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Kabalu Tshiongo J, Luzolo F, Kabena M, Kuseke L, Djimde M, Mitashi P, Lumbala C, Kayentao K, Menting S, Mens PF, Schallig HDFH, Lutumba P, Tinto H, Muhindo Mavoko H, Maketa V. Performance of ultra-sensitive malaria rapid diagnostic test to detect Plasmodium falciparum infection in pregnant women in Kinshasa, the Democratic Republic of the Congo. Malar J 2023; 22:322. [PMID: 37872634 PMCID: PMC10594769 DOI: 10.1186/s12936-023-04749-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 10/11/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Low peripheral parasitaemia caused by sequestration of Plasmodium falciparum in the placenta hampers the diagnosis of malaria in pregnant women, leading to microscopy or conventional rapid diagnostic tests (RDTs) false-negative results. Although mainly asymptomatic, maternal malaria remains harmful to pregnant women and their offspring in endemic settings and must be adequately diagnosed. Ultra-sensitive RDTs (uRDTs) are thought to be more sensitive than RDTs, and their diagnostic performance was assessed in the current study in pregnant women living in Kinshasa, a stable malaria transmission area in the Democratic Republic of the Congo. METHODS To assess and compare the diagnostic performances of both RDTs and uRDTs, 497 peripheral blood samples were tested using microscopy and quantitative polymerase chain reaction (qPCR) as the index and the reference tests, respectively. The agreement between the different diagnostic tests assessed was estimated by Cohen's Kappa test. RESULTS The median parasite density by qPCR was 292 p/μL of blood [IQR (49.7-1137)]. Using qPCR as the reference diagnostic test, the sensitivities of microscopy, RDT and uRDT were respectively [55.7% (95% CI 47.6-63.6)], [81.7% (95%CI 74.7-87.3)] and [88% (95% CI 81.9-92.6)]. The specificities of the tests were calculated at 98.5% (95% CI 96.6-99.5), 95.2% (95% CI 92.5-97.2) and 94.4% (95% CI 91.4-96.6) for microscopy, RDT and uRDT, respectively. The agreement between qPCR and uRDT was almost perfect (Kappa = 0.82). For parasite density (qPCR) below 100 p/µL, the sensitivity of RDT was 62% (95% CI 47.1-75.3) compared to 68% (95% CI 53.3-80.4) for uRDT. Between 100 and 200 p/µL, the sensitivity of RDT was higher, but still lower compared to uRDT: 89.4% (95% CI 66.8-98.7) for RDT versus 100% (95% CI 82.3-100) for uRDT. In both cases, microscopy was lower, with 20% (95% CI 10-33.7) and 47.3% (95% CI 24.4-71.1) respectively. CONCLUSIONS uRDT has the potential to improve malaria management in pregnant women as it has been found to be slightly more sensitive than RDT in the detection of malaria in pregnant women but the difference was not significant. Microscopy has a more limited value for the diagnosis of malaria during the pregnancy, because of its lower sensitivity.
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Affiliation(s)
- Japhet Kabalu Tshiongo
- Department of Tropical Medicine, University of Kinshasa (UNIKIN), Kinshasa, Democratic Republic of the Congo.
- Amsterdam University Medical Centres, Department of Medical Microbiology and Infection Prevention, Laboratory for Experimental Parasitology, Academic Medical Centres at the University of Amsterdam, Amsterdam, The Netherlands.
- Amsterdam Institute for Infection and Immunity, Infectious Diseases Programme, Amsterdam, The Netherlands.
| | - Flory Luzolo
- Department of Tropical Medicine, University of Kinshasa (UNIKIN), Kinshasa, Democratic Republic of the Congo
| | - Melissa Kabena
- Department of Tropical Medicine, University of Kinshasa (UNIKIN), Kinshasa, Democratic Republic of the Congo
| | - Lise Kuseke
- Department of Tropical Medicine, University of Kinshasa (UNIKIN), Kinshasa, Democratic Republic of the Congo
| | - Moussa Djimde
- Amsterdam University Medical Centres, Department of Medical Microbiology and Infection Prevention, Laboratory for Experimental Parasitology, Academic Medical Centres at the University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity, Infectious Diseases Programme, Amsterdam, The Netherlands
- Malaria Research and Training Center (MRTC), University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - Patrick Mitashi
- Department of Tropical Medicine, University of Kinshasa (UNIKIN), Kinshasa, Democratic Republic of the Congo
| | - Crispin Lumbala
- Clinton Health Access Initiative, Kinshasa, Democratic Republic of the Congo
- Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Kassoum Kayentao
- Malaria Research and Training Center (MRTC), University of Sciences, Techniques and Technologies of Bamako (USTTB), Bamako, Mali
| | - Sandra Menting
- Amsterdam University Medical Centres, Department of Medical Microbiology and Infection Prevention, Laboratory for Experimental Parasitology, Academic Medical Centres at the University of Amsterdam, Amsterdam, The Netherlands
| | - Petra F Mens
- Amsterdam University Medical Centres, Department of Medical Microbiology and Infection Prevention, Laboratory for Experimental Parasitology, Academic Medical Centres at the University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity, Infectious Diseases Programme, Amsterdam, The Netherlands
| | - Henk D F H Schallig
- Amsterdam University Medical Centres, Department of Medical Microbiology and Infection Prevention, Laboratory for Experimental Parasitology, Academic Medical Centres at the University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity, Infectious Diseases Programme, Amsterdam, The Netherlands
| | - Pascal Lutumba
- Department of Tropical Medicine, University of Kinshasa (UNIKIN), Kinshasa, Democratic Republic of the Congo
- Institut Supérieur Des Techniques Médicales de Kinshasa (ISTM-Kinshasa), Kinshasa, Democratic Republic of the Congo
| | - Halidou Tinto
- Institut de Recherche en Sciences de La Santé - Clinical Research Unit of Nanoro (IRSS-CRUN), Nanoro, Burkina Faso
| | - Hypolite Muhindo Mavoko
- Department of Tropical Medicine, University of Kinshasa (UNIKIN), Kinshasa, Democratic Republic of the Congo
| | - Vivi Maketa
- Department of Tropical Medicine, University of Kinshasa (UNIKIN), Kinshasa, Democratic Republic of the Congo
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Uwimana A, Sethi R, Murindahabi M, Ntirandeka C, Piercefield E, Umulisa N, Abram A, Eckert E, Munguti K, Sullivan D, Uyizeye D, Mbituyumuremyi A, Gutman JR. Effectiveness of Intermittent Screening and Treatment of Malaria in Pregnancy on Maternal and Birth Outcomes in Selected Districts in Rwanda: A Cluster Randomized Controlled Trial. Clin Infect Dis 2023; 77:127-134. [PMID: 36896967 PMCID: PMC10330390 DOI: 10.1093/cid/ciad128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 02/22/2023] [Accepted: 03/02/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Malaria during pregnancy can cause serious consequences including maternal anemia and low birthweight (LBW). Routine antenatal care (ANC) in Rwanda includes malaria symptom screening at each ANC visit. This cluster randomized controlled trial investigated whether adding intermittent screening with a malaria rapid diagnostic test at each routine ANC visit and treatment of positives during pregnancy (ISTp) is more effective than routine ANC for reducing malaria prevalence at delivery. METHODS Between September 2016 and June 2018, pregnant women initiating ANC at 14 health centers in Rwanda were enrolled into ISTp or control arms. All women received an insecticide-treated bed net at enrollment. Hemoglobin concentration, placental and peripheral parasitemia, newborn outcome, birthweight, and prematurity were assessed at delivery. RESULTS Nine hundred seventy-five women were enrolled in ISTp and 811 in the control group. Routine ANC plus ISTp did not significantly reduce polymerase chain reaction-confirmed placental malaria compared to control (adjusted relative risk [aRR], 0.94 [95% confidence interval {CI}, .59-1.50]; P = .799). ISTp had no impact on anemia (aRR, 1.08 [95% CI, .57-2.04]; P = .821). The mean birthweight of singleton newborns was not significantly different between arms (3054 g vs 3096 g, P = .395); however, women in the ISTp arm had a higher proportion of LBW (aRR, 1.59 [95% CI, 1.02-2.49]; P = .042). CONCLUSIONS This is the only study to compare ISTp to symptomatic screening at ANC in a setting where intermittent preventive treatment is not routinely provided. ISTp did not reduce the prevalence of malaria or anemia at delivery and was associated with an increased risk of LBW. CLINICAL TRIALS REGISTRATION NCT03508349.
