1
|
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.
Collapse
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.
| |
Collapse
|
2
|
Haileselassie W, Habtemichael M, Adam R, Haidar J, David RE, Belachew A, Mengesha AT, Koepfli C, Deressa W, Parker DM, Kassaw NA. OUP accepted manuscript. Int Health 2022; 15:289-298. [PMID: 35488366 PMCID: PMC10153552 DOI: 10.1093/inthealth/ihac024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/30/2021] [Accepted: 03/31/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Insecticide-treated net (ITN) use is among the most recommended strategies to prevent malaria in pregnancy. We analysed the regional and socio-economic patterns of ITN use among pregnant women in Kenya using data from the 2003, 2008 and 2014 Kenyan Demographic and Health Surveys (KDHSs). METHODS Inequality was assessed using four dimensions: economic status, education, place of residence and region. Both relative and absolute summary measures were applied. In addition, simple and complex summary measures, i.e. difference, population attributable fraction, population attributable risk and ratio were considered based on the number of subgroups in each variable. RESULTS There was overt inequality in the use of ITNs among pregnant women, with greater use among the better-off group in 2003 and 2014. Greater ITN use was also observed among pregnant women with a higher level of education. Pregnant women from urban settings tended to use ITNs (slept under a net the night before the survey) more than their rural counterparts in the 2003 KDHS. There were significant regional variations across the three surveys in all inequality summary measures, except ratio in the 2014 survey. CONCLUSIONS Significant inequality in ITN use among pregnant women was observed at a macro scale.
Collapse
Affiliation(s)
- Werissaw Haileselassie
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Mizan Habtemichael
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ruth Adam
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Jemal Haidar
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Randy E David
- Program in Public Health, College of Health Sciences, University of California at Irvine, Irvine, CA 92697, USA
| | - Ayele Belachew
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abenet Tafesse Mengesha
- School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Cristian Koepfli
- Eck Institute for Global Health, Department of Biological Sciences, 319 Galvin Life Sciences, University of Notre Dame, South Bend, IN 46556, USA
| | - Wakgari Deressa
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Daniel M Parker
- Program in Public Health, College of Health Sciences, University of California at Irvine, Irvine, CA 92697, USA
| | | |
Collapse
|
3
|
Anemia among Women of Reproductive Age: An Overview of Global Burden, Trends, Determinants, and Drivers of Progress in Low- and Middle-Income Countries. Nutrients 2021; 13:nu13082745. [PMID: 34444903 PMCID: PMC8401240 DOI: 10.3390/nu13082745] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 12/03/2022] Open
Abstract
Relatively little progress has been made in reducing anemia prevalence among women of reproductive age (WRA anemia). Interventions, policies and programs aimed at reducing WRA anemia have the potential to improve overall not only women’s, but also children’s health and nutrition outcomes. To our knowledge, this is the first review that aimed to compile evidence on the determinants and drivers of WRA anemia reduction in low- and middle-income countries (LMICs). We synthesized the available evidence on the determinants and drivers, including government policies and programs, of WRA anemia and their mitigation strategies across a wide range of countries and geographies, thus contributing to the complex and multifactorial etiology of anemia. We carried out a systematic review of published peer-reviewed and grey literature assessing national or subnational decline in WRA anemia prevalence and the associated drivers in LMICs. Among the 21 studies meeting our inclusion criteria, proximal determinants of healthcare utilization, especially during pregnancy and with the use of contraceptives, were strong drivers of WRA anemia reduction. Changes in other maternal characteristics, such as an increase in age at first pregnancy, BMI, birth spacing, and reduction in parity, were associated with modest improvements in anemia prevalence. Access to fortified foods, especially iron-fortified flour, was also a predictor of a decrease in WRA anemia. Of the intermediate determinants, an increase in household wealth, educational attainment and access to improved sanitation contributed significantly to WRA anemia reduction. Although several common determinants emerged at the proximal and intermediate levels, the set of anemia determinants and the strength of the association between each driver and WRA anemia reduction were unique in each setting included in this review. Further research is needed to provide targeted recommendations for each country and region where WRA anemia prevalence remains high.
Collapse
|
4
|
Agyeman YN, Newton S, Annor RB, Owusu-Dabo E. Intermittent preventive treatment comparing two versus three doses of sulphadoxine pyrimethamine (IPTp-SP) in the prevention of anaemia in pregnancy in Ghana: A cross-sectional study. PLoS One 2021; 16:e0250350. [PMID: 33878140 PMCID: PMC8057609 DOI: 10.1371/journal.pone.0250350] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 04/06/2021] [Indexed: 11/30/2022] Open
Abstract
In 2012 the World Health Organisation (WHO) revised the policy on Intermittent Preventive Treatment with Sulphadoxine Pyrimethamine (IPTp-SP) to at least three doses for improved protection against malaria parasitaemia and its associated effects such as anaemia during pregnancy. We assessed the different SP dosage regimen available under the new policy to determine the dose at which women obtained optimal protection against anaemia during pregnancy. A cross-sectional study was conducted among pregnant women who attended antenatal clinic at four different health facilities in Ghana. The register at the facilities served as a sampling frame and simple random sampling was used to select all the study respondents; they were enrolled consecutively as they kept reporting to the facility to receive antenatal care to obtain the required sample size. The haemoglobin level was checked using the Cyanmethemoglobin method. Multivariable logistic regression was performed to generate odds ratios, confidence intervals and p-values. The overall prevalence of anaemia among the pregnant women was 62.6%. Pregnant women who had taken 3 or more doses of IPTp-SP had anaemia prevalence of 54.1% compared to 66.6% of those who had taken one or two doses IPTp-SP. In the multivariable logistic model, primary (aOR 0.61; p = 0.03) and tertiary education (aOR 0.40; p = <0.001) decreased the odds of anaemia in pregnancy. Further, pregnant women who were anaemic at the time of enrollment (aOR 3.32; p = <0.001) to the Antenatal Care clinic and had malaria infection at late gestation (aOR 2.36; p = <0.001) had higher odds of anaemia in pregnancy. Anaemia in pregnancy remains high in the Northern region of Ghana. More than half of the pregnant women were anaemic despite the use of IPTp-SP. Maternal formal education reduced the burden of anaemia in pregnancy. The high prevalence of anaemia in pregnancy amid IPTp-SP use in Northern Ghana needs urgent attention to avert negative maternal and neonatal health outcomes.
Collapse
Affiliation(s)
- Yaa Nyarko Agyeman
- Department of Population and Reproductive Health, School of Public Health, University for Development Studies, Tamale, Ghana
| | - Sam Newton
- Department of Global and International Health, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Ellis Owusu-Dabo
- Department of Global and International Health, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| |
Collapse
|
5
|
Chua CLL, Hasang W, Rogerson SJ, Teo A. Poor Birth Outcomes in Malaria in Pregnancy: Recent Insights Into Mechanisms and Prevention Approaches. Front Immunol 2021; 12:621382. [PMID: 33790894 PMCID: PMC8005559 DOI: 10.3389/fimmu.2021.621382] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/23/2021] [Indexed: 12/13/2022] Open
Abstract
Pregnant women in malaria-endemic regions are susceptible to malaria in pregnancy, which has adverse consequences on birth outcomes, including having small for gestational age and preterm babies. These babies are likely to have low birthweights, which predisposes to infant mortality and lifelong morbidities. During malaria in pregnancy, Plasmodium falciparum-infected erythrocytes express a unique variant surface antigen, VAR2CSA, that mediates sequestration in the placenta. This process may initiate a range of host responses that contribute to placental inflammation and dysregulated placental development, which affects placental vasculogenesis, angiogenesis and nutrient transport. Collectively, these result in the impairment of placental functions, affecting fetal development. In this review, we provide an overview of malaria in pregnancy and the different pathological pathways leading to malaria in pregnancy-associated low birthweight. We also discuss current prevention and management strategies for malaria in pregnancy, and some potential therapeutic interventions that may improve birth outcomes. Lastly, we outline some priorities for future research that could bring us one step closer to reducing this health burden.
Collapse
Affiliation(s)
| | - Wina Hasang
- Department of Medicine at Royal Melbourne Hospital, Peter Doherty Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Stephen J Rogerson
- Department of Medicine at Royal Melbourne Hospital, Peter Doherty Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Andrew Teo
- Department of Medicine at Royal Melbourne Hospital, Peter Doherty Institute, University of Melbourne, Melbourne, VIC, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| |
Collapse
|
6
|
Chaponda EB, Mharakurwa S, Michelo C, Bruce J, Chandramoha D, Matthew Chico R. Sulfadoxine-pyrimethamine parasitological efficacy against Plasmodium falciparum among pregnant women and molecular markers of resistance in Zambia: an observational cohort study. Malar J 2021; 20:61. [PMID: 33482823 PMCID: PMC7821718 DOI: 10.1186/s12936-021-03596-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/15/2021] [Indexed: 11/10/2022] Open
Abstract
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.
Collapse
Affiliation(s)
| | | | - Charles Michelo
- Department of Epidemiology, School of Public Health, University of Zambia, Lusaka, Zambia.,Strategic Centre for Health Systems Metrics and Evaluations, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Jane Bruce
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Daniel Chandramoha
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - R Matthew Chico
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
7
|
Agyeman YN, Newton SK, Annor RB, Owusu-Dabo E. The Effectiveness of the Revised Intermittent Preventive Treatment with Sulphadoxine Pyrimethamine (IPTp-SP) in the Prevention of Malaria among Pregnant Women in Northern Ghana. J Trop Med 2020; 2020:2325304. [PMID: 33299426 PMCID: PMC7704196 DOI: 10.1155/2020/2325304] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/09/2020] [Accepted: 10/26/2020] [Indexed: 11/28/2022] Open
Abstract
This study investigated the effectiveness of the World Health Organization (WHO)-revised Intermittent Preventive Treatment using Sulphadoxine Pyrimethamine (IPTp-SP) dosage regimen in the prevention of malaria infections in pregnancy. The study involved a prospective cohort of pregnant women who attended the antenatal clinic in four health facilities (Tamale Teaching Hospital, Tamale West Hospital, Tamale Central Hospital, and Tamale SDA Hospital) within the Tamale metropolis. Data collection spanned a period of 12 months, from September 2016 to August 2017, to help account for seasonality in malaria. The study included 1181 pregnant women who attended antenatal clinics in four hospitals within the metropolis. The registers at the facilities served as a sampling frame, and the respondents were randomly sampled out from the number of pregnant women available during each visit. They were enrolled consecutively as they kept reporting to the facility to receive antenatal care. The participants were stratified into three groups; the no IPTp-SP, <3 doses of IPTp-SP, and ≥3 doses of IPTp-SP. The participants were followed up until 36 weeks of gestation, and blood samples were analyzed to detect the presence of peripheral malaria parasites. At the end of the study, 42.4% of the women had taken at least 3 doses of SP based on the revised WHO IPTp-SP policy. Pregnant women who had taken at least 3 doses of IPTp-SP had a malaria prevalence of 16.9% at 36 weeks of gestation, compared to 35.8% of those who had not taken IPTp-SP. In the multivariable logistic regression, those who had taken ≥3 doses of SP were associated with 56% reduced odds (aOR 0.44, CI 0.27-0.70, P = 0.001) of late gestational peripheral malaria, compared with those who did not take SP. IPTp-SP served under three or more doses provided a dose-dependent protection of 56% against maternal peripheral malaria parasitaemia detectable at the later stages of gestation (36 weeks). Since the dose-dependent potency of IPTp-SP depletes with time, there is the need for research into more sustainable approaches that offer longer protection.
Collapse
Affiliation(s)
- Yaa Nyarko Agyeman
- Department of Population and Reproductive Health, School of Public Health, University for Development Studies, Tamale, Ghana
| | - Sam Kofi Newton
- Department of Global and International Health, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Ellis Owusu-Dabo
- Department of Global and International Health, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| |
Collapse
|
8
|
Impact of Health Systems on the Implementation of Intermittent Preventive Treatment for Malaria in Pregnancy in Sub-Saharan Africa: A Narrative Synthesis. Trop Med Infect Dis 2020; 5:tropicalmed5030134. [PMID: 32842592 PMCID: PMC7558380 DOI: 10.3390/tropicalmed5030134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 11/16/2022] Open
Abstract
Malaria in pregnancy is a public health challenge with serious negative maternal and newborn consequences. Intermittent preventive treatment (IPTp) with sulphadoxine-pyrimethamine is recommended for the control of malaria during pregnancy within endemic areas, but coverage for the recommended ≥3 doses IPTp regimen has remained suboptimal. We searched PubMed, Cochrane library, and HINARI database from 1 January 2010 to 23 May 2020, for studies investigating the effect of the health system on IPTp implementation. Data extraction was independently performed by two investigators and evaluated for quality and content. Health system barriers and facilitators were explored using thematic analysis and narrative synthesis. Thirty-four out of 1032 screened articles were included. Key health system issues affecting the provision and uptake of IPTp were the ambiguity of policy and guidelines for IPTp administration, human resource shortages, drug stock-outs, conflicting policy implementation on free IPTp provision, hidden costs, unclear data recording and reporting guidelines, and poor quality of care. Factors affecting the supply and demand for IPTp services involve all pillars of the health system across different countries. The success of health programs such as IPTp will thus depend on how well the different pillars of the health system are articulated towards the success of each program.
