a course offered under Tropical Infectious Diseases

1. Malaria in Pregnancy
Dr.HellenMuringi
Lecturer,UniversityofNairobi
Visitinglecturer;BanadirUniversity;MogadishuSomalia

2. Course Objectives
By the end of this session, you should be able to:
1. Describe the burden of Malaria in Kenya including its transmission, epidemiology,
and control policy framework.
2. Outline the effects of malaria on pregnancy
3. Explain the ways of preventing malaria in pregnancy
4. Describe the management of uncomplicated malaria in pregnancy
5. Describe the management of severe malaria in pregnancy
6. Give relevant general education to a patient/community with malaria regarding
prevention and care of Malaria esp in Malaria in Pregnancy.
7. Appreciate future directions and research gaps in prevention and control of MIP
8. Identify your role in prevention and control of Malaria/MIP
This course does not require you to:
1. Demonstrate proper evaluation of a patient suspected of having Malaria.
2. Prescribe appropriate treatment for a patient with malaria.

3. Outline
1. Background
2. Epidemiology of Malaria during Pregnancy
3. Prevention of Malaria during Pregnancy: Current Strategies
4. Challenges and opportunities for Research in MIP Prevention
5. Current Evidence on Malaria in Pregnancy
6. Research/Future Directions in the Prevention & Treatment of
Malaria During Pregnancy
7. Concluding remarks

4. Introduction to Malaria
• Malaria is a blood-borne illness caused by infection with malaria parasites.
• The Illness can range from mild disease (referred to as ‘uncomplicated malaria’), to a severe life-threatening illness (‘severe
malaria’).
• It is estimated to affect between 350 to 500 million people annually and accounts for 1 to 3 million deaths per year.
• Sub-Saharan Africa has the largest burden of malarial disease, with over 90% of the world’s malaria-related deaths
occurring in this region.
• 25 million pregnant women are currently at risk for malaria, and, according to the World Health Organization (WHO, 2020),
malaria accounts for over 10,000 maternal and 200,000 neonatal deaths per year.
• In areas of low transmission of Plasmodium falciparum, where levels of acquired immunity are low, women are susceptible to
episodes of severe malaria, which can result in stillbirths or spontaneous abortion or in the death of the mother
(Luxemburger et al., 1997).
• In areas of high transmission of P. falciparum, where levels of acquired immunity tend to be high, women are susceptible to
asymptomatic infection, which can result in maternal anaemia and placental parasitaemia, both of which can subsequently
lead to low birth weight (Steketee, Wirima & Campbell, 1996)
• Infants and children under 5 years of age, pregnant women and patients with HIV/AIDS are at particular risk of developing
severe malaria
• Other vulnerable groups include people entering areas with intense malaria transmission who have not acquired partial
immunity from long exposure to the disease, or who are not taking chemopreventive therapies, such as migrants, mobile
populations and travellers.

5. How is Malaria Transmitted to Humans
 Malaria is a protozoal disease transmitted to humans by the bite of infected
female Anopheles mosquito.
 The mosquitoes acquire malaria parasites from an infected person which they
transmit to other people. On average a mosquito survives for 2-3 weeks.
 Malaria can also be transmitted through blood transfusion and mother to child
(vertical route), however these modes of transmission are rare.
•Consequences of Infection With Malaria Parasites
1. Parasites clear without causing disease: especially in patients with high levels of
immunity
2. Asymptomatic parasitaemia: occurs when malaria parasites are detected in the
blood but the person is not sick
3. Uncomplicated malaria: generally presents with constitutional symptoms like
simple fever, headache, dizziness, myalgia etc. which are not life threatening
4. Severe malaria: generally is a life threatening illness and requires urgent
attention

6. Malaria parasites
•There are five species of malaria parasites that can cause infection in
humans:
1. Plasmodium falciparum,
2. Plasmodium vivax,
3. Plasmodium malariae,
4. Plasmodium ovale, and
5. Plasmodium knowlesi.
• The commonest cause of malaria in Kenya is P. falciparum. It is also
responsible for the severe forms of the disease because:
 It attacks all ages of red blood cells
 Infected cells become sticky which affects their functioning
 It has high multiplication capacity
• P. falciparum is also responsible for the majority of malaria-related
deaths worldwide and poses the greatest risk during pregnancy due
to its ability to sequester in the placenta.