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Affiliation(s)
- Aline Uwimana
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Reena Sethi
- Maternal and Child Survival Program–Jhpiego, Washington, District of Columbia, USA
| | - Monique Murindahabi
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | | | - Emily Piercefield
- US President's Malaria Initiative, Malaria Branch, US Centers for Disease Control and Prevention, USA
| | - Noella Umulisa
- Maternal and Child Survival Program–Jhpiego, Kigali, Rwanda
| | | | - Erin Eckert
- US PMI Impact Malaria Project, Population Services International, Washington, District of Columbia, USA
| | - Kaendi Munguti
- US Agency for International Development, US President's Malaria Initiative, Kigali, Rwanda
| | - David Sullivan
- Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Didier Uyizeye
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | | | - Julie R Gutman
- Malaria Branch, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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van Eijk AM, Stepniewska K, Hill J, Taylor SM, Rogerson SJ, Cottrell G, Chico RM, Gutman JR, Tinto H, Unger HW, Yanow SK, Meshnick SR, Ter Kuile FO, Mayor A. Prevalence of and risk factors for microscopic and submicroscopic malaria infections in pregnancy: a systematic review and meta-analysis. Lancet Glob Health 2023; 11:e1061-e1074. [PMID: 37276878 PMCID: PMC10880462 DOI: 10.1016/s2214-109x(23)00194-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Malaria infections during pregnancy can cause adverse birth outcomes, yet many infections are undetected by microscopy. We aimed to describe the epidemiology of submicroscopic malaria infections in pregnant women in Asia, the Americas, and Africa using aggregated and individual participant data (IPD). METHODS For this systematic review and meta-analysis, studies (published Jan 1, 1997 to Nov 10, 2021) with information on both microscopic and submicroscopic infections during pregnancy from Asia, the Americas, or Africa, identified in the Malaria-in-Pregnancy Library, were eligible. Studies (or subgroups or study groups) that selected participants on the basis of the presence of fever or a positive blood smear were excluded to avoid selection bias. We obtained IPD (when available) and aggregated data. Estimates of malaria transmission intensity and sulfadoxine-pyrimethamine resistance, matched by study location and year, were obtained using publicly available data. One-stage multivariable logit and multinomial models with random intercepts for study site were used in meta-analysis to assess prevalence of and risk factors for submicroscopic infections during pregnancy and at delivery. This study is registered with PROSPERO, number CRD42015027342. FINDINGS The search identified 87 eligible studies, 68 (78%) of which contributed to the analyses. Of these 68 studies, 45 (66%) studies contributed IPD (48 869 participants) and 23 (34%) studies contributed aggregated data (11 863 participants). During pregnancy, median prevalence estimates were 13·5% (range 0·0-55·9, 66 substudies) for submicroscopic and 8·0% (0·0-50·6, 66 substudies) for microscopic malaria. Among women with positive Plasmodium nucleic acid amplification tests (NAATs), the median proportion of submicroscopic infections was 58·7% (range 0·0-100); this proportion was highest in the Americas (73·3%, 0·0-100), followed by Asia (67·2%, 36·4-100) and Africa (56·5%, 20·5-97·7). In individual patient data analysis, compared with women with no malaria infections, those with submicroscopic infections were more likely to present with fever in Africa (adjusted odds ratio 1·32, 95% CI 1·02-1·72; p=0·038) but not in other regions. Among women with NAAT-positive infections in Asia and the Americas, Plasmodium vivax infections were more likely to be submicroscopic than Plasmodium falciparum infections (3·69, 2·45-5·54; p<0·0001). Risk factors for submicroscopic infections among women with NAAT-positive infections in Africa included older age (age ≥30 years), multigravidity, and no HIV infection. INTERPRETATION During pregnancy, submicroscopic infections are more common than microscopic infections and are associated with fever in Africa. Malaria control in pregnancy should target both microscopic and submicroscopic infections. FUNDING Bill & Melinda Gates Foundation through the Worldwide Antimalarial Resistance Network.
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Affiliation(s)
- Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Kasia Stepniewska
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Steve M Taylor
- Division of Infectious Diseases and Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Stephen J Rogerson
- Department of Infectious Diseases, Doherty Institute, The University of Melbourne, Melbourne, VIC, Australia
| | | | - R Matthew Chico
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Halidou Tinto
- Institut de Recherche en Sciences de la Sant-Unité de Recherche Clinique de Nanoro, Ouagadougou, Burkina Faso
| | - Holger W Unger
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Stephanie K Yanow
- School of Public Health, Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada
| | - Steven R Meshnick
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Feiko O Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Alfredo Mayor
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
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Gutman JR, Mwesigwa JN, Arnett K, Kangale C, Aaron S, Babarinde D, Buekens J, Candrinho B, Debe S, Digre P, Drake M, Gansané A, Gogue C, Griffith KS, Hicks J, Kinda R, Koenker H, Lemwayi R, Munsey A, Obi E, Ogouyèmi-Hounto A, Okoko OO, Onikpo F, Onoja A, Porter T, Savaio B, Tynuv K, Uhomoibhi P, Wagman J, Wolf K, Zulliger R, Walker P, Miller JM, Robertson M. Using antenatal care as a platform for malaria surveillance data collection: study protocol. Malar J 2023; 22:99. [PMID: 36932384 PMCID: PMC10022568 DOI: 10.1186/s12936-023-04521-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/02/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND While many malaria-endemic countries have health management information systems that can measure and report malaria trends in a timely manner, these routine systems have limitations. Periodic community cross-sectional household surveys are used to estimate malaria prevalence and intervention coverage but lack geographic granularity and are resource intensive. Incorporating malaria testing for all women at their first antenatal care (ANC) visit (i.e., ANC1) could provide a more timely and granular source of data for monitoring trends in malaria burden and intervention coverage. This article describes a protocol designed to assess if ANC-based surveillance could be a pragmatic tool to monitor malaria. METHODS This is an observational, cross-sectional study conducted in Benin, Burkina Faso, Mozambique, Nigeria, Tanzania, and Zambia. Pregnant women attending ANC1 in selected health facilities will be tested for malaria infection by rapid diagnostic test and administered a brief questionnaire to capture key indicators of malaria control intervention coverage and care-seeking behaviour. In each location, contemporaneous cross-sectional household surveys will be leveraged to assess correlations between estimates obtained using each method, and the use of ANC data as a tool to track trends in malaria burden and intervention coverage will be validated. RESULTS This study will assess malaria prevalence at ANC1 aggregated at health facility and district levels, and by gravidity relative to current pregnancy (i.e., gravida 1, gravida 2, and gravida 3 +). ANC1 malaria prevalence will be presented as monthly trends. Additionally, correlation between ANC1 and household survey-derived estimates of malaria prevalence, bed net ownership and use, and care-seeking will be assessed. CONCLUSION ANC1-based surveillance has the potential to provide a cost-effective, localized measure of malaria prevalence that is representative of the general population and useful for tracking monthly changes in parasite prevalence, as well as providing population-representative estimates of intervention coverage and care-seeking behavior. This study will evaluate the representativeness of these measures and collect information on operational feasibility, usefulness for programmatic decision-making, and potential for scale-up of malaria ANC1 surveillance.