Collapse
|
9
|
Azizi SC. Uptake of intermittent preventive treatment for malaria during pregnancy with Sulphadoxine-Pyrimethamine in Malawi after adoption of updated World Health Organization policy: an analysis of demographic and health survey 2015-2016. BMC Public Health 2020; 20:335. [PMID: 32178658 PMCID: PMC7077170 DOI: 10.1186/s12889-020-08471-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/05/2020] [Indexed: 11/21/2022] Open
Abstract
Background Malawi adopted the 2012 updated Word Health Organization (WHO) Intermittent preventive treatment of malaria during pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) policy in 2013. This study aimed to estimate the proportion of and identify factors associated with the uptake of at least three doses of IPTp with SP among pregnant women in Malawi after the adoption and operationalisation of updated WHO IPTp-SP policy. Methods The 2015–16 Malawi Demographic and Health Survey dataset was analysed. Of 1219 women aged 15–49 years who had live births and the children were born after the date of July 2015, 1069 women were included in the analysis. Bivariate and multiple logistic regression were used in data analysis. The statistical analysis took into account a complex survey sample design. Results Of the 1069 women, 447 (42, 95% CI: 38.1–45.6) received three (optimal) or more doses of IPTp-SP. Less than half (47%) managed to attend at least four antenatal care (ANC) clinics. Only 52% received optimal SP doses among those who made at least four ANC visits. Only the number of ANC visits was associated with the optimal uptake of SP. Women who attended ANC three times only and those who visited ANC once or twice only were less likely to receive at least three doses of SP than those who managed to attend ANC at least four times during pregnancy (AOR = 0.71, 95% CI 0.49–1.02) and (AOR = 0.12, 95% CI 0.06–0.21) respectively. Conclusions To achieve effective malaria prevention in pregnancy, IPTP-SP is used alongside other interventions. However, there is low uptake of optimal SP doses in Malawi, and this seems to be associated with the number of ANC visits. Moreover, there is limited effectiveness of an increased number of ANC visits on the uptake of optimal SP doses. Further research should be done to explore health systems factors affecting uptake of optimal IPTp with SP doses during pregnancy.
Collapse
Affiliation(s)
- Steven Chifundo Azizi
- Malawi Defence Force, Malawi Military Health Services, Kamuzu Barracks, Lilongwe, Malawi.
| |
Collapse
|
10
|
Divala TH, Mungwira RG, Mawindo PM, Nyirenda OM, Kanjala M, Ndaferankhande M, Tsirizani LE, Masonga R, Muwalo F, Boudová S, Potter GE, Kennedy J, Goswami J, Wylie BJ, Muehlenbachs A, Ndovie L, Mvula P, Mbilizi Y, Tomoka T, Laufer MK. Chloroquine as weekly chemoprophylaxis or intermittent treatment to prevent malaria in pregnancy in Malawi: a randomised controlled trial. THE LANCET. INFECTIOUS DISEASES 2018; 18:1097-1107. [PMID: 30195996 PMCID: PMC6217965 DOI: 10.1016/s1473-3099(18)30415-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 06/01/2018] [Accepted: 06/19/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Sulfadoxine-pyrimethamine resistance threatens efficacy of intermittent preventive treatment of malaria during pregnancy, and alternative regimens need to be identified. With the return of chloroquine efficacy in southern Africa, we postulated that chloroquine either as an intermittent therapy or as weekly chemoprophylaxis would be more efficacious than intermittent sulfadoxine-pyrimethamine for prevention of malaria in pregnancy and associated maternal and newborn adverse outcomes. METHODS We did an open-label, single-centre, randomised controlled trial at Ndirande Health Centre, Blantyre, in southern Malawi. We enrolled pregnant women (first or second pregnancy) at 20-28 weeks' gestation who were HIV negative. Participants were randomly assigned in a 1:1:1 ratio using a computer-generated list to either intermittent sulfadoxine-pyrimethamine (two doses of 1500 mg sulfadoxine and 75 mg pyrimethamine, 4 weeks apart), intermittent chloroquine (two doses of 600 mg on day 1, 600 mg on day 2, and 300 mg on day 3), or chloroquine prophylaxis (600 mg on day 1 then 300 mg every week). The primary endpoint was placental malaria in the modified intent-to-treat population, which consisted of participants who contributed placental histopathology data at birth. Secondary outcomes included clinical malaria, maternal anaemia, low birthweight, and safety. This trial is registered with ClinicalTrials.gov, number NCT01443130. FINDINGS Between February, 2012, and May, 2014, we enrolled and randomly allocated 900 women, of whom 765 contributed histopathological data and were included in the primary analysis. 108 (14%) women had placental malaria, which was lower than the anticipated prevalence of placental malaria infection. Protection from placental malaria was not improved by chloroquine as either prophylaxis (30 [12%] of 259 had positive histopathology; relative risk [RR] 0·75, 95% CI 0·48-1·17) or intermittent therapy (39 [15%] of 253; RR 1·00, 0·67-1·50) compared with intermittent sulfadoxine-pyrimethamine (39 [15%] of 253). In protocol-specified analyses adjusted for maternal age, gestational age at enrolment, bednet use the night before enrolment, anaemia at enrolment, and malaria infection at enrolment, women taking chloroquine as prophylaxis had 34% lower placental infections than did those allocated intermittent sulfadoxine-pyrimethamine (RR 0·66, 95% CI 0·46-0·95). Clinical malaria was reported in nine women assigned intermittent sulfadoxine-pyrimethamine, four allocated intermittent chloroquine (p=0·26), and two allocated chloroquine prophylaxis (p=0·063). Maternal anaemia was noted in five women assigned intermittent sulfadoxine-pyrimethamine, 15 allocated intermittent chloroquine (p=0·038), and six assigned chloroquine prophylaxis (p>0·99). Low birthweight was recorded for 31 babies born to women allocated intermittent sulfadoxine-pyrimethamine, 29 assigned intermittent chloroquine (p=0·78), and 41 allocated chloroquine prophylaxis (p=0·28). Four women assigned intermittent sulfadoxine-pyrimethamine had adverse events possibly related to study product compared with 94 women allocated intermittent chloroquine (p<0·0001) and 26 allocated chloroquine prophylaxis (p<0·0001). Three women had severe or life-threatening adverse events related to study product, of whom all were assigned intermittent chloroquine (p=0·25). INTERPRETATION Chloroquine administered as intermittent therapy did not provide better protection from malaria and related adverse effects compared with intermittent sulfadoxine-pyrimethamine in a setting of high resistance to sulfadoxine-pyrimethamine. Chloroquine chemoprophylaxis might provide benefit in protecting against malaria during pregnancy, but studies with larger sample sizes are needed to confirm these results. FUNDING US National Institutes of Health.
Collapse
Affiliation(s)
- Titus H Divala
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Randy G Mungwira
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Patricia M Mawindo
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Osward M Nyirenda
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Maxwell Kanjala
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Masiye Ndaferankhande
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Lufina E Tsirizani
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Rhoda Masonga
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Francis Muwalo
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Sarah Boudová
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | - Jaya Goswami
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Blair J Wylie
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | | | - Lughano Ndovie
- Department of Obstetrics and Gynaecology, University of Malawi College of Medicine, Blantyre, Malawi
| | - Priscilla Mvula
- Department of Obstetrics and Gynaecology, University of Malawi College of Medicine, Blantyre, Malawi
| | - Yamikani Mbilizi
- Department of Obstetrics and Gynaecology, University of Malawi College of Medicine, Blantyre, Malawi
| | - Tamiwe Tomoka
- Pathology Department, University of Malawi College of Medicine, Blantyre, Malawi
| | - Miriam K Laufer
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
11
|
Nkoka O, Chuang TW, Chen YH. Association between timing and number of antenatal care visits on uptake of intermittent preventive treatment for malaria during pregnancy among Malawian women. Malar J 2018; 17:211. [PMID: 29793482 PMCID: PMC5968590 DOI: 10.1186/s12936-018-2360-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 05/16/2018] [Indexed: 11/10/2022] Open
Abstract
Background Malaria in pregnancy is a critical public health challenge, and intermittent preventive treatment for malaria during pregnancy (IPTp) has proven to be an effective intervention. However, access to and use of malaria interventions, including IPTp, remains a considerable problem among African women. This cross-sectional study investigated factors, including antenatal care (ANC) attendance (both numbers of visits and timing of the first visit) and socio-demographics, associated with the uptake of the recommended IPTp dose among Malawian women. Methods A nationally representative sample of women with a live birth in the 2 years preceding the survey from the Malawi Demographic Health Survey 2015–2016 dataset was analysed. Self-reported data on socio-demographics, ANC attendance and IPTp uptake were collected using a questionnaire and analysed using logistic models. Results Of the 6549 included women, 1981 (30.2%) took the recommended three or more IPTp doses. Despite inadequate ANC visits, early ANC initiation increased the likelihood of these women taking the recommended IPTp dose; women who initiated ANC in the first [adjusted odds ratio (aOR) = 2.24; 95% confidence interval (CI) = 1.44–3.49] and second (aOR = 2.19; 95% CI = 1.56–3.08) trimesters were more likely to take the recommended IPTp dose compared to late initiators. The effect of the number of ANC visits on IPTp uptake was significant in married women (aOR = 1.68, 95% CI = 1.42–1.98), and the timing of first ANC visit was associated with IPTp uptake only among rural women (aOR = 2.13, 95% CI = 1.54–2.95). Conclusion ANC attendance is vital in IPTp uptake. The results highlight the need for health care providers to encourage women, particularly those in high-risk groups, to make frequent ANC visits and receive early ANC initiation to ensure high coverage of the recommended IPTp dose.
Collapse
Affiliation(s)
- Owen Nkoka
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
| | - Ting-Wu Chuang
- Department of Molecular Parasitology and Tropical Diseases, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Hua Chen
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan.
| |
Collapse
|
12
|
Rogerson SJ, Desai M, Mayor A, Sicuri E, Taylor SM, van Eijk AM. Burden, pathology, and costs of malaria in pregnancy: new developments for an old problem. THE LANCET. INFECTIOUS DISEASES 2018; 18:e107-e118. [PMID: 29396010 DOI: 10.1016/s1473-3099(18)30066-5] [Citation(s) in RCA: 174] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 08/07/2017] [Accepted: 10/09/2017] [Indexed: 12/17/2022]
Abstract
Over the past 10 years, knowledge of the burden, economic costs, and consequences of malaria in pregnancy has improved, and the prevalence of malaria caused by Plasmodium falciparum has declined substantially in some geographical areas. In particular, studies outside of Africa have increased the evidence base of Plasmodium vivax in pregnancy. Rapid diagnostic tests have been poor at detecting malaria in pregnant women, while PCR has shown a high prevalence of low density infection, the clinical importance of which is unknown. Erythrocytes infected with P falciparum that express the surface protein VAR2CSA accumulate in the placenta, and VAR2CSA is an important target of protective immunity. Clinical trials for a VAR2CSA vaccine are ongoing, but sequence variation needs to be carefully studied. Health system and household costs still limit access to prevention and treatment services. Within the context of malaria elimination, pregnant women could be used to monitor malaria transmission. This Series paper summarises recent progress and highlights unresolved issues related to the burden of malaria in pregnancy.
Collapse
Affiliation(s)
- Stephen J Rogerson
- Department of Medicine at the Doherty Institute, University of Melbourne, Melbourne, Victoria, Australia.
| | - Meghna Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alfredo Mayor
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde da Manhiça (CISM), Maputo, Mozambique
| | - Elisa Sicuri
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Health Economics Group, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College, London, UK
| | - Steve M Taylor
- Division of Infectious Diseases and Duke Global Health Institute, Duke University Medical Center, Durham, NC, USA
| | - Anna M van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| |
Collapse
|
13
|
Odjidja EN, Duric P. Evaluation of demand and supply predictors of uptake of intermittent preventive treatment for malaria in pregnancy in Malawi. MALARIAWORLD JOURNAL 2017; 8:20. [PMID: 34532243 PMCID: PMC8415061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The intermittent preventive treatment (IPTp) policy of Malawi (2002) stipulates that IPTp is administered during antenatal care as a direct observation therapy (DOT). The policy further recommends that IPT should be administered monthly after 16 weeks of pregnancy until delivery. This study assessed both the demand and supply factors contributing to higher dropout of IPT after the first dose. Optimal number of doses was pegged at a minimum of three in accordance with WHO recommendation. MATERIALS AND METHODS Data were analysed from the Malawi multiple indicator cluster survey (2015) and the service provision assessment (2014) of 6637 women (aged 15- 49 yrs), 763 facilities and 2105 health workers. The sample was made up of pregnant women, health facilities and workers involved in routine antenatal services across all regions of Malawi. A composite indicator was constructed to report integration of IPTp with ANC services and administration of IPTp-SP as DOT. Multivariate and logistic regression were conducted to determine associations. RESULTS Regression analysis found that: 1. Age of women (women 35-49 yrs, AOR 1.98; 95% CI 1.42 - 2.13, number of children as well as the number of ANC visits were associated with optimal uptake of IPTp. 2. Administering IPT as DOT was higher in facilities in rural areas (AOR 1.86; 95% CI 1.54 - 1.92) than in urban areas. 3. Administration of IPTp as DOT was relatively lower in across all facilities with highest being facilities managed by CHAM (72.8%, AOR 1.40; 95% CI 1.22 - 1.54). CONCLUSION Health system bottlenecks were found to present the main cause of low coverage with optimal doses of IPTp. Incorporating these results into strategic policy IPTp formulation could help improve coverage to desired levels. This study could serve as plausible evidence for government and donors when planning malaria in pregnancy interventions, especially in remote parts of Malawi.
