High burden of malaria infection in pregnant women in a rural district of Zambia: a cross-sectional study

Methemoglobin levels in malaria: a systematic review and meta-analysis of its association with Plasmodium falciparum and Plasmodium vivax infections and disease severity

Reports indicate that Plasmodium infections influence methemoglobin levels. However, findings have been inconclusive or have varied across different geographic and demographic contexts. This systematic review and meta-analysis aimed to consolidate existing data regarding the association between Plasmodium infections and alterations in methemoglobin levels related to the severity of the infection. A comprehensive literature search of several databases, including Ovid, ProQuest, Embase, Scopus, MEDLINE, and PubMed, was conducted to identify relevant studies that examined methemoglobin levels in patients with malaria. Qualitative synthesis and meta-analysis of the pooled standardized mean difference were conducted to synthesize the differences in methemoglobin levels between: (1) patients with malaria and those without malaria and (2) patients with severe malaria and those with uncomplicated malaria based on various themes including publication year, study design, study area, Plasmodium species, age group, symptomatic status, severity status, and method of malaria detection. Of the 1846 studies that were initially identified from the main databases and additional searches on Google Scholar, 10 studies met the eligibility criteria and were selected for this review. The systematic review distinctly highlighted an association between malaria and elevated methemoglobin levels, an observation consistent across diverse geographical regions and various Plasmodium species. Furthermore, the meta-analysis confirmed this by demonstrating increased methemoglobin levels in patients with malaria compared to those without malaria (P < 0.001, Hedges' g 2.32, 95% CI 1.36-3.29, I2 97.27, 8 studies). Moreover, the meta-analysis found elevated methemoglobin levels in patients with severe malaria compared to those with uncomplicated malaria (P < 0.001, Hedges' g 2.20, 95% CI 0.82-3.58, I2 96.20, 5 studies). This systematic review and meta-analysis revealed increased methemoglobin levels in patients with P. falciparum and P. vivax infections, with a notable association between elevated methemoglobin levels and severe malaria. Future research should focus on elucidating the specific mechanisms by which changes in methemoglobin levels are related to infections by P. falciparum and P. vivax, particularly in terms of severity, and how these alterations could potentially impact patient management and treatment outcomes.

Intermittent preventive treatment with Sulfadoxine pyrimethamine for malaria: a global overview and challenges affecting optimal drug uptake in pregnant women

Malaria in Pregnancy (MiP) leading to morbidity and mortality is a major public health problem that poses significant risk to pregnant women and their fetus. To cope with this alarming situation, administration of Sulfadoxine-pyrimethamine (SP) drugs to pregnant women as an intermittent preventive treatment (IPT) from 16 weeks of gestation is recommended by the World Health Organization (WHO) guidelines. We conducted a comprehensive search of published articles related to MiP in last 10 years with predefined keywords or their synonyms. The mapping of malaria in pregnant women showed a prevalence rate up to 35% in many countries. Although IPTp-SP has been implemented in endemic regions since several years but the IPTp-SP coverage percentage vary from country to country and continue to remain below the target of 80%. Major reasons for low IPTp-SP involve gestational age at first prenatal visit, level of education, place of residence, knowledge of IPTp-SP benefits, and use of antenatal services. Several challenges including the emergence of septuple and octuple SP-resistant parasites is reported from many countries which make the prophylactic use of IPTp-SP currently debatable. This narrative review addresses the barriers for optimal use of IPTp-SP and discusses alternative approaches to increase the use and effectiveness of SP intervention for preventing MiP. The COVID pandemic has drastically affected the public health disrupting the management of diseases worldwide. In view of this, a brief summary of COVID impact on MiP situation is also included.

Uptake of four or more doses of sulfadoxine pyrimethamine for intermittent preventive treatment of malaria during pregnancy in Zambia: findings from the 2018 malaria in pregnancy survey

OBJECTIVE

To determine the prevalence and predictors of the uptake of four or more doses of sulfadoxine pyrimethamine (IPTp-SP 4+) in Zambia.

DESIGN

A cross-sectional study using secondary data from the malaria in pregnancy survey (Malaria Indicator Survey) data set conducted from April to May 2018.

SETTING

The primary survey was conducted at community level and covered all the 10 provinces of Zambia.

PARTICIPANTS

A total of 3686 women of reproductive age (15-45 years) who gave birth within the 5 years before the survey.

PRIMARY OUTCOME

Proportion of participants with four or more doses of IPTp-SP.

STATISTICAL ANALYSIS

All analyses were conducted using RStudio statistical software V.4.2.1. Descriptive statistics were computed to summarise participant characteristics and IPTp-SP uptake. Univariate logistic regression was carried out to determine association between the explanatory and outcome variables. Explanatory variables with a p value less than 0.20 on univariate analysis were included in the multivariable logistic regression model and crude and adjusted ORs (aORs) along with their 95% CIs were computed (p<0.05).

RESULTS

Of the total sample of 1163, only 7.5% of participants received IPTp-SP 4+. Province of residence and wealth tertile were associated with uptake of IPTp-SP doses; participants from Luapula (aOR=8.72, 95% CI (1.72 to 44.26, p=0.009)) and Muchinga (aOR=6.67, 95% CI (1.19 to 37.47, p=0.031)) provinces were more likely to receive IPTp-SP 4+ compared with to those from Copperbelt province. Conversely, women in the highest wealth tertile were less likely to receive IPTp-SP 4+ doses compared with those in the lowest quintile (aOR=0.32; 95% CI (0.13 to 0.79, p=0.014)).