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Affiliation(s)
- Julie R Gutman
- Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | | | | | | | | | | | | | | | - Siaka Debe
- Centre National de Recherche Et de Formation Sur Le Paludisme, Ouagadougou, Burkina Faso
| | | | | | - Adama Gansané
- Centre National de Recherche Et de Formation Sur Le Paludisme, Ouagadougou, Burkina Faso
| | | | - Kevin S Griffith
- US President's Malaria Initiative, US Agency for International Development, Washington, DC, USA
| | | | - Réné Kinda
- Centre National de Recherche Et de Formation Sur Le Paludisme, Ouagadougou, Burkina Faso
| | | | | | - Anna Munsey
- Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Emmanuel Obi
- National Malaria Elimination Program, Abuja, Nigeria
| | | | | | | | - Ali Onoja
- Ibolda Health International Ltd, Abuja, Nigeria
| | | | | | | | | | | | | | - Rose Zulliger
- US President's Malaria Initiative, US Agency for International Development, Washington, DC, USA
| | | | | | - Molly Robertson
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
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Ding XC, Incardona S, Serra-Casas E, Charnaud SC, Slater HC, Domingo GJ, Adams ER, ter Kuile FO, Samuels AM, Kariuki S, Dittrich S. Malaria in pregnancy (MiP) studies assessing the clinical performance of highly sensitive rapid diagnostic tests (HS-RDT) for Plasmodium falciparum detection. Malar J 2023; 22:60. [PMID: 36803858 PMCID: PMC9942317 DOI: 10.1186/s12936-023-04445-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 01/06/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Rapid diagnostic tests (RDTs) are effective tools to diagnose and inform the treatment of malaria in adults and children. The recent development of a highly sensitive rapid diagnostic test (HS-RDT) for Plasmodium falciparum has prompted questions over whether it could improve the diagnosis of malaria in pregnancy and pregnancy outcomes in malaria endemic areas. METHODS This landscape review collates studies addressing the clinical performance of the HS-RDT. Thirteen studies were identified comparing the HS-RDT and conventional RDT (co-RDT) to molecular methods to detect malaria in pregnancy. Using data from five completed studies, the association of epidemiological and pregnancy-related factors on the sensitivity of HS-RDT, and comparisons with co-RDT were investigated. The studies were conducted in 4 countries over a range of transmission intensities in largely asymptomatic women. RESULTS Sensitivity of both RDTs varied widely (HS-RDT range 19.6 to 85.7%, co-RDT range 22.8 to 82.8% compared to molecular testing) yet HS-RDT detected individuals with similar parasite densities across all the studies including different geographies and transmission areas [geometric mean parasitaemia around 100 parasites per µL (p/µL)]. HS-RDTs were capable of detecting low-density parasitaemias and in one study detected around 30% of infections with parasite densities of 0-2 p/µL compared to the co-RDT in the same study which detected around 15%. CONCLUSION The HS-RDT has a slightly higher analytical sensitivity to detect malaria infections in pregnancy than co-RDT but this mostly translates to only fractional and not statistically significant improvement in clinical performance by gravidity, trimester, geography or transmission intensity. The analysis presented here highlights the need for larger and more studies to evaluate incremental improvements in RDTs. The HS-RDT could be used in any situation where co-RDT are currently used for P. falciparum diagnosis, if storage conditions can be adhered to.
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Affiliation(s)
- Xavier C. Ding
- grid.452485.a0000 0001 1507 3147FIND, Geneva, Switzerland
| | | | | | | | - Hannah C. Slater
- grid.415269.d0000 0000 8940 7771Diagnostics Program, PATH, Seattle, USA
| | | | - Emily R. Adams
- grid.48004.380000 0004 1936 9764Department of Tropical Disease Biology and Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA UK
| | - Feiko O. ter Kuile
- grid.48004.380000 0004 1936 9764Department of Tropical Disease Biology and Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA UK
| | - Aaron M. Samuels
- grid.512515.7Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Kisumu, Kenya ,grid.467642.50000 0004 0540 3132Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia USA
| | - Simon Kariuki
- grid.33058.3d0000 0001 0155 5938Kenya Medical Research Institute-Centre for Global Health Research, Kisumu, Kenya
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Gutman JR, Thwing J, Mwesigwa J, McElroy PD, Robertson M. Routine Healthcare Facility- and Antenatal Care-Based Malaria Surveillance: Challenges and Opportunities. Am J Trop Med Hyg 2023; 108:4-7. [PMID: 35895587 PMCID: PMC9904165 DOI: 10.4269/ajtmh.22-0182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/11/2022] [Indexed: 02/04/2023] Open
Abstract
Most monitoring and evaluation tools for measuring malaria burden, intervention coverage, and impact of interventions use periodic nationally representative cross-sectional household surveys. These provide advantages in terms of selecting a large, unbiased, population-based sample; however, they are infrequently conducted, are resource-intensive, and do not provide longitudinal data with sufficient granularity. Given the heterogeneity of malaria transmission within most endemic countries, systems with the capacity to provide more granular and frequent data would be more actionable by national malaria control programs and local implementing partners. There is increasing interest in using routine health facility data, usually from outpatient department visits, for monitoring malaria burden. Data from pregnant women attending antenatal care (ANC) could minimize bias related to fever care-seeking among outpatient department visits and provide more granular parasite prevalence data. Most pregnant women attend ANC at least once and are thus highly representative of the overall pregnant population. A growing body of evidence suggests that malaria parasitemia in pregnant women is correlated with parasitemia in children aged < 5 years in moderate to high transmission areas, allowing for monitoring parasitemia in real time. Additional data are needed to assess whether pregnant women are sufficiently representative of the overall population to yield valid malaria prevalence and intervention coverage estimates. Although use of routinely collected ANC data faces many of the same challenges experienced by other routinely collected health facility data, the opportunity to improve parasite prevalence monitoring and the associated health benefits to mothers and infants of early detection of parasitemia make these efforts valuable.
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Affiliation(s)
- Julie R. Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia;,Address correspondence to Julie R. Gutman, Centers for Disease Control and Prevention, 1600 Clifton Rd., Mailstop H24-3, Atlanta, GA 30329. E-mail:
| | - Julie Thwing
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Peter D. McElroy
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
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Matambisso G, Brokhattingen N, Maculuve S, Cisteró P, Mbeve H, Escoda A, Miguel J, Buetas E, de Jong I, Cuna B, Melembe C, Ndimande N, Porras G, Chen H, Tetteh KKA, Drakeley C, Gamain B, Chitnis C, Chauhan V, Quintó L, Galatas B, Macete E, Mayor A. Gravidity and malaria trends interact to modify P. falciparum densities and detectability in pregnancy: a 3-year prospective multi-site observational study. BMC Med 2022; 20:396. [PMID: 36376866 PMCID: PMC9664815 DOI: 10.1186/s12916-022-02597-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 10/06/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Low-density Plasmodium falciparum infections prevail in low transmission settings, where immunity is expected to be minimal, suggesting an immune-independent effect on parasite densities. We aimed to describe parasite densities in pregnancy, and determine how gravidity and antibody-mediated immunity affect these, during a period of declining malaria transmission in southern Mozambique. METHODS We documented P. falciparum infections at first antenatal care visits (n = 6471) between November 2016 and October 2019 in Ilha Josina (high-to-moderate transmission area), Manhiça (low transmission area), and Magude (pre-elimination area). Two-way interactions in mixed-effects regression models were used to assess gravidity-dependent differences in quantitative PCR-determined P. falciparum positivity rates (PfPRqPCR) and densities, in the relative proportion of detectable infections (pDi) with current diagnostic tests (≥ 100 parasites/μL) and in antimalarial antibodies. RESULTS PfPRqPCR declined from 28 to 13% in Ilha Josina and from 5-7 to 2% in Magude and Manhiça. In primigravidae, pDi was highest in Ilha Josina at the first study year (p = 0.048), which declined with falling PfPRqPCR (relative change/year: 0.41, 95% CI [0.08; 0.73], p = 0.029), with no differences in antibody levels. Higher parasite densities in primigravidae from Ilha Josina during the first year were accompanied by a larger reduction of maternal hemoglobin levels (- 1.60, 95% CI [- 2.49; - 0.72; p < 0.001), than in Magude (- 0.76, 95% CI [- 1.51; - 0.01]; p = 0.047) and Manhiça (- 0.44, 95% CI [- 0.99; 0.10; p = 0.112). In contrast, multigravidae during the transmission peak in Ilha Josina carried the lowest pDi (p = 0.049). As PfPRqPCR declined, geometric mean of parasite densities increased (4.63, 95% CI [1.28; 16.82], p = 0.020), and antibody levels declined among secundigravidae from Ilha Josina. CONCLUSIONS The proportion of detectable and clinically relevant infections is the highest in primigravid women from high-to-moderate transmission settings and decreases with declining malaria. In contrast, the falling malaria trends are accompanied by increased parasite densities and reduced humoral immunity among secundigravidae. Factors other than acquired immunity thus emerge as potentially important for producing less detectable infections among primigravidae during marked declines in malaria transmission.