7. Life cycle of the malaria
parasite
• Malaria infection begins when an infected female Anopheles mosquito
bites a person during a blood meal, injecting Plasmodium parasites, in
the form of sporozoites, into the bloodstream.
• Within hours, the sporozoites migrate to the liver and multiply asexually
in the liver cells over the next 7 to 10 days, causing no symptoms. It
then gets released back into the host’s bloodstream as merozoites;
invading red blood cells (RBCs).
• Inside the RBCs, the parasites undergo asexual replication, leading to
the release of more merozoites that continue the cycle.
• Some parasites differentiate into sexual forms (gametocytes), which can
be taken up by mosquitoes during blood feeding, completing the
transmission cycle.
• The incubation period, from the time of mosquito bite until clinical
symptoms appear, is typically 7 to 30 days.
• Due to the cycling parasitemia in the bloodstream, patients will often
experience symptoms every 2 to 3 days (lasting for 6 to 10 hours),
depending on the type of Plasmodium with which they are infected

8. Life cycle
of Malaria
parasite

9. Epidemiology of Malaria
• Epidemiology of malaria is the study of the distribution and determinants of malaria in
specified populations, and the application of this study to control malaria.
• If we know how common malaria is in a specific area we can focus on both treatment and
prevention measures accordingly.
• If we understand what determines the transmission of malaria, we can then address specific
issues to maximize the effect of control strategies.
• An important term is endemicity, which is the degree or frequency of occurrence of a disease.
An endemic disease is one that is constantly present to a greater or lesser degree in people
of a certain class or in people living in a particular location.
• Malaria is found in tropical and subtropical areas where conditions are suitable for its
transmission. It is primarily a disease of hot, humid countries at altitudes less than 2,000
meters above sea level
• The most vulnerable people to malaria are:
 Children aged less than 5 years
 Pregnant women, especially primigravida
 People living with HIV/AIDS
 Sicklers
 Travelers from areas where there is little or no malaria

10. Epidemiology of Malaria in Kenya
• Kenya has four malaria epidemiological zones, with diversity in risk determined largely by altitude, rainfall patterns and temperature.
• Endemiczones:Areas of stable malaria have altitudes ranging from 0 to 1,300 metres around Lake Victoria in western Kenya and in the
coastal regions. Rainfall, temperature and humidity are the determinants of the perennial transmission of malaria. The vector life cycle is
usually short and survival rates are high because of the suitable climatic conditions. Transmission is intense throughout the year, with
annual entomological inoculation rates between 30 and 100. malaria endemic zones in Kenya include;
 The highland areas, including the western parts of the country, experience moderate to high transmission.
 The lowland areas along the coast, such as Kilifi and Malindi, have stable and intense transmission throughout the year.
• Seasonaltransmission: Arid and semi-arid areas of northern and south-eastern parts of the country experience short periods of intense
malaria transmission during the rainfall seasons. Temperatures are usually high and water pools created during the rainy season provide
breeding sites for the malaria vectors. Extreme climatic conditions like the El Niño southern oscillation lead to flooding in these areas,
resulting in epidemic outbreaks with high morbidity rates owing to the low immune status of the population. Includes Turkana and
Mandera regions.
• Epidemic prone areas of westernhighlands of Kenya: Malaria transmission in the western highlands of Kenya is seasonal, with
considerable year-to-year variation. Epidemics are experienced when climatic conditions favour sustainability of minimum temperatures
around 18°C. This increase in minimum temperatures during the long rains favours and sustains vector breeding, resulting in increased
intensity of malaria transmission. The whole population is vulnerable and case fatality rates during an epidemic can be up to ten times
greater than those experienced in regions where malaria occurs regularly.
• Low risk malaria areas:This zone covers the central highlands of Kenya including Nairobi. The temperatures are usually too low to allow
completion of the sporogonic cycle of the malaria parasite in the vector. However, the increasing temperatures and changes in the
hydrological cycle associated with climate change are likely to increase the areas suitable for malaria vector breeding with the
introduction of malaria transmission in areas where it had not existed before

