Patterns of cord, placental and post-delivery maternal malaria parasitemia

Malaria transmission is high and perennial in south-east Nigeria and is associated with a high burden of morbidity and mortality in children under 5 years and pregnant women. It is associated with maternal anemia, placental infection, intrauterine growth retardation and low birth weight. To evaluate the status of malaria in pregnancy in Cross River State, Nigeria, we assessed the prevalence rates of maternal, cord and placental malaria parasitemia in the dry and rainy seasons for 626 consecutively recruited pregnant women who delivered at two rural and two urban health facilities. Demographic data were obtained at delivery and maternal, placental and cord blood samples were collected and examined for malaria parasites by light microscopy. Of the mother and infant pairs, 120 (19.2%), 69 (14.7%) and 62 (13.5%), respectively, had positive maternal, placental and cord blood parasitemia. Parasitemia rates in the rainy season were higher than in the dry season (p < 0.05). There were no significant differences in maternal, placental and cord parasitemia between urban and rural areas. The prevalence rates of parasitemia at delivery indicate high malaria transmission and poor control during pregnancy.

Antimalarial drug prescribing practice in private and public health facilities in South-east Nigeria: a descriptive study

Background

Nigeria's national standard has recently moved to artemisinin combination treatments for malaria. As clinicians in the private sector are responsible for attending a large proportion of the population ill with malaria, this study compared prescribing in the private and public sector in one State in Nigeria prior to promoting ACTs.

Objective

To assess prescribing for uncomplicated malaria in government and private health facilities in Cross River State.

Method

Audit of 665 patient records at six private and seven government health facilities in 2003.

Results

Clinicians in the private sector were less likely to record history or physical examination than those in public facilities, but otherwise practice and prescribing were similar. Overall, 45% of patients had a diagnostic blood slides; 77% were prescribed monotherapy, either chloroquine (30.2%), sulphadoxine-pyrimethamine (22.7%) or artemisinin derivatives alone (15.8%). Some 20.8% were prescribed combination therapy; the commonest was chloroquine with sulphadoxine-pyrimethamine. A few patients (3.5%) were prescribed sulphadoxine-pyrimethamine-mefloquine in the private sector, and only 3.0% patients were prescribed artemisinin combination treatments.

Conclusion

Malaria treatments were varied, but there were not large differences between the public and private sector. Very few are following current WHO guidelines. Monotherapy with artemisinin derivatives is relatively common.

Artemether-lumefantrine versus artesunate plus amodiaquine for treating uncomplicated childhood malaria in Nigeria: randomized controlled trial

BACKGROUND

The therapeutic efficacy of artesunate plus amodiaquine and artemether/lumefantrine were assessed in an area of Nigeria with high levels of Plasmodium falciparum resistance to chloroquine and sulphadoxine-pyrimethamine.

PARTICIPANTS

Children aged 6 to 59 months with uncomplicated P. falciparum infection and parasite density 1,000 to 200,000 parasites/microL enrolled following informed consent by parents.

METHODS

Eligible children were randomly assigned to receive either a 3-day course of artesunate (4 mg/kg) plus amodiaquine (10 mg/kg) or 6-dose course of artemether/lumefantrine (20/120 mg tablets) over three days. Patients were followed up with clinical and laboratory assessments until day 14 using standard WHO in-vivo antimalarial drug test protocol.

RESULTS

A total 119 eligible children were enrolled but 111 completed the study. Adequate clinical and parasitological response (ACPR) was 47 (87.0%) and 47 (82.5%) for artemether-lumefantrine (AL) and artesunate+amodiaquine (AAMQ) respectively (OR 0.7, 95% confidence interval 0.22 to 2.22). Early treatment failure (ETF) occurred in one participant (1.8%) treated with AAQ but in none of those with AL. Two (3.7%) patients in the AL group and none in the AAQ group had late clinical failure. Late parasitological failure was observed in 9 (15.8) and 5 (9.3%) of patients treated with AAQ and AL respectively. None of participants had a serious adverse event.

CONCLUSION

Artemether-lumenfantrine and artesunate plus amodiaquine have high and comparable cure rates and tolerability among under-five children in Calabar, Nigeria.

