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Cheng K, Aitken EH, Hasang W, Meagher N, Price DJ, Madanitsa M, Mwapasa V, Phiri KS, Dodd J, ter Kuile FO, Rogerson SJ. Intermittent preventive treatment with sulphadoxine-pyrimethamine but not dihydroartemisinin-piperaquine modulates the relationship between inflammatory markers and adverse pregnancy outcomes in Malawi. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003198. [PMID: 38753813 PMCID: PMC11098340 DOI: 10.1371/journal.pgph.0003198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/10/2024] [Indexed: 05/18/2024]
Abstract
Women in malaria-endemic areas receive sulphadoxine-pyrimethamine (SP) as Intermittent Preventive Treatment in Pregnancy (IPTp) to reduce malaria. While dihydroartemisinin-piperaquine (DP) has superior antimalarial properties as IPTp, SP is associated with superior fetal growth. As maternal inflammation influences fetal growth, we investigated whether SP alters the relationship between inflammation and birth outcomes. We measured C-reactive protein (CRP) and alpha-1-acid glycoprotein (AGP) at enrollment (16-28 gestation weeks (gw)), visit 3 (24-36 gw) and delivery in 1319 Malawian women randomized to receive monthly SP, DP, or DP and single-dose azithromycin (AZ) in the IMPROVE trial (NCT03208179). Logistic regression was used to assess the relationship between adverse outcomes, inflammation, and treatment arm. Elevated AGP at enrollment was associated with adverse birth outcome (aRR 1.40, 95% CI: 1.15, 1.70), with similar associations observed across treatment arms, exceptions being that elevated AGP was associated with low maternal weight gain in SP recipients (aRR 1.94, 95% CI: 1.36, 2.76) and with small for gestational age in DP+AZ recepients (aRR 1.49, 95% CI 1.02, 2.17). At visit 3 there were few associations between inflammation andoutcomes. At delivery, women with elevated AGP receiving either DP or DP+AZ had an increased risk of adverse birth outcomes (aRR 1.60, 95% CI: 1.28, 2.00), including low birth weight, pre-term birth and foetal loss, this was not seen in women receiving SP (aRR 0.82, 95% CI: 0.54, 1.26). The risk of an association between elevated AGP and adverse birth outcome was higher in those receiving DP or DP+AZ compared to those receiving SP (aRR 1.95, 95% CI: 1.21, 3.13). No clear associations between CRP and adverse outcomes were observed. AGP identified women at risk of adverse pregnancy outcomes. SP modifies the relationship between inflammatory biomarkers and adverse outcomes. Our findings provide insights into potential mechanisms by which SP may improve pregnancy outcomes.
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Affiliation(s)
- Kaylene Cheng
- Department of Medicine (RMH), The Peter Doherty Institute of Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth H. Aitken
- Department of Infectious Diseases, The Peter Doherty Institute of Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
- Department of Microbiology and Immunology, The Peter Doherty Institute of Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | - Wina Hasang
- Department of Infectious Diseases, The Peter Doherty Institute of Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | - Niamh Meagher
- Department of Infectious Diseases, The Peter Doherty Institute of Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
| | - David J. Price
- Department of Infectious Diseases, The Peter Doherty Institute of Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
- Centre for Epidemiology & Biostatistics, Melbourne School of Population & Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Mwayiwawo Madanitsa
- Department of Clinical Sciences, Academy of Medical Sciences, Malawi University of Science and Technology, Thyolo, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Victor Mwapasa
- Department of Epidemiology and Biostatistics, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Kamija S. Phiri
- Department of Epidemiology and Biostatistics, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Training and Research Unit of Excellence, Blantyre, Malawi
| | - James Dodd
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Feiko O. ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Stephen J. Rogerson
- Department of Medicine (RMH), The Peter Doherty Institute of Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
- Department of Infectious Diseases, The Peter Doherty Institute of Infection and Immunity, University of Melbourne, Melbourne, Victoria, Australia
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Dionne JA, Anchang-Kimbi J, Hao J, Long D, Apinjoh T, Tih P, Mbah R, Ngah EN, Juliano JJ, Kahn M, Bruxvoort K, Van Der Pol B, Tita ATN, Marrazzo J, Achidi E. Trimethoprim-Sulfamethoxazole Plus Azithromycin to Prevent Malaria and Sexually Transmitted Infections in Pregnant Women With HIV (PREMISE): A Randomized, Double-Masked, Placebo-Controlled, Phase IIB Clinical Trial. Open Forum Infect Dis 2024; 11:ofae274. [PMID: 38807754 PMCID: PMC11130525 DOI: 10.1093/ofid/ofae274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 05/06/2024] [Indexed: 05/30/2024] Open