Collapse
Affiliation(s)
- Emmanuel N. Odjidja
- Institute of Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom,*
| | - Predrag Duric
- Institute of Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom
| |
Collapse
|
14
|
Abstract
One hundred and twenty-five million women in malaria-endemic areas become pregnant each year (see Dellicour et al. PLoS Med7: e1000221 [2010]) and require protection from infection to avoid disease and death for themselves and their offspring. Chloroquine prophylaxis was once a safe approach to prevention but has been abandoned because of drug-resistant parasites, and intermittent presumptive treatment with sulfadoxine-pyrimethamine, which is currently used to protect pregnant women throughout Africa, is rapidly losing its benefits for the same reason. No other drugs have yet been shown to be safe, tolerable, and effective as prevention for pregnant women, although monthly dihydroartemisinin-piperaquine has shown promise for reducing poor pregnancy outcomes. Insecticide-treated nets provide some benefits, such as reducing placental malaria and low birth weight. However, this leaves a heavy burden of maternal, fetal, and infant morbidity and mortality that could be avoided. Women naturally acquire resistance to Plasmodium falciparum over successive pregnancies as they acquire antibodies against parasitized red cells that bind chondroitin sulfate A in the placenta, suggesting that a vaccine is feasible. Pregnant women are an important reservoir of parasites in the community, and women of reproductive age must be included in any elimination effort, but several features of malaria during pregnancy will require special consideration during the implementation of elimination programs.
Collapse
Affiliation(s)
- Michal Fried
- Laboratory of Malaria Immunology and Vaccinology, NIAID, NIH, Bethesda, MD 20892
| | - Patrick E Duffy
- Laboratory of Malaria Immunology and Vaccinology, NIAID, NIH, Bethesda, MD 20892
| |
Collapse
|
15
|
Stephens JK, Kyei-Baafour E, Dickson EK, Ofori JK, Ofori MF, Wilson ML, Quakyi IA, Akanmori BD. Effect of IPTp on Plasmodium falciparum antibody levels among pregnant women and their babies in a sub-urban coastal area in Ghana. Malar J 2017; 16:224. [PMID: 28549426 PMCID: PMC5446726 DOI: 10.1186/s12936-017-1857-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 05/12/2017] [Indexed: 12/31/2022] Open
Abstract
Background Women exposed to Plasmodium infection develop antibodies and become semi-immune. This immunity is suppressed during pregnancy making both the pregnant woman and the foetus vulnerable to the adverse effects of malaria, particularly by Plasmodium falciparum. Intermittent preventive treatment of malaria in pregnancy (IPTp) with Sulfadoxine–pyrimethamine (SP) tablets is one of the current interventions to mitigate the effects of malaria on both the pregnant woman and the unborn child. The extent to which IPTp may interfere with the acquisition of protective immunity against pregnancy-associated malaria (PAM) is undefined in Ghana. Methods Three-hundred-and-twenty pregnant women were randomly enrolled at the antenatal clinic (ANC) in Madina, Accra. Venous blood samples were obtained at first ANC registration and at 4-week intervals (post-IPTp administration). Placental and cord blood samples were obtained at delivery and the infants were followed monthly for 6 months after birth. Anti-IgG and IgM antibodies against a crude antigen preparation and the glutamate-rich protein (GLURP) of P. falciparum were quantified by the enzyme-linked immunosorbent assay (ELISA). Results There was a general decline in the trend of mean concentrations of all the antibodies from enrolment to delivery. The levels of antibodies in cord blood and placenta were well correlated. Children did not show clinical signs of malaria at 6 months after birth. Conclusions IgG against both crude antigen and GLURP were present in placenta and cord blood and it is therefore concluded that there is a trend of declining antibody from enrolment to delivery and IPTp-SP may have reduced malaria exposure, however, this does not impact on the transfer of antibodies to the foetus in utero. The levels of maternal and cord blood antibodies at delivery showed no adverse implications on malaria among the children at 6 months. However, the quantum and quality of the antibody transferred needs further investigation to ensure that the infants are protected from severe episodes of malaria.
Collapse
Affiliation(s)
- Judith K Stephens
- Biological, Environmental and Occupational and Health Sciences Department, School of Public Health, College of Health Sciences, University of Ghana, P. O. Box LG 13, Legon, Accra, Ghana.
| | - Eric Kyei-Baafour
- Immunology Department Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, P. O. Box LG 581, Legon, Accra, Ghana
| | - Emmanuel K Dickson
- Immunology Department Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, P. O. Box LG 581, Legon, Accra, Ghana
| | - Jones K Ofori
- Biological, Environmental and Occupational and Health Sciences Department, School of Public Health, College of Health Sciences, University of Ghana, P. O. Box LG 13, Legon, Accra, Ghana
| | - Michael F Ofori
- Immunology Department Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, P. O. Box LG 581, Legon, Accra, Ghana
| | - Mark L Wilson
- Department of Epidemiology, School of Public Health, The University of Michigan, 109 Observatory Street, Ann Arbor, MI, 48109-2029, USA
| | - Isabella A Quakyi
- Biological, Environmental and Occupational and Health Sciences Department, School of Public Health, College of Health Sciences, University of Ghana, P. O. Box LG 13, Legon, Accra, Ghana
| | - Bartholomew D Akanmori
- Immunology Department Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, P. O. Box LG 581, Legon, Accra, Ghana.,Vaccine Research and Development, Immunization and Vaccines Development Cluster, Office of the Regional Director, WHO Regional Office for Africa, P. O. Box 06, Djoue, Brazzaville, Congo
| |
Collapse
|
16
|
Escamilla V, Alker A, Dandalo L, Juliano JJ, Miller WC, Kamthuza P, Tembo T, Tegha G, Martinson F, Emch M, Hoffman IF. Effects of community-level bed net coverage on malaria morbidity in Lilongwe, Malawi. Malar J 2017; 16:142. [PMID: 28388914 PMCID: PMC5383956 DOI: 10.1186/s12936-017-1767-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 03/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The protective effect of insecticide-treated bed nets against individual-level malaria transmission is well known, however community-level effects are less understood. Protective effects from community-level bed net use against malaria transmission have been observed in clinical trials, however, the relationship is less clear outside of a controlled research setting. The objective of this research was to investigate the effect of community-level bed net use against malaria transmission outside of a bed net clinical trial setting in Lilongwe, Malawi following national efforts to scale-up ownership of long-lasting, insecticide-treated bed nets. METHODS An annual, cross-sectional, household-randomized, malaria transmission intensity survey was conducted in Lilongwe, Malawi (2011-2013). Health, demographic, and geographic-location data were collected. Participant blood samples were tested for Plasmodium falciparum presence. The percentage of people sleeping under a bed net within 400-m and 1-km radii of all participants was measured. Mixed effects logistic regression models were used to measure the relationship between malaria prevalence and surrounding bed net coverage. Each year, 800 people were enrolled (400 <5 years; 200 5-19 years; 200 ≥20 years; total n = 2400). RESULTS From 2011 to 2013, malaria prevalence declined from 12.9 to 5.6%, while bed net use increased from 53.8 to 78.6%. For every 1% increase in community bed net coverage, malaria prevalence decreased among children under 5 years old [adjusted odds ratio: 0.98 (0.96, 1.00)]. Similar effects were observed in participants 5-19 years [unadjusted odds ratio: 0.98 (0.97, 1.00)]; the effect was attenuated after adjusting for individual-level bed net use. Community coverage was not associated with malaria prevalence among adults ≥20 years. Supplemental analyses identified more pronounced indirect protective effects from community-level bed net use against malaria transmission among children under 5 years who were sleeping under a bed net [adjusted odds ratio: 0.97 (0.94, 0.99)], compared to children who were not sleeping under a bed net [adjusted odds ratio: 0.99 (0.97, 1.01)]. CONCLUSIONS Malawi's efforts to scale up ownership of long-lasting, insecticide-treated bed nets are effective in increasing reported use. Increased community-level bed net coverage appears to provide additional protection against malaria transmission beyond individual use in a real-world context.
Collapse
Affiliation(s)
- Veronica Escamilla
- Carolina Population Center, University of North Carolina, 308 W Rosemary, CB 8120, Chapel Hill, NC, 27599, USA.
| | - Alisa Alker
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC, 27599, USA
| | | | - Jonathan J Juliano
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC, 27599, USA.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, 27599, USA.,Curriculum in Genetics and Molecular Biology, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - William C Miller
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC, 27599, USA.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, 27599, USA
| | | | | | | | | | - Michael Emch
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, 27599, USA.,Department of Geography, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - Irving F Hoffman
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC, 27599, USA.,UNC Project-Malawi, Lilongwe, Malawi
| |
Collapse
|
17
|
Mwendera CA, de Jager C, Longwe H, Phiri K, Hongoro C, Mutero CM. Changing the policy for intermittent preventive treatment with sulfadoxine-pyrimethamine during pregnancy in Malawi. Malar J 2017; 16:84. [PMID: 28219435 PMCID: PMC5319082 DOI: 10.1186/s12936-017-1736-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 02/14/2017] [Indexed: 11/10/2022] Open
Abstract
Background The growing resistance of Plasmodium falciparum to sulfadoxine–pyrimethamine (SP) treatment for uncomplicated malaria led to a recommendation by the World Health Organization for the use of artemisinin-based combination therapy. Inevitably, concerns were also raised surrounding the use of SP for intermittent prevention treatment of malaria during pregnancy (IPTp) amidst the lack of alternative drugs. Malawi was the first country to adopt intermittent prevention treatment with SP in 1993, and updated in 2013. This case study examines the policy updating process and the contribution of research and key stakeholders to this process. The findings support the development of a malaria research-to-policy framework in Malawi. Methods Documents and evidence published from 1993 to 2012 were systematically reviewed in addition to key informant interviews. Results The online search identified 170 potential publications, of which eight from Malawi met the inclusion criteria. Two published studies from Malawi were instrumental in the WHO policy recommendation which in turn led to the updating of national policies. The updated policy indicates that more than two SP doses, as informed by research, overcome the challenges of the first policy of two SP doses only because of ineffectiveness by P. falciparum resistance and the global lack of replacement drugs to SP for IPTp. Conclusion International WHO recommendations facilitated a smooth policy change driven by motivated local leadership with technical and financial support from development partners. Policy development and implementation should include key stakeholders and use local malaria research in a research-to-policy framework.
Collapse
Affiliation(s)
- Chikondi A Mwendera
- School of Health Systems and Public Health, Institute for Sustainable Malaria Control (UP ISMC), University of Pretoria, Private Bag X363, Pretoria, 0001, South Africa
| | - Christiaan de Jager
- School of Health Systems and Public Health, Institute for Sustainable Malaria Control (UP ISMC), University of Pretoria, Private Bag X363, Pretoria, 0001, South Africa.
| | - Herbert Longwe
- Mailman School of Public Health, ICAP at Columbia University, Pretoria, South Africa
| | - Kamija Phiri
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Charles Hongoro
- School of Health Systems and Public Health, Institute for Sustainable Malaria Control (UP ISMC), University of Pretoria, Private Bag X363, Pretoria, 0001, South Africa.,Population Health, Health Systems and Innovation, Human Sciences Research Council (HSRC), Pretoria, South Africa
| | - Clifford M Mutero
- School of Health Systems and Public Health, Institute for Sustainable Malaria Control (UP ISMC), University of Pretoria, Private Bag X363, Pretoria, 0001, South Africa.,International Centre of Insect Physiology and Ecology (ICIPE), P.O. Box 30772, Nairobi, Kenya
| |
Collapse
|
18
|
Nkhoma M, Ashorn P, Ashorn U, Dewey KG, Gondwe A, Mbotwa J, Rogerson S, Taylor SM, Maleta K. Providing lipid-based nutrient supplement during pregnancy does not reduce the risk of maternal P falciparum parasitaemia and reproductive tract infections: a randomised controlled trial. BMC Pregnancy Childbirth 2017; 17:35. [PMID: 28095801 PMCID: PMC5240436 DOI: 10.1186/s12884-016-1215-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 12/29/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Maternal infections are associated with maternal and foetal adverse outcomes. Nutrient supplementation during pregnancy may reduce the occurrence of infections by improving maternal immunity. We aimed to investigate the impact of small-quantity lipid-based nutrient supplement (SQ-LNS) on the occurrence of Plasmodium falciparum parasitaemia during pregnancy and trichomoniasis, vaginal candidiasis and urinary tract infection (UTI) after delivery. METHODS Pregnant Malawian women enrolled in the iLiNS-DYAD trial receiving daily supplementation with SQ-LNS, multiple micronutrients (MMN) or iron & folic acid (IFA) from <20 gestation weeks (gw) were assessed for P. falciparum parasitaemia at 32 gw using rapid diagnostic testing (RDT), at 36 gw using polymerase chain reaction (PCR) and at delivery using both RDT and PCR; and at one week after delivery for trichomoniasis and vaginal candidiasis using wet mount microscopy and for UTI using urine dipstick analysis. The prevalence of each infection by intervention group was estimated at the prescribed time points and the global null hypothesis was tested using logistic regression. Adjusted analyses were performed using preselected covariates. RESULTS The prevalence of P. falciparum parasitaemia was 10.7% at 32 gw, 9% at 36 gw, and 8.3% by RDT and 20.2% by PCR at delivery. After delivery the prevalence of trichomoniasis was 10.5%, vaginal candidiasis was 0.5%, and UTI was 3.1%. There were no differences between intervention groups in the prevalence of any of the infections. CONCLUSION In this population, SQ-LNS did not influence the occurrence of maternal P. falciparum parasitaemia, trichomoniasis, vaginal candidiasis or UTI. TRIAL REGISTRATION Identifier: NCT01239693 (10 November 2010).
