New Malaria in Pregnancy )https://docs.google.com/a/maternova.net/viewer?a=v&pid=gmail&attid=0.1&thid=141fff1a89b55ce2&mt=application/pdf&url=https://mail.google.com/mail/u/0/?ui%3D2%26ik%3De226118c78%26view%3Datt%26th%3D141fff1a89b55ce2%26attid%3D0.1%26disp%3Dsafe%26zw&sig=AHIEtbT5q5eeQ7GLvinVi01XhQzgtYTEBQ
1. Promoting insecticide-treated net use for pregnant women
Notable progress has been made in the distribution of ITNs, but malaria control programmes
are still far from achieving universal coverage targets for the availability and routine use of ITNs. Progress towards achieving universal coverage has been hindered by a recent decrease in the distribution of ITNs: deliveries to countries in Africa fell from 145 million ITNs in 2010 to 92 million in 2011 and then to 66 million in 2012 (3). Countries are now beginning to feel the impact of the reduced availability of ITNs and are developing strategies for prioritizing ITNs. This is an important moment for malaria control programmes and RMNCH programmes to jointly advocate for all ITNs to be replaced in a timely manner, and to work together towards universal coverage of vector
1 The WHO Regional Office for Africa has prepared a new focused antenatal care (FANC) training manual that outlines the schedule of four visits in the second and third trimester, as well as a booking visit in the first trimester to ensure early entry into care.
control for all people at risk, including pregnant women, and to ensure that advances made in
integrating ITN delivery into ANC services are sustained.
It is critical for all pregnant women in affected areas to sleep under an ITN throughout pregnancy, particularly early in the pregnancy (before the administration of the first dose of IPTp-SP) and during the postpartum period. Since many women will not know their pregnancy status immediately, malaria-endemic countries should also consider targeting women of reproductive age, to maximize preventive efforts. Delivery of ITNs through antenatal clinics should continue to be promoted but other strategies should also be used to ensure that all pregnant women sleep under an ITN from the beginning of their pregnancy, such as delivery of ITNs by community health workers.
2. Scaling up intermittent preventive treatment in pregnancy
In 2012, the WHO Malaria Policy Advisory Committee (MPAC) reviewed recent evidence on the efficacy and effectiveness of IPTp-SP and issued an updated WHO policy recommendation, promoting the increased uptake of IPTp-SP in all areas of Africa with moderate-to-high transmission of P. falciparum malaria (8). The MPAC did note, however, that there was insufficient evidence to recommend IPTp-SP outside of Africa. WHO’s recent updated policy recommendation confirms the critical importance of scaling up IPTp-SP as part of routine antenatal care services and provides the following guidance for administration of sulfadoxine-pyrimethamine (SP):
• SP should be given at each scheduled ANC visit, with the first dose being administered as early as possible in the second trimester.
• Each dose of SP should be given at least one month apart.
• The last dose of SP can be safely administered up to the time of delivery.
• IPTp-SP should ideally be administered as directly observed therapy (DOT).
• SP can be given either on an empty stomach or with food.
• Folic acid at daily doses of 5 mg or more should not be given together with SP.
• SP should not be administered to women receiving co-trimoxazole prophylaxis.
Despite the spread of SP resistance and the reduction of malaria transmission in some areas of sub-Saharan Africa, IPTp-SP continues to remain effective in preventing adverse malaria related maternal and newborn outcomes. Scientific evidence supporting these new recommendations, as well as information to assist in-country policy-makers and health-care providers with policy implementation, is summarized in the WHO policy brief for the implementation of intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (9).
3. Ensuring prompt and effective case management
Pregnant women with symptomatic acute malaria are a high-risk group, and they must promptly receive proper diagnosis and effective antimalarial treatment. The current WHO Guidelines for the treatment of malaria recommend that pregnant women in the first trimester with uncomplicated P. falciparum malaria be treated with quinine plus clindamycin for seven days (or quinine monotherapy if clindamycin is not available) (10). A combination of artesunate plus clindamycin for seven days is indicated if treatment with quinine plus clindamycin fails. Artemisinin-based combination therapies (ACTs) are recommended to treat uncomplicated falciparum malaria in the second and third trimesters of pregnancy. Alternatively, artesunate plus clindamycin (or quinine plus clindamycin) can be given for seven days during this period. For pregnant women with severe malaria, parenteral antimalarials should be administered in full doses without delay. Parenteral artesunate is preferred over quinine in the second and third trimesters. Prompt and effective case management reduces adverse maternal and newborn outcomes; this must be clearly articulated in all national policies and guidelines.
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