CONCLUSION

These findings confirm a low uptake of four or more doses of IPTp-SP in the country. Strategies should focus on increased coverage of IPTp-SP in provinces with much higher malaria burden where the risk is greatest and the ability to afford healthcare lowest.

Malaria prevalence in HIV-positive children, pregnant women, and adults: a systematic review and meta-analysis

Background

Malaria in human immunodeficiency virus (HIV)-positive patients is an ever-increasing global burden for human health. The present meta-analysis summarizes published literature on the prevalence of malaria infection in HIV-positive children, pregnant women and adults.

Methods

This study followed the PRISMA guideline. The PubMed, Science Direct, Google Scholar, Scopus and Cochrane databases were searched for relevant entries published between 1 January 1983 and 1 March 2020. All peer-reviewed original papers evaluating the prevalence of malaria among HIV-positive patients were included. Incoherence and heterogeneity between studies were quantified by the I2 index and Cochran’s Q test. Publication and population biases were assessed with funnel plots, and Egger’s regression asymmetry test.

Results

A total of 106 studies were included in this systematic review. The average prevalence of malaria among HIV-positive children, HIV-positive pregnant women and HIV-positive adults was 39.4% (95% confidence interval [CI]: 26.6–52.9), 32.3% (95% CI = 26.3–38.6) and 27.3% (95% CI = 20.1–35.1), respectively. In adult patients with HIV, CD4+ (cluster of differentiation 4) < 200 cells/µl and age < 40 years were associated with a significant increase in the odds of malaria infection (odds ratio [OR] = 1.5, 95% CI = 1.2–1.7 and OR = 1.1, 95% CI = 1–1.3, respectively). Antiretroviral therapy (ART) and being male were associated with a significant decrease in the chance of malaria infection in HIV-positive adults (OR = 0.8, 95% CI = 0.7–0.9 and OR = 0.2, 95% CI = 0.2–0.3, respectively). In pregnant women with HIV, CD4+ count < 200 cells/µl was related to a higher risk for malaria infection (OR = 1.5, 95% CI = 1.1–1.9).

Conclusions

This systematic review demonstrates that malaria infection is concerningly common among HIV-positive children, pregnant women and adults. Among HIV-positive adults, ART medication and being male were associated with a substantial decrease in infection with malaria. For pregnant women, CD4+ count of < 200 cells/µl was a considerable risk factor for malaria infection.

Graphical Abstract

Prevalence and risk factors of malaria among first antenatal care attendees in rural Burkina Faso

BACKGROUND

The WHO recommends continuous surveillance of malaria in endemic countries to identify areas and populations most in need for targeted interventions. The aim of this study was to assess the prevalence of malaria and its associated factors among first antenatal care (ANC) attendees in rural Burkina Faso.

METHODS

A cross-sectional survey was conducted between August 2019 and September 2020 at the Yako health district and included 1067 first ANC attendees. Sociodemographic, gyneco-obstetric, and medical characteristics were collected. Malaria was diagnosed by standard microscopy and hemoglobin level was measured by spectrophotometry. A multivariate logistic regression analysis was used to identify factors associated with malaria infection.

RESULTS

Overall malaria infection prevalence was 16.1% (167/1039). Among malaria-positive women, the geometric mean parasite density was 1204 [95% confidence interval (CI) 934-1552] parasites/µL and the proportion of very low (1-199 parasites/µL), low (200-999 parasites/µL), medium (1000-9999 parasites/µL) and high (≥ 10,000 parasites/µL) parasite densities were 15.0%, 35.3%, 38.3% and 11.4%, respectively. Age < 20 years (adjusted odds ratio (aOR): 2.2; 95% CI 1.4-3.5), anemia (hemoglobin < 11 g/deciliter) (aOR: 3.4; 95% CI 2.2-5.5), the non-use of bed net (aOR: 1.8; 95% CI 1.1-2.8), and the absence of intermittent preventive treatment with sulfadoxine-pyrimethamine (aOR: 5.8; 95% CI 2.1-24.5) were positively associated with malaria infection.

CONCLUSIONS

The study showed that one out of six pregnant women had a microscopy-detected P. falciparum malaria infection at their first ANC visit. Strengthening malaria prevention strategies during the first ANC visit is needed to prevent unfavorable birth outcomes.

Risk factors for Plasmodium falciparum infection in pregnant women in Burkina Faso: a community-based cross-sectional survey

Background

Malaria in pregnancy remains a public health problem in sub-Saharan Africa. Identifying risk factors for malaria in pregnancy could assist in developing interventions to reduce the risk of malaria in Burkina Faso and other countries in the region.

Methods

Two cross-sectional surveys were carried out to measure Plasmodium falciparum infection using microscopy in pregnant women in Saponé Health District, central Burkina Faso. Data were collected on individual, household and environmental variables and their association with P. falciparum infection assessed using multivariable analysis.

