Malaria control in pregnant women and children in resource-limited countries: Perspective from Tanzania and its relation to climate change

James Chrispin | jameschrispn @gmail.com

Planetary Health Campus ambassador and chairperson of Planetary Health Club from Catholic University of Health and Allied Sciences

INTRODUCTION

Climate change has the potential to significantly impact human health by altering the epidemiological distribution, natural history, and seasonality of various diseases. Climate change is related to vector borne diseases by increasing the range and abundance of mosquitoes, ticks, and other disease-carrying vectors, which can lead to an increase in diseases such as malaria, dengue fever, and Lyme disease (1).

Malaria is a parasitic infection transmitted by female anopheles mosquitoes. There are five Plasmodium species that are particularly threatening to humans; namely, Plasmodium Falciparum, Plasmodium Malariae, Plasmodium Ovale, Plasmodium Knowlesi, and Plasmodium Vivax. Half of the world’s population was at risk of malaria with an estimated 247 million reported cases and 619,000 malaria deaths worldwide in 2021 (2). The African Region contributed 95% of malaria cases and 96% of malaria deaths. Over half of all malaria deaths globally occurred in four African nations: Nigeria 31.3%, the Democratic Republic of the Congo 12.6%, Tanzania 4.1%, and Niger 3.9% (3). According to estimates, malaria prevalence in Tanzania dropped from 14.8% in 2017 to 9.7% in 2019(4). The distribution of insecticide-treated nets, indoor residual spraying, and availability of potential antimalarial medications were some of the measures that scaled up malaria control and caused this drop. Despite these advancements, malaria continues to be a major public health problem in Tanzania, with vulnerable groups being children under five and pregnant women.

The incidence of malaria in Tanzania varies depending on the region and the time of the year. Malaria transmission is highest in the coastal and low-lying areas of the country, particularly during the rainy season from March to May and from October to December.

Malaria and Pregnant women

More than 32 million pregnancies occur annually in malaria-endemic areas in sub-Saharan Africa, with a prevalence of malaria infection during pregnancy ranging from 20 to 35% (5). There is a large amount of evidence showing that the risk of malaria (both infection and clinical disease) is higher in pregnant women than in non-pregnant women. This could possibly be due to the immunological, hormonal changes or other factors occurring during pregnancy.Also, pregnant women are particularly vulnerable to Plasmodium falciparum infection because red blood cells infected with the parasite can sequester in the placenta, thereby causing adverse fetal effects (6). If antimalarial drugs do not achieve therapeutic levels in the placenta, parasites sequestered there may be released intermittently into the peripheral blood and cause recurrent maternal infection. Malaria contributes to maternal illness and anemia in pregnancy, especially in first‐time mothers, and can harm the mother and the baby. During pregnancy, malaria is known to pose effects on both the mother and the offspring, including spontaneous abortion, preterm delivery, low birth weight, stillbirth, congenital infection, maternal death, maternal anemia, and neonatal mortality (7).

There are two types of malaria that can affect pregnant women: uncomplicated and complicated. Uncomplicated malaria refers to the typical symptoms of malaria, such as fever, chills, and body aches, which can be treated effectively with antimalarial medication. Complicated malaria, on the other hand, is a more severe form of the disease that can cause severe anemia, kidney failure, convulsions, and coma.

According to a 2019 report by the Tanzanian Ministry of Health, malaria is the leading cause of morbidity and mortality among pregnant women in the country (8). The report noted that approximately 9.4% of all pregnant women in Tanzania are infected with malaria, with a higher prevalence in rural areas.

To address this issue, Tanzania has implemented various strategies to prevent and control malaria in pregnant women, including the distribution of insecticide-treated bed nets, intermittent preventive treatment with antimalarial medication, and prompt diagnosis and treatment of malaria cases (9). Despite these efforts, malaria remains a significant health problem for pregnant women in Tanzania, highlighting the ongoing need for effective malaria prevention and control strategies.

TANZANIA Interventions to Control Malaria in Pregnancy

In Tanzania, where malaria is endemic, there are several interventions aimed at preventing malaria during pregnancy and reducing its impact. These interventions are implemented through Tanzania’s National Malaria Control Program which includes:

1. Intermittent Preventive Treatment in Pregnancy (IPTp): IPTp involves the administration of anti-malarial drugs to pregnant women at scheduled intervals starting from the second trimester of pregnancy, regardless of whether they have malaria symptoms or not. The recommended drug for IPTp in Tanzania is sulfadoxine-pyrimethamine (SP) (10).
2. Insecticide-treated bed nets (ITNs): ITNs are effective in preventing malaria transmission by mosquitoes. Pregnant women are encouraged to sleep under ITNs every night to reduce their risk of infection (11).
3. Indoor residual spraying (IRS): IRS involves spraying the inside walls of houses with insecticides to kill mosquitoes that come into contact with the walls. This intervention is recommended for pregnant women living in areas with high malaria transmission (12).
4. Health education and promotion: Pregnant women are educated about the importance of malaria prevention and the use of IPTp, ITNs, and IRS. Health promotion activities are conducted in communities and health facilities to increase awareness about malaria prevention during pregnancy.
5. Early diagnosis and prompt treatment: Pregnant women who develop malaria symptoms should seek medical attention immediately for diagnosis and treatment. Early diagnosis and prompt treatment can prevent severe malaria and its complications (13).

