Missed opportunities to deliver intermittent preventive treatment for malaria to pregnant women 2003-2013: a systematic analysis of 58 household surveys in sub-Saharan Africa

Background

Despite the availability of effective preventive measures, including intermittent preventive treatment for malaria during pregnancy (IPTp), malaria continues to cause substantial disease burden among pregnant women in malaria-endemic areas. IPTp coverage remains low, despite high antenatal care (ANC) attendance. To highlight areas of potential improvement, trends in IPTp coverage were assessed over time, missed opportunities to deliver IPTp at ANC were quantified, and delivery of IPTp was compared to that of tetanus toxoid (TT).

Methods

Data from 58 Demographic and Health Surveys conducted between 2003 and 2013 in 31 sub-Saharan African countries, with relevant questions on IPTp, ANC and TT were used to assess ANC attendance, and IPTp and TT delivery. A missed opportunity for IPTp delivery is an ANC visit at which IPTp could have been delivered according to policy but was not.

Results

The proportion of pregnant women who received ≥2 doses of IPTp increased in surveyed countries from nearly zero before to a median of 29.6 % (IQR 20.1–42.5 %) seven or more years after IPTp policy adoption. ANC attendance was high (median 76.6 % reported ≥3 visits); however, even seven or more years post policy adoption, a median of 72.9 % (IQR 58.4–79.5 %) ANC visits were missed opportunities to deliver IPTp. Among primigravid women, a median of 61.5 % (IQR 50.9–72.9 %) received two doses of TT; delivery of recommended TT exceeded IPTp in all but one surveyed country.

Conclusions

IPTp coverage measured by household surveys is unsatisfactorily low, even many years after policy adoption. The many missed opportunities to deliver IPTp suggest that deficiencies in delivery at ANC are a significant contributing factor to the low coverage levels. High levels of TT delivery indicate capacity to deliver preventive measures at ANC. Further research is required to determine the factors driving the discrepancies between IPTp and TT coverage, and how these may be addressed to improve IPTp coverage.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-015-1033-4) contains supplementary material, which is available to authorized users.

Perspectives of health care providers on the provision of intermittent preventive treatment in pregnancy in health facilities in Malawi

BACKGROUND

Nearly 20 years after the adoption by the government of Malawi of the provision of intermittent preventive treatment in pregnancy (IPTp) for malaria, only 55% of pregnant women received at least two doses of sulfadoxine-pyrimethamine (SP) in 2010. Although several reasons for the low coverage have been suggested, few studies have examined the views of health care providers. This study examined the experiences of the nurses and midwives in providing antenatal care (ANC) services.

METHODS

This study was conducted in health facilities in Malawi that provide routine ANC services. Providers of ANC in Malawi were selected from in eight health care facilities of Malawi. Selected providers were interviewed using a semi-structured interview guide designed to address a series of themes related to their working conditions and their delivery of IPTp.

RESULTS

Nurses displayed detailed knowledge of ANC services and the rationale behind them. Nurses understood that they should provide two doses of IPTp during a pregnancy, but they did not agree on the timing of the doses. Nurses gave SP as directly observed therapy (DOT) at the clinic. Nurses did not give SP pills to women to take home with them because they did not trust that women would take the pills. Women who resisted taking SP explained they do not take drugs if they had not eaten, or they feared side effects, or they were not sick. Reasons for not giving the first or second dose of SP included a delay in the first ANC visit, testing positive for HIV, and presenting with malaria. None of the nurses were able to show any specific written guidelines on when to give SP. The challenges faced by the nurses include being overworked and persuading women to take SP under observation.

CONCLUSION

The findings show that the nurses had gained the knowledge and technical skills to provide appropriate ANC services. With regard to IPTp, nurses need guidelines that would be available at the health facility about how and when to give SP. The adoption of the WHO guidelines and their diffusion to health care facilities could help increase the coverage of IPTp2 (at least two doses of sulfadoxine-pyrimethamine) in Malawi.