Putting evidence into practice: how middle and low income countries "get it together"

The scarcity of resources in poorer countries means that ensuring health care is evidence based is particularly important. A group of workers active in the field describe their experiences of trying to do just that

Physical methods for treating fever in children

BACKGROUND

Health workers recommend bathing, sponging and other physical methods to treat fever in children and to avoid febrile convulsions. We know little about the most effective methods, or how these methods compare with commonly used drugs.

OBJECTIVES

To evaluate the benefits and harms of physical cooling methods used for managing fever in children.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group specialized trials register (February 2003), the Cochrane Central Register of Controlled Trials (Issue 1, 2003), MEDLINE (1966 to February 2003), EMBASE (1988 to November 2002), CINHAL (1982 to February 2003), LILACS (February 2003), Science Citation Index (1981 to February 2003), and reference lists of articles. We also contacted researchers in the field.

SELECTION CRITERIA

Randomized and quasi-randomized trials comparing physical methods with a drug placebo or no treatment in children with fever of presumed infectious origin. Studies where children in both groups were given an antipyretic drug were included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial methodological quality. One reviewer extracted data and the other checked the data for accuracy. Results were expressed as Relative Risk (RR) with 95% confidence intervals (CI) for discrete variables, and weighted mean differences for continuous outcomes.

MAIN RESULTS

Seven trials, involving 467 participants, met the inclusion criteria. One small trial (n = 30), comparing physical methods with drug placebo, did not demonstrate a difference in the proportion of children without fever by one hour after treatment in a comparison between physical methods alone and drug placebo. In 2 studies, where all children received an anti-pyretic drug, physical methods resulted in a higher proportion of children without fever at one hour (n=125, RR 11.8, CI 3.39 to 40.8). I; in a third study (n=130), which only reported mean change in temperature, no differences wereas detected. Mild adverse events (shivering and goose pimples) were more common in the physical methods group (3 trials, RR 5.09; CI 1.56 to 16.60).

REVIEWER'S CONCLUSIONS

A few small studies demonstrate that tepid sponging helps to reduce fever in children.

Routine anticonvulsants for treating cerebral malaria

BACKGROUND

Cerebral malaria is a common complication of Plasmodium falciparum infection, and kills over a million people every year. People with cerebral malaria become unconscious, and often have protracted convulsions. It is unclear whether giving anticonvulsant drugs routinely to people with cerebral malaria will improve the outcome of treatment and prevent death.

OBJECTIVES

To evaluate the effect of routine anticonvulsant drugs in people with cerebral malaria.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group specialized trials register (November 2001), The Cochrane Controlled Trials Register (Issue 4, 2001), MEDLINE (1966 to November 2001), EMBASE (1988 to October 2001), LILACS (2001, 40a Edition CD-ROM), Science Citation Index (November 2001), African Index Medicus (1999), reference lists of articles, and research organizations. We also contacted the authors for addtional information.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials of people with cerebral malaria. The trials compared anticonvulsant drugs started on admission to hospital with no anticonvulsant drug or placebo.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data from those trials eligible for inclusion. We assessed the methodological quality of the included trials by considering allocation sequence, concealment of allocation, blinding, and inclusion of all randomized participants. We used Review Manager (version 4.1) for the meta-analysis and also explored possible sources of heterogeneity.

MAIN RESULTS

Three trials with a total of 573 participants met the inclusion criteria. These trials all compared phenobarbitone with placebo or no treatment. In the two trials with adequate allocation concealment, death was more common in the anticonvulsant group (Relative Risk 2.0; 95% confidence interval 1.20 to 3.33; fixed effect model). In all three trials, phenobarbitone compared with placebo or no treatment was associated with fewer convulsions (Relative Risk 0.30; 95% confidence interval 0.19 to 0.45; fixed effect model).

REVIEWER'S CONCLUSIONS

Routine phenobarbitone in cerebral malaria is associated with fewer convulsions but possibly more deaths. Further trials with adequate design, more participants, and different doses of anticonvulsant drugs are needed.

Paracetamol for treating fever in children

BACKGROUND

Paracetamol (acetaminophen) is widely used for treating fever in children. Like ibuprofen, aspirin, and physical methods (such as fanning), paracetamol aims to provide relief from symptoms and prevent febrile convulsions. Uncertainty exists about the benefits of using it to treat fever in children.

OBJECTIVES

To assess the effects of paracetamol for treating fever in children in relation to fever clearance time, febrile convulsions, and resolution of associated symptoms.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group specialized trials register (November 2001), The Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2001), MEDLINE (1966 to November 2001), EMBASE (1988 to November 2001), LILACS (2001, 40a Edition CD-ROM), Science Citation Index (November 2001), and reference lists of articles. We also contacted researchers in the field.