Collapse
Affiliation(s)
- Minyanga Nkhoma
- University of Tampere School of Medicine, University of Tampere, Arvo building, FI-33014 Tampere, Finland
| | - Per Ashorn
- University of Tampere School of Medicine, University of Tampere, Arvo building, FI-33014 Tampere, Finland
- Department of Pediatrics, Tampere University Hospital, FI-33521 Tampere, Finland
| | - Ulla Ashorn
- University of Tampere School of Medicine, University of Tampere, Arvo building, FI-33014 Tampere, Finland
| | - Kathryn G. Dewey
- Department of Nutrition, University of California, One Shields Ave., Davis, CA 95616-8669 USA
| | - Austrida Gondwe
- University of Tampere School of Medicine, University of Tampere, Arvo building, FI-33014 Tampere, Finland
| | - John Mbotwa
- School of Public Health and Family Medicine, College of Medicine, Mahatma Gandhi Road, Blantyre, Malawi
| | - Stephen Rogerson
- Department of Medicine at the Peter Doherty Institute, 792 Elizabeth Street, Melbourne, VIC 3000 Australia
| | - Steve M. Taylor
- Division of Infectious Diseases and International Health, Duke University Medical Center, Box 102359 DUMC, Durham, NC 27705 USA
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC 27599-7435 USA
| | - Kenneth Maleta
- School of Public Health and Family Medicine, College of Medicine, Mahatma Gandhi Road, Blantyre, Malawi
| |
Collapse
|
19
|
Almond D, Madanitsa M, Mwapasa V, Kalilani-Phiri L, Webster J, Ter Kuile F, Paintain L. Provider and user acceptability of intermittent screening and treatment for the control of malaria in pregnancy in Malawi. Malar J 2016; 15:574. [PMID: 27894353 PMCID: PMC5126811 DOI: 10.1186/s12936-016-1627-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 11/18/2016] [Indexed: 11/27/2022] Open
Abstract
Background Malaria in pregnancy is a major cause of adverse maternal and fetal outcomes. Intermittent preventive treatment with sulfadoxine–pyrimethamine (IPTp-SP) is one of the control strategies promoted by WHO. In response to mounting resistance to SP, intermittent screening and treatment (ISTp) has been proposed as an alternative. The objective of this study was to explore the acceptability of ISTp for health workers and pregnant women. Methods Semi-structured interviews of ten health workers and five focus group discussions of 38 women enrolled in an ongoing trial comparing IPTp-SP and ISTp with dihydroartemisinin–piperaquine (DP) were conducted at two antenatal clinics in rural Malawi. All transcripts were coded and themes were identified using a content analysis approach. Results Amongst health workers, there were contrasting opinions on the preference of blood sampling methods, and the influence of method on reliability of diagnosis. The perceived greater effectiveness of DP compared to SP was appreciated, however concerns of user compliance with the full dose of DP in non-trial settings were raised. Despite the discomfort of repeated finger pricks, pregnant women were generally accepting of ISTp, particularly the chance for regular blood tests to check for infections and the perceived greater effectiveness with fewer side effects of DP compared to SP. Conclusion In the trial context, pregnant women tended to prefer ISTp-DP over IPTp-SP. Health workers were also accepting of ISTp-DP as an alternative to IPTp-SP in light of increasing SP resistance. However, reliability of stock, adherence to malaria test results and user adherence to the full course of DP may present barriers to successful routine implementation. Effective communication with health workers and between health workers, pregnant women and their communities will be essential for the acceptability of focused antenatal care, including the best malaria control measures available.
Collapse
Affiliation(s)
- Deborah Almond
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Mwayi Madanitsa
- College of Medicine, University of Malawi, Blantyre, Malawi.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Victor Mwapasa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Jayne Webster
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Feiko Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Lucy Paintain
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK.
| |
Collapse
|
20
|
Bouyou-Akotet MK, Mawili-Mboumba DP, Kendjo E, Moutandou Chiesa S, Tshibola Mbuyi ML, Tsoumbou-Bakana G, Zong J, Ambounda N, Kombila M. Decrease of microscopic Plasmodium falciparum infection prevalence during pregnancy following IPTp-SP implementation in urban cities of Gabon. Trans R Soc Trop Med Hyg 2016; 110:333-42. [PMID: 27268713 DOI: 10.1093/trstmh/trw034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 04/18/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Six years after the implementation of intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) in Gabon, its impact on placental malaria and pregnancy outcomes remains unknown. METHODS Age, gestational data, use of IPTp-SP and birth weight were recorded during a hospital-based cross-sectional survey performed in 2011 in 387 women at the end of pregnancy. RESULTS Malaria prevalence was 6.7 and 5.3% in peripheral and placental blood respectively. Overall, 59.0% women took at least two IPTp-SP doses which was associated with 50% reduction of Plasmodium; (P.) falciparum infection in primigravidae. Previous malaria treatment was a risk factor for peripheral P. falciparum infection, while uptake of IPTp-SP was associated with reduced parasitaemia. Anaemia prevalence was 38.0%, low birth weight and prematurity rates were 6.0 and 12.0% respectively. Young age was associated with a higher frequency of malaria, anaemia, low birth weight and preterm delivery (p<0.01). Birth weight significantly rose with increasing age (p<0.01), parity (p=0.03) and number of SP doses (p=0.03). A birth weight reduction of 230 g in case of peripheral parasitaemia (p=0.02) and of 210 g with placental parasitaemia (p=0.13) was observed. CONCLUSIONS Microscopic P. falciparum prevalence during pregnancy significantly declined between 2005 and 2011, following IPTp-SP implementation in Gabon. Young women and paucigravidae remain the most susceptible to malaria and associated outcomes.
Collapse
Affiliation(s)
- M K Bouyou-Akotet
- Department of Parasitology-Mycology, Faculty of Medicine, Université des Sciences de la Santé, Libreville, Gabon Malaria Clinical and Operational Research Unit (MCORU), Centre Hospitalier Regional de l´Estuaire Melen, Libreville, Gabon
| | - D P Mawili-Mboumba
- Department of Parasitology-Mycology, Faculty of Medicine, Université des Sciences de la Santé, Libreville, Gabon Malaria Clinical and Operational Research Unit (MCORU), Centre Hospitalier Regional de l´Estuaire Melen, Libreville, Gabon
| | - E Kendjo
- Department of Parasitology-Mycology, Faculty of Medicine, Université des Sciences de la Santé, Libreville, Gabon
| | - S Moutandou Chiesa
- Department of Gynecology, Faculty of Medicine, Université des Sciences de la Santé, Libreville, Gabon
| | - M L Tshibola Mbuyi
- Department of Parasitology-Mycology, Faculty of Medicine, Université des Sciences de la Santé, Libreville, Gabon
| | - G Tsoumbou-Bakana
- Malaria Clinical and Operational Research Unit (MCORU), Centre Hospitalier Regional de l´Estuaire Melen, Libreville, Gabon
| | - J Zong
- Malaria Clinical and Operational Research Unit (MCORU), Centre Hospitalier Regional de l´Estuaire Melen, Libreville, Gabon
| | - N Ambounda
- Gynecology and Obstetrics ward, Centre Hospitalier de Libreville, Libreville, Gabon
| | - M Kombila
- Department of Parasitology-Mycology, Faculty of Medicine, Université des Sciences de la Santé, Libreville, Gabon Malaria Clinical and Operational Research Unit (MCORU), Centre Hospitalier Regional de l´Estuaire Melen, Libreville, Gabon
| |
Collapse
|
21
|
Boudová S, Divala T, Mawindo P, Cohee L, Kalilani-Phiri L, Thesing P, Taylor TE, Laufer MK. The prevalence of malaria at first antenatal visit in Blantyre, Malawi declined following a universal bed net campaign. Malar J 2015; 14:422. [PMID: 26510414 PMCID: PMC4625940 DOI: 10.1186/s12936-015-0945-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 10/21/2015] [Indexed: 11/30/2022] Open
Abstract
Background Preventing malaria during pregnancy is important for the health of mothers and newborns. Interventions, which include distribution of bed nets and administration of intermittent preventive treatment (IPT), typically occur at the first antenatal visit, usually in the second or third trimester of pregnancy. In 2012, during the course of ongoing clinical studies of malaria among pregnant women in Malawi, a universal bed net campaign was implemented by the Government. This study tested the hypothesis that a universal bed net campaign would decrease the prevalence of malaria among pregnant women at their first antenatal visit. Methods Some 1661 women were recruited for two studies from 2009 to 2014. Quantitative PCR (qPCR) was conducted from dried blood spots collected at the first antenatal care visit (prior to administration of IPT or any study interventions) from women who were in their first or second pregnancy and less than 28 weeks gestation by clinical assessment. Results Overall, 320 of 1629 (19.6 %) women tested for malaria at their first antenatal visit were infected. Malaria infection rates declined from 28.4 % before the universal bed net campaign, to 18.5 % in 2012, to 15.0 % in the years following the universal bed net campaign. The odds of malaria infection at the time of first antenatal visit in 2012 and the years following the bed net campaign were significantly lower than in the years prior to the intervention (OR 0.6, 95 % CI 0.4–0.8; and OR 0.4, 95 % CI 0.3–0.6, respectively). A similar pattern was observed for the prevalence of clinical malaria. The inverse trend was observed for reported bed net use. However bed net use and malaria infection were not significantly associated on the individual level. Conclusions Malaria infection in pregnant women is common even after a bed net campaign in Malawi, though prevalence rates declined. These early infections may cause maternal anaemia and placental malaria resulting in adverse maternal and fetal outcomes. Infection early in pregnancy may also contribute to malaria transmission as pregnant women represent a significant untreated reservoir of parasites. Universal bed net distribution appears to have moderate success in preventing malaria early in pregnancy and these findings support continued efforts to target women early in pregnancy and all women of childbearing age.
Collapse
Affiliation(s)
- Sarah Boudová
- Division of Malaria Research, Institute for Global Health, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Titus Divala
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Patricia Mawindo
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Lauren Cohee
- Division of Malaria Research, Institute for Global Health, University of Maryland School of Medicine, Baltimore, MD, USA.
| | | | - Phillip Thesing
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Terrie E Taylor
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi. .,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA.
| | - Miriam K Laufer
- Division of Malaria Research, Institute for Global Health, University of Maryland School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
22
|
Mayor A, Bardají A, Macete E, Nhampossa T, Fonseca AM, González R, Maculuve S, Cisteró P, Rupérez M, Campo J, Vala A, Sigaúque B, Jiménez A, Machevo S, de la Fuente L, Nhama A, Luis L, Aponte JJ, Acácio S, Nhacolo A, Chitnis C, Dobaño C, Sevene E, Alonso PL, Menéndez C. Changing Trends in P. falciparum Burden, Immunity, and Disease in Pregnancy. N Engl J Med 2015; 373:1607-17. [PMID: 26488692 DOI: 10.1056/nejmoa1406459] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Prevention of reinfection and resurgence is an integral component of the goal to eradicate malaria. However, the adverse effects of malaria resurgences are not known. METHODS We assessed the prevalence of Plasmodium falciparum infection among 1819 Mozambican women who delivered infants between 2003 and 2012. We used microscopic and histologic examination and a quantitative polymerase-chain-reaction (qPCR) assay, as well as flow-cytometric analysis of IgG antibody responses against two parasite lines. RESULTS Positive qPCR tests for P. falciparum decreased from 33% in 2003 to 2% in 2010 and increased to 6% in 2012, with antimalarial IgG antibody responses mirroring these trends. Parasite densities in peripheral blood on qPCR assay were higher in 2010-2012 (geometric mean [±SD], 409±1569 genomes per microliter) than in 2003-2005 (44±169 genomes per microliter, P=0.02), as were parasite densities in placental blood on histologic assessment (50±39% of infected erythrocytes vs. 4±6%, P<0.001). The malaria-associated reduction in maternal hemoglobin levels was larger in 2010-2012 (10.1±1.8 g per deciliter in infected women vs. 10.9±1.7 g per deciliter in uninfected women; mean difference, -0.82 g per deciliter; 95% confidence interval [CI], -1.39 to -0.25) than in 2003-2005 (10.5±1.1 g per deciliter vs. 10.6±1.5 g per deciliter; difference, -0.12 g per deciliter; 95% CI, -0.67 to 0.43), as was the reduction in birth weight (2863±440 g in women with past or chronic infections vs. 3070±482 g in uninfected women in 2010-2012; mean difference, -164.5 g; 95% CI, -289.7 to -39.4; and 2994±487 g vs. 3117±455 g in 2003-2005; difference, -44.8 g; 95% CI, -139.1 to 49.5). CONCLUSIONS Antimalarial antibodies were reduced and the adverse consequences of P. falciparum infections were increased in pregnant women after 5 years of a decline in the prevalence of malaria. (Funded by Malaria Eradication Scientific Alliance and others.).