Weaning age affects growth, feed intake, gastrointestinal development, and behavior in Holstein calves fed an elevated plane of nutrition during the preweaning stage

Recent research has revealed potential advantages of feeding an elevated plane of nutrition to calves during the preweaning period. However, calves fed more nutrients preweaning may be more susceptible to depressed growth and weaning stress during the transition from liquid to solid feed. The objective of this study was to investigate the relationship between the age of weaning and feed intake, and its influence on growth, gastrointestinal development, and behavioral indicators in dairy calves fed an elevated plane of nutrition during the preweaning period. To meet this objective, 20 female Holstein calves were randomly assigned at birth to be weaned at 6 or 8 wk. Milk replacer (mixed at 150 g/L) was offered at 1.2 kg/calf per day in 2 meals until a 1-wk step-down, when meals were reduced by 50% 1 wk before weaning. Daily starter, chopped oat straw, water intake, and weekly body weights were measured until d 70 of life. To assess digestive tract development, rumen fluid, fecal, and blood samples were taken before and after weaning (d 35, 49, and 63) and analyzed for ruminal short-chain fatty acids, blood β-hydroxybutyrate, and fecal starch, respectively. Behavioral indicators of weaning stress, including vocalizing and non-nutritive oral behavior, were measured by visual observation for 1 h, 3 times per week, before the second feeding of the day during the period from 2 wk before weaning to 2 wk after weaning. The calves weaned at 8 wk compared with 6 wk had higher average daily gain for the week preweaning (0.79±0.09 vs. 0.34±0.10 kg/d) and postweaning (1.05±0.09 vs. 0.35±0.11 kg/d), and were heavier at d 70 (99.9±1.81 vs. 91.0±2.26 kg). From 5 to 8 wk of age, starter and water intakes were lower in calves weaned at 8 wk of age. However, overall starter intake did not differ during the last week of the experiment. Furthermore, calves weaned at 8 wk compared with 6 wk had higher starter intake for 1 wk preweaning (1.36±0.13 vs. 0.40±0.08 kg/d) and postweaning (2.51±0.20 vs. 1.16±0.15 kg/d). In both treatments, weaning increased ruminal short-chain fatty acids, blood β-hydroxybutyrate, and fecal starch, yet the differences between the week before and after weaning were greater for calves weaned at 6 wk compared with those weaned at 8 wk. Treatment × week relative to weaning interactions indicated that several behaviors varied between early- and later-weaned calves during the week before weaning; calves weaned at 6 wk tended to exhibit 75% more non-nutritive oral behavior and spent 55% less time ruminating, and 36% less time lying compared with calves weaned at 8 wk. Under the conditions of this study, the results suggest that calves fed an elevated plane of nutrition preweaning have higher starter intakes and average daily gain during the weaning period when weaning is extended from 6 to 8 wk of age.

Improving estimates of insecticide-treated mosquito net coverage from household surveys: using geographic coordinates to account for endemicity

Background

Coverage estimates of insecticide-treated nets (ITNs) are often calculated at the national level, but are intended to be a proxy for coverage among the population at risk of malaria. The analysis uses data for surveyed households, linking survey enumeration areas (clusters) with levels of malaria endemicity and adjusting coverage estimates based on the population at risk. This analysis proposes an approach that is not dependent on being able to identify malaria risk in a location during the survey design (since survey samples are typically selected on the basis of census sampling frames that do not include information on malaria zones), but rather being able to assign risk zones after a survey has already been completed.

Methods

The analysis uses data from 20 recent nationally representative Demographic and Health Survey (DHS), Malaria Indicator Surveys (MIS), an AIDS Indicator Survey (AIS), and an Anemia and Malaria Prevalence Survey (AMP). The malaria endemicity classification was assigned from the Malaria Atlas Project (MAP) 2010 interpolated data layers, using the Geographic Positioning System (GPS) location of the survey clusters. National ITN coverage estimates were compared with coverage estimates in intermediate/high endemicity zones (i.e., the population at risk of malaria) to determine whether the difference between estimates was statistically different from zero (p-value <0.5).

Results

Endemicity varies substantially in eight of the 20 studied countries. In these countries with heterogeneous transmission of malaria, stratification of households by endemicity zones shows that ITN coverage in intermediate/high endemicity zones is significantly higher than ITN coverage at the national level (Burundi, Kenya, Namibia, Rwanda, Tanzania, Senegal, Zambia, and Zimbabwe.). For example in Zimbabwe, the national ownership of ITNs is 28%, but ownership in the intermediate/high endemicity zone is 46%.

