Intermittent Preventive Treatment In Pregnancy With Sulfadoxine-pyrimethamine Research Articles

Enhancing IPTp Program Implementation: Provider Practices, Challenges, and Malaria Prevalence among Pregnant Women in Uganda

Malaria remains a formidable public health threat, particularly in sub-Saharan Africa, where pregnant women face heightened vulnerability. Intermittent Preventive Treatment in pregnancy with Sulfadoxine Pyrimethamine (IPTp-SP) stands as a pivotal strategy in malaria prevention efforts. However, its full potential is hindered by challenges in implementation. This study, conducted at Bushenyi Health Centre IV in Uganda, scrutinized provider practices, challenges encountered, and malaria prevalence among pregnant women attending antenatal care services. Through a descriptive cross-sectional approach involving 151 pregnant mothers and 15 antenatal care providers, analysis revealed noteworthy insights. While a majority of pregnant women received IPTp-SP, adherence to WHO guidelines regarding administration timing and frequency was suboptimal. Notably, over half of the providers reported stockouts of IPTp-SP, leading to significant delays in replenishment and impeding service delivery. Moreover, providers identified a crucial link between women's knowledge and IPTp uptake. The study also uncovered a malaria prevalence of 7.9% among pregnant women. These findings underscore the urgent need to address implementation challenges, particularly in supply chain management and health education, to fortify malaria prevention strategies for pregnant women in Uganda. Keywords: Malaria, Pregnant women, IPTp-SP, Antenatal care, Implementation challenges, Supply chain management, Health education, Uganda.

Were Women Staying on Track with Intermittent Preventive Treatment for Malaria in Antenatal Care Settings? A Cross-Sectional Study in Senegal.

A significant gap exists between high rates of antenatal care attendance and low uptake of intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) in Senegal. This study aims to investigate whether IPTp-SP is delivered per Senegal’s national guidelines and to identify factors affecting the delivery of IPTp-SP at antenatal care visits. A secondary analysis was conducted using the 2014 and 2016 Senegal’s Service Provision Assessment. The study sample consists of 1076 antenatal care across 369 health facilities. Multiple logit regression models were used to estimate the probability of receiving IPTp-SP during the antenatal care visit based on prior receipt of IPTp-SP and gestational age during the current pregnancy. At an antenatal care visit, the probability of receiving IPTp-SP is 84% (95% CI = [83%, 86%]) among women with no IPTp-SP history and 85% (95% CI = [79%, 92%]) among women with one prior dose. Women who visit a facility in the top quintile of the proportion of IPTp trained staff have a nearly 4-fold higher odds of receiving IPTp compared to those who visit a facility in the bottom quintile (95% CI = [1.54, 9.80]). The dose and timing of IPTp-SP provided in antenatal care settings in Senegal did not always conform with the national guideline. More training for providers and patient engagement is warranted to improve the uptake of IPTp-SP in antenatal care visits.

Effectiveness of Intermittent Preventive Treatment With Dihydroartemisinin-Piperaqunine Against Malaria in Pregnancy in Tanzania: A Randomized Controlled Trial.

Intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) to prevent malaria and adverse birth outcomes is threatened by Plasmodium falciparum resistance to sulfadoxine-pyrimethamine. We investigated the effectiveness of intermittent preventive treatment in pregnancy with monthly dihydroartemisinin-piperaquine (IPTp-DHP) as an alternative option to IPTp-SP. A total of 956 malaria-free (malaria rapid diagnostic test (MRDT) negative) pregnant women from moderate malaria transmission areas in Tanzania were enrolled and randomized to receive monthly IPTp-DHP (n=478) or IPTp-SP (n=478) and followed for maternal and birth outcomes. The primary outcome was the prevalence of histopathologically confirmed placental malaria (active or past infection). Secondary outcomes were overall malaria at delivery, symptomatic-malaria, parasitemia during pregnancy, and adverse birth outcomes as a composite of spontaneous-abortion, premature birth, stillbirth, and low birth weight (LBW) fetal anemia. Outcome differences between treatment groups were expressed as the protective efficacy (PE), defined as 1-prevalence ratios or 1-incidence rate ratio. The prevalence of histopathologically confirmed placental malaria was significantly lower in IPTp-DHP (2.5%, 12/478) than IPTp-SP (8.2%, 39/478); PE=69% (95% confidence interval (CI): 42-84, P<0.001). The prevalence of maternal malaria at delivery was significantly lower in IPTp-DHP (8.2%) than IPTp-SP (18.2%, P<0.001). The incidence per person-years at risk for symptomatic-malaria (0.02 vs. 0.12, P=0.002) and parasitemia during pregnancy (0.28 vs. 0.67, P<0.001) were significantly lower in the IPTp-DHP group than in the IPTp-SP group. The prevalence of any adverse birth outcomes (composite) was not significantly (P=0.06) different between IPTp-DHP (17.9%) and IPTp-SP (23.8%). However, the prevalence of LBW (4.6% vs. 9.6%, P=0.003) was significantly lower in IPTp-DHP compared with IPTp-SP. We report superior protective efficacy of monthly IPTp-DHP against malaria in pregnancy and LBW than IPTp-SP.

