Intermittent sulfadoxine-pyrimethamine in pregnancy: effectiveness against malaria morbidity in Blantyre, Malawi, in 1997-99

Participatory research for the development of information, education and communication tools to promote intermittent preventive treatment of malaria in pregnancy in the Democratic Republic of the Congo, Nigeria and Mozambique

Background

To improve the coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) in Africa, Medicines for Malaria Venture (MMV) developed, tested and validated a new packaging of sulfadoxine–pyrimethamine (SP), as well as specific communications tools designed to improve knowledge of IPTp and the motivation of women to adhere to it, particularly if it is distributed by community health workers (CHW).

Methods

This article describes and analyses the results of an empirical research carried out in the Democratic Republic of the Congo (DRC), Nigeria and Mozambique, to evaluate the perception and social acceptability of SP for healthcare providers, CHW and pregnant women, and to assess the ability of the new SP packaging and the communications tools to change their perception of SP and improve their attitudes towards IPTp.

Results

The results indicate that SP’s new individual packaging was perceived by pregnant women and healthcare providers as a “hygienic” and “safe”, with a specific identity. The graphics used in IPTp communications tools were modified according to the respondents’ feedback to make them more culturally and socially sensitive, and then validated. However, although the new blister packaging and IPTp communications tools generated greater confidence and motivation, SP side effects as well as preconceived ideas, particularly regarding its efficacy, remain a challenge that must be addressed to improve IPTp acceptance and compliance by healthcare providers and pregnant women.

Conclusion

This participatory approach to social research based on ongoing feedback to the graphic designer provided more empirical evidence to improve and adapt the textual and visual content of communication tools (SP blister packaging, leaflet, user guide) to local contexts and user preferences. Tested and validated in different socio-cultural and socio-political contexts, these tools provide a good basis for the promotion of IPTp in Africa.

Effectiveness of intermittent preventive treatment with Sulfadoxine-Pyrimethamine in pregnant women in San Pedro, Côte D'Ivoire

Malaria remains a major public health issue for pregnant women. Côte d'Ivoire has adopted a series of measures aimed at combatting this plague, and these measures include administering Sulfadoxine-Pyrimethamine (SP) as an intermittent preventive treatment to pregnant women in the second and third terms.This cross-sectional study included a parturient population after informed written consent. We recruited women from the Terre Rouge maternity ward and the labor room of the Regional Medical Center of San-Pedro. Plasmodial DNA (desoxyribo nucleic acid) was extracted from Whatman filter papers with dried blood samples prepared from the venous, placental, and cord blood, utilizing Chelex 100. The extracts obtained were amplified by nested PCR.In all, 197 women were included, with an average age of 27-year-old (sd = 6.7 years old). The rates of the placental, venous and cord blood infections were 16, 2%, 15, 2% and 3, 6%, respectively. The women who took three doses of ITP were less infected at the cord (3, 2%), placental (10,6%) and venous level (13,8%). A statistically significant relationship between the number of doses and the rate of placental infection was established (p = 0.042). IPT reduces plasmodial infestation at the placental (OR = 0.4; CI = [0.2-1]), cord (OR = 0.8; CI = [0.2-3.7]) and venous (OR = 0.8; CI = [0.6-2.3]) level.In conclusion, the low frequency of placental, venous, and cord infestation in pregnant women who consistently followed a preventive treatment strategy clearly showed the efficiency of IPT against malaria during pregnancy.

Effect of sulfadoxine-pyrimethamine doses for prevention of malaria during pregnancy in hypoendemic area in Tanzania

BACKGROUND

Malaria in pregnancy increases the risk of deleterious maternal and birth outcomes. The use of ≥ 3 doses of sulfadoxine-pyrimethamine (SP) for intermittent preventive treatment of malaria (IPTp-SP) is recommended for preventing the consequences of malaria during pregnancy. This study assessed the effect of IPTp-SP for prevention of malaria during pregnancy in low transmission settings.

METHODS

A cross-sectional study that involved consecutively selected 1161 pregnant women was conducted at Mwananyamala regional referral hospital in Dar es Salaam. Assessment of the uptake of IPTp-SP was done by extracting information from antenatal clinic cards. Maternal venous blood, cord blood, placental blood and placental biopsy were collected for assessment of anaemia and malaria. High performance liquid chromatography with ultraviolet detection (HPLC-UV) was used to detect and quantify sulfadoxine (SDX). Dried blood spots (DBS) of placental blood were collected for determination of sub-microscopic malaria using polymerase chain reaction (PCR).

RESULTS

In total, 397 (34.2%) pregnant women reported to have used sub-optimal doses (≤ 2) while 764 (65.8%) used optimal doses (≥ 3) of IPTp-SP at the time of delivery. The prevalence of placental malaria as determined by histology was 3.6%. Submicroscopic placental malaria was detected in 1.4% of the study participants. Women with peripheral malaria had six times risk of maternal anaemia than those who were malaria negative (aOR, 5.83; 95% CI 1.10-30.92; p = 0.04). The geometric mean plasma SDX concentration was 10.76 ± 2.51 μg/mL. Sub-optimal IPTp-SP dose was not associated with placental malaria, premature delivery and fetal anaemia. The use of ≤ 2 doses of IPTp-SP increased the risk of maternal anaemia by 1.36-fold compared to ≥ 3 doses (aOR, 1.36; 95% CI 1.04-1.79; p = 0.02).

CONCLUSION

The use of < 2 doses of IPTp-SP increased the risk of maternal anaemia. However, sub-optimal doses (≤ 2 doses) were not associated with increased the risk of malaria parasitaemia, fetal anaemia and preterm delivery among pregnant women in low malaria transmission setting. The use of optimal doses (≥ 3 doses) of IPTp-SP and complementary interventions should continue even in areas with low malaria transmission.

[Evaluation of the knowledge of intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine in Ivory Coast]

In 2006, because of the chloroquine-resistance and following the World Health Organization (WHO) recommendations, Côte d'Ivoire adopted a new policy for the prevention of malaria during pregnancy by intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP). However, its implementation remains limited. Objectives of this study were to evaluate the knowledge of the TPIp-SP regimen and prescribers opinion concerning this protocol. It was a knowledge attitude and pratices (KAP) cross-sectional descriptive study. We used a two-stage stratified sounding. The study took place in 12 health facilities in the health region of Abidjan 2 from march to august 2016 and involved 187 health professionals. We performed descriptive analysis, univariate and bivariate comparative analysis. The study found that half of the prescribers surveyed actually knew the ITPp program (SP - 3 doses - 2nd and 3rd trimesters). Knowledge was better among practitioners with more than 5 years of exercise (P=0.011) and at the level of first contact of health institution (P=0.001). Half of the prescribers were in favor of applying the protocol. The level of knowledge of prescribers has changed little in 2016 compared to 2008 for physicians (Pr (|Z|<|z|)=0.4861) or midwives Pr (|Z|<|z|)=0.4786). Prescribers remained faithful to the old 2-dose protocol. The opinion on the protocol was better in 2016 compared to 2008 Pr (Z<z)=0.0052. Effective knowledge of the ITPp regimen remains average for many years after its implementation. However opinions are better. Strengthening prevention interventions with health professionals is necessary for effective implementation of this protocol.

Association between timing and number of antenatal care visits on uptake of intermittent preventive treatment for malaria during pregnancy among Malawian women

Background

Malaria in pregnancy is a critical public health challenge, and intermittent preventive treatment for malaria during pregnancy (IPTp) has proven to be an effective intervention. However, access to and use of malaria interventions, including IPTp, remains a considerable problem among African women. This cross-sectional study investigated factors, including antenatal care (ANC) attendance (both numbers of visits and timing of the first visit) and socio-demographics, associated with the uptake of the recommended IPTp dose among Malawian women.

Methods

A nationally representative sample of women with a live birth in the 2 years preceding the survey from the Malawi Demographic Health Survey 2015–2016 dataset was analysed. Self-reported data on socio-demographics, ANC attendance and IPTp uptake were collected using a questionnaire and analysed using logistic models.

Results

Of the 6549 included women, 1981 (30.2%) took the recommended three or more IPTp doses. Despite inadequate ANC visits, early ANC initiation increased the likelihood of these women taking the recommended IPTp dose; women who initiated ANC in the first [adjusted odds ratio (aOR) = 2.24; 95% confidence interval (CI) = 1.44–3.49] and second (aOR = 2.19; 95% CI = 1.56–3.08) trimesters were more likely to take the recommended IPTp dose compared to late initiators. The effect of the number of ANC visits on IPTp uptake was significant in married women (aOR = 1.68, 95% CI = 1.42–1.98), and the timing of first ANC visit was associated with IPTp uptake only among rural women (aOR = 2.13, 95% CI = 1.54–2.95).

