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Plowe CV. Malaria chemoprevention and drug resistance: a review of the literature and policy implications. Malar J 2022; 21:104. [PMID: 35331231 PMCID: PMC8943514 DOI: 10.1186/s12936-022-04115-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/03/2022] [Indexed: 01/19/2023] Open
Abstract
Chemoprevention strategies reduce malaria disease and death, but the efficacy of anti-malarial drugs used for chemoprevention is perennially threatened by drug resistance. This review examines the current impact of chemoprevention on the emergence and spread of drug resistant malaria, and the impact of drug resistance on the efficacy of each of the chemoprevention strategies currently recommended by the World Health Organization, namely, intermittent preventive treatment in pregnancy (IPTp); intermittent preventive treatment in infants (IPTi); seasonal malaria chemoprevention (SMC); and mass drug administration (MDA) for the reduction of disease burden in emergency situations. While the use of drugs to prevent malaria often results in increased prevalence of genetic mutations associated with resistance, malaria chemoprevention interventions do not inevitably lead to meaningful increases in resistance, and even high rates of resistance do not necessarily impair chemoprevention efficacy. At the same time, it can reasonably be anticipated that, over time, as drugs are widely used, resistance will generally increase and efficacy will eventually be lost. Decisions about whether, where and when chemoprevention strategies should be deployed or changed will continue to need to be made on the basis of imperfect evidence, but practical considerations such as prevalence patterns of resistance markers can help guide policy recommendations.
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Abstract
BACKGROUND Intermittent preventive treatment could help prevent malaria in infants (IPTi) living in areas of moderate to high malaria transmission in sub-Saharan Africa. The World Health Organization (WHO) policy recommended IPTi in 2010, but its adoption in countries has been limited. OBJECTIVES To evaluate the effects of intermittent preventive treatment (IPT) with antimalarial drugs to prevent malaria in infants living in malaria-endemic areas. SEARCH METHODS We searched the following sources up to 3 December 2018: the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library), MEDLINE (PubMed), Embase (OVID), LILACS (Bireme), and reference lists of articles. We also searched the metaRegister of Controlled Trials (mRCT) and the WHO International Clinical Trials Registry Platform (ICTRP) portal for ongoing trials up to 3 December 2018. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared IPT to placebo or no intervention in infants (defined as young children aged between 1 to 12 months) in malaria-endemic areas. DATA COLLECTION AND ANALYSIS The primary outcome was clinical malaria (fever plus asexual parasitaemia). Two review authors independently assessed trials for inclusion, evaluated the risk of bias, and extracted data. We summarized dichotomous outcomes and count data using risk ratios (RR) and rate ratios respectively, and presented all measures with 95% confidence intervals (CIs). We extracted protective efficacy values and their 95% CIs; when an included trial did not report this data, we calculated these values from the RR or rate ratio with its 95% CI. Where appropriate, we combined data in meta-analyses and assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 12 trials that enrolled 19,098 infants; all were conducted in sub-Saharan Africa. Three trials were cluster-RCTs. IPTi with sulfadoxine-pyrimethamine (SP) was evaluated in 10 trials from 1999 to 2013 (n = 15,256). Trials evaluating ACTs included dihydroartemisinin-piperaquine (1 trial, 147 participants; year 2013), amodiaquine-artesunate (1 study, 684 participants; year 2008), and SP-artesunate (1 trial, 676 participants; year 2008). The earlier studies evaluated IPTi with SP, and were conducted in Tanzania (in 1999 and 2006), Mozambique (2004), Ghana (2004 to 2005), Gabon (2005), Kenya (2008), and Mali (2009). One trial evaluated IPTi with amodiaquine in Tanzania (2000). Later studies included three conducted in Kenya (2008), Tanzania (2008), and Uganda (2013), evaluating IPTi in multiple trial arms that included artemisinin-based combination therapy (ACT). Although the effect size varied over time and between drugs, overall IPTi impacts on the incidence of clinical malaria overall, with a 30% reduction (rate ratio 0.70, 0.62 to 0.80; 10 studies, 10,602 participants). The effect of SP appeared to attenuate over time, with trials conducted after 2009 showing little or no effect of the intervention. IPTi with SP probably resulted in fewer episodes of clinical malaria (rate ratio 0.78, 0.69 to 0.88; 8 trials, 8774 participants, moderate-certainty evidence), anaemia (rate ratio 0.82, 0.68 to 0.98; 6 trials, 7438 participants, moderate-certainty evidence), parasitaemia (rate ratio 0.66, 0.56 to 0.79; 1 trial, 1200 participants, moderate-certainty evidence), and fewer hospital admissions (rate ratio 0.85, 0.78 to 0.93; 7 trials, 7486 participants, moderate-certainty evidence). IPTi with SP probably made little or no difference to all-cause mortality (risk ratio 0.93, 0.74 to 1.15; 9 trials, 14,588 participants, moderate-certainty evidence). Since 2009, IPTi trials have evaluated ACTs and indicate impact on clinical malaria and parasitaemia. A small trial of DHAP in 2013 shows substantive effects on clinical malaria (RR 0.42, 0.33 to 0.54; 1 trial, 147 participants, moderate-certainty evidence) and parasitaemia (moderate-certainty evidence). AUTHORS' CONCLUSIONS In areas of sub-Saharan Africa, giving antimalarial drugs known to be effective against the malaria parasite at the time to infants as IPT probably reduces the risk of clinical malaria, anaemia, and hospital admission. Evidence from SP studies over a 19-year period shows declining efficacy, which may be due to increasing drug resistance. Combinations with ACTs appear promising as suitable alternatives for IPTi.
