Maternal Health: What`s Infectious Disease Got to Do With It?

Report
Maternal Health: What's
infectious disease got to
do with it?
USAID Mini-University
Karen Fogg, Charlotte Colvin, Erin Eckert
7 March 2014
Maternal Health: What's infectious
disease got to do with it?
Outline of Presentation
1. Brief Introduction (5 minutes)
2. Overview of Malaria In Pregnancy (10 minutes)
3. Overview of Maternal Health and TB (10 minutes)
4. Overview of Maternal Health and HIV/AIDS (10 minutes)
5. Question and Answer Session (15 minutes)
Proposed bold end-game: Ending preventable
maternal deaths worldwide by 2035:
Reaching MMR = 50
450
MM Ratio (1990-2010)
543,000 Deaths
Annually
MM Ratio (2010-2035)
400
MM Ratio Accelerated 50 (2010-2035)
OECD MM Ratio UL (50)
Maternal Mortality Ratio
350
OECD MM Ratio UL (50) Projected
4.1% Annual Rate of
MMR Reduction
2000-2010
Current Trend
300
287,000 Deaths
Annually
250
200
4.1% Annual Rate of
MMR Reduction
2010-2035
Current Trend
150
5.6% Annual Rate
of Reduction of
MMR 2010-2035
Accelerated Trend
100
50
1990
1995
2000
2005
2010
2015
Years
2020
2025
2030
2035 3
Required Regional Progress to Reach Proposed
MMR of 50 by 2035
900
SUB-SAHARAN AFRICA
800
Ending preventable maternal deaths worldwide by
2035-reaching MMR = 50
Maternal Mortality Ratio
700
600
SOUTHERN ASIA
(excluding India)
CURRENT
AAR
2000-2010
AAR TO
REACH MMR
= 50
Sub-Saharan Africa
-3.8%
-8.8%
Southern Asia (excluding India)
-5.2%
-6.1%
Asia
-5.7%
-4.3%
Eastern Asia (excluding China)
-3.5%
0%
LAC
-2.2%
-1.9%
OECD MMR Upper Limit
-4.8%
0%
500
400
ASIA
8.8% Annual Rate
of Reduction of
MMR 2010-2035
Accelerated Trend
300
200
100
-
LAC
OECD MMR Upper Limit
EASTERN ASIA
(excluding China)
1990
1995
2000
2005
2010
2015
Years
2020
2025
2030
2035
4
Hiding in Plain Sight:
Malaria in Pregnancy
The MIP interagency working group
USAID: Susan Youll, Erin Eckert, Meera Venkatesan, Tom Hall
CDC: Mary Hamel, Julie Gutman, Zandra Hollaway André
USAID Mini-University
March 2014
Washington, DC
Why are pregnant women at higher risk?
• Pregnant women are a
high risk group for
malaria due to shifts in
immunity
– Pregnancy causes
transient depression of
cell-mediated immunity
– Greater susceptibility to
infection means higher
risk for contracting
diseases, including malaria
Pregnancy and the Placenta:
Malaria’s special challenges
• MIP characterized by parasites that ‘sequester’ in
the placenta
• Placental infection can occur in absence of clinical
symptoms but have dire consequences on
placental function
• Peripheral parasitemia may be absent with
placental infection
– Poses a diagnostic challenge
– Potential impact on malaria indicators
MIP Symptoms and Complications:
Areas with unstable or low transmission
• Women have not acquired any significant level of
immunity
• At a two- to three-fold higher risk of developing
severe disease as compared to non-pregnant
adults
• Maternal deaths may occur directly or indirectly
– Severe malaria
– Severe anemia
MIP Symptoms and Complications:
Areas with stable or high/moderate transmission
• Impact of MIP of particular concern in first and
second pregnancies
– Maternal morbidity and mortality
– Fetal mortality
– Premature delivery
– Intrauterine growth retardation
– Delivery of low birth-weight infants (<2500 g or <5.5
pounds), a risk factor for neonatal mortality
• Circulating antibodies for placental receptors
develop over subsequent pregnancies to decrease
impact
Malaria in Pregnancy Interventions
Support a multi-pronged approach to MIP:
1. Provision of long-lasting insecticide treated
nets (LLINs) through mass distribution
campaigns and at ANC & EPI clinics
2. Intermittent preventive treatment in
pregnancy (IPTp) with SP
3. Effective case management of malaria and
anemia in pregnancy
ITNs in Pregnancy
• Among women of low
gravidity (≤4 pregnancies)
– Reduce peripheral and
placental parasitaemia
– Reduce low birthweight by
23%
– Decrease risk of fetal loss
• ITNs are the only strategy for
prevention in the first
trimester
• ITNs should be an integral part
of strategies to prevent
malaria in pregnant women
living in areas of Africa where
malaria is endemic
Case Management of Malaria in Pregnancy
• Any pregnant woman with fever should be
tested and, if positive for malaria, treated
promptly.
