How to protect pregnant women from malaria during COVID-19

In the busy corridors of St Angela Merici Health Centre in Kingeero, Kiambu County, Kenya, Emily Mateche is attending a clinic appointment. She is expecting her first child and just recently recovered from malaria. “I came to the hospital last month to seek treatment because I was feeling sickly. I was having headaches, fever and chills. But now I’m happy because my baby and I are okay” said the 35-year-old environment management specialist. Emily is one of the many women who are exposed to malaria during pregnancy.

The Centers for Disease Control and Prevention estimates that at least one million women who get pregnant in Kenya are at risk of getting malaria which can have devastating effects on both mother and fetus including premature delivery, low birth weight, maternal anemia and death.  According to Milton Munala, a Kenyan Public Health Officer and Researcher at Kenya Medical Training College (KMTC), women and children are particularly more vulnerable to malaria and COVID-19.  

During pregnancy, a woman’s immune system is lowered to prevent her body from rejecting the fetus, which puts women at risk of contracting both COVID-19 and malaria. Additionally, COVID-19 and malaria can share common symptoms, including but not limited to: onset headache, tiredness, breathing difficulties, and fever, which may lead to misdiagnoses of COVID-19 for malaria and vice versa, especially when healthcare providers rely mainly on symptoms.

“Similarities in signs and symptoms between malaria and COVID-19 have affected malaria control efforts,” says Munala.

In 2021, the World Health Organization (WHO) African region alone accounted for 11 million malaria cases during pregnancies from the estimated 33.8 million pregnancies, contributing to 819,000 children with low birth weight. Low birth weights are associated with a higher risk of infant mortality.

Even though countries worldwide mounted a remarkable response to adopt and implement WHO guidance to maintain essential malaria services during the pandemic, WHO reported that most malaria-prone regions experienced moderate levels of disruptions to the provision of malaria services, including antenatal services.

According to UNICEF, in regions where malaria is endemic, healthcare providers can provide women with medications and insecticide-treated mosquito nets to prevent them from contracting malaria. During the pandemic, such services as well as the spraying of insecticides to kill mosquitoes weresuspended in some areas.

But COVID-19 disruptions are not the only factors affecting malaria progress in Kenya. The recent study by the Kenya Medical Research Institute (KEMRI) revealed gaps in treatment of severe malaria. According to the study carried out KEMRI and the London-based Wellcome Trust, the overall knowledge level of the treatment policy for malaria was lowest among untrained health workers at 14 percent, and only slightly higher among their trained counterparts at 24 percent.

Given this context, it is clear that pandemics such as COVID-19 and other deadly diseases thrive well in health inequalities. COVID-19 has not gone away yet, and so has not malaria.  This begs the question: How do we simultaneously protect pregnant women from contracting COVID-19 and malaria?

Protecting pregnant women and infants: digitalisation

Munala recommends that countries continue adopting telemedicine to improve access to better healthcare especially in the fight against tropical diseases such as malaria. Telemedicine programmes provide a platform that allows patients and healthcare providers in rural and urban areas to interact with health experts using digital platforms such as video conferencing.

“The use of telemedicine has eased malaria control especially in malaria endemic areas of western and coastal Kenya; and not just Malaria but also COVID-19 and other non-communicable diseases. Thus, we should continue adopting digital tools to provide healthcare services,” Munala recommends.

This was also a subject of the 35^th African Union Summit of Head of States and Governments held on Sunday, February 6, 2022 at the African Union Commission in Addis Ababa, Ethiopia. Kenya’s President Uhuru Kenyatta and chair of the Africa Leaders Malaria Initiative (ALMA), lauded the continent’s gradual adoption of digital tools to strengthen the fight against malaria.

“It is notable that countries continue to expand use of digital tools to strengthen evidence-based accountability and action in the fight against malaria. Our countries are adopting national scorecard tools on malaria, reproductive maternal, new born, adolescent and child health; and neglected tropical diseases, nutrition and community scorecards,” the President said as he presented last year’s ALMA Malaria Progress Report.

Malaria prophylaxis and treated nets

Dr Lenka Beňová, Professor of Maternal Health at Institute of Tropical Medicine (ITM), Antwerp, recommends that every country continues to provide the same uninterrupted antenatal care as before COVID-19.

“The strategy to protect pregnant women from malaria relies on multiple aspects, from bed net distribution to vector control to intermittent preventive therapy given during antenatal care, and all these elements were disrupted during COVID-19 due to de-prioritization and shifting health workers to other tasks.”

Intermittent preventive treatment using sulfadoxine-pyrimethamine (IPTp-SP) should be given to pregnant women living in moderate to high malaria transmission areas in Africa, starting as early as possible in the second trimester, at least four weeks (one month) apart.  

 “This was not the first time I’m suffering from malaria; though this time it was different because I’m pregnant. And I know malaria puts the baby at risk,” Emily says, adding that she was not given a treated bed net.

According to the WHO Malaria Report 2021, if all eligible pregnant women visiting antenatal care clinics at least once received a single dose of IPTp in pregnancy, presuming the second and third doses of IPTp (IPTp2 and IPTp3) remained at current levels, an additional 45,000 out of 819,000 low birthweights would have been prevented.

If IPTp3 coverage was to be increased to the same levels as that of antenatal care clinics' first visit coverage and if subsequent antenatal visits were just as high, an additional 148 000 low birthweights would be prevented. Given that low birth weight is a strong factor for childhood mortality, reducing the rate of low birth weights will save many children.

Spread the message and raise awareness

Last year on Sunday 25 April, the world came together to commemorate World Malaria Day. People worldwide united to raise awareness and highlight the need for continued commitment for malaria prevention and control under the campaign slogan “reaching the zero malaria target”.

Munala says that while the observance is heartfelt, it is becoming more apparent that malaria awareness messaging has to continue every day. As governments, health institutions, and health activists spread the message on protecting people from COVID-19 and the importance of vaccination, stakeholders agree that the importance of including malaria prevention measures and the importance of antenatal care in this messaging cannot be overstated.

Additionally, maintaining key malaria messaging throughout health institutions, and mass education in malaria-prone areas is recommended. “We need to continue giving the message that health services are open and available to pregnant women, routine antenatal care is important, and you can minimise the spread of the SARS-CoV-2 virus by using PPE and vaccination,” Dr Beňová says.