Prevention of malaria in pregnancy in sub-Saharan Africa ... · Updated Global Malaria Action Plan ... NAMIBIA ANGOLA NIGER CHAD SUDANGUINEA ETHIOPIA DJIBOUTIBURKINA ERITREA UGANDA

Prevention of malaria in pregnancy in sub-Saharan

Africa: a synthesis and ecological analysis of

national survey data

Anna Maria van Eijk1, Jenny Hill1, Jayne Webster2, Rick Steketee3, Feiko O ter Kuile1

1 Liverpool School of Tropical Medicine, Liverpool, UK

2 London School of Tropical Medicine and Hygiene, London, UK

3 PATH, Seattle, USA

Malaria in pregnancy prevention coverage July 9, 2012 1

Background

• The use of insecticide treated nets (ITNs) and

intermittent treatment with at least two doses of

sulfadoxine-pyrimethamine (IPTp) have been shown to

reduce the burden of malaria in pregnancy and improve

maternal health and birth outcomes

Objective • To assess recent progress in coverage of these

interventions in sub-Saharan Africa

• To explore factors associated with observed coverage

• Evaluation of equity

Methods

• Evaluation of correlates associated with coverage • Time between policy and survey

• National malaria exposed births for 2010

• Population density

• Use of ANC (at least 1 or 2 visits, median month of start ANC,

start ANC before 6 months)

• Tetanus

• Country with assistance from the President’s Malaria Initiative for

>1 year before survey

• Disbursement from external funds

• Evaluation of distribution by:

– socio-economic status

– education status

– location of residence

Malaria in pregnancy prevention coverage July 9, 2012 2

Malaria in pregnancy prevention coverage July 9, 2012 3

National surveys sub-Saharan

Africa

United Nations Population

Division 2010 revised

database*

Gething 2010*: % of population

malaria exposed

Dellicour 2010*: Live and still

births

Information about ITN, IPTp

and ANC use at national level

Estimated number of

live births/country for

2010

Coverage (% and number)

for ITN and IPTp per country

and overall

Estimated number of

malaria exposed

births (live and

stillbirths) per country

*References: Gething et al 2010, PLoS Computational Biology

6(4): e1000724

Dellicour et al 2010, PLoS Medicine 7(1): e1000221.

UNDP: http://www.un.org/esa/population/

Malaria in pregnancy prevention coverage July 9, 2012 4

United Nations Population

Division 2010 revised

database*

Gething 2010*: % of population

malaria exposed

Population density

Population size

Disbursement per capita

malaria exposed persons per

year per country

Estimated number of

malaria exposed

population per country

Organisation for Economic Co-

operation and Development*

Disbursement of money for

malaria control by external

organizations per year

*References: Gething et al 2010, PLoS

Computational Biology 6(4): e1000724 UNDP: http://www.un.org/esa/population/

OECD: http://www.oecd.org

Information available in malaria in

pregnancy country profiles

Title of presentation July 9, 2012 5

By 2005:

60% of pregnant

women at risk of

malaria

-benefit from ITNs

-have access to

chemoprophylaxis

or IPTp

Source: Abuja

Declaration 2000

By 2010:

80% of people at

risk preventive

measures

Pregnant women:

-80% ITNs

-80% IPTp in areas

of stable malaria

Source: Roll Back

Malaria 2008

Global Malaria

Action Plan

By 2015:

100% of people at

risk preventive

measures

Pregnant women:

-100% ITNs

-100% IPTp

Source: Roll Back

Malaria 2011

Updated Global

Malaria Action

Plan

Targets for malaria control among pregnant women

over the last decennium in sub-Saharan Africa

Policies

• 45 countries

evaluated

– 45 ITN policy

– 38 IPT policy

Malaria in pregnancy prevention coverage July 9, 2012 7

Spread of IPTp policy across Africa

TANZANIA

BURUDI

EQUATORIAL GUINEA

ANGOLA

REP OF THE

CONGO

Zanzibar

MALAWI

ZAMBIA

MOZAMBIQUE MADAGASCAR

ZIMBABWE

BOTSWANA

SWAZILAND

LESOTHO

SOUTH

AFRICA

NAMIBIA

ANGOLA

NIGER

CHAD

SUDAN

ETHIOPIA

DJIBOUTI

ERITREA

UGANDA SOMALIA

KENYA DEMOCRATIC

REPUBLIC

OF THE CONGO

(ZAIRE)