Abstract
Background This trial tested the effectiveness of a novel regimen to prevent malaria and sexually transmitted infections (STIs) among pregnant women with HIV in Cameroon. Our hypothesis was that the addition of azithromycin (AZ) to standard daily trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis would reduce malaria and STI infection rates at delivery. Methods Pregnant women with HIV at gestational age <28 weeks were randomized to adjunctive monthly oral AZ 1 g daily or placebo for 3 days and both groups received daily standard oral TMP-SMX through delivery. Primary outcomes were (1) positive peripheral malaria infection by microscopy or polymerase chain reaction and (2) composite bacterial genital STI (Chlamydia trachomatis, Neisseria gonorrhoeae, or syphilis) at delivery. Relative risk and 95% confidence intervals were estimated using 2 × 2 tables with significance as P < .05. Results Pregnant women with HIV (n = 308) were enrolled between March 2018 and August 2020: 155 women were randomized to TMP-SMX-AZ and 153 women to TMP-SMX-placebo. Groups were similar at baseline and loss to follow up was 3.2%. There was no difference in the proportion with malaria (16.3% in TMP-SMX-AZ vs 13.2% in TMP-SMX; relative risk, 1.24 [95% confidence interval, .71-2.16]) or STI at delivery (4.2% in TMP-SMX-AZ vs 5.8% in TMP-SMX; relative risk, 0.72 [95% confidence interval, .26-2.03]). Adverse birth outcomes were not significantly different, albeit lower in the TMP-SMX-AZ arm (preterm delivery 6.7% vs 10.7% [P = .3]; low birthweight 3.4% vs 5.4% [P = .6]). Conclusions The addition of monthly azithromycin to daily TMP-SMX prophylaxis in pregnant women living with HIV in Cameroon did not reduce the risk of malaria or bacterial STI at delivery.
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Affiliation(s)
- Jodie A Dionne
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Jiaying Hao
- Departments of Biostatistics and Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Dustin Long
- Departments of Biostatistics and Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tobias Apinjoh
- Department of Parasitology and Immunology, University of Buea, Buea, Cameroon
| | - Pius Tih
- Cameroon Baptist Convention Health Services, Cameroon Health Initiative at UAB, Bamenda, Cameroon
| | - Rahel Mbah
- Cameroon Baptist Convention Health Services, Cameroon Health Initiative at UAB, Bamenda, Cameroon
| | - Edward Ndze Ngah
- Cameroon Baptist Convention Health Services, Cameroon Health Initiative at UAB, Bamenda, Cameroon
| | - Jonathan J Juliano
- Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Mauricio Kahn
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Katia Bruxvoort
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Departments of Biostatistics and Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Barbara Van Der Pol
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Alan T N Tita
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeanne Marrazzo
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Eric Achidi
- Department of Parasitology and Immunology, University of Buea, Buea, Cameroon
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Figueroa-Romero A, Pons-Duran C, Gonzalez R. Drugs for Intermittent Preventive Treatment of Malaria in Pregnancy: Current Knowledge and Way Forward. Trop Med Infect Dis 2022; 7:tropicalmed7080152. [PMID: 36006244 PMCID: PMC9416188 DOI: 10.3390/tropicalmed7080152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 11/16/2022] Open
Abstract
Malaria infection during pregnancy is an important driver of maternal and neonatal health in endemic countries. Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended for malaria prevention at each scheduled antenatal care visit, starting at the second trimester, in areas of high and moderate transmission. However, the increased resistance to SP in some endemic areas challenges its effectiveness. Furthermore, SP is contraindicated in the first trimester of pregnancy and in HIV-infected women on co-trimoxazole prophylaxis due to potential drug–drug interactions. Thus, in recent last decades, several studies evaluated alternative drugs that could be used for IPTp. A comprehensive literature review was conducted to summarize the evidence on the efficacy and safety of antimalarial drugs being evaluated for IPTp. Chloroquine, amodiaquine, mefloquine and azithromycin as IPTp have proven to be worse tolerated than SP. Mefloquine was found to increase the risk of mother-to-child transmission of HIV. Dihydroartemisin-piperaquine currently constitutes the most promising IPTp drug alternative; it reduced the prevalence of malaria infection, and placental and clinical malaria in studies among HIV-uninfected women, and it is currently being tested in HIV-infected women. Research on effective antimalarial drugs that can be safely administered for prevention to pregnant women should be prioritized. Malaria prevention in the first trimester of gestation and tailored interventions for HIV-infected women remain key research gaps to be addressed.