Results

A total of 356 pregnant women were enrolled in the surveys, 174 during the dry season and 182 during the wet season. The mean number of doses of sulfadoxine–pyrimethamine for Intermittent Preventive Treatment in pregnancy (IPTp-SP) was 0.4 doses during the first trimester, 1.1 doses at the second and 2.3 doses at the third. Overall prevalence of P. falciparum infection by microscopy was 15.7%; 17.8% in the dry season and 13.7% in the wet season. 88.2% of pregnant women reported sleeping under an insecticide-treated net (ITN) on the previous night. The odds of P. falciparum infection was 65% lower in women who reported using an ITN compared to those that did not use an ITN (Odds ratio, OR = 0.35, 95% CI 0.14–0.86, p = 0.02). IPTp-SP was also associated with reduced P. falciparum infection, with each additional dose of IPTp-SP reducing the odds of infection by 44% (OR = 0.56, 95% CI 0.39–0.79, p = 0.001). Literate women had a 2.54 times higher odds of P. falciparum infection compared to illiterate women (95% CI 1.31–4.91, p = 0.006).

Conclusions

The prevalence of P. falciparum infection among pregnant women remains high in Burkina Faso, although use of IPTp-SP and ITNs were found to reduce the odds of infection. Despite this, compliance with IPTp-SP remains far from that recommended by the National Malaria Control Programme and World Health Organization. Behaviour change communication should be strengthened to encourage compliance with protective malaria control tools during pregnancy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-03896-8.

Assessment of syndromic management of curable sexually transmitted and reproductive tract infections among pregnant women: an observational cross-sectional study

Background

This study estimated the prevalence of curable sexually transmitted and reproductive tract infections (STIs/RTIs) among pregnant women attending antenatal care (ANC) in rural Zambia, evaluated the effectiveness of syndromic management of STIs/RTIs versus reference-standard laboratory diagnoses, and identified determinants of curable STIs/RTIs during pregnancy.

Methods

A total of 1086 pregnant women were enrolled at ANC booking, socio-demographic information and biological samples were collected, and the provision of syndromic management based care was documented. The Piot-Fransen model was used to evaluate the effectiveness of syndromic management versus etiological testing, and univariate and multivariate logistic regression analyses were used to identify determinants of STIs/RTIs.

Results

Participants had a mean age of 25.6 years and a mean gestational age of 22.0 weeks. Of 1084 women, 700 had at least one STI/RTI (64.6%; 95% confidence interval [CI], 61.7, 67.4). Only 10.2% of infected women received any treatment for a curable STI/RTI (excluding syphilis). Treatment was given to 0 of 56 women with chlamydia (prevalence 5.2%; 95% CI, 4.0, 6.6), 14.7% of participants with gonorrhoea (prevalence 3.1%; 95% CI, 2.2, 4.4), 7.8% of trichomoniasis positives (prevalence 24.8%; 95% CI, 22.3, 27.5) and 7.5% of women with bacterial vaginosis (prevalence 48.7%; 95% CI, 45.2, 51.2). An estimated 7.1% (95% CI, 5.6, 8.7) of participants had syphilis and received treatment. Women < 20 years old were more likely (adjusted odds ratio [aOR] = 5.01; 95% CI: 1.23, 19.44) to have gonorrhoea compared to women ≥30. The odds of trichomoniasis infection were highest among primigravidae (aOR = 2.40; 95% CI: 1.69, 3.40), decreasing with each subsequent pregnancy. Women 20 to 29 years old were more likely to be diagnosed with bacterial vaginosis compared to women ≥30 (aOR = 1.58; 95% CI: 1.19, 2.10). Women aged 20 to 29 and ≥ 30 years had higher odds of infection with syphilis, aOR = 3.96; 95% CI: 1.40, 11.20 and aOR = 3.29; 95% CI: 1.11, 9.74 respectively, compared to women under 20.

Conclusions

Curable STIs/RTIs were common and the majority of cases were undetected and untreated. Alternative approaches are urgently needed in the ANC setting in rural Zambia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03573-3.

Sulfadoxine-pyrimethamine parasitological efficacy against Plasmodium falciparum among pregnant women and molecular markers of resistance in Zambia: an observational cohort study

Background

The World Health Organization recommends the provision of intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) at 4-week intervals from gestational week 13 to delivery in areas of moderate to high malaria transmission intensity. However, the effect of IPTp-SP has been compromised in some areas due to parasite resistance, raising the importance of parasitological and chemoprophylactic surveillance, and monitoring SP-resistance markers in the Plasmodium falciparum population.

Methods

Between November 2013 and April 2014 in Nchelenge, Zambia, 1086 pregnant women received IPTp-SP at antenatal-care bookings. Blood samples were collected on day 0, and on day 28 post-treatment to test for malaria parasites and to estimate SP parasitological efficacy in the treatment and prevention of parasitaemia. A random sample of 96, day 0 malaria-positive samples were analysed to estimate the prevalence of SP-resistance markers in the P. falciparum population.

Results

The overall parasitological and prophylactic failure among women who had paired day 0 and day 28 blood slides was 18.6% (95% CI 15.5, 21.8; 109 of 590). Among pregnant women who had asymptomatic parasitaemia on day 0, the day 28 PCR-uncorrected parasitological failure was 30.0% (95% CI 23.7, 36.2; 62 of 207) and the day 28 PCR-corrected parasitological failure was 15.6% (95% CI: 10.6, 20.6; 32 of 205). Among women who tested negative at day 0, 12.3% (95% CI: 9.0, 15.6; 47 of 383) developed parasitaemia at day 28. Among the 96 malaria-positive samples assayed from day 0, 70.8% (95% CI: 60.8, 79.2) contained the DHPS double (Gly-437 + Glu-540) mutation and 92.7% (95% CI: 85.3, 96.5) had the DHFR triple (Asn-108 + Ile-51 + Arg-59) mutation. The quintuple mutation (DHFR triple + DHPS double) and the sextuple mutant (DHFR triple + DHPS double + Arg-581) were found among 68.8% (95% CI: 58.6, 77.3) and 9.4% (95% CI: 4.2, 16.0) of samples, respectively.