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Affiliation(s)
- Glória Matambisso
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | | | - Sónia Maculuve
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Pau Cisteró
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Henriques Mbeve
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Anna Escoda
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Judice Miguel
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Elena Buetas
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Ianthe de Jong
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Boaventura Cuna
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Cardoso Melembe
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Nelo Ndimande
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Gemma Porras
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Haily Chen
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Kevin K A Tetteh
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Chris Drakeley
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Benoit Gamain
- Université de Paris, Biologie Intégrée du Globule Rouge, UMR_S1134, Inserm, 75015, Paris, France
| | - Chetan Chitnis
- Department of Parasites & Insect Vectors, Malaria Parasite Biology and Vaccines, Institut Pasteur, Paris, France
| | - Virander Chauhan
- Malaria Group, International Centre for Genetic Engineering and Biotechnology (ICGEB), New Delhi, India
| | - Llorenç Quintó
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Beatriz Galatas
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Eusébio Macete
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique.,National Directare of Health, Ministry of Health, Maputo, Mozambique
| | - Alfredo Mayor
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique. .,ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain. .,Spanish Consortium for Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain. .,Department of Physiologic Sciences, Faculty of Medicine, Universidade Eduardo Mondlane, Maputo, Mozambique.
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8
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Samuels AM, Towett O, Seda B, Wiegand RE, Otieno K, Chomba M, Lucchi N, Ljolje D, Schneider K, Walker PGT, Kwambai TK, Slutsker L, ter Kuile FO, Kariuki SK. Diagnostic Performance of Loop-Mediated Isothermal Amplification and Ultrasensitive Rapid Diagnostic Tests for Malaria Screening Among Pregnant Women in Kenya. J Infect Dis 2022; 226:696-707. [PMID: 35811308 PMCID: PMC9585193 DOI: 10.1093/infdis/jiac289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Screen-and-treat strategies with sensitive diagnostic tests may reduce malaria-associated adverse pregnancy outcomes. We conducted a diagnostic accuracy study to evaluate new point-of-care tests to screen pregnant women for malaria at their first antenatal visit in western Kenya. METHODS Consecutively women were tested for Plasmodium infection by expert microscopy, conventional rapid diagnostic test (cRDT), ultra sensitive RDT (usRDT), and loop-mediated isothermal amplification (LAMP). Photoinduced electron-transfer polymerase chain reaction (PET-PCR) served as the reference standard. Diagnostic performance was calculated and modelled at low parasite densities. RESULTS Between May and September 2018, 172 of 482 screened participants (35.7%) were PET-PCR positive. Relative to PET-PCR, expert microscopy was least sensitive (40.1%; 95% confidence interval [CI], 32.7%-47.9%), followed by cRDT (49.4%; 95% CI, 41.7%-57.1), usRDT (54.7%; 95% CI, 46.9%-62.2%), and LAMP (68.6%; 95% CI, 61.1%-75.5%). Test sensitivities were comparable in febrile women (n = 90). Among afebrile women (n = 392), the geometric-mean parasite density was 29 parasites/µL and LAMP (sensitivity = 61.9%) and usRDT (43.2%) detected 1.74 (95% CI, 1.31-2.30) and 1.21 (95% CI, 88-2.21) more infections than cRDT (35.6%). Per our model, tests performed similarly at densities >200 parasites/µL. At 50 parasites/µL, the sensitivities were 45%, 56%, 62%, and 74% with expert microscopy, cRDT, usRDT, and LAMP, respectively. CONCLUSIONS This first-generation usRDT provided moderate improvement in detecting low-density infections in afebrile pregnant women compared to cRDTs.
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Affiliation(s)
- Aaron M. Samuels
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Kisumu, 40100, Kenya
- Division of Parasitic Diseases and Malaria, CDC, Atlanta, GA, 30329, United States of America
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, United Kingdom
| | - Oliver Towett
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, 40100, Kenya
| | - Brian Seda
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, 40100, Kenya
| | - Ryan E. Wiegand
- Division of Parasitic Diseases and Malaria, CDC, Atlanta, GA, 30329, United States of America
| | - Kephas Otieno
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, 40100, Kenya
| | - Miriam Chomba
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, 40100, Kenya
| | - Naomi Lucchi
- Division of Parasitic Diseases and Malaria, CDC, Atlanta, GA, 30329, United States of America
| | - Dragan Ljolje
- Division of Parasitic Diseases and Malaria, CDC, Atlanta, GA, 30329, United States of America
| | - Kammerle Schneider
- Center for Malaria Control and Elimination, PATH, Seattle, WA, 98121, United States of America
| | - Patrick GT Walker
- Department of Infectious Disease Epidemiology, Imperial College London, SW7 2AZ, United Kingdom
| | - Titus K. Kwambai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Kisumu, 40100, Kenya
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, 40100, Kenya
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, United Kingdom
| | - Laurence Slutsker
- Center for Malaria Control and Elimination, PATH, Seattle, WA, 98121, United States of America
| | - Feiko O. ter Kuile
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, 40100, Kenya
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, United Kingdom
| | - Simon K. Kariuki
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, 40100, Kenya
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9
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Gebresenbet RF, Kamaliddin C, Bekele ZM, Teferi M, Tegegne B, Yewhalaw D, Bayih AG, Pillai DR. Active case detection and treatment of malaria in pregnancy using LAMP technology (LAMPREG): a pragmatic randomised diagnostic outcomes trial-study protocol. BMJ Open 2022; 12:e058397. [PMID: 35851027 PMCID: PMC10410974 DOI: 10.1136/bmjopen-2021-058397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 06/28/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Malaria is one of the major public health problems in sub-Saharan Africa. It contributes significantly to maternal and fetal morbidity and mortality in affected countries. This study aims to evaluate the impact of enhanced case detection using molecular testing called loop-mediated isothermal amplification (LAMP) on birth outcomes in a prospective study design. METHODS AND ANALYSIS A pragmatic randomised diagnostic outcomes trial will be conducted in several health institutes in different Ethiopian regions. Women (n=2583) in their first and second trimesters of pregnancy will be included in the study and individually randomised to the standard of care or enhanced case detection arms, and followed until delivery. Enrolment will encompass the malaria peak transmission seasons. In the standard of care arm, a venous blood sample will be collected for malaria diagnosis only in symptomatic patients. In contrast, in the intervention arm, mothers will be tested by a commercially available Conformité Européene (CE)-approved LAMP malaria test, microscopy and rapid diagnostic test for malaria regardless of their symptoms at each antenatal care visit. The primary outcome of the study is to measure birth weight. ETHICS AND DISSEMINATION The study was approved by the following ethical research boards: Armauer Hansen Research Institute/ALERT Ethics Review Committee (FORM AF-10-015.1, Protocol number PO/05/20), the Ethiopia Ministry of Science and Higher Education National Research Ethics Review Committee (approval SRA/11.7/7115/20), the Ethiopia Food and Drug Administration (approval 02/25/33/I), UCalgary Conjoint Health Research Ethics Board (REB21-0234). The study results will be shared with the institutions and stakeholders such as the Ethiopia Ministry of Health, the Foundation for Innovative Diagnostics, WHO's Multilateral initiative on Malaria - Tropical Diseases Research (TDR-MIM), Roll Back Malaria and the Malaria in Pregnancy Consortium. The study results will also be published in peer-reviewed journals and presented at international conferences. TRIAL REGISTRATION NUMBER NCT03754322.
