Effectiveness of intermittent preventive treatment in pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) in Ghana

Impact on pregnancy outcomes of intermittent preventive treatment with sulfadoxine-pyrimethamine in urban and peri-urban Papua New Guinea: a retrospective cohort study

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.

Gestational glucose intolerance among pregnant women at the Cape Coast Teaching Hospital

BACKGROUND

Malaria in pregnancy can have adverse outcomes if untreated. Both malaria and pregnancy are associated with insulin resistance and diabetes. Although malaria is treated prophylactically with gestational diabetes mellitus (GDM) screened for in pregnancy as part a routine antenatal care, their impacts have not been examined in terms of other forms of dysglycaemia. This cross-sectional study examined insulin resistance and its relationship with dysglycaemia and malaria among pregnant women in the Cape Coast Teaching Hospital (CCTH).

METHODS

Using a structured questionnaire, demographic and clinical information were obtained from 252 pregnant women aged 18-42 years. Weight and height were measured for computation of body mass index (BMI). Measurement of insulin, lipid profile and glucose were taken under fasting conditions followed by oral glucose tolerant test. Insulin resistance and beta-cell function were assessed by the homeostatic model as malaria was diagnosed by microscopy.

RESULTS

The respective prevalence of GDM, gestational glucose intolerance (GGI) and insulin resistance were 0.8% (2/252), 19.44% (49/252) and 56.75% (143/252). No malaria parasite or dyslipidaemia was detected in any of the participants. Apart from BMI that increased across trimesters, no other measured parameter differed among the participants. Junior High School (JHS) education compared with no formal education increased the odds (AOR: 2.53; CI: 1.12-5.71; P = 0.03) but 2nd trimester of pregnancy compared to the 1st decreased the odds (AOR: 0.32; CI: 0.12-0.81; P = 0.02) of having insulin resistance in the entire sample. In a sub-group analysis across trimesters, pregnant women with JHS education in their 3rd trimester had increased odds (AOR: 4.41; CI: 1.25-15.62; P = 0.02) of having insulin resistance.

CONCLUSION

Prevalence of GDM and GGI were 0.8% and 19.44% respectively. The odds of insulin resistance increased in pregnant women with JHS education in the 3rd trimester. Appropriate measures are needed to assuage the diabetogenic risk posed by GGI in our setting.

Malaria, Urogenital Schistosomiasis, and Anaemia in Pregnant Ghanaian Women

Background

Anaemia is common in sub-Saharan Africa, and parasitic infections could worsen its burden during pregnancy. Moreover, women become susceptible to malaria during pregnancy. We investigated Plasmodium falciparum (P. falciparum) and Schistosoma haematobium (S. haematobium) infections and determined their association with anaemia during pregnancy.

Methods

A cross-sectional study involving 707 pregnant women attending antenatal care visits (ANC) and 446 at delivery was conducted in Battor and Adidome hospitals. Pregnant women were screened by microscopy and qPCR for P. falciparum and S. haematobium infections. Haemoglobin (Hb) levels were determined, and most participants received intermittent preventive treatment during pregnancy (IPTp) during ANC till delivery. Regression analyses were performed for associations between parasite infection and anaemia.

Results

P. falciparum microscopy prevalence at ANC and delivery was 8% and 2%, respectively, and by PCR 24% at ANC and 12% at delivery. Anaemia prevalence at ANC was 52% and 49% at delivery. There was an increased risk of anaemia with P. falciparum infection (aOR = 1.92; p = 0.04). IPTp (p = 0.003) and age (p = 0.004) were associated with increased Hb levels at delivery. S. haematobium prevalence by microscopy was 4% at ANC and 2% at delivery. No significant correlation between S. haematobium and Hb levels was observed (coef. = -0.62 g/dl; p = 0.07).

Conclusion

High anaemia prevalence was observed during pregnancy, and P. falciparum infection was associated with anaemia at ANC. Low S. haematobium prevalence could be attributed to previous praziquantel treatment during mass drug administration. Routine diagnosis and treatment of S. haematobium infections in endemic areas could be initiated to reduce schistosomiasis during pregnancy.

