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Heilmann E, Tembo T, Fwoloshi S, Kabamba B, Chilambe F, Kalenga K, Siwingwa M, Mulube C, Seffren V, Bolton-Moore C, Simwanza J, Yingst S, Yadav R, Rogier E, Auld AF, Agolory S, Kapina M, Gutman JR, Savory T, Kangale C, Mulenga LB, Sikazwe I, Hines JZ. Trends in SARS-CoV-2 seroprevalence among pregnant women attending first antenatal care visits in Zambia: A repeated cross-sectional survey, 2021-2022. PLOS Glob Public Health 2024; 4:e0003073. [PMID: 38568905 PMCID: PMC10990173 DOI: 10.1371/journal.pgph.0003073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/11/2024] [Indexed: 04/05/2024]
Abstract
SARS-CoV-2 serosurveys help estimate the extent of transmission and guide the allocation of COVID-19 vaccines. We measured SARS-CoV-2 seroprevalence among women attending ANC clinics to assess exposure trends over time in Zambia. We conducted repeated cross-sectional SARS-CoV-2 seroprevalence surveys among pregnant women aged 15-49 years attending their first ANC visits in four districts of Zambia (two urban and two rural) during September 2021-September 2022. Serologic testing was done using a multiplex bead assay which detects IgG antibodies to the nucleocapsid protein and the spike protein receptor-binding domain (RBD). We calculated monthly SARS-CoV-2 seroprevalence by district. We also categorized seropositive results as infection alone, infection and vaccination, or vaccination alone based on anti-RBD and anti-nucleocapsid test results and self-reported COVID-19 vaccination status (vaccinated was having received ≥1 dose). Among 8,304 participants, 5,296 (63.8%) were cumulatively seropositive for SARS-CoV-2 antibodies from September 2021 through September 2022. SARS-CoV-2 seroprevalence primarily increased from September 2021 to September 2022 in three districts (Lusaka: 61.8-100.0%, Chongwe: 39.6-94.7%, Chipata: 56.5-95.0%), but in Chadiza, seroprevalence increased from 27.8% in September 2021 to 77.2% in April 2022 before gradually dropping to 56.6% in July 2022. Among 5,906 participants with a valid COVID-19 vaccination status, infection alone accounted for antibody responses in 77.7% (4,590) of participants. Most women attending ANC had evidence of prior SARS-CoV-2 infection and most SARS-CoV-2 seropositivity was infection-induced. Capturing COVID-19 vaccination status and using a multiplex bead assay with anti-nucleocapsid and anti-RBD targets facilitated distinguishing infection-induced versus vaccine-induced antibody responses during a period of increasing COVID-19 vaccine coverage in Zambia. Declining seroprevalence in Chadiza may indicate waning antibodies and a need for booster vaccines. ANC clinics have a potential role in ongoing SARS-CoV-2 serosurveillance and can continue to provide insights into SARS-CoV-2 antibody dynamics to inform near real-time public health responses.
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Affiliation(s)
- Elizabeth Heilmann
- Public Health Institute, Oakland, California, United States of America
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Tannia Tembo
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Sombo Fwoloshi
- Division of Infectious Diseases, Ministry of Health, Lusaka, Zambia
| | | | - Felix Chilambe
- Adult Centre of Excellence, University Teaching Hospital, Lusaka, Zambia
| | - Kalubi Kalenga
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Mpanji Siwingwa
- Adult Centre of Excellence, University Teaching Hospital, Lusaka, Zambia
| | | | - Victoria Seffren
- Division of Parasitic Diseases and Malaria, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | - John Simwanza
- Surveillance and Disease Intelligence, Zambia National Public Health Institute, Lusaka, Zambia
| | - Samuel Yingst
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Ruchi Yadav
- Division of Parasitic Diseases and Malaria, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Eric Rogier
- Division of Parasitic Diseases and Malaria, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Andrew F. Auld
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Simon Agolory
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
| | - Muzala Kapina
- Surveillance and Disease Intelligence, Zambia National Public Health Institute, Lusaka, Zambia
| | - Julie R. Gutman
- Division of Parasitic Diseases and Malaria, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Theodora Savory
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | - Lloyd B. Mulenga
- Division of Infectious Diseases, Ministry of Health, Lusaka, Zambia
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Jonas Z. Hines
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Lusaka, Zambia
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Schneider ZD, Shah MP, Boily MC, Busbee AL, Hwang J, Lindblade KA, Gutman JR. Mass Drug Administration to Reduce Malaria Transmission: A Systematic Review and Meta-Analysis. Am J Trop Med Hyg 2024; 110:17-29. [PMID: 38118174 PMCID: PMC10993786 DOI: 10.4269/ajtmh.22-0766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 04/18/2023] [Indexed: 12/22/2023] Open
Abstract
Malaria remains a significant cause of morbidity and mortality, even in low-transmission settings. With the advent of longer acting, more effective, and well-tolerated antimalarials, there is renewed interest in the efficacy of mass drug administration (MDA) to accelerate to elimination. We conducted a systematic review and meta-analysis to assess the efficacy of MDA to reduce the incidence and prevalence of Plasmodium falciparum (Pf) and Plasmodium vivax (Pv) infection. From 1,044 articles screened, 14 articles, including 10 randomized controlled trials (RCTs), were identified. Five included data on Pf only; five included Pf and Pv. Two of the Pf studies were conducted in areas of high-moderate transmission, the remainder were in areas of low-very low transmission. In higher transmission areas, MDA reduced incidence of Pf parasitemia (rate ratio = 0.61, 95% CI: 0.40-0.92; moderate certainty) 1 to 3 months after drug administration; no significant effect of MDA on Pf parasitemia prevalence was detected 1 to 3 months post-MDA (risk ratio [RR] = 1.76, 95% CI: 0.58-5.36; low certainty). In lower transmission settings, both incidence and prevalence of Pf parasitemia were reduced 1 to 3 months post-MDA (rate ratio = 0.37, 95% CI: 0.21-0.66; RR = 0.25, 95% CI: 0.15-0.41, respectively). Pv prevalence was reduced 1 to 3 months post-MDA (RR = 0.15, 95% CI: 0.10-0.24); there were no RCTs providing data on incidence of Pv. There was no significant effect of MDA at later time points. MDA may have short-term benefits; however, there was no evidence for longer term impact, although none of the trials assessed prolonged interventions.
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Affiliation(s)
- Zachary D. Schneider
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Monica P. Shah
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Marisa C. Boily
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Jimee Hwang
- U.S. President’s Malaria Initiative, Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kim A. Lindblade
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
- Global Malaria Programme, World Health Organization, Geneva, Switzerland
| | - Julie R. Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
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Schneider ZD, Busbee AL, Boily MC, Shah MP, Hwang J, Lindblade KA, Gutman JR. Mass Drug Administration: Contextual Factor Considerations. Am J Trop Med Hyg 2024; 110:30-37. [PMID: 38266300 PMCID: PMC10993792 DOI: 10.4269/ajtmh.22-0767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 11/13/2023] [Indexed: 01/26/2024] Open
Abstract
In designing mass drug administration (MDA) campaigns, it is imperative to consider contextual factors that affect uptake of the intervention, including acceptability, cost, feasibility, and health system considerations, to ensure optimal coverage. We reviewed the literature on contextual factors influencing MDA delivery to provide programs with information to design a successful campaign. From 1,044 articles screened, 37 included contextual factors relevant to participants' values and preferences, drivers of MDA acceptability, health equity concerns, financial and economic aspects, and feasibility barriers; 13 included relevant modeling data. Key findings were abstracted by two reviewers and summarized. No studies directly assessed values or direct health equity concerns with respect to MDA, which represents an evidence gap as unequal distributions of effects and factors that impact participant acceptability and program feasibility must be considered to ensure equitable access. Participant acceptability was the most widely surveyed factor, appearing in 28 of 37 studies; perceived adverse events were a frequently noted cause of nonparticipation, mentioned in 15 studies. Feasibility considerations included when, where, and how drugs will be delivered and how to address pregnant women, as these can all have substantial implications for participation. Mass drug administration costs (∼$1.04 to $19.40 per person per round) are driven primarily by drug prices, but the delivery mechanism can have varying costs as well, and integration with other interventions may provide cost savings. Both programmatic goals and sociopolitical and economic contexts must be carefully considered before embarking on an MDA program to ensure programmatic success.
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Affiliation(s)
- Zachary D. Schneider
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Marisa C. Boily
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Monica P. Shah
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jimee Hwang
- U.S. President’s Malaria Initiative, Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kim A. Lindblade
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
- Global Malaria Programme, World Health Organization, Geneva, Switzerland
| | - Julie R. Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
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Tenthani L, Seffren V, Kabaghe AN, Ogollah F, Soko M, Yadav R, Kayigamba F, Payne D, Wadonda-Kabondo N, Kampira E, Volkmann T, Sugandhi NS, Seydel K, Rogier E, Thwing JI, Gutman JR. SARS-CoV-2 Seroprevalence and Vaccine Uptake among Pregnant Women at First Antenatal Care Visits in Malawi. Am J Trop Med Hyg 2024:tpmd230726. [PMID: 38531097 DOI: 10.4269/ajtmh.23-0726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/01/2024] [Indexed: 03/28/2024] Open
Abstract
Many SARS-CoV-2 infections are asymptomatic, thus reported cases underestimate actual cases. To improve estimates, we conducted surveillance for SARS-CoV-2 seroprevalence among pregnant women attending their first antenatal care visit (ANC1) from June 2021 through May 2022. We administered a questionnaire to collect demographic, risk factors, and COVID-19 vaccine status information and tested dried blood spots for SARS-CoV-2 antibodies. Although <1% of ANC1 participants reported having had COVID-19, monthly SARS-CoV-2 seroprevalence increased from 15.4% (95% CI: 10.5-21.5) in June 2021 to 65.5% (95% CI: 55.5-73.7) in May 2022. Although COVID-19 vaccination was available in March 2021, uptake remained low, reaching a maximum of 9.5% (95% CI: 5.7-14.8) in May 2022. Results of ANC1 serosurveillance provided prevalence estimates helpful in understanding this population case burden that was available through self-report and national case reports. To improve vaccine uptake, efforts to address fears and misconceptions regarding COVID-19 vaccines are needed.
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Affiliation(s)
- Lyson Tenthani
- ICAP at Columbia University, International Programs - Malawi, Lilongwe, Malawi
| | - Victoria Seffren
- Malaria Branch, Division of Parasitic Diseases and Malaria, National Center for Emerging and Zoonotic Infectious Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Francis Ogollah
- ICAP at Columbia University, International Programs - Malawi, Lilongwe, Malawi
| | - Monica Soko
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Ruchi Yadav
- Malaria Branch, Division of Parasitic Diseases and Malaria, National Center for Emerging and Zoonotic Infectious Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Felix Kayigamba
- ICAP at Columbia University, International Programs - Malawi, Lilongwe, Malawi
| | - Danielle Payne
- U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | | | | | - Tyson Volkmann
- U.S. President's Malaria Initiative, U.S. Centers for Disease Control and Prevention, Lilongwe, Malawi
| | | | - Karl Seydel
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Eric Rogier
- Malaria Branch, Division of Parasitic Diseases and Malaria, National Center for Emerging and Zoonotic Infectious Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Julie I Thwing
- Malaria Branch, Division of Parasitic Diseases and Malaria, National Center for Emerging and Zoonotic Infectious Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, National Center for Emerging and Zoonotic Infectious Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
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Popkin-Hall ZR, Seth MD, Madebe RA, Budodo R, Bakari C, Francis F, Pereus D, Giesbrecht DJ, Mandara CI, Mbwambo D, Aaron S, Lusasi A, Lazaro S, Bailey JA, Juliano JJ, Gutman JR, Ishengoma DS. Prevalence of non-falciparum malaria infections among asymptomatic individuals in four regions of Mainland Tanzania. Parasit Vectors 2024; 17:153. [PMID: 38519992 PMCID: PMC10960463 DOI: 10.1186/s13071-024-06242-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 03/11/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Recent studies point to the need to incorporate the detection of non-falciparum species into malaria surveillance activities in sub-Saharan Africa, where 95% of the world's malaria cases occur. Although malaria caused by infection with Plasmodium falciparum is typically more severe than malaria caused by the non-falciparum Plasmodium species P. malariae, P. ovale spp. and P. vivax, the latter may be more challenging to diagnose, treat, control and ultimately eliminate. The prevalence of non-falciparum species throughout sub-Saharan Africa is poorly defined. Tanzania has geographical heterogeneity in transmission levels but an overall high malaria burden. METHODS To estimate the prevalence of malaria species in Mainland Tanzania, we randomly selected 1428 samples from 6005 asymptomatic isolates collected in previous cross-sectional community surveys across four regions and analyzed these by quantitative PCR to detect and identify the Plasmodium species. RESULTS Plasmodium falciparum was the most prevalent species in all samples, with P. malariae and P. ovale spp. detected at a lower prevalence (< 5%) in all four regions; P. vivax was not detected in any sample. CONCLUSIONS The results of this study indicate that malaria elimination efforts in Tanzania will need to account for and enhance surveillance of these non-falciparum species.
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Affiliation(s)
- Zachary R Popkin-Hall
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA.
| | - Misago D Seth
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Rashid A Madebe
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Rule Budodo
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Catherine Bakari
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Filbert Francis
- National Institute for Medical Research, Tanga Center, Tanga, Tanzania
| | - Dativa Pereus
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | | | - Celine I Mandara
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | | | | | | | - Samwel Lazaro
- National Malaria Control Programme, Dodoma, Tanzania
| | - Jeffrey A Bailey
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
- Center for Computational Molecular Biology, Brown University, Providence, RI, USA
| | - Jonathan J Juliano
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA
| | - Julie R Gutman
- Malaria Branch, National Center for Emerging and Zoonotic Infectious Diseases, US Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Deus S Ishengoma
- National Institute for Medical Research, Dar es Salaam, Tanzania
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Faculty of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
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Wolf K, Mostel J, Oseni L, Gomez P, Kibuka T, Emerson C, Gutman JR, Malpass A, Youll S, Mukamba JY, Tchinda Meli E, Achu D, Tjek P, Assa JL, Silue M, Tanoh MA, Kokrasset-Yah C, Babanawo F, Asiedu A, Komey M, Boateng P, Mabiria M, Ngindu A, Njiru P, Omar AH, Sidibe FA, Diallo C, Kamate B, Kone A, Elisha S, Maiga AD, Mayaki AI, Tidjani Issa Gana F, Tetteh G. Use of Supervision Data to Improve Quality of Care for Malaria in Pregnancy: Experience in Six African Countries. Am J Trop Med Hyg 2024; 110:42-49. [PMID: 38150728 PMCID: PMC10919236 DOI: 10.4269/ajtmh.23-0206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 10/06/2023] [Indexed: 12/29/2023] Open
Abstract
Malaria in pregnancy (MiP) intervention coverage, especially intermittent preventive treatment in pregnancy (IPTp), lags behind other global malaria indicators. In 2020, across Africa, only 32% of eligible pregnant women received at least three IPTp doses, despite high antenatal care attendance. We conducted a secondary analysis of data collected during Outreach Training and Supportive Supervision visits from 2019 to 2020 to assess quality of care and explore factors contributing to providers' competence in providing IPTp, insecticide-treated nets, malaria case management, and respectful maternity care. Data were collected during observations of provider-patient interactions in six countries (Cameroon, Cote d'Ivoire, Ghana, Kenya, Mali, and Niger). Competency scores (i.e., composite scores of supervisory checklist observations) were calculated across three domains: MiP prevention, MiP treatment, and respectful maternity care. Scores are used to understand drivers of competency, rather than to assess individual health worker performance. Country-specific multilinear regressions were used to assess how competency score was influenced by commodity availability, training, provider gender and cadre, job aid availability, and facility type. Average competency scores varied across countries: prevention (44-90%), treatment (78-90%), and respectful maternity care (53-93%). The relative association of each factor with competency score varied. Commodity availability, training, and access to job aids correlated positively with competency in multiple countries. To improve MiP service quality, equitable access to training opportunities for different cadres, targeted training, and access to job aids and guidelines should be available for providers. Collection and analysis of routine supervision data can support tailored actions to improve quality MiP services.
