The Cosmic project aims to advance the fight against pregnancy-associated malaria (PAM). Clinics in endemic areas do offer the recommended antenatal care, says project coordinator Henk Schallig of the Royal Tropical Institute in the Netherlands, but expectant mothers don’t necessarily seek it out — for example, because they live too far away.

Cosmic has enlisted the help of health workers to reach out into the communities, screening pregnant women regularly and providing preventive treatment. It is trialling this approach in three African countries. “We want to demonstrate that this intervention can be implemented easily and that it is effective,” Schallig explains.

Foetal attraction

Malaria is caused by a parasite that hitches a ride on mosquitoes. Expectant mothers are particularly likely to catch it. The risk is even higher if these women are pregnant for the first time, if they are HIV-positive, or if they are not originally from an endemic area, in which case their immune system will be unprepared.

Prevention tends to focus on the use of bed nets and on the administration of two rounds of a drug called sulfadoxine-pyrimethamine (SP), says Schallig. However, he adds, these measures are not sufficient, notably because of the emergence of SP-resistant malaria parasites.

A pregnant silence

PAM does not necessarily manifest itself through the symptoms usually associated with malaria, such as headaches, joint pains and high fevers. In fact, it may not manifest itself at all. However, once it has settled in the placenta, the parasite disrupts the flow of nutrients.

The infection can thus affect the health of the baby. Low birth weight and undernutrition are frequent consequences, with potentially tragic outcomes. PAM is also a cause of stillbirths, spontaneous abortions and premature deliveries.

There are also risks for the mother. PAM can, for example, lead to severe anaemia, a condition that raises expectant women’s risk of dying during labour. According to estimates, it claims the lives of about 10 000 women and at least 75 000 children per year in sub-Saharan Africa.

Nursing a new idea

Cosmic has decided to take the campaign against placental malaria directly into the villages and homes. “The health workers know the community,” Schallig explains. “They also tend to know who is pregnant. So they approach these women, and they test them frequently — ideally, once per month. If malaria is detected, the patient is referred to the clinic, where she will receive artemisin-based combination therapy to cure the infection.”

The health workers can also raise awareness of the issue and of the relevance of preventive measures, such as the recommended doses of SP. As they are already in touch with the population, involving them could be an effective and inexpensive solution, says Schallig.

However, screening for PAM is a new role for them, he notes, and so the project also provides training. “In other patients, it is very easy to detect the parasites,” Schallig explains, “but for pregnant women it is difficult, because they may not show any symptoms.”

The trials, which are carried out in Benin, Burkina Faso and The Gambia, explore three very different settings. In The Gambia, the disease has been largely eliminated, says Schallig. In the other two countries, it remains rife, he notes, with the added complication of widespread drug resistance in Burkina Faso.

The outcomes will help refine the current World Health Organisation recommendations on tackling PAM, says Schallig. The health authorities of the countries involved are taking a keen interest in the project, he reports, and the World Health Organization is a member of the consortium. Their involvement will help to ensure that the findings of Cosmic resonate beyond the project’s end in August 2016.

RDTs (Rapid Diagnostic Tests) and other research tools used for the diagnosis of malaria in pregnant women (COSMIC study, Burkina Faso)

@ Esmée Ruizendaal — KIT 2015