The document summarizes presentations from a malaria control conference. It discusses improving prevention of malaria in pregnancy through promoting early administration of IPTp-SP in the second trimester per WHO guidelines. It also discusses trends in global anemia, major causes, and programs to reduce anemia, including integrated community case management of malaria. The challenges of integrating and updating disease-specific guidelines for integrated case management are also addressed.

1. Malaria Control: Improving
Health Outcomes for Mothers
and Children
CORE Group: Global Health Practitioner Conference
April 17th, 2015

2. Session Objectives
• PresentationTitle: Prevention of Malaria in Pregnancy: Promoting IPTp-SP Early
in the SecondTrimester
• Objectives: Define theWHO policy recommendation for use of IPTp-SP;
describe determination of gestational age through history, lab test and physical
exam, and discuss implications of the policy change at facility and community
levels
• PresentationTitle: Anemia:Trends, causes and programs to address it
• Objectives: Discuss trends in global anemia, major causes of anemia, and
programs to reduce anemia
• PresentationTitle: Integrated Community Case Management: Challenges and
Successes in Diagnosis andTreatment of Malaria in the iCCM and IMCI Platforms
• Objective: Understanding of challenges related to the integration and
updating of several disease-specific guidelines for integrated case management

3. Presenters:
Lisa Noguchi
MCSP Senior Maternal Health Advisor, Jhpiego
Rae Galloway
MCSPTechnical Lead in Nutrition, PATH
Michel Pacqué
MCSPTechnical Lead in Child Health, JSI
Jane Coleman
MCSP Malaria Program Officer II, Jhpiego

4. Prevention of Malaria in
Pregnancy: Promoting IPTp-SP
Early in the SecondTrimester
Update onWHO Policy Recommendations for IPTp-SP
Lisa Noguchi, CNM, PhD
on behalf of the Maternal HealthTeam

5. Objectives
At the end of this module learners will be able
to do the following:
• Define theWHO policy recommendation for
use of IPTp-SP
• Describe determination of gestational age
through history, lab test and physical exam
• Discuss implications of the policy change at
facility and community levels

6. Why is this an important topic? (1/2)
• WHO/AFRO recommended IPTp-SP (2004)
• 1st, 2nd and 3rd dose in SSA is 64%, 38% and 23% respectively*
• Far from universal coverage recommended by Roll Back
Malaria
• Negative consequences associated with malaria in
pregnancy
• Severe malaria, severe anaemia, pre-term delivery, maternal
death, and placental malaria
• Linked to intrauterine growth restriction, stillbirth, and
delivery of low birth weight (LBW) infants**
*WHO. World Malaria Report 2013. Geneva: World Health Organization; 2013.
**Aribodor DN, Nwaorgu OC, Eneanya CI, Okoli I, Etaga HO: Association of low birth
weight and placental malarial infection in Nigeria. J Infect Dev Ctries 2009, 3:620–623.

7. Why is this an important topic? (2/2)
• PreviousWHO guidelines recommended first
dose of IPTp-SP at 16 weeks
• Country guidelines often suggested quickening as
the “benchmark”
• Now need to re-educate MOHs, training
systems, providers, and community decision-
makers about importance of a dose as early
as possible in the 2nd trimester

8. WHO Policy Recommendation for IPTp-SP (1/3)
• Starting as early as possible in second
trimester, which begins at 13 weeks, IPTp-SP is
recommended for all pregnant women at each
scheduled antenatal care (ANC) visit until
the time of delivery, provided that the
doses are given at least one month apart
• SP should not be given during first trimester
of pregnancy; however, last dose of IPTp-SP
can be administered up to time of delivery
without safety concerns

9. WHO Policy Recommendation for IPTp-SP (2/3)
• Should ideally be administered as directly
observed therapy (DOT)
• Three tablets sulfadoxine/pyrimethamine (each tablet
containing 500mg/25mg SP)
• =Total required dosage of 1500mg/75mg SP
• Can be given on empty stomach or with food
• Should not be administered to women
receiving cotrimoxazole prophylaxis due to
higher risk of adverse events

10. WHO Policy Recommendation for IPTp-SP (3/3)
• WHO recommends
administration of folic acid
0.4mg daily
• This dose may be safely used
in conjunction with SP
• Folic acid at daily dose of
5mg or higher should not
be given together with SP
• Counteracts its efficacy as an
antimalarial