Collapse
Affiliation(s)
- Alfredo Mayor
- From the Barcelona Institute for Global Health (ISGlobal), Barcelona Center for International Health Research (CRESIB), and Hospital Clínic-Universitat de Barcelona (A.M., A.B., A.M.F., R.G., P.C., M.R., J.C., A.J., L.F., J.J.A., C.D., P.L.A., C.M.), Barcelona, and Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBEREsp), Madrid (A.J.) - all in Spain; Centro de Investigação em Saúde da Manhiça (CISM) (A.M., A.B., E.M., T.N., R.G., S. Maculuve, M.R., A.V., B.S., S. Machevo, A. Nhama, L.L., J.J.A., S.A., A. Nhacolo, C.D., E.S., P.L.A., C.M.), Instituto Nacional de Saúde, Ministry of Health (T.N., S. Maculuve, B.S., A. Nhama, S.A.), and Faculdade de Medicina, Universidade Eduardo Mondlane (S. Machevo, E.S.) - all in Maputo, Mozambique; the Graduate Program in Areas of Basic and Applied Biology, Universidade do Porto, Porto, Portugal (A.M.F.); and the International Center for Genetic Engineering and Biotechnology, New Delhi, India (C.C.)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Ndeserua R, Juma A, Mosha D, Chilongola J. Risk factors for placental malaria and associated adverse pregnancy outcomes in Rufiji, Tanzania: a hospital based cross sectional study. Afr Health Sci 2015; 15:810-8. [PMID: 26957969 DOI: 10.4314/ahs.v15i3.15] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Prevention and treatment of malaria during pregnancy is crucial for reduction of malaria in pregnancy and its adverse outcomes. The spread of parasite resistance to Sulphadoxine-Pyrimethamine (SP) used for Intermittent Preventive Treatment for malaria in pregnancy (IPTp), particularly in East Africa has raised concerns about the usefulness and the reliability of the IPTp regimen. We aimed to assess the effectiveness of two doses of SP in treating and preventing occurrence of adverse pregnancy outcomes. METHODOLOGY The study was an analytical cross sectional study which enrolled 350 pregnant women from Kibiti Health Centre, South Eastern Tanzania. Structured questionnaires were used to obtain previous obstetrics and medical history of participants and verified by reviewing antenatal clinic cards. Maternal placental blood samples for microscopic examination of malaria parasites were collected after delivery. Data was analyzed for associations between SP dosage, risk for PM and pregnancy outcome. Sample size was estimated based on precision. RESULTS Prevalence of placental maternal (PM) was 8% among pregnant women (95%CI, 4.4-13.1%). Factors associated with increased risk of PM were primigravidity (P<0.001) and history of fever during pregnancy (P= 0.02). Use of at least 2 doses of SP for IPTp during pregnancy was insignificantly associated with reducing the risk PM (P=0.08), low birth weight (P=0.73) and maternal anemia (P=0.71) but associated significantly with reducing the risk of preterm birth (P<0.001). CONCLUSION Two doses of SP for IPTp regime are ineffective in preventing and treating PM and adverse pregnancy outcome. Hence a review to the current IPTp regimen should be considered with possibility of integrating it with other malaria control strategies.
Collapse
Affiliation(s)
| | - Adinan Juma
- Kilimanjaro Christian Medical Center, Community Health Department
| | - Dominic Mosha
- Kilimanjaro Christian Medical University College, Community Health Department
| | - Jaffu Chilongola
- Kilimanjaro Christian Medical University College, Biochemistry and Mol Biology
| |
Collapse
|
24
|
Harrington WE, Fried M, Duffy PE. Defending the Use of Sulfadoxine-Pyrimethamine for Intermittent Preventive Treatment for Malaria in Pregnancy: A Short-Sighted Strategy. J Infect Dis 2015; 213:496-7. [PMID: 26290607 DOI: 10.1093/infdis/jiv420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 08/07/2015] [Indexed: 11/12/2022] Open
Affiliation(s)
- Whitney E Harrington
- Department of Pediatrics, Seattle Children's Hospital/University of Washington School of Medicine
| | - Michal Fried
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland
| | - Patrick E Duffy
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland
| |
Collapse
|
25
|
Gutman J, Taylor S, Meshnick SR, Ter Kuile FO. Reply to Harrington et al. J Infect Dis 2015; 213:497-8. [PMID: 26290609 DOI: 10.1093/infdis/jiv421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 08/07/2015] [Indexed: 11/14/2022] Open
Affiliation(s)
- Julie Gutman
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Steve Taylor
- Duke University Medical Center, Durham University of North Carolina, Chapel Hill
| | | | | |
Collapse
|
26
|
Mwandama D, Gutman J, Wolkon A, Luka M, Jafali J, Ali D, Mathanga DP, Skarbinski J. The use of intermittent preventive treatment in pregnancy and insecticide-treated bed nets for malaria prevention by women of child-bearing age in eight districts in Malawi. Malar J 2015; 14:316. [PMID: 26272067 PMCID: PMC4536790 DOI: 10.1186/s12936-015-0840-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 08/06/2015] [Indexed: 11/10/2022] Open
Abstract
Background Intermittent preventive treatment in pregnancy (IPTp) and insecticide-treated bed nets (ITNs) can reduce the morbidity and mortality associated with malaria in pregnancy. Although the coverage for both IPTp and ITN use have been described in Malawi, the analysis of factors associated with IPTp receipt and ITN use is lacking. This analysis was conducted to assess IPTp and ITN use and predictors of use by women of child-bearing age (WOCBA). Methods A two-stage cluster-sample cross-sectional survey was conducted April 16–30, 2009 in eight districts across Malawi. Information on receipt of two or more doses of IPTp, ITN ownership, and ITN use the night before the survey was collected. Multivariate logistic regression was used to assess predictors of IPTp and ITN use. Results Data were collected from 7407 households containing 6985 WOCBA and 3213 recently pregnant women (women who reported a completed pregnancy in the 2 years before the survey). Most recently pregnant women (96 %) had at least one antenatal care (ANC) clinic visit; 91 % reported receiving at least one dose of IPTp, and 72 % reported receiving two or more doses of IPTp. Women in Phalombe, Rumphi, and Lilongwe were more likely to receive two doses of IPTp than those in Blantyre [adjusted odds ratio (aOR) 2.5 (95 % CI 1.5–4.5), 2.5 (95 % CI 1.5–4.3), and 2.0 (95 % CI 1.2–3.1), respectively]. Educated women were more likely to have received IPTp compared to women with no education [aOR 1.6 (95 % CI 1.0–2.6) for those who completed primary school, aOR1.9 (95 % CI 1.1–3.3) for some secondary school, and aOR 4.1 (95 % CI 1.9–8.7) for completed secondary school or above], and women in the poorest socioeconomic status quintile were less likely to receive IPTp than those in the least poor quintile [aOR 0.68 (95 % CI 0.48–0.97)]. In all, 53 % of WOCBA used an ITN the previous night. Women in Nkhotkhota and Phalombe were less likely to have slept under an ITN the previous night compared to those in Blantyre [aOR 0.52 (95 % CI 0.39–0.69) and aOR 0.67 (95 % CI 0.47–0.95), respectively]. In addition, age [aOR 0.61 (95 % CI 0.45–0.83) for women 15–19 years old], and either being currently pregnant [aOR 1.5 (95 % CI 1.2–2.0)] or having been pregnant in the previous 2 years [aOR 2.4, (95 % CI 2.1–2.8)] were associated with ITN use. Conclusion In Malawi in 2009, IPTp and ITN use in WOCBA fell short of national and international goals. Adoption of new guidelines encouraging administration of IPTp at every scheduled ANC visit might increase IPTp use. Increasing health promotion activities to encourage earlier attendance at ANC clinics and create demand for IPTp and ITNs might improve overall IPTp and ITN use.
Collapse
Affiliation(s)
- Dyson Mwandama
- Malaria Alert Centre, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Julie Gutman
- Division of Parasitic Diseases and Malaria, Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Adam Wolkon
- Division of Parasitic Diseases and Malaria, Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Madalitso Luka
- Malaria Alert Centre, University of Malawi College of Medicine, Blantyre, Malawi.
| | - James Jafali
- Malaria Alert Centre, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Doreen Ali
- National Malaria Control Programme, Ministry of Health, Lilongwe, Malawi.
| | - Don P Mathanga
- Malaria Alert Centre, University of Malawi College of Medicine, Blantyre, Malawi. .,Malawi and Department of Community Health, College of Medicine, Lilongwe, Malawi.
| | - Jacek Skarbinski
- Division of Parasitic Diseases and Malaria, Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| |
Collapse
|
27
|
Choonara S, Odimegwu CO, Elwange BC. Factors influencing the usage of different types of malaria prevention methods during pregnancy in Kenya. Afr Health Sci 2015; 15:413-9. [PMID: 26124786 DOI: 10.4314/ahs.v15i2.14] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, malaria is a leading cause of morbidity and mortality, which, during pregnancy, is associated with adverse health outcomes for both mother and foetus. Utilization of Insecticide Treated Nets (ITNs) and Intermittent Preventive Therapy (IPTp) is advocated to prevent malaria during pregnancy. OBJECTIVE To examine factors which influence the use of different types of malaria prevention methods among pregnant women in Kenya. METHODS This study used 2008-09 Kenya Demographic and Health survey. Pregnant women aged 15-49 years were included (622 women). Distribution of the study population was assessed in frequency tables. Bivariate and multivariate logistic regression analysis was employed. RESULTS Fifty-two percent of women used ITNs and 38.5% reported uptake of IPTp. In multivariate analysis age, malaria risk areas, religion, education and income influenced ITN usage, whereas only age, malaria risk areas and marital status were found to influence IPTP uptake. CONCLUSIONS ITN use and IPTp uptake were well below the 80% Kenya Malaria Strategy 2006 target. In an effort to increase uptake it is vital for future research to understand reasons for low usage and uptake of malaria prevention programmes so as to enable policy-makers to make informed decisions.
Collapse
Affiliation(s)
- Shakira Choonara
- Centre for Health Policy/MRC Health Policy Research Group; School of Public Health; Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa ; Demography and Population Studies Programme, Schools of Public Health and Social Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Clifford Obby Odimegwu
- Demography and Population Studies Programme, Schools of Public Health and Social Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bob Charlestine Elwange
- Demography and Population Studies Programme, Schools of Public Health and Social Sciences, University of the Witwatersrand, Johannesburg, South Africa ; Department of Sociology and Social Administration, Kyambogo University, Uganda
| |
Collapse
|
28
|
Teo A, Hasang W, Randall LM, Unger HW, Siba PM, Mueller I, Brown GV, Rogerson SJ. Malaria preventive therapy in pregnancy and its potential impact on immunity to malaria in an area of declining transmission. Malar J 2015; 14:215. [PMID: 26006260 PMCID: PMC4449596 DOI: 10.1186/s12936-015-0736-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 05/20/2015] [Indexed: 11/23/2022] Open
Abstract
Background Regular anti-malarial therapy in pregnancy, a pillar of malaria control, may affect malaria immunity, with therapeutic implications in regions of reducing transmission. Methods Plasma antibodies to leading vaccine candidate merozoite antigens and opsonizing antibodies to endothelial-binding and placental-binding infected erythrocytes were quantified in pregnant Melanesian women receiving sulfadoxine-pyrimethamine (SP) with chloroquine taken once, or three courses of SP with azithromycin. Results Malaria prevalence was low. Between enrolment and delivery, antibodies to recombinant antigens declined in both groups (p < 0.0001). In contrast, median levels of opsonizing antibodies did not change, although levels for some individuals changed significantly. In multivariate analysis, the malaria prevention regimen did not influence antibody levels. Conclusion Different preventive anti-malarial chemotherapy regimens used during pregnancy had limited impact on malarial-immunity in a low-transmission region of Papua New Guinea. Trial registrations NCT01136850
Collapse
Affiliation(s)
- Andrew Teo
- University of Melbourne, Department of Medicine (Royal Melbourne Hospital), Melbourne, VIC, Australia.
| | - Wina Hasang
- University of Melbourne, Department of Medicine (Royal Melbourne Hospital), Melbourne, VIC, Australia. .,Victorian Infectious Diseases Service, The Doherty Institute, Melbourne, VIC, Australia.
| | - Louise M Randall
- University of Melbourne, Department of Medicine (Royal Melbourne Hospital), Melbourne, VIC, Australia. .,Victorian Infectious Diseases Service, The Doherty Institute, Melbourne, VIC, Australia.
| | - Holger W Unger
- University of Melbourne, Department of Medicine (Royal Melbourne Hospital), Melbourne, VIC, Australia.
| | - Peter M Siba
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.
| | - Ivo Mueller
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia. .,Barcelona Centre for International Health Research (CRESIB), Barcelona, Spain.
| | - Graham V Brown
- University of Melbourne, Department of Medicine (Royal Melbourne Hospital), Melbourne, VIC, Australia. .,Victorian Infectious Diseases Service, The Doherty Institute, Melbourne, VIC, Australia. .,The Nossal Institute for Global Health, The University of Melbourne, Melbourne, VIC, Australia.
