1
|
Jain V, Sharma RK, Shukla MM, Khosla KK, Singh N, Shanmugam R. Burden of malaria during pregnancy in perennial transmission settings of two densely forested and remote blocks (Baihar and Birsa) of district Balaghat, Madhya Pradesh, central India. THE NATIONAL MEDICAL JOURNAL OF INDIA 2023; 36:351-357. [PMID: 38909309 DOI: 10.25259/nmji_535_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/24/2024]
Abstract
Background Malaria in pregnancy (MIP) is a major public health problem due to the vulnerability of pregnant women to infections, resulting in adverse maternal/foetal outcomes in endemic areas. Methods We did a field-based study to assess the burden of MIP (prevalence at the time of enrolment and follow-up) and to identify risk factors for MIP in the Birsa and Baihar blocks of district Balaghat in Madhya Pradesh, which have perennial malaria transmission. Malaria screening (during 2015-2017) was done by microscopy and bivalent rapid diagnostic test (SD Bioline RDT, malaria antigen Plasmodium falciparum/Plasmodium vivax Pf/Pv). Dried blood spots were used for haemoglobin estimation. Sociodemographic details with past and present pregnancy status were obtained. A subset of pregnant women were followed up for malaria during pregnancy. Women were also screened for malaria post delivery. Malaria treatment was given as per the National Guidelines of 2013. Multivariate analysis was done to assess independent risk factors for malaria. Results A total of 1728 pregnant women were screened, of which 1651 were included in the final analysis. Malaria prevalence at first screening was 23.4% (Pf 88%). Prevalence and Pf parasitaemia both were significantly higher among primigravid (G1) compared to multigravid (G>2; p value 0.012 and 0.019, respectively). Pregnant women of the Baiga ethnic group were more likely to have malaria compared to those belonging to the Gond group (OR [95% CI]; 2.4 [1.7-3.4]; p<0.00001) and non-indigenous group (OR [95% CI]; 8.3 [3.9-19.7]; p<0.00001). Primigravid status of women, first and second trimester of pregnancy, women belonging to indigenous ethnic tribal group and cash crop insufficiency for whole year (a socioeconomic indicator) in the family were the independent risk factors for malaria. Conclusion MIP is a major public health problem in forested tribal settlements of Birsa and Baihar blocks of Balaghat district in Madhya Pradesh and requires immediate intervention.
Collapse
Affiliation(s)
- Vidhan Jain
- ICMR-National Institute of Research in Tribal Health, Garha, Jabalpur 482003, Madhya Pradesh, India
| | - Ravendra Kumar Sharma
- ICMR-National Institute of Research in Tribal Health, Garha, Jabalpur 482003, Madhya Pradesh, India
| | - Man Mohan Shukla
- ICMR-National Institute of Research in Tribal Health, Garha, Jabalpur 482003, Madhya Pradesh, India
| | | | - Neeru Singh
- ICMR-National Institute of Research in Tribal Health, Garha, Jabalpur 482003, Madhya Pradesh, India
| | | |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Kojom Foko LP, Singh V. Malaria in pregnancy in India: a 50-year bird's eye. Front Public Health 2023; 11:1150466. [PMID: 37927870 PMCID: PMC10620810 DOI: 10.3389/fpubh.2023.1150466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 09/25/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction In 2021, India contributed for ~79% of malaria cases and ~ 83% of deaths in the South East Asia region. Here, we systematically and critically analyzed data published on malaria in pregnancy (MiP) in India. Methods Epidemiological, clinical, parasitological, preventive and therapeutic aspects of MiP and its consequences on both mother and child were reviewed and critically analyzed. Knowledge gaps and solution ways are also presented and discussed. Several electronic databases including Google scholar, Google, PubMed, Scopus, Wiley Online library, the Malaria in Pregnancy Consortium library, the World Malaria Report, The WHO regional websites, and ClinicalTrials.gov were used to identify articles dealing with MiP in India. The archives of local scientific associations/journals and website of national programs were also consulted. Results Malaria in pregnancy is mainly due to Plasmodium falciparum (Pf) and P. vivax (Pv), and on rare occasions to P. ovale spp. and P. malariae too. The overall prevalence of MiP is ~0.1-57.7% for peripheral malaria and ~ 0-29.3% for placental malaria. Peripheral Pf infection at antenatal care (ANC) visits