Conclusion

The parasitological and chemoprophylactic failure of SP, and the prevalence of resistance markers in Nchelenge is alarmingly high. Alternative therapies are urgently needed to safeguard pregnant women against malarial infection.

Piperaquine Exposure Is Altered by Pregnancy, HIV, and Nutritional Status in Ugandan Women

Dihydroartemisinin-piperaquine (DHA-PQ) provides highly effective therapy and chemoprevention for malaria in pregnant African women. PQ concentrations of >10.3 ng/ml have been associated with reduced maternal parasitemia, placental malaria, and improved birth outcomes. We characterized the population pharmacokinetics (PK) of PQ in a post hoc analysis of human immunodeficiency virus (HIV)-infected and -uninfected pregnant women receiving DHA-PQ as chemoprevention every 4 or 8 weeks. The effects of covariates such as pregnancy, nutritional status (body mass index [BMI]), and efavirenz (EFV)-based antiretroviral therapy were investigated. PQ concentrations from two chemoprevention trials were pooled to create a population PK database from 274 women and 2,218 PK observations. A three-compartment model with an absorption lag best fit the data. Consistent with our prior intensive PK evaluation, pregnancy and EFV use resulted in a 72% and 61% increased PQ clearance, compared to postpartum and HIV-uninfected pregnant women, respectively. Low BMI at 28 weeks of gestation was associated with increased clearance (2% increase per unit decrease in BMI). Low-BMI women given DHA-PQ every 8 weeks had a higher prevalence of parasitemia, malaria infection, and placental malaria compared to women with higher BMIs. The reduced piperaquine exposure in women with low BMI as well as during EFV coadministration, compared to pregnant women with higher BMIs and not taking EFV, suggests that these populations could benefit from weekly instead of monthly dosing for prevention of malaria parasitemia. Simulations indicated that because of the BMI-clearance relationship, weight-based regimens would not improve protection compared to a 2,880 mg fixed-dose regimen when provided monthly. (The clinical trials described in this paper have been registered at ClinicalTrials.gov under identifiers NCT02163447 and NCT02282293.).

Epidemiology of malaria among pregnant women during their first antenatal clinic visit in the middle belt of Ghana: a cross sectional study

Background

Malaria during pregnancy may result in unfavourable outcomes in both mothers and their foetuses. This study sought to document the current burden and factors associated with malaria and anaemia among pregnant women attending their first antenatal clinic visit in an area of Ghana with perennial malaria transmission.

Methods

A total of 1655 pregnant women aged 18 years and above with a gestational age of 13–22 weeks, who attended an antenatal care (ANC) clinic for the first time, were consented and enrolled into the study. A structured questionnaire was used to collect socio-demographic and obstetric data and information on use of malaria preventive measures. Venous blood (2 mL) was collected before sulfadoxine-pyrimethamine administration. Malaria parasitaemia and haemoglobin concentration were determined using microscopy and an automated haematology analyser, respectively. Data analysis was carried out using Stata 14.

Results

Mean age (SD) and gestational age (SD) of women at enrolment were 27.4 (6.2) years and 16.7 (4.3) weeks, respectively. Overall malaria parasite prevalence was 20.4% (95% CI 18.5–22.4%). Geometric mean parasite density was 442 parasites/µL (95% CI 380–515). Among women with parasitaemia, the proportion of very low (1–199 parasites/µL), low (200–999 parasites/µL), medium (1000–9999 parasites/µL) and high (≥ 10,000 parasites/µL) parasite density were 31.1, 47.0, 18.9, and 3.0%, respectively. Age ≥ 25 years (OR 0.57, 95% CI 0.41–0.79), multigravid (OR 0.50, 95% CI 0.33–0.74), educated to high school level or above (OR 0.53, 95% CI 0.33–0.83) and in household with higher socio-economic status (OR 0.34, 95% CI 0.21–0.54) were associated with a lower risk of malaria parasitaemia. The prevalence of anaemia (< 11.0 g/dL) was 56.0%, and the mean haemoglobin concentration in women with or without parasitaemia was 9.9 g/dL or 10.9 g/dL, respectively.

Conclusion

One out of five pregnant women attending their first ANC clinic visit in an area of perennial malaria transmission in the middle belt of Ghana had Plasmodium falciparum infection. Majority of the infections were below 1000 parasites/µL and with associated anaemia. There is a need to strengthen existing malaria prevention strategies to prevent unfavourable maternal and fetal birth outcomes in this population.

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

Introduction

Malaria in pregnancy (‘MiP’) poses risks to mother, foetus and newborn. Studies from Africa and Asia have reported high prevalence of ‘MiP’ and recommended further research to address ‘MiP’. India has a significant burden of ‘MiP’ but most of the studies are a decade old. Hardly any studies exist in India that report on asymptomatic malaria in pregnant women. The current Indian policies for malaria control are silent on ‘MiP’. A campaign was carried out by community health workers (CHWs) in 2019 to screen pregnant women across rural Chhattisgarh.

