MEETING OBJECTIVES AND EXPECTED OUTCOMES
Presenter: Silvia Schwarte
Participants (Annex 1) in the meeting were:
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technical consultation expert members;
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country participants (from Burkina Faso, Democratic Republic of the Congo, Madagascar, Malawi, Mozambique, Nigeria, Senegal and Sierra Leone); some of these countries are participating in the Transforming Intermittent Preventive Treatment for Optimal Pregnancy (TIPTOP) project, and some are non-TIPTOP countries;
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representatives from Jhpiego, the Barcelona Institute for Global Health (ISGlobal) and Medicines for Malaria Venture (MMV), who were involved in the conduct of the TIPTOP study; and
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representatives from the United States Centers for Disease Control and Prevention; the United States Agency for International Development; the Bill and Melinda Gates Foundation; the Global Fund to Fight AIDS, Tuberculosis and Malaria; Unitaid; the World Health Organization (WHO) (Global Malaria Programme, Maternal and Perinatal Health, Child Health Development); WHO country offices; and the WHO Regional Office for Africa.
Silvia Schwarte provided a brief background on the burden of malaria in general and malaria in pregnancy. With regard to intermittent preventive treatment in pregnancy (IPTp), uptake of IPTp3+ (at least three doses of sulfadoxine–pyrimethamine (SP)) has been slow in the past 10 years, estimated at 32% in 2020. WHO guidelines changed in 2017, from four recommended antenatal care (ANC) visits to eight contacts during pregnancy. The TIPTOP project – the main study on community based IPTp (c-IPTP) – was designed before this change in ANC recommendations. WHO also changed its policy-making process around 2020, with a focus on two components: guidelines on what to do, based on a systematic review of the evidence (e.g. the best way to reduce adverse effects of malaria in pregnancy); and guidance on how to do it (e.g. to increase IPTp coverage), based on experiences and operational research. “Guidance” is a term reserved for operational manuals and information notes, based on programmatic consideration. In contrast to “guidelines”, it is not necessarily based on a systematic review of the evidence.
As of 3 June 2022, the WHO IPTp guidelines state that, in malaria-endemic areas, pregnant women of all gravidities should be given antimalarial medicine at predetermined intervals to reduce disease burden in pregnancy, and adverse pregnancy and birth outcomes.
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SP has been widely used for malaria chemoprevention during pregnancy and remains effective in improving key pregnancy outcomes.
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IPTp using SP (IPTp-SP) should start as early as possible in the second trimester and not before week 13 of pregnancy.
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Doses should be given at least 1 month apart, with the objective of ensuring that at least three doses are received.
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ANC contacts are an important platform for delivering IPTp. Where inequities in ANC service and reach exist, other delivery methods (such as the use of community health workers (CHWs)) may be explored, ensuring that ANC attendance is maintained and underlying inequities in ANC delivery are addressed.
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IPTp is generally highly cost-effective, widely accepted, feasible for delivery and justified by a large body of evidence generated over several decades.
The meeting objectives were to:
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assess the effectiveness and impact of c-IPTp on IPTp coverage and ANC attendance
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review, discuss and assess the evidence generated in the context of the TIPTOP project
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review, discuss and assess the evidence obtained from additional (non-TIPTOP) countries where c-IPTp was piloted;
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discuss molecular markers of SP resistance monitored in the TIPTOP project; and
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agree on best practice for implementation of c-IPTp, if proven successful.
Outcomes expected from the meeting were:
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determination of the impact of c-IPTp on IPTp coverage and ANC attendance;
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formulation of guidance for the implementation and scale-up of IPTp-SP through community-based delivery approaches, if proven successful; and
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development of a meeting report, with summary findings and results to serve as basis for an implementation guide or operational manual to guide the implementation and scale-up of c-IPTp.
After the meeting, a meeting report and operational guidance will be developed, and c-IPTp guidance will be presented in the Malaria Policy Advisory Group meeting (11–13 October 2022); it is planned to finalize and disseminate guidance end 2022.
All 10 Expert Members attending the meeting submitted their declarations of interest, which were assessed by the WHO Secretariat. One Member reported a conflict of interests, which was deemed to be not relevant to topics for decision on the agenda (Annex 2). A due diligence search was undertaken and found nothing significant that was not already declared the Expert Members.