decreased from ~13% in 1991 to ~7% in 1995-1996 in Madhya Pradesh, while placental Pf infection at delivery unit slightly decreased from ~1.5% in 2006-2007 to ~1% in 2012-2015 in Jharkhand. In contrast, the prevalence of peripheral Pv infection at ANC increased from ~1% in 2006-2007 to ~5% in 2015 in Jharkhand, and from ~0.5% in 1984-1985 to ~1.5% in 2007-2008 in Chhattisgarh. Clinical presentation of MiP is diverse ranging from asymptomatic carriage of parasites to severe malaria, and associated with comorbidities and concurrent infections such as malnutrition, COVID-19, dengue, and cardiovascular disorders. Severe anemia, cerebral malaria, severe thrombocytopenia, and hypoglycemia are commonly seen in severe MiP, and are strongly associated with tragic consequences such as abortion and stillbirth. Congenital malaria is seen at prevalence of ~0-12.9%. Infected babies are generally small-for-gestational age, premature with low birthweight, and suffer mainly from anemia, thrombocytopenia, leucopenia and clinical jaundice. Main challenges and knowledge gaps to MiP control included diagnosis, relapsing malaria, mixed Plasmodium infection treatment, self-medication, low density infections and utility of artemisinin-based combination therapies. Conclusion All taken together, the findings could be immensely helpful to control MiP in malaria endemic areas.
Collapse
|
4
|
Bal M, Ghosal J, Das A, Sandeepta S, Pati S, Dutta A, Ranjit M. Impact of Sub-patent Malaria During Pregnancy on Birth-Weight in Odisha, India: Time-to-Event Analysis of Prospective Longitudinal Follow-Up of a Survey. J Epidemiol Glob Health 2023; 13:23-31. [PMID: 36650337 PMCID: PMC10006379 DOI: 10.1007/s44197-022-00082-0] [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: 08/18/2022] [Accepted: 11/18/2022] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE The current study aimed to estimate prevalence of malaria infection, especially sub-patent infection, in pregnant women residing in high malaria-endemic, hard-to-reach pockets of the Indian state of Odisha; and also measure its impact on birth-weight of their new-borns. METHOD A time-to-event analysis of prospective longitudinal follow-up study nested within a cross-sectional survey of people residing in high malaria-endemic six districts of Odisha was conducted during July-November 2019. Malaria status in pregnant mothers was categorized as malaria free; sub-patent, and patent. Hazards Ratio (HR) of low birth-weight (LBW; birth-weight < 2500 gms) was estimated in these three categories (n = 308) adjusted for residence (block), gravida, caste, age and gestational age at testing. RESULTS 50.3% pregnant women had sub-patent malaria infection, 3.9% had patent infection. In fully adjusted model, hazards ratio of LBW was 3.76 (95% CI 1.12, 12.64, p = 0.032) in pregnant women with patent infection and 1.82 (95% CI 0.87, 3.81, p = 0.109) in women with sub-patent infection when compared to no malaria group. CONCLUSION The study showed that half of the pregnant women in high-endemic pockets had sub-patent infection which posed deleterious influence on birth-weight of their new-borns. The study thereby flags the prevalence of sub-patent infection as a public health concern, because sub-patent infection in pregnant mothers may persist as a "silent" reservoir, with the potential to derail the malaria control program, especially when the country plans malaria elimination by 2030.
Collapse
Affiliation(s)
- Madhusmita Bal
- Indian Council of Medical Research-Regional Medical Research Centre, Chandrasekharpur, Bhubaneswar, Odisha, 751023, India
| | - Jyoti Ghosal
- Indian Council of Medical Research-Regional Medical Research Centre, Chandrasekharpur, Bhubaneswar, Odisha, 751023, India
- School of Public Health, KIIT Deemed to Be University, Bhubaneswar, Odisha, India
| | - Arundhuti Das
- Indian Council of Medical Research-Regional Medical Research Centre, Chandrasekharpur, Bhubaneswar, Odisha, 751023, India
| | - Sonali Sandeepta
- Indian Council of Medical Research-Regional Medical Research Centre, Chandrasekharpur, Bhubaneswar, Odisha, 751023, India
| | - Sanghmitra Pati
- Indian Council of Medical Research-Regional Medical Research Centre, Chandrasekharpur, Bhubaneswar, Odisha, 751023, India
| | - Ambarish Dutta
- Indian Institute of Public Health, Public Health Foundation of India, Plot No. 267/3408, Jaydev Vihar, Mayfair Lagoon Road, Bhubaneswar, Odisha, 751013, India.