Cost-effectiveness of intermittent preventive treatment with dihydroartemisinin–piperaquine for malaria during pregnancy: an analysis using efficacy results from Uganda and Kenya, and pooled data

SummaryBackgroundPrevention of malaria infection during pregnancy in HIV-negative women currently relies on the use of long-lasting insecticidal nets together with intermittent preventive treatment in pregnancy with sulfadoxine–pyrimethamine (IPTp-SP). Increasing sulfadoxine–pyrimethamine resistance in Africa threatens current prevention of malaria during pregnancy. Thus, a replacement for IPTp-SP is urgently needed, especially for locations with high sulfadoxine–pyrimethamine resistance. Dihydroartemisinin–piperaquine is a promising candidate. We aimed to estimate the cost-effectiveness of intermittent preventive treatment in pregnancy with dihydroartemisinin–piperaquine (IPTp-DP) versus IPTp-SP to prevent clinical malaria infection (and its sequelae) during pregnancy.MethodsWe did a cost-effectiveness analysis using meta-analysis and individual trial results from three clinical trials done in Kenya and Uganda. We calculated disability-adjusted life-years (DALYs) arising from stillbirths, neonatal death, low birthweight, mild and moderate maternal anaemia, and clinical malaria infection, associated with malaria during pregnancy. Cost estimates were obtained from data collected in observational studies, health-facility costings, and from international drug procurement databases. The cost-effectiveness analyses were done from a health-care provider perspective using a decision tree model with a lifetime horizon. Deterministic and probabilistic sensitivity analyses using appropriate parameter ranges and distributions were also done. Results are presented as the incremental cost per DALY averted and the likelihood that an intervention is cost-effective for different cost-effectiveness thresholds.FindingsCompared with three doses of sulfadoxine–pyrimethamine, three doses of dihydroartemisinin–piperaquine, delivered to a hypothetical cohort of 1000 pregnant women, averted 892 DALYs (95% credibility interval 274 to 1517) at an incremental cost of US$7051 (2653 to 13 038) generating an incremental cost-effectiveness ratio (ICER) of $8 (2 to 29) per DALY averted. Compared with monthly doses of sulfadoxine–pyrimethamine, monthly doses of dihydroartemisinin–piperaquine averted 534 DALYS (−141 to 1233) at a cost of $13 427 (4994 to 22 895), resulting in an ICER of $25 (−151 to 224) per DALY averted. Both results were highly robust to most or all variations in the deterministic sensitivity analysis.InterpretationOur findings suggest that among HIV-negative pregnant women with high uptake of long-lasting insecticidal nets, IPTp-DP is cost-effective in areas with high malaria transmission and high sulfadoxine–pyrimethamine resistance. These data provide a comprehensive overview of the current evidence on the cost-effectiveness of IPTp-DP. Nevertheless, before a policy change is advocated, we recommend further research into the effectiveness and costs of different regimens of IPTp-DP in settings with different underlying sulfadoxine–pyrimethamine resistance.FundingMalaria in Pregnancy Consortium, which is funded through a grant from the Bill & Melinda Gates Foundation to the Liverpool School of Hygiene and Tropical Medicine.