| | - Stephen J Rogerson
- University of Melbourne, Department of Medicine (Royal Melbourne Hospital), Melbourne, VIC, Australia. .,Victorian Infectious Diseases Service, The Doherty Institute, Melbourne, VIC, Australia.
| |
Collapse
|
29
|
Gutman J, Mwandama D, Wiegand RE, Abdallah J, Iriemenam NC, Shi YP, Mathanga DP, Skarbinski J. In vivo efficacy of sulphadoxine-pyrimethamine for the treatment of asymptomatic parasitaemia in pregnant women in Machinga District, Malawi. Malar J 2015; 14:197. [PMID: 25962439 PMCID: PMC4435920 DOI: 10.1186/s12936-015-0710-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 04/23/2015] [Indexed: 11/27/2022] Open
Abstract
Background The effectiveness of sulphadoxine-pyrimethamine (SP) intermittent preventive treatment of malaria in pregnancy (IPTp) might be compromised by high prevalence of resistance-associated Plasmodium falciparum dihydrofolate reductase (dhfr) and dihydropteroate synthase (dhps) mutations. As a proxy for IPTp-SP effectiveness, the in vivo efficacy of SP to clear parasitaemia and prevent reinfection in asymptomatic parasitaemic pregnant women in an area with high SP resistance prevalence was assessed. Methods Pregnant women 16–26 weeks’ gestation with asymptomatic parasitaemia presenting for antenatal care were given IPTp-SP and followed for 42 days. The primary outcome was polymerase chain reaction (PCR) uncorrected 42-day survival rate; the per cent of patients without recrudescence or reinfection by day 42. PCR was used to distinguish recrudescence from reinfection. DNA was sequenced to detect resistance-associated dhfr and dhps mutations. Results Of 245 pregnant women included in the intention-to-treat analysis, 93.9% cleared their parasitaemia by day 7. The day 42 PCR-uncorrected survival rate was 58.1% (95% confidence interval (CI) 51.5-65.7) and day 42 PCR-corrected survival was 68.7% (CI 61.4-76.0). Recrudescence was more common among primi- than among multigravid women; recrudescence rate 33.3% (CI 25.1-42.4%) versus 21.4% (CI 15.0-29.0%) (log rank test p-value 0.006). The quintuple mutant was present in nearly all samples (95%), while 2% were sextuple mutants with an additional mutation at dhps A581G. Conclusions SP efficacy for acute malaria treatment has been compromised by resistance, but SP retains partial activity among pregnant women with asymptomatic parasitaemia, and thus might be useful for IPTp. Nonetheless, research on non-SP IPTp regimens should continue. Trial registration ClinicalTrials.gov NCT01120145.
Collapse
Affiliation(s)
- Julie Gutman
- Malaria Branch, Division of Parasitic Diseases & Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Dyson Mwandama
- Malaria Alert Centre, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Ryan E Wiegand
- Malaria Branch, Division of Parasitic Diseases & Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Joseph Abdallah
- Rwanda Zambia HIV Research Group, Emory University, Atlanta, GA, USA.
| | - Nnaemeka C Iriemenam
- Malaria Branch, Division of Parasitic Diseases & Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Ya Ping Shi
- Malaria Branch, Division of Parasitic Diseases & Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Don P Mathanga
- Malaria Alert Centre, University of Malawi College of Medicine, Blantyre, Malawi. .,Department of Community Health, College of Medicine, Lilongwe, Malawi.
| | - Jacek Skarbinski
- Malaria Branch, Division of Parasitic Diseases & Malaria, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| |
Collapse
|
30
|
Moya-Alvarez V, Cottrell G, Ouédraogo S, Accrombessi M, Massougbodgi A, Cot M. Does Iron Increase the Risk of Malaria in Pregnancy? Open Forum Infect Dis 2015; 2:ofv038. [PMID: 26380338 PMCID: PMC4567087 DOI: 10.1093/ofid/ofv038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/15/2015] [Indexed: 12/03/2022] Open
Abstract
Background. Pregnancy-associated malaria (PAM) remains a significant health concern in sub-Saharan Africa. Cross-sectional studies report that iron might be associated with increased malaria morbidity, raising fears that current iron supplementation policies will cause harm in the present context of increasing resistance against intermittent preventive treatment in pregnancy (IPTp). Therefore, it is necessary to assess the relation of iron levels with malaria risk during the entire pregnancy. Methods. To investigate the association of maternal iron levels on malaria risk in the context of an IPTp clinical trial, 1005 human immunodeficiency virus-negative, pregnant Beninese women were monitored throughout their pregnancy between January 2010 and May 2011. Multilevel models with random intercept at the individual levels and random slope for gestational age were used to analyze the factors associated with increased risk of a positive blood smear and increased Plasmodium falciparum density. Results. During the follow-up, 29% of the women had at least 1 episode of malaria. On average, women had 0.52 positive smears (95% confidence interval [CI], 0.44-0.60). High iron levels (measured by the log10 of ferritin corrected on inflammation) were significantly associated with increased risk of a positive blood smear (adjusted odds ratio = 1.75; 95% CI, 1.46-2.11; P < .001) and high P falciparum density (beta estimate = 0.22; 95% CI, 0.18-0.27; P < .001) during the follow-up period adjusted on pregnancy parameters, comorbidities, environmental and socioeconomic indicators, and IPTp regime. Furthermore, iron-deficient women were significantly less likely to have a positive blood smear and high P falciparum density (P < .001 in both cases). Conclusions. Iron levels were positively associated with increased PAM during pregnancy in the context of IPTp. Supplementary interventional studies are needed to determine the benefits and risks of differently dosed iron and folate supplements in malaria-endemic regions.
Collapse
Affiliation(s)
- Violeta Moya-Alvarez
- MERIT- Mère et Enfant Face aux Infections Tropicales, Institut de Recherche pour le Développement, Paris, France
- Université Pierre et Marie Curie, Paris, France
- Réseau Doctoral de l'Ecole des Hautes Etudes en Santé Publique, Rennes, France
- Université Paris Descartes, Sorbonne Paris Cité, France
| | - Gilles Cottrell
- MERIT- Mère et Enfant Face aux Infections Tropicales, Institut de Recherche pour le Développement, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, France
| | - Smaila Ouédraogo
- Université Paris Descartes, Sorbonne Paris Cité, France
- MERIT- Mère et Enfant Face aux Infections Tropicales, Institut de Recherche pour le Développement, Cotonou, Benin
- Unité de Formation et de Recherche en Sciences de la Santé, Université de Ouagadougou, Burkina Faso
- Public Health Department, Centre Hospitalier Universitaire Yalgado Ouédraogo, Ouagadougou, Burkina Faso
| | - Manfred Accrombessi
- Université Pierre et Marie Curie, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, France
| | | | - Michel Cot
- MERIT- Mère et Enfant Face aux Infections Tropicales, Institut de Recherche pour le Développement, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, France
| |
Collapse
|
31
|
Taylor SM, Antonia AL, Harrington WE, Goheen MM, Mwapasa V, Chaluluka E, Fried M, Kabyemela E, Madanitsa M, Khairallah C, Kalilani-Phiri L, Tshefu AK, Rogerson SJ, Ter Kuile FO, Duffy PE, Meshnick SR. Independent lineages of highly sulfadoxine-resistant Plasmodium falciparum haplotypes, eastern Africa. Emerg Infect Dis 2015; 20:1140-8. [PMID: 24960247 PMCID: PMC4073871 DOI: 10.3201/eid2007.131720] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Parasites with increased resistance to sulfadoxine might undermine malaria control measures. Sulfadoxine-resistant Plasmodium falciparum undermines malaria prevention with sulfadoxine/pyrimethamine. Parasites with a highly resistant mutant dihydropteroate synthase (dhps) haplotype have recently emerged in eastern Africa; they negated preventive benefits of sulfadoxine/pyrimethamine, and might exacerbate placental malaria. We explored emerging lineages of dhps mutant haplotypes in Malawi, the Democratic Republic of the Congo, and Tanzania by using analyses of genetic microsatellites flanking the dhps locus. In Malawi, a triple-mutant dhps SGEG (mutant amino acids are underlined) haplotype emerged in 2010 that was closely related to pre-existing double-mutant SGEA haplotypes, suggesting local origination in Malawi. When we compared mutant strains with parasites from the Democratic Republic of the Congo and Tanzania by multiple independent analyses, we found that SGEG parasites were partitioned into separate lineages by country. These findings support a model of local origination of SGEGdhps haplotypes, rather than geographic diffusion, and have implications for investigations of emergence and effects of parasite drug resistance.
Collapse
|
32
|
Sisya TJ, Kamn'gona RM, Vareta JA, Fulakeza JM, Mukaka MFJ, Seydel KB, Laufer MK, Taylor TE, Nkhoma SC. Subtle changes in Plasmodium falciparum infection complexity following enhanced intervention in Malawi. Acta Trop 2015; 142:108-14. [PMID: 25460345 PMCID: PMC4296692 DOI: 10.1016/j.actatropica.2014.11.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 10/25/2014] [Accepted: 11/17/2014] [Indexed: 11/29/2022]
Abstract
We examined impact of intense malaria control on parasite genetic structure in Malawi. Malaria infections sampled before and after intense control were genotyped at 24 SNPs. Despite intense control efforts, parasite genetic diversity was unchanged over time. Only the mean number of heterozygous SNPs within infections showed change over time. Findings suggest minimal or no change in malaria transmission despite intense control.
With support from the Global Fund, the United States President's Malaria Initiative (PMI) and other cooperating partners, Malawi is implementing a comprehensive malaria control programme involving indoor residual spraying in targeted districts, universal coverage with insecticide-treated bed nets, use of rapid diagnostic tests to confirm the clinical diagnosis of malaria and use of the highly effective artemisinin-based combination therapy, artemether-lumefantrine (AL), as the first-line treatment for malaria. We genotyped 24 genome-wide single nucleotide polymorphisms (SNPs) in Plasmodium falciparum infections (n = 316) sampled from a single location in Malawi before (2006 and 2007) and after enhanced intervention (2008 and 2012). The SNP data generated were used to examine temporal changes in the proportion of multiple-genotype infections (MIs), mean number of heterozygous SNPs within MIs, parasite genetic diversity (expected heterozygosity and genotypic richness), multilocus linkage disequilibrium and effective population size (Ne). While the proportion of MIs, expected heterozygosity, genotypic richness, multilocus linkage disequilibrium and Ne were unchanged over time, the mean number (±standard deviation) of heterozygous SNPs within MIs decreased significantly (p = 0.01) from 9(±1) in 2006 to 7(±1) in 2012. These findings indicate that the genetic diversity of P. falciparum malaria parasites in this area remains high, suggesting that only subtle gains, if any, have been made in reducing malaria transmission. Continued surveillance is required to evaluate the impact of malaria control interventions in this area and the rest of Malawi, and to better target control interventions.
Collapse
Affiliation(s)
- Tamika J Sisya
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Raphael M Kamn'gona
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - Jimmy A Vareta
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Joseph M Fulakeza
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Mavuto F J Mukaka
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Karl B Seydel
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi; Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Miriam K Laufer
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi; Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Terrie E Taylor
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi; Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Standwell C Nkhoma
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Liverpool School of Tropical Medicine, Pembroke Place, L3 5QA Liverpool, UK.
| |
Collapse
|
33
|
Mosha D, Chilongola J, Ndeserua R, Mwingira F, Genton B. Effectiveness of intermittent preventive treatment with sulfadoxine-pyrimethamine during pregnancy on placental malaria, maternal anaemia and birthweight in areas with high and low malaria transmission intensity in Tanzania. Trop Med Int Health 2014; 19:1048-56. [DOI: 10.1111/tmi.12349] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Dominic Mosha
- Ifakara Health Institute; Rufiji HDSS; Rufiji Tanzania
- Swiss Tropical and Public Health Institute; University of Basel; Basel Switzerland
- Kilimanjaro Christian Medical University College; Tumaini University Makumira; Moshi Tanzania
| | - Jaffu Chilongola
- Kilimanjaro Christian Medical University College; Tumaini University Makumira; Moshi Tanzania
| | - Rabi Ndeserua
- Muhimbili Orthopaedic Institute; Dar es Salaam Tanzania
| | - Felista Mwingira
- Swiss Tropical and Public Health Institute; University of Basel; Basel Switzerland
| | - Blaise Genton
- Swiss Tropical and Public Health Institute; University of Basel; Basel Switzerland
- Infectious Disease Service & Department of Ambulatory Care and Community Medicine; University of Lausanne; Lausanne Switzerland
| |
Collapse
|
34
|
Ricotta E, Koenker H, Kilian A, Lynch M. Are pregnant women prioritized for bed nets? An assessment using survey data from 10 African countries. GLOBAL HEALTH: SCIENCE AND PRACTICE 2014; 2:165-72. [PMID: 25276574 PMCID: PMC4168616 DOI: 10.9745/ghsp-d-14-00021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 04/04/2014] [Indexed: 11/15/2022]
Abstract
Women of reproductive age are generally more likely to sleep under an insecticide-treated net (ITN) than other household members. Universal coverage increases ITN use by all family members, including pregnant women. However, BCC efforts are needed to achieve desired levels of bed net use, which is especially important for pregnant women. Background: Malaria in pregnancy is a major public health concern, contributing to roughly 11% of neonatal deaths and to 25% of all maternal deaths in some parts of the world. The World Health Organization has recommended priority interventions for malaria during pregnancy, including use of insecticide-treated nets (ITNs), but net distribution has shifted recently to a universal coverage paradigm rather than one targeting vulnerable populations. Methods: To determine whether and to what extent pregnant women are prioritized within the household for ITN use, we assessed national survey data from 2009–2013 in 10 African countries. Proportion of pregnant women who slept under an ITN the previous night and 95% confidence intervals were calculated and compared between countries. Within-country logistic regression examined whether pregnancy was significantly associated with ITN use the previous night compared with other risk groups, and the predicted probability of net use for each risk group was calculated holding other covariates constant. Results: A median 58% of households reported owning at least 1 ITN. On average, across all 10 countries, 35% of pregnant women in households with at least 1 ITN used a net. Households with universal coverage (at least 1 ITN per 2 people) had higher levels of net use among all family members; for example, 79% of pregnant women, on average, used a net in such households. In all countries, the predicted probability of ITN use by pregnant women was significantly higher than the probability of net use by most other household members except non-pregnant women of reproductive age. Conclusion: These findings suggest that both pregnant women and non-pregnant women of reproductive age are being prioritized within the household for net use. However, behavior change communication strategies are needed to achieve ITN use goals for pregnant women.
