivering regular chemoprophylaxis to pregnant women (10), investigators in several settings demonstrated that intermittent preventive treatment (IPT) with effective and safe antimalarial drugs can achieve important reductions in frequency of malaria and its consequences (11,12). These interventions can be particularly cost-effective (13) and reduce the intolerable burden of malaria in pregnancy. The 20th WHO Expert Committee Report recommends, "intermittent treatment with an effective, preferably one-dose antimalarial drug delivered in the context of antenatal care should be made available to primi- and secundigravidae as an appropriate and effective method for reducing the consequences of malaria in pregnancy in highly-endemic areas." In follow-up of this guidance, dialogue between the malaria community and the reproductive health community is underway with the intent to incorporate the malaria-prevention strategy into antenatal care programmes widely in malarious areas of sub-Saharan Africa and to assure necessary supplies of drugs. Like all proven and important public-health prevention strategies, this will need continued attention and much advocacy from the malaria and reproductive-health community, and advocacy and demand from the mothers (and their babies) who will benefit.
This approach using IPT has been facilitated by having sulphadoxine-pyrimethamine (SP) *, an antimalarial therapy that still has good efficacy in these semi-immune women, is a single-dose treatment, is not bitter, and is relatively well-tolerated. Importantly, studies of IPT with SP in pregnancy in numerous settings have clearly demonstrated its efficacy and effectiveness in programmes (6). Because of the single-dose treatment, the effectiveness of the programme essentially matches the efficacy of the drug as long as health workers can give it under observation in the clinic. If and when we have to move from SP to alternative drugs or drug combinations that require multi-day dosing, this will be more challenging (i. …