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Affiliation(s)
- Antia Figueroa-Romero
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic-Universitat de Barcelona, Carrer Rosselló 132, 08036 Barcelona, Spain; (A.F.-R.); (C.P.-D.)
| | - Clara Pons-Duran
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic-Universitat de Barcelona, Carrer Rosselló 132, 08036 Barcelona, Spain; (A.F.-R.); (C.P.-D.)
| | - Raquel Gonzalez
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic-Universitat de Barcelona, Carrer Rosselló 132, 08036 Barcelona, Spain; (A.F.-R.); (C.P.-D.)
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Maputo 1929, Mozambique
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), 28029 Madrid, Spain
- Correspondence:
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Kobia FM, Maiti K, Obimbo MM, Smith R, Gitaka J. Potential pharmacologic interventions targeting TLR signaling in placental malaria. Trends Parasitol 2022; 38:513-524. [DOI: 10.1016/j.pt.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/07/2022] [Accepted: 04/07/2022] [Indexed: 10/18/2022]
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Prevalence and Factors Associated with Low Birth Weight and Preterm Delivery in the Ho Municipality of Ghana. ADVANCES IN PUBLIC HEALTH 2022. [DOI: 10.1155/2022/3955869] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background. Low birth weight and preterm delivery are birth outcomes that can predict newborns’ survival, development, and long-term health outcomes. This study assessed the prevalence and factors associated with low birth weight and preterm delivery in the Ho Municipality of Ghana. Methods. This retrospective, cross-sectional study analysed data from 680 birth records between October and December 2018. Univariate and multivariate logistic regression models predicted low birth weight and preterm delivery factors. Results. The prevalence of low birth weight and preterm delivery was 12.9% and 14.1%, respectively. Increasing maternal age (AOR: 0.52; 95% CI: 0.28–0.98), multiparity (AOR: 0.54; 95% CI: 0.30–0.94) and increasing doses of sulphadoxine-pyrimethamine (AOR: 0.43; 95% CI: 0.22–0.84) significantly reduced the odds of low birth weight. However, caesarean section (AOR: 1.94; 95% CI: 0.1.16–3.27) and hypertension (AOR: 2.06; 95% CI: 1.27–03.33) significantly increased the likelihood of low birth weight. An increasing number of antenatal care visits (AOR: 0.38; 95% CI: 0.18–0.80) and doses of sulphadoxine-pyrimethamine (AOR: 0.43; 95% CI: 0.19–0.97) were significantly associated with decreased odds of preterm delivery, while caesarean section increased the odds of preterm delivery by two folds (AOR: 2.14; 95% CI: 1.15–3.99). Conclusion. This study shows that maternal age, parity, number of antenatal care visits, hypertension, SP/IPTp, and caesarean section were independently associated with low birth weight and preterm delivery. Education and interventions should be prioritised as vitally important on these factors to reduce the risk and complications associated with these birth outcomes.
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Unger HW, Laurita Longo V, Bleicher A, Ome-Kaius M, Karl S, Simpson JA, Karahalios A, Aitken EH, Rogerson SJ. The relationship between markers of antenatal iron stores and birth outcomes differs by malaria prevention regimen-a prospective cohort study. BMC Med 2021; 19:236. [PMID: 34607575 PMCID: PMC8491429 DOI: 10.1186/s12916-021-02114-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/31/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Iron deficiency (ID) has been associated with adverse pregnancy outcomes, maternal anaemia, and altered susceptibility to infection. In Papua New Guinea (PNG), monthly treatment with sulphadoxine-pyrimethamine plus azithromycin (SPAZ) prevented low birthweight (LBW; <2500 g) through a combination of anti-malarial and non-malarial effects when compared to a single treatment with SP plus chloroquine (SPCQ) at first antenatal visit. We assessed the relationship between ID and adverse birth outcomes in women receiving SPAZ or SPCQ, and the mediating effects of malaria infection and haemoglobin levels during pregnancy. METHODS Plasma ferritin levels measured at antenatal enrolment in a cohort of 1892 women were adjusted for concomitant inflammation using C-reactive protein and α-1-acid glycoprotein. Associations of ID (defined as ferritin <15 μg/L) or ferritin levels with birth outcomes (birthweight, LBW, preterm birth, small-for-gestational-age birthweight [SGA]) were determined using linear or logistic regression analysis, as appropriate. Mediation analysis assessed the degree of mediation of ID-birth outcome relationships by malaria infection or haemoglobin levels. RESULTS At first antenatal visit (median gestational age, 22 weeks), 1256 women (66.4%) had ID. Overall, ID or ferritin levels at first antenatal visit were not associated with birth outcomes. There was effect modification by treatment arm. Amongst SPCQ recipients, ID was associated with a 81-g higher mean birthweight (95% confidence interval [CI] 10, 152; P = 0.025), and a twofold increase in ferritin levels was associated with increased odds of SGA (adjusted odds ratio [aOR] 1.25; 95% CI 1.06, 1.46; P = 0.007). By contrast, amongst SPAZ recipients, a twofold increase in ferritin was associated with reduced odds of LBW (aOR 0.80; 95% CI 0.67, 0.94; P = 0.009). Mediation analyses suggested that malaria infection or haemoglobin levels during pregnancy do not substantially mediate the association of ID with birth outcomes amongst SPCQ recipients. CONCLUSIONS Improved antenatal iron stores do not confer a benefit for the prevention of adverse birth outcomes in the context of malaria chemoprevention strategies that lack the non-malarial properties of monthly SPAZ. Research to determine the mechanisms by which ID protects from suboptimal foetal growth is needed to guide the design of new malaria prevention strategies and to inform iron supplementation policy in malaria-endemic settings. TRIAL REGISTRATION ClinicalTrials.gov NCT01136850 .
