Jenny Hill

Coverage of malaria protection in pregnant women in sub-Saharan Africa: a synthesis and analysis of national survey data

Summary Background Insecticide-treated nets and intermittent preventive treatment with sulfadoxine–pyrimethamine are recommended for the control of malaria during pregnancy in endemic areas in Africa, but there has been no analysis of coverage data at a subnational level. We aimed to synthesise data from national surveys about these interventions, accounting for disparities in malaria risk within national borders. Methods We extracted data for specific strategies for malaria control in pregnant women from national malaria policies from endemic countries in Africa. We identified the most recent national household cluster-sample surveys recording intermittent preventive treatment with sulfadoxine–pyrimethamine and use of insecticide-treated nets. We reconciled data to subnational administrative units to construct a model to estimate the number of pregnant women covered by a recommended intervention in 2007. Findings 45 (96%) of 47 countries surveyed had a policy for distribution of insecticide-treated nets for pregnant women; estimated coverage in 2007 was 4·7 million (17%) of 27·7 million pregnancies at risk of malaria in 32 countries with data. 39 (83%) of 47 countries surveyed had an intermittent preventive treatment policy; in 2007, an estimated 6·4 million (25%) of 25·6 million pregnant women received at least one dose of treatment and 19·8 million (77%) visited an antenatal clinic (31 countries). Estimated coverage was lowest in areas of high-intensity transmission of malaria. Interpretation Despite success in a few countries, coverage of insecticide-treated nets and intermittent preventive treatment in pregnant African women is inadequate; increased efforts towards scale-up are needed. Funding The Malaria in Pregnancy Consortium and Wellcome Trust.

Reaching the Abuja target for intermittent preventive treatment of malaria in pregnancy in African women: a review of progress and operational challenges.

Objective  To review progress with the implementation of intermittent preventive treatment (IPT) for the control of malaria in pregnancy in sub‐Saharan Africa (SSA), in order to identify facilitating factors and operational challenges for scaling up IPT delivery.

Insecticide-treated nets

Insecticide-treated nets (ITNs) are the most powerful malaria control tool to be developed since the advent of indoor residual spraying (IRS) and chloroquine in the 1940s, and as such they have been an important component of global and national malaria control policies since the mid-1990s. Yet a decade later, coverage is still unacceptably low: only 3% of African children are currently sleeping under an ITN, and only about 20% are sleeping under any kind of net. This review charts the scientific, policy and programmatic progress of ITNs over the last 10 years. Available evidence for the range of programmatic delivery mechanisms used at country level is presented alongside the key policy debates that together have contributed to the evolution of ITN delivery strategies over the past decade. There is now global consensus around a strategic framework for scaling up ITN usage in Africa, which recognizes a role for both the public sector (targeting vulnerable groups to promote equity) and the private sector (sustainable supply). So, while progress with increasing coverage to date has been slow, there is now global support for the rapid scale-up of ITNs among vulnerable groups by integrating ITN delivery with maternal and child health programmes (and immunization in particular), at the same time working with the private sector in a complementary and supportive manner to ensure that coverage can be maintained for future generations of African children.

From evidence to action? Challenges to policy change and programme delivery for malaria in pregnancy.

This paper discusses the factors that influence whether strategies for preventing and treating malaria in pregnancy are successfully translated into national policy and programme implementation, and identifies key operational research issues. Countries require guidance on how to assess the effectiveness of intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine in the context of increasing sulfadoxine-pyrimethamine resistance. At the same time, data on the safety and efficacy of alternatives to sulfadoxine-pyrimethamine for prevention and treatment are urgently needed. Systematic examination of the cultural and operational constraints to delivery and uptake of IPTp with sulfadoxine-pyrimethamine and use of insecticide-treated nets would provide a rational basis for strategies aimed at improving coverage. Standardised methodology must be used to monitor IPTp coverage and to compare different approaches for scaling-up the delivery of insecticide-treated nets to pregnant women. Adequate budgetary provision for the implementation of policy and for operational research to improve programme delivery should be included in national applications to the Global Fund to Fight AIDS, Tuberculosis and Malaria. The provision of clear policy guidance on malaria in pregnancy and its translation into evidence-based guidelines that are made widely available at a country level are central to improving malaria control in this particularly vulnerable group.

