Maternal and perinatal outcomes during a Chikungunya outbreak in Kassala, eastern Sudan

BACKGROUND

Arboviruses (dengue, Zika, and chikungunya) have recently emerged as an important public health issue and can lead to adverse obstetrics outcomes. The current study was conducted to assess maternal and perinatal outcomes following chikungunya fever/infection and to compare adverse pregnancy outcomes with data from the community collected in a previous study.

METHODS

This study was performed during a chikungunya infection epidemic in Kassala, Sudan by recruiting all pregnant women with a confirmed chikungunya fever diagnosis by using antibodies/detection viral RNA using reverse transcriptase-polymerase chain reaction.

RESULTS

Ninety-three pregnant women with confirmed chikungunya infection were enrolled. Their mean (standard deviation) age and parity were 31.6 (3.4) years and 3.5 (1.4), respectively. Of the 93 women, 58 (62.4%) delivered a live infant at term and 18 (19.4%), 13 (13.9%), and 4 (4.3%) women experienced miscarriage, preterm birth, and stillbirth, respectively. In the logistic regression model, severe thrombocytopenia (platelets < 50,000 cells/mm³ (odds ratio [OR] = 5.1; confidence interval [CI] 1.8-14; P = 0.001) and leukopenia (OR = 4.5; CI 2.2-8.8; P < 0.001) were predictors for poor obstetric outcomes in pregnant women with chikungunya fever. The rates of miscarriage (18/93 [19.3%] vs. 1/71 [1.4%], P < 0.001) and preterm birth (13/93 [13.9%] vs. 2/71 [2.8%], P = 0.003) were significantly higher in the current study compared with the rate in the community.

CONCLUSION

Chikungunya infections during pregnancy were associated with miscarriage and preterm birth. Women with severe thrombocytopenia and leukopenia were at higher risk of poor obstetric outcomes. Women with severe thrombocytopenia and leukopenia were at higher risk of poor obstetric outcomes.

Quantification of the association between malaria in pregnancy and stillbirth: a systematic review and meta-analysis

BACKGROUND

2·6 million stillbirths occur annually worldwide. The association between malaria in pregnancy and stillbirth has yet to be comprehensively quantified. We aimed to quantify the association between malaria in pregnancy and stillbirth, and to assess the influence of malaria endemicity on the association.

METHODS

We did a systematic review of the association between confirmed malaria in pregnancy and stillbirth. We included population-based cross-sectional, cohort, or case-control studies (in which cases were stillbirths or perinatal deaths), and randomised controlled trials of malaria in pregnancy interventions, identified before Feb 28, 2017. We excluded studies in which malaria in pregnancy was not confirmed by PCR, light microscopy, rapid diagnostic test, or histology. The primary outcome was stillbirth. We pooled estimates of the association between malaria in pregnancy and stillbirth using meta-analysis. We used meta-regression to assess the influence of endemicity. The study protocol is registered with PROSPERO, protocol number CRD42016038742.

FINDINGS

We included 59 studies of 995 records identified, consisting of 141 415 women and 3387 stillbirths. Plasmodium falciparum malaria detected at delivery in peripheral samples increased the odds of stillbirth (odds ratio [OR] 1·81 [95% CI 1·42-2·30]; I²=26·1%; 34 estimates), as did P falciparum detected in placental samples (OR 1·95 [1·48-2·57]; I²=33·6%; 31 estimates). P falciparum malaria detected and treated during pregnancy was also associated with stillbirth, but to a lesser extent (OR 1·47 [95% CI 1·13-1·92]; 19 estimates). Plasmodium vivax malaria increased the odds of stillbirth when detected at delivery (2·81 [0·77-10·22]; three estimates), but not when detected and treated during pregnancy (1·09 [0·76-1·57]; four estimates). The association between P falciparum malaria in pregnancy and stillbirth was two times greater in areas of low-to-intermediate endemicity than in areas of high endemicity (ratio of ORs 1·96 [95% CI 1·34-2·89]). Assuming all women with malaria are still parasitaemic at delivery, an estimated 20% of the 1 059 700 stillbirths in malaria-endemic sub-Saharan Africa are attributed to P falciparum malaria in pregnancy; the population attributable fraction decreases to 12%, assuming all women with malaria are treated during pregnancy.

INTERPRETATION

P falciparum and P vivax malaria in pregnancy both increase stillbirth risk. The risk of malaria-associated stillbirth is likely to increase as endemicity declines. There is a pressing need for context-appropriate, evidence-based interventions for malaria in pregnancy in low-endemicity settings.

FUNDING

Australian Commonwealth Government, National Health and Medical Research Council, Australian Research Council.

Spatial patterns and determinants of malaria infection during pregnancy in Zambia

BACKGROUND

Malaria in pregnancy (MiP) is a major concern in Zambia. Here we aim to determine the burden and risk factors of MiP.