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Affiliation(s)
- Holger W Unger
- Department of Obstetrics and Gynaecology, Royal Darwin Hospital, Darwin, Northern Territory, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Valentina Laurita Longo
- Catholic University of Sacred Heart, Rome, Italy.,Department of Obstetrics and Gynaecology, San Pietro-Fatebenefratelli Hospital, Rome, Italy
| | - Andie Bleicher
- Department of Medicine (RMH), Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Maria Ome-Kaius
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Stephan Karl
- Australian Institute of Tropical Health & Medicine, James Cook University, Cairns, Australia
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Amalia Karahalios
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth H Aitken
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen J Rogerson
- Department of Medicine (RMH), Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia. .,Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia.
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Hume-Nixon M, Quach A, Reyburn R, Nguyen C, Steer A, Russell F. A Systematic Review and meta-analysis of the effect of administration of azithromycin during pregnancy on perinatal and neonatal outcomes. EClinicalMedicine 2021; 40:101123. [PMID: 34541478 PMCID: PMC8436060 DOI: 10.1016/j.eclinm.2021.101123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Currently there are trials in Africa and Asia investigating whether prophylactic azithromycin during pregnancy reduces infection-related neonatal morbidity and mortality. We undertook a systematic review and meta-analysis to determine the effect of azithromycin during pregnancy on perinatal and neonatal outcomes. METHODS We identified articles between January 1990 and 13th June 2021 by searching five electronic databases. Randomised control trials (RCTs) that included pregnant women administered azithromycin alone or in combination with other medications, and that reported outcomes of low birthweight (LBW), prematurity, stillbirth, and neonatal deaths, infections, and admissions, were eligible. Fixed effects meta-analyses were used for primary analysis. Quality appraisal was performed using Cochrane's Risk of Bias 2 tool. This review was registered with PROSPERO, CRD42019127099. FINDINGS The search generated 5777 studies, of which 14 studies were included involving 17,594 participants. Most studies investigated azithromycin as Intermittent Preventive Treatment in Pregnancy (IPTp) for malaria. More than 50% of the studies had low risk of bias for all outcomes, except for LBW and neonatal admissions. Fixed-effects meta-analyses found that azithromycin reduced the risk of LBW (seven studies, Pooled RR 0·79; 95% CI 0·68-0·93; I2 = 0·00%), and prematurity compared to controls (eight studies, Pooled RR 0·87; 95% CI 0·78-0·98; I2 = 23·28%). There was no strong evidence of any effect on neonatal mortality, infections and admissions. There was an increase in stillbirth but the 95% CI crossed the null value (seven studies, Pooled RR 1·39; 95% CI 0·94 - 2.07; I2=0·00%). However this review was limited by differences in the types of intervention and study populations, and inconsistency in outcome reporting between studies. INTERPRETATION Prophylactic azithromycin during pregnancy reduces LBW and prematurity. However, as azithromycin has been investigated as part of IPTp, it is unclear whether it would improve perinatal and neonatal outcomes in non-malaria endemic settings. The potential harm on stillbirth rates needs further investigation. FUNDING None.