Conclusion

ANC attendance is vital in IPTp uptake. The results highlight the need for health care providers to encourage women, particularly those in high-risk groups, to make frequent ANC visits and receive early ANC initiation to ensure high coverage of the recommended IPTp dose.

A brief review on features of falciparum malaria during pregnancy

Malaria in pregnancy is a serious public health problem in tropical areas. Frequently, the placenta is infected by accumulation of Plasmodium falciparum-infected erythrocytes in the intervillous space. Falciparum malaria acts during pregnancy by a range of mechanisms, and chronic or repeated infection and co-infections have insidious effects. The susceptibility of pregnant women to malaria is due to both immunological and humoral changes. Until a malaria vaccine becomes available, the deleterious effects of malaria in pregnancy can be avoided by protection against infection and prompt treatment with safe, effective antimalarial agents; however, concurrent infections such as with HIV and helminths during pregnancy are jeopardizing malaria control in sub-Saharan Africa.

Changing the policy for intermittent preventive treatment with sulfadoxine-pyrimethamine during pregnancy in Malawi

Background

The growing resistance of Plasmodium falciparum to sulfadoxine–pyrimethamine (SP) treatment for uncomplicated malaria led to a recommendation by the World Health Organization for the use of artemisinin-based combination therapy. Inevitably, concerns were also raised surrounding the use of SP for intermittent prevention treatment of malaria during pregnancy (IPTp) amidst the lack of alternative drugs. Malawi was the first country to adopt intermittent prevention treatment with SP in 1993, and updated in 2013. This case study examines the policy updating process and the contribution of research and key stakeholders to this process. The findings support the development of a malaria research-to-policy framework in Malawi.

Methods

Documents and evidence published from 1993 to 2012 were systematically reviewed in addition to key informant interviews.

Results

The online search identified 170 potential publications, of which eight from Malawi met the inclusion criteria. Two published studies from Malawi were instrumental in the WHO policy recommendation which in turn led to the updating of national policies. The updated policy indicates that more than two SP doses, as informed by research, overcome the challenges of the first policy of two SP doses only because of ineffectiveness by P. falciparum resistance and the global lack of replacement drugs to SP for IPTp.

Conclusion

International WHO recommendations facilitated a smooth policy change driven by motivated local leadership with technical and financial support from development partners. Policy development and implementation should include key stakeholders and use local malaria research in a research-to-policy framework.

Factors influencing dropout rate of intermittent preventive treatment of malaria during pregnancy

BACKGROUND

The burden of malaria in terms of morbidity and mortality is huge is Sub-Saharan Africa, particularly among pregnant women. Among the measures to curb down this burden include intermittent preventive treatment (IPT) and effective case management. These strategies were adopted by Ghana and implemented since 2003; however, there is still high dropout rate in IPT coverage. This study sought to investigate factors contributing to high dropout rate between IPT1 and IPT3 in the Tamale Metropolis, one of the health facilities with the highest IPT dropout rates in Ghana.

METHODS

Survey, in-depth interviews and short ethnographic techniques were conducted among pregnant women, antenatal care (ANC) health workers and heads of health facilities to investigate factors which account for dropout rate of intermittent treatment of malaria.

RESULTS

Shortage of sulphadoxine pyrimethamine (SP), inadequate supply of portable water for administration of SP, unavailability of IPT during outreach services, lack of knowledge by ANC staff about the dropout rate in their area of jurisdiction and poor attitude of some health workers were identified as barriers to achieving high IPT3 coverage.

CONCLUSIONS

Late ANC visit, provider and logistical barriers account for the women's missed opportunities to prevent malaria in pregnancy through IPT. Addressing the above barriers will contribute to saving lives and ensuring progress towards the goal of combating malaria as well as reducing maternal, neonatal and child mortalities.

The prevalence of malaria at first antenatal visit in Blantyre, Malawi declined following a universal bed net campaign

Background

Preventing malaria during pregnancy is important for the health of mothers and newborns. Interventions, which include distribution of bed nets and administration of intermittent preventive treatment (IPT), typically occur at the first antenatal visit, usually in the second or third trimester of pregnancy. In 2012, during the course of ongoing clinical studies of malaria among pregnant women in Malawi, a universal bed net campaign was implemented by the Government. This study tested the hypothesis that a universal bed net campaign would decrease the prevalence of malaria among pregnant women at their first antenatal visit.

Methods

Some 1661 women were recruited for two studies from 2009 to 2014. Quantitative PCR (qPCR) was conducted from dried blood spots collected at the first antenatal care visit (prior to administration of IPT or any study interventions) from women who were in their first or second pregnancy and less than 28 weeks gestation by clinical assessment.

Results

Overall, 320 of 1629 (19.6 %) women tested for malaria at their first antenatal visit were infected. Malaria infection rates declined from 28.4 % before the universal bed net campaign, to 18.5 % in 2012, to 15.0 % in the years following the universal bed net campaign. The odds of malaria infection at the time of first antenatal visit in 2012 and the years following the bed net campaign were significantly lower than in the years prior to the intervention (OR 0.6, 95 % CI 0.4–0.8; and OR 0.4, 95 % CI 0.3–0.6, respectively). A similar pattern was observed for the prevalence of clinical malaria. The inverse trend was observed for reported bed net use. However bed net use and malaria infection were not significantly associated on the individual level.

Conclusions

Malaria infection in pregnant women is common even after a bed net campaign in Malawi, though prevalence rates declined. These early infections may cause maternal anaemia and placental malaria resulting in adverse maternal and fetal outcomes. Infection early in pregnancy may also contribute to malaria transmission as pregnant women represent a significant untreated reservoir of parasites. Universal bed net distribution appears to have moderate success in preventing malaria early in pregnancy and these findings support continued efforts to target women early in pregnancy and all women of childbearing age.

Evaluation of sulphadoxine-pyrimethamine for intermittent preventive treatment of malaria in pregnancy: a retrospective birth outcomes study in Mansa, Zambia

Background

Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulphadoxine-pyrimethamine (SP) decreases placental parasitaemia, thus improving birth outcomes. Zambian policy recommends monthly SP-IPTp doses given presumptively during pregnancy at each antenatal examination, spaced one month apart after 16 weeks of gestation. The effectiveness of SP-IPTp was evaluated in Zambia where a recent study showed moderate prevalence of Plasmodium falciparum parasites with genetic mutations that confer SP resistance.

Methods

HIV-negative women were enrolled at the time of delivery at two facilities in Mansa, Zambia, an area of high malaria transmission. Women were interviewed and SP exposure was determined by antenatal card documentation or self-reports. Using Poisson regression modelling, the effectiveness of SP-IPTp was evaluated for outcomes of parasitaemia (microscopic examination of maternal peripheral, cord, and placental blood films), maternal anaemia (Hb < 11 g/dl), placental infection (histopathology), and infant outcomes (low birth weight (LBW), preterm delivery, and small for gestational age) in women who took 0–4 doses of SP-IPTp.

Results

Participants included 435 women, with a median age of 23 years (range 16–44). Thirty-four women took zero doses of SP-IPTp, while 115, 142 and 144 women took one, two, or ≥ three doses, respectively. Multivariate Poisson regression models considering age, mosquito net usage, indoor residual spraying, urban home, gravidity, facility, wet season delivery, and marital status showed that among paucigravid women ≥ two doses of SP-ITPp compared to one or less doses was associated with a protective effect on LBW (prevalence ratio (PR) 0.33, 95% confidence interval (CI) 0.12–0.91) and any infection (PR 0.76, CI 0.58–0.99). Multivariate models considering SP-IPTp as a continuous variable showed a protective dose–response association with LBW (paucigravid women: PR 0.54, CI 0.33–0.90, multigravid women: PR 0.63, CI 0.41–0.97).

Conclusions

In Mansa, Zambia, an area of moderate SP resistance, ≥ two doses of SP-IPTp were associated with a protective effect from malaria in pregnancy, especially among paucigravid women. Each dose of SP-IPTp contributed to a 46 and 37% decrease in the frequency of LBW among paucigravid and multigravid women, respectively. SP-IPTp remains a viable strategy in this context.