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Affiliation(s)
- Katherine Wolf
- PMI Impact Malaria Project, Jhpiego, Baltimore, Maryland
| | - Jadmin Mostel
- PMI Impact Malaria Project, Population Services International, Washington, District of Columbia
| | - Lolade Oseni
- PMI Impact Malaria Project, Jhpiego, Baltimore, Maryland
| | - Patricia Gomez
- PMI Impact Malaria Project, Jhpiego, Baltimore, Maryland
| | - Tabitha Kibuka
- PMI Impact Malaria Project, Population Services International, Washington, District of Columbia
| | - Courtney Emerson
- U.S. President’s Malaria Initiative, Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Julie R. Gutman
- U.S. President’s Malaria Initiative, Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ashley Malpass
- U.S. President’s Malaria Initiative, United States Agency for International Development, Washington, District of Columbia
| | - Susan Youll
- U.S. President’s Malaria Initiative, United States Agency for International Development, Washington, District of Columbia
| | | | | | | | - Paul Tjek
- Ministry of Health, Yaoundé, Cameroon
| | | | - Mamadou Silue
- PMI Impact Malaria/Cote d’Ivoire, Abidjan, Cote d’Ivoire
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Gladys Tetteh
- PMI Impact Malaria Project, Jhpiego, Baltimore, Maryland
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Castro L, Ridpath A, Mace K, Gutman JR. Have You Heard the News? Artemether-lumefantrine is Now Recommended for ALL Uncomplicated Malaria in the United States, Including in Pregnancy. Clin Infect Dis 2024; 78:245-247. [PMID: 37847222 DOI: 10.1093/cid/ciad638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/29/2023] [Accepted: 10/13/2023] [Indexed: 10/18/2023] Open
Affiliation(s)
- Laura Castro
- Malaria Branch, Division of Parasitic Diseases and Malaria, Global Health Center, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Epidemic Intelligence Service, Center for Surveillance, Epidemiology and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alison Ridpath
- Malaria Branch, Division of Parasitic Diseases and Malaria, Global Health Center, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kimberly Mace
- Malaria Branch, Division of Parasitic Diseases and Malaria, Global Health Center, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Global Health Center, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Barsosio HC, Madanitsa M, Ondieki ED, Dodd J, Onyango ED, Otieno K, Wang D, Hill J, Mwapasa V, Phiri KS, Maleta K, Taegtmeyer M, Kariuki S, Schmiegelow C, Gutman JR, Ter Kuile FO. Chemoprevention for malaria with monthly intermittent preventive treatment with dihydroartemisinin-piperaquine in pregnant women living with HIV on daily co-trimoxazole in Kenya and Malawi: a randomised, double-blind, placebo-controlled trial. Lancet 2024; 403:365-378. [PMID: 38224710 PMCID: PMC10865779 DOI: 10.1016/s0140-6736(23)02631-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/08/2023] [Accepted: 11/21/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND The efficacy of daily co-trimoxazole, an antifolate used for malaria chemoprevention in pregnant women living with HIV, is threatened by cross-resistance of Plasmodium falciparum to the antifolate sulfadoxine-pyrimethamine. We assessed whether addition of monthly dihydroartemisinin-piperaquine to daily co-trimoxazole is more effective at preventing malaria infection than monthly placebo plus daily co-trimoxazole in pregnant women living with HIV. METHODS We did an individually randomised, two-arm, placebo-controlled trial in areas with high-grade sulfadoxine-pyrimethamine resistance in Kenya and Malawi. Pregnant women living with HIV on dolutegravir-based combination antiretroviral therapy (cART) who had singleton pregnancies between 16 weeks' and 28 weeks' gestation were randomly assigned (1:1) by computer-generated block randomisation, stratified by site and HIV status (known positive vs newly diagnosed), to daily co-trimoxazole plus monthly dihydroartemisinin-piperaquine (three tablets of 40 mg dihydroartemisinin and 320 mg piperaquine given daily for 3 days) or daily co-trimoxazole plus monthly placebo. Daily co-trimoxazole consisted of one tablet of 160 mg sulfamethoxazole and 800 mg trimethoprim. The primary endpoint was the incidence of Plasmodium infection detected in the peripheral (maternal) or placental (maternal) blood or tissue by PCR, microscopy, rapid diagnostic test, or placental histology (active infection) from 2 weeks after the first dose of dihydroartemisinin-piperaquine or placebo to delivery. Log-binomial regression was used for binary outcomes, and Poisson regression for count outcomes. The primary analysis was by modified intention to treat, consisting of all randomised eligible participants with primary endpoint data. The safety analysis included all women who received at least one dose of study drug. All investigators, laboratory staff, data analysts, and participants were masked to treatment assignment. This trial is registered with ClinicalTrials.gov, NCT04158713. FINDINGS From Nov 11, 2019, to Aug 3, 2021, 904 women were enrolled and randomly assigned to co-trimoxazole plus dihydroartemisinin-piperaquine (n=448) or co-trimoxazole plus placebo (n=456), of whom 895 (99%) contributed to the primary analysis (co-trimoxazole plus dihydroartemisinin-piperaquine, n=443; co-trimoxazole plus placebo, n=452). The cumulative risk of any malaria infection during pregnancy or delivery was lower in the co-trimoxazole plus dihydroartemisinin-piperaquine group than in the co-trimoxazole plus placebo group (31 [7%] of 443 women vs 70 [15%] of 452 women, risk ratio 0·45, 95% CI 0·30-0·67; p=0·0001). The incidence of any malaria infection during pregnancy or delivery was 25·4 per 100 person-years in the co-trimoxazole plus dihydroartemisinin-piperaquine group versus 77·3 per 100 person-years in the co-trimoxazole plus placebo group (incidence rate ratio 0·32, 95% CI 0·22-0·47, p<0·0001). The number needed to treat to avert one malaria infection per pregnancy was 7 (95% CI 5-10). The incidence of serious adverse events was similar between groups in mothers (17·7 per 100 person-years in the co-trimoxazole plus dihydroartemisinin-piperaquine group [23 events] vs 17·8 per 100 person-years in the co-trimoxazole group [25 events]) and infants (45·4 per 100 person-years [23 events] vs 40·2 per 100 person-years [21 events]). Nausea within the first 4 days after the start of treatment was reported by 29 (7%) of 446 women in the co-trimoxazole plus dihydroartemisinin-piperaquine group versus 12 (3%) of 445 women in the co-trimoxazole plus placebo group. The risk of adverse pregnancy outcomes did not differ between groups. INTERPRETATION Addition of monthly intermittent preventive treatment with dihydroartemisinin-piperaquine to the standard of care with daily unsupervised co-trimoxazole in areas of high antifolate resistance substantially improves malaria chemoprevention in pregnant women living with HIV on dolutegravir-based cART and should be considered for policy. FUNDING European and Developing Countries Clinical Trials Partnership 2; UK Joint Global Health Trials Scheme (UK Foreign, Commonwealth and Development Office; Medical Research Council; National Institute for Health Research; Wellcome); and Swedish International Development Cooperation Agency.
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Affiliation(s)
- Hellen C Barsosio
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Mwayiwawo Madanitsa
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi; Academy of Medical Sciences, Malawi University of Science and Technology, Thyolo, Malawi
| | - Everlyne D Ondieki
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - James Dodd
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Eric D Onyango
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Kephas Otieno
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Victor Mwapasa
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Kamija S Phiri
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Kenneth Maleta
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Miriam Taegtmeyer
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Simon Kariuki
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Christentze Schmiegelow
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark; Department of Gynaecology and Obstetrics, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Feiko O Ter Kuile
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
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9
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Gatiba P, Laury J, Steinhardt L, Hwang J, Thwing JI, Zulliger R, Emerson C, Gutman JR. Contextual Factors to Improve Implementation of Malaria Chemoprevention in Children: A Systematic Review. Am J Trop Med Hyg 2024; 110:69-78. [PMID: 38081055 DOI: 10.4269/ajtmh.23-0478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/15/2023] [Indexed: 01/05/2024] Open
Abstract
Malaria remains a leading cause of childhood morbidity and mortality in sub-Saharan Africa, particularly among children under 5 years of age. To help address this challenge, the WHO recommends chemoprevention for certain populations. For children and infants, the WHO recommends seasonal malaria chemoprevention (SMC), perennial malaria chemoprevention (PMC; formerly intermittent preventive treatment in infants [IPTi]), and, more recently, intermittent preventive treatment in school children (IPTsc). This review describes the contextual factors, including feasibility, acceptability, health equity, financial considerations, and values and preferences, that impact implementation of these strategies. A systematic search was conducted on July 5, 2022, and repeated April 13, 2023, to identify relevant literature. Two reviewers independently screened titles for eligibility, extracted data from eligible articles, and identified and summarized themes. Of 6,295 unique titles identified, 65 were included. The most frequently evaluated strategy was SMC (n = 40), followed by IPTi (n = 18) and then IPTsc (n = 6). Overall, these strategies were highly acceptable, although with IPTsc, there were community concerns with providing drugs to girls of reproductive age and the use of nonmedical staff for drug distribution. For SMC, door-to-door delivery resulted in higher coverage, improved caregiver acceptance, and reduced cost. Lower adherence was noted when caregivers were charged with giving doses 2 and 3 unsupervised. For SMC and IPTi, travel distances and inclement weather limited accessibility. Sensitization and caregiver education efforts, retention of high-quality drug distributors, and improved transportation were key to improving coverage. Additional research is needed to understand the role of community values and preferences in chemoprevention implementation.
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Affiliation(s)
- Peris Gatiba
- Public Health Institute, Oakland, California
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jessica Laury
- Public Health Institute, Oakland, California
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Laura Steinhardt
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jimee Hwang
- U.S. President's Malaria Initiative, Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Julie I Thwing
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rose Zulliger
- U.S. President's Malaria Initiative, United States Agency for International Development, Washington, District of Columbia
| | - Courtney Emerson
- U.S. President's Malaria Initiative, Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
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Thwing J, Williamson J, Cavros I, Gutman JR. Systematic Review and Meta-Analysis of Seasonal Malaria Chemoprevention. Am J Trop Med Hyg 2024; 110:20-31. [PMID: 38081050 PMCID: PMC10793029 DOI: 10.4269/ajtmh.23-0481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/23/2023] [Indexed: 01/05/2024] Open
Abstract
Seasonal malaria chemoprevention (SMC) for children under 5 years of age for up to four monthly cycles during malaria transmission season was recommended by the WHO in 2012 and has been implemented in 13 countries in the Sahel, reaching more than 30 million children annually. Malaria control programs implementing SMC have asked the WHO to consider expanding the age range or number of monthly cycles. We conducted a systematic review and meta-analysis of SMC among children up to 15 years of age and up to six monthly cycles. Twelve randomized studies were included, with outcomes stratified by age (< 5/≥ 5 years), by three or four versus five or six cycles, and by drug where possible. Drug regimens included sulfadoxine-pyrimethamine + amodiaquine, amodiaquine-artesunate, and sulfadoxine-pyrimethamine + artesunate. Included studies were all conducted in Sahelian countries in which high-grade resistance to sulfadoxine-pyrimethamine was rare and in zones with parasite prevalence ranging from 1% to 79%. Seasonal malaria chemoprevention resulted in substantial reductions in uncomplicated malaria incidence measured during that transmission season (rate ratio: 0.27, 95% CI: 0.25-0.29 among children < 5 years; rate ratio: 0.27, 95% CI: 0.25-0.30 among children ≥ 5 years) and in the prevalence of malaria parasitemia measured within 4-6 weeks from the final SMC cycle (risk ratio: 0.38, 95% CI: 0.34-0.43 among children < 5 years; risk ratio: 0.23, 95% CI: 0.11-0.48 among children ≥ 5 years). In high-transmission zones, SMC resulted in a moderately reduced risk of any anemia (risk ratio: 0.77, 95% CI: 0.72-0.83 among children < 5 years; risk ratio: 0.70, 95% CI: 0.52-0.95 among children ≥ 5 years [one study]). Children < 10 years of age had a moderate reduction in severe malaria (risk ratio: 0.53, 95% CI: 0.37-0.76) but no evidence of a mortality reduction. The evidence suggests that in areas in which sulfadoxine-pyrimethamine and amodiaquine remained efficacious, SMC effectively reduced malaria disease burden among children both < 5 and ≥ 5 years old and that the number of cycles should be commensurate with the length of the transmission season, up to six cycles.
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Affiliation(s)
- Julie Thwing
- Malaria Branch, Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - John Williamson
- Malaria Branch, Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Irene Cavros
- U.S. President’s Malaria Initiative, Malaria Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Julie R. Gutman
- Malaria Branch, Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
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Popkin Hall ZR, Seth MD, Madebe RA, Budodo R, Bakari C, Francis F, Pereus D, Giesbrecht DJ, Mandara CI, Mbwambo D, Aaron S, Lusasi A, Lazaro S, Bailey JA, Juliano JJ, Gutman JR, Ishengoma DS. Malaria species prevalence among asymptomatic individuals in four regions of Mainland Tanzania. medRxiv 2023:2023.12.28.23300584. [PMID: 38234751 PMCID: PMC10793544 DOI: 10.1101/2023.12.28.23300584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Recent studies point to the need to incorporate non-falciparum species detection into malaria surveillance activities in sub-Saharan Africa, where 95% of malaria cases occur. Although Plasmodium falciparum infection is typically more severe, diagnosis, treatment, and control for P. malariae, P. ovale spp., and P. vivax may be more challenging. The prevalence of these species throughout sub-Saharan Africa is poorly defined. Tanzania has geographically heterogeneous transmission levels but an overall high malaria burden. In order to estimate the prevalence of malaria species in Mainland Tanzania, 1,428 samples were randomly selected from 6,005 asymptomatic isolates collected in cross-sectional community surveys across four regions and analyzed via qPCR to detect each Plasmodium species. P. falciparum was most prevalent, with P. malariae and P. ovale spp. detected at lower prevalence (<5%) in all four regions. P. vivax was not detected. Malaria elimination efforts in Tanzania will need to account for these non-falciparum species.
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Affiliation(s)
- Zachary R Popkin Hall
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA
| | - Misago D Seth
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Rashid A Madebe
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Rule Budodo
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Catherine Bakari
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Filbert Francis
- National Institute for Medical Research, Tanga Center, Tanga, Tanzania
| | - Dativa Pereus
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | | | - Celine I Mandara
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | | | | | | | - Samwel Lazaro
- National Malaria Control Programme, Dodoma, Tanzania
| | - Jeffrey A Bailey
- Department of Pathology and Laboratory Medicine, Warren Alpert Medical School, Brown University, RI, USA
- Center for Computational Molecular Biology, Brown University, RI, USA
| | - Jonathan J Juliano
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA
| | - Julie R Gutman
- Malaria Branch, Global Health Center, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Deus S Ishengoma
- National Institute for Medical Research, Dar es Salaam, Tanzania
- Harvard T. H. Chan School of Public Health, Boston, MA
- Faculty of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
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12
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Omondi S, Kosgei J, Musula G, Muchoki M, Abong'o B, Agumba S, Ogwang C, McDermott DP, Donnelly MJ, Staedke SG, Schultz J, Gutman JR, Gimnig JE, Ochomo E. Late morning biting behaviour of Anopheles funestus is a risk factor for transmission in schools in Siaya, western Kenya. Malar J 2023; 22:366. [PMID: 38037026 PMCID: PMC10691009 DOI: 10.1186/s12936-023-04806-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/23/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Children in Kenya spend a substantial amount of time at school, including at dawn and dusk when mosquitoes are active. With changing vector behaviour towards early morning biting, it is important to determine whether there is an additional risk of transmission in schools. This study sought to understand whether late morning biting by Anopheles funestus, previously documented in households in western Kenya, was replicated in schools. METHODS From the 4th to the 6th of August 2023, human landing collections were conducted hourly in four schools in Alego Usonga sub-County, Siaya County. The collections were conducted in and outside five classrooms in each school and ran for 17 h, starting at 18:00 until 11:00 h the next morning. RESULTS Anopheles funestus was the predominant species collected, forming 93.2% (N = 727) of the entire collection, with peak landing between 06:00 and 07:00 h and continuing until 11:00 h. More than half of the collected An. funestus were either fed or gravid, potentially indicative of multiple bloodmeals within each gonotrophic cycle, and had a sporozoite rate of 2.05%. CONCLUSION School children spend up to 10 h of their daytime in schools, reporting between 06:00 and 07:00 h and staying in school until as late as 17:00 h, meaning that they receive potentially infectious mosquito bites during the morning hours in these settings. There is a need to consider vector control approaches targeting schools and other peridomestic spaces in the morning hours when An. funestus is active.
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Affiliation(s)
- Seline Omondi
- Entomology Section, Centre for Global Health Research, Kenya Medical Research Institute, P.O. Box 1578-40100, Kisumu, Kenya
| | - Jackline Kosgei
- Entomology Section, Centre for Global Health Research, Kenya Medical Research Institute, P.O. Box 1578-40100, Kisumu, Kenya
| | - George Musula
- Entomology Section, Centre for Global Health Research, Kenya Medical Research Institute, P.O. Box 1578-40100, Kisumu, Kenya
| | - Margaret Muchoki
- Entomology Section, Centre for Global Health Research, Kenya Medical Research Institute, P.O. Box 1578-40100, Kisumu, Kenya
| | - Bernard Abong'o
- Entomology Section, Centre for Global Health Research, Kenya Medical Research Institute, P.O. Box 1578-40100, Kisumu, Kenya
| | - Silas Agumba
- Entomology Section, Centre for Global Health Research, Kenya Medical Research Institute, P.O. Box 1578-40100, Kisumu, Kenya
| | - Caroline Ogwang
- Entomology Section, Centre for Global Health Research, Kenya Medical Research Institute, P.O. Box 1578-40100, Kisumu, Kenya
| | - Daniel P McDermott
- Department of Vector Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Martin J Donnelly
- Department of Vector Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Sarah G Staedke
- Department of Vector Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Jonathan Schultz
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, 30333, USA
| | - Julie R Gutman
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, 30333, USA
| | - John E Gimnig
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, GA, 30333, USA
| | - Eric Ochomo
- Entomology Section, Centre for Global Health Research, Kenya Medical Research Institute, P.O. Box 1578-40100, Kisumu, Kenya.
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Munsey A, Kinyina A, Assenga M, Almeida A, Kitojo C, Reaves E, Simeo J, Aron S, Chacky F, Nhiga SL, Drake M, Lemwayi R, Lash R, Walker PGT, Gutman JR. Assessing the utility of pregnant women as a sentinel surveillance population for malaria in Geita, Tanzania, 2019 - 2021. Int J Infect Dis 2023; 136:57-63. [PMID: 37567552 PMCID: PMC10870194 DOI: 10.1016/j.ijid.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/27/2023] [Accepted: 08/07/2023] [Indexed: 08/13/2023] Open
Abstract
OBJECTIVES Estimates of malaria burden and intervention uptake in Africa are primarily based on household surveys. However, their expense and infrequency limit their utility. We investigated whether data collected during antenatal care (ANC) can provide relevant information for decision-makers. METHODS Malaria test positivity rates and questionnaire data from ANC attendees at 39 health facilities were compared to questionnaire data and positivity rates among children from two cross-sectional surveys in the facilities' corresponding catchment areas. RESULTS Trends in parasitemia among ANC attendees were predictive of trends in parasitemia among children at the council level (mean absolute error 6.0%). Primigravid ANC attendees had the lowest rates of net ownership (modeled odds ratio [OR] 0.28, 95% CI 0.19-0.40) and use (OR 0.58, 95% CI 0.42-0.79). ANC attendees reported higher levels of care-seeking (OR 1.78, 95% CI 1.48-2.14), malaria testing (OR 4.16, 95% CI 3.44-5.04), and treatment for children with fever (OR 7.66, 95% CI 4.89-11.98) compared to women surveyed in households, raising concerns about social desirability bias disproportionately impacting ANC surveys. CONCLUSION ANC surveillance is an effective strategy for tracking trends in malaria burden. More work is required to elucidate the value of administering questionnaires to ANC attendees.