11. Malaria
in Kenya

12. Factors contributing to the prevalence
•Climate plays a crucial role, as higher rainfall and warmer
temperatures favor mosquito breeding and parasite
development.
•Altitude also affects transmission, with lower altitudes
experiencing higher transmission rates.
•Proximity to water bodies encourage mosquito breeding.
•Population movement, including migration and travel, can
introduce parasites to new areas or contribute to the spread
of drug-resistant strains.

13. Malaria in Pregnancy – why is it a special topic?
• Malaria and pregnancy are mutually aggravating conditions. The physiological changes of pregnancy and the pathological
changes due to malaria have a synergistic effect on each other.
• Pregnancy increases the risk of malaria infection in all women, particularly in regions with high malaria transmission rates.
• 80% of deaths due malaria in Africa occur in pregnant women and children <5 years.
• Women in their first and second pregnancies, and all HIV infected women are at greatest risk of the complications/effects of
malaria
• Malaria and its complications are more common in pregnant women compared to the general population
• Malaria in pregnancy tends to be atypical
• Parasitaemia is ten times higher than in non-pregnant adult women
• Mortality due to malaria is also higher than in the general population
Maternal effects of malaria Foetal/infant effects of malaria
Anaemia -15% Intra-uterine growth restriction - 70%
Febrile Illness/Prostration Pre-term delivery -- 36%
Cerebral malaria Increased risk of perinatal mortality -8%
Other forms of severe malaria Congenital malaria/neonatal sepsis
Increased risk of maternal death Anaemia of the baby
Increased risk of abortions Low birth weight - 14%

14. Prevalence MiP in Sub-Saharan Africa:
• Malaria in pregnancy remains a significant global health concern, particularly in endemic
regions of sub-Saharan Africa, Southeast Asia, and the Americas.
• According to (WHO), an estimated 11 million pregnant women were infected with malaria in
2020, primarily in sub-Saharan Africa.
• Malaria in pregnancy causes infant mortality indirectly through its contribution to low birth
weight and premature deliveries.
• It has been estimated that malaria during pregnancy is responsible for 5–12% of all low birth
weight and 35% of preventable low birth weight (Steketee, Wirima & Campbell, 1996) and
contributes to 75 000 to 200 000 infant deaths in the sub-Saharan region each year
(Steketee et al., 2001).
• A modelling study among women in areas of stable malaria transmission suggested that over
60% of malaria infections during pregnancy occur by the end of the first trimester (Walker et
al, 2014).
•

15. Pathogenesis of Malaria in Pregnancy
• P. falciparum-infected RBCs adhere to the placental lining through specific receptors,
avoiding clearance by the spleen and causing placental sequestration.
 P. falciparum has the unique ability of cyto-adherence. Chondroitin sulphate A and hyaluronic acid have
been identified as the adhesion molecules for parasite attachment to placental cells.
• The sequestration of P. falciparum parasites along the surface of the placental
membrane, specifically the trophoblastic villi, extravillous trophopblasts and syncytial
bridges, triggers an inflammatory response that disrupts the normal functioning of
the placenta, resulting in impaired nutrient and oxygen delivery to the foetus.
• This can lead to haemorrhaging, maternal anemia and placental insufficiency,
affecting fetal growth and increasing the risk of low birth weight, prematurity, and
stillbirth.
• Malaria-induced inflammation and placental immune responses also contributes to
placental tissue, further contributing to adverse pregnancy outcomes.