Determinants of infant susceptibility to malaria during the first year of life in South Western cameroon

Background.  Falciparum malaria is an important pediatric infectious disease that frequently affects pregnant women and alters infant morbidity. However, the impact of some prenatal and perinatal risk factors such as season and intermittent preventive treatment during pregnancy (IPTp) on neonatal susceptibility has not been fully elucidated. Methods.  A cohort of 415 infants born to women who were positive and negative for malaria was monitored in a longitudinal study in Southwestern Cameroon. The clinical and malaria statuses were assessed throughout, whereas paired maternal-cord and 1-year-old antimalarial antibodies were assayed by enzyme-linked immunosorbent assay. Infant susceptibility to malaria was ascertained after accounting for IPTp and season in the statistical analysis. Results.  Malaria prevalence was higher in women (P = .039) who delivered during the rainy season and their infants (P = .030) compared with their dry season counterparts. Infants born to women who were positive for malaria (6.40 ± 2.83 months) were older (P = .028) than their counterparts who were negative for malaria (5.52 ± 2.85 months) when they experienced their first malaria episode. Infants born in September-November (adjusted odds ratio [OR] = 0.31, 95% confidence interval [CI] = 0.13-0.72) and to mothers on 1 or no IPTp-sulfadoxine/pyrimethamine (SP) dose (adjusted OR = 0.51, 95% CI = 0.28-0.91) were protected, whereas those born in the rainy season (adjusted OR = 2.82, 95% CI = 1.21-6.55) were susceptible to malaria. Conclusions.  Intermittent preventive treatment during pregnancy and month of birth have important implications for infant susceptibility to malaria, with 2 or more IPTp-SP dosage possibly reducing immunoglobulin M production.

Pregnant women are a reservoir of malaria transmission in Blantyre, Malawi

Background

During pregnancy, women living in malaria-endemic regions are at increased risk of malaria infection and can harbour chronic placental infections. Intermittent preventive treatment with sulphadoxine-pyrimethamine (SP-IPTp) is administered to reduce malaria morbidity. It was hypothesized that the presence of placental malaria infection and SP-IPTp use would increase the risk of peripheral blood gametocytes, the parasite stage that is transmissible to mosquitoes. This would suggest that pregnant women may be important reservoirs of malaria transmission.

Methods

Light microscopy was used to assess peripheral gametocytaemia in pregnant women enrolled in a longitudinal, observational study in Blantyre, Malawi to determine the association between placental malaria and maternal gametocytaemia. The relationship between SP-IPTp and gametocytaemia was also examined.

Results

2,719 samples from 448 women were analysed and 32 episodes of microscopic gametocytaemia were detected in 27 women. At the time of enrolment 22 of 446 women (4.9%) had gametocytaemia and of the 341 women for whom there was sufficient sampling to analyse infection over the entire course of pregnancy, 27 (7.9%) were gametocytaemic at least once. Gametocytaemia at enrolment was associated with placental malaria, defined as malaria pigment or parasites detected by histology or qPCR, respectively (OR: 32.4, 95% CI: 4.2-250.2), but was not associated with adverse maternal or foetal outcomes. Administration of SP-IPTp did not affect gametocyte clearance or release into peripheral blood.

Conclusions

Gametocytaemia is present in 5% of pregnant women at their first antenatal visit and associated with placental malaria. SP-IPTp does not alter the risk of gametocytaemia. These data suggest that pregnant women are a significant reservoir of gametocyte transmission and should not be overlooked in elimination efforts. Interventions targeting this population would benefit from reaching women prior to first antenatal visit.

Asymptomatic Plasmodium falciparum malaria in pregnant women in the Chittagong Hill Districts of Bangladesh

BACKGROUND

Pregnancy is a known risk factor for malaria which is associated with increased maternal and infant mortality and morbidity in areas of moderate-high malaria transmission intensity where Plasmodium falciparum predominates. The nature and impact of malaria, however, is not well understood in pregnant women residing in areas of low, unstable malaria transmission where P. falciparum and P. vivax co-exist.

METHODS

A large longitudinal active surveillance study of malaria was conducted in the Chittagong Hill Districts of Bangladesh. Over 32 months in 2010-2013, the period prevalence of asymptomatic P. falciparum infections was assessed by rapid diagnostic test and blood smear and compared among men, non-pregnant women and pregnant women. A subset of samples was tested for infection by PCR. Hemoglobin was assessed. Independent risk factors for malaria infection were determined using a multivariate logistic regression model.

RESULTS

Total of 34 asymptomatic P. falciparum infections were detected by RDT/smear from 3,110 tests. The period prevalence of asymptomatic P. falciparum infection in pregnant women was 2.3%, compared to 0.5% in non-pregnant women and 0.9% in men. All RDT/smear positive samples that were tested by PCR were PCR-positive, and PCR detected additional 35 infections that were RDT/smear negative. In a multivariate logistic regression analysis, pregnant women had 5.4-fold higher odds of infection as compared to non-pregnant women. Malaria-positive pregnant women, though asymptomatic, had statistically lower hemoglobin than those without malaria or pregnancy. Asymptomatic malaria was found to be evenly distributed across space and time, in contrast to symptomatic infections which tend to cluster.

CONCLUSION

Pregnancy is a risk factor for asymptomatic P. falciparum infection in the Chittagong Hill Districts of Bangladesh, and pregnancy and malaria interact to heighten the effect of each on hemoglobin. The even distribution of asymptomatic malaria, without temporal and spatial clustering, may have critical implications for malaria elimination strategies.

Factors affecting attendance at and timing of formal antenatal care: results from a qualitative study in Madang, Papua New Guinea

BACKGROUND

Appropriate antenatal care (ANC) is key for the health of mother and child. However, in Papua New Guinea (PNG), only a third of women receive any ANC during pregnancy. Drawing on qualitative research, this paper explores the influences on ANC attendance and timing of first visit in the Madang region of Papua New Guinea.

METHODS

Data were collected in three sites utilizing several qualitative methods: free-listing and sorting of terms and definitions, focus group discussions, in-depth interviews, observation in health care facilities and case studies of pregnant women. Respondents included pregnant women, their relatives, biomedical and traditional health providers, opinion leaders and community members.

RESULTS

Although generally reported to be important, respondents' understanding of the procedures involved in ANC was limited. Factors influencing attendance fell into three main categories: accessibility, attitudes to ANC, and interpersonal issues. Although women saw accessibility (distance and cost) as a barrier, those who lived close to health facilities and could easily afford ANC also demonstrated poor attendance. Attitudes were shaped by previous experiences of ANC, such as waiting times, quality of care, and perceptions of preventative care and medical interventions during pregnancy. Interpersonal factors included relationships with healthcare providers, pregnancy disclosure, and family conflict. A desire to avoid repeat clinic visits, ideas about the strength of the fetus and parity were particularly relevant to the timing of first ANC visit.

CONCLUSIONS

This long-term in-depth study (the first of its kind in Madang, PNG) shows how socio-cultural and economic factors influence ANC attendance. These factors must be addressed to encourage timely ANC visits: interventions could focus on ANC delivery in health facilities, for example, by addressing healthcare staff's attitudes towards pregnant women.

Plasmodium falciparum mutant haplotype infection during pregnancy associated with reduced birthweight, Tanzania

Intermittent preventive treatment during pregnancy with sulfadoxine–pyrimethamine (IPTp-SP) is a key strategy in the control of pregnancy-associated malaria. However, this strategy is compromised by widespread drug resistance from single-nucleotide polymorphisms in the Plasmodium falciparum dihydrofolate reductase and dihydropteroate synthetase genes. During September 2008–October 2010, we monitored a cohort of 924 pregnant women in an area of Tanzania with declining malaria transmission. P. falciparum parasites were genotyped, and the effect of infecting haplotypes on birthweight was assessed. Of the genotyped parasites, 9.3%, 46.3%, and 44.4% had quadruple or less, quintuple, and sextuple mutated haplotypes, respectively. Mutant haplotypes were unrelated to SP doses. Compared with infections with the less-mutated haplotypes, infections with the sextuple haplotype mutation were associated with lower (359 g) birthweights. Continued use of the suboptimal IPTp-SP regimen should be reevaluated, and alternative strategies (e.g., intermittent screening and treatment or intermittent treatment with safe and effective alternative drugs) should be evaluated.

