IPTp Policy in Zanzibar toward Pre-Elimination of Malaria: Results from a Study of Placental Parasitemia

by: Mwinyi Issa Msellem1, Marya Plotkin2, Khadija Said1, Natalie Hendler2, Asma Ramadhan Khamis2, Elaine Roman3, Rz Stevenson4, Chonge Kitojo5, Julie Gutman5 and Peter McElroy5 Zanzibar National Malaria Control Programme; Zanzibar Ministry of Health; 2Jhpiego, an affiliate of Johns Hopkins University/Tanzania; 3Jhpiego, an affiliate of Johns Hopkins University/ USA; 4United States Agency for International Development; 5Centers for Disease Control and Prevention and Presidents Malaria Initiative
1

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 preelimination 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].

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).

Figure 2. Timing of Sample Collection for the Parasitemia Study

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) 10,338 5,665 1,420 2,838 1,607 645 Total Number of Samples Analyzed 380 208 67 415 184 90 1,349

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.

Unguja

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?
Figure 1. Facilities in the Study with Annual Delivery Volume

Pemba

Mnazi Mmoja Hospital Mwembeladu Hospital Kivunge Health Centre Chake Chake Hospital Wete Hospital Micheweni Health Centre

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. Zanzibar Malaria Control Programme. 2011. Zanzibar Malaria Epidemic Early Detection System Biannual Report, Mid-Year 2011; Vol. 3(1). Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS) 201112. Zanzibar Malaria Control Programme. 2012. Unpublished national surveillance data.

Table 2. Positive Cases in the Placental Parasitemia Study Health Month Case Facility of of No. Delivery Delivery Sept 1. Micheweni 2011 April 2. Micheweni 2012 3. 4. 5. 6. 7. 8. 9. Micheweni Mwembeladu Mwembeladu Mwembeladu Mwembeladu Kivunge Mnazi Mmoja April 2012 Sept 2011 Oct 2011 Oct 2011 Oct 2011 Oct 2011 Nov 2011 Village of Residence Shumba Viamboni Mjini Wingwi Mjini Wingwi Kama Bumbwini Mbuzini Magogoni Unknown Kilimahewa Parity 1 1 3 4 6 2 3 1 5 Birth Weight (kg) 2.5 2.5
(macerated stillbirth)

Kivunge Health Center Micheweni Health Center Chake Chake District Hospital Wete District Hospital Mnazi Mmoja Hospital Micheweni Health Center The rainy season is MarchMay, and peak malaria transmission is MayJune.

1.8

2. 3. 4.

2.6 3.6 3.1 2.8 3.5 4.2

Funding for the production of this poster was provided by USAID through the Mothers and Infants, Safe, Healthy, Alive Program through Cooperative Agreement #621-A-00-08-00023-00. The opinions herein are those of the authors and do not necessarily reflect the views of USAID.