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Affiliation(s)
- Maeve Hume-Nixon
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Alicia Quach
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Rita Reyburn
- Asia-Pacific Health, Murdoch Children's Research Institute, Melbourne, Australia
| | - Cattram Nguyen
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Andrew Steer
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Australia
- Department of General Medicine, Royal Children's Hospital, Melbourne, Australia
| | - Fiona Russell
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Asia-Pacific Health, Murdoch Children's Research Institute, Melbourne, Australia
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Chua CLL, Hasang W, Rogerson SJ, Teo A. Poor Birth Outcomes in Malaria in Pregnancy: Recent Insights Into Mechanisms and Prevention Approaches. Front Immunol 2021; 12:621382. [PMID: 33790894 PMCID: PMC8005559 DOI: 10.3389/fimmu.2021.621382] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/23/2021] [Indexed: 12/13/2022] Open
Abstract
Pregnant women in malaria-endemic regions are susceptible to malaria in pregnancy, which has adverse consequences on birth outcomes, including having small for gestational age and preterm babies. These babies are likely to have low birthweights, which predisposes to infant mortality and lifelong morbidities. During malaria in pregnancy, Plasmodium falciparum-infected erythrocytes express a unique variant surface antigen, VAR2CSA, that mediates sequestration in the placenta. This process may initiate a range of host responses that contribute to placental inflammation and dysregulated placental development, which affects placental vasculogenesis, angiogenesis and nutrient transport. Collectively, these result in the impairment of placental functions, affecting fetal development. In this review, we provide an overview of malaria in pregnancy and the different pathological pathways leading to malaria in pregnancy-associated low birthweight. We also discuss current prevention and management strategies for malaria in pregnancy, and some potential therapeutic interventions that may improve birth outcomes. Lastly, we outline some priorities for future research that could bring us one step closer to reducing this health burden.
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Affiliation(s)
| | - Wina Hasang
- Department of Medicine at Royal Melbourne Hospital, Peter Doherty Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Stephen J Rogerson
- Department of Medicine at Royal Melbourne Hospital, Peter Doherty Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Andrew Teo
- Department of Medicine at Royal Melbourne Hospital, Peter Doherty Institute, University of Melbourne, Melbourne, VIC, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Brabin B, Tinto H, Roberts SA. Testing an infection model to explain excess risk of preterm birth with long-term iron supplementation in a malaria endemic area. Malar J 2019; 18:374. [PMID: 31771607 PMCID: PMC6880560 DOI: 10.1186/s12936-019-3013-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/16/2019] [Indexed: 12/15/2022] Open
Abstract
Background In view of recent evidence from a randomized trial in Burkina Faso that periconceptional iron supplementation substantially increases risk of spontaneous preterm birth (< 37 weeks) in first pregnancies (adjusted relative risk = 2.22; 95% CI 1.39–3.61), explanation is required to understand potential mechanisms, including progesterone mediated responses, linking long-term iron supplementation, malaria and gestational age. Methods The analysis developed a model based on a dual hit inflammatory mechanism arising from simultaneous malaria and gut infections, supported in part by published trial results. This model is developed to understand mechanisms linking iron supplementation, malaria and gestational age. Background literature substantiates synergistic inflammatory effects of these infections where trial data is unavailable. A path modelling exercise assessed direct and indirect paths influencing preterm birth and gestation length. Results A dual hit hypothesis incorporates two main pathways for pro-inflammatory mechanisms, which in this model, interact to increase hepcidin expression. Trial data showed preterm birth was positively associated with C-reactive protein (P = 0.0038) an inflammatory biomarker. The malaria pathway upregulates C-reactive protein and serum hepcidin, thereby reducing iron absorption. The enteric pathway results from unabsorbed gut iron, which induces microbiome changes and pathogenic gut infections, initiating pro-inflammatory events with lipopolysaccharide expression. Data from the trial suggest that raised hepcidin concentration is a mediating catalyst, being inversely associated with shorter gestational age at delivery (P = 0.002) and positively with preterm incidence (P = 0.007). A segmented regression model identified a change-point consisting of two segments before and after a sharp rise in hepcidin concentration. This showed a post change hepcidin elevation in women with increasing C-reactive protein values in late gestation (post-change slope 0.55. 95% CI 0.39–0.92, P < 0.001). Path modelling confirmed seasonal malaria effects on preterm birth, with mediation through C-reactive protein and (non-linear) hepcidin induction. Conclusions Following long-term iron supplementation, dual inflammatory pathways that mediate hepcidin expression and culminate in progesterone withdrawal may account for the reduction in gestational age observed in first pregnancies in this area of high malaria exposure. If correct, this model strongly suggests that in such areas, effective infection control is required prior to iron supplementation to avoid increasing preterm births. Trial registration NCT01210040. Registered with Clinicaltrials.gov on 27th September 2010