Treatment and prevention of malaria in pregnancy: opportunities and challenges

Control of malaria in pregnancy through prevention or treatment may save lives of mothers and babies. Selection of drugs for treatment of infected pregnant women, or for prevention in exposed populations is problematic owing to resistance to established drugs and lack of pregnancy-specific safety and pharmacological data for new drugs. Encouragingly, a number of new drugs and combinations of drugs hold promise for effective treatment, but adequate data on their safety in pregnancy is currently lacking. Our principal challenges are to decide which drugs to develop for use in malaria treatment and prevention in pregnancy and to develop mechanisms to rapidly and comprehensively evaluate their safety. Prevention of pregnancy malaria by vaccination may also become possible, but targets must be closely defined, and strategies developed to test candidates against meaningful end points.

Malaria and gravidity interact to modify maternal haemoglobin concentrations during pregnancy

Background

Primigravidity is one of the main risk factors for both malaria and anaemia. Since the implementation of intermittent preventive treatment (IPTp) in sub-Saharan Africa, the relationship between anaemia and gravidity and its evolution during pregnancy has been little explored. This study aimed to evaluate the impact of gravidity on the variation of haemoglobin during pregnancy according to the timing of gestation.

Methods

Data from three studies carried out in nearby areas in south Benin (Ouidah, Comé, Allada) between 2005 and 2012 were analysed. At inclusion (first antenatal visit, ANV1) women’s age, area of residence, schooling, gravidity, gestational age, weight and height were recorded. Thick blood smears were performed on ANV1, second visit (ANV2) and at delivery. In Allada, women’s serum ferritin and CRP concentrations were also assessed. The impact of gravidity on maternal haemoglobin (Hb) was analysed using a logistic or linear regression depending on the outcome. The statistical significance was set to P < 0.05.

Results

In total, data from 3,591 pregnant women were analysed. Both univariate and multivariate analyses showed a constant association between Hb concentrations and gravidity in the three periods of Hb assessment (ANV1, ANV2 and delivery). Mean Hb concentration was significantly lower in primigravidae than in multigravidae at ANV1 (mean difference = -2.4 g/L, CI 95%: [-3.4, -1.4], P < 0.001). Afterwards, there was a significant increase in primigravidae only, with a tendency to reversal between primigravidae and multigravidae, which was confirmed at delivery (mean difference = 2.8 g/L, CI 95%: [1.3, 4.2], P < 0.001). The prevalence of malaria infection was halved between ANV1 and delivery in primigravidae while it decreased by only 38% among multigravidae, who were less prone to malaria infection (prevalence at ANV1, 20% and 10% respectively). Iron deficiency was more common in multigravidae, and it decreased slightly in this group between ANV1 and delivery.

Conclusion

In a context of IPTp, Hb levels improved progressively throughout pregnancy in primigravidae, likely as a result of reduction in malaria infection. In multigravidae, the improvement was less perceptible and anaemia was mainly due to iron deficiency.

Effect of HIV infection and Plasmodium falciparum parasitemia on pregnancy outcomes in Malawi

Plasmodium falciparum and human immunodeficiency virus (HIV) are both risk factors for low birth weight (LBW) and maternal anemia, and they may interact to increase risk of adverse pregnancy outcomes. In 2005 and 2006, we followed 831 pregnant women attending antenatal care clinics in southern Malawi through delivery. HIV was associated with increased risk of LBW (adjusted prevalence ratio [PR(adj)] = 3.08, 95% confidence interval [CI] = 1.40, 6.79). Having greater than or equal to three episodes of peripheral parasitemia was also associated with increased risk of LBW (PR(adj) = 2.68, 95% CI = 1.06, 6.79). Among multigravidae, dual infection resulted in 9.59 (95% CI = 2.51, 36.6) times the risk of LBW compared with uninfected multigravidae. HIV infection and placental parasitemia were each associated with increased risk of anemia. Thus, HIV infection and parasitemia are important independent risk factors for adverse pregnancy outcomes. Among multigravidae, HIV infection and placental parasitemia may interact to produce an impact greater than the sum of their independent effects.

Validity of self-reported use of sulphadoxine-pyrimethamine intermittent presumptive treatment during pregnancy (IPTp): a cross-sectional study

BACKGROUND

Malaria in pregnancy is a major health problem that can cause maternal anaemia, stillbirth, spontaneous abortion, low birth weight and intra-uterine stunting. The WHO recommends use of sulphadoxine-pyrimethamine (SP) for intermittent preventive treatment of malaria during pregnancy (IPTp) in endemic areas. Towards monitoring and assessing IPTp coverage in the population, the Roll Back Malaria Partnership recommends the use of self-reported data. The aim of this study was to assess the validity of self-reported IPTp by testing for sulphadoxine in maternal blood at delivery.

METHODS

Two hundred and four pregnant women were consented and enrolled in a cross-sectional study in Mulago National Referral Hospital in Kampala Uganda. - Participants who reported a history of taking sulpha-containing drugs like co-trimoxazole , those who were not sure of dates relating to last menstrual period or who took IPTp within the first 20 weeks of gestation were excluded from the study. Data on demographic characteristics, obstetric history, and delivery outcome were collected. At birth, maternal venous blood was taken off aseptically and used to make thick blood smears for malaria parasites and plasma for determining sulphadoxine using high performance liquid chromatography (HPLC).

RESULTS

Of 120 participants who self reported to have used IPTp, 35 (29.2%) tested positive for sulphadoxine by HPLC, while 63 (75%) of 84 patients who reported not having used IPTp tested negative for sulphadoxine. Participants possessing post-primary education were more likely to have reported using IPTp. The low agreement (kappa coefficient = 0.037) between self-report and actual presence of the drug in the blood casts doubt on the validity of self-reported data in estimating IPTp coverage.

CONCLUSIONS

The results of this study question the accuracy of self-reported data in estimating IPTp coverage in the population. More studies on validity of self reported data are recommended. Since the validity of IPTp self reports is vital for guiding policy on malaria control in pregnancy, ways should be sought to improve accuracy of the information from such reports.

The effects of malaria and intermittent preventive treatment during pregnancy on fetal anemia in Malawi

BACKGROUND

Fetal anemia is common in malarious areas and is a risk factor for infant morbidity and mortality. Malaria during pregnancy may cause decreased cord hemoglobin (Hb) and fetal anemia among newborns. Intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is protective against malaria but may also affect hematopoiesis and contribute to fetal anemia.

METHODS

Peripheral, placental, and cord blood were examined for malaria parasitemia and Hb concentration in a cross-section of 3848 mothers and infants delivered at Queen Elizabeth Central Hospital in Blantyre, Malawi between 1997 and 2006. Unconditional linear and logistic regressions were performed with multiple imputation for missing covariates to assess the associations between malaria, IPTp with SP, and fetal anemia.

RESULTS

The overall prevalence of fetal anemia was 7.9% (n = 304). Malaria parasitemia at delivery was associated with an adjusted decrease in cord Hb of -0.24 g/dL (95% confidence interval [CI], -.42 to -.05). The adjusted prevalence odds ratio for the effect of malaria on fetal anemia was 1.41 (95% CI, 1.05-1.90). Primigravidae who did not take IPTp had infants at highest risk for fetal anemia, and density of parasitemia was correlated with the decrease in cord Hb. There was no significant association between SP use and cord Hb or fetal anemia.

CONCLUSIONS

Malaria during pregnancy, but not IPTp, decreases cord Hb and is a risk factor for fetal anemia in Malawi. Intermittent preventive treatment during pregnancy with SP may continue to be safe and effective in preventing malaria during pregnancy and fetal anemia despite development of SP resistance.

Antenatal receipt of sulfadoxine-pyrimethamine does not exacerbate pregnancy-associated malaria despite the expansion of drug-resistant Plasmodium falciparum: clinical outcomes from the QuEERPAM study

BACKGROUND

Antenatal intermittent preventive therapy with 2 doses of sulfadoxine-pyrimethamine (IPTp-SP) is the mainstay of efforts in sub-Saharan Africa to prevent pregnancy-associated malaria (PAM). Recent studies report that drug resistance may cause IPTp-SP to exacerbate PAM morbidity, raising fears that current policies will cause harm as resistance spreads.

METHODS

We conducted a serial, cross-sectional analysis of the relationships between IPTp-SP receipt, SP-resistant Plasmodium falciparum, and PAM morbidity in delivering women during a period of 9 years at a single site in Malawi. PAM morbidity was assessed by parasite densities, placental histology, and birth outcomes.

