E-drug: Re: Malaria prophylaxis in pregancy (5)
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Dear e-druggers,
This is a difficult question.
I think we have two situations to take into account :
a. Travellers
b. Women living in endemic malarious areas.
a. I think that short-time travellers can take special measures, and, as
suggested by another e-drugger, when pregnant, it would be better to avoid
traveling in endemic areas specially in chloroquine-resistant malarious
areas.
WHO advises the bi-prophylaxis "Proguanil and Chloroquine" for pregnant
women, with a special remark for avoiding Doxycycline (of course). In areas
where Pl. malariae is chloroquine - resistant, it is recommended to
prescribe Chloroquine + Proguanil during the first three months, and to
shift to Mefloquine-only prophylaxis at the beginning of the fourth month.
Quinine is the recommended drug in case of confirmed malaria.
b. But I think that the "real" problem concerns pregnant women living in
endemic malarious area, because of the public health impact of maternal,
foetal and neonatal complications of malaria. Issues on drugs costs and
accessibility should also be considered as well as drugs efficacy. Things
are not simple. I would like to add to the references presented by the
e-drug moderator, the Cochrane review on malaria prevention in pregnancy.
Its conclusions are mitigate, as you can notice :
" Conclusions: Overall chemoprophylaxis during pregnancy in endemic areas
may be beneficial with an effect on mean birthweight and incidence of low
birthweight, but any effect seems to be limited to primigravidae. Given the
existing evidence, effectiveness of prophylaxis on relevant outcomes is not
strong: it seems to protect from illness in the mother, but study sizes
mitigate against any conclusions in terms of obstetric morbidity or
fetal/infant mortality. Further community based trials of sufficient power
to test the effectiveness of various prophylaxis regimens is warranted. A
programme to prevent anaemia (including iron and folate together with
antimalarials) might have more power to detect effects on anaemia and
perinatal outcome".
So the way is still long.... " On n'est pas sorti de l'auberge" ...
May I remind you of some of the prophylactic regimens proposed during the
last years :
- a monthly curative dose of Choloroquine (the advantage is, tablets can
be administered at the monthly prenatal visits, in the MCH facilities;
countries in Central Africa tried this formula);
- a weekly dose of Chloroquine 10mg/kg (at the beginning of the pregnancy
a dose of 25mg/kg should be given);
- two curative doses of Sulfadoxine - Pyrimethamine during the pregancy
(the Mangochi Malaria Project in Malawi).
I really hope that the "Roll Back Malaria Project" developed by the new
WHO leadership will not forget the importance of the malaria prevention
during pregnancy in endemic areas. I am not a "malariologist" (my field of
expertise is reproductive health) but I think that we have to "change the
paradigm" (or, if you want, "to enter a new paradigm") if we really want
to control this disease.
Dr Denisa IONETE
Ob&Gyn, MSc in Public Health,
Consultant, Health
UNICEF Libreville, GABON
mailto: ccdi@compuserve.com
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