Low prevalence of placental malaria infection among pregnant women in Zanzibar: policy implications for IPTp

Marya Plotkin1; Khadija Said2; Natalie Hendler1; Asma Ramadhan Khamis1; Mwinyi Issa Msellem2; Abdul-wahid Al-mafazy2; Chonge Kitojo5, Maryjane Lacoste1; Elaine Roman3, Veronica Ades4, Julie Gutman5, Raz Stevenson6, Peter McElroy5
1Jhpiego

Tanzania 2Zanzibar National Malaria Control Programme, Zanzibar Ministry of Health 3Jhpiego Baltimore 4University of California San Francisco 5Centers for Disease Control and Prevention and Presidents Malaria Initiative 6United States Agency for International Development

Background
Intermittent preventive treatment for pregnant women (IPTp) with sulphadoxine-pyrimethamine (SP) was implemented in 2004 when malaria prevalence in Zanzibar exceeded 20% Further scale-up of malaria interventions has brought Zanzibar to the pre-elimination phase P. falciparum prevalence in the general population currently less than 0.5% [1], diagnostic positivity rate among febrile patients 1.2% in 2011 [2]

 Current IPTp coverage remains low: 69% reported taking any SP; 43% reported taking 2+ doses of SP in last pregnancy [3] ZMCP has introduced screening for malaria at ANC services [4]:
Year 2011 2012 N Tested Positive (%) 19,724 40 (0.2%) 11,336 18 (0.15%) *data through June 2012

The value of IPTp in the current low transmission environment is uncertain - few African countries have addressed IPTp scale-down

The Placental Parasitemia Study

A prospective observational study was conducted in selected health facilities in Zanzibar with the objectives of: measuring placental parasitemia rates among pregnant women who did not receive IPTp providing cost analyses to help inform policy decisions on the IPTp program in Zanzibar Policy questions:

Is IPTp useful at current low level of transmission in preventing maternal and neonatal morbidity? What are the costs and benefits of IPTp in Zanzibar?

Figure 1. Facilities in the study with annual delivery volume

Methods
From September 2011 - April 2012, a convenience sample of pregnant women were enrolled at six hospitals in Zanzibar on day of delivery 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) Information on client, birth weight/ outcome collected

Results Table 1. Samples analyzed

Facility Chake Chake Hospital Michiweni Cottage Hospital Wete Hospital Mnazi Mmoja Hospital Kivunge Cottage Hospital Mwembeladu Hospital

Island

Total 401 70 175 335 67 209

Pemba Pemba Pemba Unguja Unguja Unguja

Total 1,258
Data collection has finished and last samples are being processed. Results presented for 1,258 samples: final results will include approximately 200 more samples.

Results
1,258 samples have so far been processed out of 1,489 collected A shipment of SP in November 2011 increased availability of SP resulting in a dramatic drop in eligible clients by January 2012 Roughly 6% of the women delivering in the facilities were sampled into the study (range 4% - 14) Average age of women was 26.9 years 376 (32%) were primigravidas

Figure 1. Timing of collection of samples

Rainy season: March - May, peak malaria transmission May June

PCR Results and birth outcomes

4 samples out of 1,258 were positive (0.3%, 95% CI -0.12 0.81%)

Mwembeladu Hospital (October 2011): 26 year old gravida 3, HIV negative, 2.8 kg baby Mnazi Mmoja Hospital (Nov 2011): 35 year old gravida 5 from Kilimahewa, HIV negative, 4.2 kg baby Michiweni Health Center (April 10, 2012) A gravida 1 HIV negative woman, 2.5 kg baby. Michiweni Health Center (April 11, 2012). A 25 year old, gravida 3 of unknown HIV status, macerated stillbirth weighing 1.8 kg.

Table 2. Cost of IPTp program for 2011 Area SP Cost $26,353 Source / Notes Includes the procurement cost for a shipment of SP received in November 2011 as well as storage and transport costs to facilities In-service training for ANC providers on focused antenatal care (FANC) Costs of supervision for FANC which was facilitated through MAISHA program

Training Supervision TOTAL

$5,187

$10,383
$41,923

Costs associated for provision of IPTp for 2011 totaled approximately $42,000, which is relatively low for a national scale public health intevention

 Malaria infection among pregnant women who have not had IPTp is extraordinarily low (0.3%), indicating the level of risk among pregnant women is minimal

Conclusions

similar results from ANC malaria screening and population based surveys (THMIS)

Cost of provision of IPTp is relatively inexpensive for the ZMOH Coverage of IPTp among women giving birth in facilities fluctuates according to commodity logistics, but still shows consistent gaps

Recommendations
Zanzibar is adjusting its strategy for malaria prevention and control to be appropriate to the pre-elimination phase.

Weekly active case detection from 2008 with Malaria Epidemic Early Detection System (MEEDS) [2]

Malaria in pregnancy policy and strategy should follow suit ZMCP has already begun active screening for malaria parasitemia of ANC clients.

Need for more guidance and more consistent rollout, including guidelines and job aides, stronger data collection and analysis, including stratifications for first and repeat test

References
1. Bhattarai A, Ali AS, Kachur SP. 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. Zanzibar Malaria Epidemic Early Detection System Biannual Report, Mid-Year 2011; Vol. 3, (No.1); 2011. 3. Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS) 2011-12. Preliminary report. 4. Zanzibar Malaria Control Programme. 2012 National surveillance data. Personal correspondence, Mwinyi Msellem.