Interventions for malaria prevention in pregnancy; factors influencing uptake and their effect on pregnancy outcomes among post-natal women in a tertiary facility in the Volta Region of Ghana

Objectives

Malaria in pregnancy is associated with adverse pregnancy outcomes including maternal anaemia and low birthweight. Uptake of preventive interventions is sub-optimal in sub-Saharan Africa including Ghana. Understanding local-level factors that influence uptake of these interventions can enhance control. The study assessed uptake of intermittent preventive treatment of malaria during pregnancy using sulphadoxine-pyrimethamine (IPTp-SP) and insecticide-treated net (ITN) use, their determinants and effects on pregnancy outcomes.

Methods

A cross-sectional study involving 349 post-partum women was conducted from 25 August 2022 to 9 October 2022 at the Ho Teaching Hospital. A structured questionnaire was used to collect data on participant socio-demographics, ITN use, number of doses of sulphadoxine-pyrimethamine received, knowledge of malaria in pregnancy, haemoglobin levels and birth weight among others. Summary statistics were reported as frequencies, percentages and means. Associations between exposure and outcome variables were assessed using logistic regression methods and odds ratios reported with 95% confidence intervals. Statistical significance was concluded at p < 0.05.

Results

More than 80% (291) of respondents received ⩾3 doses of intermittent preventive treatment using sulphadoxine-pyrimethamine and 64.8% (226) slept under ITNs the night before the survey. Age >25 years, employment, good knowledge of malaria in pregnancy, parity ⩾2 and initiating antenatal care visits in the first trimester facilitated the uptake of these interventions. Receiving ⩾3 doses of sulphadoxine-pyrimethamine was associated with having normal-weight babies (adjusted odds ratio 2.80, 95% CI: 1.07, 7.34; p = 0.036) while ITN use was associated with having term babies (adjusted odds ratio 2.72, 95% CI: 1.24, 5.90; p = 0.013) and normal maternal haemoglobin concentration at term (adjusted odds ratio 1.57, 95% CI: 1.01, 2.47; p = 0.044).

Conclusions

The interventions were beneficial against low birthweight and preterm births which predispose to neonatal deaths and poor cognitive function in children. Malaria in pregnancy health campaigns should be intensified, especially among younger-aged primigravidae, to increase their knowledge of the condition as a way to further improve uptake of these preventive interventions.

Comparative efficacy of sulphadoxine-pyrimethamine and dihydroartemisinin-piperaquine against malaria infection during late-stage pregnancy in mice

The introduction of artemisinin combination therapies (ACTs) against malaria infections opened up a window of possibilities to combat malaria in pregnancy. However, the usefulness of ACTs in all stages of pregnancy must be critically assessed. This study was designed to evaluate dihydroartemisinin-piperaquine (DHAP) as a suitable alternative to sulphadoxine-pyrimethamine (SP) in the treatment of malaria during third-trimester pregnancy in mice. Experimental animals were inoculated with a parasitic dose of 1x10⁶Plasmodium berghei (ANKA strain) infected erythrocytes and randomly allocated into treatment groups. The animals received standard doses of chloroquine alone (CQ)[10 mg/kg], SP [25 mg/kg] and [1.25 mg/kg] and DHAP [4 mg/kg] and [18 mg/kg] combinations. Maternal and pupil survival, litter sizes, pup weight and still-births were recorded, while the effect of the drug combinations on parasite suppression, recrudescence and parasite clearance time were evaluated. The day 4 chemo-suppression of parasitemia by DHAP in infected animals was comparable to SP, and CQ treatment (P > 0.05). The mean recrudescence time was significantly delayed (P = 0.031) in the DHAP treatment group compared to the CQ treatment group, while, there was no recrudescence in animals treated with SP. The birth rate in the SP group was significantly higher than in the DHAP group (P < 0.05). There was 100% maternal and pup survival in both combination treatments comparable with the uninfected gravid controls. The overall parasitological activity of SP against Plasmodium berghei in late-stage pregnancy appeared better than DHAP. In addition, SP treatment resulted in better birth outcomes assessed compared to DHAP treatment.