Conclusion

Incorporating this study’s basic and easily reproducible approach into estimates of ITN coverage is applicable and even preferable in countries with areas at no/low risk of malaria and will help ensure that the highest-quality data are available to inform programmatic decisions in countries affected by malaria. The extension of this type of analysis to other malaria interventions can provide further valuable information to support evidence-based decision-making.

Assessment of the consistency of national-level policies and guidelines for malaria in pregnancy in five African countries

Background

At least 39 sub-Saharan African countries have policies on preventing malaria in pregnancy (MIP), including use of long-lasting insecticidal nets (LLINs), intermittent preventive treatment with sulphadoxine-pyrimethamine (IPTp-SP) and case management. However, coverage of LLINs and IPTp-SP remains below international targets in most countries. One factor contributing to low coverage may be that MIP policies typically are developed by national malaria control programmes (NMCPs), but are implemented through national reproductive health (RH) programmes.

Methods

National-level MIP policies, guidelines, and training documents from NMCPs and RH programmes in Kenya, Mali, Mozambique, mainland Tanzania and Uganda were reviewed to assess whether they reflected WHO guidelines for prevention and treatment of MIP, and how consistent MIP content was across documents from the same country. Documents were compared for adherence to WHO guidance concerning IPTp-SP timing and dose, directly observed therapy, promotion and distribution of LLINs, linkages to HIV programmes and MIP case management.

Results

The five countries reviewed had national documents promoting IPTp-SP, LLINs and MIP case management. WHO guidance from 2004 frequently was not reflected: four countries recommended the first dose of IPTp-SP at 20 weeks or later (instead of 16 weeks), and three countries restricted the first and second IPTp-SP doses to specific gestational weeks. Documents from four countries provided conflicting guidance on MIP prevention for HIV-positive women, and none provided complete guidance on management of uncomplicated and severe malaria during pregnancy. In all countries, inconsistencies between NMCPs and RH programmes on the timing or dose of IPTp-SP were documented, as was the mechanism for providing LLINs. Inconsistencies also were found in training documents from NMCPs and RH programmes in a given country. Outdated, inconsistent guidelines have the potential to cause confusion and lead to incorrect practices among health workers who implement MIP programmes, contributing to low coverage of IPTp-SP and LLINs.

Conclusions

MIP policies, guidelines and training materials are outdated and/or inconsistent in the countries assessed. Updating and ensuring consistency among national MIP documents is needed, along with re-orientation and supervision of health workers to accelerate implementation of the 2012 WHO Global Malaria Programme policy recommendations for IPTp-SP.

Gender differences in the use of insecticide-treated nets after a universal free distribution campaign in Kano State, Nigeria: post-campaign survey results

BACKGROUND

Recent expansion in insecticide-treated net (ITN) distribution strategies range from targeting pregnant women and children under five and distributing ITN at antenatal care and immunization programmes, to providing free distribution campaigns to cover an entire population. These changes in strategy raise issues of disparities, such as equity of access and equality in ITN use among different groups, including females and males. Analysis is needed to assess the effects of gender on uptake of key malaria control interventions. A recent post-universal free ITN distribution campaign survey in Kano State, Nigeria offered an opportunity to look at gender effects on ITN use.

METHODS

A post-campaign survey was conducted three to five months after the campaign in Kano State, Nigeria from 19 October to 4 November, 2009, on a random sample of 4,602 individuals. The survey was carried out using a questionnaire adapted from the Malaria Indicator Survey. Using binary logistic regression, controlling for several covariates, the authors assessed gender effects on ITN use among individuals living in households with at least one ITN.

RESULTS

The survey showed that household ITN ownership increased more than 10-fold, from 6% before to 71% after the campaign. There was no significant difference between the proportion of females and males living in households with at least one ITN. However, a higher percentage of females used ITNs compared to males (57.2% vs 48.8%). After controlling for several covariates, females remained more likely to use ITNs compared to males (OR: 1.5, 95% CI: 1.3-1.7). Adolescent boys remained the least likely group to use an ITN.

