REVIEW Bali Medical Journal (Bali MedJ) 2021, Volume 10, Number 2: 534-539 P-ISSN.2089-1180, E-ISSN: 2302-2914 Prevalence of pregnant women with malaria in , symptoms and fetomaternal outcome

Published by Bali Medical Journal Cut Rika Maharani1*, Cut Meurah Yeni2, Dara Meutia Ayu3 1,2Staff Departement of Obstetrics and Gynecology Faculty of Medicine, Universitas Syiah Kuala, Dr. Zainoel ABSTRACT Abidin Hospital, ; 3Resident of Obstetrics and Gynecology, Faculty of Medicine, WHO estimates that as many as 300 to 500 million people are infected with malaria each year. There are around 3 million Universitas Syiah Kuala, Dr. Zainoel severe malaria cases (complicated malaria) and deaths due to malaria. Other sources revealed that as many as 1.5 million Abidin Hospital, Banda Aceh. to 2.7 million people die every year, especially children and pregnant women. Malaria is a disease that is emerging and continues to affect the people of Aceh. Malaria in pregnancy is a serious problem considering its effects on the mother and *Corresponding author: fetus, which can increase maternal and neonatal mortality rates if not treated quickly and accurately. Prevention of malaria in Cut Rika Maharani; Staff Departement of Obstetrics and pregnancy can be started early through ANC visits by providing health education about malaria prevention and prophylactic Gynecology Faculty of Medicine, treatment for those living in endemic areas. The purpose of this review is to discuss the classification of the Aceh Province Universitas Syiah Kuala, Dr. Zainoel according to the level of susceptibility to malaria was based on the API value criteria, to discuss prompt treatment of malaria Abidin Hospital, Banda Aceh; will improve maternal and fetal outcomes. [email protected], [email protected] Keywords: Fetal Maternal Outcome, Malaria, Pregnancy. Received: 2021-04-17 Cite This Article: Maharani, C.R., Yeni, C.M., Ayu, D.M. 2021. Prevalence of pregnant women with malaria in Aceh, symptoms Accepted: 2021-06-19 and fetomaternal outcome. Bali Medical Journal 10(2): 534-539. DOI: 10.15562/bmj.v10i2.2388 Published: 2021-06-26

INTRODUCTION potential breeding grounds for malaria determine the number of people free of vector mosquitoes expand or increase.5 malaria in a certain area. The API value is one of the countries at risk for There were 1.038 malaria cases between is obtained from the number of malaria malaria cases with a prevalence of 1.4% 2015-2018 in Aceh, and Plasmodium cases in a year divided by the population and an incidence rate of 0.3% with an vivax is a primary cause of malarian with and multiplied by 1000. The data used is Annual Parasite Incidence (API) in 2015 1 703 cases (67,73%). Most of them were the API data for all districts/cities in the of 0.85%. One of the indicators in the found in Aceh Jaya and Aceh Selatan Aceh Province, from 2015 to 2018. API health development target is the number district.6 One of the first steps in assisting indicators have four categories, namely of districts/cities with malaria elimination 2,3 Aceh and district/city governments in No Case Incidence (API = 0), Low Case certification. identifying and eliminating malaria Incidence (LCI) if the API value is less WHO estimates that as many as 300 cases is by researching the types of than 1, Moderate Case Incidence (MCI) if to 500 million people are infected with 4 plasmodium parasites that cause malaria the API value is between 1 to 5, and High malaria each year. There are around 3 and classifying areas prone to malaria to Case Incidence if the API value is more million severe malaria cases (complicated work more on areas with a high level of than 5. However, districts/cities in Aceh malaria) and deaths due to malaria. vulnerability to malaria. The purpose of Province only have three API categories.7 Other sources say that as many as 1.5 this review is to discuss the classification Gayo Lues District is the only district million to 2.7 million people die every of the Aceh Province according to the in Aceh Province that does not have year, especially children and pregnant level of susceptibility to malaria was malaria cases or is included in category women. Outbreaks (KLB) of malaria cases based on the API value criteria to discuss 1. Furthermore, Aceh Jaya District is the occur in almost all continents, increasing prompt treatment of malaria will improve only district with the highest number public health problems and causing death, maternal and fetal outcomes. of malaria cases in Aceh Province with reducing work productivity, and gives an API value <5 and is included in the rise to other economic impacts, including ACEH PROVINCIAL category. 