Assessing nursing mothers' knowledge, perceptions and uptake of Sulphadoxine Pyrimethamine (IPTp-SP) during pregnancy in the Ho Teaching Hospital of the Volta Region of Ghana

Intermittent preventive therapy during pregnancy with Sulphadoxine Pyrimethamine (IPTp-SP) is one of the potent strategies for preventing malaria in pregnancy (MiP). Factors such as the pregnant woman's knowledge and very importantly perception or belief about IPTp-SP remains key determinant of IPTp-SP uptake. This study assessed the knowledge and perception of nursing mothers and their uptake of IPTp-SP during pregnancy in the Ho Teaching Hospital. We administered a close-ended questionnaire to 303 nursing mothers and obtained their sociodemographic details as well as information on their knowledge and perception of IPTp-SP utilization. We also reviewed the nursing mothers' antenatal care (ANC) booklets to ascertain the number of times IPTp-SP was taken during pregnancy. Pearson chi-square was used to determine the association between the sociodemographic variable and the categories of knowledge, perception, and uptake of IPTp-SP. Analysis, was done using SPSS, and the p-value of less than 5% was considered statistically significant. Of the 303 nursing mothers sampled in this study, 265(87.5%) had heard about IPTp-SP of which 138(52.1%) had average knowledge of IPTp-SP. A total of 168(63.4%) had poor perception, and 168(64.6%) had adequate uptake (3-4 doses) of IPTp. Education was significantly associated with perception and uptake, with the majority of women who demonstrated excellent perception were those who had tertiary education (7, 6.35%, p = 0.05), and the majority who demonstrated excellent uptake (5 completed doses) were women who had tertiary education (47, 37.9%, p = 0.01). While knowledge was average, perception of IPTp-SP was poor for the majority of the nursing mothers which might have hampered their uptake of IPTp-SP during pregnancy. It is important that continuous assessment of the individual factors affecting the uptake of IPTp-SP be done regularly to curb the negative influences on the uptake of IPTp-SP.

The prevalence of molecular markers of resistance to sulfadoxine-pyrimethamine among pregnant women at first antenatal clinic attendance and delivery in the forest-savannah area of Ghana

Intermittent preventive treatment during pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) is used to prevent malaria and associated unfavorable maternal and foetal outcomes in pregnancy in moderate to high malaria transmission areas. Effectiveness of IPTp-SP is, however, threatened by mutations in the Plasmodium falciparum dihydrofolate reductase (Pfdhfr) and dihydropteroate synthase (Pfdhps) genes which confer resistance to pyrimethamine and sulfadoxine, respectively. This study determined the prevalence of molecular markers of SP resistance among pregnant women in a high malaria transmission area in the forest-savannah area of Ghana. Genomic DNA was extracted from 286 P. falciparum-positive dried blood spots obtained from pregnant women aged ≥18 years (255 at first Antenatal Care (ANC) clinic visit and 31 at delivery from 2017 to 2019) using Chelex 100. Mutations in Pfdhfr and Pfdhps genes were detected using molecular inversion probes and next generation sequencing. In the Pfdhfr gene, single nucleotide polymorphisms (SNPs) were detected in 83.1% (157/189), 92.0% (173/188) and 91.0% (171/188) at codons 51, 59, and 108 respectively in samples collected at first ANC visit, while SNPs were detected in 96.6 (28/29), 96.6% (28/29) and 96.8% (30/31) in isolates collected at delivery. The Pfdhfr triple mutant N51I, C59R and S108N (IRN) was carried by 80.5% (128/159) and 96.5% (28/29) of the typed isolates collected at ANC visit and at delivery respectively. In the Pfdhps gene, SNPs were detected in 0.6% (1/174), 76.2% (138/181), 33.2% (60/181), 1.2% (2/174), 0% (0/183), and 16.6% (27/173) at codons 431, 436, 437, 540, 581 and 613 respectively in samples collected at ANC, and 0% (0/25), 72% (18/25), 40% (10/25), 3.6% (1/25), 0% (0/29) and 7.4% (2/27) in samples collected at delivery. Quadruple mutant Pfdhfr N51I, C59R, and S108N + Pfdhps A437G (IRN-GK) was present in 25.8% (33/128) and 34.8% (8/23) of isolates at ANC and at delivery respectively. Quintuple mutant alleles Pfdhfr N51I, C59R, and S108N + Pfdhps A437G and K540E (IRN-GE) were detected in 0.8% (1/128) and 4.4% (1/23) of samples collected at ANC and at delivery respectively. No mutations were identified at Pfdhfr codons 16 or 164 or Pfdhps 581. There is a high prevalence of Pfdhfr triple mutant P. falciparum infections among pregnant women in the study area. However, prevalence of the combined Pfdhfr/Pfdhps quadruple and quintuple mutants IRN-GK and IRN-GE respectively prior to commencement of IPTp-SP were low, and no Pfdhps A581G mutant was detected, indicating that SP is still likely to be efficacious for IPTp-SP in the forest-savannah area in the middle belt of Ghana.