Methods

This is a cross-sectional study. Malaria was tested in pregnant women by CHWs using bivalent rapid tests. Multi-stage sampling was used to cover 21,572 pregnant women screened across different geographical areas of rural Chhattisgarh. Cross-tabulation and multivariate regression were used to find out the relationship of ‘MiP’ with different symptoms and geographical areas. GIS maps were used to compare malaria in pregnant women against overall febrile population.

Results

In rural Chhattisgarh, malaria was present in 0.81% of the pregnant women at the time of testing. ‘MiP’ prevalence varied across geographies, reaching 4.48% in the geographical division with highest burden. Febrile pregnant women had three times greater malaria-positivity than overall febrile population and both showed a similar geographical pattern.

Discussion

Prevalence of ‘MiP’ was found to be less than earlier studies in the state. Though overall malaria in India has shown some decline, a policy response is needed for ‘MiP’ in high-burden areas. Fever, diarrhoea and jaundice remain relevant symptoms in ‘MiP’, but around one fourth of malaria-positive pregnant-women were afebrile, suggesting the need for strategies to address it.

Conclusion

The current study based on a large sample provides fresh evidence on ‘MiP’ in India. It used CHWs as skilled providers for large-scale screening for malaria. In high-burden areas, intermittent screening and treatment (IST) of all pregnant women can be a useful strategy in order to address ‘MiP’. Pregnant women can be considered as a pertinent sentinel population for malaria. The global and national policies need to evolve concrete strategies for addressing malaria in pregnancy.

Efavirenz-Based Antiretroviral Therapy Reduces Artemether-Lumefantrine Exposure for Malaria Treatment in HIV-Infected Pregnant Women

BACKGROUND

The choice of malaria treatment for HIV-infected pregnant women receiving efavirenz-based antiretroviral therapy must consider the potential impact of drug interactions on antimalarial exposure and clinical response. The aim of this study was to investigate the effects of efavirenz on artemether-lumefantrine (AL) because no studies have isolated the impact of efavirenz for HIV-infected pregnant women.

METHODS

A prospective clinical pharmacokinetic (PK) study compared HIV-infected, efavirenz-treated pregnant women with HIV-uninfected pregnant women in Tororo, Uganda. All women received the standard 6-dose AL treatment regimen for Plasmodium falciparum malaria with intensive PK samples collected over 21 days and 42-days of clinical follow-up. PK exposure parameters were calculated for artemether, its active metabolite dihydroartemisinin (DHA), and lumefantrine to determine the impact of efavirenz.

RESULTS

Nine HIV-infected and 30 HIV-uninfected pregnant women completed intensive PK evaluations. Relative to controls, concomitant efavirenz therapy lowered the 8-hour artemether concentration by 76% (P = 0.013), DHA peak concentration by 46% (P = 0.033), and day 7 and 14 lumefantrine concentration by 61% and 81% (P = 0.046 and 0.023), respectively. In addition, there were nonsignificant reductions in DHA area under the concentration-time curve0-8hr (35%, P = 0.057) and lumefantrine area under the concentration-time curve0-∞ (34%, P = 0.063) with efavirenz therapy.

CONCLUSIONS

Pregnant HIV-infected women receiving efavirenz-based antiretroviral therapy during malaria treatment with AL showed reduced exposure to both the artemisinin and lumefantrine. These data suggest that malaria and HIV coinfected pregnant women may require adjustments in AL dosage or treatment duration to achieve exposure comparable with HIV-uninfected pregnant women.

Levels of knowledge regarding malaria causes, symptoms, and prevention measures among Malawian women of reproductive age

Background

Malawi is a malaria-endemic country and approximately 6 million cases are reported annually. Improving knowledge of malaria causes and symptoms, and the overall perception towards malaria and its preventive measures is vital for malaria control. The current study investigated the levels of knowledge of the causes, symptoms and prevention of malaria among Malawian women.

Methods

Data from the 2017 wave of the Malawi Malaria Indicator Survey (MMIS) were analysed. In total, 3422 women of reproductive age (15–49 years) were sampled and analysed. The levels of women’s knowledge about: (1) causes of malaria; (2) symptoms of malaria; and, (3) preventive measures were assessed. The tertiles of the composite score were used as the cut-offs to categorize the levels of knowledge as ‘low’, ‘medium’ and ‘high’. Multinomial logistic regression models were constructed to assess the independent factors while taking into account the complex survey design.

Results

Approximately 50% of all respondents had high levels of knowledge of causes, symptoms and preventive measures. The high level of knowledge was 45% for rural women and 55% for urban dwellers. After adjusting for the a wide range of factors, women of age group 15–19 years adjusted odds ratio ((aOR): 2.58; 95% Confidence Interval (CI) 1.69–3.92), women with no formal education (aOR: 3.73; 95% CI 2.20–6.33), women whose household had no television (aOR: 1.50; 95% CI 1.02–2.22), women who had not seen/heard malaria message (aOR: 1.53; 95% CI 1.20–1.95), women of Yao tribe (aOR: 1.95; 95% CI 1.10–3.46), and women from rural areas had low levels of knowledge about the causes of malaria, symptoms of malaria and preventive measures. Additionally, the results also showed that women aged 15–19 years (beta [β] = − 0.73, standard error [SE] = 0.12); P < .0001, women with no formal education (β = − 1.17, SE = 0.15); P < .0001, women whose household had no radio (β = − 0.15, SE = 0.0816); P = 0.0715 and women who had not seen or heard malaria message (β = − 0.41, SE = 0.07); P < .0001 were likely to have a lower knowledge score.