Coverage of intermittent preventive treatment and insecticide-treated nets for the control of malaria during pregnancy in sub-Saharan Africa: a synthesis and meta-analysis of national survey data 2009-11.

BACKGROUND Pregnant women in malaria-endemic countries in sub-Saharan Africa are especially vulnerable to malaria. Recommended prevention strategies include intermittent preventive treatment with two doses of sulfadoxine-pyrimethamine and the use of insecticide-treated nets. However, progress with implementation has been slow and the Roll Back Malaria Partnership target of 80% coverage of both interventions by 2010 has not been met. We aimed to review the coverage of intermittent preventive treatment, insecticide-treated nets, and antenatal care for pregnant women in sub-Saharan Africa and to explore associations between coverage and individual and country-level factors, including the role of funding for malaria prevention. METHODS We used data from nationally representative household surveys from 2009-11 to estimate coverage of intermittent preventive treatment, use of insecticide-treated nets, and attendance at antenatal clinics by pregnant women in sub-Saharan Africa. Using demographic data for births and published data for malaria exposure, we also estimated the number of malaria-exposed births (livebirths and stillbirths combined) for 2010 by country. We used meta-regression analysis to investigate the factors associated with coverage of intermittent preventive treatment and use of insecticide-treated nets. RESULTS Of the 21·4 million estimated malaria-exposed births across 27 countries in 2010, an estimated 4·6 million (21·5%, 95% CI 19·3-23·7) were born to mothers who received intermittent preventive treatment. Insecticide-treated nets were used during pregnancy for 10·5 million of 26·9 million births across 37 countries (38·8%, 34·6-43·0). Antenatal care was attended at least once by 16·3 of 20·8 million women in 2010 (78·3%, 75·2-81·4; n=26 countries) and at least twice by 14·7 of 19·6 million women (75·1%, 72·9-77·3; n=22 countries). For the countries with previous estimates for 2007, coverage of intermittent preventive treatment increased from 13·1% (11·9-14·3) to 21·2% (18·9-23·5; n=14 countries) and use of insecticide-treated nets increased from 17·9% (15·1-20·7) to 41·6% (37·2-46·0; n=24 countries) in 2010. A fall in coverage by more than 10% was seen in two of 24 countries for intermittent preventive treatment and in three of 30 countries for insecticide-treated nets. High disbursement of funds for malaria control and a long time interval since adoption of the relevant policy were associated with the highest coverage of intermittent preventive treatment. High disbursement of funds for malaria control and high total fertility rate were associated with the greatest use of insecticide-treated nets, whereas a high per-head gross domestic product (GDP) was associated with less use of nets than was a lower GDP. Coverage of intermittent preventive treatment showed greater inequity overall than use of insecticide-treated nets, with richer, educated, and urban women more likely to receive preventive treatment than their poorer, uneducated, rural counterparts. INTERPRETATION Although coverage of intermittent preventive treatment and use of insecticide-treated nets by pregnant women has increased in most countries, coverage remains far below international targets, despite fairly high rates of attendance at antenatal clinics. The effect of the implementation of WHOs 2012 policy update for intermittent preventive treatment, which aims to simplify the message and align preventive treatment with the focused antenatal care schedule, should be assessed to find out whether it leads to improvements in coverage. FUNDING Bill & Melinda Gates Foundation.

The economics of malaria in pregnancy--a review of the evidence and research priorities.