Malaria knowledge and experiences with community health workers among recently pregnant women in Malawi

BackgroundThe World Health Organization recommends three or more doses of intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) to mitigate the negative effects of malaria in pregnancy (MIP). Many pregnant women in Malawi are not receiving the recommended number of doses. Community delivery of IPTp (cIPTp) is being piloted as a new approach to increase coverage. This survey assessed recently pregnant women’s knowledge of MIP and their experiences with community health workers (CHWs) prior to implementing cIPTp.MethodsData were collected via a household survey in Ntcheu and Nkhata Bay Districts, Malawi, from women aged 16–49 years who had a pregnancy resulting in a live birth in the previous 12 months. Survey questions were primarily open response and utilized review of the woman’s health passport whenever possible. Analyses accounted for selection weighting and clustering at the health facility level and explored heterogeneity between districts.ResultsA total of 370 women were interviewed. Women in both districts found their community health workers (CHWs) to be helpful (77.9%), but only 35.7% spoke with a CHW about antenatal care and 25.8% received assistance for malaria during their most recent pregnancy. A greater proportion of women in Nkhata Bay than Ntcheu reported receiving assistance with malaria from a CHW (42.7% vs 21.9%, p = 0.01); women in Nkhata Bay were more likely to cite IPTp-SP as a way to prevent MIP (41.0% vs 24.8%, p = 0.02) and were more likely to cite mosquito bites as the only way to spread malaria (70.6% vs 62.0% p = 0.03). Women in Nkhata Bay were more likely to receive 3 + doses of IPTp-SP (IPTp3) (59.2% vs 41.8%, p = 0.0002). Adequate knowledge was associated with increased odds of receiving IPTp3, although not statistically significantly so (adjusted odds ratio = 1.50, 95% confidence interval 0.97–2.32, p-value 0.066).ConclusionsWomen reported positive experiences with CHWs, but there was not a focus on MIP. Women in Nkhata Bay were more likely to be assisted by a CHW, had better knowledge, and were more likely to receive IPTp3+ . Increasing CHW focus on the dangers of MIP and implementing cIPTp has the potential to increase IPTp coverage.

Effectiveness of Sulfadoxine-Pyrimethamine for Intermittent Preventive Treatment of Malaria and Adverse Birth Outcomes in Pregnant Women.

Effectiveness of intermittent preventive treatment in pregnancy with sulfadoxine–pyrimethamine (IPTp-SP) for prevention of malaria and adverse birth outcomes can be compromised by parasites-resistance to sulfadoxine–pyrimethamine. This study prospectively evaluated the effectiveness of IPTp-SP in Southeast Tanzania. From January 2017 to May 2019, HIV-negative and malaria-negative (mRDT) pregnant women attending their first antenatal-care visit in the second or third trimester (n = 500) were enrolled to receive monthly IPTp-SP and followed the protocol till delivery. The primary outcome was the prevalence of histopathological placental malaria. Secondary outcomes were anemia, malaria parasites detected during pregnancy and at delivery, adverse birth outcomes (low-birth-weight [LBW], premature birth, fetal anemia, still birth, and spontaneous abortion). Rates of histopathological placental malaria, any parasitemia at delivery (placental, cord or maternal), and any adverse birth outcome were 9.4%, 20.9%, and 26.5%, respectively. Rates of symptomatic malaria and parasitemia during pregnancy were 2.8% and 16%, respectively. Histopathological placental malaria significantly increased the odds of any adverse birth outcomes, particularly LBW. IPTp-SP with more than or equal to three doses significantly improved birth weight and reduced the risk of LBW by 56% compared to <3 SP doses (p = 0.009). IPTp-SP with more than or equal to three doses is still effective in improving birth weight. However, the detection of histopathological placental-malaria in one-tenth and parasitemia in one-fifth of pregnant women reflects the need to optimize the prevention of malaria during pregnancy.