RESULTS

The prevalence of parasites with highly SP-resistant haplotypes increased from 17% to 100% (P < .001), and the proportion of women receiving full IPTp (≥2 doses) increased from 25% to 82% (P < .001). Women who received full IPTp with SP had lower peripheral (P = .018) and placental (P < .001) parasite densities than women who received suboptimal IPTp (<2 doses). This effect was not significantly modified by the presence of highly SP-resistant haplotypes. After adjustment for covariates, the receipt of SP in the presence of SP-resistant P. falciparum did not exacerbate any parasitologic, histologic, or clinical measures of PAM morbidity.

CONCLUSIONS

In this longitudinal study of malaria at delivery, the receipt of SP as IPTp did not potentiate PAM morbidity despite the increasing prevalence and fixation of SP-resistant P. falciparum haplotypes. Even when there is substantial resistance, SP may be used in modified IPTp regimens as a component of comprehensive antenatal care.

Comparative efficacy of uncontrolled and controlled intermittent preventive treatment during pregnancy (IPTp) with combined use of LLTNs in high resistance area to sulfadoxine-pyrimethamine in Côte d'Ivoire

Introduction

In recent years, intermittent preventive treatment for pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) has become policy in much of sub-Saharan Africa. But resistance to SP has been spreading across sub-Saharan Africa and thus the effectiveness of IPTp-SP has been questioned. The present study therefore sought to assess the incidence of placental malaria, low birth weight, and anemia of two IPTp-SP approaches (directly observed treatment scheme versus no directly observed treatment) in Anonkoua-Kouté and Samo, Côte d’Ivoire where the reported prevalence of dfr single mutant 108 was 62% and 52.2%, respectively.

Methods

The study was a longitudinal design involving pregnant women and was conducted in Anonkoua-Kouté, a suburban area, and Samo, a rural area, from January 2008 through March 2009. Women of a pregnancy less than 28 weeks duration were randomized to receive SP (1.5 g/0.075 g SP) in a single intake twice and were followed up monthly until delivery. Doses were administered under supervision in the controlled IPTp group, while SP was given free to women in the uncontrolled IPTp group with a recommendation to take it at home. The primary end point was the proportion of low birth weight infants (body weight < 2500 g) and the secondary end point was the rate of severe anemia and placental malaria detected at delivery.

Results

A total of 420 pregnant women were enrolled (212 and 208, respectively, in the controlled and uncontrolled groups). Delivery outcome was available for 378 women. In the modified intention-to-treat analysis, low birth weight infants were born from 15.5% of women of the uncontrolled IPTp group and from 11.9% of women in the controlled IPTp group (P = 0.31). The per-protocol population analysis showed consistent results. The proportion of women with placental malaria infection, moderate anemia (hemoglobin < 11 g/dL), and severe anemia (hemoglobin < 8 g/dL) at delivery were similar between the two groups (P > 0.05).

Conclusion

The study showed that the two approaches were equivalent, suggesting that unsupervised IPTp-SP free of charge should be used in areas where implementation of the directly observed treatment scheme suffers from many constraints.

Use and effects of malaria control measures in pregnancy in Lagos, Nigeria

In Nigeria, malaria causes up to 11% of maternal mortality. Our main aim was to find out the most common mosquito control measures employed by the pregnant women in Lagos and their effects on malaria infection. The study was carried out over a period of 6 months during which trained interviewers administered questionnaires to 400 pregnant women. The prevalence of malaria was 8.4%. There was no significant association between the prevalence of malaria and age, level of education, or occupation of the participants. Pregnant women in the age range 26-30 had the mean parasite density (409.9 ± 196.80). Insecticide spray (32.8%), mosquito coil (27.5%), and insecticide-treated nets (ITN) (15.5%) were the major mosquito control measures employed by the participants while the prevalence of infection among them were 2.3%, 6.2%, and 3.2%, respectively (P<0.05). Only 18.3% of the women had taken more than one dose of intermittent preventive treatment (IPT), while another 11.8% had taken a single dose. The infection rate among them was 4.1% and 6.4%, respectively. Malaria prevalence was highest among those who had not received any dose of IPT (10%). This study showed that the use of ITN and IPT among the pregnant women were still unacceptably low. It also showed that the use of insecticide spray which was the most common malaria control measure adopted by the participants was effective despite the fact that it is not a National Malaria Control Policy. We recommend that a sustained integrated mosquito management and public education should be strengthened in Nigeria.

Molecular markers of Plasmodium falciparum drug resistance in southern highland Rwanda

In Rwanda, frequent mutations in the pfdhfr and pfdhps genes of Plasmodium falciparum have suggested intense sulfadoxine-pyrimethamine resistance. However, data on pfmdr1 are not available but might be important in the context of the first-line treatment with artemether-lumefantrine. During a survey among 749 children under five years of age in southern highland Rwanda, 104 P. falciparum isolates were obtained. Parasite polymorphisms associated with drug sensitivity were typed including the genes pfdhfr, pfdhps, pfmdr1, and pfcrt. Plasma concentrations of chloroquine and pyrimethamine were measured by ELISA. Treatment with artemether-lumefantrine within the preceding two weeks was stated by 12.5% of the respondents; chloroquine in plasma was detected in 17.6%, pyrimethamine in none. Isolates with pfdhfr triple and pfdhps double/triple mutations occurred in 75% and 93%, respectively; 69% of the isolates comprised pfdhfr/pfdhps quintuple or sextuple mutations associated with high-grade sulfadoxine-pyrimethamine resistance. Pfdhfr L164 was absent. The pfmdr1 pattern revealed more than 50% of the F184 polymorphism and almost 40% of the N86-F184-D1246 allele combination known to be selected in infections reappearing following artemether-lumefantrine treatment. Molecular markers demonstrate intense antifolate drug resistance of P. falciparum in southern Rwanda. The present, first-time data on pfmdr1 alleles from Rwanda reveal a pattern which might reflect a predominance of wild types for some alleles or, alternatively, substantial artemether-lumefantrine pressure on the local parasite population.

Adaptive evolution and fixation of drug-resistant Plasmodium falciparum genotypes in pregnancy-associated malaria: 9-year results from the QuEERPAM study

Sulfadoxine-pyrimethamine (SP) has been widely deployed in Africa for malaria control and molecular evidence of parasite drug-resistance is prevalent. However, the temporal effects on the selection of Plasmodium falciparum are not well understood. We conducted a retrospective serial cross-sectional study between 1997 and 2006 to investigate changes in drug-resistant malaria among pregnant women delivering at a single hospital in Blantyre, Malawi. P. falciparum parasites were genotyped for parasite clone multiplicity and drug-resistance mutations, and the strength of selection upon mutant genotypes was quantified. Five mutations in the dihydrofolate reductase and dihydropteroate synthase genes began at moderate frequencies and achieved fixation by 2005; the frequency of the highly-SP-resistant "quintuple mutant" haplotype increased from 19% to 100%. The selective advantage of alleles and haplotypes were quantified with selection coefficients: Selection was positive on all mutant alleles and haplotypes associated with SP resistance, and the relative fitness of the quintuple mutant haplotype was 0.139 (95% C.I. 0.067-0.211), indicating a substantial positive selective advantage. Mutations that confer higher levels of resistance to SP did not emerge. SP-resistant haplotypes were rapidly selected for and fixed in P. falciparum populations infecting pregnant women while SP was widely deployed in Malawi. These results underscore the pressing need for new preventive measures for pregnancy-associated malaria and provide a real-world model of the selection landscape malaria parasites.

Intermittent preventive treatment with sulfadoxine-pyrimethamine against malaria and anemia in pregnant women

The effectiveness of intermittent preventive treatment during pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) against malaria and anemia is unclear because of the spread of SP-resistant Plasmodium falciparum. This study evaluates the effectiveness of IPTp-SP among pregnant women attending the antenatal clinic at Korle-Bu Teaching Hospital in Accra, Ghana. A cross-sectional study comparing malaria and anemia prevalence among pregnant women using IPTp-SP with non-IPTp-SP users was conducted during June-August 2009. A total of 363 pregnant women (202 of IPTp users and 161 non-IPTp users) were recruited. A total of 15.3% of IPTp users had malaria compared with 44.7% of non-IPTp users (P < 0.001). A total of 58.4% of non-IPTp users were anemic compared with 22.8% of IPTp users (P < 0.001). When we controlled for other variables, the difference in the prevalence of malaria (odds ratio = 0.18, 95% confidence interval = 0.08-0.37) and anemia (odds ratio = 0.20, 95% confidence interval = 0.12-0.34) remained significant. The recommended IPTp-SP regimen is useful in preventing malaria and anemia among pregnant women in Ghana.