11. Side effects of IPTp-SP
• SP for IPTp generally very well
tolerated
• Mild and transient side effects
• N/V, weakness, dizziness
• Most side effects reported with
first dose of SP
• Tend to decrease with further
doses
• Should be discussed openly and
managed in the ANC clinic

12. Implementation of theWHO Policy:
Questions to Consider (1/2)
• What components of theWHO Policy may present challenges
to implementation and scale-up? How can these be resolved?
• Provider/patient barriers, logistics, procurement,
financing for additional doses
• What strategies can be developed to increase access to SP
without increasing risks, e.g., administration in 1st trimester or
inadvertent disclosure of HIV status (cotrimoxazole)?
• How can messages about IPTp be integrated into IEC about
early initiation of ANC / ANC?
• What role can community health workers, communities,
community leaders and other facilitators play in increasing
uptake of IPTp?

13. • Which cadres are competent to determine if gestational
age (GA) is less than 13 weeks and SP should not be
administered?
• Which cadres should be authorized to administer IPTp?
• Should some cadres have only limited authorization to
administer IPTp?
• e.g., when easy to ascertain that pregnancy is NOT 1st trimester
• What strategies can be used to ensure that all providers
are informed of the new policy on IPTp?
Implementation of theWHO Policy:
Questions to Consider (2/2)

14. Determination of Gestational Age (GA) for 1st
SP Dose in Pregnancy - History
• First day of last normal menstrual period
(LNMP)
• Quickening
- Primigravidas note quickening around
18 – 20 weeks
- Multigravidas ~16 weeks (or earlier)
• Potential problems
- LNMP may be uncertain
- Breastfeeding and progestin-only
contraception (can have anovulatory
vaginal bleeding/spotting)
- Quickening varies greatly among
individuals

15. Determination of GA for 1st SP dose in
pregnancy – Physical exam
• Assessment of GA needs to
consider multiple data sources
- Physical exam is just one component
• First trimester
- Uterus grows from lemon to orange
size
- Cannot be palpated abdominally
• Second trimester (13+ weeks)
- Uterus is size of grapefruit and can be
palpated abdominally above symphysis
pubis
NOTE: Pelvic (internal) exams are not
necessary to determine uterine size in 2nd
trimester, but may be needed for other care.

16. Determination of GA for 1st SP dose in
pregnancy - Other
• Pregnancy tests, if available/affordable, can confirm
pregnancy
• Symphysis-pubis fundal height (SFH) measurement
- Generally only used after 20 - 24 weeks’ gestation
• Ultrasound
- Can be superior to dating via LNMP or physical
examination, depending on clinical circumstances
- However
• Dating precision decreases with gestational age
• Controversial if all women should undergo U/S
• Ultrasound machines not universally available

17. Determining Uterine Size and GA (1/3)
• At the beginning of the second trimester (13
weeks), the top of the uterus is usually just
above the mother’s pubic bone (where her
pubic hair begins)
• At about five months (20-22 weeks), the top
of the uterus is usually right at the mother’s
bellybutton (umbilicus or navel)

18. Determining Uterine Size and GA (2/3)
• To feel the uterus, make sure the mother has
emptied her bladder
• Have the mother lie on her back with some
support under her head and ask her to bend
her knees, keeping feet flat on bed
• Explain to her what you are going to do (and
why) before you examine her abdomen
• Your touch should be firm but gentle

19. Determining Uterine Size and GA (3/3)
• Place fingers on the pubic bone and walk them
up the center of the abdomen until you feel
the top of her uterus (fundus) under the skin.
• It will feel like a hard ball
• You can feel the top by curving your fingers gently
into the abdomen
• Uterus palpated a few fingerbreadths above
the pubic bone is compatible with pregnancy
in the second trimester

20. Client Counseling about IPTp-SP (1/2)
• Women are used to starting SP later in pregnancy
• Counsel about importance of earlier dosing
• Malaria parasites can attack in first trimester
• If not cleared with SP, can affect placental development and
fetal growth early in pregnancy
• Women’s concerns must be addressed
• Take SP with or without food
• Folic acid 0.4 mg can be taken with SP
• Not harmful to woman or baby
• Can cause nausea, vomiting or dizziness, but short-lived
and subsides with further doses