SELECTION CRITERIA

Randomized and quasi-randomized trials of children with fever from infections comparing: (1) paracetamol with placebo or no treatment; and (2) paracetamol with physical cooling methods (eg, sponging, bathing, or fanning). The primary outcomes were fever clearance time and febrile convulsion.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data on methods, types of participants, interventions, and outcomes. The meta-analysis was conducted using Relative Risk with 95% confidence intervals for discrete variables, and weighted mean differences for continuous outcomes.

MAIN RESULTS

12 trials (n = 1509 participants) met the inclusion criteria. Outcomes varied between trials. No data were available on the primary outcome. There is insufficient evidence to show whether paracetamol influenced the risk of febrile convulsions. In a meta-analysis of two trials (n = 120), the proportion of children without fever by the second hour after treatment did not differ significantly between those given paracetamol and those sponged (Relative Risk 1.84; confidence interval 0.94 to 3.61, random effects model). The statistical test showed significant heterogeneity between the groups receiving paracetamol or physical methods. No severe adverse events were reported. The number of children with mild adverse events did not differ significantly between paracetamol and placebo, or paracetamol and physical methods, but numbers were small.

REVIEWER'S CONCLUSIONS

Trial evidence that paracetamol has a superior antipyretic effect than placebo is inconclusive. There is limited evidence that there is no difference between the antipyretic effect of paracetamol and physical methods. Data on adverse events in these trials were limited. Establishing standard outcomes will help comparisons between studies and meta-analysis.

High first dose quinine regimen for treating severe malaria

BACKGROUND

Quinine is used for treating severe malaria. There are arguments for giving an initial high dose. We examined the evidence for and against this policy.

OBJECTIVES

To assess clinical outcomes and adverse events of a high first (loading) dose regimen of quinine with a uniform (no loading) dose regimen in people with severe malaria.

SEARCH STRATEGY

We searched the Cochrane Infectious Diseases Group specialized trials register (May 2002), The Cochrane Controlled Trials Register (Issue 2, 2002), MEDLINE (1966 to April 2002), EMBASE (1988 to March 2002), LILACS (www.bireme.br; accessed February 2002), and conference proceedings for relevant abstracts. We also contacted researchers working in the field and checked the reference lists of all studies.

SELECTION CRITERIA

Randomized controlled trials.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the methodological quality of the trials and extracted data. Review Manager (Version 4.1) was used to analyse the data: Relative Risk for binary data and weighted mean difference (WMD) for continuous data. Study authors were contacted for additional information.

MAIN RESULTS

Three small trials, with two contributing to a meta-analysis of 72 participants. Loading dose was associated with fewer deaths, but this was not statistically significant (RR 0.43; 95% confidence interval (CI) 0.09 to 2.15). Loading dose was associated with faster clearance of parasites (WMD 7.44; 95% CI 1.64 to 13.2 hours), resolution of fever (WMD 11.11; 95% CI 2.18 to 20.04 hours), and transient hearing loss (RR 3.14; 95% CI 1.05 to 9.38). No significant difference was detected for recovery of consciousness, neurological sequelae, or convulsions, but the numbers were small.

REVIEWER'S CONCLUSIONS

Quinine loading dose reduced fever clearance time and parasite clearance time. Data are insufficient to confirm or refute whether a loading dose reduced the risk of death or convulsions.

Rapid assessment method for prevalence and intensity of Loa loa infection

OBJECTIVE

To assess the validity of observations on eye worm and Calabar swellings for the rapid assessment of the prevalence and intensity of loiasis at the community level.

METHOD

A total of 12895 individuals over the age of 15 years living in 102 communities in Cameroon and Nigeria took part in the study. A standardized questionnaire was administered to participants from whom finger-prick blood samples were collected and examined for Loa loa microfilariae. Rapid assessments of the prevalence and intensity of loiasis were made on the basis of a history of eye worm or Calabar swellings.

FINDINGS

There was a strong correlation between the indices of the rapid assessment procedures and the parasitological indices of L. loa endemicity. The rapid assessment indices were effective in diagnosing high-risk communities (sensitivity 94-100%; specificity 66-92%). The highest sensitivity (100%) and specificity (92%) were obtained with a rapid assessment procedure based on a history of eye worm lasting 1-7 days together with confirmation by the guided recognition of a photograph of adult L. loa in the eye.