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Affiliation(s)
- Ekpereonne B Esu
- Department of Public Health, College of Medical Sciences, University of Calabar, Calabar, Nigeria
| | - Chioma Oringanje
- GIDP Entomology and Insect Science, University of Tucson, Tucson, Arizona, USA
| | - Martin M Meremikwu
- Department of Paediatrics, University of Calabar Teaching Hospital, Calabar, Nigeria
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Abstract
BACKGROUND Intermittent preventive treatment could help prevent malaria in infants (IPTi) living in areas of moderate to high malaria transmission in sub-Saharan Africa. The World Health Organization (WHO) policy recommended IPTi in 2010, but its adoption in countries has been limited. OBJECTIVES To evaluate the effects of intermittent preventive treatment (IPT) with antimalarial drugs to prevent malaria in infants living in malaria-endemic areas. SEARCH METHODS We searched the following sources up to 3 December 2018: the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library), MEDLINE (PubMed), Embase (OVID), LILACS (Bireme), and reference lists of articles. We also searched the metaRegister of Controlled Trials (mRCT) and the WHO International Clinical Trials Registry Platform (ICTRP) portal for ongoing trials up to 3 December 2018. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared IPT to placebo or no intervention in infants (defined as young children aged between 1 to 12 months) in malaria-endemic areas. DATA COLLECTION AND ANALYSIS The primary outcome was clinical malaria (fever plus asexual parasitaemia). Two review authors independently assessed trials for inclusion, evaluated the risk of bias, and extracted data. We summarized dichotomous outcomes and count data using risk ratios (RR) and rate ratios respectively, and presented all measures with 95% confidence intervals (CIs). We extracted protective efficacy values and their 95% CIs; when an included trial did not report this data, we calculated these values from the RR or rate ratio with its 95% CI. Where appropriate, we combined data in meta-analyses and assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 12 trials that enrolled 19,098 infants; all were conducted in sub-Saharan Africa. Three trials were cluster-RCTs. IPTi with sulfadoxine-pyrimethamine (SP) was evaluated in 10 trials from 1999 to 2013 (n = 15,256). Trials evaluating ACTs included dihydroartemisinin-piperaquine (1 trial, 147 participants; year 2013), amodiaquine-artesunate (1 study, 684 participants; year 2008), and SP-artesunate (1 trial, 676 participants; year 2008). The earlier studies evaluated IPTi with SP, and were conducted in Tanzania (in 1999 and 2006), Mozambique (2004), Ghana (2004 to 2005), Gabon (2005), Kenya (2008), and Mali (2009). One trial evaluated IPTi with amodiaquine in Tanzania (2000). Later studies included three conducted in Kenya (2008), Tanzania (2008), and Uganda (2013), evaluating IPTi in multiple trial arms that included artemisinin-based combination therapy (ACT). Although the effect size varied over time and between drugs, overall IPTi impacts on the incidence of clinical malaria overall, with a 27% reduction (rate ratio 0.73, 0.65 to 0.82; 10 studies, 10,602 participants). The effect of SP appeared to attenuate over time, with trials conducted after 2009 showing little or no effect of the intervention. IPTi with SP probably resulted in fewer episodes of clinical malaria (rate ratio 0.79, 0.74 to 0.85; 8 trials, 8774 participants, moderate-certainty evidence), anaemia (rate ratio 0.82, 0.68 to 0.98; 6 trials, 7438 participants, moderate-certainty evidence), parasitaemia (rate ratio 0.66, 0.56 to 0.79; 1 trial, 1200 participants, moderate-certainty evidence), and fewer hospital admissions (rate ratio 0.85, 0.78 to 0.93; 7 trials, 7486 participants, moderate-certainty evidence). IPTi with SP probably made little or no difference to all-cause mortality (risk ratio 0.93, 0.74 to 1.15; 9 trials, 14,588 participants, moderate-certainty evidence). Since 2009, IPTi trials have evaluated ACTs and indicate impact on clinical malaria and parasitaemia. A small trial of DHAP in 2013 shows substantive effects on clinical malaria (RR 0.42, 0.33 to 0.54; 1 trial, 147 participants, moderate-certainty evidence) and parasitaemia (moderate-certainty evidence). AUTHORS' CONCLUSIONS In areas of sub-Saharan Africa, giving antimalarial drugs known to be effective against the malaria parasite at the time to infants as IPT probably reduces the risk of clinical malaria, anaemia, and hospital admission. Evidence from SP studies over a 19-year period shows declining efficacy, which may be due to increasing drug resistance. Combinations with ACTs appear promising as suitable alternatives for IPTi. 2 December 2019 Up to date All studies incorporated from most recent search All eligible published studies found in the last search (3 Dec, 2018) were included.