21. Client Counseling about IPTp-SP (2/2)
• Pregnant women can receive SP at all
scheduled ANC visits
• Starting at 13 weeks
• As long as doses are at least one month
apart
• Can be taken up to the time of
delivery

22. Client Counseling about Iron/Folic Acid
• Iron and folic acid (IFA)
tablets should be given to
women at all ANC visits
• Folic acid can be taken at the
same time as SP
• WHO-recommended dose is
0.4mg
• Pregnant women should not
receive a dose exceeding 5mg

23. Client Counseling about MIP
• Don’t forget to provide LLIN as
early as possible in pregnancy, or
let her know where she can
obtain one!
• Advise return to facility for
danger signs: fever, headache,
N/V, fatigue, etc.
• Can be signs of malaria
• Must have diagnostic test for
malaria immediately and be treated
if positive

24. Thank you!
• Acknowledgements
• Patricia Gomez
• Jane Coleman

25. Q&A

26. Trends in Maternal and Child
Anemia and Control Programs
Presentation at the Core Group
Conference,April 17, 2015
Rae Galloway
TechnicalTeam Lead for Nutrition
MCSP

27. Goals for the Presentation
• Definition,
consequences, causes
• Trends in anemia
• Anemia control &
coverage of
interventions
• Changes in anemia with
at-scale implementation
• What are “at scale”
implementation and
program components?

28. What is Anemia?
• Low hemoglobin in the
blood
• Hemoglobin is carried
in the blood by red
blood cells
• The function of
hemoglobin is to carry
oxygen from the lungs

29. Why is low hemoglobin a significant health
problem?
Oxygen is needed by
almost every cell in the
body to generate energy
(ATP) to support body
functions and life
At the center of
hemoglobin is iron (Fe)
which fixes oxygen in the
lungs

30. What are the consequences of anemia (lack of
oxygen or iron-dependent co-factors)?
• The early sign is fatigue
• The worst case is
cardiovascular arrest
and death
Others consequences:
• Low productivity
• Cognitive damage
• Poor maternal and birth
outcomes-post partum
hemorrhage, LBW

31. What are the causes of anemia?
• Direct causes
• Decreased production of
Hb and RBCs (nutrition
deficiencies), infectious
diseases (malaria,TB)
• RBC destruction
(malaria)
• RBC loss (helminths,
bacterial infections,
reproduction)
• Contributing causes
• Lack of knowledge about
diet and lack of access to
food with iron
• Environmental (lead)
• Poor sanitation and
hygiene
• Lack of access to
services (ANC and IPTp,
trained birth attendants,
bed nets)

32. WHO Guidance on Estimating the Public Health
Significance of Anemia
Anemia Prevalence
≥40%
20-39.9%
5-19.9%
0-4.9%
Public Health
Significance
Severe
Moderate
Mild
Normal

33. What progress are we making in reducing
anemia?
Changes in anemia in pregnant women have
been slow with only 5 out of 10 regions attaining
more than a 5 percentage point change from
1995 to 2011
Regions with≤5 ppts change:
• South Asia (53% to 52%)
• Central andWest Africa (61% to 56%)
• South Africa (34% to 31%)

34. 34
High Income, 1995: 23%High Income, 2011: 22%Central and Eastern Europe, 1995: 30%Central and Eastern Europe, 2011: 24%East and Southeast Asia, 1995: 34%East and Southeast Asia, 2011: 25%South Asia, 1995: 53%South Asia, 2011: 52%Central Asia, Middle East, and North Africa, 1995: 37%Central Asia, Middle East, and North Africa, 2011: 31%Central and West Africa, 1995: 61%Central and West Africa, 2011: 56%East Africa, 1995: 46%East Africa, 2011: 36%Southern Africa, 1995: 34%Southern Africa, 2011: 31%Andean and Central LAC and Caribbean, 1995: 37%Andean and Central LAC and Caribbean, 2011: 27%Southern and Tropical LAC, 1995: 43%Southern and Tropical LAC, 2011: 38%

35. Anemia in Children<5 years 1995 to 2011
The situation is even more alarming with a
decrease in anemia of more than five percentage
points in only three regions--South Asia (12
ppts), Central &West Africa (9 ppts), and East
Africa (19 ppts)
In southern Africa anemia in children increased
from 30% to 46%