CENTRAL AFRICAN REPUBLIC

RWANDA GABON

NIGERIA

CAMEROON

Berbera

Africa TUNISIA

WESTERN

SAHARA

ALGERIA

MALI

LIBYA EGYPT

BENIN

TOGO COTE DTVOIRE

BURKINA

GUINEA

SENEGAL

GHANA

LIBERIA

MAURITANIA

SIERRA LEONE

GAMBIA

GUINEA BISSAU

THE

MOROCCO

IPTp coverage

(%) in surveys

2009-11

0-9%

10-19%

20-29%

30-39%

40-49%

50-59%

60-69%

No data

No IPTp

No malaria

Countries with data

from surveys in 2005-

8 but not in 2009-11

Benin ’06 3%

Central African

Republic ‘06

9%

Cote d’Ivoire ‘06 12%

Gambia ‘08 49%

Ghana ‘08 44%

Guinea ’05 3%

Mali ‘06 4%

IPTp current situation 2009-2011, 23 countries

Median

coverage: 24.5%

(IQR 17.5-38.6)

Coverage of IPTp and tetanus by ANC

use (at least one visit)

Title of presentation July 9, 2012 9

0

20

40

60

80

100

0 20 40 60 80 100

Co

ve

rag

e (

%)

ANC coverage (at least one visit, %)

Coverage tetanus Use of IPTp

Spearman test ANC and IPTp: rho = 0.638, p=0.001;

Tetanus and IPTp: rho = 0.596, p=0.004

Tetanus

median coverage:

73.3%

(IQR 63.3-83.6%)

(21 countries)

Cameroon Chad

Equatorial Guinea

Liberia

Madagascar

Malawi

Sao Tome & P

Senegal Sierra Leona

Zambia

Zimbabwe

0

20

40

60

80

0 1 2 3 4 5 6 7

IPT

p

co

ve

rag

e (

%)

Average amount of disbursement for malaria control by external organizations per year per capita malaria exposed in the 2 years

before the survey in US$

Disbursements for malaria control by external

organizations vs. IPTp coverage in 21 sub-

Saharan countries, 2009-2011

Spearman test: rho = 0.412, p=0.062

Median

disbursement

US$ 1.44

Range 0.02-6.21

21 countries

Socio-economic status

Risk ratio 2 highest vs.