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Affiliation(s)
- Ekpereonne B Esu
- College of Medical Sciences, University of CalabarDepartment of Public HealthCalabarCross River StateNigeria
| | - Chioma Oringanje
- University of TucsonGIDP Entomology and Insect ScienceTucsonArizonaUSA85721
| | - Martin M Meremikwu
- University of Calabar Teaching HospitalDepartment of PaediatricsPMB 1115CalabarCross River StateNigeria
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Ruh E, Bateko JP, Imir T, Taylan-Ozkan A. Molecular identification of sulfadoxine-pyrimethamine resistance in malaria infected women who received intermittent preventive treatment in the Democratic Republic of Congo. Malar J 2018; 17:17. [PMID: 29316929 PMCID: PMC5761196 DOI: 10.1186/s12936-017-2160-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 12/23/2017] [Indexed: 11/30/2022] Open
Abstract
Background Point mutations in Plasmodium falciparum dihydrofolate reductase (Pfdhfr) and dihydropteroate synthase (Pfdhps) genes which confer resistance to sulfadoxine-pyrimethamine (SP) occur at increasing rates. The present study aimed to identify Pfdhfr and Pfdhps mutations in P. falciparum isolates recovered from women who received two doses of SP during pregnancy in Bandundu, the Democratic Republic of Congo (DRC). Methods A total of 48 women with confirmed P. falciparum infection were enrolled in the study. Finger-prick blood samples that were collected on filter paper at the time of delivery were used for DNA isolation. Pfdhfr and Pfdhps genes were amplified by a nested PCR protocol. DNA sequencing was performed on both strands, and the point mutations were analysed. Results All of the 48 (100.0%) P. falciparum isolates carried at least one polymorphism in both genes. The wild-type haplotypes of Pfdhfr (CNCSI [C50, N51, C59, S108, I164]) and Pfdhps (SAKAA [S436, A437, K540, A581, A613]) were not observed in the study. In Pfdhfr, N51I (85.4%), C59R (60.4%), and S108N (100.0%) polymorphisms were detected. Triple mutation (CIRNI) (mutant amino acids are underlined) was the most prevalent (47.9%) Pfdhfr haplotype. In the study, all P. falciparum isolates (100.0%) harboured the A437G allele in Pfdhps gene. Also, K540E and A581G polymorphisms were observed in one (2.1%) isolate. Single mutant haplotype (SGKAA) was detected in 97.9% of the isolates. Mutant Pfdhfr and Pfdhps allele combinations revealed quintuple (CICNI-SGEGA; 2.1%), quadruple (CIRNI-SGKAA; 47.9%), triple (CICNI-SGKAA; 35.4%, CNRNI-SGKAA; 12.5%), and double (CNCNI-SGKAA; 2.1%) haplotypes. Conclusions In the study, the rate of SGEGA haplotype was low (2.1%). Although K540E and A581G alleles are more common in Eastern Africa, a distinct lineage of SGEGA is also present in the DRC, which is located in Central Africa. This haplotype is associated with decreased efficacy of SP in pregnant women and infants, therefore, it should be carefully considered in the DRC and SP resistance should be routinely monitored.
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Affiliation(s)
- Emrah Ruh
- Department of Medical Microbiology and Clinical Microbiology, Near East University Faculty of Medicine, Near East Boulevard, 99138, Nicosia, Northern Cyprus.
| | - Jean Paul Bateko
- Department of Medical Microbiology and Clinical Microbiology, Near East University Faculty of Medicine, Near East Boulevard, 99138, Nicosia, Northern Cyprus.,Department of Medical Biology, Higher Institute of Medical Technology, Bandundu, Democratic Republic of the Congo
| | - Turgut Imir
- Department of Medical Microbiology and Clinical Microbiology, Near East University Faculty of Medicine, Near East Boulevard, 99138, Nicosia, Northern Cyprus
| | - Aysegul Taylan-Ozkan
- Department of Medical Microbiology and Clinical Microbiology, Near East University Faculty of Medicine, Near East Boulevard, 99138, Nicosia, Northern Cyprus.,Department of Medical Microbiology, Hitit University Faculty of Medicine, Corum, Turkey
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Kesteman T, Randrianarivelojosia M, Rogier C. The protective effectiveness of control interventions for malaria prevention: a systematic review of the literature. F1000Res 2017; 6:1932. [PMID: 29259767 PMCID: PMC5721947 DOI: 10.12688/f1000research.12952.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2017] [Indexed: 12/22/2022] Open
Abstract
Background: Thanks to a considerable increase in funding, malaria control interventions (MCI) whose efficacy had been demonstrated by controlled trials have been largely scaled up during the last decade. Nevertheless, it was not systematically investigated whether this efficacy had been preserved once deployed on the field. Therefore, we sought the literature to assess the disparities between efficacy and effectiveness and the effort to measure the protective effectiveness (PE) of MCI. Methods: The PubMed database was searched for references with keywords related to malaria, to control interventions for prevention and to study designs that allow for the measure of the PE against parasitemia or against clinical outcomes. Results: Our search retrieved 1423 references, and 162 articles were included in the review. Publications were scarce before the year 2000 but dramatically increased afterwards. Bed nets was the MCI most studied (82.1%). The study design most used was a cross-sectional study (65.4%). Two thirds (67.3%) were conducted at the district level or below, and the majority (56.8%) included only children even if the MCI didn’t target only children. Not all studies demonstrated a significant PE from exposure to MCI: 60.6% of studies evaluating bed nets, 50.0% of those evaluating indoor residual spraying, and 4/8 showed an added PE of using both interventions as compared with one only; this proportion was 62.5% for intermittent preventive treatment of pregnant women, and 20.0% for domestic use of insecticides. Conclusions: This review identified numerous local findings of low, non-significant PE –or even the absence of a protective effect provided by these MCIs. The identification of such failures in the effectiveness of MCIs advocates for the investigation of the causes of the problem found. Ideal evaluations of the PE of MCIs should incorporate both a large representativeness and an evaluation of the PE stratified by subpopulations.