| | - Manoranjan Ranjit
- Indian Council of Medical Research-Regional Medical Research Centre, Chandrasekharpur, Bhubaneswar, Odisha, 751023, India.
| |
Collapse
|
5
|
Jain K, Gupta P, Balodhi A, Deeba F, Salam N. Prevalence of Pregnancy Associated Malaria in India. Front Glob Womens Health 2022; 3:832880. [PMID: 35692947 PMCID: PMC9178198 DOI: 10.3389/fgwh.2022.832880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/28/2022] [Indexed: 12/03/2022] Open
Abstract
Malaria in pregnancy is a major public health concern. It results in impaired maternal health and adversely effects fetal and perinatal outcomes. The present systematic review was conducted to assess the prevalence, distribution and adverse pregnancy outcomes in malaria infected females in India. A comprehensive search and review of PubMed and Web of Science based on PRISMA guidelines was carried out to find articles reporting prevalence of malaria in pregnant women from India. Data from 16 studies were analyzed and prevalence of malaria among pregnant women in India was found to be 11.4 % (95 % CI: 7.3, 16.3). Prevalence of malaria among asymptomatic and symptomatic pregnant women was found to be 10.62% (95% CI: 6.05, 16.23) and 13.13% (95% CI: 7.2, 20.52), respectively. P. falciparum and P. vivax were both reported with in the same population. The geospatial distribution of malaria in pregnancy spanned over nine very populous states of India. The review also reported severe maternal and perinatal outcomes. Given the seriousness of malaria in pregnant women and its effects on the fetus and new-born, a stringent district wise guideline for early detection and prophylaxis in regions identified in this review will help in its better control.
Collapse
Affiliation(s)
- Khushi Jain
- Department of Microbiology, Central University of Punjab, Bathinda, India
| | - Palak Gupta
- Department of Microbiology, Central University of Punjab, Bathinda, India
| | - Ashutosh Balodhi
- Department of Microbiology, Central University of Punjab, Bathinda, India
| | - Farah Deeba
- Centre for Interdisciplinary Research in Basic Sciences, Jamia Millia Islamia, New Delhi, India
| | - Nasir Salam
- Department of Microbiology, Central University of Punjab, Bathinda, India
- *Correspondence: Nasir Salam
| |
Collapse
|
6
|
Pandey M, Rahi M, Sharma A. The Indian burden of malaria in pregnancy needs assessment. MED 2021; 2:464-469. [DOI: 10.1016/j.medj.2021.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/29/2021] [Accepted: 04/16/2021] [Indexed: 10/21/2022]
|
7
|
Garg S, Dewangan M, Barman O. Malaria prevalence in symptomatic and asymptomatic pregnant women in a high malaria-burden state in India. Trop Med Health 2020; 48:71. [PMID: 32831578 PMCID: PMC7436977 DOI: 10.1186/s41182-020-00259-y] [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: 05/18/2020] [Accepted: 08/10/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction Malaria in pregnancy (‘MiP’) poses risks to mother, foetus and newborn. Studies from Africa and Asia have reported high prevalence of ‘MiP’ and recommended further research to address ‘MiP’. India has a significant burden of ‘MiP’ but most of the studies are a decade old. Hardly any studies exist in India that report on asymptomatic malaria in pregnant women. The current Indian policies for malaria control are silent on ‘MiP’. A campaign was carried out by community health workers (CHWs) in 2019 to screen pregnant women across rural Chhattisgarh. Methods This is a cross-sectional study. Malaria was tested in pregnant women by CHWs using bivalent rapid tests. Multi-stage sampling was used to cover 21,572 pregnant women screened across different geographical areas of rural Chhattisgarh. Cross-tabulation and multivariate regression were used to find out the relationship of ‘MiP’ with different symptoms and geographical areas. GIS maps were used to compare malaria in pregnant women against overall febrile population. Results In rural Chhattisgarh, malaria was present in 0.81% of the pregnant women at the time of testing. ‘MiP’ prevalence varied across geographies, reaching 4.48% in the geographical division with highest burden. Febrile pregnant women had three times greater malaria-positivity than overall febrile population and both showed a similar geographical pattern. Discussion Prevalence of ‘MiP’ was found to be less than earlier studies in the state. Though overall malaria in India has shown some decline, a policy response is needed for ‘MiP’ in high-burden areas. Fever, diarrhoea and jaundice remain relevant symptoms in ‘MiP’, but around one fourth of malaria-positive pregnant-women were afebrile, suggesting the need for strategies to address it. Conclusion The current study based on a large sample provides fresh evidence on ‘MiP’ in India. It used CHWs as skilled providers for large-scale screening for malaria. In high-burden areas, intermittent screening and treatment (IST) of all pregnant women can be a useful strategy in order to address ‘MiP’. Pregnant women can be considered as a pertinent sentinel population for malaria. The global and national policies need to evolve concrete strategies for addressing malaria in pregnancy.
