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Cellich P, Unger HW, Rogerson SJ, Mola GDL. Impact on pregnancy outcomes of intermittent preventive treatment with sulfadoxine-pyrimethamine in urban and peri-urban Papua New Guinea: a retrospective cohort study. Malar J 2024; 23:201. [PMID: 38970076 PMCID: PMC11225125 DOI: 10.1186/s12936-024-05010-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 06/04/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND Intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) reduces malaria-attributable adverse pregnancy outcomes and may also prevent low birth weight (< 2,500 g) through mechanisms independent of malaria. Malaria transmission in Papua New Guinea (PNG) is highly heterogeneous. The impact of IPTp-SP on adverse birth outcomes in settings with little or no malaria transmission, such as PNG's capital city Port Moresby, is unknown. METHODS A retrospective cohort study was conducted amongst HIV-negative women with a singleton pregnancy who delivered at Port Moresby General Hospital between 18 July and 21 August 2022. The impact of IPTp-SP doses on adverse birth outcomes and anaemia was assessed using logistic and linear regression models, as appropriate. RESULTS Of 1,140 eligible women amongst 1,228 consecutive births, 1,110 had a live birth with a documented birth weight. A total of 156 women (13.7%) did not receive any IPTp-SP, 347 women (30.4%) received one, 333 (29.2%) received two, and 304 (26.7%) received the recommended ≥ 3 doses of IPTp-SP. A total of 65 of 1,110 liveborn babies (5.9%) had low birth weight and there were 34 perinatal deaths (3.0%). Anaemia (haemoglobin < 100 g/L) was observed in 30.6% (243/793) of women, and 14 (1.2%) had clinical malaria in pregnancy. Compared to women receiving 0-1 dose of IPTp-SP, women receiving ≥ 2 doses had lower odds of LBW (adjusted odds ratio [aOR] 0.50; 95% confidence interval [CI] 0.26, 0.96), preterm birth (aOR 0.58; 95% CI 0.32, 1.04), perinatal death (aOR 0.49; 95% CI 0.18, 1.38), LBW/perinatal death (aOR 0.55; 95% CI 0.27, 1.12), and anaemia (OR 0.50; 95% CI 0.36, 0.69). Women who received 2 doses versus 0-1 had 45% lower odds of LBW (aOR 0.55, 95% CI 0.27, 1.10), and a 16% further (total 61%) reduction with ≥ 3 doses (aOR 0.39, 95% CI 0.14, 1.05). Birth weights for women who received 2 or ≥ 3 doses versus 0-1 were 81 g (95% CI -3, 166) higher, and 151 g (58, 246) higher, respectively. CONCLUSIONS Provision of IPTp-SP in a low malaria-transmission setting in PNG appears to translate into substantial health benefits, in a dose-response manner, supporting the strengthening IPTp-SP uptake across all transmission settings in PNG.
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Affiliation(s)
- Philip Cellich
- Division of Obstetrics and Gynaecology, School of Medicine and Health Sciences, Port Moresby General Hospital, University of Papua New Guinea, Port Moresby, Papua New Guinea.
- Department of Obstetrics and Gynaecology, Canterbury Hospital, 575 Canterbury Road, Campsie 2194, NSW, Australia.
| | - Holger W Unger
- Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina 0810, NT, Australia.
- Department of Obstetrics and Gynaecology, Royal Darwin Hospital, Darwin, NT, Australia.
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
- Department of Infectious Diseases, University of Melbourne, The Doherty Institute, Melbourne, VIC, Australia.
| | - Stephen J Rogerson
- Department of Infectious Diseases, University of Melbourne, The Doherty Institute, Melbourne, VIC, Australia
- Department of Medicine, University of Melbourne, The Doherty Institute, Melbourne, VIC, Australia
| | - Glen D L Mola
- Division of Obstetrics and Gynaecology, School of Medicine and Health Sciences, Port Moresby General Hospital, University of Papua New Guinea, Port Moresby, Papua New Guinea
- School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
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2
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Unger HW, Acharya S, Arnold L, Wu C, van Eijk AM, Gore-Langton GR, Ter Kuile FO, Lufele E, Chico RM, Price RN, Moore BR, Thriemer K, Rogerson SJ. The effect and control of malaria in pregnancy and lactating women in the Asia-Pacific region. Lancet Glob Health 2023; 11:e1805-e1818. [PMID: 37858590 DOI: 10.1016/s2214-109x(23)00415-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 08/10/2023] [Accepted: 08/23/2023] [Indexed: 10/21/2023]
Abstract
Half of all pregnancies at risk of malaria worldwide occur in the Asia-Pacific region, where Plasmodium falciparum and Plasmodium vivax co-exist. Despite substantial reductions in transmission, malaria remains an important cause of adverse health outcomes for mothers and offspring, including pre-eclampsia. Malaria transmission is heterogeneous, and infections are commonly subpatent and asymptomatic. High-grade antimalarial resistance poses a formidable challenge to malaria control in pregnancy in the region. Intermittent preventive treatment in pregnancy reduces infection risk in meso-endemic New Guinea, whereas screen-and-treat strategies will require more sensitive point-of-care tests to control malaria in pregnancy. In the first trimester, artemether-lumefantrine is approved, and safety data are accumulating for other artemisinin-based combinations. Safety of novel antimalarials to treat artemisinin-resistant P falciparum during pregnancy, and of 8-aminoquinolines during lactation, needs to be established. A more systematic approach to the prevention of malaria in pregnancy in the Asia-Pacific is required.