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Affiliation(s)
- Thomas Kesteman
- Fondation Mérieux, Lyon, France.,Malaria Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | | | - Christophe Rogier
- Malaria Research Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar.,Ecole doctorale Sciences de la vie et de l'environnement, Université d'Antananarivo, Antananarivo, Madagascar.,Institute for Biomedical Research of the French Armed Forces (IRBA), Brétigny-Sur-Orge , France.,Unité de recherche sur les maladies infectieuses et tropicales émergentes - (URMITE), Marseille, France
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Bouyou-Akotet MK, Mawili-Mboumba DP, Kendjo E, Moutandou Chiesa S, Tshibola Mbuyi ML, Tsoumbou-Bakana G, Zong J, Ambounda N, Kombila M. Decrease of microscopic Plasmodium falciparum infection prevalence during pregnancy following IPTp-SP implementation in urban cities of Gabon. Trans R Soc Trop Med Hyg 2016; 110:333-42. [PMID: 27268713 DOI: 10.1093/trstmh/trw034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 04/18/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Six years after the implementation of intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) in Gabon, its impact on placental malaria and pregnancy outcomes remains unknown. METHODS Age, gestational data, use of IPTp-SP and birth weight were recorded during a hospital-based cross-sectional survey performed in 2011 in 387 women at the end of pregnancy. RESULTS Malaria prevalence was 6.7 and 5.3% in peripheral and placental blood respectively. Overall, 59.0% women took at least two IPTp-SP doses which was associated with 50% reduction of Plasmodium; (P.) falciparum infection in primigravidae. Previous malaria treatment was a risk factor for peripheral P. falciparum infection, while uptake of IPTp-SP was associated with reduced parasitaemia. Anaemia prevalence was 38.0%, low birth weight and prematurity rates were 6.0 and 12.0% respectively. Young age was associated with a higher frequency of malaria, anaemia, low birth weight and preterm delivery (p<0.01). Birth weight significantly rose with increasing age (p<0.01), parity (p=0.03) and number of SP doses (p=0.03). A birth weight reduction of 230 g in case of peripheral parasitaemia (p=0.02) and of 210 g with placental parasitaemia (p=0.13) was observed. CONCLUSIONS Microscopic P. falciparum prevalence during pregnancy significantly declined between 2005 and 2011, following IPTp-SP implementation in Gabon. Young women and paucigravidae remain the most susceptible to malaria and associated outcomes.
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Affiliation(s)
- M K Bouyou-Akotet
- Department of Parasitology-Mycology, Faculty of Medicine, Université des Sciences de la Santé, Libreville, Gabon Malaria Clinical and Operational Research Unit (MCORU), Centre Hospitalier Regional de l´Estuaire Melen, Libreville, Gabon
| | - D P Mawili-Mboumba
- Department of Parasitology-Mycology, Faculty of Medicine, Université des Sciences de la Santé, Libreville, Gabon Malaria Clinical and Operational Research Unit (MCORU), Centre Hospitalier Regional de l´Estuaire Melen, Libreville, Gabon
| | - E Kendjo
- Department of Parasitology-Mycology, Faculty of Medicine, Université des Sciences de la Santé, Libreville, Gabon
| | - S Moutandou Chiesa
- Department of Gynecology, Faculty of Medicine, Université des Sciences de la Santé, Libreville, Gabon
| | - M L Tshibola Mbuyi
- Department of Parasitology-Mycology, Faculty of Medicine, Université des Sciences de la Santé, Libreville, Gabon
| | - G Tsoumbou-Bakana
- Malaria Clinical and Operational Research Unit (MCORU), Centre Hospitalier Regional de l´Estuaire Melen, Libreville, Gabon
| | - J Zong
- Malaria Clinical and Operational Research Unit (MCORU), Centre Hospitalier Regional de l´Estuaire Melen, Libreville, Gabon
| | - N Ambounda
- Gynecology and Obstetrics ward, Centre Hospitalier de Libreville, Libreville, Gabon
| | - M Kombila
- Department of Parasitology-Mycology, Faculty of Medicine, Université des Sciences de la Santé, Libreville, Gabon Malaria Clinical and Operational Research Unit (MCORU), Centre Hospitalier Regional de l´Estuaire Melen, Libreville, Gabon
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Williams JE, Cairns M, Njie F, Laryea Quaye S, Awine T, Oduro A, Tagbor H, Bojang K, Magnussen P, Ter Kuile FO, Woukeu A, Milligan P, Chandramohan D, Greenwood B. The Performance of a Rapid Diagnostic Test in Detecting Malaria Infection in Pregnant Women and the Impact of Missed Infections. Clin Infect Dis 2015; 62:837-844. [PMID: 26721833 PMCID: PMC4787605 DOI: 10.1093/cid/civ1198] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 12/16/2015] [Indexed: 12/02/2022] Open
Abstract
The sensitivity of a rapid diagnostic test (RDT) for malaria was compared with that of a polymerase chain reaction assay in pregnant West African women. The sensitivity of the RDT was high at enrollment but lower at delivery. Background. Intermittent screening and treatment in pregnancy (ISTp) is a potential strategy for the control of malaria during pregnancy. However, the frequency and consequences of malaria infections missed by a rapid diagnostic test (RDT) for malaria are a concern. Methods. Primigravidae and secundigravidae who participated in the ISTp arm of a noninferiority trial in 4 West African countries were screened with an HRP2/pLDH RDT on enrollment and, in Ghana, at subsequent antenatal clinic (ANC) visits. Blood samples were examined subsequently by microscopy and by a polymerase chain reaction (PCR) assay. Results. The sensitivity of the RDT to detect peripheral blood infections confirmed by microscopy and/or PCR at enrollment ranged from 91% (95% confidence interval [CI], 88%, 94%) in Burkina Faso to 59% (95% CI, 48%, 70% in The Gambia. In Ghana, RDT sensitivity was 89% (95% CI, 85%, 92%), 83% (95% CI, 76%, 90%) and 77% (95% CI, 67%, 86%) at enrollment, second and third ANC visits respectively but only 49% (95% CI, 31%, 66%) at delivery. Screening at enrollment detected 56% of all infections detected throughout pregnancy. Seventy-five RDT negative PCR or microscopy positive infections were detected in 540 women; these were not associated with maternal anemia, placental malaria, or low birth weight. Conclusions. The sensitivity of an RDT to detect malaria in primigravidae and secundigravidae was high at enrollment in 3 of 4 countries and, in Ghana, at subsequent ANC visits. In Ghana, RDT negative malaria infections were not associated with adverse birth outcomes but missed infections were uncommon.