CONCLUSIONS

This study reveals gender disparity in ITN use, with males less likely to use ITNs particularly among ages 15-25 years. The uptake of the intervention among the most at-risk group (females) is higher than males, which may be reflective of earlier strategies for malaria interventions. Further research is needed to identify whether gender disparities in ITN use are related to traditional targeting of pregnant women and children with malaria interventions; however, results provide evidence to design gender-sensitive messaging for universal ITN distribution campaigns to ensure that males benefit equally from such communications and activities.

Can universal insecticide-treated net campaigns achieve equity in coverage and use? the case of northern Nigeria

Background

Insecticide-treated nets (ITNs) are effective tools for malaria prevention and can significantly reduce severe disease and mortality due to malaria, especially among children under five in endemic areas. However, ITN coverage and use remain low and inequitable among different socio-economic groups in sub-Saharan Africa, particularly in Nigeria. Several strategies have been proposed to increase coverage and use and reduce inequity in Nigeria, including free distribution campaigns recently conducted by the Nigerian federal government. Using data from the first post-campaign survey, the authors investigated the effect of the mass free distribution campaigns in achieving equity in household ownership and use of ITNs.

Methods

A post-campaign survey was undertaken in November 2009 in northern Nigeria to assess the effect of the campaigns in addressing equity across different socio-economic groups. The survey included 987 households randomly selected from 60 clusters in Kano state. Using logistic regression and the Lorenz concentration curve and index, the authors assessed equity in ITN coverage and use.

Results

ITN ownership coverage increased from 10% before the campaigns to 70%-a more than fivefold increase. The campaigns reduced the ownership coverage gap by 75%, effectively reaching parity among wealth quintiles (Concentration index 0.02, 95% CI (-0.02 ; 0.05) versus 0.21 95%CI (0.08 ; 0.34) before the campaigns). ITN use (individuals reporting having slept under an ITN the night before the survey visit) among individuals from households owning at least one ITN, was 53.1% with no statistically significant difference between the lowest, second, third and fourth wealth quintiles and the highest wealth quintile (lowest: odds ratio (OR) 0.87, 95% confidence interval (CI) (0.67 ; 1.13); second: OR 0.85, 95% CI (0.66 ; 1.24); third: OR 1.10 95% CI (0.86 ; 1.4) and fourth OR 0.91 95% CI (0.72 ; 1.15).

Conclusion

The campaign had a significant impact by increasing ITN coverage and reducing inequity in ownership and use. Free ITN distribution campaigns should be sustained to increase equitable coverage. These campaigns should be supplemented with other ITN distribution strategies to cover newborns and replace aging nets.

Expression of 14 von Willebrand factor mutations identified in patients with type 1 von Willebrand disease from the MCMDM-1VWD study

BACKGROUND

Candidate von Willebrand factor (VWF) mutations were identified in 70% of index cases in the European study 'Molecular and Clinical Markers for the Diagnosis and Management of type 1 von Willebrand Disease'. The majority of these were missense mutations.

OBJECTIVES

To assess whether 14 representative missense mutations are the cause of the phenotype observed in the patients and to examine their mode of pathogenicity.

METHODS

Transfection experiments were performed with full-length wild-type or mutant VWF cDNA for these 14 missense mutations. VWF antigen levels were measured, and VWF multimer analysis was performed on secreted and intracellular VWF.

RESULTS

For seven of the missense mutations (G160W, N166I, L2207P, C2257S, C2304Y, G2441C, and C2477Y), we found marked intracellular retention and impaired secretion of VWF, major loss of high molecular weight multimers in transfections of mutant constructs alone, and virtually normal multimers in cotransfections with wild-type VWF, establishing the pathogenicity of these mutations. Four of the mutations (R2287W, R2464C, G2518S, and Q2520P) were established as being very probably causative, on the basis of a mild reduction in the secreted VWF or on characteristic faster-running multimeric bands. For three candidate changes (G19R, P2063S, and R2313H), the transfection results were indistinguishable from wild-type recombinant VWF and we could not prove these changes to be pathogenic. Other mechanisms not explored using this in vitro expression system may be responsible for pathogenicity.

CONCLUSIONS

The pathogenic nature of 11 of 14 candidate missense mutations identified in patients with type 1 VWD was confirmed. Intracellular retention of mutant VWF is the predominant responsible mechanism.

The management of dysphagia in esophageal cancer patients undergoing neoadjuvant chemotherapy: Is invasive tube feeding required?