3. Meanwhile, the other 21 reduced tourism due to imported malaria. CLASSIFICATION BASED ON districts/cities fall into category 2, with Imported malaria is a malaria case in a MALARIA VULNERABILITY LEVEL API values ​​varying from 0 to 1, making it person who visits an area prone to malaria possible to divide these districts/cities into In this case, the classification of the disease and then returns to his/her home new clusters. Regions in one cluster will Aceh Province according to the level of area, which is not an endemic malaria have adjacent API values, while regions susceptibility to malaria was based on the area. Some malaria outbreaks are caused with different clusters will have distant API value criteria. API is an indicator to by changes in the environment where the API values. This clustering is carried

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Table 1. Classification of districts/cities in Aceh Province based on the API indicator Category / City Information Category 1 No Case Incidence Regency. Gayo Lues There are no cases Category 2 Low Case Regency. Simeulue, Kab. Aceh Singkil, Kab. Southeast Aceh, Kab. Low Cluster 1 Incidence Cluster1 East Aceh, Kab. Central Aceh, Kab. West Aceh, Kab. Aceh Besar, Kab. Pidie, Kab. Bireuen, Kab. North Aceh, Kab. Southwest Aceh, Kab. Aceh Tamiang, Kab. Nagan Raya, Kab. Bener Meriah, Kab. Pidie Jaya, Banda Aceh City, City, City, Subulussalam City Regency. South Aceh Low Case Incidence Low Cluster 2 Cluster2 Low Case Incidence Sabang City Low Cluster 3 Cluster 3 Category 3 Moderate Case Regency. Aceh Jaya Moderate Incidence out to facilitate related parties, such as Tamiang, Kab. Nagan Raya, Kab. Bener are associated with malaria incidence.4 the Aceh Provincial and District/City Meriah, Kab. Pidie Jaya, Banda Aceh City, Health Offices, to identify areas prone to City of Langsa, City of Lhokseumawe and IMMUNOPATHOLOGY OF malaria disease so that malaria prevention City of Subulussalam. Furthermore, one RESPONSE IMMUNE AGAINST programs can be focused on areas with a region is included in cluster 2 (Low Case MALARIA INFECTION DURING higher level of vulnerability. The number Incidence Cluster 2), namely Kab. South PREGNANCY of clusters used in this study was 3 clusters, Aceh and cluster 3 (Low Case Incidence Response Specific immunity consists namely Low Case Incidence Cluster 1, Cluster 3), namely Sabang City.7 of cellular immunity carried out by T Low Case Incidence Cluster 2 and Low Table 1 also shows that there is 1 area lymphocytes, and humoral immunity Case Incidence Cluster 3. Cluster 1 is the included in category 1 (districts/cities carried out by B lymphocytes. These area with the lowest level of vulnerability, with no malaria cases), namely Gayo cytokines play a role in activating and cluster 3 is the area with the highest Lues Regency and one region in category humoral immunity. CD4+ functions as a vulnerability level. high to Low Case 3 (Moderate Case Incidence), Aceh Jaya regulator by helping produce antibodies Incidence categories are used so that the District. Areas included in category 3 are and activation of other phagocytes, while malaria prevention program can focus on areas with the highest malaria susceptibility CD8+ acts as a direct cause for parasitic areas with a higher level of vulnerability.7 cases among other categories in Aceh phagocytosis and inhibits parasite K-means clustering analysis is based on Province. Aceh Jaya District, Sabang City development by producing IFN-γ. In the distance between observations or data. and South Aceh District are the three areas this case, the parasite antigen epitopes The closest distance between data and a with the highest level of vulnerability to will bind to B lymphocyte receptors particular cluster will determine where malaria cases in Aceh Province compared that act as antigen-presenting cells to the data is located in the available clusters. to other districts/cities. So it is hoped T lymphocytes, CD4+. Furthermore, T The clustering results of 21 districts/cities that the Health Office and other related cells will differentiate into Th-1 and Th-2 included in the Low Case Incidence (LCI) institutions, both