Malaria in pregnancy is a major public-health problem in the developing world. However, on review of the evidence, we found its economic impact is not well documented. Adequately capturing the economic burden of malaria in pregnancy requires good epidemiological data including effects to the mother and baby, and better understanding of the long-term health and economic costs of malaria in pregnancy. We reviewed evidence on coverage, equity, cost, and cost-effectiveness of interventions to tackle malaria in pregnancy and found that although key interventions are highly cost effective, coverage is currently inadequate and fails to reach the poor. The evidence on interventions to improve treatment of malaria in pregnancy is scarce, and fails to adequately capture the benefits. There is also lack of data on cost-effectiveness of other interventions, especially outside of Africa, in low transmission settings, and for non-falciparum malaria. Research priorities on the economics of malaria in pregnancy are identified.

Malaria in pregnancy: priorities for research

Research on the important topic of malaria in pregnancy has been relatively neglected. The seven technical reviews in this special issue on malaria in pregnancy provide an overview of current knowledge on key aspects of malaria in pregnancy and highlight the gaps where more research is needed. In this paper, we prioritise research needs, focusing on areas of research likely to lead to improvements in maternal and child health in malaria endemic areas in the near or mid term. We have selected the following as the highest priorities for research: identification of new safe and effective drugs to treat malaria in pregnancy; identification of new drugs to replace sulfadoxine-pyrimethamine for intermittent preventive treatment in pregnancy; identification of optimum combinations of control measures in different epidemiological settings; and determination of optimum ways of scaling-up the use of insecticide-treated mosquito nets and intermittent preventive treatment.

Comparative efficacy of chloroquine and sulphadoxine – pyrimethamine in pregnant women and children: a meta‐analysis

Objective  To compare the efficacy of chloroquine and sulphadoxine–pyremethamine against Plasmodium falciparum infection in pregnant women and in children from the same endemic areas of Africa, with the aim of determining the level of correspondence in efficacy determinations in these two risk groups.

Experience of targeting subsidies on insecticide‐treated nets: what do we know and what are the knowledge gaps?

Widespread coverage of vulnerable populations with insecticide‐treated nets (ITNs) constitutes an important component of the Roll Back Malaria (RBM) strategy to control malaria. The Abuja Targets call for 60% coverage of children under 5 years of age and pregnant women by 2005; but current coverage in Africa is unacceptably low. The RBM ‘Strategic Framework for Coordinated National Action in Scaling‐up Insecticide‐Treated Netting Programmes in Africa’ promotes coordinated national action and advocates sustained public provision of targeted subsidies to maximise public health benefits, alongside support and stimulation of the private sector. Several countries have already planned or initiated targeted subsidy schemes either on a pilot scale or on a national scale, and have valuable experience which can inform future interventions. The WHO RBM ‘Workshop on mapping models for delivering ITNs through targeted subsidies’ held in Zambia in 2003 provided an opportunity to share and document these country experiences. This paper brings together experiences presented at the workshop with other information on experiences of targeting subsidies on ITNs, net treatment kits and retreatment services (ITN products) in order to describe alternative approaches, highlight their similarities and differences, outline lessons learnt, and identify gaps in knowledge. We find that while there is a growing body of knowledge on different approaches to targeting ITN subsidies, there are significant gaps in knowledge in crucial areas. Key questions regarding how best to target, how much it will cost and what outcomes (levels of coverage) to expect remain unanswered. High quality, well‐funded monitoring and evaluation of alternative approaches to targeting ITN subsidies is vital to develop a knowledge base so that countries can design and implement effective strategies to target ITN subsidies.

Delivery of insecticide-treated net services through employer and community-based approaches in Kenya

Background and objectives  Many approaches have been used to deliver insecticide‐treated nets (ITNs) to African communities in different settings. Between 1992 and 2002, the African Medical and Research Foundation (AMREF), Kenya, used two ITN delivery models: the employer‐based approach and the community‐based approach. These two approaches have never been compared in order to inform their potential for future ITN delivery. We aimed to (1) compare the extent of ITN ownership, use and retreatment coverage in different population groups in the employer and community‐based models and (2) identify options for improving peoples acceptance and use of treatment/retreatment services.