METHODS

Monthly reported district-level malaria cases among pregnant women (count data) from January 2009 to December 2014 were obtained from the Zambian District Health Information System. Negative binomial regression model was used to investigate the associations between vector control tools, coverage of health care facilities, transportation networks and population density. Data on MiP treatment were obtained from the 2012 Zambian Malaria Indicator Survey. Yearly clusters of MiP were investigated using spatial statistics in ArcGIS v 10.1.

RESULTS

The results indicated that MiP decreased in Zambia between 2010 and 2013. MiP was observed throughout the year, but showed a strong seasonal pattern. Persistent hotspots of MiP were reported in the southeast and northeast regions of Zambia, with districts that had better access to rail road and presence of water bodies associated with decreased prevalence of MiP. Better indoor residual spraying and long-lasting insecticide-treated nets coverage was demonstrated to be protective against MiP.

CONCLUSIONS

Mapping the distribution of MiP to track the future requirements for scaling up essential disease-prevention efforts in stable hotspots can help the Zambian National Malaria Control Center to further develop strategies to reduce malaria prevalence in this vulnerable sub-population.

Plasmodium vivax malaria during pregnancy, Bolivia

Plasmodium vivax is a major cause of illness in areas with low transmission of malaria in Latin America, Asia, and the Horn of Africa. However, pregnancy-associated malaria remains poorly characterized in such areas. Using a hospital-based survey of women giving birth and an antenatal survey, we assessed the prevalence rates of Plasmodium spp. infections in pregnant women in Bolivia, and evaluated the consequences of malaria during pregnancy on the health of mothers and newborns. P. vivax infection was detected in 7.9% of pregnant women attending antenatal visits, and placental infection occurred in 2.8% of deliveries; these rates did not vary with parity. Forty-two percent of all P. vivax malaria episodes were symptomatic. P. vivax-infected pregnant women were frequently anemic (6.5%) and delivered babies of reduced birthweight. P. vivax infections during pregnancy are clearly associated with serious adverse outcomes and should be considered in prevention strategies of pregnancy-associated malaria.

Pharmacokinetics of piperaquine in pregnant women in Sudan with uncomplicated Plasmodium falciparum malaria

The pharmacokinetic properties of piperaquine were investigated in 12 pregnant and 12 well-matched, non-pregnant women receiving a three-day oral fixed dose combination regimen of dihydroartemisinin and piperaquine for treatment of uncomplicated Plasmodium falciparum at New Halfa Hospital in eastern Sudan. Frequent venous plasma samples were drawn from the patients over a 63-day period and a complete concentration–time profile was collected for 7 pregnant and 11 non-pregnant patients. Piperaquine was quantified using a liquid chromatography–mass spectrometry/mass spectrometry method. Pregnant women had a significantly higher total drug exposure (median area under the curve [range] = 1,770 [1,200–5,600] hr × ng/mL versus 858 [325–2,370] hr × ng/mL; P = 0.018) and longer time to maximal concentration (4.00 [1.50–4.03] hr versus 1.50 [0.500–8.00] hr; P = 0.02) after the first dose compared with non-pregnant women. There was no other significant difference observed in piperaquine pharmacokinetics between pregnant and non-pregnant women, including no difference in total drug exposure or maximum concentration. The overall pharmacokinetic properties of piperaquine in this study were consistent with previously published reports in non-pregnant patients.

Thrombocytopenia in pregnant women with Plasmodium falciparum malaria in an area of unstable malaria transmission in eastern Sudan

BACKGROUND

Blood platelet levels are being evaluated as predictive and prognostic indicators of the severity of malaria infections in humans. However, there are few studies on platelets and Plasmodium falciparum malaria during pregnancy.

METHODS

A case-control study was conducted at Gadarif Hospital in Eastern Sudan, an area characterized by unstable malaria transmission. The aim of the study was to investigate thrombocytopenia in pregnant women with P. falciparum malaria (cases) and healthy pregnant women (controls).

RESULTS

The median (interquartile) platelet counts were significantly lower in patients with malaria (N = 60) than in the controls (N = 60), 61, 000 (43,000-85,000) vs. 249,000 (204,000-300,000)/μL, respectively, p < 0.001. However, there was no significant difference in the platelet counts in patients with severe P. falciparum malaria (N = 12) compared with those patients with uncomplicated P. falciparum malaria (N = 48), 68, 000 (33,000-88,000)/μL vs. 61, 000 (45,000-85,000)/μL, respectively, p = 0.8. While none of the control group had thrombocytopenia (platelet count <75, 000/μL), it was found that 6/12 (50%) and 27/48 (56.2%) (p <0.001) of the patients with severe malaria and uncomplicated malaria had thrombocytopenia, respectively. Pregnant women with P. falciparum malaria, compared with the pregnant healthy control group, were at higher risk (OR = 10.1, 95% CI = 4.1-25.18; p < 0.001) of thrombocytopenia. Two patients experienced bleeding, and there was one maternal death due to cerebral malaria where the patient's platelet count was only 28,000/μL.

CONCLUSION

P. falciparum malaria is associated with thrombocytopenia in pregnant women in this setting. More research is needed.