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Affiliation(s)
- Anna Munsey
- U.S. President's Malaria Initiative, Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA.
| | | | | | | | - Chonge Kitojo
- U.S. President's Malaria Initiative, U.S. Agency for International Development (USAID), Dar es Salaam, Tanzania
| | - Erik Reaves
- U.S. President's Malaria Initiative, U.S. Centers for Disease Control and Prevention, Dar es Salaam, Tanzania
| | | | | | | | | | | | | | - Ryan Lash
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA
| | - Patrick G T Walker
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College, London, UK
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA
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14
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Alruwaili M, Uwimana A, Sethi R, Murindahabi M, Piercefield E, Umulisa N, Abram A, Eckert E, Munguti K, Mbituyumuremyi A, Gutman JR, Sullivan DJ. Peripheral and Placental Prevalence of Sulfadoxine-Pyrimethamine Resistance Markers in Plasmodium falciparum among Pregnant Women in Southern Province, Rwanda. Am J Trop Med Hyg 2023; 109:1057-1062. [PMID: 37783456 PMCID: PMC10622487 DOI: 10.4269/ajtmh.23-0225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/22/2023] [Indexed: 10/04/2023] Open
Abstract
Intermittent preventive therapy during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended in areas of moderate to high malaria transmission intensity. As a result of the increasing prevalence of SP resistance markers, IPTp-SP was withdrawn from Rwanda in 2008. Nonetheless, more recent findings suggest that SP may improve birthweight even in the face of parasite resistance, through alternative mechanisms that are independent of antimalarial effects. The prevalence of single nucleotide polymorphisms in Plasmodium falciparum dihydropteroate synthase (pfdhps) and dihydrofolate reductase (pfdhfr) genes associated with SP resistance among 148 pregnant women from 2016 to 2018 within Rwanda's Southern Province (Huye and Kamonyi districts) was measured using a ligase detection reaction-fluorescent microsphere assay. The frequency of pfdhps K540E, A581G, and the quintuple (pfdhfr N51I + C59R + S108N/pfdhps A437G + K540E) and sextuple (pfdhfr N51I + C59R + S108N/pfdhps A437G + K540E + A581G) mutant genotypes was 90%, 38%, 75%, and 28%, respectively. No significant genotype difference was seen between the two districts, which are approximately 50 km apart. Observed agreements for matched peripheral to placental blood were reported and found to be 207 of 208 (99%) for pfdhfr and 239 of 260 (92%) for pfdhps. The peripheral blood sample did not miss any pfdhfr drug-resistant mutants or pfdhps except at the S436 loci. At this level of the sextuple mutant, the antimalarial efficacy of SP for preventing low birthweight is reduced, although overall SP still exerts a nonmalarial benefit during pregnancy. This study further reveals the need to intensify preventive measures to sustain malaria control in Rwanda to keep the overall incidence of malaria during pregnancy low.
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Affiliation(s)
- Muharib Alruwaili
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Jouf University, Sakaka, Saudi Arabia
- Department of Tropical Medicine, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Aline Uwimana
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Reena Sethi
- Maternal and Child Survival Program/Jhpiego, Washington, District of Columbia
| | - Monique Murindahabi
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
- Roll Back Malaria, Ouagadougou, Burkina Faso
| | - Emily Piercefield
- U.S. President’s Malaria Initiative, Malaria Branch, U.S. Centers for Disease Control and Prevention, Kigali, Rwanda
| | - Noella Umulisa
- Maternal and Child Survival Program/Jhpiego, Kigali, Rwanda
| | | | - Erin Eckert
- RTI International, Washington, District of Columbia
| | - Kaendi Munguti
- U.S. President’s Malaria Initiative, U.S. Agency for International Development, Kigali, Rwanda
| | | | - Julie R. Gutman
- Malaria Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David J. Sullivan
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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15
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Mtove G, Chico RM, Madanitsa M, Barsosio HC, Msemo OA, Saidi Q, Gore-Langton GR, Minja DTR, Mukerebe C, Gesase S, Mwapasa V, Phiri KS, Hansson H, Dodd J, Magnussen P, Kavishe RA, Mosha F, Kariuki S, Lusingu JPA, Gutman JR, Alifrangis M, Ter Kuile FO, Schmiegelow C. Fetal growth and birth weight are independently reduced by malaria infection and curable sexually transmitted and reproductive tract infections in Kenya, Tanzania, and Malawi: A pregnancy cohort study. Int J Infect Dis 2023; 135:28-40. [PMID: 37516425 PMCID: PMC10878282 DOI: 10.1016/j.ijid.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/04/2023] [Accepted: 07/16/2023] [Indexed: 07/31/2023] Open
Abstract
OBJECTIVES Malaria and sexually transmitted and reproductive tract infections (STIs/RTIs) are highly prevalent in sub-Saharan Africa and associated with poor pregnancy outcomes. We investigated the individual and combined effects of malaria and curable STIs/RTIs on fetal growth in Kenya, Tanzania, and Malawi. METHODS This study was nested within a randomized trial comparing monthly intermittent preventive treatment for malaria in pregnancy with sulfadoxine-pyrimethamine vs dihydroartemisinin-piperaquine, alone or combined with azithromycin. Fetal weight gain was assessed by serial prenatal ultrasound. Malaria was assessed monthly, and Treponema pallidum, Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis, and bacterial vaginosis at enrollment and in the third trimester. The effect of malaria and STIs/RTIs on fetal weight/birthweight Z-scores was evaluated using mixed-effects linear regression. RESULTS In total, 1435 pregnant women had fetal/birth weight assessed 3950 times. Compared to women without malaria or STIs/RTIs (n = 399), malaria-only (n = 267), STIs/RTIs only (n = 410) or both (n = 353) were associated with reduced fetal growth (adjusted mean difference in fetal/birth weight Z-score [95% confidence interval]: malaria = -0.18 [-0.31,-0.04], P = 0.01; STIs/RTIs = -0.14 [-0.26,-0.03], P = 0.01; both = -0.20 [-0.33,-0.07], P = 0.003). Paucigravidae experienced the greatest impact. CONCLUSION Malaria and STIs/RTIs are associated with poor fetal growth especially among paucigravidae women with dual infections. Integrated antenatal interventions are needed to reduce the burden of both malaria and STIs/RTIs.
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Affiliation(s)
- George Mtove
- National Institute for Medical Research, Department of Research Program, Tanga, Tanzania.
| | - R Matthew Chico
- London School of Hygiene & Tropical Medicine, Department of Disease Control, London, United Kingdom
| | - Mwayiwawo Madanitsa
- Kamuzu University of Health Sciences, Blantyre, School of Global and Public Health, Malawi; Malawi University of Science and Technology, Academy of Medical Sciences, Limbe, Malawi
| | - Hellen C Barsosio
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Omari Abdul Msemo
- National Institute for Medical Research, Department of Research Program, Tanga, Tanzania
| | - Queen Saidi
- Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Georgia R Gore-Langton
- London School of Hygiene & Tropical Medicine, Department of Disease Control, London, United Kingdom
| | - Daniel T R Minja
- National Institute for Medical Research, Department of Research Program, Tanga, Tanzania
| | - Crispin Mukerebe
- National Institute for Medical Research, Department of Research Program, Tanga, Tanzania
| | - Samwel Gesase
- National Institute for Medical Research, Department of Research Program, Tanga, Tanzania
| | - Victor Mwapasa
- Kamuzu University of Health Sciences, Blantyre, School of Global and Public Health, Malawi
| | - Kamija S Phiri
- Kamuzu University of Health Sciences, Blantyre, School of Global and Public Health, Malawi
| | - Helle Hansson
- University of Copenhagen, Centre for Medical Parasitology, Department of Immunology, Microbiology and Infectious Diseases, Copenhagen, Denmark
| | - James Dodd
- Liverpool School of Tropical Medicine, Department of Clinical Sciences, Liverpool, United Kingdom
| | - Pascal Magnussen
- University of Copenhagen, Centre for Medical Parasitology, Department of Immunology, Microbiology and Infectious Diseases, Copenhagen, Denmark
| | - Reginald A Kavishe
- Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Franklin Mosha
- Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Simon Kariuki
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - John P A Lusingu
- National Institute for Medical Research, Department of Research Program, Tanga, Tanzania
| | - Julie R Gutman
- Centers for Disease Control and Prevention, Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Atlanta, United States of America
| | - Michael Alifrangis
- University of Copenhagen, Centre for Medical Parasitology, Department of Immunology, Microbiology and Infectious Diseases, Copenhagen, Denmark
| | - Feiko O Ter Kuile
- Liverpool School of Tropical Medicine, Department of Clinical Sciences, Liverpool, United Kingdom
| | - Christentze Schmiegelow
- University of Copenhagen, Centre for Medical Parasitology, Department of Immunology, Microbiology and Infectious Diseases, Copenhagen, Denmark
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Osoro CB, Dellicour S, Ochodo E, Young T, Ter Kuile FO, Gutman JR, Hill J. Perceptions and drivers of healthcare provider and drug dispenser practices for the treatment of malaria in pregnancy in the context of multiple first-line therapies in western Kenya: a qualitative study. Malar J 2023; 22:274. [PMID: 37710229 PMCID: PMC10503024 DOI: 10.1186/s12936-023-04698-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/01/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Emergence of Plasmodium falciparum resistance to artemether-lumefantrine in Africa prompted the pilot introduction of multiple first-line therapies (MFT) against malaria in Kenya, potentially exposing women-of-childbearing-age (WOCBAs) to anti-malarials with unknown safety profiles in the first trimester. This qualitative study explored knowledge and perceptions among healthcare providers providing malaria treatment to WOCBAs and pregnant women. METHODS In-depth interviews were conducted with purposively selected public and private health facility (HF) and drug outlet (DO) providers within and outside the pilot-MFT area. County health managers were interviewed about their knowledge of the national treatment guidelines. Transcripts were coded by content analysis using the World Health Organization health system building blocks (leadership/governance, financing, health workforce, health information systems, access to medicines, and service delivery). RESULTS Thirty providers (HF:21, DO:9) and three health managers were interviewed. Eighteen providers were from HFs in the pilot-MFT area; the remaining three and all nine DOs were outside the pilot-MFT area. The analysis revealed that providers had not been trained in malaria case management in the previous twelve months. DO providers were unfamiliar with national treatment guidelines in pregnancy and reported having no pregnancy tests. Health managers were unable to supervise DOs due to resource limitations. Providers from HFs and DOs noted poor sensitivity of malaria rapid diagnostic tests (RDTs) and hesitancy among patients who associated malaria-RDTs with HIV testing. Almost all providers reported anti-malarial stock-outs, with quinine most affected. Patient preference was a major factor in prescribing anti-malarials. Providers in HFs and DOs reported preferentially using artemether-lumefantrine in the first trimester due to the side effects and unavailability of quinine. CONCLUSION Knowledge of malaria case management in drug outlets and health facilities remains poor. Improved regulation of DO providers is warranted. Optimizing treatment of malaria in pregnancy requires training, availability of malaria commodities, and pregnancy tests.
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Affiliation(s)
- Caroline B Osoro
- Centre for Global Health Research, Kenya Medical Research Institute, P.O. Box 1578, Kisumu, 40100, Kenya.
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, P.O. Box 241, Cape Town, 8000, South Africa.
| | - Stephanie Dellicour
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, Liverpool, L3 5QA, UK
| | - Eleanor Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, P.O. Box 1578, Kisumu, 40100, Kenya
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, P.O. Box 241, Cape Town, 8000, South Africa
| | - Taryn Young
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, P.O. Box 241, Cape Town, 8000, South Africa
| | - Feiko O Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, Liverpool, L3 5QA, UK
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, U.S. Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, Liverpool, L3 5QA, UK
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Osoro CB, Dellicour S, Ochodo E, Young T, Ter Kuile F, Gutman JR, Hill J. Healthcare provider and drug dispenser knowledge and adherence to guidelines for the case management of malaria in pregnancy in the context of multiple first-line artemisinin-based combination therapy in western Kenya. Malar J 2023; 22:262. [PMID: 37679753 PMCID: PMC10486056 DOI: 10.1186/s12936-023-04692-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/29/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Concerns about emerging resistance to artemether-lumefantrine (AL) in Africa prompted the pilot introduction of multiple first-line therapies (MFT) in Western Kenya, potentially exposing women-of-childbearing-age (WOCBA) to anti-malarials with unknown safety profiles in the first trimester. The study assessed healthcare provider knowledge and adherence to national guidelines for managing malaria in pregnancy in the context of the MFT pilot. METHODS From March to April 2022, a cross-sectional study was conducted in 50 health facilities (HF) and 40 drug outlets (DO) using structured questionnaires to assess pregnancy detection, malaria diagnosis, and treatment choices by trimester. Differences between HF and DO providers and between MFT and non-MFT HFs were assessed using Chi-square tests. RESULTS Of 174 providers (77% HF, 23% DO), 56% were from MFT pilot facilities. Most providers had tertiary education; 5% HF and 20% DO had only primary or secondary education. More HF than DO providers had knowledge of malaria treatment guidelines (62% vs. 40%, p = 0.023), received training in malaria in pregnancy (49% vs. 20%, p = 0.002), and reported assessing for pregnancy in WOCBA (98% vs. 78%, p < 0.001). Most providers insisted on parasitological diagnosis, with 59% HF using microscopy and 85% DO using rapid diagnostic tests. More HF than DO providers could correctly name the drugs for treating uncomplicated malaria in the first trimester (oral quinine, or AL if quinine is unavailable) (90% vs. 58%, p < 0.001), second and third trimesters (artemisinin-based combination therapy) (84% vs. 70%, p = 0.07), and for severe malaria (parenteral artesunate/artemether) (94% vs. 60%, p < 0.001). Among HF providers, those in the MFT pilot had more knowledge of malaria treatment guidelines (67% vs. 49%, p = 0.08) and had received training on treatment of malaria in pregnancy (56% vs. 32%, p = 0.03). Few providers (10% HF and 12% DO) had adequate knowledge of malaria treatment in pregnancy, defined as the correct drug and dose for uncomplicated and severe malaria in all trimesters. CONCLUSIONS Knowledge of national malaria in pregnancy treatment guidelines among providers in Western Kenya is suboptimal. Robust training on appropriate anti-malarial and dosage is needed, particularly given the recent change in recommendation for artemether-lumefantrine use in the first trimester. Supervision of DO and HF practices is essential for correct treatment of malaria in pregnancy in the context of MFT programmes.
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Affiliation(s)
- Caroline B Osoro
- Centre for Global Health Research, Kenya Medical Research Institute, P.O. Box 1578, Kisumu, 40100, Kenya.
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, P.O. Box 241, Cape Town, 8000, South Africa.
| | - Stephanie Dellicour
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool Pembroke Place, Liverpool, L3 5QA, UK
| | - Eleanor Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, P.O. Box 1578, Kisumu, 40100, Kenya
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, P.O. Box 241, Cape Town, 8000, South Africa
| | - Taryn Young
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, P.O. Box 241, Cape Town, 8000, South Africa
| | - Feiko Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool Pembroke Place, Liverpool, L3 5QA, UK
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, U.S. Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool Pembroke Place, Liverpool, L3 5QA, UK
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Olapeju B, Bride M, Gutman JR, Butts JK, Malpass A, McCartney-Melstad A, Van Lith LM, Rodriguez K, Youll S, Mbeye N, Ntoya F, Lankhulani S, Mpata F, Babalola S. Malaria-Related Psychosocial Factors, Past Antenatal Care-Seeking Behaviors, and Future Antenatal Care-Seeking Intentions by Maternal Age in Malawi and Democratic Republic of the Congo. Am J Trop Med Hyg 2023; 109:277-283. [PMID: 37364859 PMCID: PMC10397429 DOI: 10.4269/ajtmh.23-0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/17/2023] [Indexed: 06/28/2023] Open
Abstract
Young women in sub-Saharan Africa are a group at increased risk for malaria in pregnancy. Early antenatal care (ANC) seeking makes it more likely that women will receive the recommended doses of intermittent preventive treatment of malaria in pregnancy. This study used data from national Malaria Behavior Surveys conducted in Malawi and the Democratic Republic of the Congo (DRC) in 2021 to explore the association between intention to attend ANC in the first trimester for a future pregnancy (early ANC intention) and psychosocial factors among women aged 15-49 years. Eight psychosocial factors related to ANC and based on the ideation model were included, including knowledge, attitudes, and self-efficacy. The study used multivariable logistic regression models controlling for demographic characteristics to evaluate associations between early ANC intention and the individual ideational factors and the composite measure. Analysis included 2,148 women aged 15-49 years (Malawi: 827, DRC: 1,321). Antenatal care ideation was lower among young (aged 15-20 years) than among older (aged 21-49 years) women in Malawi. Young mothers with higher ANC ideation were more likely to intend to attend ANC early in their next pregnancy in both countries. Specific ideational factors associated with intention to attend ANC early varied by country and included positive attitudes, knowledge of ANC, and positive self-efficacy. In Malawi and the DRC, youth-friendly social and behavior change interventions to increase ANC-related ideation could increase future early ANC attendance among young women to improve malaria and birth outcomes.
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Affiliation(s)
- Bolanle Olapeju
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Michael Bride
- Johns Hopkins Center for Communication Programs, Baltimore, Maryland
| | - Julie R. Gutman
- Malaria Branch, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jessica K. Butts
- U.S. President’s Malaria Initiative, Malaria Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ashley Malpass
- U.S. President’s Malaria Initiative, United States Agency for International Development, Washington, District of Columbia
| | | | - Lynn M. Van Lith
- Johns Hopkins Center for Communication Programs, Baltimore, Maryland
| | - Katie Rodriguez
- Johns Hopkins Center for Communication Programs, Baltimore, Maryland
| | - Susan Youll
- U.S. President’s Malaria Initiative, United States Agency for International Development, Washington, District of Columbia
| | - Nyanyiwe Mbeye
- Department of Epidemiology and Biostatistics, Kamuzu University of Health Sciences, Lilongwe, Malawi
| | - Ferdinand Ntoya
- U.S. President’s Malaria Initiative, United States Agency for International Development, Kinshasa, Democratic Republic of the Congo
| | - Sosten Lankhulani
- National Malaria Control Program, Ministry of Health, Lilongwe, Malawi
| | - Florence Mpata
- Johns Hopkins Center for Communication Programs, Baltimore, Maryland
| | - Stella Babalola
- Johns Hopkins Center for Communication Programs, Baltimore, Maryland
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19
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Andronescu LR, Buchwald AG, Sharma A, Bauleni A, Mawindo P, Liang Y, Gutman JR, Mathanga DP, Chinkhumba J, Laufer MK. Plasmodium falciparum infection and disease in infancy associated with increased risk of malaria and anaemia in childhood. Malar J 2023; 22:217. [PMID: 37496052 PMCID: PMC10369742 DOI: 10.1186/s12936-023-04646-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/11/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Infants under 6 months of age are often excluded from malaria surveillance and observational studies. The impact of malaria during early infancy on health later in childhood remains unknown. METHODS Infants from two birth cohorts in Malawi were monitored at quarterly intervals and whenever they were ill from birth through 24 months for Plasmodium falciparum infections and clinical malaria. Poisson regression and linear mixed effects models measured the effect of exposure to malaria in infancy on subsequent malaria incidence, weight-for-age z-scores (WAZ), and haemoglobin concentrations after 6 months. RESULTS Infants with at least one P. falciparum infection during their first 6 months had increased incidence ratio (IRR) of P. falciparum infection (IRR = 1.27, 95% CI, 1.06-1.52) and clinical malaria (IRR = 2.37, 95% CI, 2.02-2.80) compared to infants without infection. Infants with clinical malaria had increased risk of P. falciparum infection incidence between 6 and 24 months (IRR = 1.64, 95% CI, 1.38-1.94) and clinical malaria (IRR = 1.85, 95% CI, 1.48-2.32). Exposure to malaria was associated with lower WAZ over time (p = 0.02) and lower haemoglobin levels than unexposed infants at every time interval (p = 0.02). CONCLUSIONS Infants experiencing malaria infection or clinical malaria are at increased risk of subsequent infection and disease, have poorer growth, and lower haemoglobin concentrations.