Scaling up of intermittent preventive treatment of malaria in pregnancy using sulphadoxine-pyrimethamine: prospects and challenges

Intermittent preventive treatment of malaria during pregnancy with sulphadoxine-pyrimethamine (IPTpSP) is one of the major strategies of malaria control in most African countries where malaria is endemic. The use of sulphadoxine-pyrimethamine (SP) for intermittent preventive treatment of malaria during pregnancy was adopted when proof of its superiority to weekly prophylactic dosing with either chloroquine or pyrimethamine became evident from studies in different malaria endemic countries. The administration of 2 and 3 treatment doses of SP for HIV-negative and HIV-positive pregnant women respectively, given after quickening and at an interval not less than 4 weeks was recommended. The prospects of this control strategy lies on the efficacy of SP, convenient treatment dose and high compliance rate. However, the implementation of this strategy and the efficacy of SP are faced with challenges such as: timing of SP administration, rising levels of parasite resistance to SP in the general population, effect of folate supplementation, adequacy of the recommended doses with regards to malaria endemicity and HIV status, interactions between SP and antiretroviral drugs and low coverage in the bid to scale-up its use. This review highlights the prospects and challenges of scaling up IPTp-SP.

Two strategies for the delivery of IPTc in an area of seasonal malaria transmission in the Gambia: a randomised controlled trial

BACKGROUND

The Expanded Programme on Immunisation (EPI) provides an effective way of delivering intermittent preventive treatment for malaria (IPT) to infants. However, it is uncertain how IPT can be delivered most effectively to older children. Therefore, we have compared two approaches to the delivery of IPT to Gambian children: distribution by village health workers (VHWs) or through reproductive and child health (RCH) trekking teams. In rural areas, RCH trekking teams provide most of the health care to children under the age of 5 years in the Infant Welfare Clinic, and provide antenatal care for pregnant women.

METHODS AND FINDINGS

During the 2006 malaria transmission season, the catchment populations of 26 RCH trekking clinics in The Gambia, each with 400-500 children 6 years of age and under, were randomly allocated to receive IPT from an RCH trekking team or from a VHW. Treatment with a single dose of sulfadoxine pyrimethamine (SP) plus three doses of amodiaquine (AQ) were given at monthly intervals during the malaria transmission season. Morbidity from malaria was monitored passively throughout the malaria transmission season in all children, and a random sample of study children from each cluster was examined at the end of the malaria transmission season. The primary study endpoint was the incidence of malaria. Secondary endpoints included coverage of IPTc, mean haemoglobin (Hb) concentration, and the prevalence of asexual malaria parasitaemia at the end of malaria transmission period. Financial and economic costs associated with the two delivery strategies were collected and incremental cost and effects were compared. A nested case-control study was used to estimate efficacy of IPT treatment courses. Treatment with SP plus AQ was safe and well tolerated. There were 49 cases of malaria with parasitaemia above 5,000/µl in the areas where IPT was delivered through RCH clinics and 21 cases in the areas where IPT was delivered by VHWs, (incidence rates 2.8 and 1.2 per 1,000 child months, respectively, rate difference 1.6 [95% confidence interval (CI) -0.24 to 3.5]). Delivery through VHWs achieved a substantially higher coverage level of three courses of IPT than delivery by RCH trekking teams (74% versus 48%, a difference of 27% [95% CI 16%-38%]). For both methods of delivery, coverage was unrelated to indices of wealth, with similar coverage being achieved in the poorest and wealthiest groups. The prevalence of anaemia was low in both arms of the trial at the end of the transmission season. Efficacy of IPTc against malaria during the month after each treatment course was 87% (95% CI 54%-96%). Delivery of IPTc by VHWs was less costly in both economic and financial terms than delivery through RCH trekking teams, resulting in incremental savings of US$872 and US$1,244 respectively. The annual economic cost of delivering at least the first dose of each course of IPTc was US$3.47 and US$1.63 per child using trekking team and VHWs respectively.

CONCLUSIONS

In this setting in The Gambia, delivery of IPTc to children 6 years of age and under by VHWs is more effective and less costly than delivery through RCH trekking clinics.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00376155. Please see later in the article for the Editors' Summary.

Effect of repeated treatment of pregnant women with sulfadoxine-pyrimethamine and azithromycin on preterm delivery in Malawi: a randomized controlled trial

Preterm delivery, which is associated with infections during pregnancy, is common in sub-Saharan Africa. We enrolled 1,320 pregnant women into a randomized, controlled trial in Malawi to study whether preterm delivery and low birth weight (LBW) incidence can be reduced by intermittent preventive treatment of maternal malaria and reproductive tract infections. The participants received either sulfadoxine-pyrimethamine (SP) twice (controls), monthly SP, or monthly SP and two doses of azithromycin (AZI-SP). The incidence of preterm delivery was 17.9% in controls, 15.4% in the monthly SP group (P = 0.32), and 11.8% in AZI-SP group (risk ratio = 0.66, P = 0.01). Compared with controls, those in AZI-SP group had a risk ratio of 0.61 (P = 0.02) for LBW. Incidence of serious adverse events was low in all groups. In conclusion, the incidence of preterm delivery and LBW can in some conditions be reduced by treating pregnant women with monthly SP and two azithromycin doses.

A trial of intermittent preventive treatment and home-based management of malaria in a rural area of The Gambia

Background

Individual malaria interventions provide only partial protection in most epidemiological situations. Thus, there is a need to investigate whether combining interventions provides added benefit in reducing mortality and morbidity from malaria. The potential benefits of combining IPT in children (IPTc) with home management of malaria (HMM) was investigated.

Methods

During the 2008 malaria transmission season, 1,277 children under five years of age resident in villages within the rural Farafenni demographic surveillance system (DSS) in North Bank Region, The Gambia were randomized to receive monthly IPTc with a single dose of sulphadoxine/pyrimethamine (SP) plus three doses of amodiaquine (AQ) or SP and AQ placebos given by village health workers (VHWs) on three occasions during the months of September, October and November, in a double-blind trial. Children in all study villages who developed an acute febrile illness suggestive of malaria were treated by VHWs who had been taught how to manage malaria with artemether-lumefantrine (Coartem™). The primary aims of the project were to determine whether IPTc added significant benefit to HMM and whether VHWs could effectively combine the delivery of both interventions.

Results

The incidence of clinical attacks of malaria was very low in both study groups. The incidence rate of malaria in children who received IPTc was 0.44 clinical attacks per 1,000 child months at risk while that for control children was 1.32 per 1,000 child months at risk, a protective efficacy of 66% (95% CI -23% to 96%; p = 0.35). The mean (standard deviation) haemoglobin concentration at the end of the malaria transmission season was similar in the two treatment groups: 10.2 (1.6) g/dL in the IPTc group compared to 10.3 (1.5) g/dL in the placebo group. Coverage with IPTc was high, with 94% of children receiving all three treatments during the study period.

Conclusion

Due to the very low incidence of malaria, no firm conclusion can be drawn on the added benefit of IPTc in preventing clinical episodes of malaria among children who had access to HMM in The Gambia. However, the study showed that VHWs can successfully combine provision of HMM with provision of IPTc.

Trial Registration

ClinicalTrials.gov NCT00944840

Symptom-based diagnosis of malaria and its implication on antimalarial drug use in pregnancy in Central Uganda: results from a community trial

Diagnosis of malaria based on the symptomatic approach has been associated with over-treatment. We sought to assess the magnitude of antimalarial drug use in pregnancy in order to contribute to the debate of introducing effective diagnostic tools for malaria.

METHODS

Data on malaria morbidity and treatment seeking practices were collected from pregnant women as part of a community intervention study testing new approaches to deliver intermittent preventive treatment of malaria in pregnancy in Mukono district, central Uganda.

RESULTS

A high proportion of pregnant women, 261/667 (39.1%) at the health units reported having fever; and of these 124/559 (22.2%) had positive smears for Plasmodium faciliparum. The symptom-based approach had a low sensitivity of 26.4%, leading to many pregnant women with malaria undiagnosed. Similarly, a high proportion of pregnant women, 145/383 (37.9%) with negative blood smears for P. falciparum received antimalarial drugs in addition to intermittent preventive treatment (IPTp) with sulfadoxine-pyrimethamine (SP).

CONCLUSION

The results call for urgent strategies to identify effective diagnostic tools for malaria in pregnancy and to assess the negative effects of the over-use of antimalarial drugs in pregnancy.