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Affiliation(s)
| | - Matthew Cairns
- Faculties of Epidemiology and Population Health and Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, United Kingdom
| | - Fanta Njie
- Medical Research Unit, Fajara, The Gambia
| | | | | | | | - Harry Tagbor
- Department of Community Medicine, Kwame Nkrumah University of Sciences and Technology, Kumasi, Ghana
| | | | - Pascal Magnussen
- Department of Veterinary Disease Biology and Centre for Medical Parasitology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Feiko O Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, United Kingdom
| | - Arouna Woukeu
- Faculties of Epidemiology and Population Health and Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, United Kingdom
| | - Paul Milligan
- Faculties of Epidemiology and Population Health and Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, United Kingdom
| | - Daniel Chandramohan
- Faculties of Epidemiology and Population Health and Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, United Kingdom
| | - Brian Greenwood
- Faculties of Epidemiology and Population Health and Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, United Kingdom
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Matangila JR, Mitashi P, Inocêncio da Luz RA, Lutumba PT, Van Geertruyden JP. Efficacy and safety of intermittent preventive treatment for malaria in schoolchildren: a systematic review. Malar J 2015; 14:450. [PMID: 26574017 PMCID: PMC4647321 DOI: 10.1186/s12936-015-0988-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 11/04/2015] [Indexed: 11/10/2022] Open
Abstract
Background Intermittent preventive treatment (IPT) is a proven malaria control strategy in infants and pregnancy. School-aged children represent 26 % of the African population, and an increasing percentage of them are scholarized. Malaria is causing 50 % of deaths in this age group and malaria control efforts may shift the malaria burden to older age groups. Schools have been suggested as a platform for health interventions delivery (deworming, iron-folic acid, nutrients supplementation, (boost-)immunization) and as a possible delivery system for IPT in schoolchildren (IPTsc). However, the current evidence on the efficacy and safety of IPTsc is limited and the optimal therapeutic regimen remains controversial. Methods A systematic search for studies reporting efficacy and safety of IPT in schoolchildren was conducted using PubMed, Web of Science, Clinicaltrials and WHO/ICTRP database, and abstracts from congresses with the following key words: intermittent, preventive treatment AND malaria OR Plasmodium falciparum AND schoolchildren NOT infant NOT pregnancy. Results Five studies were identified. Most IPTsc regimes demonstrated substantial protection against malaria parasitaemia, with dihydroartemisinin-piperaquine (DP) given monthly having the highest protective effect (PE) (94 %; 95 % CI 93–96). Contrarily, SP did not provide any PE against parasitaemia. However, no IPT regimen provided a PE above 50 % in regard to anaemia, and highest protection was provided by SP+ amodiaquine (AQ) given four-monthly (50 %; 95 % CI 41–53). The best protection against clinical malaria was observed in children monthly treated with DP (97 %; 95 % CI 87–98). However, there was no protection when the drug was given three-monthly. No severe adverse events were associated with the drugs used for IPTsc. Conclusion IPTsc may reduce the malaria-related burden in schoolchildren. However, more studies assessing efficacy of IPT in particular against malaria-related anaemia and clinical malaria in schoolchildren must be conducted.
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Affiliation(s)
- Junior R Matangila
- Département de Médecine Tropicale, Faculté de Médecine, Université de Kinshasa, BP 747, Kinshasa, XI, Democratic Republic of the Congo. .,Epidemiology for Global Health Institute, University of Antwerp, Campus DrieEiken, Universiteitsplein 1, Wilrijk, 2610, Belgium.
| | - Patrick Mitashi
- Département de Médecine Tropicale, Faculté de Médecine, Université de Kinshasa, BP 747, Kinshasa, XI, Democratic Republic of the Congo.
| | - Raquel A Inocêncio da Luz
- Epidemiology for Global Health Institute, University of Antwerp, Campus DrieEiken, Universiteitsplein 1, Wilrijk, 2610, Belgium.
| | - Pascal T Lutumba
- Département de Médecine Tropicale, Faculté de Médecine, Université de Kinshasa, BP 747, Kinshasa, XI, Democratic Republic of the Congo.
| | - Jean-Pierre Van Geertruyden
- Epidemiology for Global Health Institute, University of Antwerp, Campus DrieEiken, Universiteitsplein 1, Wilrijk, 2610, Belgium.