36. How many African countries are tracking
maternal and child anemia (DHS)?
• No surveys (7):Angola, Chad, Eritrea, Kenya (women),
Namibia, Nigeria, Zambia
• One survey (10): Burundi, CapeVerde, DRC, Eq. Guinea, Kenya
(MIS-children), Mozambique, Sao Tome & Principe, Senegal,
Sierra Leone, Swaziland
• Two+ surveys (16): Benin, Burkina Faso, Cameroon, Congo
(Brazzaville), Ethiopia, Ghana*, Guinea, Lesotho*, Madagascar,
Malawi, Mali*, Niger, Rwanda,Tanzania, Uganda, Zimbabwe
(*increase in anemia)
36

37. What are the major anemia control
interventions?
• Three major interventions
will address the greatest
burden of the disease
• MIP (IPTp & ITNs)
• ITNs for children
• Nutrition improvement
(dietary & iron-folic acid
supplements)
• Deworming
37

38. What are the trends in coverage of these interventions where
severe anemia in pregnant women has decreased ≥80%?
Country Change in
severe
anemia
ITN/LLINs IPTp 90+ IFA Deworming
Madagascar 80% dec 50% any
46% ITN
48% any; 12% SP 8% 39%
Congo-Brazzaville 87% dec 64% any; 4% ITN 65% any drug;
16%
l’amodiaquine 3%
SP
2% NA
Malawi 89% dec 56% any; 50%
LLIN
78% any;
77% SP
32% 27%
Rwanda 93% dec 73% any; 72%
LLIN
NA 1% 39%
Uganda 100% dec 80% any; 71%
LLIN
66% any; 63% SP 4% NA
38
PROGRESS APPEARS TO BE FROM INCREASED COVERAGE
OF MIP

39. Clearly more can & should be done to increase
coverage of IFA with IPTp
A secondary analysis byTitaley, et al., 2010 of DHS from
19 malaria-endemic countries in sub-Saharan African
countries found:
• The combined effect of IFA and IPTp decreased the risk of
neonatal death by 24% (when women took≥90 IFA) and 18%
(when women took <90 IFA)
• There was no significant protection from neonatal death with
either IFA or IPTp alone
39

40. IFA & IPTp need to be fully complementary:
a word about getting the dose of folic acid right
• Folic acid is an essential nutrient for both humans and the
malaria parasite
• Humans cannot synthesize folic acid; they obtain it from the
diet or from supplements
• Pregnant women are given folic acid to meet increased needs
in pregnancy NOT to prevent neural tube defects which form
within 28 days after conception
• The malaria parasite obtains folic acid by de novo synthesis &
salvaging folic acid from the host (humans) so giving too much
folic acid helps malaria to thrive and multiply
40

41. Giving folic acid ≥5 mg increases risk of treatment
failure with SP in pregnant women (Ouma, et al., 2006)
Tx failure at 14 days with
SP and different doses of
folic acid (FA):
• Placebo: 13.9%
• 0.4 mg FA: 14.5%
• 5 mg FA: 27.1%
• There was no difference
in mean Hb in either FA
group
41

42. As a result of this study,WHO recommends a
dose of folic acid<5 mg
• This is not a problem in most countries which are giving a
combined IFA supplement containing 60 mg of iron and 400
mcg folic acid
• Are some countries still giving the 5 mg dose of folic acid—
yes!
• Countries should reduce stores of the 5 mg dose (which isn’t
needed to meet folic acid requirements) & transition to the
combined IFA supplement with the lower dose of folic acid
42

43. How can we improve programs and obtain at-
scale coverage?
• Get the dose & timing right (first trimester may be important
for IFA to improve birth outcomes)
• Deliver and monitor the integrated package (IPTp and IFA;
deworming?)
• Accurate forecasting & delivery of commodities
• Procure adequate numbers of IFA and SP based on estimated
numbers of pregnant women, not past use
• Counseling messages on why and when to take
• Reach coverage of >80%
43

44. What impact could these interventions have if they
were scaled-up?
Selected effects from controlled studies:
• 38% decrease in severe anemia with IPTp
• 56% decrease in overall anemia with improved iron
intake (IFA tablets; food) & decreased iron loss (deworming)
• 20-40% decrease in LBW with IPTp and 11-18% decrease in
neonatal and 5-19% of infant deaths (pauci- to multi-gravidae)
• 18% decrease in LBW with improved iron status of mothers
and 30-60% decrease in neonatal mortality when mothers take
IFA early in pregnancy and for 6 months
44

