Editorial: Maternal malaria: time for action

Mass administration of the antimalarial drug mefloquine to Guantánamo detainees: a critical analysis

Recently, evidence has emerged from an unusual form of mass drug administration practised among detainees held at US Naval Station Guantánamo Bay, Cuba ('Guantánamo'), ostensibly as a public health measure. Mefloquine, an antimalarial drug originally developed by the US military, whose use is associated with a range of severe neuropsychiatric adverse effects, was administered at treatment doses to detainees immediately upon their arrival at Guantánamo, prior to laboratory testing for malaria and irrespective of symptoms of disease. In this analysis, the history of mefloquine's development is reviewed and the indications for its administration at treatment doses are discussed. The stated rationale for the use of mefloquine among Guantánamo detainees is then evaluated in the context of accepted forms of population-based malaria control. It is concluded that there was no plausible public health indication for the use of mefloquine at Guantánamo and that based on prevailing standards of care, the clinical indications for its use are decidedly unclear. This analysis suggests the troubling possibility that the use of mefloquine at Guantánamo may have been motivated in part by knowledge of the drug's adverse effects, and points to a critical need for further investigation to resolve unanswered questions regarding the drug's potentially inappropriate use.

A randomized, controlled trial of intermittent preventive treatment with sulfadoxine-pyrimethamine, amodiaquine, or the combination in pregnant women in Ghana

BACKGROUND

The use of sulfadoxine-pyrimethamine (SP) for intermittent preventive treatment in pregnancy (IPTp) is threatened by the spread of resistance to SP. Therefore, we studied the efficacy, safety, and tolerance of amodiaquine (AQ) or the combination of AQ and SP (SPAQ) as possible alternative treatments.

METHODS

The study was performed in Ghana from June 2004 through February 2007. Women were individually randomized to receive IPTp with SP (n=1328), AQ (n= 986), or SPAQ (n=1328). Incidences of anemia, peripheral anemia, and placental parasitemia at delivery were assessed for paucigravidae, as were the birth weights of their infants. Delivery outcomes and the incidence of adverse events were investigated for all women.

RESULTS

The prevalences of anemia (as defined by a hemoglobin concentration of <11.0 g/dL) at delivery were comparable between the SP and AQ groups and between the SP and SPAQ groups. Similarly, there was no significant difference between the SP and AQ groups or between the SP and SPAQ groups with regard to the incidences of low birth weight (LBW). Women who received AQ or SPAQ were more likely to report adverse events than were those who received SP.

CONCLUSION

The effects of IPTp with AQ or SPAQ on maternal anemia and LBW were comparable to the effects of IPTp with SP; however, IPTp regimens that contain AQ are unlikely to be useful as an alternative to IPTp with SP in Ghana, because of a high frequency of associated adverse events.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT00146783 .

Safety and toxicity of sulfadoxine/pyrimethamine: implications for malaria prevention in pregnancy using intermittent preventive treatment

Plasmodium falciparum infection during pregnancy is strongly associated with maternal anaemia and low birth weight, contributing to substantial morbidity and mortality in sub-Saharan Africa. Intermittent preventive treatment in pregnancy with sulfadoxine/pyrimethamine (IPTp-SP) has been one of the most effective approaches to reduce the burden of malaria during pregnancy in Africa. IPTp-SP is based on administering >or=2 treatment doses of sulfadoxine/pyrimethamine to pregnant women at predefined intervals after quickening (around 18-20 weeks). Randomised, controlled trials have demonstrated decreased rates of maternal anaemia and low birth weight with this approach. The WHO currently recommends IPTp-SP in malaria-endemic areas of sub-Saharan Africa. However, implementation has been suboptimal in part because of concerns of potential drug toxicities. This review evaluates the toxicity data of sulfadoxine/pyrimethamine, including severe cutaneous adverse reactions, teratogenicity and alterations in bilirubin metabolism. Weekly sulfadoxine/pyrimethamine prophylaxis is associated with rare but potentially fatal cutaneous reactions. Fortunately, sulfadoxine/pyrimethamine use in IPTp programmes in Africa, with 2-4 treatment doses over 6 months, has been well tolerated in multiple IPTp trials. However, sulfadoxine/pyrimethamine should not be administered concurrently with cotrimoxazole given their redundant mechanisms of action and synergistic worsening of adverse drug reactions. Therefore, HIV-infected pregnant women in malaria endemic areas who are already receiving cotrimoxazole prophylaxis should not also receive IPTp-SP. Although folate antagonist use in the first trimester is associated with neural tube defects, large case-control studies have demonstrated that sulfadoxine/pyrimethamine administered as IPTp (exclusively in the second and third trimesters and after organogenesis) does not result in an increased risk of teratogenesis. Folic acid supplementation is recommended for all pregnant women to reduce the rate of congenital anomalies but high doses of folic acid (5 mg/day) may interfere with the antimalarial efficacy of sulfadoxine/pyrimethamine. However, the recommended standard dose of folic acid supplementation (0.4 mg/day) does not affect antimalarial efficacy and may provide the optimal balance to prevent neural tube defects and maintain the effectiveness of IPTp-SP. No clinical association between sulfadoxine/pyrimethamine use and kernicterus has been reported despite the extensive use of sulfadoxine/pyrimethamine and related compounds to treat maternal malaria and congenital toxoplasmosis in near-term pregnant women and newborns. Although few drugs in pregnancy can be considered completely safe, sulfadoxine/pyrimethamine - when delivered as IPTp - has a favourable safety profile. Improved pharmacovigilance programmes throughout Africa are now needed to confirm its safety as access to IPTp-SP increases. Given the documented benefits of IPTp-SP in malaria endemic areas of Africa, access to this treatment for pregnant women should continue to expand.