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Affiliation(s)
| | - Claire Kamaliddin
- Pathology and Laboratory Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Microbiology, Immunology and Infectious Diseases, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | | | - Mekonnen Teferi
- Clinical Trials Unit, Armauer Hansen Research Institute, Addis Ababa, Oromia, Ethiopia
| | - Banchamlak Tegegne
- Medical Parasitology, Amhara Public Health Institute, Bahir Dar, Ethiopia
| | - Delenasaw Yewhalaw
- Department of Medical Laboratory Sciences and Pathology, Jimma University College of Public Health and Medical Sciences, Jimma, Ethiopia
| | | | - Dylan R Pillai
- Pathology and Laboratory Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Microbiology, Immunology and Infectious Diseases, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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10
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Clark RL. Safety of Treating Malaria with Artemisinin-Based Combination Therapy in the First Trimester of Pregnancy. Reprod Toxicol 2022; 111:204-210. [PMID: 35667524 DOI: 10.1016/j.reprotox.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/29/2022] [Accepted: 05/31/2022] [Indexed: 11/25/2022]
Abstract
There have been recent calls for the use of artemisinin-based combination therapies (ACTs) for uncomplicated malaria in the first trimester of pregnancy. Nevertheless, the 2021 WHO Guidelines for Malaria reaffirmed their position that there is not adequate clinical safety data on artemisinins to support that usage. The WHO's position is consistent with several issues with the existing clinical data. First, first trimester safety results from multiple ACTs were lumped in a meta-analysis which does not demonstrate that each of the included ACTs is equally safe. Second, safety results from all periods of the first trimester were lumped in the meta-analysis which does not demonstrate the same level of safety for all subperiods, particularly gestational Weeks 6 to 8 which is likely to be the most sensitive period. Third, even if there is evidence of a lack of an effect on miscarriage for a particular ACT, it does not follow then there are no developmental effects for any ACT. In monkeys, artesunate caused marked embryonal anemia leading to embryo death but the long-term consequences of lower levels of embryonal anemia are not known. Fourth, there have been advances in the sensitivity and usage of rapid diagnostic tests that will lead to diagnoses of malaria earlier in gestation which is less well studied and more likely sensitive to artemisinins. Any clinical studies of the safety of ACTs in the first trimester need to evaluate the results of treatment with individual ACTs during different 1- to 2-week periods of the first trimester.
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11
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Das S, Kérah-Hinzoumbé C, Kebféné M, Srisutham S, Nagorngar TY, Saralamba N, Vongpromek R, Khomvarn T, Sibley CH, Guérin PJ, Imwong M, Dhorda M. Molecular surveillance for operationally relevant genetic polymorphisms in Plasmodium falciparum in Southern Chad, 2016–2017. Malar J 2022; 21:83. [PMID: 35279140 PMCID: PMC8917628 DOI: 10.1186/s12936-022-04095-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 02/19/2022] [Indexed: 11/17/2022] Open
Abstract
Background Resistance to anti-malarials is a serious threat to the efforts to control and eliminate malaria. Surveillance based on simple field protocols with centralized testing to detect molecular markers associated with anti-malarial drug resistance can be used to identify locations where further investigations are needed. Methods Dried blood spots were collected from 398 patients (age range 5–59 years, 99% male) with Plasmodium falciparum infections detected using rapid diagnostic tests over two rounds of sample collection conducted in 2016 and 2017 in Komé, South-West Chad. Specimens were genotyped using amplicon sequencing or qPCR for validated markers of anti-malarial resistance including partner drugs used in artemisinin-based combination therapy (ACT). Results No mutations in the pfk13 gene known to be associated with artemisinin resistance were found but a high proportion of parasites carried other mutations, specifically K189T (190/349, 54.4%, 95%CI 49.0–59.8%). Of 331 specimens successfully genotyped for pfmdr1 and pfcrt, 52% (95%CI 46.4–57.5%) carried the NFD-K haplotype, known to be associated with reduced susceptibility to lumefantrine. Only 20 of 336 (6.0%, 95%CI 3.7–9.0%) had parasites with the pfmdr1-N86Y polymorphism associated with increased treatment failures with amodiaquine. Nearly all parasites carried at least one mutation in pfdhfr and/or pfdhps genes but ‘sextuple’ mutations in pfdhfr—pfdhps including pfdhps -A581G were rare (8/336 overall, 2.4%, 95%CI 1.2–4.6%). Only one specimen containing parasites with pfmdr1 gene amplification was detected. Conclusions These results provide information on the likely high efficacy of artemisinin-based combinations commonly used in Chad, but suggest decreasing levels of sensitivity to lumefantrine and high levels of resistance to sulfadoxine-pyrimethamine used for seasonal malaria chemoprevention and intermittent preventive therapy in pregnancy. A majority of parasites had mutations in the pfk13 gene, none of which are known to be associated with artemisinin resistance. A therapeutic efficacy study needs to be conducted to confirm the efficacy of artemether-lumefantrine. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-022-04095-9.
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12
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Slater HC, Ding XC, Knudson S, Bridges DJ, Moonga H, Saad NJ, De Smet M, Bennett A, Dittrich S, Slutsker L, Domingo GJ. Performance and utility of more highly sensitive malaria rapid diagnostic tests. BMC Infect Dis 2022; 22:121. [PMID: 35120441 PMCID: PMC8815208 DOI: 10.1186/s12879-021-07023-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 12/30/2021] [Indexed: 12/03/2022] Open
Abstract
Background A new more highly sensitive rapid diagnostic test (HS-RDT) for Plasmodium falciparum malaria (Alere™/Abbott Malaria Ag P.f RDT [05FK140], now called NxTek™ Eliminate Malaria Ag Pf) was launched in 2017. The test has already been used in many research studies in a wide range of geographies and use cases. Methods In this study, we collate all published and available unpublished studies that use the HS-RDT and assess its performance in (i) prevalence surveys, (ii) clinical diagnosis, (iii) screening pregnant women, and (iv) active case detection. Two individual-level data sets from asymptomatic populations are used to fit logistic regression models to estimate the probability of HS-RDT positivity based on histidine-rich protein 2 (HRP2) concentration and parasite density. The performance of the HS-RDT in prevalence surveys is estimated by calculating the sensitivity and positive proportion in comparison to polymerase chain reaction (PCR) and conventional malaria RDTs. Results We find that across 18 studies, in prevalence surveys, the mean sensitivity of the HS-RDT is estimated to be 56.1% (95% confidence interval [CI] 46.9–65.4%) compared to 44.3% (95% CI 32.6–56.0%) for a conventional RDT (co-RDT) when using nucleic acid amplification techniques as the reference standard. In studies where prevalence was estimated using both the HS-RDT and a co-RDT, we found that prevalence was on average 46% higher using a HS-RDT compared to a co-RDT. For use in clinical diagnosis and screening pregnant women, the HS-RDT was not significantly more sensitive than a co-RDT. Conclusions Overall, the evidence presented here suggests that the HS-RDT is more sensitive in asymptomatic populations and could provide a marginal improvement in clinical diagnosis and screening pregnant women. Although the HS-RDT has limited temperature stability and shelf-life claims compared to co-RDTs, there is no evidence to suggest, given this test has the same cost as current RDTs, it would have any negative impacts in terms of malaria misdiagnosis if it were widely used in all four population groups explored here. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-07023-5.