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Background: The dysphagia commonly associated with esophageal cancer often interferes with patient tolerance of neo-adjuvant chemotherapy. Surgical or endoscopic invasive tube feeding (ITF - gastroscopy/jejunostomy/stent) is a commonly employed strategy to maintain nutritional support however it can cause significant morbidity in its own right. We sought to determine if a strategy of careful dietary counseling and appropriately-timed neoadjuvant chemotherapy can obviate the need for ITF. Methods: Pts undergoing neoadjuvant chemotherapy (TAX/CDDP/5FU Q3 weeks x3) for esophageal or GEJ adenocarcinoma at a single institution from 3/07–7/08 were identified from a prospective database. All received dietary counseling and were closely monitored for signs/ symptoms of malnutrition with serial (baseline, after 1st cycle, pre-surgery) Body Mass Index (BMI), albumin, dysphagia scores (0 best - 4 worse), and quality of life (FACT-E). We assessed the response of dysphagia and nutritional status to neoadjuvant treatment and the need for ITF. Data presented as median (range) or mean (±SD), paired t-test or Wilcoxon signed ranks test determined significance. Results: 25 pts received neoadjuvant chemotherapy and significant dysphagia (score 2–4) was found in 14. Dysphagia scores improved in all 14 (all results in Table 1 ), and 10/13 improved after the first cycle. No patient required ITF. QoL as assessed by the FACT-E improved in 13/14 patients. A small decrease in BMI was noted, however serum albumin did not significantly decrease. Conclusions: Appropriately timed neoadjuvant chemotherapy with a highly effective regimen rapidly restores normal swallowing, maintains nutritional status, and obviates the need for ITF in patients with significant dysphagia from esophageal adenocarcinoma. [Table: see text]

No significant financial relationships to disclose.

The role of user charges and structural attributes of quality on the use of maternal health services in Morocco

Health care decision makers in settings with low levels of utilization of primary services are faced with the challenge of balancing the sometimes competing goals of increasing coverage and utilization of maternity services, particularly among the poor, with that of ensuring the financial viability of the health system. Morocco is a case in point where this policy dilemma is currently being played out. This study examines the role of household out-of-pocket costs and structural attributes of quality on the use of maternity care in Morocco using empirical data collected from both households and health care facilities. A nested logit model is estimated, and the coefficient estimates are used to carry out policy simulations of the impact of changes in the levels of out-of-pocket fees and structural attributes of quality in order to help guide policy makers responsible for the design of pending social insurance programs. The results of the paper suggest that social insurance strategies that involve increases in out-of-pocket charges in the form of copayments could be implemented without untoward effects on appropriate use of maternity care for non-poor women, but would be contraindicated for poorer and rural households.

Estimating the needs for artesunate-based combination therapy for malaria case-management in Africa

Because of inadequacies in national health information systems, the volumes of drugs required to support an effective policy transition toward artesunate-based combination therapy (ACT) are unknown for most African countries. A series of national surveys and population projections have been used to estimate the age-structured fever burden among 41 malaria endemic countries in Africa. Under present fever-management guidelines, commodity costs and internationally agreed coverage targets, the financial resources to meet the needs of ACT in most African countries are huge. Between US$1.6 billion and US$3.4 billion per annum must be found to give Africa the chance to consider a drug policy based on ACT. Substantial reductions in these costs would be achieved through more effective targeting of resources--only 20% of drugs would be required to manage fevers among the most at-risk pediatric patient populations. Better diagnostics would also be an important consideration for a new ACT policy in Africa.

Comparison of viability assays for Cryptosporidium parvum oocysts after disinfection

In order to test various viability assays for Cryptosporidium parvum oocysts were used to infect HCT-8 cells in vitro or baby mice. Infected cells were either stained with fluorescent anti-Cryptosporidium-antibody or lysed and subjected to C. parvum-specific PCR after 48 h. Titrations with infective oocysts were performed and compared to oocysts disinfected with Neopredisan for 2 h at varying concentrations. Caecal smears and histological sections from infected animals were examined in parallel. The number of foci of parasite development in vitro after immunofluorescent staining correlated well with the infection dose. PCR was less quantifiable and the results were not always reproducible, especially when low infection doses were used. Disinfection resulted in a dose-dependent reduction of oocyst infectivity when compared to the controls in all three assays. The infection of cells cultured in vitro with oocysts of C. parvum provides a suitable tool for the estimation of viability after treatment with chemical disinfectants. Immunofluorescence is easy to perform and gives quantitative results, while PCR-based detection of parasite DNA, although possible, requires the use of more sophisticated tools for quantification.