Collapse
Affiliation(s)
- Samir Garg
- State Health Resource Centre, Raipur, Chhattisgarh India
| | | | | |
Collapse
|
8
|
Malarial anemia among pregnant women in the south-western coastal city of Mangaluru in India. INFORMATICS IN MEDICINE UNLOCKED 2019. [DOI: 10.1016/j.imu.2019.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
9
|
Sabin L, Hecht EMS, Brooks MI, Singh MP, Yeboah-Antwi K, Rizal A, Wylie BJ, Bondzie PA, Banos M, Tuchman J, Singh N, Hamer DH. Prevention and treatment of malaria in pregnancy: what do pregnant women and health care workers in East India know and do about it? Malar J 2018; 17:207. [PMID: 29776369 PMCID: PMC5960115 DOI: 10.1186/s12936-018-2339-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 05/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Limited qualitative research has been performed in India to investigate views and behaviours of pregnant women regarding malaria despite the threat of malaria-related adverse maternal and neonatal outcomes. To address this gap, a comprehensive study on malaria prevention and treatment attitudes, knowledge and behaviour among pregnant women in India was conducted. METHODS Pregnant women and healthcare workers (HCWs), encompassing clinic-based providers, traditional birth attendants, and auxiliary nurse-midwives were enrolled for in-depth interviews (IDIs) at 7 hospital sites and nearby communities in Jharkhand and Chhattisgarh States. Questions addressed health concerns and attitudes, knowledge and practices regarding malaria prevention and treatment; probing covered modern and traditional approaches. Data were analyzed using a thematic approach. RESULTS A total of 83 pregnant women and 119 HCWs participated in 202 IDIs, 90 in Jharkhand and 112 in Chhattisgarh. A majority of Jharkhand respondents, but only one-fourth in Chhattisgarh, named malaria among top health issues for pregnant women. Just over half of pregnant women were willing to try new prevention methods (especially insecticide-treated bed nets), although cost-related barriers to such methods were stressed. Most respondents voiced concerns about malaria treatment during pregnancy, mainly citing potential harm to the baby. Most knew that mosquitoes transmitted malaria, but a substantial minority, including among HCWs, described incorrect transmission modes. Most knew a proven prevention method (usually bed nets or coils); a few knew other methods. A minority of pregnant women, but most HCWs, knew about malaria treatment, although some HCWs described unproven treatments. Most respondents described use of modern prevention methods in their communities, typically bed nets, although probing revealed irregular use. Half (especially in Jharkhand and particularly HCWs) described use of traditional prevention approaches such as burning leaves and rubbing oils on the body; traditional remedies for malaria treatment were common, and varied by site and population. CONCLUSIONS Understanding of malaria varied as a concern for pregnant women, continued use of unproven malaria prevention and treatment strategies was evident in this population in India. These results highlight the need to educate both pregnant women and HCWs about effective malaria methods to protect pregnant women and their babies from malaria.
Collapse
Affiliation(s)
- Lora Sabin
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA, USA.