45. ThankYou!
45

46. Q&A

47. Integrated (Community) Case
Management
Challenges and Successes in Diagnosis and
Treatment of Malaria in the iCCM and IMCI
Platforms
Michel Pacqué
Maternal and Child Survival Program

48. iCCM
• The good news
• Global Fund New Funding Model
• Challenges
• Fit into larger Health System/political ownership
• Financing and sustainability
• Technical “updates” – quality of care

49. Are technical updates a challenge
to “assuring quality” of care.

50. Technical Updates and Quality of Care
Quality of care depends on how well
national guidelines as well as health worker
training and supervisory materials conform
to the most recent World Health
Organization standards.

51. Quality Assessment of Diagnosis and
Treatment of Malaria
Method:
• To assess the level of adherence to WHO standards,
we collected training and supervisory materials for
health workers in President’s Malaria Initiative (PMI)
countries and appraised them for adherence to the
standard WHO materials. Special attention was paid
to training in and use of diagnostics like rapid
diagnostic tests (RDTs) and assessment and
management of severe febrile diseases.

52. Methods
• Training and supervision materials voluntarily
provided by PMI countries
• Training materials from 13 countries and
supervision tools from 7 countries were reviewed
(out of the total 19 countries contacted).

53. Countries included
COUNTRY IMCI and or Malaria Tools Supervision Tools
1 ANGOLA N N
2 BENIN Y (IMCI) N
3 DRC Y (IMCI/CCM – NMCP) Y
4 ETHIOPIA Y (IMCI/CCM – NMCP) Y
5 GHANA N N
6 GUINEA N N
7 KENYA Y (IMCI) N
8 LIBERIA N Y
9 MADAGASCAR Y (IMCI) N
10 MALAWI Y (IMCI) Y
11 MALI Y (IMCI) Y
12 MOZAMBIQUE* Y (IMCI – NMCP) Y
13 NIGERIA Y (IMCI) N
14 RWANDA Y (IMCI) Y
15 SENEGAL Y (IMCI) N
16 TANZANIA (Zanzibar) N Y
17 UGANDA Y (IMCI/CCM – NMCP) N
18 ZAMBIA Y (IMCI) N
19 ZIMBABWE Y (IMCI) N
Total Received 14 8
Total Assessed 13 7

54. Methods
• Desk review
• Tools compared with most updated IMCI algorithms
• Incorporates diagnostic testing for malaria
• Particular attention to adherence to updated WHO
guidelines on diagnostic testing and management of severe
febrile illness
• Spreadsheet developed comparing specific steps in the
algorithm with what is contained in country training and
supervision materials

55. Questions not addressed by the study
• At the community level:
• How are CHWs doing?
• How often are they correctly diagnosing and treating
kids for malaria?
• What supply chain issues exist?
• How are CHWs trained?
• How do they maintain skills?
• case load, supervision, etc.

56. Selected Findings

57. Classification of fever
• 12 countries defined fever correctly
• Mali: Fever defined only as measured axillary temperature >38 degrees C
A child will be considered as “having fever” if:
The child has had any fever with the current illness
The child feels hot
The child has an axillary (underarm) temperature of 37.5°C
(38°C rectal) or above
High fever is defined as a temperature of 38.5°C or above

58. Classification of fever
• 8 countries classified severe febrile illness in line with IMCI
guidelines
• Rwanda: Differentiates Severe Malaria from Very Severe Febrile Illness,
based on diagnostic test result
Severe febrile illness:
Fever plus
Any general danger sign (unable to drink or breastfeed;
vomits everything; convulsion(s); lethargic or unconscious)
And/or
Stiff neck

59. DiagnosticTesting for Malaria
Nine countries have introduced diagnostic testing for malaria in their fever algorithms
• Only four have instructions on how to perform an RDT
• Only two countries include instructions to perform an RDT when a child has
been identified as having anemia
WHO Guidelines for Parasitological/laboratory diagnosis of
malaria
Prompt parasitological confirmation by microscopy, or RDT, is
recommended in all patients suspected of malaria before
treatment is started.
Treatment solely on the basis of clinical suspicion should only be
considered when a parasitological diagnosis is not accessible or
will be delayed for more than two hours.
However, patients with suspected severe malaria, and other high
risk groups, should be treated immediately on clinical grounds.