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Affiliation(s)
- Holger W Unger
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Obstetrics and Gynaecology, Royal Darwin Hospital, Tiwi, NT, Australia; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Sanjaya Acharya
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Lachlan Arnold
- Royal Melbourne Hospital Clinical School, The University of Melbourne, Parkville, VIC, Australia
| | - Connie Wu
- Royal Melbourne Hospital Clinical School, The University of Melbourne, Parkville, VIC, Australia
| | - Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Georgia R Gore-Langton
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Feiko O Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Elvin Lufele
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Vector-Borne Diseases Unit, Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - R Matthew Chico
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Ric N Price
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Brioni R Moore
- Curtin Medical School, Curtin University, Bentley, WA, Australia; Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia; Telethon Kids Institute, Perth Children's Hospital, Nedlands, WA, Australia
| | - Kamala Thriemer
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Stephen J Rogerson
- Department of Infectious Diseases, University of Melbourne, The Doherty Institute, Melbourne, VIC, Australia; Department of Medicine, University of Melbourne, The Doherty Institute, Melbourne, VIC, Australia
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3
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Waltmann A, McQuade ETR, Chinkhumba J, Operario DJ, Mzembe E, Itoh M, Kayange M, Puerto-Meredith SM, Mathanga DP, Juliano JJ, Carroll I, Bartelt LA, Gutman JR, Meshnick SR. The positive effect of malaria IPTp-SP on birthweight is mediated by gestational weight gain but modifiable by maternal carriage of enteric pathogens. EBioMedicine 2022; 77:103871. [PMID: 35217408 PMCID: PMC8866062 DOI: 10.1016/j.ebiom.2022.103871] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 01/24/2022] [Accepted: 01/24/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Poor pregnancy and birth outcomes are common in sub-Saharan Africa and have complex aetiologies. Sulfadoxine-pyrimethamine (SP), given for intermittent preventive therapy of malaria in pregnancy (IPTp), is one of few existing interventions that improves outcomes of both mother and baby despite widespread SP-resistant malaria. Compelling evidence exists that malaria-independent pathways contribute to this protective effect, but the exact sources of non anti-malarial protection remained unknown. We hypothesized that the beneficial effect of SP on birthweight is mediated by SP activity on maternal factors, including increased gestational weight gain and antibiotic activity on pathogens in the maternal gut. METHODS Expectant mothers from a larger randomized control trial comparing the efficacy of IPTp-SP to IPTp with dihydroartemisinin-piperaquine (DP) were also enrolled in this sub-study study at their first antenatal care visit before commencement of IPTp (n = 105). Participants were followed monthly until delivery. Weights and mid-to-upper-arm circumferences (MUAC) were recorded. Monthly stool samples were collected and screened for five Escherichia coli pathotypes, Shigella spp., Vibrio cholerae, Salmonella, Campylobacter coli/jejuni, and three protozoa (Giardia spp., Entameba histolytica, and Cryptosporidium spp.) using previously validated molecular assays. FINDINGS IPTp-SP vs. IPTP-DP was associated with higher maternal gestational weight gain (GWG) and nutritional indicators (MUAC and body-mass index, BMI). GWG was found to be a mediator of the birthweight and IPTp-SP relationship, as the birthweight of SP infants, but not DP infants, varied according to maternal GWG. The burden of maternal enteric infections was high. The three most commonly observed pathogens were enteroaggregative E. coli (EAEC), atypical enteropathogenic E.coli/enterohaemorrhagic E. coli (aEPEC/EHEC), and typical enteropathogenic E.coli (tEPEC). We found that SP reduced the prevalence of EAEC in a dose-dependent manner. After 3 or more doses, SP-recipients were 90% less likely to be infected with EAEC compared to DP-recipients (ORadj = 0.07, CI95 = 0.12, 0.39, p = 0.002). Compared to DP, this coincided with higher maternal gestational weight gain (GWG) and nutritional indicators (MUAC and body-mass index, BMI). The beneficial effect of SP on maternal GWG, MUAC and BMI, was lower if SP mothers had detectable EAEC, aEPEC/EHEC, tEPEC, and LT-ETEC at baseline. Maternal EAEC and tEPEC at baseline associated with lower birthweight for babies of both SP mothers and DP mothers. When comparing IPTp regimens, the positive effect of SP on birthweight compared to DP was only observed for infants of women who did not test positive for EAEC at baseline (adjusted mean birthweight difference SP vs. DP = 156.0 g, CI95 = -18.0 g, 336.9 g, p = 0.087), though confidence intervals crossed the null. INTERPRETATION Our findings indicate that in pregnant Malawian women, IPTp-SP vs. IPTp-DP is consistently associated with higher MUAC, BMI, and GWG following the WHO-recommended regimen of at least 3 doses, but carriage of maternal gut pathogens before initiation of IPTp lessens this effect. Because GWG was a mediator of the association between birthweight and SP, we show that SP's previously proven positive effect on birthweight is by promoting maternal weight gain. Overall, our results present one plausible pathway SP exerts malaria-independent protection against poor birth outcomes in the context of its waning antimalarial activity and warrants further investigation. FUNDING A full list of funding bodies that contributed to this study can be found in the Acknowledgements section.
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Affiliation(s)
- Andreea Waltmann
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA.
| | | | - Jobiba Chinkhumba
- Malaria Alert Centre (MAC), University of Malawi College of Medicine, Blantyre, Malawi
| | - Darwin J Operario
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia, VA, USA
| | - Enala Mzembe
- Malaria Alert Centre (MAC), University of Malawi College of Medicine, Blantyre, Malawi
| | - Megumi Itoh
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Don P Mathanga
- Malaria Alert Centre (MAC), University of Malawi College of Medicine, Blantyre, Malawi
| | - Jonathan J Juliano
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Ian Carroll
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Luther A Bartelt
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Steven R Meshnick
- Institute for Global Health and Infectious Diseases, School of Medicine, University of North Carolina, Chapel Hill, NC, USA; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
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Lingani M, Zango SH, Valéa I, Bonko MDA, Samadoulougou SO, Rouamba T, Tahita MC, Sanou M, Robert A, Tinto H, Donnen P, Dramaix M. Malaria and curable sexually transmitted and reproductive tract coinfection among pregnant women in rural Burkina Faso. Trop Med Health 2021; 49:90. [PMID: 34736524 PMCID: PMC8567650 DOI: 10.1186/s41182-021-00381-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/27/2021] [Indexed: 11/11/2022] Open
Abstract
Background Malaria and sexually transmitted/reproductive tract infections (STI/RTI) are leading and preventable causes of low birthweight in sub-Saharan Africa. Reducing their impact on pregnancy outcomes requires efficient interventions that can be easily integrated into the antenatal care package. The paucity of data on malaria and STI/RTI coinfection, however, limits efforts to control these infections. This study aimed to determine the prevalence and associated factors of malaria and STI/RTI coinfection among pregnant women in rural Burkina Faso.
Methods A cross-sectional survey was conducted among 402 pregnant women attending antenatal clinics at the Yako health district. Sociodemographic and behavioral data were collected, and pregnant women were tested for peripheral malaria by microscopy. Hemoglobin levels were also measured by spectrophotometry and curable bacterial STI/RTI were tested on cervico-vaginal swabs using rapid diagnostic test for chlamydia and syphilis, and Gram staining for bacterial vaginosis. A multivariate logistic regression model was used to assess the association of malaria and STI/RTI coinfection with the characteristics of included pregnant women.
