In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Classification of evidence levels (1++ to 4) and grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.
What Are the Medical Complications of Malaria in Pregnancy?
C - Malaria infection in pregnancy carries significant risks to mother and baby.
B - UK-based residents have low premunition and high susceptibility to malaria infection.
B - Malaria infection in pregnancy may result in reduced birth weight in the fetus and this may have health consequences in later life.
Prevention of Malaria Infection in Pregnancy
What Advice Should Pregnant Women Be Given if They Are Considering Travel to a Malaria Endemic Area?
C - Pregnant women should consider the risks of travel to malaria endemic countries and consider postponing their trip, unless travel is unavoidable.
A health professional advising a prospective UK resident who is pregnant or thinking about becoming pregnant and who is intending to go to a malaria endemic area should suggest that the woman consider not going or postponing her trip until she is no longer pregnant (see Table 1 in the original guideline document).
If Travel Is Unavoidable What Advice Should Pregnant Women Receive about Preventing Malaria Infection?
B - Advise the woman to seek guidance from a centre with expertise on malaria risks and avoidance strategies.
B - Advise women that a fever or flu-like illness while travelling or upon returning home, up to 1 year or more, may indicate malaria and requires medical attention.
B - Advise the woman on the risk of being exposed to malaria at her intended area of travel.
There are no measures specific to pregnancy that can be taken to prevent malaria beyond those that non-pregnant travellers can apply.
The 'ABCD' of malaria prevention is a useful formula to remember the components of malaria prevention:
- Awareness of risk (see Section 5.2.1 in the original guideline document)
- Bite prevention (see Section 5.3 in the original guideline document)
- Chemoprophylaxis (see Section 5.4 in the original guideline document)
- Diagnosis and treatment which must be prompt (see Section 5.5 in the original guideline document)
Women need to be educated about possible measures and, where possible, provided with written information in their own language.
What Needs to Be Done to Raise Pregnant Traveller's Awareness of the Risk of Malaria?
Despite applying effective anti-mosquito measures and good compliance to chemoprophylaxis, women can still contract malaria. Education about the symptoms of malaria (such as a fever or flu-like illness) is beneficial to travellers: it enables them to realise that they need to seek medical attention without delay and to state that they have travelled to a malarious area. Worryingly, some migrant groups and their families do not access effective antimalarial prophylaxis. Adult travellers born in Africa were reported to hold a belief that malaria was trivial or that they were protected from severe malaria. It is important to challenge and advise on misconceptions. Awareness of the risk is vital. Women may find the websites listed in Box 1 of the original guideline document useful to learn about malaria for travellers and to reinforce the points already made to them.
How Should Bites Be Prevented?
A - Inform women about bite prevention measures, including skin repellents, knock-down mosquito sprays, insecticide-treated bed nets, clothing and room protection.
The anopheline mosquito has different preferred biting times in different parts of the world but making the assumption that the risk period is from dawn to dusk will suffice. In pregnancy, other mosquito-borne diseases, such as dengue, which is caused by a daytime-biting mosquito, should be prevented, so applying mosquito bite prevention measures 24 hours a day is advisable.
Repellents – the Evidence Favours Skin Repellents Containing 50% DEET (N,N-diethyl-m-toluamide or N,N-diethly-3-methyl-benzamide)
As the consequences of malaria in pregnancy can be devastating and higher concentrations give longer protection, 50% DEET is recommended. In a sweaty environment, the effect of repellent is lowered and more frequent applications are required. [Evidence level 1]
Knock-Down Mosquito Sprays: Permethrin and Pyrethroids Sprays Kill Resting and Flying Mosquitoes
Whether women stay in air-conditioned hotel rooms or tents, a can of insect spray active against mosquitoes is useful to help clear the room of mosquitoes. Pyrethroids will quickly kill mosquitoes and are the preferred ingredient in sprays, while permethrin will both repel and kill mosquitoes when used regularly in the same room. [Evidence level 2+]
Insecticide Treated Bed Nets: Long Lasting Pyrethroid-Impregnated Bed Nets Offer Significant Protection
Women sleeping outdoors or in unscreened accommodation should use long-lasting pyrethroid-impregnated nets. If the net is not long-lasting it needs reimpregnating every 6 months, starting from the first date on which the net is used after purchase. Permethrin-impregnated hammocks are another possibility. [Evidence level 1++]
Clothing That Covers the Body and Forms a Barrier from Biting Mosquitoes Will Reduce the Risk of Malaria
After sunset, long sleeves, long trousers, loose-fitting clothing and socks, regardless of colour, are recommended. Clothes can be impregnated with permethrin or permethrin or DEET can be spayed on to the clothes. [Evidence level 1–]
Room Protection: Electrically Heated Mats Will Kill Mosquitoes in the Room
If electricity can be relied upon, an electrically heated device that vaporises synthetic pyrethroids from a mat tablet can kill mosquitoes. A supply of mats is required, as new mat is needed each night. While mosquito coils could be used as an alternative, they are not as effective and not recommended indoors. [Evidence level 2+]
Which Drug Can Be Recommended for Malaria Prevention in Pregnancy?