16. Prevention of Malaria in Pregnancy
• Malaria in pregnancy is an obstetric , social and medial problem requiring multidisciplinary,
integrated and multidimensional approach.
• Preventive measures are crucial in reducing the burden of malaria in pregnancy.
• There are two major ways to prevent malaria in pregnancy?
1. The provision of intermittent preventive treatment in pregnancy (IPTp) .
 Involves the administration of antimalarial drugs during antenatal care visits, regardless of malaria symptoms.
 Starts in the second trimester of pregnancy (13 wks).
 At least two doses of Sulfadoxine + Pyrimethamine (Fansidar) are taken one month apart as directly observed therapy
 For pregnant women who are HIV positive and are not on septrin prophlyaxis (cotrimoxazole), three doses of SP are
recommended.
 Patients who for one reason or another cannot take SP are advised to use mosquito nets consistently and to seek
malaria treatment promptly as soon as they fall sick with fever.
 ANC visits provide an opportunity for early diagnosis, treatment, and the administration of IPTp.
2. Regular use of Insecticide Treated Mosquito Nets (ITNs)
 ITN’s are the backbone of malaria prevention for pregnant mothers.
 Every woman should sleep under an insecticide treated mosquito net
 Indoor residual spraying (IRS) targets mosquitoes resting indoors.
 It is important that the antenatal clinic is insisting that pregnant mothers use ITN’s.
 Integrating malaria prevention services, such as distribution of ITNs and health education, into routine ANC visits
ensures comprehensive care for pregnant women.

17. Prevention of Malaria in Pregnant Women with HIV
1. Cotrimoxazole Prophylaxis (or IPTp) for pregnant women living with HIV
 Cotrimoxazole is used to prevent opportunistic infections in People Living with HIV/AIDS
(PLWHA).
 All HIV infected individuals, regardless of whether they are on ART treatment or not, should be
taking Cotrimoxazole.
 HIV positive pregnant women who are on Cotrimoxazole as prophylaxis should continue on
this treatment to reduce the risk of infection of malaria. They should not receive Cotrimoxazole
and Sulfadoxine/Pyrimethamine (SP) together as there is evidence that this increases the risk
of adverse drug reactions.
 HIV positive pregnant women who are not on Cotrimoxazole prophylaxis should receive
Intermittent Preventive treatment (IPT) for malaria
 Mothers who are not infected with HIV receive two doses of Sulfadoxine/Pyrimethamine (SP)
for their IPT treatment. However, pregnant women infected with HIV require more frequent
dosing with SP, preferably monthly but at least three times during pregnancy (starting in the
second trimester
 Remember this is not required if the woman is on Cotrimoxazole prophylaxis
2. Insecticide Treated Nets (ITNs)
 All pregnant women, regardless if they are infected with HIV or not, should sleep under an
Insecticide Treated Nets (ITN) every night

18. Malaria in Pregnancy and Mother-to-Child transmission of HIV
1. Overall, one in three babies gets infected with HIV through mother
to child transmission, either through pregnancy, labour or
breastfeeding if no preventive measures are taken.
 This risk can be increased by malaria.
2. It is important to aggressively treat and prevent malaria in
pregnant women, especially those living with HIV
 To reduce the risk of malaria: Use ITN’s and either Cotrimoxazole or IPT
 To reduce the risk of transmission of HIV to the child: Utilize Prevention of Mother-to Child
Transmission (PMTCT) ARV regimens as recommended by MOH PMTCT guidelines.
3. HIV infection also leads to increased rates of malaria in children.
Therefore, children born to HIV infected mothers need to be
protected from malaria.
 This should include Cotrimoxazole prophylaxis starting at 6 weeks after delivery and the
use of ITNs.

19. Symptoms and Diagnosis
• Malaria symptoms in pregnant women are similar to those in non-pregnant individuals
• Some common symptoms include:
 fever,
 chills,
 headache,
 muscle aches, and
 fatigue.
 Anorexia / Bitter taste in the mouth
 Malaise
 Nausea/vomitting
Note: These symptoms can be easily mistaken for common pregnancy discomforts, making
diagnosis more challenging.
• In high-transmission settings, despite the adverse effects on fetal growth, malaria is usually
asymptomatic in pregnancy or is associated with only mild, non-specific symptoms.
• In low-transmission areas, malaria in pregnancy is associated with increased risks for severe
malaria, pregnancy loss and death. The risk of malaria infection is highest in the first and
second trimesters of pregnancy (Desai M et al, 2007).