Conclusions

The levels of malaria knowledge were reported to be unsatisfactory among adult women, underscoring the need to scale up efforts on malaria education. Beside insecticide-treated bed nets (ITNs) and prompt diagnosis, malaria can be best managed in Malawi by increasing knowledge of malaria causes, and symptoms especially for younger women, women with no formal education, women whose households have no media, women from Yao tribes, and rural dwellers.

Prevalence and Correlates of Asymptomatic Malaria and Anemia on First Antenatal Care Visit among Pregnant Women in Southeast, Tanzania

Asymptomatic malaria and anemia during pregnancy increase the risk of negative birth outcomes. This cross-sectional study investigated the prevalence and correlates of asymptomatic malaria and anemia during first antenatal care (ANC) visit among pregnant women in a rural district, Tanzania. HIV-uninfected pregnant women without symptoms of malaria (n = 819) attending their first ANC at Kibiti Health Centre were enrolled from February 2017 to February 2018. Asymptomatic malaria was detected by malaria rapid-diagnostic tests (mRDT) and real-time PCR. Hemoglobin concentration was determined by HemoCue Hemoglobin 201+. The study outcomes were the prevalence of asymptomatic malaria and anemia (Hemoglobin level <11 g/dL). The overall prevalence of asymptomatic malaria was 36.4% (95% CI: 33.1, 39.8). The monthly prevalence of asymptomatic malaria remained >25% throughout the year, and the highest prevalence (40%) was recorded during the rainy season. Asymptomatic malaria was significantly associated with primigravida, younger maternal age, and anemia. The prevalence of anemia was 68.5% (95% CI: 65.2, 71.6). Asymptomatic malaria, primigravida, younger maternal age and low Body Mass Index were significant predictors of low hemoglobin concentration. We report high prevalence of asymptomatic malaria and anemia among pregnant women on the first ANC visit. Screening of malaria and anemia during the first ANC visit is recommended for targeted interventions.

Improving socioeconomic status may reduce the burden of malaria in sub Saharan Africa: A systematic review and meta-analysis

Background

A clear understanding of the effects of housing structure, education, occupation, income, and wealth on malaria can help to better design socioeconomic interventions to control the disease. This literature review summarizes the relationship of housing structure, educational level, occupation, income, and wealth with the epidemiology of malaria in sub-Saharan Africa (SSA).

Methods

A systematic review and meta-analysis was conducted following the preferred reporting items for systematic reviews and meta-analyses guidelines. The protocol for this study is registered in PROSPERO (ID=CRD42017056070), an international database of prospectively registered systematic reviews. On January 16, 2016, available literature was searched in PubMed, Embase, CINAHL, and Cochrane Library. All but case studies, which reported prevalence or incidence of Plasmodium infection stratified by socioeconomic status among individuals living in SSA, were included without any limits. Odds Ratio (OR) and Relative Risk (RR), together with 95% CI and p-values were used as effect measures. Heterogeneity was assessed using chi-square, Moran’s I², and tau² tests. Fixed (I²<30%), random (I²≥30%) or log-linear dose-response model was used to estimate the summary OR or RR.

Results

After removing duplicates and screening of titles, abstracts, and full text, 84 articles were found eligible for systematic review, and 75 of them were included in the meta-analyses. Fifty-seven studies were cross-sectional, 12 were prospective cohort, 10 were case-control, and five were randomized control trials. The odds of Plasmodium infection increased among individuals who were living in poor quality houses (OR 2.13, 95% CI 1.56–3.23, I² = 27.7), were uneducated (OR 1.36, 95% CI 1.19–1.54, I² = 72.4.0%), and were farmers by occupation (OR 1.48, 95% CI 1.11–1.85, I² = 0.0%) [p<0.01 for all]. The odds of Plasmodium infection also increased with a decrease in the income (OR 1.02, 95% CI 1.01–1.03, tau²<0.001), and wealth index of individuals (OR 1.25, 95% CI 1.18–1.35, tau² = 0.028) [p<0.001 for both]. Longitudinal studies also showed an increased risk of Plasmodium infection among individuals who were living in poor quality houses (RR 1.86, 95% CI 1.47–2.25, I² = 0.0%), were uneducated (OR 1.27, 1.03–1.50, I² = 0.0%), and were farmers (OR 1.36, 1.18–1.58) [p<0.01 for all].

Conclusions

Lack of education, low income, low wealth, living in poorly constructed houses, and having an occupation in farming may increase risk of Plasmodium infection among people in SSA. Public policy measures that can reduce inequity in health coverage, as well as improve economic and educational opportunities for the poor, will help in reducing the burden of malaria in SSA.

Uptake of intermittent preventive treatment and pregnancy outcomes: health facilities and community surveys in Chókwè district, southern Mozambique

Background

Malaria in pregnancy leads to serious adverse effects on the mother and the child and accounts for 75,000–200,000 infant deaths every year. Currently, the World Health Organization recommends intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine–pyrimethamine (SP) at each scheduled antenatal care (ANC) visit. This study aimed to assess IPTp-SP coverage in mothers delivering in health facilities and at the community. In addition, factors associated with low IPTp-SP uptake and malaria adverse outcomes in pregnancy were investigated.