Results The prevalence of malaria and at least one STI/RTI coinfection was 12.9% (95% confidence interval, CI: [9.8–16.7]), malaria and bacterial vaginosis coinfection was 12.2% (95% CI: [9.3–15.9]), malaria and chlamydial coinfection was 1.6% (95% CI: [0.6–3.8]). No coinfection was reported for malaria and syphilis. The individual prevalence was 17.2%, 7.2%, 0.6%, 67.7% and 73.3%, respectively, for malaria infection, chlamydia, syphilis, bacterial vaginosis and STI/RTI combination. Only 10% of coinfections were symptomatic, and thus, 90% of women with coinfection would have been missed by the symptoms-based diagnostic approach. In the multivariate analysis, the first pregnancy (aOR = 2.4 [95% CI: 1.2–4.7]) was the only factor significantly associated with malaria and STI/RTI coinfection. Clinical symptoms were not associated with malaria and STI/RTI coinfection. Conclusion The prevalence of malaria and curable STI/RTI coinfection was high among pregnant women. The poor performance of the clinical symptoms to predict coinfection suggests that alternative interventions are needed.
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Affiliation(s)
- Moussa Lingani
- École de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique. .,Institut de Recherche en Sciences de la Santé/Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso.
| | - Serge H Zango
- Institut de Recherche en Sciences de la Santé/Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso.,Epidemiology and Biostatistics Research Division, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Bruxelles, Belgique
| | - Innocent Valéa
- Institut de Recherche en Sciences de la Santé/Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
| | - Massa Dit A Bonko
- Institut de Recherche en Sciences de la Santé/Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
| | - Sékou O Samadoulougou
- Evaluation Platform On Obesity Prevention, Quebec Heart and Lung Institute Research Center, Quebec, Canada
| | - Toussaint Rouamba
- Institut de Recherche en Sciences de la Santé/Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
| | - Marc C Tahita
- Institut de Recherche en Sciences de la Santé/Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
| | - Maïmouna Sanou
- Institut de Recherche en Sciences de la Santé/Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
| | - Annie Robert
- Epidemiology and Biostatistics Research Division, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Bruxelles, Belgique
| | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé/Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
| | - Philippe Donnen
- École de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
| | - Michèle Dramaix
- École de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
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Ramblière L, Guillemot D, Delarocque-Astagneau E, Huynh BT. Impact of mass and systematic antibiotic administration on antibiotic resistance in low- and middle-income countries? A systematic review. Int J Antimicrob Agents 2021; 58:106364. [PMID: 34044108 DOI: 10.1016/j.ijantimicag.2021.106364] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/09/2021] [Accepted: 05/15/2021] [Indexed: 11/29/2022]
Abstract
Antibiotic consumption is a key driver of antimicrobial resistance (AR), particularly in low- and middle-income countries (LMICs) where risk factors for AR emergence and spread are prevalent. However, the potential contribution of mass drug administration (MDA) and systematic drug administration (SDA) of antibiotics to AR spread is unknown. We conducted a systematic review to provide an overview of MDA/SDA in LMICs, including indications, antibiotics used and, if investigated, levels of AR over time. This systematic review is reported in accordance with the PRISMA statement. Of 2438 identified articles, 63 were reviewed: indications for MDA/SDA were various, and targeted populations were particularly vulnerable, including pregnant women, children, human immunodeficiency virus (HIV)-infected populations, and communities in outbreak settings. Available data suggest that MDA/SDA may lead to a significant increase in AR, especially following azithromycin administration. However, only 40% of studies evaluated AR. Integrative approaches that evaluate AR in addition to clinical outcomes are needed to understand the consequences of MDA/SDA implementation, combined with standardised AR surveillance for timely detection of AR emergence.
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Affiliation(s)
- Lison Ramblière
- Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective Evasion and Pharmacoepidemiology Team, F- 78180, Montigny-Le-Bretonneux, France; Institut Pasteur, Epidemiology and Modelling of Antibiotic Evasion (EMAE), F-75015, Paris, France.
| | - Didier Guillemot
- Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective Evasion and Pharmacoepidemiology Team, F- 78180, Montigny-Le-Bretonneux, France; Institut Pasteur, Epidemiology and Modelling of Antibiotic Evasion (EMAE), F-75015, Paris, France; AP-HP Paris Saclay, Public Health, Medical Information, Clinical Research, F-94276, Le Kremlin-Bicêtre, France
| | - Elisabeth Delarocque-Astagneau
- Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective Evasion and Pharmacoepidemiology Team, F- 78180, Montigny-Le-Bretonneux, France; AP-HP Paris Saclay, Public Health, Medical Information, Clinical Research, F-94276, Le Kremlin-Bicêtre, France
| | - Bich-Tram Huynh
- Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective Evasion and Pharmacoepidemiology Team, F- 78180, Montigny-Le-Bretonneux, France; Institut Pasteur, Epidemiology and Modelling of Antibiotic Evasion (EMAE), F-75015, Paris, France
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6
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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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7
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Peric M, Pešić D, Alihodžić S, Fajdetić A, Herreros E, Gamo FJ, Angulo-Barturen I, Jiménez-Díaz MB, Ferrer-Bazaga S, Martínez MS, Gargallo-Viola D, Mathis A, Kessler A, Banjanac M, Padovan J, Bencetić Mihaljević V, Munic Kos V, Bukvić M, Eraković Haber V, Spaventi R. A novel class of fast-acting antimalarial agents: Substituted 15-membered azalides. Br J Pharmacol 2020; 178:363-377. [PMID: 33085774 PMCID: PMC9328652 DOI: 10.1111/bph.15292] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 09/01/2020] [Accepted: 10/08/2020] [Indexed: 12/18/2022] Open
Abstract
Background and Purpose Efficacy of current antimalarial treatments is declining as a result of increasing antimalarial drug resistance, so new and potent antimalarial drugs are urgently needed. Azithromycin, an azalide antibiotic, was found useful in malaria therapy, but its efficacy in humans is low. Experimental Approach Four compounds belonging to structurally different azalide classes were tested and their activities compared to azithromycin and chloroquine. in vitro evaluation included testing against sensitive and resistant Plasmodium falciparum, cytotoxicity against HepG2 cells, accumulation and retention in human erythrocytes, antibacterial activity, and mode of action studies (delayed death phenotype and haem polymerization). in vivo assessment enabled determination of pharmacokinetic profiles in mice, rats, dogs, and monkeys and in vivo efficacy in a humanized mouse model. Key Results Novel fast‐acting azalides were highly active in vitro against P. falciparum strains exhibiting various resistance patterns, including chloroquine‐resistant strains. Excellent antimalarial activity was confirmed in a P. falciparum murine model by strong inhibition of haemozoin‐containing trophozoites and quick clearance of parasites from the blood. Pharmacokinetic analysis revealed that compounds are metabolically stable and have moderate oral bioavailability, long half‐lives, low clearance, and substantial exposures, with blood cells as the preferred compartment, especially infected erythrocytes. Fast anti‐plasmodial action is achieved by the high accumulation into infected erythrocytes and interference with parasite haem polymerization, a mode of action different from slow‐acting azithromycin. Conclusion and Implications The hybrid derivatives described here represent excellent antimalarial drug candidates with the potential for clinical use in malaria therapy.