20. Rapid assessment of burden of malaria during pregnancy
• peripheral malaria parasitemia and
anemia
Survey at
antenatal care
• Peripheral and placental parasitemia, birth
weight, and gestational age
Survey at
delivery units
• severe disease, health facility assessment,
rapid ethnographic evaluation
Other
modules:

21. Parasitological Diagnosis of Malaria
• The recommended tests to detect the presence of malaria parasites and parasite products are;
1. Microscopy: microscopy is the gold standard method for parasitological diagnosis of malaria.
2. Malaria rapid diagnostic tests (mRDTs): used where microscopy services are not available.
• Quality assurance of microscopy and RDTs is vital for ensuring the reliability of test results.
• Other possible Parasite Detection Methods -
 Serological Tests - detection of antibodies against asexual blood stage malaria parasites. They measure prior exposure and
not current infection. Examples are; latex agglutination assay immunofluorescence antibody testing (IFA), enzyme linked
immunosorbent assay (ELISA) and enzyme immunoassay (EIA).
 Detection of parasite DNA - detects current infections since DNA is specific.
 Qualitative Buffy Coat (QBC) technique This method involves staining parasite DNA in microhematocrit tubes with
fluorescent dyes, e.g. acridine orange, and subsequent detection by epifluorescent microscopy
 Molecular techniques - Polymerase chain reaction (PCR) is sensitive and a specific technique but requires specialized and
costly equipment and reagents, as well as strict laboratory conditions.
 Parasite culture – not routinely done in clinical diagnosis of malaria

22. Challenges in diagnosing malaria during pregnancy
• Timely diagnosis is crucial to initiate appropriate treatment and prevent
complications.
• Diagnosing malaria in pregnancy can be challenging due to overlapping
symptoms with other common conditions during pregnancy.
• Furthermore, pregnant women may have lower parasite densities, making
microscopic detection more difficult.
• Diagnostic methods such as rapid diagnostic tests (RDTs) and molecular
techniques like polymerase chain reaction (PCR) are essential for accurate
detection, especially in areas with low parasite densities.

23. Management and Control of Malaria in Pregnancy
• Addressing malaria in pregnancy requires a multi-sectoral approach involving collaboration among
healthcare providers, policymakers, and community stakeholders.
• Early diagnosis and prompt treatment are essential in preventing severe complications of malaria in
pregnancy
• All pregnant women with a fever should have a blood smear or RDT done for malaria parasites.
• Timely administration of appropriate antimalarial treatment reduces parasite burden, alleviates
symptoms, and minimizes the risk of adverse pregnancy outcomes and helps prevent disease
progression to severe forms.
• Artemisinin-based combination therapies (ACTs) are the recommended first-line treatment for
uncomplicated malaria caused by P. falciparum.
• Quinine-based regimens are used as alternative treatments, particularly in the first trimester and in
areas with artemisinin resistance.
• Ongoing research and development efforts are necessary to identify and develop new antimalarial
therapies that are safe and effective, particularly in regions with emerging drug resistance.
• Surveillance systems and monitoring programs are critical in detecting and responding to changes in
drug resistance patterns. prevention and control of malaria can be done through prompt and effective
case management, ITN use and Intermittent Preventative Therapy (IPTp).
• Cases of severe anaemia in a pregnant mother should be fully investigated to find out the cause of
anaemia.
• Pregnant women should be given deworming tablets and haematinics routinely at antenatal clinics.