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Affiliation(s)
- Liana R Andronescu
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, 21201, USA
| | - Andrea G Buchwald
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, 21201, USA
| | - Ankur Sharma
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, 21201, USA
| | - Andy Bauleni
- Malaria Alert Center, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Patricia Mawindo
- Malaria Alert Center, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Yuanyuan Liang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, 21201, USA
| | - Julie R Gutman
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, 30333, USA
| | - Don P Mathanga
- Malaria Alert Center, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Jobiba Chinkhumba
- Malaria Alert Center, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Miriam K Laufer
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, 21201, USA.
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Uwimana A, Sethi R, Murindahabi M, Ntirandeka C, Piercefield E, Umulisa N, Abram A, Eckert E, Munguti K, Sullivan D, Uyizeye D, Mbituyumuremyi A, Gutman JR. Effectiveness of Intermittent Screening and Treatment of Malaria in Pregnancy on Maternal and Birth Outcomes in Selected Districts in Rwanda: A Cluster Randomized Controlled Trial. Clin Infect Dis 2023; 77:127-134. [PMID: 36896967 PMCID: PMC10330390 DOI: 10.1093/cid/ciad128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 02/22/2023] [Accepted: 03/02/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Malaria during pregnancy can cause serious consequences including maternal anemia and low birthweight (LBW). Routine antenatal care (ANC) in Rwanda includes malaria symptom screening at each ANC visit. This cluster randomized controlled trial investigated whether adding intermittent screening with a malaria rapid diagnostic test at each routine ANC visit and treatment of positives during pregnancy (ISTp) is more effective than routine ANC for reducing malaria prevalence at delivery. METHODS Between September 2016 and June 2018, pregnant women initiating ANC at 14 health centers in Rwanda were enrolled into ISTp or control arms. All women received an insecticide-treated bed net at enrollment. Hemoglobin concentration, placental and peripheral parasitemia, newborn outcome, birthweight, and prematurity were assessed at delivery. RESULTS Nine hundred seventy-five women were enrolled in ISTp and 811 in the control group. Routine ANC plus ISTp did not significantly reduce polymerase chain reaction-confirmed placental malaria compared to control (adjusted relative risk [aRR], 0.94 [95% confidence interval {CI}, .59-1.50]; P = .799). ISTp had no impact on anemia (aRR, 1.08 [95% CI, .57-2.04]; P = .821). The mean birthweight of singleton newborns was not significantly different between arms (3054 g vs 3096 g, P = .395); however, women in the ISTp arm had a higher proportion of LBW (aRR, 1.59 [95% CI, 1.02-2.49]; P = .042). CONCLUSIONS This is the only study to compare ISTp to symptomatic screening at ANC in a setting where intermittent preventive treatment is not routinely provided. ISTp did not reduce the prevalence of malaria or anemia at delivery and was associated with an increased risk of LBW. CLINICAL TRIALS REGISTRATION NCT03508349.
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Affiliation(s)
- Aline Uwimana
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Reena Sethi
- Maternal and Child Survival Program–Jhpiego, Washington, District of Columbia, USA
| | - Monique Murindahabi
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | | | - Emily Piercefield
- US President's Malaria Initiative, Malaria Branch, US Centers for Disease Control and Prevention, USA
| | - Noella Umulisa
- Maternal and Child Survival Program–Jhpiego, Kigali, Rwanda
| | | | - Erin Eckert
- US PMI Impact Malaria Project, Population Services International, Washington, District of Columbia, USA
| | - Kaendi Munguti
- US Agency for International Development, US President's Malaria Initiative, Kigali, Rwanda
| | - David Sullivan
- Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Didier Uyizeye
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | | | - Julie R Gutman
- Malaria Branch, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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van Eijk AM, Stepniewska K, Hill J, Taylor SM, Rogerson SJ, Cottrell G, Chico RM, Gutman JR, Tinto H, Unger HW, Yanow SK, Meshnick SR, Ter Kuile FO, Mayor A. Prevalence of and risk factors for microscopic and submicroscopic malaria infections in pregnancy: a systematic review and meta-analysis. Lancet Glob Health 2023; 11:e1061-e1074. [PMID: 37276878 PMCID: PMC10880462 DOI: 10.1016/s2214-109x(23)00194-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Malaria infections during pregnancy can cause adverse birth outcomes, yet many infections are undetected by microscopy. We aimed to describe the epidemiology of submicroscopic malaria infections in pregnant women in Asia, the Americas, and Africa using aggregated and individual participant data (IPD). METHODS For this systematic review and meta-analysis, studies (published Jan 1, 1997 to Nov 10, 2021) with information on both microscopic and submicroscopic infections during pregnancy from Asia, the Americas, or Africa, identified in the Malaria-in-Pregnancy Library, were eligible. Studies (or subgroups or study groups) that selected participants on the basis of the presence of fever or a positive blood smear were excluded to avoid selection bias. We obtained IPD (when available) and aggregated data. Estimates of malaria transmission intensity and sulfadoxine-pyrimethamine resistance, matched by study location and year, were obtained using publicly available data. One-stage multivariable logit and multinomial models with random intercepts for study site were used in meta-analysis to assess prevalence of and risk factors for submicroscopic infections during pregnancy and at delivery. This study is registered with PROSPERO, number CRD42015027342. FINDINGS The search identified 87 eligible studies, 68 (78%) of which contributed to the analyses. Of these 68 studies, 45 (66%) studies contributed IPD (48 869 participants) and 23 (34%) studies contributed aggregated data (11 863 participants). During pregnancy, median prevalence estimates were 13·5% (range 0·0-55·9, 66 substudies) for submicroscopic and 8·0% (0·0-50·6, 66 substudies) for microscopic malaria. Among women with positive Plasmodium nucleic acid amplification tests (NAATs), the median proportion of submicroscopic infections was 58·7% (range 0·0-100); this proportion was highest in the Americas (73·3%, 0·0-100), followed by Asia (67·2%, 36·4-100) and Africa (56·5%, 20·5-97·7). In individual patient data analysis, compared with women with no malaria infections, those with submicroscopic infections were more likely to present with fever in Africa (adjusted odds ratio 1·32, 95% CI 1·02-1·72; p=0·038) but not in other regions. Among women with NAAT-positive infections in Asia and the Americas, Plasmodium vivax infections were more likely to be submicroscopic than Plasmodium falciparum infections (3·69, 2·45-5·54; p<0·0001). Risk factors for submicroscopic infections among women with NAAT-positive infections in Africa included older age (age ≥30 years), multigravidity, and no HIV infection. INTERPRETATION During pregnancy, submicroscopic infections are more common than microscopic infections and are associated with fever in Africa. Malaria control in pregnancy should target both microscopic and submicroscopic infections. FUNDING Bill & Melinda Gates Foundation through the Worldwide Antimalarial Resistance Network.
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Affiliation(s)
- Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Kasia Stepniewska
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Steve M Taylor
- Division of Infectious Diseases and Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Stephen J Rogerson
- Department of Infectious Diseases, Doherty Institute, The University of Melbourne, Melbourne, VIC, Australia
| | | | - R Matthew Chico
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Halidou Tinto
- Institut de Recherche en Sciences de la Sant-Unité de Recherche Clinique de Nanoro, Ouagadougou, Burkina Faso
| | - Holger W Unger
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Stephanie K Yanow
- School of Public Health, Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, AB, Canada
| | - Steven R Meshnick
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Feiko O Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Alfredo Mayor
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
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22
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Unger HW, Hadiprodjo AJ, Gutman JR, Briand V, Fievet N, Valea I, Tinto H, D'Alessandro U, Landis SH, Ter Kuile F, Ouma P, Oneko M, Mwapasa V, Slutsker L, Terlouw DJ, Kariuki S, Ayisi J, Nahlen B, Desai M, Madanitsa M, Kalilani-Phiri L, Ashorn P, Maleta K, Tshefu-Kitoto A, Mueller I, Stanisic D, Cates J, Van Eijk AM, Ome-Kaius M, Aitken EH, Rogerson SJ. Fetal sex and risk of pregnancy-associated malaria in Plasmodium falciparum-endemic regions: a meta-analysis. Sci Rep 2023; 13:10310. [PMID: 37365258 DOI: 10.1038/s41598-023-37431-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 06/21/2023] [Indexed: 06/28/2023] Open
Abstract
In areas of moderate to intense Plasmodium falciparum transmission, malaria in pregnancy remains a significant cause of low birth weight, stillbirth, and severe anaemia. Previously, fetal sex has been identified to modify the risks of maternal asthma, pre-eclampsia, and gestational diabetes. One study demonstrated increased risk of placental malaria in women carrying a female fetus. We investigated the association between fetal sex and malaria in pregnancy in 11 pregnancy studies conducted in sub-Saharan African countries and Papua New Guinea through meta-analysis using log binomial regression fitted to a random-effects model. Malaria infection during pregnancy and delivery was assessed using light microscopy, polymerase chain reaction, and histology. Five studies were observational studies and six were randomised controlled trials. Studies varied in terms of gravidity, gestational age at antenatal enrolment and bed net use. Presence of a female fetus was associated with malaria infection at enrolment by light microscopy (risk ratio 1.14 [95% confidence interval 1.04, 1.24]; P = 0.003; n = 11,729). Fetal sex did not associate with malaria infection when other time points or diagnostic methods were used. There is limited evidence that fetal sex influences the risk of malaria infection in pregnancy.
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Affiliation(s)
- Holger W Unger
- Department of Obstetrics and Gynaecology, Royal Darwin Hospital, Darwin, NT, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anastasia Jessica Hadiprodjo
- Department of Medicine (RMH), Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Valerie Briand
- Université de Paris, UMR261, IRD, Paris, France
- Epicentre MSF, Paris, France
| | | | - Innocent Valea
- Unite de Recherche Clinique de Nanoro, Institut de Recherche en Sciences de La Santé-DRCO, Nanoro, Burkina Faso
- Departement de Recherche Clinique, Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Halidou Tinto
- Unite de Recherche Clinique de Nanoro, Institut de Recherche en Sciences de La Santé-DRCO, Nanoro, Burkina Faso
- Departement de Recherche Clinique, Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Umberto D'Alessandro
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, Gambia
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Feiko Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Peter Ouma
- Kenya Medical Research Institute (KEMRI)/Centre for Global Health Research, Kisumu, Kenya
| | - Martina Oneko
- Kenya Medical Research Institute (KEMRI)/Centre for Global Health Research, Kisumu, Kenya
| | - Victor Mwapasa
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Laurence Slutsker
- Malaria and Neglected Tropical Diseases, Center for Malaria Control and Elimination, PATH, Seattle, WA, USA
| | - Dianne J Terlouw
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Simon Kariuki
- Kenya Medical Research Institute (KEMRI)/Centre for Global Health Research, Kisumu, Kenya
| | - John Ayisi
- Kenya Medical Research Institute (KEMRI)/Centre for Global Health Research, Kisumu, Kenya
| | | | - Meghna Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Linda Kalilani-Phiri
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Per Ashorn
- Faculty of Medicine and Health Technology, Center for Child, Adolescent and Maternal Health Research, Tampere University, Tampere, Finland
- Department for Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Kenneth Maleta
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Ivo Mueller
- Walter and Eliza Hall Institute, Parkville, VIC, Australia
| | - Danielle Stanisic
- Institute for Glycomics, Griffith University, Gold Coast, QLD, Australia
| | - Jordan Cates
- Department of Epidemiology, UNC-Chapel Hill, Chapel Hill, NC, USA
| | - Anna Maria Van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Maria Ome-Kaius
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Elizabeth H Aitken
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
| | - Stephen J Rogerson
- Department of Medicine (RMH), Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia.
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia.
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia.
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Madanitsa M, Barsosio HC, Minja DTR, Mtove G, Kavishe RA, Dodd J, Saidi Q, Onyango ED, Otieno K, Wang D, Ashorn U, Hill J, Mukerebe C, Gesase S, Msemo OA, Mwapasa V, Phiri KS, Maleta K, Klein N, Magnussen P, Lusingu JPA, Kariuki S, Mosha JF, Alifrangis M, Hansson H, Schmiegelow C, Gutman JR, Chico RM, Ter Kuile FO. Effect of monthly intermittent preventive treatment with dihydroartemisinin-piperaquine with and without azithromycin versus monthly sulfadoxine-pyrimethamine on adverse pregnancy outcomes in Africa: a double-blind randomised, partly placebo-controlled trial. Lancet 2023; 401:1020-1036. [PMID: 36913959 PMCID: PMC10063957 DOI: 10.1016/s0140-6736(22)02535-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 09/28/2022] [Accepted: 12/06/2022] [Indexed: 03/12/2023]
Abstract
BACKGROUND Intermittent preventive treatment in pregnancy (IPTp) with dihydroartemisinin-piperaquine is more effective than IPTp with sulfadoxine-pyrimethamine at reducing malaria infection during pregnancy in areas with high-grade resistance to sulfadoxine-pyrimethamine by Plasmodium falciparum in east Africa. We aimed to assess whether IPTp with dihydroartemisinin-piperaquine, alone or combined with azithromycin, can reduce adverse pregnancy outcomes compared with IPTp with sulfadoxine-pyrimethamine. METHODS We did an individually randomised, double-blind, three-arm, partly placebo-controlled trial in areas of high sulfadoxine-pyrimethamine resistance in Kenya, Malawi, and Tanzania. HIV-negative women with a viable singleton pregnancy were randomly assigned (1:1:1) by computer-generated block randomisation, stratified by site and gravidity, to receive monthly IPTp with sulfadoxine-pyrimethamine (500 mg of sulfadoxine and 25 mg of pyrimethamine for 1 day), monthly IPTp with dihydroartemisinin-piperaquine (dosed by weight; three to five tablets containing 40 mg of dihydroartemisinin and 320 mg of piperaquine once daily for 3 consecutive days) plus a single treatment course of placebo, or monthly IPTp with dihydroartemisinin-piperaquine plus a single treatment course of azithromycin (two tablets containing 500 mg once daily for 2 consecutive days). Outcome assessors in the delivery units were masked to treatment group. The composite primary endpoint was adverse pregnancy outcome, defined as fetal loss, adverse newborn baby outcomes (small for gestational age, low birthweight, or preterm), or neonatal death. The primary analysis was by modified intention to treat, consisting of all randomised participants with primary endpoint data. Women who received at least one dose of study drug were included in the safety analyses. This trial is registered with ClinicalTrials.gov, NCT03208179. FINDINGS From March-29, 2018, to July 5, 2019, 4680 women (mean age 25·0 years [SD 6·0]) were enrolled and randomly assigned: 1561 (33%; mean age 24·9 years [SD 6·1]) to the sulfadoxine-pyrimethamine group, 1561 (33%; mean age 25·1 years [6·1]) to the dihydroartemisinin-piperaquine group, and 1558 (33%; mean age 24·9 years [6.0]) to the dihydroartemisinin-piperaquine plus azithromycin group. Compared with 335 (23·3%) of 1435 women in the sulfadoxine-pyrimethamine group, the primary composite endpoint of adverse pregnancy outcomes was reported more frequently in the dihydroartemisinin-piperaquine group (403 [27·9%] of 1442; risk ratio 1·20, 95% CI 1·06-1·36; p=0·0040) and in the dihydroartemisinin-piperaquine plus azithromycin group (396 [27·6%] of 1433; 1·16, 1·03-1·32; p=0·017). The incidence of serious adverse events was similar in mothers (sulfadoxine-pyrimethamine group 17·7 per 100 person-years, dihydroartemisinin-piperaquine group 14·8 per 100 person-years, and dihydroartemisinin-piperaquine plus azithromycin group 16·9 per 100 person-years) and infants (sulfadoxine-pyrimethamine group 49·2 per 100 person-years, dihydroartemisinin-piperaquine group 42·4 per 100 person-years, and dihydroartemisinin-piperaquine plus azithromycin group 47·8 per 100 person-years) across treatment groups. 12 (0·2%) of 6685 sulfadoxine-pyrimethamine, 19 (0·3%) of 7014 dihydroartemisinin-piperaquine, and 23 (0·3%) of 6849 dihydroartemisinin-piperaquine plus azithromycin treatment courses were vomited within 30 min. INTERPRETATION Monthly IPTp with dihydroartemisinin-piperaquine did not improve pregnancy outcomes, and the addition of a single course of azithromycin did not enhance the effect of monthly IPTp with dihydroartemisinin-piperaquine. Trials that combine sulfadoxine-pyrimethamine and dihydroartemisinin-piperaquine for IPTp should be considered. FUNDING European & Developing Countries Clinical Trials Partnership 2, supported by the EU, and the UK Joint-Global-Health-Trials-Scheme of the Foreign, Commonwealth and Development Office, Medical Research Council, Department of Health and Social Care, Wellcome, and the Bill-&-Melinda-Gates-Foundation.