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Affiliation(s)
- Bernard Brabin
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L35QA, UK. .,Institute of Infection and Global Health, University of Liverpool, Liverpool, UK. .,Global Child Health Group, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - Halidou Tinto
- Clinical Research Unit of Nanoro (URCN/IRSS), Nanoro, Burkina Faso
| | - Stephen A Roberts
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre (MAHSC), Manchester, UK
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10
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Jiang L, Zhang L, Rui C, Liu X, Mao Z, Yan L, Luan T, Wang X, Wu Y, Li P, Zeng X. The role of the miR1976/CD105/integrin αvβ6 axis in vaginitis induced by Escherichia coli infection in mice. Sci Rep 2019; 9:14456. [PMID: 31594987 PMCID: PMC6783613 DOI: 10.1038/s41598-019-50902-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 09/19/2019] [Indexed: 01/10/2023] Open
Abstract
Vaginitis is very common among women, especially women of childbearing age, and is associated with significantly increased risk of preterm birth and pelvic inflammatory diseases. An imbalance in the vaginal flora, the primary cause of vaginitis, promotes the initiation and progression of vaginal infections. However, the responsible mechanisms are still poorly understood. Using a murine vaginitis model of Escherichia coli infection, we demonstrated that decreased expression of microRNA1976 and increased expression of CD105 and integrin αvβ6 were closely associated with the progression of vaginal infection. Importantly, we demonstrated for the first time that the microRNA1976/CD105/integrin αvβ6 axis regulates E. coli-mediated vaginal infection in mice, as evidenced by the finding that E. coli-induced vaginal infection was reversed by microRNA1976 overexpression and exacerbated by CD105 overexpression. The regulation of CD105 and integrin αvβ6 by microRNA1976 was further confirmed in a murine model of vaginitis with adenoviral vector treatment. Taken together, our data suggested that microRNA1976 negatively regulates E. coli-induced vaginal infection in mice at least in part by suppressing CD105 and integrin αvβ6 expression. These findings may provide new insight into the mechanisms of E. coli-induced vaginitis, identify a novel diagnostic biomarker and a potential therapeutic target for flora imbalance-associated vaginitis.
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Affiliation(s)
- Lisha Jiang
- Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, 210004, China.,Department of Obstetrics and Gynecology, The Second Hospital of Anhui Medical University, Anhui, 230601, China
| | - Lingling Zhang
- Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, 210004, China
| | - Can Rui
- Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, 210004, China
| | - Xia Liu
- Department of Obstetrics and Gynecology, Jiangsu Taizhou People's Hospital, Taizhou, 225300, China
| | - Zhiyuan Mao
- Department of Anatomy, Histology, and Embryology, Nanjing Medical University, Nanjing, 210004, China
| | - Lina Yan
- Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, 210004, China
| | - Ting Luan
- Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, 210004, China
| | - Xinyan Wang
- Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, 210004, China
| | - Ying Wu
- Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, 210004, China
| | - Ping Li
- Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, 210004, China.
| | - Xin Zeng
- Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, 210004, China.
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11
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Elphinstone RE, Weckman AM, McDonald CR, Tran V, Zhong K, Madanitsa M, Kalilani-Phiri L, Khairallah C, Taylor SM, Meshnick SR, Mwapasa V, ter Kuile FO, Conroy AL, Kain KC. Early malaria infection, dysregulation of angiogenesis, metabolism and inflammation across pregnancy, and risk of preterm birth in Malawi: A cohort study. PLoS Med 2019; 16:e1002914. [PMID: 31574087 PMCID: PMC6772002 DOI: 10.1371/journal.pmed.1002914] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 08/21/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Malaria in pregnancy is associated with adverse birth outcomes. However, the underlying mechanisms remain poorly understood. Tight regulation of angiogenic, metabolic, and inflammatory pathways are essential for healthy pregnancies. We hypothesized that malaria disrupts these pathways leading to preterm birth (PTB). METHODS AND FINDINGS We conducted a secondary analysis of a randomized trial of malaria prevention in pregnancy conducted in Malawi from July 21, 2011, to March 18, 2013. We longitudinally assessed circulating mediators of angiogenic, metabolic, and inflammatory pathways during pregnancy in a cohort of HIV-negative women (n = 1,628), with a median age of 21 years [18, 25], and 562 (35%) were primigravid. Pregnancies were ultrasound dated, and samples were analyzed at 13 to 23 weeks (Visit 1), 28 to 33 weeks (Visit 2), and/or 34 to 36 weeks (Visit 3). Malaria prevalence was high; 70% (n = 1,138) had PCR-positive Plasmodium falciparum infection at least once over the course of pregnancy