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Chico RM, Cano J, Ariti C, Collier TJ, Chandramohan D, Roper C, Greenwood B. Influence of malaria transmission intensity and the 581G mutation on the efficacy of intermittent preventive treatment in pregnancy: systematic review and meta-analysis. Trop Med Int Health 2015; 20:1621-33. [PMID: 26325263 DOI: 10.1111/tmi.12595] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To estimate where intermittent preventive treatment (IPTp) using sulphadoxine-pyrimethamine (SP) could be withdrawn as an intervention due to declining malaria transmission intensity, or due to increasing prevalence of the Plasmodium falciparum dihydropteroate synthetase resistance mutation at codon 581G. METHODS We conducted a systematic review and meta-analysis of protection against the incidence of low birth weight (LBW) conferred by ≥2 doses of IPTp-SP. We matched these outcomes to a proxy measure of malaria incidence in women of the same studies, applied meta-regression models to these data and conducted sensitivity analysis of the 581G mutation. RESULTS Variation in the protective effect of IPTp-SP against LBW could not be explained by malaria transmission intensity. Among primi- and secundigravidae, IPTp-SP protected against LBW where 581G was ≤10.1% [odds ratio (OR): 0.49; 95% confidence intervals (CI): 0.29, 0.81; P = <0.01] and 581G was >10.1% (OR = 0.73; 95% CI: 0.29, 1.81; P = 0.03). Random-effects models among multigravidae showed that IPTp-SP protects against LBW where 581G was ≤10.1% (OR = 0.56; 95% CI: 0.37, 0.86; P = 0.07), a finding of borderline statistical significance. No evidence of protection against LBW was observed where 581G was >10.1% (OR = 0.96; 95% CI: 0.70, 1.34; P = 0.47). CONCLUSION There appears to be a prevalence of 581G above which IPTp-SP no longer protects against LBW. Pregnancy studies are urgently needed where 581G is >10.1% to define the specific prevalence threshold where new strategies should be deployed.
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Affiliation(s)
| | - Jorge Cano
- London School of Hygiene & Tropical Medicine, London, UK
| | - Cono Ariti
- London School of Hygiene & Tropical Medicine, London, UK.,Nuffield Trust, London, UK
| | | | | | - Cally Roper
- London School of Hygiene & Tropical Medicine, London, UK
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Muanda FT, Chaabane S, Boukhris T, Santos F, Sheehy O, Perreault S, Blais L, Bérard A. Antimalarial drugs for preventing malaria during pregnancy and the risk of low birth weight: a systematic review and meta-analysis of randomized and quasi-randomized trials. BMC Med 2015; 13:193. [PMID: 26275820 PMCID: PMC4537579 DOI: 10.1186/s12916-015-0429-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 07/17/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND It is known that antimalarial drugs reduce the risk of low birth weight (LBW) in pregnant patients. However, a previous Cochrane review did not evaluate whether the level of antimalarial drug resistance could modify the protective effect of antimalarial drugs in this regard. In addition, no systematic review exists comparing current recommendations for malaria prevention during pregnancy to alternative regimens in Africa. Therefore, we conducted a comprehensive systematic review and meta-analysis to assess the efficacy of antimalarial drugs for malaria prevention during pregnancy in reducing the risk of LBW. METHODS We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) for articles published up to 21 November 2014, in English or French, and identified additional studies from reference lists. We included randomized and quasi-randomized studies reporting LBW as one of the outcomes. We extracted data and assessed the risk of bias in selected studies. All pooled analyses were based on a random effect model, and we used a funnel plot and trim and fill method to test and adjust for publication bias. RESULTS A total of 25 studies met the inclusion criteria (37,981 subjects). Compared to no use, all combined antimalarial drugs were associated with a 27% (RR 0.73, 95% CI 0.56-0.97, ten studies) reduction in the risk of LBW. The level of antimalarial drug resistance modified the protective effect of the antimalarial drug used for prevention of LBW during pregnancy. Sulfadoxine-pyrimethamine was not associated with a reduction in the risk of LBW in regions where the prevalence of the dihydropteroate synthase 540E mutation exceeds 50% (RR 0.99, 95% CI 0.80-1.22, three studies). The risk of LBW was similar when sulfadoxine-pyrimethamine was compared to mefloquine (RR 1.05, 95% CI 0.86-1.29, two studies). CONCLUSION Prophylactic antimalarial drugs and specifically sulfadoxine-pyrimethamine may no longer protect against the risk of LBW in areas of high-level resistance. In Africa, there are currently no suitable alternative drugs to replace sulfadoxine-pyrimethamine for malaria prevention during pregnancy.
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Affiliation(s)
- Flory Tsobo Muanda
- Faculty of Pharmacy, University of Montreal, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada. .,Research Center, CHU Sainte-Justine, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
| | - Sonia Chaabane
- Faculty of Pharmacy, University of Montreal, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada. .,Research Center, CHU Sainte-Justine, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
| | - Takoua Boukhris
- Faculty of Pharmacy, University of Montreal, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada. .,Research Center, CHU Sainte-Justine, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
| | - Fabiano Santos
- Faculty of Medicine, McGill University, 3605 Rue de la Montagne, Montreal, QC, H3G 2M1, Canada.
| | - Odile Sheehy
- Research Center, CHU Sainte-Justine, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
| | - Sylvie Perreault
- Faculty of Pharmacy, University of Montreal, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada.
| | - Lucie Blais
- Faculty of Pharmacy, University of Montreal, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada.