A - Inform women (and their general practitioner) of the risks and benefits of chemoprophylaxis versus the risks of malaria.
A - Remind women that there is no malaria prophylaxis regimen that is 100% protective.
The choice of drug and advice about chemoprophylaxis in pregnant women depends on the level of chloroquine-resistant Plasmodium falciparum and P. vivax malaria and the trimester of pregnancy. There are malaria prevention guidelines produced for travellers who are UK residents and these are detailed: by country and popular destination and updated regularly. It is not the aim of this guideline to reproduce these guidelines here. They can be directly accessed on the Health Protection Agency website (www.hpa.org.uk/HPA/Topics/InfectiousDiseases/InfectionsAZ ) and clicking on malaria. Updates to guidelines, such as change in resistance or transmission, can be found at the same place.
Chemoprophylaxis for malaria can be causal or suppressive. Causal prophylaxis is directed against liver schizont stage, which takes approximately 7 days to develop so these drugs (for example, atovaquone-proguanil [Malarone®] need to be continued for 7 days after leaving a malarious area. Suppressive prophylaxis (such as mefloquine) is directed against the red blood cell stages of the malaria parasite and so should be continued for 4 weeks after leaving a malarious area. The full listings of drug actions, dosages, adverse effects, interactions and contraindications is contained in the British National Formulary (www.bnf.org ) and will not be repeated here. Women should be warned that drugs purchased in endemic countries or over the internet may be cheaper but they may be fake. [Evidence level 1+]
Chemoprophylaxis for Women Planning a Pregnancy
Women planning pregnancy and travelling to a destination where there is a risk of contracting malaria should be advised there may be harmful consequences for the pregnancy. Prophylaxis is not 100% effective and malaria is associated with increased risk of miscarriage. Women should be advised not to travel or to choose an alternative destination. If it is not possible to delay either the pregnancy or the travel plan, advice from a specialist with current experience of malaria should be sought (Box 2). Chloroquine and proguanil are not efficacious in chloroquine-resistant areas and cannot be recommended because of this. There are very few chloroquine-sensitive areas remaining.
To avoid completely any potential adverse drug effects from preconceptual and first-trimester exposure, it is advisable to wait for complete excretion of the drug, if it was taken for prophylaxis, before becoming pregnant (see Table 3 in the original guideline document). Nevertheless, unplanned conception while taking malaria prophylaxis is not considered a reason to recommend termination of pregnancy, owing to the low risk of teratogenicity.
Chemoprophylaxis for Pregnant or Breastfeeding Women
Mefloquine (5mg/kg once a week) is the recommended drug of choice for prophylaxis in the second and third trimesters for chloroquine-resistant areas. With very few areas in the world free from chloroquine resistance, mefloquine is essentially the only drug considered safe for prophylaxis in pregnant travellers (see Table 4 in the original guideline document).
Emergency Standby Treatment in Pregnancy?
D - Written instructions should be given to a pregnant traveller regarding emergency standby malaria treatment in the event of suspected malaria without access to medical care.
Suspected malaria is a medical emergency and women should seek diagnosis and treatment at a health facility at the earliest opportunity. [Evidence level 3]
Grades of Recommendations
A - At least one meta-analysis, systematic review, or randomised controlled trial rated as 1++ and directly applicable to the target population; or
A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+ directly applicable to the target population and demonstrating overall consistency of results
B - A body of evidence including studies rated as 2++ directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C - A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D - Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Point - Recommended best practice based on the clinical experience of the guideline development group
Classification of Evidence Levels
1++ High-quality meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias
1– Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias
2++ High-quality systematic reviews of case–control or cohort studies or high-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
2– Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal
3 Non-analytical studies; e.g., case reports, case series
4 Expert opinion