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Affiliation(s)
- Mwayiwawo Madanitsa
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Clinical Sciences, Academy of Medical Sciences, Malawi University of Science and Technology, Thyolo, Malawi
| | - Hellen C Barsosio
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Daniel T R Minja
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - George Mtove
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Reginald A Kavishe
- Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - James Dodd
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Queen Saidi
- Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Eric D Onyango
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Kephas Otieno
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ulla Ashorn
- Centre for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Samwel Gesase
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Omari A Msemo
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Victor Mwapasa
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Kamija S Phiri
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Kenneth Maleta
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Nigel Klein
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Pascal Magnussen
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen and Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - John P A Lusingu
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Simon Kariuki
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Jacklin F Mosha
- Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Michael Alifrangis
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen and Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - Helle Hansson
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen and Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christentze Schmiegelow
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen and Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - R Matthew Chico
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Feiko O Ter Kuile
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
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24
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Gutman JR, Mwesigwa JN, Arnett K, Kangale C, Aaron S, Babarinde D, Buekens J, Candrinho B, Debe S, Digre P, Drake M, Gansané A, Gogue C, Griffith KS, Hicks J, Kinda R, Koenker H, Lemwayi R, Munsey A, Obi E, Ogouyèmi-Hounto A, Okoko OO, Onikpo F, Onoja A, Porter T, Savaio B, Tynuv K, Uhomoibhi P, Wagman J, Wolf K, Zulliger R, Walker P, Miller JM, Robertson M. Using antenatal care as a platform for malaria surveillance data collection: study protocol. Malar J 2023; 22:99. [PMID: 36932384 PMCID: PMC10022568 DOI: 10.1186/s12936-023-04521-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/02/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND While many malaria-endemic countries have health management information systems that can measure and report malaria trends in a timely manner, these routine systems have limitations. Periodic community cross-sectional household surveys are used to estimate malaria prevalence and intervention coverage but lack geographic granularity and are resource intensive. Incorporating malaria testing for all women at their first antenatal care (ANC) visit (i.e., ANC1) could provide a more timely and granular source of data for monitoring trends in malaria burden and intervention coverage. This article describes a protocol designed to assess if ANC-based surveillance could be a pragmatic tool to monitor malaria. METHODS This is an observational, cross-sectional study conducted in Benin, Burkina Faso, Mozambique, Nigeria, Tanzania, and Zambia. Pregnant women attending ANC1 in selected health facilities will be tested for malaria infection by rapid diagnostic test and administered a brief questionnaire to capture key indicators of malaria control intervention coverage and care-seeking behaviour. In each location, contemporaneous cross-sectional household surveys will be leveraged to assess correlations between estimates obtained using each method, and the use of ANC data as a tool to track trends in malaria burden and intervention coverage will be validated. RESULTS This study will assess malaria prevalence at ANC1 aggregated at health facility and district levels, and by gravidity relative to current pregnancy (i.e., gravida 1, gravida 2, and gravida 3 +). ANC1 malaria prevalence will be presented as monthly trends. Additionally, correlation between ANC1 and household survey-derived estimates of malaria prevalence, bed net ownership and use, and care-seeking will be assessed. CONCLUSION ANC1-based surveillance has the potential to provide a cost-effective, localized measure of malaria prevalence that is representative of the general population and useful for tracking monthly changes in parasite prevalence, as well as providing population-representative estimates of intervention coverage and care-seeking behavior. This study will evaluate the representativeness of these measures and collect information on operational feasibility, usefulness for programmatic decision-making, and potential for scale-up of malaria ANC1 surveillance.
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Affiliation(s)
- Julie R Gutman
- Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | | | | | | | | | | | | | | | - Siaka Debe
- Centre National de Recherche Et de Formation Sur Le Paludisme, Ouagadougou, Burkina Faso
| | | | | | - Adama Gansané
- Centre National de Recherche Et de Formation Sur Le Paludisme, Ouagadougou, Burkina Faso
| | | | - Kevin S Griffith
- US President's Malaria Initiative, US Agency for International Development, Washington, DC, USA
| | | | - Réné Kinda
- Centre National de Recherche Et de Formation Sur Le Paludisme, Ouagadougou, Burkina Faso
| | | | | | - Anna Munsey
- Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Emmanuel Obi
- National Malaria Elimination Program, Abuja, Nigeria
| | | | | | | | - Ali Onoja
- Ibolda Health International Ltd, Abuja, Nigeria
| | | | | | | | | | | | | | - Rose Zulliger
- US President's Malaria Initiative, US Agency for International Development, Washington, DC, USA
| | | | | | - Molly Robertson
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
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25
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Gutman JR, Thwing J, Mwesigwa J, McElroy PD, Robertson M. Routine Healthcare Facility- and Antenatal Care-Based Malaria Surveillance: Challenges and Opportunities. Am J Trop Med Hyg 2023; 108:4-7. [PMID: 35895587 PMCID: PMC9904165 DOI: 10.4269/ajtmh.22-0182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/11/2022] [Indexed: 02/04/2023] Open
Abstract
Most monitoring and evaluation tools for measuring malaria burden, intervention coverage, and impact of interventions use periodic nationally representative cross-sectional household surveys. These provide advantages in terms of selecting a large, unbiased, population-based sample; however, they are infrequently conducted, are resource-intensive, and do not provide longitudinal data with sufficient granularity. Given the heterogeneity of malaria transmission within most endemic countries, systems with the capacity to provide more granular and frequent data would be more actionable by national malaria control programs and local implementing partners. There is increasing interest in using routine health facility data, usually from outpatient department visits, for monitoring malaria burden. Data from pregnant women attending antenatal care (ANC) could minimize bias related to fever care-seeking among outpatient department visits and provide more granular parasite prevalence data. Most pregnant women attend ANC at least once and are thus highly representative of the overall pregnant population. A growing body of evidence suggests that malaria parasitemia in pregnant women is correlated with parasitemia in children aged < 5 years in moderate to high transmission areas, allowing for monitoring parasitemia in real time. Additional data are needed to assess whether pregnant women are sufficiently representative of the overall population to yield valid malaria prevalence and intervention coverage estimates. Although use of routinely collected ANC data faces many of the same challenges experienced by other routinely collected health facility data, the opportunity to improve parasite prevalence monitoring and the associated health benefits to mothers and infants of early detection of parasitemia make these efforts valuable.
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Affiliation(s)
- Julie R. Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia;,Address correspondence to Julie R. Gutman, Centers for Disease Control and Prevention, 1600 Clifton Rd., Mailstop H24-3, Atlanta, GA 30329. E-mail:
| | - Julie Thwing
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Peter D. McElroy
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
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26
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Mtove G, Minja DTR, Abdul O, Gesase S, Maleta K, Divala TH, Patson N, Ashorn U, Laufer MK, Madanitsa M, Ashorn P, Mathanga D, Chinkhumba J, Gutman JR, Ter Kuile FO, Møller SL, Bygbjerg IC, Alifrangis M, Theander T, Lusingu JPA, Schmiegelow C. The choice of reference chart affects the strength of the association between malaria in pregnancy and small for gestational age: an individual participant data meta-analysis comparing the Intergrowth-21 with a Tanzanian birthweight chart. Malar J 2022; 21:292. [PMID: 36224585 PMCID: PMC9559842 DOI: 10.1186/s12936-022-04307-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The prevalence of small for gestational age (SGA) may vary depending on the chosen weight-for-gestational-age reference chart. An individual participant data meta-analysis was conducted to assess the implications of using a local reference (STOPPAM) instead of a universal reference (Intergrowth-21) on the association between malaria in pregnancy and SGA. METHODS Individual participant data of 6,236 newborns were pooled from seven conveniently identified studies conducted in Tanzania and Malawi from 2003-2018 with data on malaria in pregnancy, birthweight, and ultrasound estimated gestational age. Mixed-effects regression models were used to compare the association between malaria in pregnancy and SGA when using the STOPPAM and the Intergrowth-21 references, respectively. RESULTS The 10th percentile for birthweights-for-gestational age was lower for STOPPAM than for Intergrowth-21, leading to a prevalence of SGASTOPPAM of 14.2% and SGAIG21 of 18.0%, p < 0.001. The association between malaria in pregnancy and SGA was stronger for STOPPAM (adjusted odds ratio (aOR) 1.30 [1.09-1.56], p < 0.01) than for Intergrowth-21 (aOR 1.19 [1.00-1.40], p = 0.04), particularly among paucigravidae (SGASTOPPAM aOR 1.36 [1.09-1.71], p < 0.01 vs SGAIG21 aOR 1.21 [0.97-1.50], p = 0.08). CONCLUSIONS The prevalence of SGA may be overestimated and the impact of malaria in pregnancy underestimated when using Intergrowth-21. Comparing local reference charts to global references when assessing and interpreting the impact of malaria in pregnancy may be appropriate.
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Affiliation(s)
- George Mtove
- Tanga Medical Research Centre, National Institute for Medical Research, P. O. Box, 210, Tanga, Tanzania.
| | - Daniel T R Minja
- Tanga Medical Research Centre, National Institute for Medical Research, P. O. Box, 210, Tanga, Tanzania
| | - Omari Abdul
- Tanga Medical Research Centre, National Institute for Medical Research, P. O. Box, 210, Tanga, Tanzania
| | - Samwel Gesase
- Tanga Medical Research Centre, National Institute for Medical Research, P. O. Box, 210, Tanga, Tanzania
| | | | | | - Noel Patson
- Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Ulla Ashorn
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | | | | | - Per Ashorn
- Faculty of Medicine and Health Technology, Center for Child, Adolescent, and Maternal Health Research, Tampere University, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Don Mathanga
- Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Diseases Control and Prevention, Atlanta, GA, USA
| | - Feiko O Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sofie Lykke Møller
- Section of Global Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Ib C Bygbjerg
- Section of Global Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Michael Alifrangis
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Thor Theander
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - John P A Lusingu
- Tanga Medical Research Centre, National Institute for Medical Research, P. O. Box, 210, Tanga, Tanzania
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Christentze Schmiegelow
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
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27
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Rubenstein BL, Chinkhumba J, Chilima E, Kwizombe C, Malpass A, Cash S, Wright K, Troell P, Nsona H, Kachale F, Ali D, Kaunda E, Lankhulani S, Kayange M, Mathanga DP, Munthali J, Gutman JR. A cluster randomized trial of delivery of intermittent preventive treatment of malaria in pregnancy at the community level in Malawi. Malar J 2022; 21:195. [PMID: 35729612 PMCID: PMC9210049 DOI: 10.1186/s12936-022-04216-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 06/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Malaria in pregnancy doubles the risk of low birthweight; up to 11% of all neonatal deaths in sub-Saharan Africa are associated with malaria in pregnancy. To prevent these and other adverse health consequences, the World Health Organization recommends administering intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine–pyrimethamine for all pregnant women at each antenatal care (ANC) visit, starting as early as possible in the second trimester. The target is for countries to administer a minimum of three doses (IPTp3+) to at least 85% of pregnant women. Methods A cluster randomized, controlled trial was conducted to assess the effect of delivery of IPTp by community health workers on the coverage of IPTp3 + and ANC visits in Malawi. Community delivery of IPTp was implemented within two districts in Malawi over a 21-month period, from November 2018 to July 2020. In control sites, IPTp was delivered at health facilities. Representative samples of women who delivered in the prior 12 months were surveyed at baseline (n = 370, December 2017) and endline (n = 687, August 2020). A difference in differences analysis was conducted to assess the change in coverage of IPTp and ANC over time, accounting for clustering at the health facility level. Results Overall IPTp coverage increased over the study period. At baseline, women received a mean of 2.3 IPTp doses (range 0–5 doses) across both arms, and at endline, women received a mean of 2.8 doses (range 0–9 doses). Despite overall increases, the change in IPTp3 + coverage was not significantly different between intervention and control groups (6.9%, 95% CI: -5.9%, 19.6%). ANC4 + coverage increased significantly in the intervention group compared with the control group, with a difference-in-differences of 25.3% points (95% CI: 1.3%, 49.3%). Conclusions In order to reduce the burden of malaria in pregnancy, new strategies are needed to improve uptake of effective interventions such as IPTp. While community health workers’ delivery of IPTp did not increase uptake in this study, they may be effective in other settings or circumstances. Further research can help identify the health systems characteristics that are conducive to community delivery of IPTp and the operational requirements for effective implementation. Trial registration: ClinicalTrials.gov Identifier: NCT03376217. Registered December 6, 2017, https://clinicaltrials.gov/ct2/show/NCT03376217.
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Affiliation(s)
- Beth L Rubenstein
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd, Atlanta, GA, 30329, USA
| | - Jobiba Chinkhumba
- University of Malawi College of Medicine, Malaria Alert Centre, Blantyre, Malawi
| | - Ethel Chilima
- Management Sciences for Health (MSH), Lilongwe, Malawi
| | - Collins Kwizombe
- U.S. President's Malaria Initiative, United States Agency for International Development (USAID), Lilongwe, Malawi
| | - Ashley Malpass
- U.S. President's Malaria Initiative, United States Agency for International Development (USAID), Washington, D.C, USA
| | - Shelby Cash
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, U.S. President's Malaria Initiative, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Peter Troell
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, U.S. President's Malaria Initiative, Centers for Disease Control and Prevention, Lilongwe, Malawi
| | | | | | | | | | | | | | - Don P Mathanga
- University of Malawi College of Medicine, Malaria Alert Centre, Blantyre, Malawi
| | - John Munthali
- Management Sciences for Health (MSH), Lilongwe, Malawi
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd, Atlanta, GA, 30329, USA.
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28
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Waltmann A, McQuade ETR, Chinkhumba J, Operario DJ, Mzembe E, Itoh M, Kayange M, Puerto-Meredith SM, Mathanga DP, Juliano JJ, Carroll I, Bartelt LA, Gutman JR, Meshnick SR. The positive effect of malaria IPTp-SP on birthweight is mediated by gestational weight gain but modifiable by maternal carriage of enteric pathogens. EBioMedicine 2022; 77:103871. [PMID: 35217408 PMCID: PMC8866062 DOI: 10.1016/j.ebiom.2022.103871] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 01/24/2022] [Accepted: 01/24/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Poor pregnancy and birth outcomes are common in sub-Saharan Africa and have complex aetiologies. Sulfadoxine-pyrimethamine (SP), given for intermittent preventive therapy of malaria in pregnancy (IPTp), is one of few existing interventions that improves outcomes of both mother and baby despite widespread SP-resistant malaria. Compelling evidence exists that malaria-independent pathways contribute to this protective effect, but the exact sources of non anti-malarial protection remained unknown. We hypothesized that the beneficial effect of SP on birthweight is mediated by SP activity on maternal factors, including increased gestational weight gain and antibiotic activity on pathogens in the maternal gut. METHODS Expectant mothers from a larger randomized control trial comparing the efficacy of IPTp-SP to IPTp with dihydroartemisinin-piperaquine (DP) were also enrolled in this sub-study study at their first antenatal care visit before commencement of IPTp (n = 105). Participants were followed monthly until delivery. Weights and mid-to-upper-arm circumferences (MUAC) were recorded. Monthly stool samples were collected and screened for five Escherichia coli pathotypes, Shigella spp., Vibrio cholerae, Salmonella, Campylobacter coli/jejuni, and three protozoa (Giardia spp., Entameba histolytica, and Cryptosporidium spp.) using previously validated molecular assays. FINDINGS IPTp-SP vs. IPTP-DP was associated with higher maternal gestational weight gain (GWG) and nutritional indicators (MUAC and body-mass index, BMI). GWG was found to be a mediator of the birthweight and IPTp-SP relationship, as the birthweight of SP infants, but not DP infants, varied according to maternal GWG. The burden of maternal enteric infections was high. The three most commonly observed pathogens were enteroaggregative E. coli (EAEC), atypical enteropathogenic E.coli/enterohaemorrhagic E. coli (aEPEC/EHEC), and typical enteropathogenic E.coli (tEPEC). We found that SP reduced the prevalence of EAEC in a dose-dependent manner. After 3 or more doses, SP-recipients were 90% less likely to be infected with EAEC compared to DP-recipients (ORadj = 0.07, CI95 = 0.12, 0.39, p = 0.002). Compared to DP, this coincided with higher maternal gestational weight gain (GWG) and nutritional indicators (MUAC and body-mass index, BMI). The beneficial effect of SP on maternal GWG, MUAC and BMI, was lower if SP mothers had detectable EAEC, aEPEC/EHEC, tEPEC, and LT-ETEC at baseline. Maternal EAEC and tEPEC at baseline associated with lower birthweight for babies of both SP mothers and DP mothers. When comparing IPTp regimens, the positive effect of SP on birthweight compared to DP was only observed for infants of women who did not test positive for EAEC at baseline (adjusted mean birthweight difference SP vs. DP = 156.0 g, CI95 = -18.0 g, 336.9 g, p = 0.087), though confidence intervals crossed the null. INTERPRETATION Our findings indicate that in pregnant Malawian women, IPTp-SP vs. IPTp-DP is consistently associated with higher MUAC, BMI, and GWG following the WHO-recommended regimen of at least 3 doses, but carriage of maternal gut pathogens before initiation of IPTp lessens this effect. Because GWG was a mediator of the association between birthweight and SP, we show that SP's previously proven positive effect on birthweight is by promoting maternal weight gain. Overall, our results present one plausible pathway SP exerts malaria-independent protection against poor birth outcomes in the context of its waning antimalarial activity and warrants further investigation. FUNDING A full list of funding bodies that contributed to this study can be found in the Acknowledgements section.
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Affiliation(s)
- Andreea Waltmann
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.
| | | | - Jobiba Chinkhumba
- Malaria Alert Centre (MAC), University of Malawi College of Medicine, Blantyre, Malawi
| | - Darwin J Operario
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia, VA, USA
| | - Enala Mzembe
- Malaria Alert Centre (MAC), University of Malawi College of Medicine, Blantyre, Malawi
| | - Megumi Itoh
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Don P Mathanga
- Malaria Alert Centre (MAC), University of Malawi College of Medicine, Blantyre, Malawi
| | - Jonathan J Juliano
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Ian Carroll
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Luther A Bartelt
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Steven R Meshnick
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
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Gutman JR, Khairallah C, Stepniewska K, Tagbor H, Madanitsa M, Cairns M, L'lanziva AJ, Kalilani L, Otieno K, Mwapasa V, Meshnick S, Kariuki S, Chandramohan D, Desai M, Taylor SM, Greenwood B, ter Kuile FO. Intermittent screening and treatment with artemisinin-combination therapy versus intermittent preventive treatment with sulphadoxine-pyrimethamine for malaria in pregnancy: a systematic review and individual participant data meta-analysis of randomised clinical trials. EClinicalMedicine 2021; 41:101160. [PMID: 34746720 PMCID: PMC8556518 DOI: 10.1016/j.eclinm.2021.101160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/16/2021] [Accepted: 09/30/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND In sub-Saharan Africa, the efficacy of intermittent preventive therapy in pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) for malaria in pregnancy is threatened by parasite resistance. We conducted an individual-participant data (IPD) meta-analysis to assess the efficacy of intermittent screening with malaria rapid diagnostic tests (RDTs) and treatment of RDT-positive women with artemisinin-based combination therapy (ISTp-ACT) compared to IPTp-SP, and understand the importance of subpatent infections. METHODS We searched MEDLINE and the Malaria-in-Pregnancy Library on May 6, 2021 for trials comparing ISTp-ACT and IPTp-SP. Generalised linear regression was used to compare adverse pregnancy outcomes (composite of small-for-gestational-age, low birthweight (LBW), or preterm delivery) and peripheral or placental Plasmodium falciparum at delivery. The effects of subpatent (PCR-positive, RDT/microscopy-negative) infections were assessed in both arms pooled using multi-variable fixed-effect models adjusting for the number of patent infections. PROSPERO registration: CRD42016043789. FINDINGS Five trials conducted between 2007 and 2014 contributed (10,821 pregnancies), two from high SP-resistance areas where dhfr/dhps quintuple mutant parasites are saturated, but sextuple mutants are still rare (Kenya and Malawi), and three from low-resistance areas (West-Africa). Four trials contributed IPD data (N=10,362). At delivery, the prevalence of any malaria infection (relative risk [RR]=1.08, 95% CI 1.00-1.16, I2=67.0 %) and patent infection (RR=1.02, 0.61-1.16, I2=0.0%) were similar. Subpatent infections were more common in ISTp recipients (RR=1.31, 1.05-1.62, I2=0.0%). There was no difference in adverse pregnancy outcome (RR=1.00, 0.96-1.05; studies=4, N=9,191, I2=54.5%). Subpatent infections were associated with LBW (adjusted RR=1.13, 1.07-1.19), lower mean birthweight (adjusted mean difference=32g, 15-49), and preterm delivery (aRR=1.35, 1.15-1.57). INTERPRETATION ISTp-ACT was not superior to IPTp-SP and may result in more subpatent infections than the existing IPTp-SP policy. Subpatent infections were associated with increased LBW and preterm delivery. More sensitive diagnostic tests are needed to detect and treat low-grade infections. FUNDING Centers for Disease Control and Prevention and Worldwide Antimalarial Resistance Network.