60. Treatment of severe malaria
WHO recommendation: artesunate treatment for severe P.
falciparum malaria in children
Artesunate is preferred over quinine for the treatment of severe
P. falciparum malaria in children.
• Intravenous or intramuscular artesunate has been shown to
reduce significantly the risk of death from severe malaria
compared to intravenous quinine. Intravenous artesunate is
associated with a lower risk of hypoglycemia.

61. First-line drug for pre-referral treatment
of severe febrile disease
IMCI guidelines
Pre-referral treatments of choice: artesunate or
quinine
Benin Artesunate suppository
Democratic Republic of
Congo
Artesunate suppository
Ethiopia Artesunate suppository:
Kenya Quinine or parenteral artesunate or artemether
Madagascar Quinine
Malawi Quinine
Mali
IMCI: Quinine - NMCP: Artemether or Artesunate or
quinine
Nigeria Quinine
Rwanda Artemether
Senegal Quinine
Uganda Artesunate or Quinine or Artemether
Zambia Quinine
Zimbabwe Quinine

62. Management ofTreatment Failure
• Eleven countries addressed treatment failure
• Five have retesting with a RDT in the protocol
• Another 5 countries use a clinical diagnosis to re-classify the child
If fever persists after 2 days, or child returns within 14 days:
Do a full reassessment of the child.
If any general danger signs or stiff neck: treat for VERY SEVERE FEBRILE DISEASE – and refer to hospital.
If any cause of fever other than malaria: provide treatment for that cause.
If the fever has been present for 7 days: refer for assessment.
If there is no other apparent cause of fever:
o For children who were classified as having malaria:
◦ Do microscopy. If parasites are present and the child has finished a full course of the first line antimalarial,
give the second-line antimalarial, if available, or refer the child to a hospital.
◦ If you do not have a microscope to check for parasites, refer the child to a hospital.
DO NOT REPEAT the Rapid Diagnostic Test if it was positive on
the initial visit
o For children who had fever and were classified as having no
malaria:
◦ Repeat the malaria test. If a child has a positive malaria test, give
first-line oral antimalarial. Advise the mother to return in 3 days if
the fever persists.

63. Major findings
• In almost all countries assessed, there were one or more areas where
training materials significantly deviated from the most recentWHO
guidance
• In some countries, IMCI guidelines also deviated from national malaria
treatment guidelines
• Some of the disparities may be because national policies were last
updated before these new guidelines were issued
• Supervision tools appear to be available in only a minority of countries,
raising the question whether standardized supervision checklists are
used in some countries
• All countries should review and revise their guidelines and training
materials, as appropriate, to ensure they align with the latest WHO
guidance, and then on a regular basis thereafter

64. Questions for discussion
• What can NGOs do about “quality” as defined
earlier
• What are the biggest challenges and how can
NGOs with other partners approach them

65. Thank you!

66. Q&A

67. KeyTake Aways
• Anemia is a prevalent and static public health problem in
women and children
• Delivering IFA and IPTp-SP to 80% of pregnant women will
improve maternal and newborn health and survival
• The dose of folic acid needs to be <5 mg to ensure the
effectiveness of SP as an anti-malaria
• iCCM needs to be integrated to malaria and maternal child
health program
• Updating guidelines, disseminating, and implementing is a stpe
by step process

68. Take Aways
• Decreasing the risk of severe negative perinatal consequences
from MIP requires initiation of IPTp-SP as early as possible in
the 2nd trimester.
• A comprehensive approach to accurate estimation of
gestational age is necessary for appropriate timing of IPTp-SP.
• Safely and effectively increasing uptake of appropriately timed
IPTp-SP will entail the engagement of a broad group of
stakeholders.

69. For more information, please visit
www.mcsprogram.org
This presentation was made possible by the generous support of the American people through the
United States Agency for International Development (USAID), under the terms of the Cooperative
Agreement AID-OAA-A-14-00028. The contents are the responsibility of the authors and do not
necessarily reflect the views of USAID or the United States Government.
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