and/or positive placental histology. The risk of delivering preterm in the entire cohort was 20% (n = 304/1506). Women with malaria before 24 weeks gestation had a higher risk of PTB (24% versus 18%, p = 0.005; adjusted relative risk [aRR] 1.30, 95% confidence interval [CI] 1.04-1.63, p = 0.021); and those who were malaria positive only before week 24 had an even greater risk of PTB (28% versus 17%, p = 0.02; with an aRR of 1.67, 95% CI 1.20-2.30, p = 0.002). Using linear mixed-effects modeling, malaria before 24 weeks gestation was associated with altered kinetics of inflammatory (C-Reactive Protein [CRP], Chitinase 3-like protein-1 [CHI3L1], Interleukin 18 Binding Protein [IL-18BP], soluble Tumor Necrosis Factor receptor II [sTNFRII], soluble Intercellular Adhesion Molecule-1 [sICAM-1]), angiogenic (soluble Endoglin [sEng]), and metabolic mediators (Leptin, Angiopoietin-like 3 [Angptl3]) over the course of pregnancy (χ2 > 13.0, p ≤ 0.001 for each). Limitations include being underpowered to assess the impact on nonviable births, being unable to assess women who had not received any antimalarials, and, because of the exposure to antimalarials in the second trimester, there were limited numbers of malaria infections late in pregnancy. CONCLUSIONS Current interventions for the prevention of malaria in pregnancy are initiated at the first antenatal visit, usually in the second trimester. In this study, we found that many women are already malaria-infected by their first visit. Malaria infection before 24 weeks gestation was associated with dysregulation of essential regulators of angiogenesis, metabolism, and inflammation and an increased risk of PTB. Preventing malaria earlier in pregnancy may reduce placental dysfunction and thereby improve birth outcomes in malaria-endemic settings.
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Affiliation(s)
- Robyn E. Elphinstone
- Sandra Rotman Centre for Global Health, University Health Network-University of Toronto, Toronto, Ontario, Canada
| | - Andrea M. Weckman
- Sandra Rotman Centre for Global Health, University Health Network-University of Toronto, Toronto, Ontario, Canada
| | - Chloe R. McDonald
- Sandra Rotman Centre for Global Health, University Health Network-University of Toronto, Toronto, Ontario, Canada
| | - Vanessa Tran
- Sandra Rotman Centre for Global Health, University Health Network-University of Toronto, Toronto, Ontario, Canada
| | - Kathleen Zhong
- Sandra Rotman Centre for Global Health, University Health Network-University of Toronto, Toronto, Ontario, Canada
| | | | | | - Carole Khairallah
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Steve M. Taylor
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Division of Infectious Diseases and Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Steven R. Meshnick
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Victor Mwapasa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Feiko O. ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Andrea L. Conroy
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, United States of America
| | - Kevin C. Kain
- Sandra Rotman Centre for Global Health, University Health Network-University of Toronto, Toronto, Ontario, Canada
- * E-mail:
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12
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Weckman AM, Ngai M, Wright J, McDonald CR, Kain KC. The Impact of Infection in Pregnancy on Placental Vascular Development and Adverse Birth Outcomes. Front Microbiol 2019; 10:1924. [PMID: 31507551 PMCID: PMC6713994 DOI: 10.3389/fmicb.2019.01924] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/05/2019] [Indexed: 12/16/2022] Open
Abstract
Healthy fetal development is dependent on nutrient and oxygen transfer via the placenta. Optimal growth and function of placental vasculature is therefore essential to support in utero development. Vasculogenesis, the de novo formation of blood vessels, and angiogenesis, the branching and remodeling of existing vasculature, mediate the development and maturation of placental villi, which form the materno-fetal interface. Several lines of evidence indicate that systemic maternal infection and consequent inflammation can disrupt placental vasculogenesis and angiogenesis. The resulting alterations in placental hemodynamics impact fetal growth and contribute to poor birth outcomes including preterm delivery, small-for-gestational age (SGA), stillbirth, and low birth weight (LBW). Furthermore, pathways involved in maternal immune activation and placental vascularization parallel those involved in normal fetal development, notably neurovascular development. Therefore, immune-mediated disruption of angiogenic pathways at the materno-fetal interface may also have long-term neurological consequences for offspring. Here, we review current literature evaluating the influence of maternal infection and immune activation at the materno-fetal interface and the subsequent impact on placental vascular function and birth outcome. Immunomodulatory pathways, including chemokines and cytokines released in response to maternal infection, interact closely with the principal pathways regulating placental vascular development, including the angiopoietin-Tie-2, vascular endothelial growth factor (VEGF), and placental growth factor (PlGF) pathways. A detailed mechanistic understanding of how maternal infections impact placental and fetal development is critical to the design of effective interventions to promote placental growth and function and thereby reduce adverse birth outcomes.