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Affiliation(s)
- Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Carole Khairallah
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
| | - Harry Tagbor
- University of Health and Allied Science, Ho, Ghana
| | | | | | - Anne Joan L'lanziva
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Linda Kalilani
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kephas Otieno
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Victor Mwapasa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Steve Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Simon Kariuki
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | | | - Meghna Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Steve M. Taylor
- Division of Infectious Diseases and Duke Global Health Institute, Duke University Medical Center, Durham, NC, USA
| | | | - Feiko O. ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
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30
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Andronescu LR, Sharma A, Peterson I, Kachingwe M, Kachepa W, Liang Y, Gutman JR, Mathanga DP, Chinkhumba J, Laufer MK. The effect of intermittent preventive treatment of malaria during pregnancy and placental malaria on infant risk of malaria. J Infect Dis 2021; 225:248-256. [PMID: 34216212 DOI: 10.1093/infdis/jiab351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/02/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Intermittent preventive treatment of malaria during pregnancy (IPTp) with dihydroartemisinin-piperaquine (DP) provides greater protection from placental malaria than sulfadoxine-pyrimethamine (SP). Some studies suggest placental malaria alters the risk of malaria infection in infants, but few studies have quantified the effect of IPTp on infant susceptibility to malaria. METHODS Infants born to pregnant women enrolled in a randomized clinical trial comparing IPTp-SP and IPTp-DP in Malawi were followed from birth to 24 months to assess effect of IPTp and placental malaria on time to first malaria episode and P. falciparum incidence. RESULTS In total, 192 infants born to mothers randomized to IPTp-SP and 195 to mothers randomized to IPTp-DP were enrolled. Infants in the IPTp exposure groups did not differ significantly regarding incidence of clinical malaria (IRR= 1.03; 95% CI: 0.58 - 1.86) or incidence of infection (IRR= 1.18; 95% CI: 0.92-1.55). Placental malaria exposure was not associated with incidence of clinical malaria (IRR= 1.03; 95% CI: 0.66-1.59) or incidence of infection (IRR:= 1.15; 95% CI: 0.88-1.50). Infant sex, season of birth, and maternal gravidity did not confound results. CONCLUSIONS We did not find evidence that IPTp regimen or placental malaria exposure influenced risk of malaria during infancy in this population.
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Affiliation(s)
- Liana R Andronescu
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201 USA
| | - Ankur Sharma
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201 USA
| | - Ingrid Peterson
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201 USA
| | - Martin Kachingwe
- Malaria Alert Center, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Witness Kachepa
- Malaria Alert Center, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Yuanyuan Liang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201 USA
| | - Julie R Gutman
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, GA 30333 USA
| | - Don P Mathanga
- Malaria Alert Center, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jobiba Chinkhumba
- Malaria Alert Center, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Miriam K Laufer
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201 USA
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31
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Kitojo C, Chacky F, Kigadye ES, Mugasa JP, Lusasi A, Mohamed A, Reaves EJ, Gutman JR, Ishengoma DS. Acceptability of single screening and treatment policy for the control of malaria in pregnancy: perceptions of providers and pregnant women from selected health facilities in Lindi region, Tanzania. Malar J 2021; 20:256. [PMID: 34103047 PMCID: PMC8188655 DOI: 10.1186/s12936-021-03782-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tanzania started implementing single screening and treatment (SST) for all pregnant women attending their first antenatal care (ANC) visits in 2014, using malaria rapid diagnostic tests (RDTs) and treating those who test positive according to the national guidelines. However, there is a paucity of data to show the acceptability of SST to both pregnant women and health care workers (HCWs), taking into consideration the shortage of workers and the added burden of this policy to the health system. This study assessed the perceptions and opinions of health service users and providers to determine the acceptability of SST policy. METHODS Pregnant women and HCWs in eight health facilities in two districts of Lindi region (Kilwa and Lindi) were interviewed using semi-structured questionnaires with open and close-ended questions. Both qualitative and quantitative data were collected, including demographic characteristics, women's experience, their perception on SST and challenges they face when receiving services for malaria offered at ANC. Experience of HCWs regarding the implementation of SST as part of routine services and the challenges encountered when providing ANC services for malaria in pregnancy (MIP) were also assessed. RESULTS Of the 143 pregnant women interviewed, 97% viewed testing favourably and would wish to be tested for malaria again, while 95% were satisfied with services and reasons for testing during the first ANC visit. Nearly all (99%) would recommend their fellow pregnant women to be tested for malaria and all women recommended that the Ministry of Health should continue the SST strategy. This was despite the fact that 76% of the women experienced pain and 16% had anxiety as a result of finger prick. Sixteen HCWs (mostly nurses) were interviewed; they also viewed SST implementation favourably and reported feeling empowered to use RDTs for malaria screening. The main challenge identified by HCWs was that nurses are not allowed to prescribe anti-malarials to women who test positive and need to refer them to the outpatient department for treatment. CONCLUSION SST was considered an acceptable approach to control MIP by HCWs and pregnant women, and they recommended the continuation of the policy. In addition, consideration should be given to implementing a task-shifting policy to allow nurses to dispense anti-malarials to pregnant women.
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Affiliation(s)
- Chonge Kitojo
- US President's Malaria Initiative, United States Agency for International Development, Dar es Salaam, United Republic of Tanzania. .,The Open University of Tanzania, Dar es Salaam, United Republic of Tanzania.
| | - Frank Chacky
- National Malaria Control Programme, Dodoma, United Republic of Tanzania
| | - Emmanuel S Kigadye
- The Open University of Tanzania, Dar es Salaam, United Republic of Tanzania
| | - Joseph P Mugasa
- PMI Impact Malaria Population Services International (PSI), Dar es Salaam, United Republic of Tanzania
| | - Abdallah Lusasi
- National Malaria Control Programme, Dodoma, United Republic of Tanzania
| | - Ally Mohamed
- National Malaria Control Programme, Dodoma, United Republic of Tanzania
| | - Erik J Reaves
- US President's Malaria Initiative, Centers for Disease Control and Prevention, Dar es Salaam, United Republic of Tanzania
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Deus S Ishengoma
- National Institute for Medical Research, Dar es Salaam, United Republic of Tanzania.,Faculty of Pharmaceutical Sciences, Monash University, Melbourne, Australia.,School of Public Health, Harvard University, Boston, MA, USA
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Steinhardt LC, Richie TL, Yego R, Akach D, Hamel MJ, Gutman JR, Wiegand RE, Nzuu EL, Dungani A, Kc N, Murshedkar T, Church LWP, Sim BKL, Billingsley PF, James ER, Abebe Y, Kariuki S, Samuels AM, Otieno K, Sang T, Kachur SP, Styers D, Schlessman K, Abarbanell G, Hoffman SL, Seder RA, Oneko M. Safety, Tolerability, and Immunogenicity of Plasmodium falciparum Sporozoite Vaccine Administered by Direct Venous Inoculation to Infants and Young Children: Findings From an Age De-escalation, Dose-Escalation, Double-blind, Randomized Controlled Study in Western Kenya. Clin Infect Dis 2021; 71:1063-1071. [PMID: 31555824 DOI: 10.1093/cid/ciz925] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 09/16/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The whole Plasmodium falciparum sporozoite (PfSPZ) vaccine is being evaluated for malaria prevention. The vaccine is administered intravenously for maximal efficacy. Direct venous inoculation (DVI) with PfSPZ vaccine has been safe, tolerable, and feasible in adults, but safety data for children and infants are limited. METHODS We conducted an age de-escalation, dose-escalation randomized controlled trial in Siaya County, western Kenya. Children and infants (aged 5-9 years, 13-59 months, and 5-12 months) were enrolled into 13 age-dose cohorts of 12 participants and randomized 2:1 to vaccine or normal saline placebo in escalating doses: 1.35 × 105, 2.7 × 105, 4.5 × 105, 9.0 × 105, and 1.8 × 106 PfSPZ, with the 2 highest doses given twice, 8 weeks apart. Solicited adverse events (AEs) were monitored for 8 days after vaccination, unsolicited AEs for 29 days, and serious AEs throughout the study. Blood taken prevaccination and 1 week postvaccination was tested for immunoglobulin G antibodies to P. falciparum circumsporozoite protein (PfCSP) using enzyme-linked immunosorbent assay. RESULTS Rates of AEs were similar in vaccinees and controls for solicited (35.7% vs 41.5%) and unsolicited (83.9% vs 92.5%) AEs, respectively. No related grade 3 AEs, serious AEs, or grade 3 laboratory abnormalities occurred. Most (79.0%) vaccinations were administered by a single DVI. Among those in the 9.0 × 105 and 1.8 × 106 PfSPZ groups, 36 of 45 (80.0%) vaccinees and 4 of 21 (19.0%) placebo controls developed antibodies to PfCSP (P < .001). CONCLUSIONS PfSPZ vaccine in doses as high as 1.8 × 106 can be administered to infants and children by DVI, and was safe, well tolerated, and immunogenic. CLINICAL TRIALS REGISTRATION NCT02687373.
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Affiliation(s)
- Laura C Steinhardt
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Reuben Yego
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Dorcas Akach
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Mary J Hamel
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Ryan E Wiegand
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Elizabeth L Nzuu
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Allan Dungani
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | | | | | | | | | | | | | | | - Simon Kariuki
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Aaron M Samuels
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kephas Otieno
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Tony Sang
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - S Patrick Kachur
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Mailman School of Public Health, Columbia University, New York, New York, USA
| | | | | | - Ginnie Abarbanell
- Washington University School of Medicine and St Louis Children's Hospital, St Louis, Missouri, USA
| | | | | | - Martina Oneko
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
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Kitojo C, Chacky F, Kigadye ES, Mugasa JP, Lusasi A, Mohamed A, Walker P, Reaves EJ, Gutman JR, Ishengoma DS. Evaluation of a single screen and treat strategy to detect asymptomatic malaria among pregnant women from selected health facilities in Lindi region, Tanzania. Malar J 2020; 19:438. [PMID: 33256758 PMCID: PMC7708125 DOI: 10.1186/s12936-020-03513-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/19/2020] [Indexed: 02/07/2023] Open
Abstract
Background In areas of high transmission, malaria in pregnancy (MiP) primarily causes asymptomatic infections; these infections nonetheless increase the risk of adverse maternal and fetal outcomes. In 2014, Tanzania initiated a single screening and treatment (SST) strategy for all pregnant women at their first antenatal care (ANC) visit using malaria rapid diagnostic tests (RDT) for surveillance purposes. However, there is paucity of data on the effectiveness of SST in the prevention of MiP. The objective of this study was to estimate the number of asymptomatic infections among pregnant women detected by SST, which would have been missed in the absence of the policy. Methods Data from pregnant women attending their first ANC visits between October 2017 and June 2018, including gestational age, history of fever, and RDT results, were abstracted from ANC registers in eight health centres in two randomly selected districts, Kilwa and Lindi, in Lindi Region. The proportion of symptomatic (with history of fever in the past 48 h) and asymptomatic pregnant women with positive RDTs were calculated and stratified by trimester (first, second and third). The study areas were categorized as low transmission with prevalence < 10% or moderate/high with ≥ 10%. Results Over the study period, 1,845 women attended their first ANC visits; 22.1% were in the first trimester (< 12 weeks gestation age). Overall 15.0% of the women had positive RDTs, and there was a trend towards higher malaria prevalence in the first (15.9%) and second (15.2%) trimesters, compared to the third (7.1%), although the differences were not statistically significant (p = 0.07). In total, 6.9% of women reported fever within the past 48 h and, of these, 96.1% were RDT positive. For every 100 pregnant women in the moderate/high and low transmission areas, SST identified 60 and 26 pregnant women, respectively, with asymptomatic infections that would have otherwise been missed. Among the 15.9% of women detected in the first trimester, 50.7% were asymptomatic. Conclusion In areas of moderate/high transmission, many infected women were asymptomatic, and would have been missed in the absence of SST. The benefits on maternal and fetal birth outcomes of identifying these infections depend heavily on the protection afforded by treatment, which is likely to be greatest for women presenting in the first trimester when intermittent preventive treatment (IPTp) with sulfadoxine-pyrimethamine (SP) is contraindicated, and in areas with high SP resistance, such as most parts of Tanzania. An evaluation of the impact and cost-effectiveness of SST across different transmission strata is warranted.
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Affiliation(s)
- Chonge Kitojo
- US President's Malaria Initiative, United States Agency for International Development, Dar es Salaam, United Republic of Tanzania. .,The Open University of Tanzania, Dar es Salaam, United Republic of Tanzania.
| | - Frank Chacky
- National Malaria Control Programme, Dodoma, United Republic of Tanzania
| | - Emmanuel S Kigadye
- The Open University of Tanzania, Dar es Salaam, United Republic of Tanzania
| | - Joseph P Mugasa
- USAID Boresha Afya Southern Zone, FHI 360, Dar es Salaam, United Republic of Tanzania
| | - Abdallah Lusasi
- National Malaria Control Programme, Dodoma, United Republic of Tanzania
| | - Ally Mohamed
- National Malaria Control Programme, Dodoma, United Republic of Tanzania
| | - Patrick Walker
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Erik J Reaves
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention and US President's Malaria Initiative, Dar es Salaam, United Republic of Tanzania.,Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA
| | - Deus S Ishengoma
- National Institute for Medical Research, Dar Es Salaam, United Republic of Tanzania.,Faculty of Pharmaceutical Sciences, Monash University, Melbourne, Australia.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Gutman JR, Stephens DK, Tiendrebeogo J, Badolo O, Dodo M, Burke D, Williamson J, Vibbert K, Youll SJ, Savadogo Y, Brieger WR. A cluster randomized trial of delivery of intermittent preventive treatment of malaria in pregnancy at the community level in Burkina Faso. Malar J 2020; 19:282. [PMID: 32758233 PMCID: PMC7409482 DOI: 10.1186/s12936-020-03356-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 07/29/2020] [Indexed: 11/28/2022] Open
Abstract
Background Malaria in pregnancy is responsible for 8–14% of low birth weight and 20% of stillbirths in sub-Saharan Africa. To prevent these adverse consequences, the World Health Organization recommends intermittent preventive treatment of pregnant women (IPTp) with sulfadoxine–pyrimethamine be administered at each ANC visit starting as early as possible in the second trimester. Global IPTp coverage in targeted countries remains unacceptably low. Community delivery of IPTp was explored as a means to improve coverage. Methods A cluster randomized, controlled trial was conducted in 12 health facilities in a 1:1 ratio to either an intervention group (IPTp delivered by CHWs) or a control group (standard practice, with IPTp delivered at HFs) in three districts of Burkina Faso to assess the effect of IPTp administration by community health workers (CHWs) on the coverage of IPTp and antenatal care (ANC). The districts and facilities were purposively selected taking into account malaria epidemiology, IPTp coverage, and the presence of active CHWs. Pre- and post-intervention surveys were carried out in March 2017 and July–August 2018, respectively. A difference in differences (DiD) analysis was conducted to assess the change in coverage of IPTp and ANC over time, accounting for clustering at the health facility level. Results Altogether 374 and 360 women were included in the baseline and endline surveys, respectively. At baseline, women received a median of 2.1 doses; by endline, women received a median of 1.8 doses in the control group and 2.8 doses in the intervention group (p-value < 0.0001). There was a non-statistically significant increase in the proportion of women attending four ANC visits in the intervention compared to control group (DiD = 12.6%, p-value = 0.16). By the endline, administration of IPTp was higher in the intervention than control, with a DiD of 17.6% for IPTp3 (95% confidence interval (CI) − 16.3, 51.5; p-value 0.31) and 20.0% for IPTp4 (95% CI − 7.2, 47.3; p-value = 0.15). Conclusions Community delivery of IPTp could potentially lead to a greater number of IPTp doses delivered, with no apparent decrease in ANC coverage.
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Affiliation(s)
- Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop H24-3, Atlanta, GA, 30329, USA.
| | - Daniel K Stephens
- The Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | | | - John Williamson
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop H24-3, Atlanta, GA, 30329, USA
| | | | - Susan J Youll
- US President's Malaria Initiative, US Agency for International Development, Washington, D.C., USA
| | - Yacouba Savadogo
- National Malaria Control Programme, Ministry of Health, Ouagadougou, Burkina Faso
| | - William R Brieger
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop H24-3, Atlanta, GA, 30329, USA
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Gutman JR, Lucchi NW, Cantey PT, Steinhardt LC, Samuels AM, Kamb ML, Kapella BK, McElroy PD, Udhayakumar V, Lindblade KA. Malaria and Parasitic Neglected Tropical Diseases: Potential Syndemics with COVID-19? Am J Trop Med Hyg 2020; 103:572-577. [PMID: 32484155 PMCID: PMC7410484 DOI: 10.4269/ajtmh.20-0516] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 05/26/2020] [Indexed: 12/21/2022] Open
Abstract
The COVID-19 pandemic, caused by SARS-CoV-2, have surpassed 5 million cases globally. Current models suggest that low- and middle-income countries (LMICs) will have a similar incidence but substantially lower mortality rate than high-income countries. However, malaria and neglected tropical diseases (NTDs) are prevalent in LMICs, and coinfections are likely. Both malaria and parasitic NTDs can alter immunologic responses to other infectious agents. Malaria can induce a cytokine storm and pro-coagulant state similar to that seen in severe COVID-19. Consequently, coinfections with malaria parasites and SARS-CoV-2 could result in substantially worse outcomes than mono-infections with either pathogen, and could shift the age pattern of severe COVID-19 to younger age-groups. Enhancing surveillance platforms could provide signals that indicate whether malaria, NTDs, and COVID-19 are syndemics (synergistic epidemics). Based on the prevalence of malaria and NTDs in specific localities, efforts to characterize COVID-19 in LMICs could be expanded by adding testing for malaria and NTDs. Such additional testing would allow the determination of the rates of coinfection and comparison of severity of outcomes by infection status, greatly improving the understanding of the epidemiology of COVID-19 in LMICs and potentially helping to mitigate its impact.