3 lowest wealth

quintiles, 95% CI

Education status

Risk ratio any education

vs. none, 95% CI

Place of residence

Risk ratio urban vs. rural

location, 95% CI

Zimbabwe '10 Madagascar '08-9 Malawi '10 DRC '10

Liberia '08-9

Sao Tome '08-9 Tanzania '10 Zambia '10 Sierra Leone '10 Uganda '09

Kenya '10

Senegal '10-11 South Sudan '09 Angola '11 Nigeria '10

0.3 3

Zimbabwe '10-11 Liberia '08-9 DRC '10 Uganda '09

Malawi '10

Sierra Leone '10 Zambia '10 Madagascar '08-9 Tanzania '10 Senegal '10-11

South Sudan '09

Sao Tome '08-9 Kenya '10 Angola '11 Nigeria '10

Zimbabwe '10-11 Malawi '10 DRC '10 Congo B '11-12

Liberia '08-9

Kenya '10 Zambia '10 Tanzania '09 Sierra Leone '10 Sao Tome '08-9

Senegal '10-11

Uganda '09 Cameroon '11 Madagascar '11 Mozambique '11 Nigeria '10

South Sudan '09

Burkina Faso '10 Angola '11

0.4 4

0.3 3

IPTp coverage by socio-economic status, educational status and

place of residence in sub-Saharan countries, 2009-2011

1 1

1

Socio-economic status

Risk ratio 2 highest vs. 3

lowest wealth quintiles,

95% CI

Education status

Risk ratio any education

vs. none, 95% CI

Place of residence

Risk ratio urban vs. rural

location, 95% CI

Uganda '09-10 Sao Tome '08-9 Rwanda '10-11

Sierra Leone '10

Malawi '10

Tanzania '09-10 Zimbabwe '10-11 Liberia '08-9 Kenya '10

Senegal '10-11

DRC '10

Madagascar '08-9 Namibia '09 Nigeria '10 South Sudan '09

Zimbabwe '10-11 Rwanda '10-11 Sierra Leone '10

Uganda '11

Tanzania '09-10

Malawi '10 Sao Tome '08-9 Liberia '08-9 Senegal '10-11

Mozambique '11

DRC '10

Madagascar '08-9 Kenya '10 South Sudan '09 Nigeria '10

Djibouti '08-9 Swaziland '10 Zimbabwe '10-11 Burundi '10-11 Rwanda '10-11 Sao Tome '08-9 Malawi '10 Sierra Leone Uganda '11 Kenya '10 Tanzania '09-10 Burkina Faso '10 Liberia '08-9 DRC '10 Zambia '07 Mozambique '11 Senegal '10-11 Congo B '11-12 Madagascar '08-9 Cameroon '11 Angola '06 Nigeria '10 South Sudan '09 Ethiopia '10-11

0.3 3 0.3 3.0

0.3 3

ANC coverage (at least one visit) by socio-economic status, educational

status and place of residence in sub-Saharan countries, 2009-2011

1 1

1

0

20

40

60

80

100

1999 2001 2003 2005 2007 2009 2011

Zambia

Malawi

Zanzibar

Ghana

Senegal

Sierra Leone

Tanzania M

Kenya

Uganda

Mozambique

Angola

Nigeria

Zimbabwe

13 Countries with information on IPTp

coverage from three or more surveys

TANZANIA

BURUDI

EQUATORIAL GUINEA

ANGOLA

REP OF THE

CONGO

Zanzibar

MALAWI

ZAMBIA

MOZAMBIQUE MADAGASCAR

ZIMBABWE

BOTSWANA

SWAZILAND

LESOTHO

SOUTH

AFRICA

NAMIBIA

ANGOLA

NIGER

CHAD

SUDAN

ETHIOPIA

DJIBOUTI

ERITREA

UGANDA SOMALIA

KENYA DEMOCRATIC

REPUBLIC

OF THE CONGO

(ZAIRE)

CENTRAL AFRICAN REPUBLIC

RWANDA GABON

NIGERIA

CAMEROON

Berbera

Africa TUNISIA

WESTERN

SAHARA

ALGERIA

MALI

LIBYA EGYPT

BENIN

TOGO COTE DTVOIRE

BURKINA

GUINEA

SENEGAL

GHANA

LIBERIA

MAURITANIA

SIERRA LEONE

GAMBIA

GUINEA BISSAU

THE

MOROCCO

ITN coverage (%) in

pregnancy

surveys 2009-11

0-9

10-19

20-29

30-39

40-49

50-59

60-69

70-79

No data

No risk

Countries with data

from surveys in 2005-

8 but not in 2009-11

Benin ’06 20%

Ethiopia ‘07 35%

Gabon ‘08 36%

Gambia ‘08 45%

Ghana ‘08 20%

Guinea ‘07 3%

ITN coverage in pregnancy 2009-11

Median

coverage:

35.2%

(range 5.2-72.3)

Burundi

Equatorial Guinea

Madagascar Mali

Niger Rwanda

Sao Tome & P

Swaziland

Tanzania

0

20

40

60

80

0 2 4 6 8 10

Us

e o

f IT

Ns

in

pre

gn

an

cy (%

)

Average amount of disbursement for malaria control by external organizations per year per capita malaria exposed in the 2 years