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Affiliation(s)
- Mihaela Peric
- GlaxoSmithKline Research Centre Zagreb Ltd., Zagreb, Croatia.,Center for Translational and Clinical Research, Department for Intercellular Communication, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Dijana Pešić
- GlaxoSmithKline Research Centre Zagreb Ltd., Zagreb, Croatia.,Fidelta Ltd., Zagreb, Croatia
| | - Sulejman Alihodžić
- GlaxoSmithKline Research Centre Zagreb Ltd., Zagreb, Croatia.,Fidelta Ltd., Zagreb, Croatia
| | - Andrea Fajdetić
- GlaxoSmithKline Research Centre Zagreb Ltd., Zagreb, Croatia.,Fidelta Ltd., Zagreb, Croatia
| | - Esperanza Herreros
- GlaxoSmithKline, Tres Cantos Medicines Development Campus, Diseases of the Developing World, Tres Cantos (Madrid), Spain.,Medicines for Malaria Venture, Geneva 15, Switzerland
| | - Francisco Javier Gamo
- GlaxoSmithKline, Tres Cantos Medicines Development Campus, Diseases of the Developing World, Tres Cantos (Madrid), Spain
| | - Iñigo Angulo-Barturen
- GlaxoSmithKline, Tres Cantos Medicines Development Campus, Diseases of the Developing World, Tres Cantos (Madrid), Spain.,The Art of Discovery, Bizkaia, Basque Country, Spain
| | - María Belén Jiménez-Díaz
- GlaxoSmithKline, Tres Cantos Medicines Development Campus, Diseases of the Developing World, Tres Cantos (Madrid), Spain.,The Art of Discovery, Bizkaia, Basque Country, Spain
| | - Santiago Ferrer-Bazaga
- GlaxoSmithKline, Tres Cantos Medicines Development Campus, Diseases of the Developing World, Tres Cantos (Madrid), Spain
| | - María S Martínez
- GlaxoSmithKline, Tres Cantos Medicines Development Campus, Diseases of the Developing World, Tres Cantos (Madrid), Spain
| | - Domingo Gargallo-Viola
- GlaxoSmithKline, Tres Cantos Medicines Development Campus, Diseases of the Developing World, Tres Cantos (Madrid), Spain.,ABAC Therapeutics, Barcelona, Spain
| | - Amanda Mathis
- GlaxoSmithKline, Research Triangle Park, North Carolina, USA.,BioCryst Pharmaceuticals, Durham, North Carolina, USA
| | - Albane Kessler
- GlaxoSmithKline, Tres Cantos Medicines Development Campus, Diseases of the Developing World, Tres Cantos (Madrid), Spain
| | - Mihailo Banjanac
- GlaxoSmithKline Research Centre Zagreb Ltd., Zagreb, Croatia.,Fidelta Ltd., Zagreb, Croatia
| | - Jasna Padovan
- GlaxoSmithKline Research Centre Zagreb Ltd., Zagreb, Croatia.,Fidelta Ltd., Zagreb, Croatia
| | | | - Vesna Munic Kos
- GlaxoSmithKline Research Centre Zagreb Ltd., Zagreb, Croatia.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Mirjana Bukvić
- GlaxoSmithKline Research Centre Zagreb Ltd., Zagreb, Croatia.,Fidelta Ltd., Zagreb, Croatia
| | - Vesna Eraković Haber
- GlaxoSmithKline Research Centre Zagreb Ltd., Zagreb, Croatia.,Fidelta Ltd., Zagreb, Croatia
| | - Radan Spaventi
- GlaxoSmithKline Research Centre Zagreb Ltd., Zagreb, Croatia.,Triadelta Partners Ltd, Zagreb, Croatia
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A Randomized Open-Label Evaluation of the Antimalarial Prophylactic Efficacy of Azithromycin-Piperaquine versus Sulfadoxine-Pyrimethamine in Pregnant Papua New Guinean Women. Antimicrob Agents Chemother 2019; 63:AAC.00302-19. [PMID: 31405866 DOI: 10.1128/aac.00302-19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 07/26/2019] [Indexed: 11/20/2022] Open
Abstract
Emerging malaria parasite sulfadoxine-pyrimethamine (SP) resistance has prompted assessment of alternatives for intermittent preventive treatment in pregnancy (IPTp). The objective was to evaluate the tolerability and prophylactic efficacy of azithromycin (AZ) plus piperaquine (PQ) in pregnant women in Papua New Guinea. The study was an open-label, randomized, parallel-group trial. A total of 122 women (median gestation, 26 weeks [range, 14 to 32 weeks]) were randomized 1:1 to three daily doses of 1 g AZ plus 960 mg PQ tetraphosphate or single-dose SP (4,500 mg sulfadoxine plus 225 mg pyrimethamine), based on computer-generated block randomization. Tolerability was assessed to day 7, and efficacy was assessed to day 42 (when participants were returned to usual care) and at delivery. Data for 119 participants (AZ-PQ, n = 61; SP, n = 58) were analyzed. Both regimens were well tolerated, but AZ-PQ was associated with more gastrointestinal side effects (31%) and dizziness (21%). Eight women (6.7%) were parasitemic at recruitment but all were aparasitemic by 72 h. There were no differences in blood smear positivity rates between AZ-PQ and SP up to day 42 (0% versus 5.2%; relative risk [RR], 0.14 [95% confidence interval [CI], 0.01 to 2.58] [P = 0.18]; absolute risk reduction [ARR], 5.2% [95% CI, -1.3 to 11.6%]) and at the time of delivery (0% versus 8.7%; RR, 0.11 [95% CI, 0.01 to 2.01] [P = 0.14]; ARR, 8.7% [95% CI, -0.2 to 17.6%]). Of 92 women who were monitored to parturition, 89 (97%) delivered healthy babies; there were 3 stillbirths (SP, n = 1; AZ-PQ, n = 2 [twins]). There was a higher live birth weight (mean ± standard deviation) in the AZ-PQ group (3.13 ± 0.42 versus 2.88 ± 0.55 kg [P = 0.016]; mean difference, 0.25 kg [95% CI, 0.02 to 0.48 kg]). AZ-PQ is a promising candidate for IPTp.