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Affiliation(s)
- Julie R. Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Naomi W. Lucchi
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Paul T. Cantey
- Parasitic Diseases Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Laura C. Steinhardt
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Aaron M. Samuels
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Mary L. Kamb
- Parasitic Diseases Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Bryan K. Kapella
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
- U.S. President’s Malaria Initiative, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Peter D. McElroy
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Venkatachalam Udhayakumar
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Kim A. Lindblade
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
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Abstract
Pregnant travelers face numerous risks, notably increased susceptibility to or severity of multiple infections, including malaria. Because pregnant women residing in areas non-endemic for malaria are unlikely to have protective immunity, travel to endemic areas poses risk of severe illness and pregnancy complications, such as low birthweight and fetal loss. If travel to malaria-endemic areas cannot be avoided, preventive measures are critical. However, malaria chemoprophylaxis in pregnancy can be challenging, since commonly used regimens have varying levels of safety data and national guidelines differ. Furthermore, although chloroquine and mefloquine have wide acceptance for use in pregnancy, regional malaria resistance and non-pregnancy contraindications limit their use. Mosquito repellents, including N,N-diethyl-m-toluamide (DEET) and permethrin treatment of clothing, are considered safe in pregnancy and important to prevent malaria as well as other arthropod-borne infections such as Zika virus infection. Pregnant travelers at risk for malaria exposure should be advised to seek medical attention immediately if any symptoms of illness, particularly fever, develop.
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Affiliation(s)
- Kimberly L. McKinney
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Air Force Institute of Technology, Wright-Patterson Air Force Base, OH, USA
| | - Henry M. Wu
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Kathrine R. Tan
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Julie R. Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
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Kitojo C, Gutman JR, Chacky F, Kigadye E, Mkude S, Mandike R, Mohamed A, Reaves EJ, Walker P, Ishengoma DS. Estimating malaria burden among pregnant women using data from antenatal care centres in Tanzania: a population-based study. Lancet Glob Health 2020; 7:e1695-e1705. [PMID: 31708150 PMCID: PMC8752309 DOI: 10.1016/s2214-109x(19)30405-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 09/04/2019] [Accepted: 09/09/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND More timely estimates of malaria prevalence are needed to inform optimal control strategies and measure progress. Since 2014, Tanzania has implemented nationwide malaria screening for all pregnant women within the antenatal care system. We aimed to compare malaria test results during antenatal care to two population-based prevalence surveys in Tanzanian children aged 6-59 months to examine their potential in measuring malaria trends and progress towards elimination. METHODS Malaria test results from pregnant women screened at their first antenatal care visits at health-care facilities (private and public) in all 184 districts of Tanzania between Jan 1, 2014, and Dec 31, 2017, were collected from the Health Management Information Systems and District Health Information System 2. We excluded facilities with no recorded antenatal care attendees during the time period. We standardised results to account for testing uptake and weighted them by the timing of two population-based surveys of childhood malaria prevalence done in 2015-16 (Demographic and Health Survey) and 2017 (Malaria Indicator Survey). We assessed regional-level correlation using Spearman's coefficient and assessed the consistency of monthly district-level prevalence ranking using Kendall's correlation coefficient. FINDINGS Correlation between malaria prevalence at antenatal care and among children younger than 5 years was high (r≥0·83 for both surveys), although declines in prevalence at antenatal care were generally smaller than among children. Consistent heterogeneity (p<0·05) in antenatal care prevalence at the district level was evident in all but one region (Kilimanjaro). Data from antenatal care showed declining prevalence in three regions (Arusha, Kilimanjaro, and Manyara) where surveys estimated zero prevalence. INTERPRETATION Routine antenatal care-based screening can be used to assess heterogeneity in transmission at finer resolution than population-based surveys, and provides sample sizes powered to detect changes, notably in areas of low transmission where surveys lack power. Declines in prevalence at antenatal care might lag behind those among children, highlighting the value of monitoring burden and continuing prevention efforts among pregnant women as transmission declines. The pregnancy-specific benefits and cost-effectiveness of antenatal care-based screening remain to be assessed. FUNDING None.
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Affiliation(s)
- Chonge Kitojo
- US President's Malaria Initiative, USAID, Dar es Salaam, Tanzania; Open University of Tanzania, Dar es Salaam, Tanzania.
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Frank Chacky
- National Malaria Control Programme, Dodoma, Tanzania
| | | | | | | | - Ally Mohamed
- National Malaria Control Programme, Dodoma, Tanzania
| | - Erik J Reaves
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, and US President's Malaria Initiative, Dar es Salaam, Tanzania
| | - Patrick Walker
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Deus S Ishengoma
- National Institute for Medical Research, Tanga Research Centre, Tanga, Tanzania
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Oneko M, Cherop YR, Sang T, Gutman JR, Wiegand R, Nyang'au EM, Odila AD, Akach D, Hamel MJ, Samuels AM, Kariuki S, Abebe Y, Nzuu EL, Wijayalath W, James ER, Sim BKL, Billingsley PF, Richie TL, Hoffman SL, Seder RA, Steinhardt LC. Feasibility of direct venous inoculation of the radiation-attenuated Plasmodium falciparum whole sporozoite vaccine in children and infants in Siaya, western Kenya. Vaccine 2020; 38:4592-4600. [PMID: 32444192 DOI: 10.1016/j.vaccine.2020.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 10/24/2022]
Abstract
PfSPZ Vaccine, composed of radiation-attenuated, aseptic, purified, cryopreserved Plasmodium falciparum sporozoites, is administered by direct venous inoculation (DVI) for maximal efficacy against malaria. A critical issue for advancing vaccines that are administered intravenously is the ability to efficiently administer them across multiple age groups. As part of a pediatric safety, immunogenicity, and efficacy trial in western Kenya, we evaluated the feasibility and tolerability of DVI, including ease of venous access, injection time, and crying during the procedure across age groups. Part 1 was an age de-escalation, dose escalation trial in children aged 13 months-5 years and infants aged 5-12 months; part 2 was a vaccine efficacy trial including only infants, using the most skilled injectors from part 1. Injectors could use a vein viewer, if needed. A total of 1222 injections (target 0.5 mL) were initiated by DVI in 511 participants (36 were 5-9-year-olds, 65 were 13-59-month-olds, and 410 infants). The complete volume was injected in 1185/1222 (97.0%) vaccinations, 1083/1185 (91.4%) achieved with the first DVI. 474/511 (92.8%) participants received only complete injections, 27/511 (5.3%) received at least one partial injection (<0.5 mL), and in 10/511 (2.0%) venous access was not obtained. The rate of complete injections by single DVI for infants improved from 77.1% in part 1 to 92.8% in part 2. No crying occurred in 51/59 (86.4%) vaccinations in 5-9-year-olds, 25/86 (29.1%) vaccinations in 13-59-month-olds and 172/1067 (16.1%) vaccinations in infants. Mean administration time ranged from 2.6 to 4.6 minutes and was longer for younger age groups. These data show that vaccination by DVI was feasible and well tolerated in infants and children in this rural hospital in western Kenya, when performed by skilled injectors. We also report that shipping and storage in liquid nitrogen vapor phase was simple and efficient. (Clinicaltrials.gov NCT02687373).
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Affiliation(s)
- M Oneko
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya.
| | - Y R Cherop
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - T Sang
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - J R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - R Wiegand
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - E M Nyang'au
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - A D Odila
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - D Akach
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - M J Hamel
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - A M Samuels
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - S Kariuki
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Y Abebe
- Sanaria Inc., Rockville, MD, USA
| | - E L Nzuu
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | | | | | | | | | | | | | - R A Seder
- National Institutes of Health, Bethesda, MD, USA
| | - L C Steinhardt
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Gutman JR, Chico RM. Evidence for treating malaria with artemisinin-based combination therapy in the first trimester of pregnancy. Lancet Infect Dis 2020; 20:880-881. [PMID: 32546326 PMCID: PMC10186202 DOI: 10.1016/s1473-3099(20)30131-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Diseases Control and Prevention, Atlanta, GA 30329, USA.
| | - R Matthew Chico
- Department of Disease Control, Faculty of Infectious and Tropical Disease, London School of Hygiene & Tropical Medicine, London, UK
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Malpass A, Chinkhumba J, Davlantes E, Munthali J, Wright K, Ramsey K, Troell P, Kayange M, Kachale F, Mathanga DP, Chatata D, Gutman JR. Malaria knowledge and experiences with community health workers among recently pregnant women in Malawi. Malar J 2020; 19:154. [PMID: 32295579 PMCID: PMC7161231 DOI: 10.1186/s12936-020-03228-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/07/2020] [Indexed: 11/22/2022] Open
Abstract
Background The World Health Organization recommends three or more doses of intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) to mitigate the negative effects of malaria in pregnancy (MIP). Many pregnant women in Malawi are not receiving the recommended number of doses. Community delivery of IPTp (cIPTp) is being piloted as a new approach to increase coverage. This survey assessed recently pregnant women’s knowledge of MIP and their experiences with community health workers (CHWs) prior to implementing cIPTp. Methods Data were collected via a household survey in Ntcheu and Nkhata Bay Districts, Malawi, from women aged 16–49 years who had a pregnancy resulting in a live birth in the previous 12 months. Survey questions were primarily open response and utilized review of the woman’s health passport whenever possible. Analyses accounted for selection weighting and clustering at the health facility level and explored heterogeneity between districts. Results A total of 370 women were interviewed. Women in both districts found their community health workers (CHWs) to be helpful (77.9%), but only 35.7% spoke with a CHW about antenatal care and 25.8% received assistance for malaria during their most recent pregnancy. A greater proportion of women in Nkhata Bay than Ntcheu reported receiving assistance with malaria from a CHW (42.7% vs 21.9%, p = 0.01); women in Nkhata Bay were more likely to cite IPTp-SP as a way to prevent MIP (41.0% vs 24.8%, p = 0.02) and were more likely to cite mosquito bites as the only way to spread malaria (70.6% vs 62.0% p = 0.03). Women in Nkhata Bay were more likely to receive 3 + doses of IPTp-SP (IPTp3) (59.2% vs 41.8%, p = 0.0002). Adequate knowledge was associated with increased odds of receiving IPTp3, although not statistically significantly so (adjusted odds ratio = 1.50, 95% confidence interval 0.97–2.32, p-value 0.066). Conclusions Women reported positive experiences with CHWs, but there was not a focus on MIP. Women in Nkhata Bay were more likely to be assisted by a CHW, had better knowledge, and were more likely to receive IPTp3+ . Increasing CHW focus on the dangers of MIP and implementing cIPTp has the potential to increase IPTp coverage.
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Affiliation(s)
- Ashley Malpass
- U.S. President's Malaria Initiative, United States Agency for International Development (USAID), Lilongwe, Malawi.
| | - Jobiba Chinkhumba
- University of Malawi College of Medicine, Malaria Alert Centre, Blantyre, Malawi
| | - Elizabeth Davlantes
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd. NE, Mailstop A06, Atlanta, GA, 30322, USA
| | - John Munthali
- Management Sciences for Health (MSH), Medford, MA, USA
| | | | | | - Peter Troell
- U.S. President's Malaria Initiative, Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Lilongwe, Malawi
| | | | | | - Don P Mathanga
- University of Malawi College of Medicine, Malaria Alert Centre, Blantyre, Malawi
| | - Dziko Chatata
- Management Sciences for Health (MSH), Medford, MA, USA
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention (CDC), 1600 Clifton Rd. NE, Mailstop A06, Atlanta, GA, 30322, USA.
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Gutman JR, Tan KR. Response to Behrens and Edwards: Atovaquone-proguanil exposure in pregnancy should not be condemned from current evidence. Travel Med Infect Dis 2020; 34:101599. [PMID: 32084590 PMCID: PMC10966678 DOI: 10.1016/j.tmaid.2020.101599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 02/17/2020] [Indexed: 10/25/2022]
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Roman E, Andrejko K, Wolf K, Henry M, Youll S, Florey L, Ferenchick E, Gutman JR. Determinants of uptake of intermittent preventive treatment during pregnancy: a review. Malar J 2019; 18:372. [PMID: 31752868 PMCID: PMC6873519 DOI: 10.1186/s12936-019-3004-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 11/11/2019] [Indexed: 11/10/2022] Open
Abstract
Malaria in pregnancy (MiP) contributes to devastating maternal and neonatal outcomes. Coverage of intermittent preventive treatment during pregnancy (IPTp) remains alarmingly low. Data was compiled from MiP programme reviews and performed a literature search on access to and determinants of IPTp. National malaria control and reproductive health (RH) policies may be discordant. Integration may improve coverage. Medication stock-outs are a persistent problem. Quality improvement programmes are often not standardized. Capacity building varies across countries. Community engagement efforts primarily focus on promotion of services. The majority of challenges can be addressed at country level to improve IPTp coverage.
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Affiliation(s)
| | - Kristin Andrejko
- Division of Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | | | - Marianne Henry
- U.S. President's Malaria Initiative, U.S. Agency for International Development, Washington, DC, USA
| | - Susan Youll
- U.S. President's Malaria Initiative, U.S. Agency for International Development, Washington, DC, USA
| | - Lia Florey
- U.S. President's Malaria Initiative, U.S. Agency for International Development, Washington, DC, USA
| | - Erin Ferenchick
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, U.S Centers for Disease Control and Prevention, Atlanta, GA, USA
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Gutman JR, Hall C, Khodr ZG, Bukowinski AT, Gumbs GR, Conlin AMS, Wells NY, Tan KR. Atovaquone-proguanil exposure in pregnancy and risk for adverse fetal and infant outcomes: A retrospective analysis. Travel Med Infect Dis 2019; 32:101519. [PMID: 31747537 PMCID: PMC11001272 DOI: 10.1016/j.tmaid.2019.101519] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/08/2019] [Accepted: 11/09/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Malaria in pregnancy can cause severe maternal and fetal complications. Chloroquine (CQ) and mefloquine (MQ) are recommended for chemoprophylaxis in pregnancy, but are not always suitable. Atovaquone-proguanil (AP) might be a viable option for malaria prevention in pregnancy, but more safety data are needed. METHODS Data for pregnancies and live births among active duty military women, 2003-2014, from the Department of Defense Birth and Infant Health Research program were linked with pharmacy data to determine antimalarial exposure. Multivariable Cox and logistic regression models were used to assess the relationship of antimalarial exposure with fetal and infant outcomes, respectively. RESULTS Among 198,164 pregnancies, 50 were exposed to AP, 156 to MQ, and 131 to CQ. Overall, 17.6% of unexposed pregnancies and 28.0%, 16.0%, and 6.1% of pregnancies exposed to AP, MQ, and CQ, respectively, ended in fetal loss (spontaneous abortion or stillbirth) (adjusted hazard ratios [aHR] = 1.46, 95% confidence interval [CI] 0.87-2.46; aHR = 1.06, 95% CI 0.72-1.57; and aHR = 0.47, 95% CI 0.24-0.94, respectively). CONCLUSIONS The small number of AP exposed pregnancies highlights the difficulty in assessing safety. While definitive conclusions are not possible, these data suggest further research of AP exposure in pregnancy and fetal loss is warranted. TWITTER LINE More research on fetal loss following atovaquone-proguanil exposure in pregnancy is warranted.
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Affiliation(s)
- Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Clinton Hall
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA; Leidos Inc, San Diego, CA, USA
| | - Zeina G Khodr
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA; Leidos Inc, San Diego, CA, USA
| | - Anna T Bukowinski
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA; Leidos Inc, San Diego, CA, USA
| | - Gia R Gumbs
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA; Leidos Inc, San Diego, CA, USA
| | - Ava Marie S Conlin
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA
| | - Natalie Y Wells
- Deployment Health Research Department, Naval Health Research Center, San Diego, CA, USA
| | - Kathrine R Tan
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Abstract
BACKGROUND Malaria during pregnancy increases the risk of maternal and foetal complications. There are very limited options for prophylaxis in pregnant travellers. Atovaquone-Proguanil (AP or Malarone®) is an effective and well-tolerated antimalarial medication, but is not recommended for use in pregnancy due to limited data on safety. Passively reported adverse event data may provide additional information on the safety of AP during pregnancy. METHODS We analysed adverse event data on pregnancy and birth outcomes following accidental exposures to AP during pregnancy, which were passively reported to GlaxoSmithKline LLC (GSK) between 13 May 1997 and 15 August 2017. Birth outcomes of interest included live birth, miscarriage, and stillbirth. Adverse outcomes of interest were defined as any of the following: small for gestational age (SGA), low birth weight (LBW, <2500 gm), congenital anomalies, and a composite 'poor live birth outcome,' including preterm birth (PTB), LBW or SGA. RESULTS Among 198 women who received AP during pregnancy or breastfeeding, 96.5% occurred in women taking malaria prophylaxis, and 79.8% of exposures occurred in the first trimester. Among 195 with available birth outcome data, 18.5% resulted in miscarriage and 11.8% were elective terminations. Available adverse outcomes included SGA in 3.5% (3/85), LBW in 7.0% of infants (6/86), and the composite 'poor live birth outcome' in 13.7% (14/102). Congenital anomalies were reported in 30/124 (24.2%), with no specific pattern to suggest an effect related to AP. CONCLUSIONS These data provide a description of outcomes in the pregnancies reported to this dataset, and it should be noted that there is likely a bias towards reporting cases resulting in poor outcomes. While there was no specific signal to suggest a teratogenic effect of AP, AP data during pregnancy were too limited to determine AP's safety with confidence. As inadvertent exposures are not infrequent, better data are needed.