Early infant growth monitoring - time well spent?

BACKGROUND

In sub-Saharan Africa, growth monitoring for every infant consumes time and resources with no evidence of any benefits. We consider an alternative pragmatic approach which provides scheduled monitoring for low birth weight infants only, and takes advantage of non-routine clinic visits for normal birth weight infants. We investigate the implications for the number of weighing episodes and performance as a screening tool using data from a cohort study of infants followed-up from birth to 98 days.

METHODS

Babies delivered in a Kenyan district hospital and enrolled in a birth cohort were weighed at birth and at follow-up visits coinciding with their immunizations at 6, 10 and 14 weeks. Episodes of illness resulting in clinic visits, hospital admissions or death were identified and recorded.

RESULTS

Four-fifths (81%) of the 2210 babies weighed 2500 g or more at birth, of whom 133 (7%) were admitted to hospital or died before 14 weeks of age. 85% of the deaths and 67% of admissions occurred within 3 weeks of birth. Most babies weighing 2500 g or more and who had weight measurements grew well. Only 4% of infants were exclusively breastfed at 14 weeks of age. Neither universal nor pragmatic growth monitoring was a good screening tool among this group of infants for episodes of illness in the short-term. Pragmatic monitoring would involve 72% fewer weighing episodes.

CONCLUSIONS

A pragmatic approach in early infancy would not represent a major change in policy, would appear to have no disadvantages and would probably increase the time available for implementing interventions of greater benefit such as breastfeeding promotion.

Malaria in pregnancy and the endemicity spectrum: what can we learn?

The increased susceptibility of pregnant women to malaria infection has long been recognized, but the magnitude of the disease burden in this particular group, together with the pathophysiology of maternal malaria and the specific difficulties in treatment, have only recently been the focus of research. Most research on maternal malaria has derived from sub-Saharan Africa where transmission is high, whereas most of the studies on the treatment of malaria and the effect of non-falciparum species has been conducted in low-transmission areas of Asia. In this paper, we attempt to improve our understanding of the disease and its mechanisms from observed differences and similarities between contrasting areas of transmission, and to identify priorities for future research.

Malaria and the pregnant traveller

Malaria in pregnancy contributes to significant maternal and foetal mortality and morbidity in women in the tropics. Adverse effects for non-immune travellers are potentially devastating for mother and foetus. Women travellers should always be strongly advised against visiting malarious areas if they are pregnant or intend to get pregnant. Chemoprophylactic and treatment options for pregnant women (or those planning to conceive) are extremely limited and lag behind what can currently be offered to non-pregnant travellers. This is because of spread of multi-resistant strains of P. falciparum. Personal protection from malaria vectors remains essential. Mosquito-net and skin repellents (DEET (20%)) are effective. Diagnosis of malaria in travellers is difficult and is more likely to be missed in pregnant travellers due to lower parasitaemia. Pregnant women can succumb rapidly to severe malaria. Should the returned traveller survive an episode of malaria in pregnancy and go on to deliver, the adverse effects on the infant are potentially irreversible. These risks need to be clearly communicated.

Can amodiaquine be used safely during pregnancy?

Several African countries have begun using amodiaquine-containing combinations as first-line antimalarial treatment, with the result that a substantial number of pregnant women are likely to be exposed to amodiaquine. However, little information is available on amodiaquine safety and efficacy during pregnancy. Between 1948 and 1990 only six published studies reported amodiaquine use in pregnancy. Only one publication mentioned adverse events, without details. Six additional studies on amodiaquine delivered by mass drug administration or medicated salts gave very little information on amodiaquine safety. Therefore, there is an urgent need for studies on amodiaquine safety and tolerability during pregnancy since current data are not sufficient to recommend its use during pregnancy, particularly as intermittent preventive treatment.