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Unger HW, Hansa AP, Buffet C, Hasang W, Teo A, Randall L, Ome-Kaius M, Karl S, Anuan AA, Beeson JG, Mueller I, Stock SJ, Rogerson SJ. Sulphadoxine-pyrimethamine plus azithromycin may improve birth outcomes through impacts on inflammation and placental angiogenesis independent of malarial infection. Sci Rep 2019; 9:2260. [PMID: 30783215 PMCID: PMC6381158 DOI: 10.1038/s41598-019-38821-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/10/2019] [Indexed: 12/23/2022] Open
Abstract
Intermittent preventive treatment with sulphadoxine-pyrimethamine (SP) and SP plus azithromycin (SPAZ) reduces low birthweight (<2,500 g) in women without malarial and reproductive tract infections. This study investigates the impact of SPAZ on associations between plasma biomarkers of inflammation and angiogenesis and adverse pregnancy outcomes in 2,012 Papua New Guinean women. Concentrations of C-reactive protein (CRP), α-1-acid glycoprotein (AGP), soluble endoglin (sEng), soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) were measured at enrolment and delivery in a trial comparing SPAZ to SP plus chloroquine (SPCQ). At antenatal enrolment higher CRP (adjusted odds ratio 1.52; 95% confidence interval [CI] 1.03–2.25), sEng (4.35; 1.77, 10.7) and sFlt1 (2.21; 1.09, 4.48) were associated with preterm birth, and higher sEng with low birthweight (1.39; 1.11,3.37), in SPCQ recipients only. Increased enrolment sFlt1:PlGF ratios associated with LBW in all women (1.46; 1.11, 1.90). At delivery, higher AGP levels were strongly associated with low birthweight, preterm birth and small-for-gestational age babies in the SPCQ arm only. Restricting analyses to women without malaria infection did not materially alter these relationships. Women receiving SPAZ had lower delivery AGP and CRP levels (p < 0.001). SPAZ may protect against adverse pregnancy outcomes by reducing inflammation and preventing its deleterious consequences, including dysregulation of placental angiogenesis, in women with and without malarial infection.
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Affiliation(s)
- Holger W Unger
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia.
| | - Annjaleen P Hansa
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia.,Central Clinical School and Department of Microbiology, Monash University, Victoria, Australia
| | - Christelle Buffet
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Wina Hasang
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Andrew Teo
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Louise Randall
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Maria Ome-Kaius
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.,Walter and Eliza Hall Institute, Parkville, Victoria, Australia.,Department of Medical Biology, University of Melbourne, Parkville, Victoria, Australia
| | - Stephan Karl
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea.,Walter and Eliza Hall Institute, Parkville, Victoria, Australia.,Department of Medical Biology, University of Melbourne, Parkville, Victoria, Australia.,Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, Australia
| | - Ayen A Anuan
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
| | - James G Beeson
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia.,Central Clinical School and Department of Microbiology, Monash University, Victoria, Australia.,Burnet Institute, Melbourne, Victoria, Australia
| | - Ivo Mueller
- Walter and Eliza Hall Institute, Parkville, Victoria, Australia.,Department of Medical Biology, University of Melbourne, Parkville, Victoria, Australia.,Institut Pasteur, Paris, France
| | - Sarah J Stock
- Tommy's Centre for Maternal and Fetal Health, MRC Centre for Reproductive Health, Queen's Medical Research Institute, Edinburgh, UK
| | - Stephen J Rogerson
- Department of Medicine at the Doherty Institute, University of Melbourne, Parkville, Victoria, Australia
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10
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Roca A, Camara B, Oluwalana C, Lette K, Bottomley C, D’Alessandro U. Long-lasting effect of oral azithromycin taken by women during labour on infant nutrition: Follow-up cohort of a randomized clinical trial in western Gambia. PLoS One 2018; 13:e0206348. [PMID: 30359447 PMCID: PMC6201939 DOI: 10.1371/journal.pone.0206348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 10/11/2018] [Indexed: 11/20/2022] Open
Abstract
Objective To assess the effect of administering an oral dose of 2g of azithromycin in Gambian women during labour on infant growth. Methods Children whose mothers had been randomized to receive either an oral dose of 2g of azithromycin or placebo during labour were visited at home at the end of infancy by trained study nurses blind to the treatment allocation. The follow-up visit of these cohorts (exposed and non-exposed to azithromycin), which was not part of the original trial design, was conducted between November 2014 and May 2015 when the infants were 11 to 13 months of age. During visits, nurses recorded anthropometrical measurements and transcribed information from the infants’ welfare cards. Results Four-hundred and sixty-five (79.6%) of the 584 infants aged 11–13 months at the time of the survey were recruited. The proportion of children with an age-adjusted Z-score <-2SD for mid-upper-arm circumference (MUAC) was lower among those exposed to azithromycin [1.3% versus 6.3%, OR = 0.21 95%CI (0.06,0.72), p = 0.006] and there was weak evidence of a difference in the proportion of infants with weight-for-age (WAZ) Z-score <-2SD [7.1% versus 12.1%, OR = 0.58 95%CI (0.33,1.04), p = 0.065]. For all other malnutrition indicators the proportions were similar in the exposed and un-exposed cohort. Conclusions Our results show that azithromycin in labour may have a beneficial effect in MUAC among children who are below the curve. Larger studies with closer follow-up are warranted. Trial registration (main trial) ClinicalTrials.gov Identifier NCT01800942.