| | - Anick Bérard
- Faculty of Pharmacy, University of Montreal, 2940 Chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada. .,Research Center, CHU Sainte-Justine, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
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11
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Tagbor H, Cairns M, Bojang K, Coulibaly SO, Kayentao K, Williams J, Abubakar I, Akor F, Mohammed K, Bationo R, Dabira E, Soulama A, Djimdé M, Guirou E, Awine T, Quaye S, Njie F, Ordi J, Doumbo O, Hodgson A, Oduro A, Meshnick S, Taylor S, Magnussen P, ter Kuile F, Woukeu A, Milligan P, Chandramohan D, Greenwood B. A Non-Inferiority, Individually Randomized Trial of Intermittent Screening and Treatment versus Intermittent Preventive Treatment in the Control of Malaria in Pregnancy. PLoS One 2015; 10:e0132247. [PMID: 26258474 PMCID: PMC4530893 DOI: 10.1371/journal.pone.0132247] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 06/10/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The efficacy of intermittent preventive treatment for malaria with sulfadoxine-pyrimethamine (IPTp-SP) in pregnancy is threatened in parts of Africa by the emergence and spread of resistance to SP. Intermittent screening with a rapid diagnostic test (RDT) and treatment of positive women (ISTp) is an alternative approach. METHODS AND FINDINGS An open, individually randomized, non-inferiority trial of IPTp-SP versus ISTp was conducted in 5,354 primi- or secundigravidae in four West African countries with a low prevalence of resistance to SP (The Gambia, Mali, Burkina Faso and Ghana). Women in the IPTp-SP group received SP on two or three occasions whilst women in the ISTp group were screened two or three times with a RDT and treated if positive for malaria with artemether-lumefantrine (AL). ISTp-AL was non-inferior to IPTp-SP in preventing low birth weight (LBW), anemia and placental malaria, the primary trial endpoints. The prevalence of LBW was 15.1% and 15.6% in the IPTp-SP and ISTp-AL groups respectively (OR = 1.03 [95% CI: 0.88, 1.22]). The mean hemoglobin concentration at the last clinic attendance before delivery was 10.97g/dL and 10.94g/dL in the IPTp-SP and ISTp-AL groups respectively (mean difference: -0.03 g/dL [95% CI: -0.13, +0.06]). Active malaria infection of the placenta was found in 24.5% and in 24.2% of women in the IPTp-SP and ISTp-AL groups respectively (OR = 0.95 [95% CI 0.81, 1.12]). More women in the ISTp-AL than in the IPTp-SP group presented with malaria parasitemia between routine antenatal clinics (310 vs 182 episodes, rate difference: 49.4 per 1,000 pregnancies [95% CI 30.5, 68.3], but the number of hospital admissions for malaria was similar in the two groups. CONCLUSIONS Despite low levels of resistance to SP in the study areas, ISTp-AL performed as well as IPTp-SP. In the absence of an effective alternative medication to SP for IPTp, ISTp-AL is a potential alternative to IPTp in areas where SP resistance is high. It may also have a role in areas where malaria transmission is low and for the prevention of malaria in HIV positive women receiving cotrimoxazole prophylaxis in whom SP is contraindicated. TRIAL REGISTRATION ClinicalTrials.gov NCT01084213 Pan African Clinical trials Registry PACT201202000272122.
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Affiliation(s)
- Harry Tagbor
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Matthew Cairns
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | - Kassoum Kayentao
- Malaria Research and Training Centre, Faculty of Medicine and Odonto-stomatology, University of Sciences, Technics and Technologies, Bamako, Mali
| | | | | | - Francis Akor
- Medical Research Council Unit, Fajara, The Gambia
| | | | - Richard Bationo
- Faculty of Health Sciences, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Edgar Dabira
- Faculty of Health Sciences, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Alamissa Soulama
- Faculty of Health Sciences, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Moussa Djimdé
- Malaria Research and Training Centre, Faculty of Medicine and Odonto-stomatology, University of Sciences, Technics and Technologies, Bamako, Mali
| | - Etienne Guirou
- Malaria Research and Training Centre, Faculty of Medicine and Odonto-stomatology, University of Sciences, Technics and Technologies, Bamako, Mali
| | | | | | - Fanta Njie
- Medical Research Council Unit, Fajara, The Gambia
| | - Jaume Ordi
- Barcelona Centre for International Health Research (CRESIB), Department of Pathology, Hospital Clinic-Universitat de Barcelona, Barcelona, Spain
| | - Ogobara Doumbo
- Malaria Research and Training Centre, Faculty of Medicine and Odonto-stomatology, University of Sciences, Technics and Technologies, Bamako, Mali
| | | | | | - Steven Meshnick
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States of America
| | - Steve Taylor
- Duke University Medical Center, Durham, NC, United States of America
| | - Pascal Magnussen
- (Institute of International Health, Immunology and Microbiology and Institute of Veterinary Disease Biology, University of Copenhagen, Copenhagen, Denmark
| | - Feiko ter Kuile
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Arouna Woukeu
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Paul Milligan
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Brian Greenwood
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
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12
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Prevalence of Plasmodium falciparum resistance markers to sulfadoxine-pyrimethamine among pregnant women receiving intermittent preventive treatment for malaria in Uganda. Antimicrob Agents Chemother 2015; 59:5475-82. [PMID: 26124154 DOI: 10.1128/aac.00507-15] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 06/17/2015] [Indexed: 01/13/2023] Open
Abstract
The aim of this study was to assess the prevalence of mutations in Plasmodium falciparum dihydrofolate reductase (Pfdhfr) and dihydropteroate synthase (Pfdhps) genes among pregnant women using sulfadoxine-pyrimethamine (SP) as an intermittent preventive treatment (IPTp). A molecular epidemiological study of P. falciparum parasite resistance markers to SP was conducted from August 2010 to February 2012 in Mukono district in central Uganda. DNA was extracted from 413 P. falciparum-positive samples. Real-time PCR, followed by melting curve analysis, was used to characterize point mutations in the Pfdhfr and Pfdhps genes that are associated with SP resistance. The prevalence of the single-nucleotide mutations in Pfdhfr at codons 51I, 59R, and 108N and in Pfdhps at codons 437G and 540E was high (>98%), reaching 100% fixation after one dose of SP, while the prevalence of 581G was 3.3% at baseline, reaching 12.5% after one dose of SP. At baseline, the prevalence of Pfdhfr and Pfdhps quintuple mutations was 89%, whereas the sextuple mutations (including 581G) were not prevalent (3.9%), reaching 16.7% after one dose of SP. However, the numbers of infections at follow-up visits were small, and hence there was insufficient statistical power to test whether there was a true rise in the prevalence of this allele. The overall high frequency of Pfdhfr and Pfdhps quintuple mutations throughout pregnancy excluded further analyses of possible associations between certain haplotypes and the risk of lower birth weight and anemia. However, women infected with P. falciparum had 1.3-g/dl-lower hemoglobin levels (P = 0.001) and delivered babies with a 400-g-lower birth weight (P = 0.001) compared to nonparasitemic women. Despite this, 44 women who were P. falciparum positive at baseline became negative after one or two doses of SP (i.e., 50.5%), implying that SP-IPTp still has some efficacy. P. falciparum resistance markers to SP are high in this population, whereas P. falciparum infection was associated with poor birth outcomes.