– Quinine in first trimester; ACTs after 12 weeks
• All pregnant women should be screened for
anemia
– High dose folate should not be given for 14 days
after taking IPTp-SP or treatment with SP-AS
Intermittent Preventive Treatment (IPTp)
• All pregnant women in areas of stable malaria
transmission should receive a dose of IPT with
SP at every ANC visit after quickening
• There should be at least 1 month in between
doses of SP
• HIV+ women on cotrimoxazole should not
receive IPTp
• Rationale for IPTp
– Clearance of existing asymptomatic infections
– Prophylactically preventing new infections during
periods of fetal growth
New Rationale for the Timing
of More SP Doses
Fetal growth velocity 
Rx
Rx
Rx
Rx
Quickening
Conception
10
1st Trimester
16
20
Weeks of gestation
30
Birth
14
Missed Opportunities: Percentage of Pregnant Women Who
Make >2 Antenatal Clinic Visits (ANC) and IPTp2 Coverage
ANC visit data from DHS (2005-2011). Angola indicates at least one ANC visit.
ANC visits infrequently occur prior to quickening
Malaria and Maternal Health Programs:
Need for Integration and Collaboration
Challenges:
• Maternal/Reproductive Health programs
responsible for delivery of ANC, FANC and MIP
services
• Central level malaria and maternal health
provide separate management and leadership
• Separate malaria and maternal health
strategies and guidelines
• Facility ANC staff relied on to administer IPTp
• HIV+ women routed to PMTCT programs
Take Home Messages
• Malaria is a serious health risk for pregnant women
and their babies
• A comprehensive program of bednets, IPTp, and
case management is effective at reducing malariarelated morbidity and mortality
• ANC is an accessible platform to provide prevention
for malaria in pregnancy
MCH and malaria programs need to
coordinate better to achieve mutual aims
For more information www.pmi.org
Thank You!
Tuberculosis and Maternal
Health
Charlotte Colvin
7 March 2014
Tuberculosis (TB) 101
• Airborne, typically affects lungs
• Symptoms - cough, fever, weight loss, night sweats
• Diagnosis
– Smear microscopy
– Chest X-ray, culture, molecular methods
– Clinical algorithms among HIV+ and children
• Treatment
– 6 month antibiotic treatment regimen
• Comorbidities
– HIV, diabetes
• Drug resistant TB
– Challenging to diagnose and treat
– 18-24 month treatment regimen
TB Burden
• 2 billion infected
• 8.7 million cases
– >500,000 children
• 1.4 million deaths
– 430,000 HIV+
– 500,000 women
– 64,000 children
From WHO Global TB Report 2012
• Highest overall burden
in Asia and Africa
• 80% TB/HIV coinfected in Africa
• 60% of MDR-TB found
in India, China, Russia,
South Africa
TB Cases by Type and Region,
2011
Estimated TB
cases, all forms
Estimated
HIV+ TB
cases
Estimated MDR
cases (2010)
Americas, 2%
Asia/Middle East,
61%
Europe, 26%
Americas, 3%
Europe, 4%
Americas, 3%
Asia/Middle
Europe, 2%
East, 17%
22
Africa, 11%
TB/HIV co-infection
• Among PLHA, 10% annual chance of developing active
TB
– Without HIV, 10% lifetime chance of developing active TB
• Active TB associated with increased viral load,
decreased CD4 count
• TB is the most common cause of death among people
with HIV
– 85% of all HIV-associated TB deaths among women were in
Africa
• TB clinic is critical entry point for PLHA to receive TB
and HIV services
– TB/HIV cascade
p. 20 WHO Global TB Report 2012
What do we know about TB in
women?
