PREMA-EU

PREMA-EU: A network dealing with the problem of malaria control in pregnant women

In endemic countries, pregnant women have a higher risk for peripheral parasitaemia and placental malaria. They also suffer a higher number of clinical malaria attacks than non-pregnant women. Malaria during pregnancy increases the risk of low birth weight (LBW) and infant mortality and morbidity. LBW contributes substantially to neonatal, perinatal and infant mortality. Each year at least 75,000-200,000 infant deaths are associated with malaria infection in pregnancy. Anaemia in pregnancy, for which malaria represents an important cause, is also associated with LBW. Effective chemoprophylaxis consistently reduces malaria clinical episodes and anaemia, and improves mean birth weight among primigravidae. Good efficacy can be achieved with SP intermittent treatment. It is possible to reduce the burden of malaria among pregnant women with improved availability, access and use of appropriate antimalarial drugs. Further research is urgently needed on alternative effective safe drugs and the use of newly available drugs or combinations. In future drug resistance will be a main obstacle to improved malaria control in pregnancy. At a certain level of drug resistance, prophylaxis must become ineffective. Appropriate strategies will need to be found which will protect drugs now available and new ones under development against the emergence and selection of drug resistance.

Several other questions need to be urgently answered:

• What is the optimal regime for HIV positive women?
• What is the best way of delivering SP as part of an anaemia control strategy?
• Is there an interaction between SP and folic acid supplements routinely given during pregnancy?
• How can we most effectively monitor malaria control strategies and their effects on pregnant women and their infants?

Insecticide-treated nets are effective at reducing malaria morbidity and all-cause mortality in children and adults and have been shown in recent studies in Kenya to significantly improve birth weight and reduce severe maternal malarial anaemia. The implementation of integrated programs employing both bed nets and prophylaxis may be the way forward.

One of the major problems for programme managers and implementers remains how to utilise the available knowledge for the benefit of operational programmes. Despite its importance, many countries have no policy or programme for controlling malaria in pregnancy. This is often due to lack of clarity as to what the policy should be, but also due to difficulties in communication between researchers, policymakers, those responsible for reproductive health and those responsible for malaria control. Few African countries have implemented programs that have achieved good coverage among pregnant women and little attention has been given to this problem. How can the delivery and coverage of such interventions, particularly for primigravidae be improved? The answer to this question is far from being obvious.

The idea of creating a network dealing with the problem of malaria in pregnancy originated from discussions with several colleagues involved in this field of research and after having attended the meeting on this topic organised by the Centres for Disease Control/KEMRI in November 1997 in Kisumu, Kenya. In 1998, we organised a symposium on malaria in pregnancy at the 2nd European Congress of Tropical Medicine in Liverpool, UK. The interest generated encouraged us to proceed further. It was also at this meeting that the name of PREMA (Pregnancy, Malaria, Anaemia) was chosen. In 2000, another workshop was organised within the MIM conference in Durban, South Africa. Finally, a partnership meeting of several of the stakeholders was held in July 2000. The content of this meeting was also discussed with colleagues at USAID, CDC and WHO.

A proposal to support PREMA has been successfully submitted to the European Commission in September 2000 under the name of PREMA-EU. The objectives of PREMA-EU are the following: (i) To review, synthesise and inform on the `state of the art' concerning malaria and anaemia in pregnancy, including burden of disease, programme strategies and research priorities; (ii) To address specific technical and operational issues that are critical for the control of malaria and anaemia in pregnancy; (iii) To promote the implementation of research findings into feasible interventions for malaria control in pregnant women; (iv) To generate information that would help RBM in formulating national and district-based policy for the control of malaria in pregnant women. The activities of PREMA-EU will be based on: (i) Production of a "state of the art" data compilation and standard data collection format; (ii) Six-monthly Newsletter related to technical/operational issues made available on the Website and emailed to people on the PREMA register. (iii) Annual international PREMA meeting (PREMA-EU + wider PREMA+ interested parties) to review/discuss gaps in knowledge, research protocol development and produce consensus papers; (iv) In-country policy development meetings with each of the partners. The network at present comprises 10 partners, 5 from Africa, 4 from Europe and 1 from Asia. The network is coordinated by the Liverpool School of Tropical Medicine, UK and by the Prince Leopold Institute of Tropical Medicine, Antwerp, Belgium. It is our intention to open this activity to as many health managers, Ministry of Health staff, sociologists, scientists and policy makers whose contribution would be relevant to the objectives stated above. Hopefully, the PREMA-EU group would in time become a constituent of a larger group that would be expected to have donor support from several sources. It is our intention to carry out our activities in full consultation with WHO and in particular with the RBM movement.

Activities have started gradually but are starting to gain momentum. Day to day activities of the network are managed by Dr Francine Verhoeff, based in Liverpool. A first partners meeting was held in April 2002 in Antwerp and we are planning to have our annual meeting at the MIM meeting in Arusha scheduled for this month. People interested in malaria control in pregnancy are invited to contact us.

B. Brabin & U. D'Alessandro, November 2002