Collapse
Affiliation(s)
- Emily Ricotta
- Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs , Baltimore, MD , USA
| | - Hannah Koenker
- Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs , Baltimore, MD , USA
| | | | - Matthew Lynch
- Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs , Baltimore, MD , USA
| |
Collapse
|
35
|
Teo A, Hasang W, Randall LM, Feng G, Bell L, Unger H, Langer C, Beeson JG, Siba PM, Mueller I, Molyneux ME, Brown GV, Rogerson SJ. Decreasing malaria prevalence and its potential consequences for immunity in pregnant women. J Infect Dis 2014; 210:1444-55. [PMID: 24799599 DOI: 10.1093/infdis/jiu264] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND As malaria control is intensified, pregnant women may be less exposed to malaria, thus affecting the acquisition of protective antibody. METHODS Plasma samples were collected from Malawian and Papua New Guinean (PNG) pregnant women enrolled over 7-year periods, during which malaria prevalence fell by over two thirds. Immunoglobulin G (IgG) levels to schizont extract, merozoite antigens, and VAR2CSA-DBL5ε were measured by enzyme-linked immunosorbent assay (ELISA). Levels of IgG to variant surface antigens of infected erythrocytes (IEs) and merozoites and levels of opsonizing IgG to IEs were measured by flow cytometry. RESULTS In both settings, levels of antibodies in pregnant women to recombinant antigens and to intact IEs but not of opsonizing antibodies decreased over time. After adjustment for coverage with insecticide-treated bed nets (ITNs), these differences disappeared in the Malawian cohort, whereas in the PNG cohort, time was independently associated with a decrease in several antibody responses measured by ELISA. CONCLUSIONS The impact of falling parasite prevalence on anti-Plasmodium falciparum serological indicators in pregnant women varies by setting. Increased ITN coverage may affect development of antibodies to recombinant antigens, but levels of opsonizing IgG remained stable over time. Opsonizing IgG against placental-binding IEs may persist, thus offering longer-lasting protection against malaria during pregnancy.
Collapse
Affiliation(s)
- Andrew Teo
- Department of Medicine Doherty Institute
| | - Wina Hasang
- Department of Medicine Victorian Infectious Diseases Service Doherty Institute
| | - Louise M Randall
- Department of Medicine Victorian Infectious Diseases Service Doherty Institute
| | | | - Lauren Bell
- Nossal Institute for Global Health, University of Melbourne
| | | | | | | | - Peter M Siba
- Papua New Guinea Institute of Medical Research, Goroka
| | - Ivo Mueller
- Walter and Eliza Hall Institute of Medical Research, Parkville Barcelona Center for International Health Research, Spain
| | - Malcolm E Molyneux
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme College of Medicine, Blantyre Liverpool School of Tropical Medicine, United Kingdom
| | - Graham V Brown
- Nossal Institute for Global Health, University of Melbourne
| | - Stephen J Rogerson
- Department of Medicine Victorian Infectious Diseases Service Doherty Institute
| |
Collapse
|
36
|
A model of parity-dependent immunity to placental malaria. Nat Commun 2013; 4:1609. [PMID: 23511473 PMCID: PMC3615483 DOI: 10.1038/ncomms2605] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 02/14/2013] [Indexed: 11/08/2022] Open
Abstract
Plasmodium falciparum placental infection during pregnancy is harmful for both mother and child. Protection from placental infection is parity-dependent, that is, acquired over consecutive pregnancies. However, the infection status of the placenta can only be assessed at delivery. Here, to better understand the mechanism underlying this parity-dependence, we fitted a model linking malaria dynamics within the general population to observed placental histology. Our results suggest that immunity resulting in less prolonged infection is a greater determinant of the parity-specific patterns than immunity that prevents placental sequestration. Our results also suggest the time when maternal blood first flows into the placenta is a high-risk period. Therefore, preventative strategies implementable before or early in pregnancy, such as insecticide-treated net usage in women of child-bearing age or any future vaccine, could substantially reduce the number of women who experience placental infection.
Collapse
|
37
|
van Eijk AM, Hill J, Larsen DA, Webster J, Steketee RW, Eisele TP, ter Kuile FO. Coverage of intermittent preventive treatment and insecticide-treated nets for the control of malaria during pregnancy in sub-Saharan Africa: a synthesis and meta-analysis of national survey data, 2009-11. THE LANCET. INFECTIOUS DISEASES 2013; 13:1029-42. [PMID: 24054085 DOI: 10.1016/s1473-3099(13)70199-3] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pregnant women in malaria-endemic countries in sub-Saharan Africa are especially vulnerable to malaria. Recommended prevention strategies include intermittent preventive treatment with two doses of sulfadoxine-pyrimethamine and the use of insecticide-treated nets. However, progress with implementation has been slow and the Roll Back Malaria Partnership target of 80% coverage of both interventions by 2010 has not been met. We aimed to review the coverage of intermittent preventive treatment, insecticide-treated nets, and antenatal care for pregnant women in sub-Saharan Africa and to explore associations between coverage and individual and country-level factors, including the role of funding for malaria prevention. METHODS We used data from nationally representative household surveys from 2009-11 to estimate coverage of intermittent preventive treatment, use of insecticide-treated nets, and attendance at antenatal clinics by pregnant women in sub-Saharan Africa. Using demographic data for births and published data for malaria exposure, we also estimated the number of malaria-exposed births (livebirths and stillbirths combined) for 2010 by country. We used meta-regression analysis to investigate the factors associated with coverage of intermittent preventive treatment and use of insecticide-treated nets. RESULTS Of the 21·4 million estimated malaria-exposed births across 27 countries in 2010, an estimated 4·6 million (21·5%, 95% CI 19·3-23·7) were born to mothers who received intermittent preventive treatment. Insecticide-treated nets were used during pregnancy for 10·5 million of 26·9 million births across 37 countries (38·8%, 34·6-43·0). Antenatal care was attended at least once by 16·3 of 20·8 million women in 2010 (78·3%, 75·2-81·4; n=26 countries) and at least twice by 14·7 of 19·6 million women (75·1%, 72·9-77·3; n=22 countries). For the countries with previous estimates for 2007, coverage of intermittent preventive treatment increased from 13·1% (11·9-14·3) to 21·2% (18·9-23·5; n=14 countries) and use of insecticide-treated nets increased from 17·9% (15·1-20·7) to 41·6% (37·2-46·0; n=24 countries) in 2010. A fall in coverage by more than 10% was seen in two of 24 countries for intermittent preventive treatment and in three of 30 countries for insecticide-treated nets. High disbursement of funds for malaria control and a long time interval since adoption of the relevant policy were associated with the highest coverage of intermittent preventive treatment. High disbursement of funds for malaria control and high total fertility rate were associated with the greatest use of insecticide-treated nets, whereas a high per-head gross domestic product (GDP) was associated with less use of nets than was a lower GDP. Coverage of intermittent preventive treatment showed greater inequity overall than use of insecticide-treated nets, with richer, educated, and urban women more likely to receive preventive treatment than their poorer, uneducated, rural counterparts. INTERPRETATION Although coverage of intermittent preventive treatment and use of insecticide-treated nets by pregnant women has increased in most countries, coverage remains far below international targets, despite fairly high rates of attendance at antenatal clinics. The effect of the implementation of WHO's 2012 policy update for intermittent preventive treatment, which aims to simplify the message and align preventive treatment with the focused antenatal care schedule, should be assessed to find out whether it leads to improvements in coverage. FUNDING Bill & Melinda Gates Foundation.
Collapse
Affiliation(s)
- Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | | | | | | | | | | | | |
Collapse
|
38
|
Arinaitwe E, Ades V, Walakira A, Ninsiima B, Mugagga O, Patil TS, Schwartz A, Kamya MR, Nasr S, Chang M, Filler S, Dorsey G. Intermittent preventive therapy with sulfadoxine-pyrimethamine for malaria in pregnancy: a cross-sectional study from Tororo, Uganda. PLoS One 2013; 8:e73073. [PMID: 24023811 PMCID: PMC3762885 DOI: 10.1371/journal.pone.0073073] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 07/17/2013] [Indexed: 11/19/2022] Open
Abstract
Background Intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is widely recommended in sub-Saharan Africa to reduce the risk of malaria and improve birth outcomes. However, there are reports that the efficacy of IPTp with SP is waning, especially in parts of Africa where antimalarial resistance to this drug has become widespread. Methodology/Principal Findings We conducted a cross-sectional study of 565 HIV-uninfected women giving birth at Tororo District Hospital in southeastern Uganda. The primary objective of the study was to measure associations between use of SP during pregnancy from antenatal records and the risk of adverse outcomes including placental malaria, low birth weight, maternal parasitemia and maternal anemia. The proportion of women who reported taking 0, 1, 2, and 3 doses of SP during pregnancy was 5.7%, 35.8%, 56.6% and 2.0% respectively. Overall, the prevalence of placental malaria was 17.5%, 28.1%, and 66.2% by placental smear, PCR, and histopathology, respectively. In multivariate analyses controlling for potential confounders, ≥2 doses of SP was associated with non-significant trends towards lower odds of placental malaria by placental smear (OR = 0.75, p = 0.25), placental malaria by PCR (OR = 0.93, p = 0.71), placental malaria by histopathology (OR = 0.75, p = 0.16), low birth weight (OR = 0.63, p = 0.11), maternal parasitemia (OR = 0.88, p = 0.60) and maternal anemia (OR = 0.88, p = 0.48). Using a composite outcome, ≥2doses of SP was associated with a significantly lower odds of placental malaria, low birth weight, maternal parasitemia, or maternal anemia (OR = 0.52, p = 0.01). Conclusions/Significance In this area of Uganda with intense malaria transmission, the prevalence of placental malaria by histopathology was high even among women who reported taking at least 2 doses of SP during pregnancy. The reported use of ≥2 doses of SP was not associated with protection against individual birth and maternal outcome measures but did protect against a composite measure of any adverse outcome.
Collapse
Affiliation(s)
| | - Veronica Ades
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | | | - Boaz Ninsiima
- Infectious Disease Research Collaboration, Kampala, Uganda
| | - Olive Mugagga
- Infectious Disease Research Collaboration, Kampala, Uganda
| | - Teja S. Patil
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Alanna Schwartz
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Moses R. Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Sussann Nasr
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Michelle Chang
- Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Scott Filler
- The Global Fund to Fight Acquired Immune Deficiency Syndrome, Tuberculosis, and Malaria, Geneva, Switzerland
| | - Grant Dorsey
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| |
Collapse
|
39
|
Gutman J, Mwandama D, Wiegand RE, Ali D, Mathanga DP, Skarbinski J. Effectiveness of intermittent preventive treatment with sulfadoxine-pyrimethamine during pregnancy on maternal and birth outcomes in Machinga district, Malawi. J Infect Dis 2013; 208:907-16. [PMID: 23801600 DOI: 10.1093/infdis/jit276] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Malaria during pregnancy is associated with low birth weight and increased perinatal mortality, especially among primigravidae. Despite increasing prevalence of malarial parasite resistance to sulfadoxine-pyrimethamine (SP), SP continues to be recommended for intermittent preventive treatment in pregnancy (IPTp). METHODS Women without human immunodeficiency virus infection were enrolled upon delivery. Data on the number of SP doses received during pregnancy were recorded. The primary outcome was placental infection demonstrated by histologic analysis. Secondary outcomes included malaria parasitemia (in peripheral, placental, cord blood specimens) at delivery and composite birth outcome (small for gestational age, preterm delivery, or low birth weight). RESULTS.: Of 703 women enrolled, 22% received <2 SP doses. Receipt of ≥ 2 SP doses had no impact on histologically confirmed placental infection. IPTp-SP was associated with a dose-dependent protective effect on composite birth outcome in primigravidae, with an adjusted prevalence ratio of 0.50 (95% confidence interval [CI], .30-.82), 0.30 (95% CI, .19-.48), and 0.18 (95% CI, .05-.61) for 1, 2, and ≥ 3 doses, respectively, compared with 0 doses. CONCLUSIONS IPTp-SP did not reduce the frequency of placental infection but was associated with improved birth outcomes. Few women received no SP, so the true effect of IPTp-SP may be underestimated. Malawian pregnant women should continue to receive IPTp-SP, but alternative strategies and antimalarials for preventing malaria during pregnancy should be investigated.