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Affiliation(s)
- Hannah C Slater
- Diagnostics Program, PATH, Seattle, WA, USA. .,Malaria and Neglected Tropical Diseases, PATH, Seattle, WA, USA.
| | - Xavier C Ding
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | | | - Daniel J Bridges
- PATH Malaria Control and Elimination Partnership in Africa (MACEPA), Lusaka, Zambia
| | - Hawela Moonga
- National Malaria Elimination Centre, Zambia Ministry of Health, Lusaka, Zambia
| | - Neil J Saad
- Médecins Sans Frontières, Phnom Penh, Preah Vihear, Cambodia
| | | | - Adam Bennett
- Malaria and Neglected Tropical Diseases, PATH, Seattle, WA, USA.,Malaria Elimination Initiative, Global Health Group, University of California San Francisco, San Francisco, CA, USA
| | - Sabine Dittrich
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
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13
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OUP accepted manuscript. J Infect Dis 2022; 225:1777-1785. [DOI: 10.1093/infdis/jiac012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
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14
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Kabuya JBB, Ippolito MM, Sikalima J, Tende C, Champo D, Mwakazanga D, Young AMP, Mulenga M, Chongwe G, Manyando C. Safety and efficacy of intermittent presumptive treatment with sulfadoxine-pyrimethamine using rapid diagnostic test screening and treatment with dihydroartemisinin-piperaquine at the first antenatal care visit (IPTp-SP+): study protocol for a randomized controlled trial. Trials 2021; 22:820. [PMID: 34801059 PMCID: PMC8605457 DOI: 10.1186/s13063-021-05745-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/20/2021] [Indexed: 11/23/2022] Open
Abstract
Background Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended by the World Health Organization for the prevention of malaria in pregnancy (MIP)-associated adverse outcomes in high burden areas. However, the efficacy of IPTp-SP has decreased in step with increasing parasite drug resistance. Suitable alternative strategies are needed. Methods This is a protocol for a phase IIIb open-label, two-armed randomized controlled superiority trial to assess the safety and efficacy of a hybrid approach to IPTp combining screening and treatment with dihydroartemisinin-piperaquine (DP) to the current IPTp-SP regimen at the first antenatal care clinic visit. Pregnant women without HIV infection and without signs or symptoms of malaria will be randomized to either standard IPTp-SP or hybrid IPTp-SP plus screening and treatment (IPTp-SP+). In the IPTp-SP+ arm, participants who screen positive by rapid diagnostic test for P. falciparum will be treated with DP at the first antenatal visit while those who screen negative will receive SP per current guidelines. All participants will be administered SP on days 35 and 63 and will be actively followed biweekly up to day 63 and then monthly until delivery. Infants will be followed until 1 year after delivery. The primary endpoint is incident PCR-confirmed MIP at day 42. Secondary endpoints include incident MIP at other time points, placental malaria, congenital malaria, hemoglobin trends, birth outcomes, and incidence of adverse events in infants up to the first birthday. Discussion A hybrid approach to IPTp that combines screening and treatment with an artemisinin-based combination therapy at the first visit with standard IPTp-SP is hypothesized to confer added benefit over IPTp-SP alone in a high malaria transmission area with prevalent SP resistant parasites. Trial registration Pan African Clinical Trials Registry 201905721140808. Registered retrospectively on 11 May 2019 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05745-0.
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Affiliation(s)
- Jean-Bertin Bukasa Kabuya
- Department of Clinical Sciences, Tropical Diseases Research Centre, P.O. Box 71769, Copperbelt Province, Ndola, Zambia.
| | - Matthew M Ippolito
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jay Sikalima
- Department of Clinical Sciences, Tropical Diseases Research Centre, P.O. Box 71769, Copperbelt Province, Ndola, Zambia
| | - Clifford Tende
- Department of Clinical Sciences, Tropical Diseases Research Centre, P.O. Box 71769, Copperbelt Province, Ndola, Zambia
| | - Davies Champo
- Department of Clinical Sciences, Tropical Diseases Research Centre, P.O. Box 71769, Copperbelt Province, Ndola, Zambia
| | - David Mwakazanga
- Department of Clinical Sciences, Tropical Diseases Research Centre, P.O. Box 71769, Copperbelt Province, Ndola, Zambia
| | | | - Modest Mulenga
- Department of Clinical Sciences, Tropical Diseases Research Centre, P.O. Box 71769, Copperbelt Province, Ndola, Zambia
| | - Gershom Chongwe
- Department of Clinical Sciences, Tropical Diseases Research Centre, P.O. Box 71769, Copperbelt Province, Ndola, Zambia
| | - Christine Manyando
- Department of Clinical Sciences, Tropical Diseases Research Centre, P.O. Box 71769, Copperbelt Province, Ndola, Zambia
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15
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Gutman JR, Khairallah C, Stepniewska K, Tagbor H, Madanitsa M, Cairns M, L'lanziva AJ, Kalilani L, Otieno K, Mwapasa V, Meshnick S, Kariuki S, Chandramohan D, Desai M, Taylor SM, Greenwood B, ter Kuile FO. Intermittent screening and treatment with artemisinin-combination therapy versus intermittent preventive treatment with sulphadoxine-pyrimethamine for malaria in pregnancy: a systematic review and individual participant data meta-analysis of randomised clinical trials. EClinicalMedicine 2021; 41:101160. [PMID: 34746720 PMCID: PMC8556518 DOI: 10.1016/j.eclinm.2021.101160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/16/2021] [Accepted: 09/30/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND In sub-Saharan Africa, the efficacy of intermittent preventive therapy in pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) for malaria in pregnancy is threatened by parasite resistance. We conducted an individual-participant data (IPD) meta-analysis to assess the efficacy of intermittent screening with malaria rapid diagnostic tests (RDTs) and treatment of RDT-positive women with artemisinin-based combination therapy (ISTp-ACT) compared to IPTp-SP, and understand the importance of subpatent infections. METHODS We searched MEDLINE and the Malaria-in-Pregnancy Library on May 6, 2021 for trials comparing ISTp-ACT and IPTp-SP. Generalised linear regression was used to compare adverse pregnancy outcomes (composite of small-for-gestational-age, low birthweight (LBW), or preterm delivery) and peripheral or placental Plasmodium falciparum at delivery. The effects of subpatent (PCR-positive, RDT/microscopy-negative) infections were assessed in both arms pooled using multi-variable fixed-effect models adjusting for the number of patent infections. PROSPERO registration: CRD42016043789. FINDINGS Five trials conducted between 2007 and 2014 contributed (10,821 pregnancies), two from high SP-resistance areas where dhfr/dhps quintuple mutant parasites are saturated, but sextuple mutants are still rare (Kenya and Malawi), and three from low-resistance areas (West-Africa). Four trials contributed IPD data (N=10,362). At delivery, the prevalence of any malaria infection (relative risk [RR]=1.08, 95% CI 1.00-1.16, I2=67.0 %) and patent infection (RR=1.02, 0.61-1.16, I2=0.0%) were similar. Subpatent infections were more common in ISTp recipients (RR=1.31, 1.05-1.62, I2=0.0%). There was no difference in adverse pregnancy outcome (RR=1.00, 0.96-1.05; studies=4, N=9,191, I2=54.5%). Subpatent infections were associated with LBW (adjusted RR=1.13, 1.07-1.19), lower mean birthweight (adjusted mean difference=32g, 15-49), and preterm delivery (aRR=1.35, 1.15-1.57). INTERPRETATION ISTp-ACT was not superior to IPTp-SP and may result in more subpatent infections than the existing IPTp-SP policy. Subpatent infections were associated with increased LBW and preterm delivery. More sensitive diagnostic tests are needed to detect and treat low-grade infections. FUNDING Centers for Disease Control and Prevention and Worldwide Antimalarial Resistance Network.