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Affiliation(s)
- Anna Roca
- MRC Unit at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
- * E-mail:
| | - Bully Camara
- MRC Unit at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Claire Oluwalana
- MRC Unit at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Kodou Lette
- MRC Unit at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | | | - Umberto D’Alessandro
- MRC Unit at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
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11
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Cates JE, Westreich D, Unger HW, Bauserman M, Adair L, Cole SR, Meshnick S, Rogerson SJ. Intermittent Preventive Therapy in Pregnancy and Incidence of Low Birth Weight in Malaria-Endemic Countries. Am J Public Health 2018; 108:399-406. [PMID: 29346002 DOI: 10.2105/ajph.2017.304251] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To estimate the impact of hypothetical antimalarial and nutritional interventions (which reduce the prevalence of low midupper arm circumference [MUAC]) on the incidence of low birth weight (LBW). METHODS We analyzed data from 14 633 pregnancies from 13 studies conducted across Africa and the Western Pacific from 1996 to 2015. We calculated population intervention effects for increasing intermittent preventive therapy in pregnancy (IPTp), full coverage with bed nets, reduction in malaria infection at delivery, and reductions in the prevalence of low MUAC. RESULTS We estimated that, compared with observed IPTp use, administering 3 or more doses of IPTp to all women would decrease the incidence of LBW from 9.9% to 6.9% (risk difference = 3.0%; 95% confidence interval = 1.7%, 4.0%). The intervention effects for eliminating malaria at delivery, increasing bed net ownership, and decreasing low MUAC prevalence were all modest. CONCLUSIONS Increasing IPTp uptake to at least 3 doses could decrease the incidence of LBW in malaria-endemic countries. The impact of IPTp on LBW was greater than the effect of prevention of malaria, consistent with a nonmalarial effect of IPTp, measurement error, or selection bias.
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Affiliation(s)
- Jordan E Cates
- Jordan E. Cates, Daniel Westreich, Stephen R. Cole, and Steven Meshnick are with the Department of Epidemiology, University of North Carolina-Chapel Hill (UNC). Holger W. Unger is with the Department of Medicine at the Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia. Melissa Bauserman is with the Department of Pediatrics, Division of Neonatal-Perinatal Medicine, School of Medicine, UNC. Linda Adair is with the Department of Nutrition, UNC. Stephen J. Rogerson is with the Department of Medicine at the Doherty Institute, The University of Melbourne
| | - Daniel Westreich
- Jordan E. Cates, Daniel Westreich, Stephen R. Cole, and Steven Meshnick are with the Department of Epidemiology, University of North Carolina-Chapel Hill (UNC). Holger W. Unger is with the Department of Medicine at the Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia. Melissa Bauserman is with the Department of Pediatrics, Division of Neonatal-Perinatal Medicine, School of Medicine, UNC. Linda Adair is with the Department of Nutrition, UNC. Stephen J. Rogerson is with the Department of Medicine at the Doherty Institute, The University of Melbourne
| | - Holger W Unger
- Jordan E. Cates, Daniel Westreich, Stephen R. Cole, and Steven Meshnick are with the Department of Epidemiology, University of North Carolina-Chapel Hill (UNC). Holger W. Unger is with the Department of Medicine at the Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia. Melissa Bauserman is with the Department of Pediatrics, Division of Neonatal-Perinatal Medicine, School of Medicine, UNC. Linda Adair is with the Department of Nutrition, UNC. Stephen J. Rogerson is with the Department of Medicine at the Doherty Institute, The University of Melbourne
| | - Melissa Bauserman
- Jordan E. Cates, Daniel Westreich, Stephen R. Cole, and Steven Meshnick are with the Department of Epidemiology, University of North Carolina-Chapel Hill (UNC). Holger W. Unger is with the Department of Medicine at the Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia. Melissa Bauserman is with the Department of Pediatrics, Division of Neonatal-Perinatal Medicine, School of Medicine, UNC. Linda Adair is with the Department of Nutrition, UNC. Stephen J. Rogerson is with the Department of Medicine at the Doherty Institute, The University of Melbourne
| | - Linda Adair
- Jordan E. Cates, Daniel Westreich, Stephen R. Cole, and Steven Meshnick are with the Department of Epidemiology, University of North Carolina-Chapel Hill (UNC). Holger W. Unger is with the Department of Medicine at the Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia. Melissa Bauserman is with the Department of Pediatrics, Division of Neonatal-Perinatal Medicine, School of Medicine, UNC. Linda Adair is with the Department of Nutrition, UNC. Stephen J. Rogerson is with the Department of Medicine at the Doherty Institute, The University of Melbourne
| | - Stephen R Cole
- Jordan E. Cates, Daniel Westreich, Stephen R. Cole, and Steven Meshnick are with the Department of Epidemiology, University of North Carolina-Chapel Hill (UNC). Holger W. Unger is with the Department of Medicine at the Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia. Melissa Bauserman is with the Department of Pediatrics, Division of Neonatal-Perinatal Medicine, School of Medicine, UNC. Linda Adair is with the Department of Nutrition, UNC. Stephen J. Rogerson is with the Department of Medicine at the Doherty Institute, The University of Melbourne
| | - Steven Meshnick
- Jordan E. Cates, Daniel Westreich, Stephen R. Cole, and Steven Meshnick are with the Department of Epidemiology, University of North Carolina-Chapel Hill (UNC). Holger W. Unger is with the Department of Medicine at the Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia. Melissa Bauserman is with the Department of Pediatrics, Division of Neonatal-Perinatal Medicine, School of Medicine, UNC. Linda Adair is with the Department of Nutrition, UNC. Stephen J. Rogerson is with the Department of Medicine at the Doherty Institute, The University of Melbourne
| | - Stephen J Rogerson
- Jordan E. Cates, Daniel Westreich, Stephen R. Cole, and Steven Meshnick are with the Department of Epidemiology, University of North Carolina-Chapel Hill (UNC). Holger W. Unger is with the Department of Medicine at the Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia. Melissa Bauserman is with the Department of Pediatrics, Division of Neonatal-Perinatal Medicine, School of Medicine, UNC. Linda Adair is with the Department of Nutrition, UNC. Stephen J. Rogerson is with the Department of Medicine at the Doherty Institute, The University of Melbourne
| | -
- Jordan E. Cates, Daniel Westreich, Stephen R. Cole, and Steven Meshnick are with the Department of Epidemiology, University of North Carolina-Chapel Hill (UNC). Holger W. Unger is with the Department of Medicine at the Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia. Melissa Bauserman is with the Department of Pediatrics, Division of Neonatal-Perinatal Medicine, School of Medicine, UNC. Linda Adair is with the Department of Nutrition, UNC. Stephen J. Rogerson is with the Department of Medicine at the Doherty Institute, The University of Melbourne
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12
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Rogerson SJ, Unger HW. Prevention and control of malaria in pregnancy - new threats, new opportunities? Expert Rev Anti Infect Ther 2016; 15:361-375. [PMID: 27973923 DOI: 10.1080/14787210.2017.1272411] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Over 100 million women and their babies are at risk of malaria in pregnancy each year. Malaria prevention in pregnancy relies on long-lasting insecticidal nets (LLINs), and, in Africa, intermittent preventive treatment in pregnancy (IPTp). Increasing resistance of malaria parasites to sulfadoxine-pyrimethamine, the only drug endorsed for IPTp, and increasing mosquito resistance to pyrethroids used in LLINs, threaten the efficacy of these proven strategies, while operational challenges restrict their implementation in areas of great need. Areas Covered: This review summarizes strategies for malaria prevention in pregnancy (both currently used and those undergoing preclinical and clinical evaluation), primarily drawing on publications and study protocols from the last decade. Challenges associated with each strategy are discussed, including the particular problem of HIV and malaria in pregnancy, and areas of further research are highlighted. Expert Commentary: Alternative drugs for IPTp are needed. Dihydroartemisinin-piperaquine is particularly promising, but requires further evaluation, and might contribute to artemisinin resistance. Intermittent screening and treatment in pregnancy (ISTp) is an alternative to IPTp that could reduce unnecessary antenatal drug exposure and resistance risk, but it is not recommended with current, insensitive screening tests. Optimal strategies for areas of low or declining malaria transmission remain to be determined.