Efficacy of intermittent preventive treatment with sulfadoxine-pyrimethamine on placental parasitemia in pregnant women in midwestern Nigeria

OBJECTIVE

To assess the effect of intermittent preventive treatment with sulfadoxine and pyrimethamine (IPT-SP) on placental parasitemia and maternal and perinatal outcome.

METHODS

We compared placental malaria parasitemia during pregnancy and pregnancy outcome in 2 groups of women receiving antenatal care at University of Benin Teaching Hospital. One group was prophylactically treated with IPT-SP and the other was not treated.

RESULTS

The parasitemia rates for peripheral, placental, and cord blood were 11.9%, 11.4%, and 2.7% in the IPT-SP group (n=370) and 19.1%, 22.6%, and 6.2% in the control group (n=371) (P=0.006, P=0.002, and P=0.02, respectively). The treatment reduced the odds of placental parasitemia by 37% (OR 0.63; 95% CI, 0.48-0.81). Peripheral (P=0.002) and placental (P=0.001) parasitemia were significantly reduced in the subgroup of women who took 2 or 3 doses of SP. Fewer women (16.2%) in the IPT-SP group than the control group (23.7%) had symptomatic malaria. Anemia at delivery was significantly lower in the IPT-SP group (10.8 vs 1.6%). The risks of abortion, preterm delivery, and low birth weight were also significantly lower in the IPT-SP group.

CONCLUSION

IPT-SP is effective in preventing placental parasitemia, and reduces rates of malaria, maternal anemia, abortion, preterm delivery and low birth weight among pregnant women.

Anti-folate drug resistance in Africa: meta-analysis of reported dihydrofolate reductase (dhfr) and dihydropteroate synthase (dhps) mutant genotype frequencies in African Plasmodium falciparum parasite populations

BACKGROUND

Mutations in the dihydrofolate reductase (dhfr) and dihydropteroate synthase (dhps) genes of Plasmodium falciparum are associated with resistance to anti-folate drugs, most notably sulphadoxine-pyrimethamine (SP). Molecular studies document the prevalence of these mutations in parasite populations across the African continent. However, there is no systematic review examining the collective epidemiological significance of these studies. This meta-analysis attempts to: 1) summarize genotype frequency data that are critical for molecular surveillance of anti-folate resistance and 2) identify the specific challenges facing the development of future molecular databases.

METHODS

This review consists of 220 studies published prior to 2009 that report the frequency of select dhfr and dhps mutations in 31 African countries. Maps were created to summarize the location and prevalence of the highly resistant dhfr triple mutant (N51I, C59R, S108N) genotype and dhps double mutant (A437G and K540E) genotype in Africa. A hierarchical mixed effects logistic regression was used to examine the influence of various factors on reported mutant genotype frequency. These factors include: year and location of study, age and clinical status of sampled population, and reporting conventions for mixed genotype data.

RESULTS

A database consisting of dhfr and dhps mutant genotype frequencies from all African studies that met selection criteria was created for this analysis. The map illustrates particularly high prevalence of both the dhfr triple and dhps double mutant genotypes along the Kenya-Tanzania border and Malawi. The regression model shows a statistically significant increase in the prevalence of both the dhfr triple and dhps double mutant genotypes in Africa.

CONCLUSION

Increasing prevalence of the dhfr triple mutant and dhps double mutant genotypes in Africa are consistent with the loss of efficacy of SP for treatment of clinical malaria in most parts of this continent. Continued assessment of the effectiveness of SP for the treatment of clinical malaria and intermittent preventive treatment in pregnancy is needed. The creation of a centralized resistance data network, such as the one proposed by the WorldWide Antimalarial Resistance Network (WWARN), will become a valuable resource for planning timely actions to combat drug resistant malaria.

Decreasing burden of malaria in pregnancy in Malawian women and its relationship to use of intermittent preventive therapy or bed nets

Background

The World Health Organization recommends insecticidal bednets and intermittent preventive treatment to reduce malaria in pregnancy. Longitudinal data of malaria prevalence and pregnancy outcomes are valuable in gauging the impact of these antimalarial interventions.

Methodology/Principal Findings

We recruited 8,131 women delivering in a single Malawian hospital over 9 years. We recorded demographic data, antenatal prescription of intermittent preventive therapy during pregnancy with sulfadoxine-pyrimethamine and bed net use, and examined finger-prick blood for malaria parasites and hemoglobin concentration. In 4,712 women, we examined placental blood for malaria parasites and recorded the infant's birth weight. Peripheral and placental parasitemia prevalence declined from 23.5% to 5.0% and from 25.2% to 6.8% respectively. Smaller declines in prevalence of low birth weight and anemia were observed. Coverage of intermittent preventive treatment and bednets increased. Number of sulfadoxine-pyrimethamine doses received correlated inversely with placental parasitemia (Odds Ratio (95% CI): 0.79 (0.68, 0.91)), maternal anemia (0.81, (0.73, 0.90)) and low birth weight from 1997–2001 (0.63 (0.53, 0.75)), but not from 2002–2006. Bednet use protected from peripheral parasitemia (0.47, (0.37, 0.60)) and placental parasitemia (0.41, (0.31, 0.54)) and low birth weight (0.75 (0.59, 0.95)) but not anemia throughout the study. Compared to women without nets who did not receive 2-dose sulfadoxine-pyrimethamine, women using nets and receiving 2-dose sulfadoxine-pyrimethamine were less likely to have parasitemia or low birth weight babies. Women receiving 2-dose sulfadoxine-pyrimethamine alone had little evidence of protection whereas bednets alone gave intermediate protection.

Conclusions/Significance

Increased bednet coverage explains changes in parasitemia and birth weight among pregnant women better than sulfadoxine-pyrimethamine use. High bed net coverage, and sulfadoxine-pyrimethamine resistance, may be contributing to its apparent loss of effectiveness.

Methods for evaluating delivery systems for scaling-up malaria control intervention

Background

Despite increased resources over the past few years the coverage of malaria control interventions is still inadequate to reach national and international targets and achieve the full potential of the interventions to improve population health. One of the reasons for this inadequate coverage of efficacious interventions is the limited understanding of the optimum delivery systems of the interventions in different contexts. Although there have been debates about how to deliver interventions, the methods for evaluating the effectiveness of different delivery systems have rarely been discussed. Delivery of interventions is relatively complex and a thorough evaluation would need to look holistically at multiple steps in the delivery process and at multiple factors influencing the process. A better understanding of the strength of the evidence on delivery system effectiveness is needed in order to optimise delivery of efficacious interventions.

Methods

A literature review was conducted of methods used to evaluate delivery systems for insecticide treated nets, intermittent preventive treatment in pregnant women, and treatment for malaria in children.

Results

The methodology of delivery system evaluations varied. There were inconsistencies between objectives and methods of the evaluations including inappropriate outcome measures and unnecessary controls. There were few examples where the delivery processes were adequately described, or measured. We propose a cross sectional observational study design with attribution of the outcomes to a specific delivery system as an appropriate method for evaluating delivery systems at scale.

Conclusions

The proposed evaluation framework is adaptable to natural experiments at scale, and can be applied using data from routine surveys such as the Demographic and Health Surveys, modified by the addition of one to two questions for each intervention. This framework has the potential to enable wider application of rigorous evaluations and thereby improve the evidence base on which decisions about delivery systems for malaria control and other public health interventions are taken.

Burden of malaria during pregnancy at the time of IPTp/SP implementation in Gabon

The new recommendations to prevent malaria in pregnant women have recently been implemented in Gabon. There is little information on the pregnancy indicators that are useful for their evaluation. A cross-sectional study for the assessment of the prevalence of peripheral, placental, and cord malaria and anemia among delivering women was performed at the largest public hospital of Gabon. Malaria prevalence was 34.4%, 53.6%, and 18.2% for maternal peripheral, placental, and cord blood respectively, with no difference between primigravidae and multigravidae. Submicroscopic infections were frequent and concerned all the positive cord samples. Maternal peripheral, late placental, and cord infections were all associated with a reduced mean birth weight in primigravidae (P = 0.02). Anemia prevalence was 53%, low birth rate was 13%, and prematurity was 25%. The use of intermittent preventive treatment with sulfadoxine-pyrimethamine (greater than or equal to one dose) combined with bed net was associated with a reduction in infection only in multigravidae and with a reduced risk of maternal anemia.

