Malaria is a disease of major public health concern to Kenya. Indeed the latest 2020 Kenya Economic Survey indicates that the disease is the second most common condition that affects people in the country, after respiratory ailments.
In the past year alone, the report indicates that over four million (4,675,362) malaria cases were confirmed in public health facilities across the country.
The disease affects many people, especially those in hot spots such as the Western and Coastal regions of Kenya. But the most affected are children below five years old and pregnant women due to low immunity.
For expectant mothers specifically, the disease makes them highly susceptible to anaemia.
Women with the condition lack sufficient healthy red blood cells to carry oxygen throughout the body. This can lead to the failure of vital body organs and death.
For the unborn child, maternal anaemia increases the risk of spontaneous abortions, stillbirths, premature deliveries and having babies with low birth weight that increases their chances of dying.
To avert these challenges, the World Health Organisation (WHO) recommends that pregnant women should sleep under insecticide treated bed nets to prevent malaria.
In high-risk areas, all expectant women are also supposed to be given malaria preventive drugs known as sulphadoxine-pyrimethamine (SP).
In spite of the above interventions, many women in sub-Saharan African countries like Kenya still end up getting malaria during pregnancy, mainly due to low awareness about the prevention strategies or failure to adhere to them.
When this happens, prompt diagnosis and treatment is important to cushion the expectant women and her unborn child from the adverse effects of the ailment.
For the general population, the WHO recommends the use of a class of drugs known as Artemisinin Combination Therapies (ACTs) as the first line treatment for uncomplicated malaria caused by parasites referred to as Plasmodium Falciparum that are responsible for most malaria cases in Africa.
Most clinical studies that assessed the efficacy and safety of these drugs were conducted among normal people who were not pregnant.
As such, there has been limited evidence vouching for the use of ACTs in expectant women, especially during the early stages of pregnancy.
Due to this scarcity of evidence, the WHO recommends the use of a drug known as quinine (plus clindamycine) for treatment of malaria during the first trimester of pregnancy.
When clindamycine is not available, as is the case in most sub-Saharan African countries, quinine is often used alone. And in most countries, the drug is used throughout all pregnancy trimesters
Despite their common use, a new study published in the Lancet Infectious Diseases Journal recommends the adoption of ACTs for treatment of malaria during the early stages of pregnancy.
The findings of the research, which assessed multiple scientific studies conducted over the years globally, found that the ACTs were safer and more effective for treating malaria in early pregnancy, compared to quinine.
The study was conducted as a joint project between scientists from different countries – including Kenya - under the WorldWide Antimalarial Resistance Network (WWARN).
During the research, the scientists analysed individual patient records of 4,968 pregnant women that were drawn from 19 studies across 10 countries.
The findings of the study showed that in general, all ACTs are significantly more effective at treating malaria during pregnancy compared to quinine. There are many types of ACTs. The commonly used one - known artemether-lumefantrine (AL) – was found to have the least side effects in pregnancy.
But it ranked the lowest with regards to efficacy or effectiveness, compared to other ACTs.
The researchers suggest that this may be due to the low drug doses for AL that are recommended for pregnant women, compared to other ACT drugs.
As such, they note that further studies are needed to determine an optimal dose for AL that will achieve the highest treatment success in pregnancy to protect both the mother and her unborn child from the adverse effects of malaria infection.
In spite of the low treatment efficacy linked to AL compared to other ACTs, the drug was still found to be much better than quinine.
Indeed, the study found that in high transmission areas, malaria reoccurred in 58 percent of pregnant women within 28 days of being treated with quinine, compared to 13.8 percent among mothers that were given AL.
In low transmission areas, the disease reoccurred in 33.6 percent of women treated with quinine within the same period.
“We found that women in their first pregnancy or with higher malaria parasite burden were at a higher risk of treatment failure and should be carefully monitored," noted Dr Makoto Saito, the lead author of the study and infectious disease specialist at the WorldWide Antimalarial Resistance Network.
Aside from the higher treatment failure rates, the findings of the research showed that quinine was further associated with lower tolerability among pregnant women due to higher risks of side effects such as abdominal pain, nausea and vomiting.
This could be further exacerbated by morning sickness in the first trimester which women experience during the early stages of pregnancy.
Women treated with quinine were also more likely to transmit the malaria parasites to others.
"As the safety of ACTs have been shown in previous studies, the most efficacious drug with fewer side effects should be used to minimise the adverse impact of malaria on the mother and unborn child. Although the current dosing of ACT for pregnant women may not be optimal, pregnant women no longer have to put up with quinine," said Dr Saito.
To avert malaria, health experts note that pregnant women who do not attend antenatal clinics or those who attend only for the first visit or too late during pregnancy need to be reached.