at the provincial and cells. Th-2 cells will produce IL-4 and IL- category are shown in Table 1 in category the three districts/cities level, will be more 5, which promote the formation of Ig by 2. Table 1 lists the districts/cities included proactive in dealing with malaria cases.7 B lymphocytes. These Ig also increase the in category 1 (No Case Incidence) and 3 Health status in an area is influenced by phagocytosis ability of macrophages. Th-1 (Moderate Case Incidence). Districts/ four interrelated and mutually influencing cells produce IFN-γ and TNF-α, which cities that are included in categories 1 factors: environmental factors, behavior, activate cellular immunity components and 3 are not included in the K-means health services, and heredity. The sea such as macrophages, monocytes, and NK clustering analysis generally borders 30 Areas that are prone cells.8 Based on Table 1 in category 2, it to malaria. The potential breeding habitat Pregnant women are more likely to is known that of the 21 districts/cities for Anopheles spp. as vectors of malaria develop falciparum malaria that is found analyzed, 19 districts/cities are included in are lagoons, rivers and rice fields located more severe compared to nonpregnant cluster 1 (Low Case Incidence Cluster 1), close to the coastline. Reproductive habitat women. Concentrations of erythrocytes namely Kab. Simeulue, Kab. Aceh Singkil, for Anopheles spp. It is more conducive in infected with parasites are found in the Kab. Southeast Aceh, Kab. East Aceh, Kab. water that is cloudy and exposed to direct placenta, so that it is suspected that the Central Aceh, Kab. West Aceh, Kab. Aceh sunlight. Also, individual and behavioral immune response to parasites in that Besar, Kab. Pidie, Kab. Bireuen, Kab. North factors such as education, income, area is suppressed. This is related to the Aceh, Kab. Southwest Aceh, Kab. Aceh knowledge, attitudes, actions, and bed nets

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suppression of the immune system, both (example: Southeast Asia and South in nonimmune women (in non-endemic humoral and cellular, during pregnancy America) areas) varies from mild malaria without due to the presence of the fetus as a a. People in these areas are rarely complications (uncomplicated malaria) “foreign object” in the mother’s body.9 exposed to malaria and only receive with high fever, until severe malaria Suppression of the immune system an average of <1 infective mosquito (complicated malaria) with a high risk for during pregnancy is related to the bite/year. Pregnant women (semi- both mother and fetus (20-50% maternal hormonal state. The progesterone immune) in areas of stable/ mortality rate and often fatal to the fetus).11 hormone concentration, which increases high endemic transmission will during pregnancy, inhibits T lymphocyte experience: Clinical diagnosis (without laboratory activation against antigen stimulation. b. Increase in parasite rate (in examination) Also, the immunosuppression effect of primigravida in Africa, parasite 1) Mild/uncomplicated clinical malaria. cortisol plays a role in inhibiting immune rate in pregnant women increases On the history, malaria should be response.9 30-40% compared to nonpregnant suspected in a person from a malaria- women) endemic area with acute fever in all CLINICAL SYMPTOMS c. Increased density of peripheral forms, with/without other symptoms, parasitemia. It causes fewer clinical there is a history of travel to malaria- The main symptom of malaria infection effects, except for maternal anemia endemic areas in the last two weeks, is fever which is thought to be associated as the main complication that or history of living in a malaria area with the schizogony process (rupture often occurs in primigravida. The or malaria treatment. On physical of merozoites/schizonts) and cytokines anemia can worsen, causing serious examination can be found temperature and/or other toxins. In hyperendemic consequences for both the mother >37.50C, an enlarged spleen and areas, patients with parasitemia are and the fetus.10 anemia. The typical classic malaria often found without fever symptoms. On the other hand, in unstable/ symptoms consist of 3 successive The characteristic features of malaria are non-endemic/low-endemic areas where stages, namely chills (15 - 60 minutes), periodic fever, anemia and splenomegaly. most of the population are not immune fever (2-6 hours), and sweating (2-4 There are frequent prodromal symptoms to malaria, pregnancy will increase the hours). The classic symptoms above such as malaise, headache, bone/muscle risk of serious mental illness, fetal death, do not appear sequentially. Not all pain, anorexia and mild diarrhea. The preterm birth and death. Pregnant women of these symptoms can be found. effects of malaria on pregnancy can be suffering from severe malaria in this area Apart from the classic symptoms divided into two groups: the effects on have a more than ten times possibly fatal above, other symptoms / local specific the mother and the effects on the fetus. risk than nonpregnant women suffering symptoms may also be accompanied, Effect on mothers there are anemia, from severe malaria in the same area such as weakness, headaches, myalgia, circulatory system disorders, orthostatic abdominal pain, nausea/vomiting, and hypotension is common, pulmonary ETIOLOGY diarrhea.12 edema, hypoglycemia, placenta infection, 2) Severe clinical malaria / with electrolyte disturbances, cerebral malaria. Malaria is an infectious disease caused complications. Effect on the fetus there are fetal death in by Plasmodium parasites that enter the Severe malaria / complicated malaria utero, abortion, premature birth, low birth human body, transmitted by the anopheles is a serious and dangerous form of weight, placental malaria. tina mosquito (WHO 1981). The four falciparum malaria, which requires However, the clinical effect of malaria Plasmodium species that cause malaria immediate and intensive treatment. on pregnant women depends more on in humans are: Plasmodium falciparum Therefore, it is very important to the level of immunity of pregnant women (P. falciparum), Plasmodium vivax (P. recognize the signs and symptoms of against the disease, while immunity to vivax), Plasmodium ovale (P. ovale), severe malaria for health service units malaria is determined more by the level Plasmodium malariae (P. malariae). The to reduce malaria mortality. Some of of malaria transmission where pregnant types of Plasmodium commonly found in the important diseases similar to severe women live/originate, which is divided Indonesia are P. falciparum and P. vivax or malaria are meningitis, encephalitis, into two major groups:10 a mixture of both, while P. malariae is only septicemia, typhoid fever, viral 1) Stable transmission, or endemic found in East Nusa Tenggara and P. ovale infection, etc. This causes laboratory (example: Sub-Saharan Africa) is found in Papua.11 tests to be urgently needed to add a. People in this area are constantly strength to the diagnosis.12 exposed to malaria because they DIAGNOSIS OF MALARIA IN often receive an effective mosquito PREGNANCY Laboratory diagnosis (by examination bite every month. Malaria in pregnancy is confirmed by of blood slides) b. Immunity to malaria builds up finding the malaria parasite in maternal Microscopic examination is still the most significantly.10 blood and placental blood through important examination in malaria because 2) Unstable transmission/transmission biopsy. The clinical findings of malaria the interpretation of this examination can is unstable, epidemic or non-endemic

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Table 2. Classification of antimalarial drugs smear examination / DDR (+) need more Safety in pregnant careful monitoring, as follows: Antimalarial drugs Oral dosage women At stage I: Chloroquine 25 mg base / Kg for 3 days Safe for all a. Pregnant women with severe malaria (10 mg/Kg day I-II, 5 mg/Kg day III) trimesters infection should be admitted to an Amodiakuin 25 mg base/Kg for 3 days Not recommended intensive care unit (whenever possible). for the 1st trimester b. Close monitoring of uterine Sulfadoxin- Sulfadoxine: 25 mg/Kg Not recommended contractions and fetal heart rate Pyrimethamine (SP) Pyrimethamine: 1 mg/Kg for the 1st trimester (CTG monitoring) to monitor fetal Mefloquine 15-20 mg base / Kg (single dose) Not recommended emergencies early. st for the 1 trimester c. If monitoring shows signs of fetal Kinin 10 mg salt / Kg every 8 hours for Safe for all emergency at delivery, it is an indication 5 - 7 days Trimester to end with cesarean section. Artesunate 10-12 mg / Kg per day for 2-3 days Not recommended Or: Artemether for the I trimester General treatment at stage I: • For fever, if the rectal temperature is >390C, then compress it and give it an identify the type of Plasmodium accurately e. Monthly hemoglobin and malaria antipyretic (paracetamol 3-4x500 mg/ and count the number of parasites so that parasitology examination. day). the degree of parasitemia can be known. f. Provision of iron and folic acid • Pregnant women with anemia may One laboratory test is an examination by tablets and TT immunization must be be given packed red cell (PRC) microscope: complete. transfusions. 