Establishing guidelines for pharmacotherapy trials in bulimia nervosa and anorexia nervosa

OBJECTIVE

This paper addresses the lack of a standard protocol for pharmacotherapy trials for patients with bulimia nervosa (BN) and anorexia nervosa (AN).

METHOD

Twenty-two surveys were sent to established researchers in the field of eating disorders to elicit their opinions regarding medication trials, including baseline laboratory tests, the optimal length/frequency of medication management sessions, and the information that should or should not be included in these sessions.

RESULTS

Sixteen of 22 researchers completed and returned the survey. Their answers are the basis of the data presented.

DISCUSSION

We propose a battery of screening laboratory tests for both conditions. We suggest 30-45-min initial medication management sessions in both AN and BN trials with 15-min follow-ups to be held weekly for AN subjects, and weekly for 2 weeks, then biweekly for 2 weeks, then monthly, for BN subjects. We also recommend that published trials should include explicit details of medication management.

Epinephrine, but not dexamethasone, induces apoptosis in retinal pigment epithelium cells in vitro: possible implications on the pathogenesis of central serous chorioretinopathy

BACKGROUND

The pathogenesis of central serous chorioretinopathy is poorly understood. It is believed to be due to dysfunction of the retinal pigment epithelium and/or choroid and has been associated with elevated levels of epinephrine and administration of corticosteroids. Epinephrine and corticosteroids have previously been shown to induce apoptosis (programmed cell death) in various types of cells. The objective of this study was to investigate whether these agents can induce apoptosis in cultured retinal pigment epithelium cells. This may help elucidate the pathogenesis of central serous chorioretinopathy.

METHODS

Third-passage porcine retinal pigment epithelium cells were grown to confluence and incubated for 1-7 days in culture medium containing epinephrine (10(2)-10(9) pg/ml) or a corticosteroid, dexamethasone (4-4x10(4) ng/ml). The cultures were evaluated for apoptosis by phase-contrast microscopy and in situ terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling.

RESULTS

Epinephrine (7x10(7)-10(9) pg/ml) induced apoptosis in a dose- and time-dependent manner. Exposure to lower concentrations of epinephrine (10(2)-6x10(7) pg/ml) and all tested levels of dexamethasone did not result in apoptosis.

CONCLUSION

Retinal pigment epithelium cells may undergo apoptosis following exposure to elevated levels of epinephrine. These findings suggest a possible pathophysiologic mechanism for the development of central serous chorioretinopathy.

Semiquantitative analysis of low levels of mRNA expression from small amounts of brain tissue by nonradioactive reverse transcriptase-polymerase chain reaction

We have developed an easy and fast method to semiquantify low levels of mRNA from small amounts of brain tissues based on nonradioactive reverse transcription-polymerase chain reaction (RT-PCR). The regulation of mRNA for the growth associated protein GAP-43/B-50 and the homeodomain protein islet-1 was examined in the facial nucleus of the rat after a unilateral transection of the nerve. In both cases a similar sensitivity for radioactive and nonradioactive RT-PCR methods was found. The expression of the housekeeping gene, cyclophilin A was used to normalize total mRNA amounts and PCR conditions. After amplification the PCR products were separated electrophoretically on polyacrylamide gels. For nonradioactive semiquantification gels were stained with ethidium bromide and recorded using a CCD camera and transillumination. The recordings were evaluated with specialized software. Using nonradioactive RT-PCR, the increase in GAP-43/B-50 mRNA in response to axotomy was easily detectable in the small volume of tissue obtained from the facial nucleus. In contrast, the low expression of islet-1 mRNA made it necessary to develop a two-step amplification procedure in order to provide a reliable semiquantitative analysis. The procedure included preamplification of the cDNA and subsequent purification of the cDNA. Using this method, the down-regulation of islet-1 could be demonstrated with a similar sensitivity to that previously shown with radioactive RT-PCR.