Uptake of intermittent preventive treatment in pregnancy for malaria: further analysis of the 2016 Ghana Malaria Indicator Survey

Significant proportions of pregnant women living in malaria-endemic countries throughout the world are exposed to the risk of malaria. The World Health Organization (WHO) suggests the use of intermittent preventive treatment in pregnancy with sulfadoxine–pyrimethamine (IPTp-SP) in at least three doses to achieve the optimal benefit of preventing malaria among pregnant women. The study uses secondary data from the 2016 Ghana Malaria Indicator Survey (GMIS). The analysis included a total of 1220 women aged from 15 to 49 who had children under the age of 24 months and who attended antenatal care (ANC) during their pregnancy. Multinomial logistic regression is used to examine the uptake of partial and optimal doses of IPTp-SP. The results show that, overall, the proportion of women in Ghana with uptake of IPTp-SP during pregnancy was 63% for three or more doses, 27% for one to two doses, and 10% for no dose. Uptake varies by background characteristics. At the bivariate level, sociodemographic factors (level of education and religion) and knowledge-related factors (exposure to messages on treatment of malaria and covered by health insurance) predicted partial (1–2 doses) or optimal uptake (3+ doses) of IPTp-SP compared to no uptake among pregnant women. The multinomial regression analysis showed that region, education, wealth, and exposure to messages on treatment of malaria are associated with uptake of optimal doses of IPTp-SP compared to partial uptake. The Ministry of Health, the National Malaria Control Program, Ghana Health Service, and other stakeholders should take cognizance of these factors in planning programs for improving uptake of IPTp-SP among pregnant women. Efforts should be made by stakeholders to increase women’s exposure to mass media messages on the use of IPTp-SP for malaria during pregnancy.

Health Workers' Awareness and Knowledge of Current Recommendation of Intermittent Preventive Treatment in Pregnancy in South-Western Nigeria.

Malaria in pregnancy is of public health significance because of its associated maternal and fetal complications. This study aimed to assess health workers' awareness and knowledge of the current World Health Organisation (WHO) recommendation of intermittent preventive treatment in pregnancy with Sulfadoxine-Pyrimethamine (IPTp-SP). A cross-sectional study among 148 health workers who offer obstetrics care in selected health facilities in Ibadan, Nigeria using a self-administered questionnaire to evaluate their awareness and knowledge of the current WHO IPTp-SP. Information on their socio-demographic and professional characteristics, awareness, knowledge and practice of the current IPTp recommendation were obtained. Data analysis involved descriptive and bivariate analyses using SPSS version 20.0 with level of significance set at p<0.05. The majority, 85(57.4%), of the health workers had been providing obstetrics care for less than 5 years with most of them, 114(77.0%), practicing at tertiary health facility. More than half, 92(62.2%), of them were aware of the current WHO IPTp-SP recommendation while about two-fifth (39.1%) had its correct knowledge. Of the health workers who were knowledgeable of the current IPTp-SP recommendation almost three-quarter, 29(72.2%) of them prescribed it. The health workers' professional cadre (p<0.001) and duration of providing obstetrics care (p=0.012) were significantly associated with their awareness and correct knowledge of the current IPTp-SP recommendation. Most of the health workers are aware but not knowledgeable of the correct administration of the current IPTp-SP recommendation. Likewise, many of them do not prescribe it. This calls for regular training and update of health workers and institutional protocol so as to effectively reduce the prevalence of malaria in pregnancy and its complications.

Factors influencing adherence to the new intermittent preventive treatment of malaria in pregnancy policy in Keta District of the Volta region, Ghana

BackgroundAbout 25% of pregnant women in malaria-endemic areas are infected with malaria and this accounts for about 15% of maternal deaths globally. Intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) is one of the main strategies for prevention of malaria in pregnancy. A new recommendation was made by the World Health Organization (WHO) that at least three doses of IPTp-SP should be administered before delivery. This study sought to determine the factors influencing adherence to the new IPTp-SP policy in Keta District, Volta region, Ghana.MethodsA cross-sectional quantitative study among 375 nursing mothers at four selected health facilities in Keta district, Ghana was conducted using a structured questionnaire to interview participants. Sampling proportionate to the size of facility was used to determine the number of nursing mothers from each facility based on the caseload. For each facility systematic random sampling was used to select eligible nursing mothers. Data was analyzed using STATA 15. Chi-square was used to test bivariate association between categorical variables and adherence. Logistic regression analysis was used to examine sociodemographic, individual and institutional factors influencing adherence to IPTp-SP.ResultAbout 82.1% of participants adhered to the WHO policy recommendations of at least three doses of IPTp-SP. However, only 17.1% received Ghana’s five dose coverage recommendation. The proportion of IPTp-SP coverage for IPTp1 was 98.9%; IPTp2 95.5%; IPTp3 80.8%; IPTp4 39.5%; IPTp5 17.1%.ConclusionAdherence to IPTp-SP was satisfactory according to WHO’s policy recommendation, however, majority of the participants had less than the five doses recommended in Ghana. Number of Antenatal Care (ANC) visits and knowledge of malaria were the main determinants of adherence to IPTp-SP.

