Cookies on this website
We use cookies to ensure that we give you the best experience on our website. If you click 'Continue' we'll assume that you are happy to receive all cookies and you won't see this message again. Click 'Find out more' for information on how to change your cookie settings.

From The Lancet Correspondence. In the opening to the 2019 World Malaria Report, entitled Leaving no one behind in the march to a malaria free world, the WHO’s Director-General notes that the scourge of malaria continues to strike hardest against pregnant women and children in Africa.

© 2020 MORU. Photographer: Mehul Dhorda.
Women being recruited for a malaria study in Kinshasa

WHO’s Director-General reports that “some 11 million pregnant women in sub- Saharan Africa were infected with malaria and, consequently, nearly 900 000 children were born with a low birthweight.” Furthermore, he notes that “Malaria in pregnancy compromises the mother’s health and puts her at greater risk of death. It impacts the health of the fetus, leading to prematurity and low birthweight, major contributors to neonatal and infant mortality.”1

In sub-Saharan Africa, Plasmodium falciparum is responsible for an estimated 50,000 maternal deaths and 200,000 stillbirths each year, in addition to substantial adverse neonatal morbidity (preterm birth and small-for-gestational-age) predisposing to death in infancy and non-communicable diseases in later life.2 This intolerable carnage is preventable.

Artemisinin combination treatments (ACTs) are first-line treatments for falciparum malaria throughout the world, and they are recommended by WHO as the treatment of choice for women in the second and third trimesters of pregnancy, but puzzlingly they are still not recommended by WHO in the first trimester. Concerns over the use of artemisinin derivatives in the first trimester have been systematically addressed.2,3 In 2015 an Evidence Review Group convened by the WHO’s Global Malaria Programme (WHO GMP) reported a detailed review of all available data and recommended that the clear benefits exceeded any potential risks and that ACTs should be used to treat uncomplicated falciparum malaria in the first trimester.

The WHO GMP’s own malaria policy advisory group then recommended “review of the WHO Guidelines for the treatment of malaria to consider the timely inclusion of ACT as a first-line therapeutic option for uncomplicated falciparum malaria”,4 a process WHO GMP initiated through its Treatment Guidelines Committee in 2017. Yet today, well over 4 years after the original recommendation, WHO still recommends quinine, a drug for which there are few data on safety in the first trimester. Quinine is poorly tolerated, poorly adhered to, and therefore less effective than ACTs.2,3 Hospitals, antenatal clinics, and malaria control programmes all have to retain quinine for this one unnecessary indication.5

Why is WHO leaving behind women in the first trimester of pregnancy? Nothing has justified this more than 4-year delay. We urge WHO to heed the advice of the Evidence Review Group and revise its outdated recommendations on the treatment of malaria in early pregnancy as a matter of urgency.

- Rose McGready, François Nosten, Karen I Barnes, Olugbenga Mokuolu, Nicholas J White

 

Declaration of interests’ statement

KB, OM and NW were all members of the  WHO Technical Expert Group on Malaria Chemotherapy

 

Shoklo Malaria Research Unit (RM, FN) and Mahidol–Oxford Tropical Medicine Research Unit (RM, FN, NJW), Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand;

Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK (RM, FN, NJW);

Division of Clinical Pharmacology and SAMRC Collaborating Centre for Optimising Antimalarial Therapy, Department of Medicine, University of Cape Town, Cape Town, South Africa (KIB); and Department of Paediatrics and Child Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria (OM)

 

1 WHO. World Malaria Report 2019. 2019. https://www.who.int/publications-detail/ world-malaria-report-2019 (accessed Jan 22, 2020).

2 Saito M, Gilder ME, McGready R, Nosten F. Antimalarial drugs for treating and preventing malaria in pregnant and lactating women. Expert Opin Drug Saf 2018; 17: 1129–44.

3 Dellicour S, Sevene E, McGready R, et al. First-trimester artemisinin derivatives and quinine treatments and the risk of adverse pregnancy outcomes in Africa and Asia: A meta-analysis of observational studies. PLoS Med 2017; 14: e1002290.

4 WHO Malaria Policy Advisory Committee and Secretariat. Malaria Policy Advisory Committee to the WHO: conclusions and recommendations of eighth biannual meeting (September 2015). Malaria J 2016; 15: e117

5 Rao VB, Jensen TO, Jimenez BC, et al. Malaria in pregnancy: a call for a safe, efficient, and patient-centred approach to first-trimester treatment. Lancet Glob Health 2018; 6: e607–08.

Similar stories

Check-list recommended to improve reporting of microscopy methods and results in malaria studies

MORU Bangkok Publication Research

A study to explore the variations of how microscopy methods are reported in published malaria studies has recommended standardised procedures should be implemented for methodological consistency and comparability of clinical trial outcomes.

The COVID-19 vaccine: do we know enough to end the pandemic?

MORU Bangkok Research

Blog by Rima Shretta. Preliminary efficacy results from three vaccine candidates currently in Phase 3 trials have shown an efficacy of more than 90% against the development of symptomatic COVID-19. While these results are promising, all vaccines are in relatively early stages of testing. A comprehensive and transparent roadmap is urgently needed, to determine how limited doses of the first vaccines to be licensed will be distributed, together with which groups will initially be prioritized.

New study on the risk of Plasmodium vivax parasitaemia after Plasmodium falciparum malaria

MORU Bangkok Publication Research

A new study quantifying the high risk of Plasmodium vivax parasitaemia after treatment of Plasmodium falciparum malaria aims to identify populations in which a policy of universal radical cure, combining artemisinin-based combination therapy with a hypnozoitocidal antimalarial drug, would be most beneficial.

Clare Ling awarded honorary FRCPath

Awards & Appointments SMRU

Dr Clare Ling has been made an honorary Fellow of the Royal College of Pathologists (FRCPath). Currently running Shoklo Malaria Research Unit (SMRU) Microbiology department and supporting the unit’s molecular activities, Clare is a clinical scientist who has worked at SMRU on the Thai-Myanmar border since 2012.

Life at the Thai-Myanmar border through the eyes of a frontline researcher

Public Engagement SMRU

Ethox programme REACH (Resilience, Empowerment and Advocacy in Women's and Children's Health Research) posted a visual research gallery as a Public Engagement project. Six galleries of photos by SMRU's Suphak Nosten depict aspects of migrant workers' daily lives: the Thai-Myanmar border; work; cultural and spiritual values; the often-difficult journeys seeking healthcare; striving for better; and dedicated frontline health workers. Richly coloured, sometimes personal, Suphak’s photography is deeply empathetic and memorable.

Oxford Global Research

COMRU MOCRU MORU Bangkok Research SMRU

Oxford is world-famous for research excellence and home to some of the most talented people from across the globe. To showcase our global research, the University launched a Global Research Map, highlighting areas of research we are conducting overseas.