Intermittent screening and treatment or intermittent preventive treatment compared to current policy of single screening and treatment for the prevention of malaria in pregnancy in Eastern Indonesia: acceptability among health providers and pregnant women

Abstract

BackgroundThe control of malaria in pregnancy in much of Asia relies on screening asymptomatic women for malaria infection, followed by passive case detection and prevention with insecticide-treated nets. In 2012, Indonesia introduced screening for malaria by microscopy or rapid diagnostic tests (RDTs) at pregnant women’s first antenatal care (ANC) visit to detect and treat malaria infections regardless of the presence of symptoms. Acceptability among health providers and pregnant women of the current ‘single screen and treat’ (SSTp) strategy compared to two alternative strategies that were intermittent preventive treatment (IPTp) and intermittent screening and treatment (ISTp) was assessed in the context of a clinical trial in two malaria endemic provinces of Eastern Indonesia.MethodsQualitative data were collected through in-depth interviews with 121 health providers working in provision of antenatal care, heads of health facilities and District Health Office staff. Trial staff were also interviewed. Focus group discussions were conducted with 16 groups of pregnant women (N = 106) to discuss their experiences of each intervention in the trial.ResultsHealth providers and pregnant women were receptive to screening for malaria at every ANC visit due to the increased opportunity to detect and treat asymptomatic infections. A primary concern for providers was the accuracy and availability of RDTs used for screening in the SSTp and ISTp arms, which they considered less accurate than microscopy. Providers had reservations about giving anti-malarials presumptively as IPTp, due to concerns of causing potential harm to mother and baby and as a possible driver of drug resistance. Pregnant women were accepting of all three interventions. Women in the IPTp arm were happy to take anti-malarials presumptively to protect themselves and their babies against malaria.ConclusionsThe findings indicate that, within a trial context, malaria screening of pregnant women at every ANC visit ISTp was an acceptable strategy among both health providers and pregnant women owing to an existing culture of screening and treatment. The adoption of IPTp however would require a considerable shift in health provider attitudes and a clear communication strategy. By contrast, pregnant women welcomed the opportunity to prevent malaria infections during pregnancy.Electronic supplementary materialThe online version of this article (10.1186/s12936-018-2490-3) contains supplementary material, which is available to authorized users.

Efficacy and safety of intermittent preventive treatment and intermittent screening and treatment versus single screening and treatment with dihydroartemisinin–piperaquine for the control of malaria in pregnancy in Indonesia: a cluster-randomised, open-label, superiority trial

“…In a linked feasibility analysis, monthly screening with malaria rapid diagnostic tests was found to be well accepted by asymptomatic participants and providers 28 . By contrast, in this current study, the withdrawal rate was relatively high in the IPT cluster, particularly in Papua, where 14% of participants withdrew, compared with 0% and 2% in the IST and SST clusters, respectively.…”

“…By contrast, in this current study, the withdrawal rate was relatively high in the IPT cluster, particularly in Papua, where 14% of participants withdrew, compared with 0% and 2% in the IST and SST clusters, respectively. High rates of withdrawal from IPT were related to concerns about dihydroartemisinin–piperaquine causing potential harm to the mother and baby and being a potential driver of drug resistance 28 . The concept of using dihydroartemisinin–piperaquine for chemoprevention in asymptomatic individuals is new in this region, where to date it has been used only for case management of febrile patients with acute malaria.…”

Malaria prevalence in symptomatic and asymptomatic pregnant women in a high malaria-burden state in India

“…The fear of needle prick in IST was not found to be a big barrier. IST was found to be acceptable to pregnant women and providers in Indonesia [42,47]. The acceptability of IST was found to be high where the providers enjoyed trust of community, especially women [27].…”

“…A recurring theme in literature on 'MiP', from both Africa and Asia, has been of the perceived apprehensions associated with taking anti-malarial drugs during pregnancy [42,[45][46][47][48]. Such fears had posed challenges for IPT but to a lesser extent for IST.…”

Cost-effectiveness of intermittent preventive treatment with dihydroartemisinin-piperaquine versus single screening and treatment for the control of malaria in pregnancy in Papua, Indonesia: a provider perspective analysis from a cluster-randomised trial

“…The first-line anti-malarial for second and third trimesters, dihydroartemisinin-piperaquine, 10 was used in all three groups. Cost-effectiveness, acceptability, and feasibility studies were done alongside the trial, [11][12][13] together with an evaluation of the implementation of single screening and treatment. 13 Intermittent preventive treatment was effective at reducing maternal malaria infection and maternal anaemia in Papua but not in Sumba.…”