Antenatal visits are positively associated with uptake of tetanus toxoid and intermittent preventive treatment in pregnancy in Ivory Coast

BackgroundMalaria and tetanus infections among pregnant women represent two major public health problems in sub-Saharan Africa. Optimum use of Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (IPTp-SP) and immunization against tetanus among pregnant women during antenatal care (ANC) visits are recommended strategies to prevent these issues. Despite these recommendations, many women in Africa remain deprived of these cost-effective and life-saving interventions. In this study, we aimed to examine the prevalence of women using these two services, and the association between women’s uptake of IPTp-SP and tetanus toxoid (TT) with antenatal care use in Ivory Coast.MethodsThis study was based on the fifth round of Multiple Indicator Cluster Survey (MICS 5) conducted in Ivory Coast in 2016. Participants were 9583 women aged between 15 and 49 years. Outcomes were TT and Intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP). Data analysis was conducted using bivariate and multiple logistic regression.ResultsIn this study, the prevalence of taking TT immunization and IPTp-SP drugs was 81.97 and 17.83% respectively. Of the participants who took these drugs at all, the prevalence of taking adequate doses of TT immunization was 78.75% and that of IPTp-SP was 35.46%. In the multivariable analysis model, higher age groups, 25–29 years (OR = 2.028, 95%CI = 1.120–3.669) were found to be positively associated with uptake of adequate doses of IPTp-SP drugs. Women who attended at least four ANC visits had higher odds of taking IPTp-SP drugs (OR = 1.656, 95%CI = 1.194–2.299) and TT immunization (OR = 2.347, 95%CI = 1.384–3.981), and also had higher odds of receiving adequate doses of IPTp-SP drugs (OR = 3.291, 95%CI = 2.157–5.020) and that of TT immunization (OR = 1.968, 95%CI = 1.398–2.771). The odds of taking IPTp-SP drugs were significantly higher among women with primary (OR = 2.504, 95%CI = 1.020–6.146) and secondary/higher education (OR = 3.298, 95%CI = 1.343–8.097) compared to those with no education. Also, women with higher parity had lower odds of taking TT immunization (OR = 0.218, 95%CI = 0.055–0.858) compared to those with lower parity. Findings from this study also revealed that the odds of taking adequate doses of IPTp-SP drugs were significantly lower among participants from Mandé du Nord ethnicity (OR = 0.378,95%CI = 0.145–0.983) compared to those from other ethnicities.ConclusionIn this study, uptake of IPTp-SP drugs was much lower than TT immunization. High number of ANC visits were found to be significantly associated with taking IPTp-SP drugs and TT immunization and also with that of taking them in adequate doses. Vaccination promotion is necessary to protect pregnant women and reduce adverse health outcomes among the newborn in Ivory Coast.

Évaluation de la connaissance du traitement préventif intermittent au cours de la grossesse (TPIg) par la sulfadoxine-pyriméthamine en Côte d’Ivoire

In 2006, because of the chloroquine-resistance and following the World Health Organization (WHO) recommendations, Côte d'Ivoire adopted a new policy for the prevention of malaria during pregnancy by intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP). However, its implementation remains limited. Objectives of this study were to evaluate the knowledge of the TPIp-SP regimen and prescribers opinion concerning this protocol. It was a knowledge attitude and pratices (KAP) cross-sectional descriptive study. We used a two-stage stratified sounding. The study took place in 12 health facilities in the health region of Abidjan 2 from march to august 2016 and involved 187 health professionals. We performed descriptive analysis, univariate and bivariate comparative analysis. The study found that half of the prescribers surveyed actually knew the ITPp program (SP - 3 doses - 2nd and 3rd trimesters). Knowledge was better among practitioners with more than 5 years of exercise (P=0.011) and at the level of first contact of health institution (P=0.001). Half of the prescribers were in favor of applying the protocol. The level of knowledge of prescribers has changed little in 2016 compared to 2008 for physicians (Pr (|Z|<|z|)=0.4861) or midwives Pr (|Z|<|z|)=0.4786). Prescribers remained faithful to the old 2-dose protocol. The opinion on the protocol was better in 2016 compared to 2008 Pr (Z<z)=0.0052. Effective knowledge of the ITPp regimen remains average for many years after its implementation. However opinions are better. Strengthening prevention interventions with health professionals is necessary for effective implementation of this protocol.

