Different Approaches for Delivery of Intermittent Preventive Treatment (IPT) to Pregnant Women in Burkina Faso

Alphonse Ouédraogo*1, Sheick O. Coulibaly*3,4, Amidou Diarra1, Abdoulaye Traoré1, Sodiomon B. Sirima1,2, Pascal Magnussen5

Affiliation :1Centre National de Recherche et de Formation sur le Paludisme 2Groupe de Recherche Action en Santé 3Laboratoire National de Santé Publique 4Université de Ouagadougou 5Université de Copenhague

Introduction

 In Africa, the burden of malaria in pregnancy is highest in rural areas.

 Many publications showed a very poor coverage and compliance with CQ chemoprophylaxis among pregnant women and might explain the failure of this preventive strategy rather than increased levels of CQ resistance.

 In many sub-Saharan African countries, Intermittent Preventive Treatment/Sulfadoxine Pyrimethamine (IPTp/SP) has been adopted to replace chloroquine chemoprophylaxis. Introduction

 The new strategy is being implemented, but no delivery approach was defined, and IPTp/SP is only delivered to pregnant women presenting at antenatal clinic (ANC) visits.

 Weak health services may limit the effectiveness of this strategy.

 In this study, we compare three approaches of IPTp/SP delivery to pregnant women in term of improving coverage.

 These three approaches are: i) Passive health centre services, ii) Extended delivery outreach services, iii) Community based distribution delivery approach. Objectives

To assess different IPTp/SP delivery approaches in rural Burkina Faso with the aim of improving coverage among pregnant women.

1.To implement three approaches of IPTp/SP delivery to pregnant women based on health centre distribution, and in addition community based distribution either by health services or by community members;

2.To compare the effects of the approaches on coverage of IPTp/SP;

3.To assess the effects of the approaches on malaria burden.

Methods: Study site

 The research was implemented in Burkina Faso. The study took place in the health district of Saponé, located at 35 Km South- East of Ouagadougou.

 Malaria is endemic with seasonal transmission; the entomological inoculation rate is estimated at 0.3 and 44.4 infective bites/person/month during the dry and rainy seasons, respectively

 A total of 12/14 sub- districts were randomly selected.

Methods: Study site

 Each community clinic and its catchments areas were considered as a cluster.

 Clusters were randomly assigned to 2 intervention arms and 1 control arm.

 Four clusters were assigned to every arm. Methods: Study population

 Intervention  All pregnant women residing in the study area who consented to participate in the study and met the inclusion criteria were included in the study.  Pregnant women who have gestational age of 15 weeks or more at the time of the visit and who were not allergic to sulphonamide-containing drugs (SP).

 For the evaluation surveys,  we included all women present at the day of ANC and who gave their consent to participate in the study.

Methods:Design

 It was an open, randomised, controlled clustered trial comparing 3 arms (2 interventions & 1 control)

 The 2 intervention arms:  The first one was extended delivery approach including outreach services. The pregnant women were reached during preventive outreach activities that the health staff carries regularly in villages, such as immunization, health promotion, and even ANC visits. Methods:Design

 The second was community-based distribution delivery approach. SP was distributed at the community level by community health workers.

 The control arm: IPTp/SP has been delivered to all pregnant women presenting to the health unit either for ANC visit or for care seeking consultation.

 Drugs were administered as a directly observed treatment in the 3 arms. Methods:Design

 The study phases  The preparatory phase: training, sensitization, baseline survey  The intervention: Study drugs supplying, Recruitment of pregnant women, Supervision  Evaluation: cross sectional survey

 Two cross-sectional surveys were planned to measure key outcome indicators;

 One at the beginning of the trial  The second one at the end of the study (post-intervention).  Clinical and biological data were collected (parasitemia and haemoglobin).