Methods

A community and a health facility-based surveys were conducted in mothers delivering in Chókwè district, southern Mozambique. Social-demographic data, malaria prevention practices and obstetric history were recorded through self-report and antenatal records. For women delivering at health facilities, a clinical examination of mother and child was performed, and malaria infection at delivery was determined by rapid diagnostic test, microscopy, quantitative PCR and placental histology.

Results

Of 1141 participants, 46.6, 30.2, 13.5 and 9.6% reported taking ≥ 3, two, one and none SP doses, respectively. Low IPTp uptake (< 3 doses) was associated with non-institutional deliveries (AOR = 2.9, P < 0.001), first ANC visit after week 28 (AOR = 5.4, P < 0.001), low awareness of IPTp-SP (AOR = 1.6, P < 0.002) and having no or only primary education (AOR = 1.3, P = 0.041). The overall prevalence of maternal malaria (peripheral and/or placental) was 16.8% and was higher among women from rural areas compared to those from urban areas (AOR = 1.9, P < 0.001). Younger age (< 20 years; AOR = 1.6, P = 0.042) and living in rural areas (AOR = 1.9, P < 0.001) were predictors of maternal malaria at delivery. Being primigravidae (AOR = 2.2, P = 0.023) and preterm delivery (AOR = 2.6, P < 0.001) predicted low birth weight while younger age was also associated with premature delivery (AOR = 1.4, P = 0.031).

Conclusion

The coverage for two and ≥ 3 doses of IPTp-SP is moderately higher than estimates from routine health facility records in Gaza province in 2015. However, this is still far below the national target of 80% for ≥ 3 doses. Ongoing campaigns aiming to increase the use of malaria prevention strategies during pregnancy should particularly target rural populations, increasing IPTp-SP knowledge, stimulate early visits to ANC, improve access to health services and the quality of the service provided.

Electronic supplementary material

The online version of this article (10.1186/s12936-018-2255-z) contains supplementary material, which is available to authorized users.

Seasonal Dynamics of Malaria in Pregnancy in West Africa: Evidence for Carriage of Infections Acquired Before Pregnancy Until First Contact with Antenatal Care

In malaria-endemic areas, Plasmodium falciparum prevalence is often high in young women because of 1) low use of insecticide-treated nets before their first pregnancy and 2) acquired immunity, meaning infections are asymptomatic and thus untreated. Consequently, a common source of malaria in pregnancy (MiP) may be infected women becoming pregnant, rather than pregnant women becoming infected. In this study, prevalence of infection was determined by microscopy at first antenatal care (ANC) visit in primigravidae and secundigravidae in Ghana, Burkina Faso, Mali, and The Gambia, four countries with strong seasonal variations in transmission. Duration of pregnancy spent in the rainy season and other risk factors for infection were evaluated using multivariable Poisson regression. We found that the overall prevalence of malaria at first ANC was generally high and increased with time spent pregnant during the rainy season: prevalence among those with the longest exposure was 59.7% in Ghana, 56.7% in Burkina Faso, 42.2% in Mali, and 16.8% in Gambia. However, the prevalence was substantial even among women whose entire pregnancy before first ANC had occurred in the dry season: 41.3%, 34.4%, 11.5%, and 7.8%, respectively, in the four countries. In multivariable analysis, risk of infection was also higher among primigravidae, younger women, and those of lower socioeconomic status, independent of seasonality. High prevalence among women without exposure to high transmission during their pregnancy suggests that part of the MiP burden results from long-duration infections, including those acquired preconception. Prevention of malaria before pregnancy is needed to reduce the MiP burden.

Antiretroviral Therapy With Efavirenz Accentuates Pregnancy-Associated Reduction of Dihydroartemisinin-Piperaquine Exposure During Malaria Chemoprevention

Dihydroartemisinin (DHA)-piperaquine is promising for malaria chemoprevention in pregnancy. We assessed the impacts of pregnancy and efavirenz-based antiretroviral therapy on exposure to DHA and piperaquine in pregnant Ugandan women. Intensive sampling was performed at 28 weeks gestation in 31 HIV-uninfected pregnant women, in 27 HIV-infected pregnant women receiving efavirenz, and in 30 HIV-uninfected nonpregnant women. DHA peak concentration and area under the concentration time curve (AUC0-8hr ) were 50% and 47% lower, respectively, and piperaquine AUC0-21d was 40% lower in pregnant women compared to nonpregnant women. DHA AUC0-8hr and piperaquine AUC0-21d were 27% and 38% lower, respectively, in pregnant women receiving efavirenz compared to HIV-uninfected pregnant women. Exposure to DHA and piperaquine were lower among pregnant women and particularly in women on efavirenz, suggesting a need for dose modifications. The study of modified dosing strategies for these populations is urgently needed.

Sulfadoxine-Pyrimethamine Exhibits Dose-Response Protection Against Adverse Birth Outcomes Related to Malaria and Sexually Transmitted and Reproductive Tract Infections

Background.

We conducted a prospective cohort study in Zambia among pregnant women who received intermittent preventive treatment using sulfadoxine-pyrimethamine (IPTp-SP).

Methods.

We calculated the odds ratios (ORs) of adverse birth outcomes by IPTp-SP exposure, 0–1 dose (n = 126) vs ≥2 doses (n = 590) and ≥2 doses (n = 310) vs ≥3 doses (n = 280) in 7 categories of malaria infection and sexually transmitted and reproductive tract infections (STIs/RTIs).

Results.