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Affiliation(s)
| | - Kathrine R Tan
- Malaria Branch, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Julie R Gutman
- Malaria Branch, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Fulakeza J, McNitt S, Vareta J, Saidi A, Mvula G, Taylor T, Mathanga DP, Small DS, Skarbinski J, Gutman JR, Seydel K. Comparison of msp genotyping and a 24 SNP molecular assay for differentiating Plasmodium falciparum recrudescence from reinfection. Malar J 2019; 18:84. [PMID: 30885193 PMCID: PMC6423793 DOI: 10.1186/s12936-019-2695-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 03/01/2019] [Indexed: 08/23/2023] Open
Abstract
Background Current World Health Organization guidelines for conducting anti-malarial drug efficacy clinical trials recommend genotyping Plasmodium falciparum genes msp1 and msp2 to distinguish recrudescence from reinfection. A more recently developed potential alternative to this method is a molecular genotyping assay based on a panel of 24 single nucleotide polymorphism (SNP) markers. Methods Performance parameters of these two genotyping methods were compared using data from two recently completed drug efficacy trials. Blood samples from two anti-malarial therapeutic trials were analysed by both msp genotyping and the 24 SNP assay. Additionally, to conserve time and resources, the statistical program R was used to select the most informative SNPs for a set of unrelated Malawian samples to develop a truncated SNP-based assay for the region surrounding Blantyre, Malawi. The ability of this truncated assay to distinguish reinfection from recrudescence when compared to the full 24 SNP assay was then analysed using data from the therapeutic trials. Results A total of 360 samples were analysed; 66 for concordance of msp and SNP barcoding methodologies, and 294 for assessing the most informative of the 24 SNP markers. SNP genotyping performed comparably to msp genotyping, with only one case of disagreement among the 50 interpretable results, where the SNP assay identified the sample as reinfection and the msp typing as recrudescence. Furthermore, SNP typing was more robust; only 6% of samples were uninterpretable by SNP typing, compared to 19.7% when msp genotyping was used. For discriminating reinfection from recrudescence, a truncated 6 SNP assay was found to perform at 95.1% the accuracy of the full 24 SNP bar code. Conclusions The use of SNP analysis has similar sensitivity to the standard msp genotyping in determining recrudescence from reinfection. Although more expensive, SNP typing is faster and less work intensive. Limiting the assay to those SNPs most informative in the geographical region of interest may further decrease the workload and the cost, making this technique a feasible and affordable alternative in drug efficacy trials. Electronic supplementary material The online version of this article (10.1186/s12936-019-2695-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Joseph Fulakeza
- Department of Biomedical Sciences, University of Malawi, College of Medicine, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Sarah McNitt
- Department of Cell and Molecular Biology, Michigan State University, East Lansing, MI, USA
| | - Jimmy Vareta
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Alex Saidi
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Godfrey Mvula
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Terrie 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
| | - Don P Mathanga
- Department of Biomedical Sciences, University of Malawi, College of Medicine, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Dylan S Small
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, USA
| | | | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Center for Disease Control and Prevention, Atlanta, USA
| | - Karl Seydel
- 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.
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Henry M, Florey L, Youll S, Gutman JR. An analysis of country adoption and implementation of the 2012 WHO recommendations for intermittent preventive treatment for pregnant women in sub-Saharan Africa. Malar J 2018; 17:364. [PMID: 30326904 PMCID: PMC6192297 DOI: 10.1186/s12936-018-2512-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/08/2018] [Indexed: 11/24/2022] Open
Abstract
Background An estimated 30 million women give birth annually in malaria endemic areas of sub-Saharan Africa. Malaria in pregnancy is associated with an increased risk of adverse maternal and infant outcomes. To combat the adverse effects of MiP, the World Health Organization (WHO) recommends the provision of intermittent preventive treatment in pregnancy with sulfadoxine–pyrimethamine (IPTp–SP) in areas of moderate to high malaria transmission. In 2012, the WHO updated its policy with respect to IPTp administration to recommend administration at each antenatal care visit in the second and third trimesters, with a minimum of three, rather than two, doses. While rapid improvements in coverage were expected, gains have occurred more slowly than anticipated. Methods The President’s Malaria Initiative (PMI) assessed IPTp uptake before and after countries implemented the new WHO policy, and assessed how long it took for implementation to occur, using a combination of data from household surveys, routine health management information systems, and programmatic data provided to PMI. Results It took an average of 2 years for countries to complete the process of revising their IPTp policies, and it was not until 2015 that all 17 PMI countries had updated their policies. Policy dissemination and training had not been completed in several countries as of early 2018, and only seven countries had fully implemented the new policy including updating their antenatal care registers to collect information on IPTp3+ coverage. The coverage of IPTp1+, 2+, and 3+ has increased by 19, 16, and 13 percentage points since the revised IPTp policy adoption. Discussion Overall, coverage of both IPTp2+ and IPTp3+ has improved in recent years. The change in policy from a minimum of two to a minimum of three doses has likely contributed to these improvements. Progress has been slow, likely related to the complicated process of policy adoption exacerbated by the lag in measurement through national household surveys. The impact of future policy changes may be more readily seen if the policy change and implementation process were more streamlined and coordinated between key stakeholders (National Malaria Control Programmes and Reproductive Health Programmes), with more real-time data reporting. Electronic supplementary material The online version of this article (10.1186/s12936-018-2512-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marianne Henry
- U.S. President's Malaria Initiative, U.S. Agency for International Development, Washington, DC, USA
| | - Lia Florey
- U.S. President's Malaria Initiative, U.S. Agency for International Development, Washington, DC, USA
| | - Susan Youll
- U.S. President's Malaria Initiative, U.S. Agency for International Development, Washington, DC, USA
| | - Julie R Gutman
- Malaria Branch, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Rd. NE, Mailstop A06, Atlanta, GA, 30322, USA.
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Tan KR, Fairley JK, Wang M, Gutman JR. A survey on outcomes of accidental atovaquone-proguanil exposure in pregnancy. Malar J 2018; 17:198. [PMID: 29764439 PMCID: PMC5952583 DOI: 10.1186/s12936-018-2352-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 05/07/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Malaria chemoprophylaxis options in pregnancy are limited, and atovaquone-proguanil (AP) is not recommended because of insufficient safety evidence. An anonymous, internet-based survey was disseminated to describe outcomes of pregnancies accidentally exposed to AP. Outcomes of interest included miscarriage (defined as pregnancy loss before 20 weeks), stillbirth (defined as pregnancy loss at or after 20 weeks), preterm birth or live birth prior to 37 weeks, and the presence of congenital anomalies. RESULTS A total of 487 women responded and reported on 822 pregnancies. Of the 807 pregnancies with information available on exposure and outcomes, 10 (1.2%) had atovaquone-proguanil exposure, all in the first trimester, and all resulted in term births with no birth defects. CONCLUSIONS Use of an anti-malarial not recommended in pregnancy is likely to occur before the woman knows of her pregnancy. This study adds to the limited evidence of the safety of AP in pregnancy. Further study on use of AP in pregnancy should be a high priority, as an alternative option for the prevention of malaria in pregnancy in non-immune travellers is urgently needed.
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Affiliation(s)
- Kathrine R Tan
- Malaria Branch, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Rd. MS A6, Atlanta, GA, 30329, USA.
| | - Jessica K Fairley
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, 201 Dowman Dr., Atlanta, GA, 30322, USA
| | - Mengxi Wang
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA, 30322, USA
| | - Julie R Gutman
- Malaria Branch, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Rd. MS A6, Atlanta, GA, 30329, USA
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48
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Källander K, Alfven T, Workineh AA, Hailemariam A, Petzold M, Getachew D, Barat L, Steinhardt LC, Gutman JR. Universal Versus Conditional Third Day Follow-Up Visit for Children With Nonsevere Unclassified Fever at the Community Level in Ethiopia: Protocol for a Cluster Randomized Noninferiority Trial. JMIR Res Protoc 2018; 7:e99. [PMID: 29650505 PMCID: PMC5920148 DOI: 10.2196/resprot.9780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/05/2018] [Accepted: 02/10/2018] [Indexed: 11/13/2022] Open
Abstract
Background Under the World Health Organization’s integrated community case management strategy, febrile children seen by community health workers (on day 1) without a diagnosable illness and without danger signs are advised to return on day 3, regardless of symptom resolution. This advice might be unnecessary and place additional time and cost burdens on caregivers and community health workers. However, the safety of not following up with respect to children with unclassified fever is unknown. Objective The objective of this study is to establish the safety of conditional follow-up of nonsevere unclassified fever, that is, nonsevere illness with fever, no malaria, pneumonia, diarrhea, or danger signs, compared with universal follow-up on day 3, through a 2-arm cluster randomized controlled noninferiority trial. Methods The study is being conducted in 3 districts in southwest Ethiopia. A total of 25 health facilities are randomized to one of the 2 intervention arms; all 144 health posts and 284 community health workers are included. All enrolled children are followed-up after 1 week (on day 8) for re-assessment. If still sick on day 8, additional follow-up takes place after 2 weeks (day 15) and 1 month (day 29). To demonstrate that there is no significant increase in the percentage of children deteriorating clinically, the sample size needed for a noninferiority margin of 4%, a power of 80%, an alpha of 5%, and a design effect of 3 is 4284 children with unclassified fever. Main outcome is treatment failure on day 8, defined as death, hospitalization, one or more danger signs, or persistent fever. Results The project was funded in 2015 and enrollment was completed 2016. Data analysis is currently under way, and the first results are expected to be submitted for publication in 2018. Conclusions This study addresses the question as to whether there is any benefit in recommending universal follow-up among children seen for nonsevere unclassified fever, or whether parents can be counseled to return in the event of persistent fever, using a cluster randomized controlled trial design embedded in a national program. Outcomes will be relevant for policy makers and are important for the evaluation of current and future World Health Organization guidelines for the management of children with fever. Trial Registration ClinicalTrials.gov NCT02926625; https://clinicaltrials.gov/ct2/show/NCT02926625 (Archived by WebCite at http://www.webcitation.org/6xrQWn50t)
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Affiliation(s)
- Karin Källander
- Malaria Consortium, London, United Kingdom.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Tobias Alfven
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,Sachs' Children and Youth Hospital, Stockholm, Sweden
| | | | | | - Max Petzold
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Lawrence Barat
- US President's Malaria Initiative, United States Agency for International Development, Washington, DC, United States
| | - Laura C Steinhardt
- Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Julie R Gutman
- Malaria Branch, US Centers for Disease Control and Prevention, Atlanta, GA, United States
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Källander K, Alfvén T, Funk T, Abebe A, Hailemariam A, Getachew D, Petzold M, Steinhardt LC, Gutman JR. Universal versus conditional day 3 follow-up for children with non-severe unclassified fever at the community level in Ethiopia: A cluster-randomised non-inferiority trial. PLoS Med 2018; 15:e1002553. [PMID: 29664899 PMCID: PMC5903591 DOI: 10.1371/journal.pmed.1002553] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 03/14/2018] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND With declining malaria prevalence and improved use of malaria diagnostic tests, an increasing proportion of children seen by community health workers (CHWs) have unclassified fever. Current community management guidelines by WHO advise that children seen with non-severe unclassified fever (on day 1) should return to CHWs on day 3 for reassessment. We compared the safety of conditional follow-up reassessment only in cases where symptoms do not resolve with universal follow-up on day 3. METHODS AND FINDINGS We undertook a 2-arm cluster-randomised controlled non-inferiority trial among children aged 2-59 months presenting with fever and without malaria, pneumonia, diarrhoea, or danger signs to 284 CHWs affiliated with 25 health centres (clusters) in Southern Nations, Nationalities, and Peoples' Region, Ethiopia. The primary outcome was treatment failure (persistent fever, development of danger signs, hospital admission, death, malaria, pneumonia, or diarrhoea) at 1 week (day 8) of follow-up. Non-inferiority was defined as a 4% or smaller difference in the proportion of treatment failures with conditional follow-up compared to universal follow-up. Secondary outcomes included the percentage of children brought for reassessment, antimicrobial prescription, and severe adverse events (hospitalisations and deaths) after 4 weeks (day 29). From December 1, 2015, to November 30, 2016, we enrolled 4,595 children, of whom 3,946 (1,953 universal follow-up arm; 1,993 conditional follow-up arm) adhered to the CHW's follow-up advice and also completed a day 8 study visit within ±1 days. Overall, 2.7% had treatment failure on day 8: 0.8% (16/1,993) in the conditional follow-up arm and 4.6% (90/1,953) in the universal follow-up arm (risk difference of treatment failure -3.81%, 95% CI -∞, 0.65%), meeting the prespecified criterion for non-inferiority. There were no deaths recorded by day 29. In the universal follow-up arm, 94.6% of caregivers reported returning for reassessment on day 3, in contrast to 7.5% in the conditional follow-up arm (risk ratio 22.0, 95% CI 17.9, 27.2, p < 0.001). Few children sought care from another provider after their initial visit to the CHW: 3.0% (59/1,993) in the conditional follow-up arm and 1.1% (22/1,953) in the universal follow-up arm, on average 3.2 and 3.4 days later, respectively, with no significant difference between arms (risk difference 1.79%, 95% CI -1.23%, 4.82%, p = 0.244). The mean travel time to another provider was 2.2 hours (95% CI 0.01, 5.3) in the conditional follow-up arm and 2.6 hours (95% CI 0.02, 4.5) in the universal follow-up arm (p = 0.82); the mean cost for seeking care after visiting the CHW was 26.5 birr (95% CI 7.8, 45.2) and 22.8 birr (95% CI 15.6, 30.0), respectively (p = 0.69). Though this study was an important step to evaluate the safety of conditional follow-up, the high adherence seen may have resulted from knowledge of the 1-week follow-up visit and may therefore not transfer to routine practice; hence, in an implementation setting it is crucial that CHWs are well trained in counselling skills to advise caregivers on when to come back for follow-up. CONCLUSIONS Conditional follow-up of children with non-severe unclassified fever in a low malaria endemic setting in Ethiopia was non-inferior to universal follow-up through day 8. Allowing CHWs to advise caregivers to bring children back only in case of continued symptoms might be a more efficient use of resources in similar settings. TRIAL REGISTRATION www.clinicaltrials.gov, identifier NCT02926625.
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Affiliation(s)
- Karin Källander
- Malaria Consortium, London, United Kingdom
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Tobias Alfvén
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Sachs’ Children and Youth Hospital, Stockholm, Sweden
| | - Tjede Funk
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | | | | | | | - Max Petzold
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Laura C. Steinhardt
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Julie R. Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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50
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Mullany LC, van Boetzelaer EW, Gutman JR, Steinhardt LC, Ngoy P, Barbera Lainez Y, Wittcoff A, Harvey SA, Ho LS. Universal versus conditional day 3 follow-up for children with non-severe unclassified fever at the community level in the Democratic Republic of the Congo: A cluster-randomized, community-based non-inferiority trial. PLoS Med 2018; 15:e1002552. [PMID: 29664951 PMCID: PMC5903590 DOI: 10.1371/journal.pmed.1002552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 03/14/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The World Health Organization's integrated community case management (iCCM) guidelines recommend that all children presenting with uncomplicated fever and no danger signs return for follow-up on day 3 following the initial consultation on day 1. Such fevers often resolve rapidly, however, and previous studies suggest that expectant home care for uncomplicated fever can be safely recommended. We aimed to determine if a conditional follow-up visit was non-inferior to a universal follow-up visit for these children. METHODS AND FINDINGS We conducted a cluster-randomized, community-based non-inferiority trial among children 2-59 months old presenting to community health workers (CHWs) with non-severe unclassified fever in Tanganyika Province, Democratic Republic of the Congo. Clusters (n = 28) of CHWs were randomized to advise caregivers to either (1) return for a follow-up visit on day 3 following the initial consultation on day 1, regardless of illness resolution (as per current WHO guidelines; universal follow-up group) or (2) return for a follow-up visit on day 3 only if illness continued (conditional follow-up group). Children in both arms were assessed again at day 8, and classified as a clinical failure if fever (caregiver-reported), malaria, diarrhea, pneumonia, or decline of health status (development of danger signs, hospitalization, or death) was noted (failure definition 1). Alternative failure definitions were examined, whereby caregiver-reported fever was first restricted to caregiver-reported fever of at least 3 days (failure definition 2) and then replaced with fever measured via axillary temperature (failure definition 3). Study participants, providers, and investigators were not masked. Among 4,434 enrolled children, 4,141 (93.4%) met the per-protocol definition of receipt of the arm-specific advice from the CHW and a timely day 8 assessment (universal follow-up group: 2,210; conditional follow-up group: 1,931). Failure was similar (difference: -0.7%) in the conditional follow-up group (n = 188, 9.7%) compared to the universal follow-up group (n = 230, 10.4%); however, the upper bound of a 1-sided 95% confidence interval around this difference (-∞, 5.1%) exceeded the prespecified non-inferiority margin of 4.0% (non-inferiority p = 0.089). When caregiver-reported fever was restricted to fevers lasting ≥3 days, failure in the conditional follow-up group (n = 159, 8.2%) was similar to that in the universal follow-up group (n = 200, 9.1%) (difference: -0.8%; 95% CI: -∞, 4.1%; p = 0.053). If caregiver-reported fever was replaced by axillary temperature measurement in the definition of failure, failure in the conditional follow-up group (n = 113, 5.9%) was non-inferior to that in the universal follow-up group (n = 160, 7.2%) (difference: -1.4%; 95% CI: -∞, 2.5%; p = 0.012). In post hoc analysis, when the definition of failure was limited to malaria, diarrhea, pneumonia, development of danger signs, hospitalization, or death, failure in the conditional follow-up group (n = 108, 5.6%) was similar to that in the universal follow-up group (n = 147, 6.7%), and within the non-inferiority margin (95% CI: -∞, 2.9%; p = 0.017). Limitations include initial underestimation of the proportion of clinical failures as well as substantial variance in cluster-specific failure rates, reducing the precision of our estimates. In addition, heightened security concerns slowed recruitment in the final months of the study. CONCLUSIONS We found that advising caregivers to return only if children worsened or remained ill on day 3 resulted in similar rates of caregiver-reported fever and other clinical outcomes on day 8, compared to advising all caregivers to return on day 3. Policy-makers could consider revising guidelines for management of uncomplicated fever within the iCCM framework. TRIAL REGISTRATION ClinicalTrials.gov NCT02595827.
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Affiliation(s)
- Luke C. Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | | | - Julie R. Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Laura C. Steinhardt
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Pascal Ngoy
- International Rescue Committee, Kalemie, Democratic Republic of the Congo
| | | | - Alison Wittcoff
- International Rescue Committee, Kalemie, Democratic Republic of the Congo
| | - Steven A. Harvey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Lara S. Ho
- International Rescue Committee, New York, New York, United States of America
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