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Yasuoka J, Jimba M, Levins R. Application of loop analysis for evaluation of malaria control interventions. Malar J 2014; 13:140. [PMID: 24713031 PMCID: PMC4017832 DOI: 10.1186/1475-2875-13-140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Accepted: 04/01/2014] [Indexed: 11/10/2022] Open
Abstract
Background Despite continuous efforts and recent rapid expansion in the financing and implementation of malaria control interventions, malaria still remains one of the most devastating global health issues. Even in countries that have been successful in reducing the incidence of malaria, malaria control is becoming more challenging because of the changing epidemiology of malaria and waning community participation in control interventions. In order to improve the effectiveness of interventions and to promote community understanding of the necessity of continued control efforts, there is an urgent need to develop new methodologies that examine the mechanisms by which community-based malaria interventions could reduce local malaria incidence. Methods This study demonstrated how the impact of community-based malaria control interventions on malaria incidence can be examined in complex systems by qualitative analysis combined with an extensive review of literature. First, sign digraphs were developed through loop analysis to analyse seven interventions: source reduction, insecticide/larvicide use, biological control, treatment with anti-malarials, insecticide-treated mosquito net/long-lasting insecticidal net, non-chemical personal protection measures, and educational intervention. Then, for each intervention, the sign digraphs and literature review were combined to analyse a variety of pathways through which the intervention can influence local malaria incidence as well as interactions between variables involved in the system. Through loop analysis it is possible to see whether increases in one variable qualitatively increases or decreases other variables or leaves them unchanged and the net effect of multiple, interacting variables. Results Qualitative analysis, specifically loop analysis, can be a useful tool to examine the impact of community-based malaria control interventions. Without relying on numerical data, the analysis was able to describe pathways through which each intervention could influence malaria incidence on the basis of the qualitative patterns of the interactions between variables in complex systems. This methodology is generalizable to various disease control interventions at different levels, and can be utilized by a variety of stakeholders such as researchers, community leaders and policy makers to better plan and evaluate their community-based disease control interventions.
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Affiliation(s)
- Junko Yasuoka
- Department of Community and Global Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
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Matangila JR, Lufuluabo J, Ibalanky AL, Inocêncio da Luz RA, Lutumba P, Van Geertruyden JP. Asymptomatic Plasmodium falciparum infection is associated with anaemia in pregnancy and can be more cost-effectively detected by rapid diagnostic test than by microscopy in Kinshasa, Democratic Republic of the Congo. Malar J 2014; 13:132. [PMID: 24690179 PMCID: PMC3976674 DOI: 10.1186/1475-2875-13-132] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 03/28/2014] [Indexed: 11/11/2022] Open
Abstract
Background In areas of high malaria transmission, Plasmodium falciparum infection during pregnancy is characterized by malaria-related anaemia, placental malaria and does not always result in clinical symptoms. This situation is associated with poor pregnancy outcomes. The aim of this study was to determine the extent of asymptomatic P. falciparum infection, its relation with anaemia as well as the most cost-effective technique for its diagnosis in healthy pregnant women living in Kinshasa, Democratic Republic of the Congo. Methods In a cross-sectional study design, information on socio-demographic characteristics and cost data were collected in healthy pregnant women attending antenatal care consultations. Plasmodium falciparum infection was diagnosed using rapid diagnostic test (RDT), microscopy and polymerase chain reaction (PCR). Haemoglobin concentration was also determined. Results In total, 332 pregnant women were enrolled. RDT and microscopy data were available for all the blood samples and 166 samples were analysed by PCR. The prevalence of asymptomatic P. falciparum infection using microscopy, RDTs and PCR, were respectively 21.6%, 27.4% and 29.5%. Taking PCR as a reference, RDTs had a sensitivity of 81.6% and a specificity of 94.9% to diagnose asymptomatic P. falciparum infection. The corresponding values for microscopy were 67.3% and 97.4%. The prevalence of anaemia was 61.1% and asymptomatic malaria increased five times the odds (p < 0.001) of having anaemia. RDTs were more cost-effective compared to microscopy. Incremental cost-effectiveness ratio was US$ 63.47 per microscopy adequately diagnosed case. Conclusion These alarming results emphasize the need to actively diagnose and treat asymptomatic malaria infection during all antenatal care visits. Moreover, in DRC, malaria and anaemia control efforts should be strengthened by promoting the use of insecticide-treated nets, intermittent preventive treatment with sulphadoxine-pyrimethamine and iron and folic acid supplements.
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Affiliation(s)
- Junior R Matangila
- Département de Médecine Tropicale, Université de Kinshasa, B,P, 747, Kinshasa, XI, République Démocratique du Congo.
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