CONCLUSION

Rapid assessment of the prevalence and intensity of loiasis at the community level can be achieved using a procedure based on the history of eye worm lasting 1-7 days together with confirmation by the guided recognition of a photograph of an adult L. loa in the eye.

Iron chelating agents for treating malaria

BACKGROUND

Mortality from Plasmodium falciparum malaria remains high; death and sequelae occur in even in patients treated with antimalarial drugs. Researchers are exploring the effects of adding treatments to the main antimalarial regimens in an attempt to reduce mortality. Iron chelation is one potential chemotherapeutic adjuvant treatment. Before advocating adjunctive therapy, the effects of iron chelators in improving patient outcomes needs to be examined.

OBJECTIVES

To assess the effects of iron-chelating agents combined with antimalarial drugs, or iron chelators alone, for treating Plasmodium falciparum malaria in adults and children, in relation to mortality, coma recovery time, parasite clearance, and adverse effects.

SEARCH STRATEGY

Electronic searches of the Cochrane Library, MEDLINE, and EMBASE, using the standard Cochrane search strategy. Bibliographies of retrieved studies were scrutinized in order to identify further relevant trials. Organisations, experts and other individuals in malaria research were contacted for unpublished studies.

SELECTION CRITERIA

All randomised controlled trials of adults or children with P.falciparum malaria.

DATA COLLECTION AND ANALYSIS

Trials were identified and extracted by a single reviewer (HS) and checked by a second (MM). Inclusion criteria were applied, and data were extracted independently by both reviewers. Authors were contacted for missing and additional data. Meta-analysis used Relative Risk (RR) and 95% Confidence Intervals.

MAIN RESULTS

No evidence of benefit or harm were shown in relation to mortality, but studies were small, and one trial was tending towards more deaths with the intervention when it was stopped. The risk of experiencing persistent seizures was significantly lower with desferrioxamine compared to placebo treatment (RR 0.80, 95% CI 0.67 to 0.95). Many adverse effects were more common in participants treated with desferrioxamine.

REVIEWER'S CONCLUSIONS

Trends suggestive of both harm (death) and potential benefit (fewer seizures) are demonstrated in this review. It is not possible to comment on time to event outcomes that include coma recovery or parasitaemia as we are clarifying data with the trialists. Whether to conduct further trials will depend on a judgement about potential benefit.

Antipyretic measures for treating fever in malaria

OBJECTIVES

Fever control measures are commonly used in treating malaria. Some researchers have suggested that fever reduction may prolong malaria illness. We aim to assess whether antipyretic measures in malaria influences outcome, measured by length of illness, parasitaemia, and occurrence of convulsions.

SEARCH STRATEGY

We searched the Cochrane infectious Diseases Group Trial Register, the Cochrane Controlled Trial Register, and other electronic bibliographies, and contacted researchers and organizations working in this field.

SELECTION CRITERIA

Randomised or pseudo-randomised trials which compared antipyretic drugs with mechanical or no antipyretic measures in patients with slide-confirmed malaria.

DATA COLLECTION AND ANALYSIS

Inclusion criteria were independently applied by two reviewers. We extracted data from selected trials using a standard form. Weighted mean difference with 95% confidence interval was calculated for continuous data.

MAIN RESULTS

Three randomised trials with pooled 128 adults and children with falciparum malaria; all unblinded; allocation concealment unclear in two. Inconsistent pattern of fever clearance between trials, but malaria cure rate reported to be similar between intervention and control in all trials. Mean parasite clearance time reported to be similar in one trial but longer in paracetamol group in two trials: sample size in one trial was too small to conclude anything (n=7), while the other trial was difficult to evaluate.

REVIEWER'S CONCLUSIONS

There is no statistically significant data to draw any conclusions. The clinical significance of preliminary report suggesting that antipyretic drugs prolong malaria parasitaemia was not confirmed.

Blood transfusion for treating malarial anaemia

BACKGROUND

Blood transfusion is used in patients with severe malarial anaemia, but risks adverse reactions, transmission of disease, and is complicated to organise in developing countries.

OBJECTIVES

This review evaluates the effects of routine blood transfusion for severe anaemia on death and adverse outcomes in malarious areas.