1. Giemsa’s stain on the blood smear to In non-chloroquine resistant areas: • Hypoglycemia (blood sugar levels look for parasites a. Nonimmune pregnant women are <40 mg%) often occurs in pregnant 2. Acridine Orange stain to look for given Chloroquine 2 tablets/week from women both before and after quinine infected erythrocytes the first arrival until the puerperium. therapy. Occurs due to increased 3. Quantitative Buffy Coat (QBC)b. Semi-immune pregnant women metabolic requirements at fever, tissue Fluorescence Check are given SP in the early II and III hypoxia. Another cause is thought to Meanwhile, examination of thick and trimesters. be an increase in glucose uptake by the thin blood samples at the health center/ c. For the Minahasa / North Sulawesi malaria parasite. Actions: field/hospital is used to determine the region, chloroquine is still very 1) Give 50 - 100 ml Glucose 40% IV by threshold value and determine the density effective, that’s the same way P. bolus injection. of parasites (especially hospitalized Vivax was generally still sensitive to 2) Infusion of 10% glucose slowly for patients) in blood samples. In areas with chloroquine. maintenance / preventing recurrent laboratory facilities and microscope hypoglycemia. personnel, malaria diagnosis is based In chloroquine-resistant area 3) Regular monitoring of blood sugar solely on clinical examination (history All pregnant women, both nonimmune levels every 4-6 hours. taking and physical examination) without and semi-pregnant, were given SP in the • Cerebral malaria. Sufferers must be laboratory examination. early II and III trimesters. cared for with care, fluid balance and In areas where P. falcaria is already level of consciousness considered. Can MANAGEMENT OF MALARIA IN resistant to chloroquine, alternative be given an injection of 10-15 mg/kg PREGNANCY treatments can be given Mefloquine if intramuscular sodium phenobarbium treatment with quinine or SP is resistant, Management of malaria in pregnancy in a single dose, and if a seizure occurs, but its use in young pregnancy should be depends on the degree of transmission and diazepam 0.15 mg/kgBW intravenously considered because data on its use in the the surveillance of the following factors (maximum 10 mg) can be given. first trimester are still limited. If there is during pregnancy in all health lines. • Pulmonary edema. This is a fatal multiple resistance, the treatment options a. Monitor maternal and fetal health, as complication that often leads to death are Quinine Salt 10 mg / Kg BW orally 3 well as pregnancy progress. because severe malaria should be times for 7 days PLUS clindamycin 300 mg b. Prompt (timely) diagnosis and treated to prevent pulmonary edema. 4 times a day for 5 days. (can be used in treatment. The patient may cough, shortness of quinine-resistant areas) OR Artesunate 4 c. Admission of chemoprophylactic breath, rapid and shallow breathing. On mg / Kg BW orally in several dose day I, drugs for the mother. auscultation, he hears full crackles in continued 2 mg / Kg BW orally as a single d. Personal protection to prevent contact all parts of the lung. Chest X-ray shows dose during 6 days. (can be used in the II with vectors, for example, the use of a a large infiltration across the lung field. & III trimesters and no other alternatives). mosquito net. If there are signs of acute pulmonary Handling of deliveries of malaria edema, the patient is immediately patients who are positive on thick blood