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Affiliation(s)
- Andrea M Weckman
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Michelle Ngai
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | - Julie Wright
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Chloe R McDonald
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | - Kevin C Kain
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
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13
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Brabin B, Gies S, Roberts SA, Diallo S, Lompo OM, Kazienga A, Brabin L, Ouedraogo S, Tinto H. Excess risk of preterm birth with periconceptional iron supplementation in a malaria endemic area: analysis of secondary data on birth outcomes in a double blind randomized controlled safety trial in Burkina Faso. Malar J 2019; 18:161. [PMID: 31060615 PMCID: PMC6501288 DOI: 10.1186/s12936-019-2797-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 04/29/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Iron supplementation before a first pregnancy may improve the future health of mother and baby by reducing maternal anaemia. Iron supplementation could, however, increase malaria infections, notably in primigravidae who are most susceptible. The pathogenicity of other iron-utilizing pathogens could also increase, causing inflammation leading to increased risk of adverse birth outcomes. This paper reports pre-specified secondary birth outcomes from a safety trial in Burkina Faso in an area of high malaria endemicity. Primary outcomes from that trial had investigated effects of long-term weekly iron supplementation on malaria and genital tract infections in non-pregnant and pregnant women. METHODS A double-blind, randomized controlled trial. Nulliparous, mainly adolescent women, were individually randomized periconceptionally to receive weekly either 60 mg elemental iron and 2.8 mg folic acid, or 2.8 mg folic acid alone, continuing up to the first antenatal visit for those becoming pregnant. Secondary outcomes were ultrasound-dated gestational age, fetal growth, placental malaria, chorioamnionitis and iron biomarkers. Seasonal effects were assessed. Analysis was by intention to treat. RESULTS 478 pregnancies occurred to 1959 women: 258/980 women assigned iron and folic acid and 220/979 women assigned folic acid alone. Malaria prevalence at the first antenatal visit was 53% (iron) and 55% (controls). Mean birthweight was 111 g lower in the iron group (95% CI 9:213 g, P = 0.033). Mean gestational ages were 264 days (iron) and 269 days (controls) (P = 0.012), with 27.5% under 37 weeks compared to 13.9% in controls (adjRR = 2.22; 95% CI 1.39-3.61) P < 0.001). One-third of babies were growth restricted, but incidence did not differ by trial arm. Half of placentae had evidence of past malaria infection. C-reactive protein > 5 mg/l was more common prior to births < 37 weeks (adjRR = 2.06, 95% CI 1.04-4.10, P = 0.034). Preterm birth incidence during the rainy season was ~ 50% in the iron arm and < 20% in controls (P = 0.001). Chorioamnionitis prevalence peaked in the dry season (P = 0.046), with no difference by trial arm (P = 0.14). CONCLUSION Long-term weekly iron supplementation given to nulliparous women in a malaria endemic area was associated with higher risk of preterm birth in their first pregnancy. Trial Registration NCT01210040. Registered with Clinicaltrials.gov on 27th September 2010.
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Affiliation(s)
- Bernard Brabin
- Clinical Division, Liverpool School of Tropical Medicine, and Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.
- Global Child Health Group, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - Sabine Gies
- Department of Biomedical Sciences, Prince Leopold Institute of Tropical Medicine, Antwerp, Belgium
- Medical Mission Institute, Würzburg, Germany
| | - Stephen A Roberts
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre (MAHSC), Manchester, UK
| | - Salou Diallo
- Institute for Research in Health Sciences-Clinical Research Unit of Nanoro, (IRSS-URCN), Nanoro, Burkina Faso
| | - Olga M Lompo
- Service d'Anatomocytopathologie et de Médicine Légale, Centre Hospitalier Universitaire Yalgado Ouedraogo, Ouagadougou, Burkina Faso
| | - Adama Kazienga
- Institute for Research in Health Sciences-Clinical Research Unit of Nanoro, (IRSS-URCN), Nanoro, Burkina Faso
| | - Loretta Brabin
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre (MAHSC), Manchester, UK
| | - Sayouba Ouedraogo
- Institute for Research in Health Sciences-Clinical Research Unit of Nanoro, (IRSS-URCN), Nanoro, Burkina Faso
| | - Halidou Tinto
- Institute for Research in Health Sciences-Clinical Research Unit of Nanoro, (IRSS-URCN), Nanoro, Burkina Faso
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