Collapse
Affiliation(s)
- Julie Gutman
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia 30322, USA.
| | | | | | | | | | | |
Collapse
|
40
|
A systematic review of the impact of malaria prevention in pregnancy on low birth weight and maternal anemia. Int J Gynaecol Obstet 2013; 121:103-9. [PMID: 23490427 DOI: 10.1016/j.ijgo.2012.12.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 12/06/2012] [Accepted: 01/25/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Malaria in pregnancy is a significant contributor to adverse pregnancy outcome, especially in Sub-Saharan Africa. Prevention with sulfadoxine/pyrimethamine (SP) during pregnancy has been recommended in malaria-endemic areas but concerns remain about its benefit. OBJECTIVES To evaluate the association between recommended preventative SP programs in pregnancy and low birth weight (LBW) and maternal anemia through available clinical trial, observational, and programmatic evaluation studies. SEARCH STRATEGY Systematic review of published studies on malaria in pregnancy and pregnancy outcomes. SELECTION CRITERIA Clinical studies from Sub-Saharan Africa from the past 10 years were included. DATA COLLECTION AND ANALYSIS English articles published since 2002 and listed in PubMed were identified using defined keywords, and their source documents were reviewed. Thirty-three studies involving malaria in pregnancy that recorded treatment rates and birth outcomes were included. MAIN RESULTS SP use among primigravidae was consistently associated with decreased LBW and anemia rates in clinical trials. Effects were less consistent in observational studies. CONCLUSIONS Although randomized trials have demonstrated the efficacy of SP, studies evaluating scale-up programs found less consistent reductions in LBW and maternal anemia. Additional strategies to improve SP coverage may reduce the LBW and maternal anemia associated with malaria in pregnancy.
Collapse
|
41
|
|
42
|
Taylor SM, Antonia AL, Mwapasa V, Feng G, Molyneux ME, ter Kuile FO, Meshnick SR, Rogerson SJ. Reply to Harrington et al. Clin Infect Dis 2012. [DOI: 10.1093/cid/cis570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
43
|
Bouyou-Akotet MK, Mawili-Mboumba DP, Kendjo E, Eyang Ekouma A, Abdou Raouf O, Engohang Allogho E, Kombila M. Complicated malaria and other severe febrile illness in a pediatric ward in Libreville, Gabon. BMC Infect Dis 2012; 12:216. [PMID: 22973831 PMCID: PMC3520876 DOI: 10.1186/1471-2334-12-216] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 09/05/2012] [Indexed: 11/10/2022] Open
Abstract
Background Although a substantial decline of Plasmodium falciparum infection is observed in Africa following implementation of new control strategies, malaria is still considered as the major cause of febrile illness in hospitalized African children. The present study was designed to assess the management of febrile illness and to determine the proportion of children with febrile illness hospitalized for primary diagnosis of malaria who had confirmed complicated malaria after implementation of new malaria control strategies in Libreville, Gabon. Methods Demographic, clinical and biological data from hospitalized children with fever or a history of fever, with a primary diagnosis of clinical malaria, aged less than 18 years old, who benefited from hematological measurements and microscopic malaria diagnosis, were recorded and analyzed during a prospective and observational study conducted in 2008 in the Centre Hospitalier de Libreville. Results A total of 418 febrile children were admitted at hospital as malaria cases. Majority of them (79.4%) were aged below five years. After medical examination, 168 were diagnosed and treated as clinical malaria and, among them, only 56.7% (n = 95) had Plasmodium falciparum positive blood smears. Age above five years, pallor, Blantyre Coma Score ≤2 and thrombocytopenia were predictive of malaria infection. Respiratory tract infections were the first leading cause of hospitalization (41.1%), followed by malaria (22.7%); co-morbidities were frequent (22%). Less than 5% of suspected bacterial infections were confirmed by culture. Global case fatality rate was 2.1% and 1% for malaria. Almost half (46%) of the children who received antimalarial therapy had negative blood smears. Likewise, antibiotics were frequently prescribed without bacteriological confirmation. Conclusions The use of clinical symptoms for the management of children febrile illness is frequent in Gabon. Information, training of health workers and strengthening of diagnosis tools are necessary to improve febrile children care.
Collapse
|
44
|
Bardají A, Bassat Q, Alonso PL, Menéndez C. Intermittent preventive treatment of malaria in pregnant women and infants: making best use of the available evidence. Expert Opin Pharmacother 2012; 13:1719-36. [PMID: 22775553 DOI: 10.1517/14656566.2012.703651] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Malaria continues to represent a huge global health burden on the most vulnerable populations. The Intermittent Preventive Treatment (IPT) strategy has been shown to be an efficacious intervention in preventing most of the deleterious effects of malaria in pregnant women and infants. Yet, the effectiveness of the IPT strategy may be impaired by the increasing resistance to sulfadoxine-pyrimethamine (SP), and the scarcity of alternative antimalarial drugs. AREAS COVERED This review examines all the available information on IPT, in an aim to provide the scientific community with a framework to understand the benefits and limitations of this malaria control strategy. It includes the understanding of the historical background of the IPT strategy, the drug's mechanisms of actions, updated information on current available evidence, the implications of drug resistance and choice of alternative drugs, and a comprehensive discussion on the perspectives of IPT for malaria control in pregnant women and infants. EXPERT OPINION IPT in pregnancy and infants is a cost-effective strategy that can contribute significantly to the control of malaria in endemic areas. Monitoring its effectiveness will allow tracking of progress, evaluation of the adequacy of currently used drugs and will highlight the eventual need for new therapies or alternative interventions.
Collapse
Affiliation(s)
- Azucena Bardají
- University of Barcelona, Hospital Clínic, Barcelona Centre for International Health Research, Roselló, 132, 08036, Barcelona, Spain.
| | | | | | | |
Collapse
|
45
|
Gutman J. Intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine: the controversy continues. Clin Infect Dis 2012; 55:1103-5. [PMID: 22767650 DOI: 10.1093/cid/cis604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
|
46
|
Rogawski ET, Chaluluka E, Molyneux ME, Feng G, Rogerson SJ, Meshnick SR. The effects of malaria and intermittent preventive treatment during pregnancy on fetal anemia in Malawi. Clin Infect Dis 2012; 55:1096-102. [PMID: 22767651 DOI: 10.1093/cid/cis597] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Fetal anemia is common in malarious areas and is a risk factor for infant morbidity and mortality. Malaria during pregnancy may cause decreased cord hemoglobin (Hb) and fetal anemia among newborns. Intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is protective against malaria but may also affect hematopoiesis and contribute to fetal anemia. METHODS Peripheral, placental, and cord blood were examined for malaria parasitemia and Hb concentration in a cross-section of 3848 mothers and infants delivered at Queen Elizabeth Central Hospital in Blantyre, Malawi between 1997 and 2006. Unconditional linear and logistic regressions were performed with multiple imputation for missing covariates to assess the associations between malaria, IPTp with SP, and fetal anemia. RESULTS The overall prevalence of fetal anemia was 7.9% (n = 304). Malaria parasitemia at delivery was associated with an adjusted decrease in cord Hb of -0.24 g/dL (95% confidence interval [CI], -.42 to -.05). The adjusted prevalence odds ratio for the effect of malaria on fetal anemia was 1.41 (95% CI, 1.05-1.90). Primigravidae who did not take IPTp had infants at highest risk for fetal anemia, and density of parasitemia was correlated with the decrease in cord Hb. There was no significant association between SP use and cord Hb or fetal anemia. CONCLUSIONS Malaria during pregnancy, but not IPTp, decreases cord Hb and is a risk factor for fetal anemia in Malawi. Intermittent preventive treatment during pregnancy with SP may continue to be safe and effective in preventing malaria during pregnancy and fetal anemia despite development of SP resistance.
Collapse
Affiliation(s)
- Elizabeth T Rogawski
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC 27599-7435, USA.
| | | | | | | | | | | |
Collapse
|
47
|
Harrington W, McGready R, Muehlenbachs A, Fried M, Nosten F, Duffy P. Intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine: the times they are a-changin'. Clin Infect Dis 2012; 55:1025-6; author reply 1026-7. [PMID: 22715177 DOI: 10.1093/cid/cis568] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
48
|
Glennie SJ, Nyirenda M, Williams NA, Heyderman RS. Do multiple concurrent infections in African children cause irreversible immunological damage? Immunology 2012; 135:125-32. [PMID: 22044389 DOI: 10.1111/j.1365-2567.2011.03523.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Much of the developing world, particularly sub-Saharan Africa, has high levels of morbidity and mortality associated with infectious diseases. The greatest risk of invasive disease is in the young, the malnourished and HIV-infected individuals. In many regions in Africa these vulnerable groups and the wider general population are under constant immune pressure from a range of environmental factors, under-nutrition and multiple concurrent infections from birth through to adulthood. Intermittent microbial exposure during childhood is required for the generation of naturally acquired immunity capable of protection against a range of infectious diseases in adult life. However, in the context of a resource-poor setting, the heavy burden of malarial, diarrhoeal and respiratory infections in childhood may subvert or suppress immune responses rather than protect, resulting in sub-optimal immunity. This review will explore how poor maternal health, HIV exposure, socio-economic and seasonal factors conspire to weaken childhood immune defences to disease and discuss the hypothesis that recurrent infections may drive immune dysregulation, leading to relative immune senescence and premature immunological aging.
Collapse
Affiliation(s)
- Sarah J Glennie
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
| | | | | | | |
Collapse
|
49
|
Taylor SM, Antonia AL, Chaluluka E, Mwapasa V, Feng G, Molyneux ME, ter Kuile FO, Meshnick SR, Rogerson SJ. Antenatal receipt of sulfadoxine-pyrimethamine does not exacerbate pregnancy-associated malaria despite the expansion of drug-resistant Plasmodium falciparum: clinical outcomes from the QuEERPAM study. Clin Infect Dis 2012; 55:42-50. [PMID: 22441649 DOI: 10.1093/cid/cis301] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Antenatal intermittent preventive therapy with 2 doses of sulfadoxine-pyrimethamine (IPTp-SP) is the mainstay of efforts in sub-Saharan Africa to prevent pregnancy-associated malaria (PAM). Recent studies report that drug resistance may cause IPTp-SP to exacerbate PAM morbidity, raising fears that current policies will cause harm as resistance spreads. METHODS We conducted a serial, cross-sectional analysis of the relationships between IPTp-SP receipt, SP-resistant Plasmodium falciparum, and PAM morbidity in delivering women during a period of 9 years at a single site in Malawi. PAM morbidity was assessed by parasite densities, placental histology, and birth outcomes. RESULTS The prevalence of parasites with highly SP-resistant haplotypes increased from 17% to 100% (P < .001), and the proportion of women receiving full IPTp (≥2 doses) increased from 25% to 82% (P < .001). Women who received full IPTp with SP had lower peripheral (P = .018) and placental (P < .001) parasite densities than women who received suboptimal IPTp (<2 doses). This effect was not significantly modified by the presence of highly SP-resistant haplotypes. After adjustment for covariates, the receipt of SP in the presence of SP-resistant P. falciparum did not exacerbate any parasitologic, histologic, or clinical measures of PAM morbidity. CONCLUSIONS In this longitudinal study of malaria at delivery, the receipt of SP as IPTp did not potentiate PAM morbidity despite the increasing prevalence and fixation of SP-resistant P. falciparum haplotypes. Even when there is substantial resistance, SP may be used in modified IPTp regimens as a component of comprehensive antenatal care.
Collapse
Affiliation(s)
- Steve M Taylor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, 27599, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Mathanga DP, Walker ED, Wilson ML, Ali D, Taylor TE, Laufer MK. Malaria control in Malawi: current status and directions for the future. Acta Trop 2012; 121:212-7. [PMID: 21763670 DOI: 10.1016/j.actatropica.2011.06.017] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 06/26/2011] [Accepted: 06/29/2011] [Indexed: 11/18/2022]
Abstract
The last decade has seen an increase in investment and concerted efforts by the Malawi Ministry of Health and partners to control malaria disease. This report summarizes what is known about the burden of malaria and the strategies being implemented to control it in Malawi. Over the past 5 years, roll out of treatment and prevention efforts have been successful in the country, as demonstrated by increased use of insecticide treated nets, improved access to prompt and effective treatment and the initiation of pilot studies of indoor residual spraying. However, unlike other countries in the region, the recent data have not suggested a decrease in the burden of disease. We describe the environment in which the activities of Malawi's International Center for Excellence in Malaria Research (ICEMR) will be carried out and provide the rationale for the clinical, entomological and molecular studies. Our approach is to establish consistent, stainable data collection systems that are embedded within the public health sector. Through standardized and long-term studies of hosts, parasites and vectors, we hope to contribute to assessment of malaria disease burden, the appropriate application of interventions and policies and provide both the data collection and the health care infrastructure to ultimately eliminate the disease.
Collapse
Affiliation(s)
- Don P Mathanga
- Department of Community Health, University of Malawi College of Medicine, Blantyre, Malawi.
| | | | | | | | | | | |
Collapse
|