Intermittent screening and treatment versus intermittent preventive treatment of malaria in pregnancy: user acceptability

BACKGROUND

Malaria in pregnancy is associated with increased risks of maternal and foetal complications. Currently, intermittent preventive treatment (IPT) of malaria during pregnancy with sulphadoxine-pyrimethamine (SP) is recommended by the WHO as part of a package of interventions also including insecticide-treated nets and effective case management. However, with increasing resistance to SP, the effectiveness of SP-IPT has been questioned. A randomized controlled trial (RCT) to investigate the relative efficacy of an alternative strategy of intermittent screening and treatment (IST), which involves a rapid diagnostic test for malaria at scheduled ANC visits and treatment of women only if positive, versus SP-IPT has been conducted in Ashanti region, Ghana. This paper reports on a complementary study investigating the acceptability of the different strategies to women enrolled in the trial.

METHODS

Data were collected through twelve focus group discussions with women selected at random from the different arms of the RCT, exploring their experiences and perceptions about antenatal care and their involvement in the trial. Content analysis was used to identify relevant themes to structure the results.

RESULTS

Five main themes emerged from participants' experiences of ANC and the RCT that would influence their acceptability of malaria prevention strategies during pregnancy: health benefits; drugs received; tests received; other services received; and health worker attitude. Their own health and that of their baby were strong motivations for attending ANC, and reported favourably as an outcome of being in the RCT. Women were not always clear on the biomedical function of drugs or blood tests but generally accepted them due to strong trust in the health staff. Home visits by staff and free ITNs as part of the trial were appreciated. Politeness and patience of health staff was a very strong positive factor.

CONCLUSIONS

Overall, both intermittent screening and treatment and intermittent preventive treatment appeared equally acceptable to pregnant women as strategies for the control of malaria in pregnancy. The women were more concerned about quality of services received, in particular the polite and patient attitude of health staff, and positive health implications for themselves and their babies than about the nature of the intervention.

Use of intermittent preventive treatment for malaria by pregnant women in Buea, Cameroon

We identified individual factors associated with IPT use, by comparing characteristics of pregnant women who use IPT to those who do not. A cross-sectional study was conducted in antenatal clinics in Buea, Cameroon, from December 2006 to December 2007. Information on factors: age, parity, gravidity, gestational age, level of education, use of insecticide treated nets (ITN), socioeconomic status and IPT use was collected through interview and filled in a questionnaire. Data was entered using EPIDATA version 3 and analysis done using STATA version 8.2. A total of 527 pregnant women were interviewed with a mean (+/-SD) age of 26.45+/-5.37 years. 69.71% of the pregnant women used at least two doses of IPT. Logistic regression revealed women with higher educational status were more likely to use IPT compared to those with lower educational status (OR=3.14, 95% CI=1.20-8.25, p=0.02). Meanwhile, multigravid women tend to use IPT less than their primigravid counterparts (OR=0.47, 95% CI=0.26-0.84, p=0.01). There was no evidence that maternal age, parity, marital status, gestational age, use of ITN and socioeconomic status were each associated to IPT use. In antenatal clinics in Buea, South Western Cameroon, educational status and gravidity are the key determinants of IPT use.

Malaria at parturition in Nigeria: current status and delivery outcome

BACKGROUND

To evaluate the current status of malaria at parturition and its impact on delivery outcome in Nigeria.

METHODS

A total of 2500 mother-neonate pairs were enrolled at 4 sites over a 12-month period. Maternal and placental blood smears for malaria parasitaemia and haematocrit were determined.

RESULTS

Of the 2500 subjects enrolled, 625 were excluded from analysis because of breach in study protocol. The mean age of the remaining 1875 mothers was 29.0 +/- 5.1 years. The prevalence of parasitaemia was 17% and 14% in the peripheral blood and placenta of the parturient women, respectively. Peripheral blood parasitaemia was negatively associated with increasing parity (P < .0001). Maternal age <20 years was significantly associated with both peripheral blood and placental parasitaemia. After adjusting for covariates only age <20 years was associated with placental parasitaemia. Peripheral blood parasitaemia in the women was associated with anaemia (PCV < or =30%) lower mean hematocrit (P < .0001). lower mean birth weight (P < .001) and a higher proportion of low birth weight babies (LBW), (P = .025).

CONCLUSION

In Nigeria, maternal age < 20 years was the most important predisposing factor to malaria at parturition. The main impacts on pregnancy outcome were a twofold increase in rate of maternal anaemia and higher prevalence of LBW.

Competitive facilitation of drug-resistant Plasmodium falciparum malaria parasites in pregnant women who receive preventive treatment

Intermittent preventive treatment in pregnancy (IPTp) is used to prevent Plasmodium falciparum malaria. However, parasites resistant to the IPTp drug sulfadoxine-pyrimethamine (SP) have emerged worldwide, and infections with mixed resistant and susceptible parasites are exacerbated by pyrimethamine in mice. In a prospective delivery cohort in Muheza, Tanzania, we examined the effects of SP IPTp on parasite resistance alleles, parasite diversity, level of parasitemia, and inflammation in the placenta. IPTp use was associated with an increased fraction of parasites carrying the resistance allele at DHPS codon 581, an increase in the level of parasitemia, and more intense placental inflammation. The lowest mean level of parasite diversity and highest mean level of parasitemia occurred in women after recent IPTp use. These findings support a model of parasite release and facilitation, whereby the most highly resistant parasites out-compete less fit parasite populations and overgrow under drug pressure. Use of partially effective anti-malarial agents for IPTp may exacerbate malaria infections in the setting of widespread drug resistance.

Relationship between human immunodeficiency virus type 1 coinfection, anemia, and levels and function of antibodies to variant surface antigens in pregnancy-associated malaria

Human immunodeficiency virus type 1 (HIV-1) coinfection decreases antibodies to variant surface antigens implicated in pregnancy-associated malaria (VSA-PAM) caused by Plasmodium falciparum. The effect of HIV-1 on antibody functions that may protect mothers from pregnancy-associated malaria is unknown. Sera from multigravid pregnant women with malaria and HIV-1 coinfection (n=58) or malaria alone (n=29) and from HIV-1-infected (n=102) or -uninfected (n=54) multigravidae without malaria were analyzed for anti-VSA-PAM antibodies by flow cytometry, the ability to inhibit adhesion to chondroitin sulfate A, or to opsonize CS2-infected erythrocytes for phagocytosis by THP-1 cells. In women with malaria, anti-VSA-PAM levels correlated better with opsonic activity (r=0.60) than with adhesion-blocking activity (r=0.33). In univariate analysis, HIV-1 coinfection was associated with lower opsonic activity but not adhesion-blocking activity or anti-VSA-PAM levels. Malaria-infected women with anemia (hemoglobin levels of <11.0 g/dl) had lower opsonic activity than nonanemic women (P=0.007) independent of HIV-1 status. By multivariate analysis, in malaria-infected women, anemia (but not HIV status) was associated with opsonic activity. In women without malaria, opsonic activity was not associated with either anemia or HIV-1 status. In multigravid pregnant women with malaria, impaired serum opsonic activity may contribute to anemia and possibly to the decreased immunity to pregnancy-associated malaria associated with HIV-1.

Efficacy of intermittent preventive treatment versus chloroquine prophylaxis to prevent malaria during pregnancy in Benin

BACKGROUND

In West Africa, treatment for the prevention of malaria during pregnancy has recently changed from chloroquine (CQ) prophylaxis to intermittent preventive treatment (IPTp). We assessed the benefits of IPTp with respect to those of CQ, using a before-after study.

METHODS

CQ efficacy was evaluated during a cross-sectional survey conducted in Benin between April 2004 and April 2005. IPTp efficacy was assessed using data from an ongoing clinical trial to compare sulfadoxine-pyrimethamine with mefloquine that began in the same maternity clinics during July 2005; the present analysis is limited to women who delivered between November 2005 and November 2006. Treatment assignments were not unblinded. We compared the efficacy of the 2 strategies against low birth weight and placental infection by performing multiple logistic regressions.

RESULTS

A total of 1699 women (1090 in the CQ group and 609 in the IPTp group) who delivered live singletons were analyzed. Characteristics of women in the CQ group were similar to those of women in the IPTp group. We showed that women in the IPTp group had a significantly decreased risk of delivering an infant with a low birth weight (adjusted odds ratio [aOR], 0.54; 95% confidence interval [CI], 0.38-0.78) and placental infection (aOR, 0.15; 95% CI, 0.09-0.24).

CONCLUSION

We clearly evidenced that IPTp is substantially more beneficial than CQ for the prevention of malaria during pregnancy.