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Affiliation(s)
- Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Carole Khairallah
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
| | - Harry Tagbor
- University of Health and Allied Science, Ho, Ghana
| | | | | | - Anne Joan L'lanziva
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Linda Kalilani
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kephas Otieno
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Victor Mwapasa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Steve Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Simon Kariuki
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | | | - Meghna Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Steve M. Taylor
- Division of Infectious Diseases and Duke Global Health Institute, Duke University Medical Center, Durham, NC, USA
| | | | - Feiko O. ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
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16
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Ter Kuile FO. Towards intermittent preventive therapy in pregnancy with dihydroartemisinin-piperaquine? Clin Pharmacol Ther 2021; 110:1432-1434. [PMID: 34389977 DOI: 10.1002/cpt.2394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/30/2021] [Indexed: 11/05/2022]
Abstract
Malaria is a major cause of adverse pregnancy outcomes in sub-Saharan Africa, but resistance to sulfadoxine-pyrimethamine, the only antimalarial recommended by the World Health Organisation for intermittent preventive therapy, is threatening the gains made in the last two decades. In this issue, Mlugu and colleagues present the results of a trial of dihydroartemisinin-piperaquine as an alternative to sulfadoxine-pyrimethamine. The results are impressive but raise the question why they differ so much from three previous trials.
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Affiliation(s)
- Feiko O Ter Kuile
- Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA, Liverpool, United Kingdom
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Hoyt J, Hill J, Achieng F, Ouma P, Kariuki S, Desai M, Webster J. Healthcare provider and pregnant women's perspectives on the implementation of intermittent screening and treatment with dihydroartemisinin-piperaquine for malaria in pregnancy in western Kenya: a qualitative study. Malar J 2021; 20:291. [PMID: 34187458 PMCID: PMC8243500 DOI: 10.1186/s12936-021-03826-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 06/17/2021] [Indexed: 11/22/2022] Open
Abstract
Background In malaria endemic regions in Kenya, pregnant women are offered long-lasting insecticidal nets and intermittent preventive treatment (IPTp) with sulfadoxine–pyrimethamine (SP) at antenatal care (ANC) to prevent the adverse effects of malaria. Fears of growing SP resistance have heightened the search for alternative strategies. The implementation feasibility of intermittent screening and treatment (ISTp) with dihydroartemisinin–piperaquine (DP) in routine ANC settings was evaluated using qualitative and quantitative methods, including the exploration of healthcare provider and pregnant women’s perceptions. Methods Qualitative methods included data from 13 focus group discussions (FGDs) with pregnant women and 43 in-depth interviews with healthcare providers delivering ANC services. FGDs were conducted with women who had received either ISTp-DP or current policy (IPTp-SP). Thematic analysis was used to explore experiences among women and providers and findings were used to provide insights into results of the parallel quantitative study. Results Women were accepting of testing with rapid diagnostic tests (RDTs) and receiving treatment if malaria positive. Providers perceived DP to be an effective drug and well tolerated by women. Some providers indicated a preference for test and treat strategies to reduce unnecessary exposure to medication in pregnancy, others preferred a hybrid strategy combining screening at every ANC visit followed by IPTp-SP for women who tested negative, due to the perception that RDTs missed some infections and concerns about the growing resistance to SP. Testing with RDTs during ANC was appreciated as it was perceived to reduce wait times. The positive attitude of healthcare providers towards ISTp supports findings from the quantitative study that showed a high proportion (90%) of women were tested at ANC. There were concerns about affordability of DP and the availability of sufficient RDT stocks. Conclusion In ANC settings, healthcare providers and pregnant women found ISTp-DP to be an acceptable strategy for preventing malaria in pregnancy when compared with IPTp-SP. DP was considered an effective anti-malarial and a suitable alternative to IPTp-SP in the context of SP resistance. Despite providers’ lack of confidence in RDT results at current levels of sensitivity and specificity, the quantitative findings show their willingness to test women routinely at ANC. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-021-03826-8.
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Affiliation(s)
- Jenna Hoyt
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Florence Achieng
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
| | - Peter Ouma
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
| | - Simon Kariuki
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
| | - Meghna Desai
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jayne Webster
- Disease Control Department, London School of Tropical Medicine and Hygiene, London, UK
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Okello WO, MacLeod ET, Muhanguzi D, Waiswa C, Welburn SC. Controlling Tsetse Flies and Ticks Using Insecticide Treatment of Cattle in Tororo District Uganda: Cost Benefit Analysis. Front Vet Sci 2021; 8:616865. [PMID: 33829051 PMCID: PMC8019991 DOI: 10.3389/fvets.2021.616865] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/08/2021] [Indexed: 01/09/2023] Open
Abstract
Background: The endemic vector-borne diseases transmitted by tsetse and ticks impose heavy burdens on the livestock keepers in Africa. Applying deltamethrin to the belly, legs, and ears of cattle offers a possibility of mitigating these losses at a cost affordable to livestock keepers. Although studies have quantified the impacts of individual diseases on livestock productivity, little is known about the dual economic benefits of controlling both tsetse and ticks, nor about the number of cattle that need to be treated to confer these benefits. Alongside an epidemiological study in south-east Uganda, a farm level assessment was done to investigate the benefits and costs of spraying different proportions of the village cattle population using this restricted application protocol. Methods: A study comprising 1,902 semi-structured interviews was undertaken over a period of 18 months. Financial data on household income and expenditure on cattle was collected, and cost-benefit analysis was done pre- and post-intervention and for different spraying regimes. The total cost of the intervention was obtained from the implementation costs of the epidemiological study and from expenses incurred by participating farmers enabling examination of benefit-cost ratios and incremental benefit-cost ratios for each treatment regime. Results: The benefit-cost analysis of spraying 25%, 50%, and 75% of the cattle population yielded average benefit-cost ratios of 3.85, 4.51, and 4.46. The incremental benefit-cost ratios from spraying each additional 25% of the cattle population were 11.38, 3.89, and 0.79, showing a very high return on investment for spraying 50% of the population, with returns reducing thereafter. Conclusion: Comparing the gross margins per bovine, the study found that increasing the proportion of cattle sprayed yielded increasing benefits to the farmers, but that these benefits were subject to diminishing returns. From a practical viewpoint, this study recommends spraying only draft cattle to control trypanosomiasis and tick-borne diseases in this area as they make 38.62% of the cattle population, approaching the 50% threshold. In areas with a lower proportion of draft males, farmers could be advised to also include cows.