before the survey in US$

Disbursements for malaria control by external

organizations vs. ITN coverage in 31 sub-

Saharan countries, 2009-2011

Spearman test: rho = 0.345, p=0.062

Median

disbursement

US$ 1.52

Range 0.05-8.65

30 countries

Socio-economic status

Risk ratio 2 highest vs. 3

lowest wealth quintiles,

95% CI

Education status

Risk ratio any education

vs. none, 95% CI

Place of residence

Risk ratio urban vs. rural

location, 95% CI

Nigeria '10 Djibouti '08-9 Senegal '10-11

Liberia '08-9

Namibia '09 Zambia '10 Sierra Leone '10 Kenya '10 Zimbabwe '10-11

Madagascar '08-9

Tanzania '10 DRC '10 Rwanda '10-11 Uganda '09-10 Sao Tome '08-9

Malawi '10

Angola '11 South Sudan '09

Nigeria '10 Liberia '08-9 Madagascar '08-9

Senegal '10-11

Uganda '09-10 Tanzania '09-10 Kenya '10 Malawi '10 Sierra Leone '10

Angola '11

Rwanda '10-11 DRC '10

Nigeria '10 Congo B '11-12 Zambia '10 Djibouti '08-9 Tanzania '09-10 Namibia '09 Liberia '08-9 Burkina Faso '10 Madagascar '11 Zimbabwe '10-11 Kenya '10 Sierra Leone '10 Senegal '10-11 DRC '10 Rwanda '10-11 Cameroon '11 Angola '11 Uganda '11 Malawi '10 Burundi '10-11 Sao Tome '08-9 South Sudan '09 Mozambique '11

0.3 3

0.3 3

0.3 3

ITN use by socio-economic status, educational status and place of

residence in sub-Saharan countries, 2009-2011

1

1

1

12 Countries with three or more surveys with

information on ITN use in pregnancy

Title of presentation July 9, 2012 17

0

20

40

60

80

100

1999 2001 2003 2005 2007 2009 2011

Rwanda

Tanzania M

Zanzibar

Zambia

Uganda

Kenya

Senegal

Malawi

Nigeria

Angola

Zimbabwe

Swaziland

Correlates with coverage

IPTp rho*, p ITN rho*, p

Time between policy adoption and survey 0.257, p=0.2 0.024, p=0.9

National number of malaria exposed births -0.308, p=0.2 0.206, p=0.3

Population density 0.270, p=0.2 0.343, p=0.05

ANC coverage (at least 1 visit) 0.638, p<0.01† 0.364, p=0.04

Support Presidential Malaria Initiative† p=0.1‡ P=0.02‡

Disbursement for malaria control§ 0.412, p=0.06 0.345, p=0.06

Title of presentation July 9, 2012 18

*: Spearman’s rho for correlation (non-parametric test)

† Also significant for at least two ANC visits, and ANC started before 6 months of

gestation

‡ Mann-Whitney U test (non-parametric test)

§Average amount of disbursement for malaria control by external organizations per

year per capita malaria exposed in the 2 years before the survey in US$

Extrapolation of survey data to absolute

numbers of births

2007

Surveys 2004-2009

IPTp 2 doses

• Data from 19 countries

• 13.6% covered

– 2.7 million births

ITN

• Data from 32 countries

• 17% covered

– 4.7 million births

2010

Surveys 2009-2011

IPTp 2 doses

• Data from 23 countries

• 21.6% covered

– 4.4 million births

ITN

• Data from 33 countries

• 38.5% covered

– 9.3 million births

Malaria in pregnancy prevention coverage July 9, 2012 19

Some limitations

• Reliance on public availability of national reports

– MICS IV reports 2010-11 not available : West African countries

more affected

– All countries received Global Fund money, no guarantee for

public reports

• no (recent) public reports on coverage for ITNs: Eritrea, Cote

d’Ivoire, Central African Republic, Mauritania

• No reports on IPTp for Mauritania, Gabon

• Tetanus not ideal for comparison at ANC level

• Estimates risk ratios for equity not adjusted for survey

design

• Analysis not by first administrative units

– National coverage misleading in countries which are only

partly malaria endemic

Title of presentation July 9, 2012 20

For the meeting participants Take away headlines &

surprising findings

• Slow increase overall, but large

discrepancies between

countries

• External funding and assistance

important, but not the most

important factor

• Number of births or population

density not an important factor

• ANC correlated with ITN use

• Discrepancies in equity by

country for IPTp & ITN – E.g. Nigeria: ITNs among poor,

uneducated, rural women; IPTp

among richer, educated, urban

women

Of importance for malaria

programs

• Determination important

• For countries with inequity:

malaria mainly rural, so

rural women priority!

• An ITN against malaria for

everybody, but pregnant

women and children

FIRST!