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Affiliation(s)
- Stephen J Rogerson
- a Department of Medicine at the Doherty Institute , University of Melbourne , Melbourne , Australia
| | - Holger W Unger
- a Department of Medicine at the Doherty Institute , University of Melbourne , Melbourne , Australia.,b Department of Obstetrics and Gynaecology , Royal Infirmary of Edinburgh , Edinburgh , UK
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13
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Unger HW, Cates JE, Gutman J, Briand V, Fievet N, Valea I, Tinto H, d'Alessandro U, Landis SH, Adu-Afarwuah S, Dewey KG, Ter Kuile F, Dellicour S, Ouma P, Slutsker L, Terlouw DJ, Kariuki S, Ayisi J, Nahlen B, Desai M, Madanitsa M, Kalilani-Phiri L, Ashorn P, Maleta K, Mueller I, Stanisic D, Schmiegelow C, Lusingu J, Westreich D, van Eijk AM, Meshnick S, Rogerson S. Maternal Malaria and Malnutrition (M3) initiative, a pooled birth cohort of 13 pregnancy studies in Africa and the Western Pacific. BMJ Open 2016; 6:e012697. [PMID: 28003287 PMCID: PMC5223676 DOI: 10.1136/bmjopen-2016-012697] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
PURPOSE The Maternal Malaria and Malnutrition (M3) initiative has pooled together 13 studies with the hope of improving understanding of malaria-nutrition interactions during pregnancy and to foster collaboration between nutritionists and malariologists. PARTICIPANTS Data were pooled on 14 635 singleton, live birth pregnancies from women who had participated in 1 of 13 pregnancy studies. The 13 studies cover 8 countries in Africa and Papua New Guinea in the Western Pacific conducted from 1996 to 2015. FINDINGS TO DATE Data are available at the time of antenatal enrolment of women into their respective parent study and at delivery. The data set comprises essential data such as malaria infection status, anthropometric assessments of maternal nutritional status, presence of anaemia and birth weight, as well as additional variables such gestational age at delivery for a subset of women. Participating studies are described in detail with regard to setting and primary outcome measures, and summarised data are available from each contributing cohort. FUTURE PLANS This pooled birth cohort is the largest pregnancy data set to date to permit a more definite evaluation of the impact of plausible interactions between poor nutritional status and malaria infection in pregnant women on fetal growth and gestational length. Given the current comparative lack of large pregnancy cohorts in malaria-endemic settings, compilation of suitable pregnancy cohorts is likely to provide adequate statistical power to assess malaria-nutrition interactions, and could point towards settings where such interactions are most relevant. The M3 cohort may thus help to identify pregnant women at high risk of adverse outcomes who may benefit from tailored intensive antenatal care including nutritional supplements and alternative or intensified malaria prevention regimens, and the settings in which these interventions would be most effective.
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Affiliation(s)
- Holger W Unger
- Department of Obstetrics and Gynaecology, Edinburgh Royal Infirmary, Edinburgh, UK
- Department of Medicine at the Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia
| | - Jordan E Cates
- Department of Epidemiology, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Julie Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Valerie Briand
- Institut de Recherche pour le Développement (IRD), Mère et enfant face aux infections tropicales (UMR216), Paris, France
- COMUE Sorbonne Paris Cité, Faculté de Pharmacie, Université Paris Descartes, Paris, France
| | - Nadine Fievet
- Institut de Recherche pour le Développement (IRD), Mère et enfant face aux infections tropicales (UMR216), Paris, France
- COMUE Sorbonne Paris Cité, Faculté de Pharmacie, Université Paris Descartes, Paris, France
| | - Innocent Valea
- Unite de Recherche Clinique de Nanoro, Institut de Recherche en Sciences de la Santé-DRO, Bobo-Dioulasso, Burkina Faso
- Departement de Recherche Clinique, Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Halidou Tinto
- Unite de Recherche Clinique de Nanoro, Institut de Recherche en Sciences de la Santé-DRO, Bobo-Dioulasso, Burkina Faso
- Departement de Recherche Clinique, Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Umberto d'Alessandro
- Medical Research Council Unit, The Gambia
- London School of Hygiene and Tropical Medicine, UK
- Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, California, USA
| | - Feiko Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Stephanie Dellicour
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Peter Ouma
- Kenya Medical Research Institute (KEMRI)/Center for Global Health Research, Kisumu, Kenya
| | - Laurence Slutsker
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Dianne J Terlouw
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme Liverpool School of Tropical Medicine, Liverpool, UK
| | - Simon Kariuki
- Kenya Medical Research Institute (KEMRI)/Center for Global Health Research, Kisumu, Kenya
| | - John Ayisi
- Kenya Medical Research Institute (KEMRI)/Center for Global Health Research, Kisumu, Kenya
| | | | - Meghna Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mwayi Madanitsa
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Linda Kalilani-Phiri
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Per Ashorn
- Tampere Center for Child Health Research, Tampere, Finland
- Department for Pediatrics, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Kenneth Maleta
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Ivo Mueller
- Walter and Eliza Hall Institute, Parkville, Victoria, Australia
| | - Danielle Stanisic
- Institute for Glycomics, Griffith University, Gold Coast, Queensland, Australia
| | - Christentze Schmiegelow
- Faculty of Health Science, Department of Immunology and Microbiology, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - John Lusingu
- Faculty of Health Science, Department of Immunology and Microbiology, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Daniel Westreich
- Department of Epidemiology, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Steven Meshnick
- Department of Epidemiology, UNC-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stephen Rogerson
- Department of Medicine at the Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia
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14
