IPTp Policy in Zanzibar toward PreElimination of Malaria: Results from a Study of Placental Parasitemia

Mwinyi Issa Msellem1; Marya Plotkin2; Khadija S Ramadhan Khamis2, Elaine Roman3, Raz Steve Gutman5, Peter McElroy5
1Zanzibar

National Malaria Control Programme, Zan

Background
Due to scale-up of malaria prevention and treatment by the Zanzibar Malaria Control Programme (ZMCP) of the Ministry of Health (MOH), Zanzibar is in the pre-elimination phase of malaria control. P. falciparum prevalence in the general population is currently less than 0.5% [1], and the diagnostic positivity rate among febrile patients was 1.2% in 2011. [2]

 Control of malaria in pregnancy (MIP) follows the three-pronged approach recommended by the World Health Organization:

Intermittent preventive treatment for pregnant women (IPTp) with sulfadoxine-pyrimethamine (SP) distributed through antenatal care (ANC) services Long-lasting insecticide-treated nets Case management of MIP

 IPTp-SP was implemented in 2004 when malaria prevalence exceeded 20%. Coverage among pregnant women remains low. In their last pregnancy:

69% women reported taking any SP 43% women reported taking 2+ doses of SP [3]

The MOH of Zanzibar is reconsidering provision of IPTp through ANC services in light of very low malaria prevalence.

 ZMCP has introduced screening for malaria in ANC services:

In 2011 and 2012, 0.2% of ANC clients tested positive for malaria using mRDT (19,724 malaria tests were performed in 2011 and 27,186 performed in 2012). [4]

The Placental Parasitemia Study

A prospective observational study was conducted in selected health facilities in Zanzibar with the objective of measuring placental parasitemia rates among pregnant women who did not receive IPTp.

Policy question:

Is IPTp useful at current level of transmission in preventing maternal and neonatal morbidity?

The rainy season is MarchMay, and peak malaria transmission is MayJune

Methods
Convenience sample of pregnant women enrolled at six hospitals in Zanzibar on day of delivery. September 2011April 2012. Client card checked for documentation of provision of IPTp (eligible = no doses of SP, resident of Zanzibar). Informed consent obtained from eligible clients. Sample taken from maternal side of placenta by labor ward midwives. Dried blood spots (DBS) on filter paper were prepared from placental blood specimens. DBS were analyzed via polymerase chain reaction indicating active Plasmodium infection (all species).

Results
1,423 deliveries were enrolled from Pemba (52%) and Unguja (48%), representing 6% of the total deliveries at the six facilities. Average age of women was 26.9 years. 376 (32%) were primigravidae. 9 of 1,349 (0.8%, 95% confidence interval 0.23.3%) placental specimens were PCR positive. Only P. falciparum was detected.

Table 1. Facilities and Annual Delivery Volume

Island

Facility

Annual Deliveries (2011)

Number of Samples Analyzed

Unguja

Mnazi Mmoja Hospital

10,338

380

Mwembeladu Hospital

5,665

208

Kivunge Health Centre

1,420

67

Pemba

Chake Chake Hospital

2,838

415

Wete Hospital Micheweni Health Centre

1,607 645

184 90

Table 2. Positive Cases in the Placental Parasitemia Study

Case Number 1 Health Facility of Delivery Micheweni Sep 2011 Month of Delivery Village of Residence Shumba Viamboni 1 Parity Birth Weight (kg) 2.5

2 3

Micheweni Micheweni

Apr 2012 Apr 2012

Mjini Wingwi Mjini Wingwi

1 3

2.5 1.8 (macerated stillbirth)

4 5 6 7 8

Mwembeladu Mwembeladu Mwembeladu Mwembeladu Kivunge

Sep 2011 Oct 2011 Oct 2011 Oct 2011 Oct 2011

Kama Bumbwini Mbuzini Magogoni Unknown

4 6 2 3 1

2.6 3.6 3.1 2.8 3.5

Mnazi Mmoja

Nov 2011

Kilimahewa

4.2

Figure 1. Timing of Sample Collection for the Parasitemia Study

The majority of the samples were collected in the first five months of the study (AugustDecember 2011). A shipment of SP received in November 2011 increased availability of SP in the islands, and a dramatic drop in eligible clients was seen by January 2012.

 Six (66%) of the nine placental infections were from Unguja deliveries. Eight placental infections were accompanied by a normal birth weight delivery ( 2500 g). Placental infections were not more common during the seasonal transmission increases of 20112012.

Conclusions
Malaria infection among pregnant women who have not had IPTp is extraordinarily low (0.8%). Given the low prevalence of placental malaria infection among women who had not had IPTp, in combination with the overall low prevalence of malaria on the islands, a policy shift away from IPTp is not an unreasonable option, if it is done with expanded surveillance of MIP and strengthening of detection and case management of women with MIP.

Recommendations
Enhance surveillance of MIP through expansion of the existing surveillance system, MEEDS, to capture symptomatic pregnant women diagnosed at ANC and ensure that pregnancy status is recorded for women diagnosed at the outpatient department. Strengthen case management of MIP and ensure continued high ownership and use of insecticidetreated nets, particularly among women of reproductive age. Conduct an internal review of costs and findings from surveillance to inform on whether the cost of screening every pregnant woman in antenatal care is justified.

References
1. Bhattarai A, Ali AS, Kachur SP, et al. 2007. Impact of artemisinin-based combination therapy and insecticide-treated nets on malaria burden in Zanzibar. PloS Med 4(11): e309. 2. Zanzibar Malaria Control Programme. 2011. Zanzibar Malaria Epidemic Early Detection System Biannual Report, Mid-Year 2011; Vol. 3(1). 3. Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS) 201112. 4. Zanzibar Malaria Control Programme. 2012. Unpublished National surveillance data.