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referred to them, and before that, the Management of severe malaria in Prophylaxis is started 1 to 2 weeks following actions are taken: pregnancy before visiting endemic areas, with 1) Administration of highly Treatment of severe malaria requires chloroquine (300 mg base) given once a concentrated oxygen to correct speed and accuracy in the earliest possible week and continued for up to 4 weeks after hypoxia diagnosis. For each patient with severe returning to non-infectious areas (Bradley 2) Limitation of provision of fluids malaria, the following actions/treatments and Warhurst, 1995). Several studies have 3) If anemia is accompanied, give a need to be done are: general/symptomatic shown that chemoprophylaxis reduces PRC transfusion. action, providing anti-malarial drugs, maternal anemia and increases the weight 4) To reduce the burden on the right treatment of complications. of babies born. heart can be done: Improve the general condition of the • Position of the patient ½ sitting. patient (administration of fluids and PREVENTION MALARIA IN • Administered furosemide 40 mg general care). Administration of fluids is a PREGNANCY iv if necessary repeated 1 hour very important factor in the management Contact between mothers and vectors can later or the dose is increased of severe malaria. If it is excessive, it will be prevented by wearing a mosquito net to 200 mg (maximum) while cause pulmonary edema. On the other dipped with insecticide (e.g., permethrin), monitoring the urine output and hand, if it is not enough, it will cause acute wearing long trousers and long-sleeved vital signs. tubular necrosis, which results in acute shirts, use of mosquito repellents, use of • Venaseksi, remove the patient’s renal failure. mosquito netting on doors and windows. blood into a transfusion/donor Monitoring of vital signs includes: Any woman who lives in endemic areas bag as much as 250-500 ml will general condition, awareness, respiration, or will travel to endemic areas should greatly help reduce tightness. If blood pressure, temperature and pulse be given chemoprophylaxis. Although the patient’s condition is normal, every 30 minutes (always recorded for this does not provide absolute protection the blood can be returned to the progress), uterine contractions, and fetal against malaria infection, it can reduce patient. heart sounds should also be monitored. parasitemia, prevent severe malaria 5) Chloroquine is the safest drug of Keep Street breath to avoid asphyxia. Give complications, and increase baby body choice given to pregnant women oxygen if necessary. Giving antipyretic to weight. (safe in 3 trimesters of pregnancy) prevent hyperthermia: paracetamol 10 Chloroquine is the safest drug for at a 25 mg/kgBW for 3 consecutive mg/kg BW / x, and compresses can be pregnant women, with a dose of 300 mg days or on days I-II as much as 600 done. base (2 tablets) every week. For pregnant and on day III as much as 300 mg. If convulsions, give anti-convulsants: women who will travel to malaria- If chloroquine resistance is found, Diazepam 5-10 mg IV (slowly over 2 endemic areas, the provision is started one quinine can be given at a dose of minutes) repeat 15 minutes later if still week before leaving, while in the endemic 3x400 mg for 7 days. seizures. Do not give more than 100 mg/ area, up to 4 weeks after leaving the area. Pregnant women with severe malaria 24 hours. If Diazepam is not available, Another effort to prevent malaria infection are given an infusion of chloroquine at a as an alternative, Phenobarbital 100 mg is to break the chain of transmission to the dose of 10 mg/kgBW in isotonic fluids at IM/x (adult) can be used twice a day. To host, agent or environment by: a constant rate for 8 hours and followed confirm the diagnosis, perform a thick a) Reducing contact / Anopheles by 15 mg/kgBW for the next 24 hours SD examination. Assessment according mosquito bite by using a mosquito net, or with chloroquine at a dose of 5 mg/ to microscopic diagnostic criteria. If mosquito repellent kgBW given by constant speed for 6 hours adequate facilities are not available, b) Kills adult mosquitoes and repeated every 6 hours for a total of prepare the patient for a higher level of c) Kills mosquito larvae. 