24. Control/Policy framework for Malaria in Pregnancy in Kenya
• There are four major ways that malaria can be controlled:
1. Use of insecticide treated mosquito nets - ITNs create a physical barrier which prevents
human to mosquito contact. They also repel and kill mosquitoes.
2. Reduction of the mosquito population - The reduction of the adult mosquitoes can be done
through spraying of the internal walls of houses with residual insecticide.
3. Destruction of malaria parasites – through;
o Case management - Early diagnosis and prompt effective treatment of malaria eliminates the parasites in the
blood. Hence, reduced transmission of malaria. ACTs kill gametocytes, the infective form for mosquitoes
o Intermittent preventive treatment of pregnant women (IPTp) reduces the risk of poor pregnancy outcomes.
o Chemoprophylaxis for special risk groups for example; sicklers and non-immune visitors.
4. Health education and community mobilization - Provision of malaria control interventions,
aggressive advocacy among decision makers at all levels and the public at large. As health
workers, we can contribute to prevention messages and interventions , health education,
mobilization of communities, the understanding of cultural perceptions and other potential
barriers to prevention and control of MIP. Engaging community stakeholders ensures
ownership, sustainability, and effective implementation of malaria control measures.
5. Surveillance, Epidemic Preparedness and Response – intergrated

25. Other Important Issues on Malaria in Pregnancy
1. Ongoing research efforts focus on various aspects of malaria in pregnancy, including
understanding the immune response, identifying biomarkers for adverse outcomes, and
evaluating new prevention and treatment strategies.
2. Research is also conducted to address knowledge gaps in specific populations, such as
HIV-positive pregnant women, to optimize malaria management in co-infected individuals.
3. Climate change and environmental factors can influence the prevalence and distribution of
malaria.
4. Changes in temperature and rainfall patterns can alter mosquito breeding habitats,
expand the geographical range of malaria vectors, and affect the timing and intensity of
transmission seasons.
5. Understanding these dynamics is crucial for adapting control strategies and implementing
timely interventions in response to changing malaria patterns.
 Roll Back Malaria Partnership, a global initiative, aims to coordinate efforts to reduce the global burden of malaria.
 The partnership brings together governments, organizations, and stakeholders to strengthen malaria control
interventions, improve access to prevention and treatment, and promote research and innovation.
6. Collaborative initiatives like these are instrumental in advancing malaria elimination and
control goals.

26. Other Important Issues on Malaria in Pregnancy
Antimalarial Treatment Failure
• Antimalarial treatment failure is when a patient remains parasiteamic with
or without being symptomatic after completion of antimalarial treatment.
• In order to make a conclusion of antimalarial treatment failure, the patient
must have:
 Had a positive blood slide or RDT before starting therapy
 Been prescribed a complete course of an effective malaria medication such as an ACT
 Been 100% compliant to treatment given or prescribed
• There are five ways that antimalarial treatment failure can occur, each of
them caused by something different.
1. Clinical failure
2. Parasitological failure
3. Recrudescence
4. Re-infection
5. Mixed infection

27. Potential research areas
• Please refer to the WHO 2023 guidelines pages 87-90 for potential areas of further
research.
• Can include any of these priority areas
1. Epidemiology and Burden of Malaria in Pregnancy
 Incidence, prevalence and importance of MiP in low transmission areas
 Impact of malaria in the first trimester 4-10 weeks?
2. Pathogenesis and immunity
 How does malaria cause severe anemia or low birth weight in pregnancy ?
3. Case Management
 Optimization of diagnostic strategies for MiP.
 Influence of MiP on efficacy and pharmacokinetics of antimalarial drugs/ARVs?
4. Prevention of MiP
 How preventive strategies (ITNs, indoor residual spraying [IRS], IPTp, repellents) can be used together most effectively in
different epidemiologic situations; effectiveness of nets in situations of residual/outdoor transmission; impact of ITNs in
transmission ‘hotspots’ and elimination settings.
 Any novel control mechanisms, such as a pregnancy-specific vaccine.
5. Economic aspects of MiP
 Overall economic burden, cost effectiveness of different control measures in different circumstances.
6. Health systems research
 Integration, scale-up and programming of ITNs and IPTp. Evaluate new technologies for identifying aquatic habitats.
 Implementation research to increase the acceptability and use of G6PD point-of-care testing.