12 Community B A clinics S E L I N E

S Control arm Intervention arm Intervention arm U 4 community clinics (community distribution) (outreach distribution) R 4 community clinics 4 community clinics V E 1689 expected pregnancies 1767 expected pregnancies 1790 expected pregnancies Y

I N T E R 648 women received SP1 841 women received SP1 243 women received SP1 V

E 411 women received SP2 589 women received SP2 246 women received SP2 N T I O N

E V A L 47/130 peripheral parasitemia 63/243 peripheral parasitemia 33/135 peripheral parasitemia U

A 106/130 anemia 184/243 anemia 92/135 anemia T I O N Results: Study profile

Results 1: IPTp coverage of pregnant women by using different interventions Intervention Health Center Expected number Number of pregnant Coverage rate Coverage rate of pregnancies women received SP SP1 (%) SP2 (%)

SP1 SP2 Arm1: Health Centre Kalghin 212 97 76 45,75% 35,85% based delivery 261 108 74 41,38% 28,35% approach HCD 337 185 109 54,90% 32,34% (Control) 879 258 152 29,35% 17,29% Total 1689 648 411 38,37% 24,33% 430 85 52 19,77% 12,09% Arm2: Community Sambin 298 116 110 38,93% 36,91% distribution approach 534 188 98 35,21% 18,35% Ilyala 505 452 329 89,50% 65,15% Total 1767 841 589 47,59% 33,33% 498 141 120 28,31% 24,10% Arm3: Outreach Urbain 689 13 15 1,89% 2,18% distribution approach Sapo. M 270 37 57 13,70% 21,11% Pissy 333 52 54 15,62% 16,22% Total 1790 243 246 13,58% 13,74% The mean coverage of 2 doses of IPT is higher in the community based arm than in the control group (33% vs 24%; P<0.001). Results 2: The effect of interventions on peripheral parasitemia according to the number of SP doses

Arms All participants Arm1: Health Arm2: Arm3: outreach Centre based community distribution delivery approach distribution approach HCD (Control) approach Peripheral parasitemia Asexual parasitemia at baseline (%) SP0 15(35.7) 31(31.6) 22(50.0) 68(37.0) SP1 12(17.1) 15(15.6) 12(20.3) 39(17.3) SP2 3(15.8) 5(11.4) 7(16.7) 15(14.3) Any 31(23.1) 51(20.9) 42(27.8) 124(23.4) Asexual parasitemia at close out (%) SP0 19(70.4) 26(28.9) 13(48.1) 58(40.3) SP1 12(24.0) 24(27.9) 10(18.9) 46(24.3) SP2 15(29.4) 13(20.3) 10(18.9) 38(22.6) Any 47(36.2) 63(25.9) 33(24.4) 143(28.1) After the intervention, there was decrease of peripheral parasitemia from 36.2% at health units to 25.9% at community based approach (P=0.03). Results 3: The effect of interventions on anemia according to the number of SP doses

Arms All participants

Arm1: Health Arm2: Arm3: outreach Centre based community distribution delivery approach distribution approach HCD (Control) approach Moderate anemia Anemia at baseline(%) SP0 30(71.4) 82(83.7) 30(68.2) 44(77.2) SP1 49(70.0) 65(67.7) 41(69.5) 155(68.9) SP2 13(68.4) 29(72.5) 31(73.8) 73(72.3) Any 95(70.9) 145(70.7) 105(70) 345(70.6) Anemia at close out (%) SP0 23(85.2) 64(71.1) 18(66.7) 105(72.9) SP1 41(82.0) 68(79.1) 40(75.5) 149(78.8) SP2 41(80.0) 51(79.7) 34(64.2) 126(75.0) Any 106(81.5) 184(75.7) 92(68.1) 382(75.1)

There was also decrease of anemia from 81.5% in health units to 75.7 and 68.1% in intervention arms (P=0.01). Major Outcome

 Community based delivery system has shown a good coverage rather than a health facility based delivery system.

 Women treated trough community and outreach based approaches had a lower proportion of parasitemia compared to those treated according to the health facility approach. This confirms the best coverage in the community-based approach group.

 Women who received IPT at outreach distribution had a lower proportion of anemia compared to those at the others approaches.

Conclusion & perspectives

 IPTp using community-based achieve high coverage in pregnant women.

 Women who assessed IPTp at community-based approaches had a lower proportion of peripheral parasitemia and anemia.

 Therefore a combination of health facility-based and community-based approaches might be needed to maximise the impact of IPTp.