Community-based Malaria Screening and Treatment for Pregnant Women Receiving Standard Intermittent Preventive Treatment With Sulfadoxine-Pyrimethamine: A Multicenter (The Gambia, Burkina Faso, and Benin) Cluster-randomized Controlled Trial.

We investigated whether adding community scheduled malaria screening and treatment (CSST) with artemether-lumefantrine by community health workers (CHWs) to standard intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) would improve maternal and infant health. In this 2-arm cluster-randomized, controlled trial, villages in Burkina Faso, The Gambia, and Benin were randomized to receive CSST plus IPTp-SP or IPTp-SP alone. CHWs in the intervention arm performed monthly CSST during pregnancy. At each contact, filter paper and blood slides were collected, and at delivery, a placental biopsy was collected. Primary and secondary endpoints were the prevalence of placental malaria, maternal anemia, maternal peripheral infection, low birth weight, antenatal clinic (ANC) attendance, and IPTp-SP coverage. Malaria infection was detected at least once for 3.8% women in The Gambia, 16.9% in Benin, and 31.6% in Burkina Faso. There was no difference between study arms in terms of placenta malaria after adjusting for birth season, parity, and IPTp-SP doses (adjusted odds ratio, 1.06 [95% confidence interval, .78-1.44]; P = .72). No difference between the study arms was found for peripheral maternal infection, anemia, and adverse pregnancy outcomes. ANC attendance was significantly higher in the intervention arm in Burkina Faso but not in The Gambia and Benin. Increasing number of IPTp-SP doses was associated with a significantly lower risk of placenta malaria, anemia at delivery, and low birth weight. Adding CSST to existing IPTp-SP strategies did not reduce malaria in pregnancy. Increasing the number of IPTp-SP doses given during pregnancy is a priority. NCT01941264; ISRCTN37259296.

Intermittent preventive therapy in pregnancy with sulfadoxine/pyrimethamine for malaria prophylaxis among parturients in Ilorin, Nigeria

Background: The use of intermittent preventive treatment in pregnancy with sulfadoxine/pyrimethamine (IPTp-SP) for malaria remains an important tool for improving pregnancy outcome in malaria endemic areas. Objective: To assess the knowledge, attitude, and factors associated with the use of IPTp-SP among antenatal clinic attendees in Ilorin. Materials and Methods: A prospective, multicentre, cross-sectional study among consenting parturients receiving antenatal care at three public health facilities in Ilorin, Nigeria. Statistical analysis was conducted with the Statistical Package for the Social Sciences version 20.0 software (SPSS Inc., Chicago, IL, United States) with the calculation of percentages, chi square, odds ratios (ORs), and confidence intervals (CIs); P Results: There were 422 participants with mean age of 28.8 ± 4.7 years and 368 (87.2%) were aware of the use of IPTp-SP for malaria prevention, while 388 (91.9%) were willing to use IPTp-SP. Only 154 (36.5%) had prescription for IPTp-SP among whom 139 (90.3%) were compliant; IPTp-SP uptake in preceding pregnancy was 148 (59.7%). The most common reason for the nonuse of IPTp-SP prescribed was the fear of harm to the fetus (53.3%). Significant determinants of willingness to use IPTp-SP were maternal age (P = 0.007) and monthly income (P = 0.013), IPTp-SP use in preceding pregnancy (P = 0.001), and the treatment for malaria in index pregnancy (P = 0.014). On logistic regression, maternal age Conclusion: Parturients desire IPTp-SP, but the prescription rate by healthcare providers was low. Healthcare providers should increase the prescription and address the concerns about its teratogenicity. Governments and other agencies should prioritize free provision and the availability of SP at health facilities.

