Date Published: February 28, 2017
Publisher: Public Library of Science
Author(s): James G. Beeson, Julie A. Simpson
Partial Text: Low birth weight (LBW) is one of the most important risk factors for neonatal mortality and morbidity, childhood stunting, reduced cognitive development, and chronic diseases later in life. In sub-Saharan Africa, where the burden of LBW is very high, Plasmodium falciparum malaria is one of the major causes, contributing to an estimated 20% of LBW cases . A new report suggests that substantial gains in reducing LBW in sub-Saharan Africa could be achieved by scaling up a key malaria intervention known as intermittent preventive treatment in pregnancy (IPTp) .
In new research published in PLOS Medicine, Walker and colleagues performed a comprehensive mathematical modelling study to provide estimates of LBW deliveries that would be averted if IPTp SP coverage were to be substantially increased in sub-Saharan Africa . In their analysis, they allowed for areas with limited SP effectiveness due to drug resistance and declining malaria transmission and also considered the effect of ITN coverage. Their findings indicate that enormous health gains can be achieved through maximizing IPTp coverage despite concerns regarding SP resistance or declining malaria burden in some regions. Their modelling estimated an additional 215,000 LBW deliveries could be prevented each year if IPTp SP were to be administered to all women attending at least three ANC visits in malaria-endemic regions of sub-Saharan Africa. Their modelling also found that IPTp scale-up would have major benefits even with good ITN coverage. Others have reported the benefits of IPT in children in the context of good ITN coverage , supporting the concept that there is benefit in implementing both interventions.
Calls for the scale-up of IPTp SP coverage have not been without criticisms . A key concern relates to declining efficacy of SP as a result of increasing drug resistance. Some data suggested that SP use in populations with high levels of resistance is associated with worse pregnancy outcomes , but this has not been a consistent finding . The modelling by Walker et al. considered SP resistance and found that there was still a major benefit of IPTp in Africa because the major burden occurs in regions where SP efficacy remains high. They estimated that SP would have greatly reduced efficacy in 25% of the at-risk population where high-level resistance occurs.
Given that an estimated 75% of pregnant women attend ANC at least twice , the low coverage of IPTp and ITNs is concerning and points to broader issues. Low coverage of recommended preventive strategies reflects many challenges to the delivery and implementation of public health interventions in resource-limited settings in sub-Saharan Africa . Key factors include barriers in accessing health services, limited or inconsistent drug supply at health centres, adherence to policy, training and professional development of health care staff, and under-resourced and under-staffed facilities. Community knowledge of IPTp benefits and the cost, convenience, and acceptability of IPTp are also important.
The findings from Walker et al. support prioritising the scale-up of IPTp and ITNs for malaria in pregnancy. However, in light of SP resistance, prioritisation of new drug regimens and monitoring resistance and efficacy are critical. Further operational and implementation research is essential to understand why coverage is so low and to develop and test new strategies and implementation models. Unfortunately, this research tends to be a lower priority for research funding, but it is essential for ensuring that effective interventions widely reach populations at risk. Strengthening the coverage of existing IPTp and ITN interventions will serve as a foundation for the implementation of future interventions. Moreover, commitment to a strong integrated global plan that includes all malaria-endemic regions and prevention of P. falciparum and P. vivax malaria is paramount.