USAID Mini-University
Karen Fogg, Charlotte Colvin, Erin Eckert
7 March 2014

Maternal Health: What's infectious disease got to do with it?
Outline of Presentation
1. Brief Introduction (5 minutes)
2. Overview of Malaria In Pregnancy (10 minutes)
3. Overview of Maternal Health and TB (10 minutes)
4. Overview of Maternal Health and HIV/AIDS (10 minutes)
5. Question and Answer Session (15 minutes)

200
150
100
50
-
450
400
350
300
250
1990
543,000 Deaths
Annually
1995 2000
Proposed bold end-game: Ending preventable maternal deaths worldwide by 2035:
Reaching MMR = 50
MM Ratio (1990-2010)
MM Ratio (2010-2035)
MM Ratio Accelerated 50 (2010-2035)
OECD MM Ratio UL (50)
OECD MM Ratio UL (50) Projected
4.1% Annual Rate of
MMR Reduction
2000-2010
Current Trend
287,000 Deaths
Annually
4.1% Annual Rate of
MMR Reduction
2010-2035
Current Trend
5.6% Annual Rate of Reduction of
MMR 2010-2035
Accelerated Trend
2005 2010
Years
2015 2020 2025 2030 2035 3

Required Regional Progress to Reach Proposed
MMR of 50 by 2035
900
800
700
600
SUB-SAHARAN AFRICA
Ending preventable maternal deaths worldwide by
= 50
Sub-Saharan Africa
2000-2010
2035-reaching MMR = 50
-8.8%
Southern Asia (excluding India) -5.2% -6.1%
SOUTHERN ASIA
(excluding India)
Asia
Eastern Asia (excluding China)
LAC
OECD MMR Upper Limit
-5.7%
-3.5%
-2.2%
-4.8%
-4.3%
0%
-1.9%
0%
500
ASIA
400
300
8.8% Annual Rate of Reduction of
MMR 2010-2035
Accelerated Trend
200
100
-
LAC
OECD MMR Upper Limit
EASTERN ASIA
(excluding China)
1990 1995 2000 2005 2010
Years
2015 2020 2025 2030 2035
4

The MIP interagency working group
USAID: Susan Youll, Erin Eckert, Meera Venkatesan, Tom Hall
CDC: Mary Hamel, Julie Gutman, Zandra Hollaway André
USAID Mini-University
March 2014
Washington, DC

• Pregnant women are a high risk group for malaria due to shifts in immunity
– Pregnancy causes transient depression of cell-mediated immunity
– Greater susceptibility to infection means higher risk for contracting diseases, including malaria

Pregnancy and the Placenta:
Malaria’s special challenges
• MIP characterized by parasites that ‘sequester’ in the placenta
• Placental infection can occur in absence of clinical symptoms but have dire consequences on placental function
• Peripheral parasitemia may be absent with placental infection
– Poses a diagnostic challenge
– Potential impact on malaria indicators

Areas with unstable or low transmission
• Women have not acquired any significant level of immunity
• At a two- to three-fold higher risk of developing severe disease as compared to non-pregnant adults
• Maternal deaths may occur directly or indirectly
– Severe malaria
– Severe anemia

Areas with stable or high/moderate transmission
• Impact of MIP of particular concern in first and second pregnancies
– Maternal morbidity and mortality
– Fetal mortality
– Premature delivery
– Intrauterine growth retardation
– Delivery of low birth-weight infants (<2500 g or <5.5 pounds), a risk factor for neonatal mortality
• Circulating antibodies for placental receptors develop over subsequent pregnancies to decrease impact

Support a multi-pronged approach to MIP:
1. Provision of long-lasting insecticide treated
nets (LLINs) through mass distribution campaigns and at ANC & EPI clinics
2. Intermittent preventive treatment in pregnancy (IPTp) with SP
3. Effective case management of malaria and anemia in pregnancy

• Among women of low gravidity (≤4 pregnancies)
– Reduce peripheral and placental parasitaemia
– Reduce low birthweight by
23%
– Decrease risk of fetal loss
• ITNs are the only strategy for prevention in the first trimester
• ITNs should be an integral part of strategies to prevent malaria in pregnant women living in areas of Africa where malaria is endemic

• Any pregnant woman with fever should be tested and, if positive for malaria, treated promptly.
– Quinine in first trimester; ACTs after 12 weeks
• All pregnant women should be screened for anemia
– High dose folate should not be given for 14 days after taking IPTp-SP or treatment with SP-AS

• All pregnant women in areas of stable malaria transmission should receive a dose of IPT with
SP at every ANC visit after quickening
• There should be at least 1 month in between doses of SP
• HIV+ women on cotrimoxazole should not receive IPTp
• Rationale for IPTp
– Clearance of existing asymptomatic infections
– Prophylactically preventing new infections during periods of fetal growth

New Rationale for the Timing of More SP Doses
Fetal growth velocity 
Rx Rx Rx Rx
Quickening
Conception
10
1 st Trimester
16 20
Weeks of gestation
30
Birth
14

Missed Opportunities: Percentage of Pregnant Women Who
Make >2 Antenatal Clinic Visits (ANC) and IPTp2 Coverage
ANC visit data from DHS (2005-2011). Angola indicates at least one ANC visit.
ANC visits infrequently occur prior to quickening

Challenges:
• Maternal/Reproductive Health programs responsible for delivery of ANC, FANC and MIP services
• Central level malaria and maternal health provide separate management and leadership
• Separate malaria and maternal health strategies and guidelines
• Facility ANC staff relied on to administer IPTp
• HIV+ women routed to PMTCT programs

• Malaria is a serious health risk for pregnant women and their babies
• A comprehensive program of bednets, IPTp, and case management is effective at reducing malariarelated morbidity and mortality
• ANC is an accessible platform to provide prevention for malaria in pregnancy