Investigation of pregnancy-associated malaria by microscopy, rapid diagnostic test and PCR in Bandundu, the Democratic Republic of Congo.

The study was conducted to investigate malaria prevalence among a group of women in the Democratic Republic of Congo (DRC) who received intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP). A total of 250 women from Bandundu city who received two doses of IPTp-SP were enrolled in the survey. Blood samples were collected at the time of delivery and malaria prevalence was determined using microscopy, rapid diagnostic test (RDT), and nested polymerase chain reaction (PCR). Malaria infection was detected in 81 (32.4%), 93 (37.2%), and 92 (36.8%) samples by microscopy, RDT, and PCR, respectively. Among 92 samples, P. falciparum mono-infection (n=87; 94.5%), P. falciparum+P. vivax (n=2; 2.2%) and P. falciparum+P. malariae (n=1; 1.1%) mixed infections, and P. vivax mono-infection (n=2; 2.2%) were detected. Prevalence of malaria was not affected by age and number of pregnancies (p>0.05). Microscopy and RDT, either alone (κ=0.29; p<0.001) or in combination (κ=0.33; p<0.001) showed a fair agreement with PCR. Our findings indicate that two doses of IPTp-SP did not protect the women against malaria in the DRC, and support the World Health Organization (WHO) guidelines that ensure a minimum of three doses of SP in pregnancy.

Safety and Toxicity of Sulfadoxine/Pyrimethamine

Plasmodium falciparum infection during pregnancy is strongly associated with maternal anaemia and low birth weight, contributing to substantial morbidity and mortality in sub-Saharan Africa. Intermittent preventive treatment in pregnancy with sulfadoxine/pyrimethamine (IPTp-SP) has been one of the most effective approaches to reduce the burden of malaria during pregnancy in Africa. IPTp-SP is based on administering >or=2 treatment doses of sulfadoxine/pyrimethamine to pregnant women at predefined intervals after quickening (around 18-20 weeks). Randomised, controlled trials have demonstrated decreased rates of maternal anaemia and low birth weight with this approach. The WHO currently recommends IPTp-SP in malaria-endemic areas of sub-Saharan Africa. However, implementation has been suboptimal in part because of concerns of potential drug toxicities. This review evaluates the toxicity data of sulfadoxine/pyrimethamine, including severe cutaneous adverse reactions, teratogenicity and alterations in bilirubin metabolism. Weekly sulfadoxine/pyrimethamine prophylaxis is associated with rare but potentially fatal cutaneous reactions. Fortunately, sulfadoxine/pyrimethamine use in IPTp programmes in Africa, with 2-4 treatment doses over 6 months, has been well tolerated in multiple IPTp trials. However, sulfadoxine/pyrimethamine should not be administered concurrently with cotrimoxazole given their redundant mechanisms of action and synergistic worsening of adverse drug reactions. Therefore, HIV-infected pregnant women in malaria endemic areas who are already receiving cotrimoxazole prophylaxis should not also receive IPTp-SP. Although folate antagonist use in the first trimester is associated with neural tube defects, large case-control studies have demonstrated that sulfadoxine/pyrimethamine administered as IPTp (exclusively in the second and third trimesters and after organogenesis) does not result in an increased risk of teratogenesis. Folic acid supplementation is recommended for all pregnant women to reduce the rate of congenital anomalies but high doses of folic acid (5 mg/day) may interfere with the antimalarial efficacy of sulfadoxine/pyrimethamine. However, the recommended standard dose of folic acid supplementation (0.4 mg/day) does not affect antimalarial efficacy and may provide the optimal balance to prevent neural tube defects and maintain the effectiveness of IPTp-SP. No clinical association between sulfadoxine/pyrimethamine use and kernicterus has been reported despite the extensive use of sulfadoxine/pyrimethamine and related compounds to treat maternal malaria and congenital toxoplasmosis in near-term pregnant women and newborns. Although few drugs in pregnancy can be considered completely safe, sulfadoxine/pyrimethamine - when delivered as IPTp - has a favourable safety profile. Improved pharmacovigilance programmes throughout Africa are now needed to confirm its safety as access to IPTp-SP increases. Given the documented benefits of IPTp-SP in malaria endemic areas of Africa, access to this treatment for pregnant women should continue to expand.