5 doses. Another alternative can be given health care that provides intensive care. d) Increase power hold on the body quinine dihydrochloride 20 mg/kgBW through vaccination. intravenously for 4 hours in 5% dextrose Chemoprophylaxis malaria in Severe complications of malaria is and a maintenance dose of 10 mg/kgBW pregnancy severe anemia, so the prevention of anemia every 8-12 hours until the patient receives WHO recommends giving a dossier begins at this point: give iron supplements: the drug orally. treatment (dose antimalarial therapy for 300 mg ferrosus sulfas (60 mg elemental all pregnant women in malaria-endemic iron)/day, and 1 mg folic acid / day, for the General treatment at stage II areas at the first ANC visit, later followed treatment of moderate anemia (Hb 7-10 g Within the first 6 hours, then if there are by regular chemoprophylaxis. Currently, / dl), a 2x-fold iron dose is given, check Hb no contraindications for vaginal delivery, the malaria treatment policy in Indonesia every ANC control. the indication for delivery by vacuum requires only the use of chloroquine extraction/forceps depends on the for prophylaxis in pregnancy. Pregnant CONCLUSION indication for the obstacle course. women with nonimmune status should be avoided from entering malaria-endemic Based on the analysis that has been done, areas. it can be concluded that the 3 types of

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plasmodium parasites that cause the FUNDING Village, Bengkulu City. Unnes J Public highest malaria cases in Aceh Province Heal. 2017;6(2):107–12. are plasmodium vivax, plasmodium This article did not require any funding. 6. Badan Litbangkes Kemenkes RI. Laporan falciparum and Plasmodium knowlesi. Hasil Riset Kesehatan Dasar (Riskesdas) AUTHOR CONTRIBUTION [Internet]. 2010. p. 1–466. Available K-means clustering analysis shows that from: http://labdata.litbang.kemkes.go.id/ most areas of Aceh Province have a low CRM as a specialist in obstetrics and images/download/laporan/RKD/2010/ level of vulnerability to malaria cases. The gynecology, she’s the woman in charge lp_rkd2010.pdf 3 areas most vulnerable to malaria cases of investigating this article review and 7. Zohra A, Anwar S, Fitri A, Nasution in Aceh Province are Aceh Jaya District, final editing and review in drafting the M. Klasifikasi Wilayah Provinsi Aceh Sabang City and South Aceh District. manuscript. CMY as a fetomaternal Berdasarkan Tingkat Kerentanan Kasus Recommendations that can be given to consultant in obstetrics and gynecology Malaria Tahun 2015 – 2018. J Kesehat the Government of Aceh, especially the prepares the design, and review the Lingkung Indones. 2019;18(1):25–33. Aceh Provincial Health Office, to pay manuscript. DMA is a resident in obstetrics 8. Beeson JG, Duffy PE. The immunology and pathogenesis of malaria during special attention to eliminating malaria and gynecology department search the pregnancy. Curr Top Microbiol Immunol. cases in Aceh Jaya District, Sabang City literature, clinical studies and editing 2005;297:187–227. and South Aceh District, the highest level manuscripts. All authors discussed the 9. Manirakiza A, Serdouma E, Ngbalé RN, of susceptibility to malaria cases compared results and commented the manuscript. Moussa S, Gondjé S, Degana RM, et al. to other districts/cities. For people who A brief review on features of falciparum live in these three areas, it is hoped that REFERENCES malaria during pregnancy. J Public Health they will be more concerned with the Africa. 2017;8(2):190–201. 1. RI Ministry of Health. Indonesia Health 10. Bejon P, Williams TN, Liljander A, Noor factors that cause malaria and participate Profile 2014. Jakarta; 2015. in the success of government programs in AM, Wambua J, Ogada E, et al. Stable and 2. National Development Planning Agency. unstable malaria hotspots in longitudinal efforts to eliminate malaria cases in Aceh National Medium Term Development cohort studies in Kenya. PLoS Med. Province. Plan (RPJMN) 2015-2019 Book I of the 2010;7(7). Our study limitation was the results National Development Agenda. Jakarta; 11. Romi T, Putra I. Malaria Dan of this review article have a lack of data 2014. Permasalahannya. J Kedokt Syiah Kuala. regarding the incidence of malaria in 3. RI Ministry of Health. Elimination of 2011;11(2):103–14. pregnancy in Aceh that has not been well Malaria in Indonesia. Decree Number: 12. Siahaan L. Symptoms and Clinical Signs of 293 / MENKES / SK / IV / 2009. Jakarta; documented, therefore the fetomaternal Malaria in Endem area. Nusant Med Mag. 2009. 2008;2(5):211–5. outcome from case to case cannot be 4. World Health Organization (WHO). evaluated directly, research is needed World Malaria Report 2017. Geneva. to better record malaria cases in this 2017. pregnancy. 5. Triana D, Rosana E, Anggraini R. Knowledge and Attitudes towards CONFLICT OF INTEREST Behavior in Malaria Control in Sukarami The authors declare there is no conflict of interests.

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