28. Summary
• Malaria in Pregnancy is a significant public health problem, associated with anemia, LBW and increased infant mortality
• Effective intervention strategies for prevention of MiP exist, and need to be implemented
 ITNs, IPTp, Effective Case Management, anemia prevention and treatment, deworming
• Combating MiP will require
 Better coordination and harmony among various groups invested in this subject (research + program)
 Stronger advocacy
• The United States, Europe, and parts of Central and South America have had success in eradicating malaria, whereas sub-
Saharan Africa continues to bear the burden of disease.
• Recent advances in diagnosis include immunochromotographic dipstick assays that report sensitivity above 90% and may
be a better diagnostic tool for use in pregnant women.
• Pregnant women are 3 times more likely to suffer from severe disease as compared with their nonpregnant counterparts
and have a mortality rate from severe malarial infection that approaches 50%.
• Interventions to manage malaria in Kenya have been integrated and include:
 Active case detection, notification, investigation, and response system(s) for elimination in targeted counties
 Strengthen malaria surveillance and use of the information
 Strengthen Social Behavioral Change
• Relevant Surveys on malaria indicators for monitoring and evaluation of interventions to prevent and control malaria in
pregnancy.
 Demographic and health surveys and multiple indicator cluster surveys involving 4000–12 000 women aged 15–49 years, living in households that are sampled in
a multiple-stage cluster design, are conducted in many developing countries at 5-year intervals.
 Malaria indicator surveys such as in 2004 the Roll Back Malaria programme (2004), MACRO International and the ‘lean malaria module’ are used to supplement the
standardized data collected from the demographic and health and multiple indicator cluster surveys,

29. References/Further Reading
• Guidelines for Diagnosis, treatment and prevention of Malaria in Kenya, 6th Edition, 2020
• World Health Organization [WHO] (2020). World Malaria Report 2020. Geneva: World Health Organization. [Google Scholar]
• World Health Organization Guidelines for Malaria, 14 March 2023 154431 7
• World Health Organization (2000). Severe falciparum malaria. Transactions of the Royal Society of Tropical Medicine and Hygiene 94,
supplement 1 (especially pages S1/20-S1/30).
• World Health Organization (2007), Malaria in Pregnancy. Guidelines for measuring key monitoring and evaluation indicators
• Desai M, ter Kuile FO, Nosten F, McGready R, Asamoa K, Brabin B, et al. : Epidemiology and burden of malaria in pregnancy. The Lancet.
Infectious diseases 2007;7(2):93-104 Pubmed
• Walker PGT, ter Kuile FO, Garske T, Menendez C, Ghani AC : Estimated risk of placental infection and low birthweight attributable to
Plasmodium falciparum malaria in Africa in 2010: a modelling study. The Lancet. Global health 2014;2(8):e460-7 Pubmed Journal
• Gitau G.M., Eldred J.M., (2005). Malaria in pregnancy: clinical, therapeutic and prophylactic considerations. The Obstetrician &Gynaecologist;
7:5–11. Full text at http://onlinetog.org/cgi/reprint/7/1/5.pdf
• Luxemburger Cet al. (1997). The epidemiology of severe malaria in an area of low transmission in Thailand. Transactions of the Royal Society
of Tropical Medicine and Hygiene, 91:256–262.
• Steketee RW, Wirima JJ, Campbell CC (1996). Developing effective strategies for malaria prevention programs for pregnant African women.
American Journal of Tropical Medicine and Hygiene, 55:95–100.
• Steketee RW et al. (2001). The burden of malaria in pregnancy in malaria-endemic countries. American Journal of Tropical Medicine and
Hygiene, 6:28–35.
• Roll Back Malaria, MEASURE Evaluation, World Health Organization, UNICEF (2004). Guidelines for Core Population Coverage Indicators for Roll
Back Malaria: To Be Obtained from Household Surveys. MEASURE Evaluation: Calverton, Maryland.