SEARCH STRATEGY

The Cochrane Controlled Trials Register, African Index Medicus, LILACS, EMBASE and reference lists of relevant articles, and contact with researchers and organizations working in the field.

SELECTION CRITERIA

Randomised and quasi-randomised trials of blood transfusion compared with conservative management in malaria-associated severe anaemia.

DATA COLLECTION AND ANALYSIS

Trials were identified and extracted by a single reviewer (MM) and checked by a second (HS). Inclusion criteria were applied and data were extracted independendtly by both reviewers.

MAIN RESULTS

Two randomised trials of 230 children were included. In the transfusion group, there was a non-significant tendency towards fewer deaths (RR 0.41, 95% CI 0.06 to 2.70), but significantly more severe adverse events (RR 8.60, 95% CI 1.11 to 66. 43). In one trial by Bojang (1997a) respiratory distress was less common and hospital stay was shorter in the transfusion group (WMD 1.9 days, 95% CI 2.4 to 1.3). Subsequent need for urgent blood transfusion was less common in the transfusion group (RR 0.11, 95% CI 0.02 to 0.62). Day 28 packed cell volume was less in the transfusion group (WMD -1.34, 95% CI -2.57 to -0.11). There was no information on HIV or Hepatitis B virus transmission.

REVIEWER'S CONCLUSIONS

There is insufficient data to be sure whether routinely giving blood to clinically stable children with severe anaemia in endemic malarious areas reduces death, or results in higher haematocrit measured at one month.

Cross-national HIV infection control practices and fear of AIDS: a comparison between Nigeria and the USA

Fears about occupational transmission of HIV may have a significant impact on the behaviour of health care workers and on infection control practices. We investigated the relationships between fear of AIDS and infection control practices in health care workers in major university teaching hospitals in Nigeria and the USA. Data from the fear of AIDS scale and on a measure of infection control practices and beliefs showed that knowledge of whether the patient was HIV-infected determined infection control practices in Calabar but not Texas. Where the patient was known to be infected, there were no differences between the 2 countries. Fears of AIDS were related to infection control practices significantly more in the USA than in Nigeria where there was almost no relationship. These data may be influenced by the greater availability of disposable equipment in the USA compared with Nigeria.

HIV/AIDS infection control enforcement: a comparison between Nigeria and the United States

We examined differences in approaches to HIV-related infection control practices in two university teaching hospitals in the United States and Nigeria. Health care workers (n = 202 in Nigeria and 186 in the USA) responded to a previously validated measure of infection control practices. There were significant differences in the estimated probability of treating a person with HIV disease (higher in USA), and a greater probability of peer ridicule as a way of enforcing group norms on infection control in Nigeria. Peer enforcement of norms was significantly lower in the USA. In both countries, more precautions would be taken if it was known that the patient was HIV infected. Infection control practices were more likely to be followed in the USA compared with Nigeria if they were praised for this activity, if appropriate facilities (sharps containers, gloves, etc.) were nearby, and if they felt that infection control procedures were effective. These data point to the importance of normative social pressures in Nigeria and of knowing the patient is HIV infected in the USA and feeling that infection control procedures are effective ways of avoiding occupational HIV infection. The role of normative pressures and assumptions about HIV infection status as well as cues and availability of facilities for infection control appear to differ between these health care workers in Nigeria and the USA.

New trends in chloroquine efficacy in the treatment of malaria: significance of low (scanty) parasitaemia in an endemic area, with emerging chloroquine-resistant P. falciparum

In a continuous malaria therapy surveillance, using in vivo (WHO) seven-day-test, extended to 14 days follow up, we evaluated the significance of low (scanty) parasitaemia, in an area with chloroquine resistance P. falciparum (CRPF), where self-medication is widely practised. We found that 30.9 pc of the patients screened had Plasmodium species, and 71.4 pc of these had low parasite counts of less than 500 parasites/mm3, whole blood. Eight pc of these were febrile and 41.7 pc of the parasite strains were not susceptible to chloroquine. Parasite strains from four of the patients were also resistant to other antimalarials. These patients gave psychosomatic symptoms, and were seen by a psychiatrist. We conclude that 41 pc of the patients with low parasite counts consist of patients with CRPF and/or multiple-drug resistant P. falciparum in this area. These do not only cause chronic anaemia, but also may be responsible for moderate psychosomatic symptoms in all ages.