Malaria in pregnancy prevention coverage July 9, 2012 21

Conclusion

Considerable

success in

some

countries

More work

needs to be

done in

others

IPTp may be

harder to

deliver than

ITN

Malaria in pregnancy prevention coverage July 9, 2012 22

Thank you

Margaret Nagasa, Family-tenderly together, 2003

July 9, 2012 Malaria in pregnancy library 23

0 20 40 60 80

Mauritania '03Chad '10Benin '06

Somalia '08Djibouti '08

Sierra Leone '08South Sudan '09

Guinea B '10Liberia '08Gabon '08

Burkina Faso '10Gambia '08

Togo '10Burundi '10

Sao Tome & P '08

Guinea '05, '07Sudan '05, '09

Mozambique '07, '11Cameroon '04, '11

Ghana '03, '08Congo B '05, '11Namibia '06, '09

Sierra Leone '08, '10Ethiopia '05, '07

Equatorial Guinea '08,…DRC '07, '10

Eritrea '02, '04Mali '06, '10

Madagascar '08, '11Niger '06, '10

ITN coverage pregnancy (%)

Second and last availablesurvey

First or only survey

30 countries with information on ITN use

limited to one or two surveys

0 20 40 60 80

Sudan '05Guinea '05

Benin '06Mali '06

Cote d'Ivoire '06CAR '06

Namibia '06South Sudan '09

Togo '06Chad '10

Congo B '11-12Liberia '08

Sao Tome & P '08

Burkina Faso '06, '10Guinea B '06, '10

DRC '07, '10Madagascar '08, '11

Cameroon '06, '11Equatorial Guinea '08, '09

Ghana '06, '08Gambia '05, '08

IPTp coverage (%)

Second and last availablesurvey

First or only survey

21 countries with information on IPTp coverage

limited to one or two surveys

0

20

40

60

80

100

0 20 40 60 80

Use

of

ITN

th

e p

revi

ou

s n

igh

t am

on

g p

regn

ant

wo

me

n in

ho

use

ho

lds

wit

h

ITN

(%

)

Use of ITN the previous night among pregnant women (%)

Scatter plot of the use of ITNs the previous night among

pregnant women vs. the use of ITNs the previous night

among pregnant women in a household with an ITN, 21

sub-Saharan countries, 2009-2011

Comparison use of SP and use of any antimalarial for

prevention of MiP in 17 countries with information

0 20 40 60 80 100

Angola MIS 2011

DRC MICS 2010

EG MIS 2009 combined

Kenya MIS 2010

Liberia MIS 2008-9

Madagascar MIS 2011

Malawi DHS 2010

Nigeria MIS 2010

Sao Tome & Principe DHS 2008-9

Senegal DHS 2010

Sierra Leone MICS 2010

South Sudan MIS 2009

Tanzania Mainl DHS 2009

Uganda MIS 2009-10

Zambia MIS 2010

Zanzibar DHS 2009

Zimbabwe DHS 2010

Use (%)

SP at least one dose, any source Any antimalarial for prevention of MiP

*Countries with a difference > 9% indicative of use of considerable use of

antimalarials other than SP for MiP prevention. These include: DRC, Equatorial

Guinea, Kenya, Nigeria, Senegal, Sierra Leone, South Sudan and Zimbabwe . Type of other antimarial used not reported in these national surveys.

*

* *

*

*

*

*

*

TANZANIA

BURUDI

EQUATORIAL GUINEA

ANGOLA

REP OF THE

CONGO

Zanzibar

SOUTH AFRICA

MALAWI

ZAMBIA

MOZAMBIQUE MADAGASCAR

ZIMBABWE

BOTSWANA

SWAZILAND

LESOTHO

SOUTH

AFRICA

NAMIBIA

ANGOLA

NIGER

CHAD

SUDAN

ETHIOPIA

DJIBOUTI

ERITREA

UGANDA SOMALIA

KENYA DEMOCRATIC

REPUBLIC

OF THE CONGO

(ZAIRE)