We found no significant differences in baseline prevalence of infection across IPTp-SP exposure groups. However, among women given 2 doses compared to 0–1 dose, the odds of any adverse birth outcome were reduced 45% (OR, 0.55; 95% confidence interval [CI], 0.36, 0.86) and 13% further with ≥3 doses (OR, 0.43; 95% CI, 0.27, 0.68). Two or more doses compared to 0–1 dose reduced preterm delivery by 58% (OR, 0.42; 95% CI, 0.27, 0.67) and 21% further with ≥3 doses (OR, 0.21; 95% CI, 0.13, 0.35). Women with malaria at enrollment who received ≥2 doses vs 0-1 had 76% lower odds of any adverse birth outcome (OR, 0.24; 95% 0.09, 0.66), and Neisseria gonorrhoeae and/or Chlamydia trachomatis had 92% lower odds of any adverse birth outcome (OR, 0.08; 95% CI, 0.01, 0.64). Women with neither a malaria infection nor STIs/RTIs who received ≥2 doses had 73% fewer adverse birth outcomes (OR, 0.27; 95% CI, 0.11, 0.68).

Conclusions.

IPTp-SP appears to protect against malaria, STIs/RTIs, and other unspecified causes of adverse birth outcome.

Predictors of the use of interventions to prevent malaria in pregnancy in Cameroon

BACKGROUND

Malaria in pregnancy is common in sub-Saharan Africa where it contributes to perinatal morbidity and mortality. Use of insecticide-treated bed nets and intermittent preventive therapy with sulfadoxine-pyrimethamine during pregnancy are effective but underutilized interventions to prevent infection. Factors associated with bed net ownership and usage, and use of prophylaxis among recently pregnant women in Cameroon were investigated.

METHODS

National data from the 2011 Cameroon Demographic Health Survey was used to identify women with a pregnancy within the previous 5 years. Logistic regression models were created to assess for independent predictors of reported bed net ownership, bed net usage, and the use of malaria prophylaxis medications during pregnancy.

RESULTS

Nearly one in two women surveyed had a recent pregnancy (n = 7647). In this group, bed net ownership and usage rates were low (33.7 and 16.9%, respectively); 61.6% used medication for malaria prophylaxis during pregnancy. Bed net ownership and usage were associated with maternal literacy (aOR 1.4 for net usage, 95% CI 1.1-1.8) and the presence of children under age 5 in the home (aOR 2.3 for net usage, 95% CI 1.6-3.3). The use of malaria prophylaxis medication was associated with measures of healthcare access (aOR 17.8, 95% CI 13-24.5 for ≥4 antenatal care visits), higher maternal education (aOR 1.5, 95% CI 1.1-2.1) and maternal literacy (aOR 1.4, 95% CI 1.1-1.7).

CONCLUSIONS

Women in Cameroon and their antenatal providers missed many opportunities to prevent malaria in pregnancy. Efforts toward ensuring universal bed net provision, consistent antenatal care and the education of girls are likely to improve birth outcomes attributable to malaria infection.

Changes in Malaria Epidemiology in Africa and New Challenges for Elimination

Although the burden of Plasmodium falciparum malaria is gradually declining in many parts of Africa, it is characterized by spatial and temporal variability that presents new and evolving challenges for malaria control programs. Reductions in the malaria burden need to be sustained in the face of changing epidemiology whilst simultaneously tackling significant pockets of sustained or increasing transmission. Large-scale, robust surveillance mechanisms that measure rather than estimate the actual burden of malaria over time from large areas of the continent where such data are lacking need to be prioritized. We review these fascinating developments, caution against complacency, and make the case that improving the extent and quality of malaria surveillance is vital for Africa as she marches on towards elimination.

Malarial Infection and Curable Sexually Transmitted and Reproductive Tract Infections Among Pregnant Women in a Rural District of Zambia

Malarial infection and curable sexually transmitted and reproductive tract infections (STIs/RTIs) are important causes of adverse birth outcomes. Reducing the burden of these infections in pregnancy requires interventions that can be easily integrated into the antenatal care (ANC) package. However, efforts to integrate the control of malarial infection and curable STIs/RTIs in pregnancy have been hampered by a lack of evidence related to their coinfection. Thus, we investigated the prevalence of coinfection among pregnant women of rural Zambia. A prospective cohort study was conducted in Nchelenge District, Zambia, involving 1,086 first ANC attendees. We screened participants for peripheral malarial infection and curable STIs/RTIs (syphilis, Chlamydia, gonorrhea, trichomoniasis, and bacterial vaginosis), and collected relevant sociodemographic data at booking. Factors associated with malarial and STI/RTI coinfection were explored using univariate and multivariate regression models. Among participants with complete results (N = 1,071), 38.7% (95% confidence interval [CI] = 35.7-41.6) were coinfected with malaria parasites and at least one STI/RTI; 18.9% (95% CI = 16.5-21.2) were infected with malaria parasites only; 26.0% (95% CI = 23.5-28.8) were infected with at least one STI/RTI but no malaria parasites, and 16.4% (95% CI = 14.1-18.6) had no infection. Human immunodeficiency virus (HIV)-infected women had a higher risk of being coinfected than HIV-uninfected women (odds ratio [OR] = 3.59 [95% CI = 1.73-7.48], P < 0.001). The prevalence of malarial and STI/RTI coinfection was high in this population. An integrated approach to control malarial infection and STIs/RTIs is needed to reduce this dual burden in pregnancy.