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Unger HW, Ashorn P, Cates JE, Dewey KG, Rogerson SJ. Undernutrition and malaria in pregnancy - a dangerous dyad? BMC Med 2016; 14:142. [PMID: 27645498 PMCID: PMC5029041 DOI: 10.1186/s12916-016-0695-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 09/15/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In low-resource settings, malaria and macronutrient undernutrition are major health problems in pregnancy, contributing significantly to adverse pregnancy outcomes such as preterm birth and fetal growth restriction. Affected pregnancies may result in stillbirth and neonatal death, and surviving children are at risk of poor growth and infection in infancy, and of non-communicable diseases in adulthood. Populations exposed to macronutrient undernutrition frequently reside in malaria-endemic areas, and seasonal peaks of low food supply and malaria transmission tend to coincide. Despite these geographic and temporal overlaps, integrated approaches to these twin challenges are infrequent. DISCUSSION This opinion article examines the current evidence for malaria-macronutrition interactions and discusses possible mechanisms whereby macronutrient undernutrition and malaria may interact to worsen pregnancy outcomes. Macronutrient undernutrition dysregulates the immune response. In pregnant women, undernutrition may worsen the already increased susceptibility to malarial infection and could impair development of protective immunity to malaria, and is likely to exacerbate the impact of placental malaria on fetal growth. Malarial infection, in turn, can drive nutritional depletion; poor gestational weight gain and weight loss in pregnancy increases the risk of adverse pregnancy outcomes. Despite a commendable number of studies and trials that, in isolation, attempt to address the challenges of malaria and undernutrition in pregnancy, few dare to venture beyond the 'single disease - single solution' paradigm. We believe that this may be a lost opportunity: researching malaria-nutrition interactions, and designing and implementing integrated interventions to prevent and treat these commonly co-existing and intertwining conditions, may markedly reduce the high burden of preterm birth and fetal growth restriction in affected areas. CONCLUSION We call for more collaboration between researchers studying malaria and nutrition in pregnancy, and propose a research agenda to address this important twin health problem.
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Affiliation(s)
- Holger W. Unger
- Department of Medicine at the Doherty Institute, The University of Melbourne, Melbourne, Victoria Australia
- Simpson Centre for Reproductive Health, Edinburgh Royal Infirmary, Edinburgh, UK
| | - Per Ashorn
- Department of Paediatrics, University of Tampere School of Medicine, Tampere, Finland
- Department for International Health, University of Tampere School of Medicine, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Jordan E. Cates
- Department of Epidemiology, University of North Carolina-Chapel Hill, Chapel Hill, NC USA
| | - Kathryn G. Dewey
- Program in International and Community Nutrition and Department of Nutrition, University of California, Davis, CA USA
| | - Stephen J. Rogerson
- Department of Medicine at the Doherty Institute, The University of Melbourne, Melbourne, Victoria Australia
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15
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Unger HW, Wangnapi RA, Ome-Kaius M, Boeuf P, Karl S, Mueller I, Rogerson SJ. Azithromycin-containing intermittent preventive treatment in pregnancy affects gestational weight gain, an important predictor of birthweight in Papua New Guinea - an exploratory analysis. MATERNAL AND CHILD NUTRITION 2015; 12:699-712. [PMID: 26373537 DOI: 10.1111/mcn.12215] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In Papua New Guinea, intermittent preventive treatment with sulphadoxine-pyrimethamine and azithromycin (SPAZ-IPTp) increased birthweight despite limited impact on malaria and sexually transmitted infections. To explore possible nutrition-related mechanisms, we evaluated associations between gestational weight gain (GWG), enrolment body mass index (BMI) and mid-upper arm circumference (MUAC), and birthweight. We investigated whether the increase in birthweight associated with SPAZ-IPTp may partly be driven by a treatment effect on GWG. The mean GWG rate was 393 g/week (SD 250; n = 948). A 100 g/week increase in GWG was associated with a 14 g (95% CI 2.6, 25.4) increase in birthweight (P = 0.016). Enrolment BMI and MUAC also positively correlated with birthweight. SPAZ-IPTp was associated with increased GWG [58 g/week (26, 900), P < 0.001, n = 948] and with increased birthweight [48 g, 95% CI (8, 880), P = 0.019] when all eligible women were considered (n = 1947). Inclusion of GWG reduced the birthweight coefficient associated with SPAZ-IPTp by 18% from 44 to 36 g (n = 948), although SPAZ-IPTp was not significantly associated with birthweight among women for whom GWG data were available (P = 0.13, n = 948). One month post-partum, fewer women who had received SPAZ-IPTp had a low post-partum BMI (<18.5 kg m(-2) ) [adjusted risk ratio: 0.55 (95% CI 0.36, 0.82), P = 0.004] and their babies had a reduced risk of wasting [risk ratio 0.39 (95% CI 0.21, 0.72), P = 0.003]. SPAZ-IPTp increased GWG, which could explain its impact on birthweight and maternal post-partum BMI. Future trials of SPAZ-IPTp must incorporate detailed anthropometric evaluations to investigate mechanisms of effects on maternal and child health.
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Affiliation(s)
- Holger W Unger
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea
| | - Regina A Wangnapi
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea
| | - Maria Ome-Kaius
- Vector Borne Diseases Unit, Papua New Guinea Institute of Medical Research (PNG IMR), Goroka, Papua New Guinea
| | - Philippe Boeuf
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Victorian Infectious Diseases Service, Melbourne Health, Melbourne, Victoria, Australia
| | - Stephan Karl
- Infection and Immunity Division, Walter and Eliza Hall Institute of Medical Research (WEHI), Melbourne, Victoria, Australia.,Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia
| | - Ivo Mueller
- Infection and Immunity Division, Walter and Eliza Hall Institute of Medical Research (WEHI), Melbourne, Victoria, Australia.,Department of Medical Biology, University of Melbourne, Melbourne, Victoria, Australia.,Barcelona Centre for International Health Research (CRESIB), Barcelona, Spain
| | - Stephen J Rogerson
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia. .,Victorian Infectious Diseases Service, Melbourne Health, Melbourne, Victoria, Australia.
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