CENTRAL AFRICAN REPUBLIC

RWANDA GABON

NIGERIA

CAMEROON

Berbera

Africa TUNISIA

WESTERN

SAHARA

ALGERIA

MALI

LIBYA EGYPT

BENIN

TOGO COTE DTVOIRE

BURKINA

GUINEA

SENEGAL

GHANA

LIBERIA

MAURITANIA

SIERRA LEONE

GAMBIA

GUINEA BISSAU

THE

MOROCCO

2+ ANC visits (%) DHS

surveys 2000-11

20-29%

30-39%

40-49%

50-59%

60-69%

70-79%

80-89%

90-100%

No data

Not of interest

2+ ANC visits in

pregnancy DHS surveys 2000-11

TANZANIA

BURUDI

EQUATORIAL GUINEA

ANGOLA

REP OF THE

CONGO

Zanzibar

MALAWI

ZAMBIA

MOZAMBIQUE MADAGASCAR

ZIMBABWE

BOTSWANA

SWAZILAND

LESOTHO

SOUTH

AFRICA

NAMIBIA

ANGOLA

NIGER

CHAD

SUDAN

ETHIOPIA

DJIBOUTI

ERITREA

UGANDA SOMALIA

KENYA DEMOCRATIC

REPUBLIC

OF THE CONGO

(ZAIRE)

CENTRAL AFRICAN REPUBLIC

RWANDA GABON

NIGERIA

CAMEROON

Berbera

Africa TUNISIA

WESTERN

SAHARA

ALGERIA

MALI

LIBYA EGYPT

BENIN

TOGO COTE DTVOIRE

BURKINA

GUINEA

SENEGAL

GHANA

LIBERIA

MAURITANIA

SIERRA LEONE

GAMBIA

GUINEA BISSAU

THE

MOROCCO

Start ANC visits < 6 m (%) DHS

surveys 2000-11

20-29%

30-39%

40-49%

50-59%

60-69%

70-79%

80-89%

No data

Not of interest

Start of ANC visit

before 6 months of

gestational age DHS surveys 2000-11

Median month of gestational age at first ANC visit among ANC attendees in 25 countries with IPTp policy

and DHS between 2004-2011

0 1 2 3 4 5 6

Liberia DHS 2006-7Senegal DHS 2005

Ghana DHS 2008Congo DHS 2005

Sao Tome Principe DHS 2008Benin DHS 2006

Mali DHS 2006Cameroon DHS 2004

Chad DHS 2004Guinea ONS 2007-8

Sierra Leone DHS 2008Burkina Faso DHS 2003

Namibia DHS 2006-7Madagascar 2008-9

Niger DHS 2006Nigeria DHS 2008

Mozambique DHS 2003Zambia DHS 2007

DR Congo DHS 2007Zanzibar DHS 2009-10

Zimbabwe DHS 2010-11Tanzania M DHS 2009-10

Uganda DHS 2006Malawi DHS 2010

Kenya DHS 2008-9

Median month of gestational age at first ANC visit among ANC attendees

Gestational age at first ANC visit (%) among survey participants with last live birth in previous 5 years in 25 countries with IPTp

policy and DHS between 2004-2011

0 10 20 30 40 50 60 70 80 90 100

Sierra Leone DHS 2008Malawi DHS 2010

Niger DHS 2006Kenya DHS 2008-9

Tanzania M DHS 2009-10Uganda DHS 2006

Chad DHS 2004Zanzibar DHS 2009-10

Mozambique DHS 2003DR Congo DHS 2007

Zambia DHS 2007Zimbabwe DHS 2010-11Burkina Faso DHS 2003

Madagascar 2008-9Mali DHS 2006

Namibia DHS 2006-7Cameroon DHS 2004

Guinea ONS 2007-8Nigeria DHS 2008

Benin DHS 2006Congo DHS 2005

Sao Tome Principe DHS…Ghana DHS 2008

Senegal DHS 2005Liberia DHS 2006-7

Start ANC visits < 6months gestationalage

Start ANC visits < 4months gestationalage

Four or more ANC visits among survey participants with last live birth in previous 5 years in 26 countries with IPTp policy and

national survey between 2004-2011

0 20 40 60 80 100

Somalia MICS 2006Niger DHS 2006Chad DHS 2004Mali DHS 2006

Rwanda DHS 2010-11Senegal DHS 2005

Tanzania M DHS 2009-10DR Congo MICS 2010

Nigeria DHS 2008Malawi DHS 2010

Kenya DHS 2008-9Uganda DHS 2006

Zanzibar DHS 2009-10Madagascar 2008-9Guinea ONS 2007-8

Mozambique MIS 2007Sierra Leone DHS 2008

Zambia DHS 2007Cameroon DHS 2004

Benin DHS 2006Zimbabwe DHS 2010-11

Liberia DHS 2006-7Namibia DHS 2006-7

Sao Tome Principe DHS 2008Congo DHS 2005Ghana DHS 2008