Pregnant woman and children sleeping under mosquito treated net

Health education and promotion to Community about Malaria in Mwanza Tanzania

Reason for the Failure of Full Elimination of Malaria in Tanzania, Despite the Interventions

1. Presence of mosquito breeding sites: Stagnant water is where most malaria-carrying mosquitoes breed. In Tanzania, places like rice fields, irrigation canals, and ponds have a high prevalence of stagnant water. Mosquitoes find these places to be excellent breeding sites.
2. Lack of access to preventive measures: Many individuals in Tanzania still do not have access to malaria prevention programs including insecticide-treated bed nets and indoor residual spraying, despite attempts to enhance access to these interventions. This is especially true in rural areas, where there is little access to medical treatment and preventative measures.
3. Lack of awareness of Malaria: The community is lacking awareness of malaria morbidity and mortality. Awareness of symptoms is important for early treatment and preventing other people from getting malaria.
4. Poor attendance to Antenatal clinics by pregnant women: Malaria prevention including the use of Malaria Intermittent Preventive Therapy and the provision of mosquito nets during antenatal clinic visits. Women in rural areas have a poor participation in antenatal clinics.
5. Resistance to antimalarial drugs: malaria parasites have become resistant to some basic medications used to treat the condition. This can contribute to the spread of the disease and makes it harder to successfully treat malaria infections.
6. Poverty: The prevalence of malaria in Tanzania is significantly influenced by poverty. The persistent burden of malaria in the nation is a result of poor living circumstances, inadequate healthcare, and restricted access to preventive measures. Poor housing conditions permit the entrance of mosquitos through the windows and openings in the house. The inability to get recommended Malaria treatment increases the chance of transmission of Malaria to healthy individuals.
7. Lack of accessibility to medical care: This includes diagnosis and treatment for malaria to pregnant women and young children under the age of five, especially in rural areas. This lack of accessibility causes failure to treat and diagnose Malaria, leading to increased risk of complications and development of severe malaria.

SOLUTION TO END MALARIA IN TANZANIA

1. Community involvement in preventing the spread of malaria

In Tanzania, limiting the spread of malaria requires active community participation. This includes cooperating with members and community leaders in the fight to end Malaria, which will enhance the health and wellbeing of each and every member of the community. Below is an explanation of how communities can be engaged in the fight to end Malaria

1. Awareness campaigns: This aims at increasing public understanding of the causes, the symptoms, and the prevention of malaria. Community members can organize and take part in education programs by setting up neighborhood gatherings, distributing educational materials, and carrying out door-to-door educational outreach.
2. Environmental control program: Community members can cooperate to maintain their surroundings clear and free of standing water, which can act as mosquito breeding grounds. This may entail clearing up trash, draining standing water, and doing routine maintenance on water storage containers.
3. Improving housing conditions: Community members are advised to improve their housing conditions to minimize the chance of vectors and mosquitoes entering the house and transmitting malaria to family members. This includes covering windows and doors to prevent mosquitoes from entering.
4. Empowering local leaders and advocacy in Malaria prevention and control: Community members can push for stronger local and national malaria prevention and implementation of policies and programs in their areas. This includes interacting with local leaders, representatives of the local government, medical professionals, and other interested parties to guarantee that sufficient funds are allotted for malaria prevention initiatives.
5. Community health care workers: This involves training community members in diagnosing malaria, establishing malaria treatment centers in local areas, and ensuring availability and accessibility to care and treatment, in order to provide early diagnosis and treatment of malaria. Community members can collaborate with medical professionals in establishing community-based treatment facilities and educating local healthcare professionals on how to recognize and treat malaria.
6. International and local collaborations in malaria control

International collaboration is important for successful malaria control and elimination by working together on resource allocation and sharing expertise and knowledge to develop and implement effective strategies to reduce the burden of malaria. Malaria has affected our community at all levels, leading to a call to establish partnerships with various institutions and organizations, ranging from the public to private level, all aimed at joining efforts in malaria elimination.

1. Technological Innovations and Research

Effective malaria control depends on research and innovation. They offer the resources and information required to stop, identify, and treat the disease as well as to gradually create more efficient control measures. Below is an explanation of how research and innovation can be used to control malaria.

1. Prevention: Research and innovation can be used to develop new insecticides and bed nets sprayed with insecticides, which are the best instruments for controlling malaria in regions where the illness is endemic. The use of research to develop new vaccinations can offer long-term malaria protection.
2. Diagnosis: For malaria to be effectively controlled, a prompt and accurate diagnosis is necessary. Rapid diagnostic tests (RDTs), which are affordable and simple to use can be carried out in the field and have been developed as a result of research and invention. The development of novel diagnostic methods that can identify the presence of malaria parasites at low levels even before symptoms emerge
3. Treatment: The most potent medications now on the market for treating malaria are artemisinin-based combination treatments (ACTs), which were developed as a result of research and invention. There is a need to use research in the creation of new medications– to treat malaria strains that are resistant to existing medications
4. Leadership, policy formulation & implementation, and youth engagement in movements to end malaria

We need strong leadership in advocacy, resource mobilization in the movement to end malaria, and the formulation of new policies which are targeting implementation of strategic plans to end malaria and the implementation of the policies at a community level. Youth make up the majority of the population, occupying more than 60% of the African population. It is an energetic and working age group that could be engaged fully in malaria prevention, control programs, and movements.

CONCLUSION

Malaria is an old disease. We are still fighting to reduce its consequences. It has killed many people, especially pregnant women and children under five years of age. We have had some movements to control the disease by adapting to various local and international guidelines for malaria control. Community engagement, local and international collaborations, technological innovations and research, good leadership in policy formulation and implementation of policies, and engagement of youth in malaria prevention programs need to be integrated into the fight to eliminate malaria. A malaria vaccine could be the most important component in malaria elimination, especially for the most affected groups in malaria endemic regions. Increased funding to support the movements and fight to end malaria is another important pillar in malaria control and elimination. We can achieve full elimination of malaria. We need to work together and keep the movement in motion.

Author: James Chrispin

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