• TB is the leading infectious cause of death among women
• Extrapulmonary and smear negative TB more common
among women
– TB & infertility
• More TB cases are reported among men (1.7:1 M/F ratio
among notified cases)
– But women develop active disease faster and are more likely to
die of TB than men;
– In some settings, men are at higher risk
– In other settings, equal risk but different outcomes
– > 1% HIV prevalence “rule” evens ratio to 1:1
• A large proportion of women in Africa who are diagnosed
with TB are found in HIV clinics
What do we know about TB &
Pregnancy? (1)
• Active TB disease, TB/HIV co-infection associated
with:
– Low birthweight, IUGR, prematurity, fetal death, TB
disease in infant and mother (Marais et al, Lancet, 2010)
– HIV+ pregnant women have ≥10-fold higher risk of
developing TB disease than non-HIV+ (Pillay et al, So Afr
Med J, 2001)
– HIV+ pregnant women with TB disease 2.5x more likely
to transmit HIV to infant (Gupta et al, JID, 2010)
– 15-16% of mothers with TB transmit the infection to their
infants within the first 3 weeks of life (Uwimana et al.)
What do we know about TB &
Pregnancy? (2)
• First line TB drugs are safe for pregnant women
– Risk of TB disease outweighs risk of adverse effects
• First line TB treatment and ART also considered safe
– Again, risk of TB disease outweighs risk of adverse effects
• Some second line TB drugs risky for pregnant
women (aminoglycosides, fluoroquinolones)
– BUT risk of MDR-TB is greater than potential adverse effects
• Second line TB drugs and ART - ???
– Again, risk of MDR-TB and HIV co-infection is greater than
potential adverse effects
– This is likely to be an important issue in South Africa
But wait…. How many pregnant women even
have TB?
• Short answer: We don’t know.
– No routine recording
– Limited evidence from one PMTCT study (Kali et al. 2006 J
Acquired Immuno-Deficiency Syndrome)
• 32% of pregnant women had suspected TB
• Prevalence of TB disease among HIV+ pregnant women 210 per
100,000
• But we’re working on it!
Globally, how many pregnant women have active TB
disease each year and could potentially benefit from
improved TB services in ANC settings?
• UN data on total population, age/sex distribution, crude
birth rate, TB prevalence, case notification rate by age/sex
used to derive point estimate for pregnant women
• Monte Carlo simulations to derive uncertainty limits around
point estimates by country
• Country level point estimates entered into model to derive
global estimate
• (Preliminary) results
 About 500,000 pregnant women with active TB at
global level
Resources
• http://www.who.int/tb/country/en/
– TB data, including 2013 Global TB Report to be released on 23
October
– 2012 Report includes highlight on TB mortality among women
and estimation of TB among children
Recommendations
•
•
•
•
•
•
Address critical research gaps on the intersection of infectious disease
and maternal health, including cost-effective integration models
For pregnant women, continue scale up HIV counseling, voluntary
testing, and treatment; TB screening, diagnosis and treatment; and
preventive treatment, long lasting insecticide treated bednets, and
management of malaria
Provide integrated infectious disease and MCH services to pregnant
and postpartum women and their families – across the continuum of
care
Promote a smoother transition from maternity to long-term care and
support for women with HIV and TB
Address and mitigate social factors that contribute to poor maternal
health outcomes and are barriers to treatment and care
Promote social support for pregnant and postpartum women and
mobilize communities in favor of respectful, high quality HIV, TB,
malaria and MCH services
Thank you!
For more information:
Malaria – Erin Eckert
TB – Charlotte Colvin
HIV – Eni Martin
Maternal – Karen Fogg
[email protected]
[email protected]
[email protected]
[email protected]
Thank you!
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The Closing Session will begin at
4pm in the Grand Ballroom.
Closing remarks will be followed by
a 30-minute social gathering
(refreshments will be served). Come
meet new people and discuss the
highlights of the day!

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