The Use of Intermittent Preventive Treatment With Sulfadoxine-Pyrimethamine for Preventing Malaria in Pregnant Women

Abstract

When a woman is pregnant, especially for the first and second times, she is susceptible to more frequent and severe malaria infections than when she was not pregnant. These infections are associated with maternal anemia, premature deliveries, and low birth weight infants. In areas where malaria is endemic, strategies to control malaria during pregnancy include preventive measures, such as the use of insecticide-treated mosquito nets (ITNs) and intermittent preventive treatment (IPTp), as well as case management as a curative measure. With regard to IPTp in the African Region, the World Health Organization (WHO) recommends 2 or 3 doses of sulfadoxine-pyrimethamine (SP) that are given during the second and third trimesters, at least 1 month apart [1]. This policy has been accepted by most African countries, and SP is delivered at routine antenatal visits. IPTp is being scaled up through reproductive health programs, particularly with funds from the Global Fund for the fight against Tuberculosis, AIDS, and Malaria. Results from other trials have shown that an additional dose of SP adds more benefit over the 2-dose regimen among human immunodeficiency virus (HIV)– infected women who are primiand secundi-gravidae [2]. Thus, the WHO recommends 2 or 3 doses of IPTp SP, with 3 doses being used where the prevalence of HIV infection among women is high. Some countries, such as Cameroon, have selected 3 doses of SP in their policy for all pregnant women, whereas some countries, such as Mali, chose 2 doses. In this issue of the journal, Maiga et al [3] report on a randomized clinical trial performed in Mali, which shows the superiority of 3 over 2 doses of IPTp SP for the prevention of placenta malaria and associated low birth weight infants. Mali, as the authors describe, has highly seasonal malaria transmission, moderate levels of ITN use, and low levels of SP resistance. Mali had adopted a 2-dose strategy in 2003. A survey of 1696 pregnant women during 2005–2007 showed that women who completed IPT SP early during the third trimester had reinfections later during the third trimester, meaning that the 2 doses provided insufficient protection. Therefore, the study reported in this issue was undertaken. Results of this randomized clinical trial clearly showed that adding a third dose of SP halved the risk of placenta malaria and low birth weight in all gravidae, compared with the standard 2-dose regimen. This study has therefore provided evidence that was needed in Mali, to move their policy from 2 to 3 doses. In the study design, the use of ITNs was not considered as a factor, most likely because Mali has moderate levels of ITN use. Studies from Kenya and the Gambia [2] have shown that IPTp SP provides less benefit to pregnant women who are using ITNs. Thus, increased use of ITNs may overcome the need for a third dose of SP, which would result in less use of SP by the population and, consequently, put less drug pressure on the parasite. Increased drug use and its consequence of drug pressure is an important factor that drives the development of drug-resistant parasites. Received 25 April 2011; accepted 29 April 2011. Correspondence: Rose Gana Fomban Leke, PhD, Department of Microbiology, Immunology and Hematology, Faculty of Medicine and Biomedical Sciences, Biotechnology Center, University of Yaounde 1, Yaounde, Cameroon (roseleke@ yahoo.com). Clinical Infectious Diseases 2011;53(3):231–233 The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. permissions@oup.com. 1058-4838/2011/533-0003$14.00 DOI: 10.1093/cid/cir383