Charlotte Colvin
7 March 2014

Tuberculosis (TB) 101
• Airborne, typically affects lungs
• Symptoms - cough, fever, weight loss, night sweats
• Diagnosis
– Smear microscopy
– Chest X-ray, culture, molecular methods
– Clinical algorithms among HIV+ and children
• Treatment
– 6 month antibiotic treatment regimen
• Comorbidities
– HIV, diabetes
• Drug resistant TB
– Challenging to diagnose and treat
– 18-24 month treatment regimen

TB Burden
• 2 billion infected
• 8.7 million cases
– >500,000 children
• 1.4 million deaths
– 430,000 HIV+
– 500,000 women
– 64,000 children
From WHO Global TB Report 2012
• Highest overall burden in Asia and Africa
• 80% TB/HIV coinfected in Africa
• 60% of MDR-TB found in India, China, Russia,
South Africa

22
Estimated TB cases, all forms
TB Cases by Type and Region,
2011
Estimated
HIV+ TB cases
Estimated MDR cases (2010)
Americas, 3%
Europe, 4%
Asia/Middle
East, 17%
Americas, 3%
Europe, 2%
Americas, 2%
Europe, 26%
Asia/Middle East,
Africa, 11%
61%

TB/HIV co-infection
• Among PLHA, 10% annual chance of developing active
TB
– Without HIV, 10% lifetime chance of developing active TB
• Active TB associated with increased viral load, decreased CD4 count
• TB is the most common cause of death among people with HIV
– 85% of all HIV-associated TB deaths among women were in
Africa
• TB clinic is critical entry point for PLHA to receive TB and HIV services
– TB/HIV cascade

p. 20 WHO Global TB Report 2012

What do we know about TB in women?
• TB is the leading infectious cause of death among women
• Extrapulmonary and smear negative TB more common among women
– TB & infertility
• More TB cases are reported among men (1.7:1 M/F ratio among notified cases)
– But women develop active disease faster and are more likely to die of TB than men;
– In some settings, men are at higher risk
– In other settings, equal risk but different outcomes
– > 1% HIV prevalence “rule” evens ratio to 1:1
• A large proportion of women in Africa who are diagnosed with TB are found in HIV clinics

What do we know about TB &
Pregnancy? (1)
• Active TB disease, TB/HIV co-infection associated with:
– Low birthweight, IUGR, prematurity, fetal death, TB disease in infant and mother (Marais et al, Lancet , 2010)
– HIV+ pregnant women have ≥10-fold higher risk of developing TB disease than non-HIV+ (Pillay et al, So Afr
Med J, 2001)
– HIV+ pregnant women with TB disease 2.5x more likely to transmit HIV to infant (Gupta et al, JID , 2010)
– 15-16% of mothers with TB transmit the infection to their infants within the first 3 weeks of life ( Uwimana et al.)

What do we know about TB &
Pregnancy? (2)
• First line TB drugs are safe for pregnant women
– Risk of TB disease outweighs risk of adverse effects
• First line TB treatment and ART also considered safe
– Again, risk of TB disease outweighs risk of adverse effects
• Some second line TB drugs risky for pregnant women (aminoglycosides, fluoroquinolones)
– BUT risk of MDR-TB is greater than potential adverse effects
• Second line TB drugs and ART - ???
– Again, risk of MDR-TB and HIV co-infection is greater than potential adverse effects
– This is likely to be an important issue in South Africa

But wait …. How many pregnant women even have TB?
• Short answer: We don’t know.
– No routine recording
– Limited evidence from one PMTCT study (Kali et al. 2006 J
Acquired Immuno-Deficiency Syndrome )
• 32% of pregnant women had suspected TB
• Prevalence of TB disease among HIV+ pregnant women 210 per
100,000
• But we’re working on it!

Globally, how many pregnant women have active TB disease each year and could potentially benefit from improved TB services in ANC settings?
• UN data on total population, age/sex distribution, crude birth rate, TB prevalence, case notification rate by age/sex used to derive point estimate for pregnant women
• Monte Carlo simulations to derive uncertainty limits around point estimates by country
• Country level point estimates entered into model to derive global estimate
• (Preliminary) results
 About 500,000 pregnant women with active TB at global level

Resources
• http://www.who.int/tb/country/en/
– TB data, including 2013 Global TB Report to be released on 23
October
– 2012 Report includes highlight on TB mortality among women and estimation of TB among children

Recommendations
• Address critical research gaps on the intersection of infectious disease and maternal health, including cost-effective integration models
• For pregnant women, continue scale up HIV counseling, voluntary testing, and treatment; TB screening, diagnosis and treatment; and preventive treatment, long lasting insecticide treated bednets, and management of malaria
• Provide integrated infectious disease and MCH services to pregnant and postpartum women and their families – across the continuum of care
• Promote a smoother transition from maternity to long-term care and support for women with HIV and TB
• Address and mitigate social factors that contribute to poor maternal health outcomes and are barriers to treatment and care
• Promote social support for pregnant and postpartum women and mobilize communities in favor of respectful, high quality HIV, TB, malaria and MCH services

For more information:
Malaria – Erin Eckert eeckert@usaid.gov
TB – Charlotte Colvin ccolvin@usaid.gov
HIV – Eni Martin enmartin@usaid.gov
Maternal – Karen Fogg kfogg@usaid.gov

Please fill out an evaluation by going to this session’s page on your mobile app OR by filling out a paper evaluation in the back of the room.
The Closing Session will begin at
4pm in the Grand Ballroom.
Closing remarks will be followed by a 30-minute social gathering
(refreshments will be served). Come meet new people and discuss the highlights of the day!