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Affiliation(s)
- Walter O. Okello
- Infection Medicine, Deanery of Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, United Kingdom
- Commonwealth Scientific and Industrial Research Organisation, Black Mountain Science and Innovation Park, Canberra, ACT, Australia
| | - Ewan T. MacLeod
- Infection Medicine, Deanery of Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, United Kingdom
| | - Dennis Muhanguzi
- Infection Medicine, Deanery of Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, United Kingdom
- Department of Biomolecular and Biolaboratory Sciences, School of Biosecurity, Biotechnical and Laboratory Sciences, College of Veterinary Medicine Animal Resources and Biosecurity, Makerere University, Kampala, Uganda
| | - Charles Waiswa
- Infection Medicine, Deanery of Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, United Kingdom
- Department of Biomolecular and Biolaboratory Sciences, School of Biosecurity, Biotechnical and Laboratory Sciences, College of Veterinary Medicine Animal Resources and Biosecurity, Makerere University, Kampala, Uganda
- The Coordinating Office for Control of Trypanosomiasis in Uganda, Kampala, Uganda
| | - Susan C. Welburn
- Infection Medicine, Deanery of Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, United Kingdom
- Zhejiang University–University of Edinburgh Institute, Zhejiang University, International Campus, Haining, China
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Kitojo C, Chacky F, Kigadye ES, Mugasa JP, Lusasi A, Mohamed A, Walker P, Reaves EJ, Gutman JR, Ishengoma DS. Evaluation of a single screen and treat strategy to detect asymptomatic malaria among pregnant women from selected health facilities in Lindi region, Tanzania. Malar J 2020; 19:438. [PMID: 33256758 PMCID: PMC7708125 DOI: 10.1186/s12936-020-03513-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/19/2020] [Indexed: 02/07/2023] Open
Abstract
Background In areas of high transmission, malaria in pregnancy (MiP) primarily causes asymptomatic infections; these infections nonetheless increase the risk of adverse maternal and fetal outcomes. In 2014, Tanzania initiated a single screening and treatment (SST) strategy for all pregnant women at their first antenatal care (ANC) visit using malaria rapid diagnostic tests (RDT) for surveillance purposes. However, there is paucity of data on the effectiveness of SST in the prevention of MiP. The objective of this study was to estimate the number of asymptomatic infections among pregnant women detected by SST, which would have been missed in the absence of the policy. Methods Data from pregnant women attending their first ANC visits between October 2017 and June 2018, including gestational age, history of fever, and RDT results, were abstracted from ANC registers in eight health centres in two randomly selected districts, Kilwa and Lindi, in Lindi Region. The proportion of symptomatic (with history of fever in the past 48 h) and asymptomatic pregnant women with positive RDTs were calculated and stratified by trimester (first, second and third). The study areas were categorized as low transmission with prevalence < 10% or moderate/high with ≥ 10%. Results Over the study period, 1,845 women attended their first ANC visits; 22.1% were in the first trimester (< 12 weeks gestation age). Overall 15.0% of the women had positive RDTs, and there was a trend towards higher malaria prevalence in the first (15.9%) and second (15.2%) trimesters, compared to the third (7.1%), although the differences were not statistically significant (p = 0.07). In total, 6.9% of women reported fever within the past 48 h and, of these, 96.1% were RDT positive. For every 100 pregnant women in the moderate/high and low transmission areas, SST identified 60 and 26 pregnant women, respectively, with asymptomatic infections that would have otherwise been missed. Among the 15.9% of women detected in the first trimester, 50.7% were asymptomatic. Conclusion In areas of moderate/high transmission, many infected women were asymptomatic, and would have been missed in the absence of SST. The benefits on maternal and fetal birth outcomes of identifying these infections depend heavily on the protection afforded by treatment, which is likely to be greatest for women presenting in the first trimester when intermittent preventive treatment (IPTp) with sulfadoxine-pyrimethamine (SP) is contraindicated, and in areas with high SP resistance, such as most parts of Tanzania. An evaluation of the impact and cost-effectiveness of SST across different transmission strata is warranted.
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Affiliation(s)
- Chonge Kitojo
- US President's Malaria Initiative, United States Agency for International Development, Dar es Salaam, United Republic of Tanzania. .,The Open University of Tanzania, Dar es Salaam, United Republic of Tanzania.
| | - Frank Chacky
- National Malaria Control Programme, Dodoma, United Republic of Tanzania
| | - Emmanuel S Kigadye
- The Open University of Tanzania, Dar es Salaam, United Republic of Tanzania
| | - Joseph P Mugasa
- USAID Boresha Afya Southern Zone, FHI 360, Dar es Salaam, United Republic of Tanzania
| | - Abdallah Lusasi
- National Malaria Control Programme, Dodoma, United Republic of Tanzania
| | - Ally Mohamed
- National Malaria Control Programme, Dodoma, United Republic of Tanzania
| | - Patrick Walker
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Erik J Reaves
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention and US President's Malaria Initiative, Dar es Salaam, United Republic of Tanzania.,Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA
| | - Deus S Ishengoma
- National Institute for Medical Research, Dar Es Salaam, United Republic of Tanzania.,Faculty of Pharmaceutical Sciences, Monash University, Melbourne, Australia.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Hill J, Ouma P, Oluoch S, Bruce J, Kariuki S, Desai M, Webster J. Intermittent screening and treatment with dihydroartemisinin-piperaquine for the prevention of malaria in pregnancy: implementation feasibility in a routine healthcare system setting in western Kenya. Malar J 2020; 19:433. [PMID: 33238999 PMCID: PMC7690090 DOI: 10.1186/s12936-020-03505-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/17/2020] [Indexed: 02/01/2023] Open
Abstract
Background Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended for preventing malaria in pregnancy in areas of moderate-to-high transmission in sub-Saharan Africa. However, due to increasing parasite resistance to SP, research on alternative strategies is a priority. The study assessed the implementation feasibility of intermittent screening and treatment (ISTp) in the second and third trimester at antenatal care (ANC) with malaria rapid diagnostic tests (RDTs) and treatment of positive cases with dihydroartemisinin-piperaquine (DP) compared to IPTp-SP in western Kenya. Methods A 10-month implementation study was conducted in 12 government health facilities in four sub-counties. Six health facilities were assigned to either ISTp-DP or IPTp-SP. Evaluation comprised of facility audits, ANC observations, and exit interviews. Intermediate and cumulative effectiveness analyses were performed on all processes involved in delivery of ISTp-DP including RDT proficiency and IPTp-SP ± directly observed therapy (DOT, standard of care). Logistic regression was used to identify predictors of receiving each intervention. Results A total of 388 and 389 women were recruited in the ISTp-DP and IPTp-SP arms, respectively. For ISTp-DP, 90% (289/320) of eligible women received an RDT. Of 11% (32/289) who tested positive, 71% received the correct dose of DP and 31% the first dose by DOT, and only 6% were counselled on subsequent doses. Women making a sick visit and being tested in a facility with a resident microscopist were more likely to receive ISTp-DP (AOR 1.78, 95% CI 1.31, 2.41; and AOR 3.75, 95% CI 1.31, 2.40, respectively). For IPTp-SP, only 57% received a dose of SP by DOT. Payment for a laboratory test was independently associated with receipt of SP by DOT (AOR 6.43, 95% CI 2.07, 19.98). Conclusions The findings indicate that the systems effectiveness of ANC clinics to deliver ISTp-DP under routine conditions was poor in comparison to IPTp-SP. Several challenges to integration of ISTp with ANC were identified that may need to be considered by countries that have introduced screening at first ANC visit and, potentially, for future adoption of ISTp with more sensitive RDTs. Understanding the effectiveness of ISTp-DP will require additional research on pregnant women’s adherence to ACT.
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Affiliation(s)
- Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Peter Ouma
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
| | - Seth Oluoch
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
| | - Jane Bruce
- Disease Control Department, London School of Tropical Medicine and Hygiene, London, UK
| | - Simon Kariuki
- Kenya Medical Research Institute/Centre for Global Health Research, Kisumu, Kenya
| | - Meghna Desai
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Jayne Webster
- Disease Control Department, London School of Tropical Medicine and Hygiene, London, UK
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