| | - Evan M S Hecht
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA, USA
| | - Mohamad I Brooks
- Pathfinder, International, 9 Galen Street, Suite 217, Watertown, MA, USA
| | - Mrigendra P Singh
- ICMR-National Institute of Malaria Research Field Station, IDVC Mission Medical College Campus, Jabalpur, India
| | - Kojo Yeboah-Antwi
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA, USA
| | - Abanish Rizal
- Harvard University, Massachusetts Hall, Cambridge, MA, USA
| | - Blair J Wylie
- Department of Obstetrics, Gynecology, and Reproductive Biology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, USA
| | - Philip A Bondzie
- Boston University School of Medicine, 72 East Concord St, Boston, MA, USA
| | - Matthew Banos
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA, USA
| | - Jordan Tuchman
- Abt Associates, 4550 Montgomery Ave, #800N, Bethesda, MA, USA
| | - Neeru Singh
- ICMR-National Institute of Malaria Research Field Station, IDVC Mission Medical College Campus, Jabalpur, India
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Ave, Boston, MA, USA.,Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| |
Collapse
|
10
|
Pincelli A, Neves PAR, Lourenço BH, Corder RM, Malta MB, Sampaio-Silva J, de Souza RM, Cardoso MA, Castro MC, Ferreira MU, For The Mina Brazil Working Group. The Hidden Burden of Plasmodium vivax Malaria in Pregnancy in the Amazon: An Observational Study in Northwestern Brazil. Am J Trop Med Hyg 2018; 99:73-83. [PMID: 29741155 DOI: 10.4269/ajtmh.18-0135] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We measured the prevalence of malaria in pregnancy and estimated its impact on birth weight and length and maternal hemoglobin in 1,180 women from Juruá Valley, the main malaria hotspot in Brazil. Antenatal malaria episodes, 74.6% of them due to Plasmodium vivax, were microscopically diagnosed in 8.0% of the women and were associated with an average reduction in birth weight z-scores of 0.35 (95% confidence interval [CI] = 0.14-0.57) and in birth length z-scores of 0.31 (95% CI = 0.08-0.54), compared with malaria-free pregnancies. Affected mothers had a mean decrease in hemoglobin concentration at delivery of 0.33 g/100 mL (95% CI = 0.05-0.62 g/100 mL); 51.6% were anemic. The timing and frequency of antenatal infections influenced pregnancy outcomes and first- or second-trimester infections were not associated with decreased birth weight and length and maternal hemoglobin at delivery. Although repeated antenatal vivax infections were associated with poorer birth outcomes, even a single vivax malaria episode was associated with a significant reduction in birth weight and length and maternal hemoglobin. Overall, 7.5% women had the parasite's DNA found in peripheral blood at delivery. Most (83.1%) of these 89 perinatal infections were due to P. vivax and only 7.9% of them progressed to symptomatic disease after delivery. Plasmodium vivax and Plasmodium falciparum DNA was found in 0.6% and 0.3% of 637 cord blood samples examined, respectively, but only one newborn developed clinical neonatal malaria. Our results further challenge the notion that vivax malaria is relatively benign during pregnancy and call for better strategies for its prevention.
Collapse
Affiliation(s)
- Anaclara Pincelli
- Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Paulo A R Neves
- Department of Nutrition, School of Public Health, University of São Paulo, São Paulo, Brazil
| | - Barbara H Lourenço
- Department of Preventive Medicine, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, Brazil.,Department of Nutrition, School of Public Health, University of São Paulo, São Paulo, Brazil
| | - Rodrigo M Corder
- Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Maíra B Malta
- Department of Nutrition, School of Public Health, University of São Paulo, São Paulo, Brazil
| | - Juliana Sampaio-Silva
- Department of Nutrition, School of Public Health, University of São Paulo, São Paulo, Brazil
| | - Rodrigo M de Souza
- Multidisciplinary Center, Federal University of Acre, Cruzeiro do Sul, Brazil
| | - Marly A Cardoso
- Department of Nutrition, School of Public Health, University of São Paulo, São Paulo, Brazil
| | - Marcia C Castro
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Marcelo U Ferreira
- Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | | |
Collapse
|
11
|
Otuli NL, Nguma JDB, Mike-Antoine MA, O’yandjo AM, Bosunga GK, Likwela JL, Okenge JPM. Prevalence of Gestational Malaria in Kisangani, Democratic Republic of Congo. ACTA ACUST UNITED AC 2018. [DOI: 10.4236/ojog.2018.810089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
12
|
Mørch K, Manoharan A, Chandy S, Chacko N, Alvarez-Uria G, Patil S, Henry A, Nesaraj J, Kuriakose C, Singh A, Kurian S, Gill Haanshuus C, Langeland N, Blomberg B, Vasanthan Antony G, Mathai D. Acute undifferentiated fever in India: a multicentre study of aetiology and diagnostic accuracy. BMC Infect Dis 2017; 17:665. [PMID: 28978319 PMCID: PMC5628453 DOI: 10.1186/s12879-017-2764-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 09/25/2017] [Indexed: 01/04/2023] Open
Abstract
Background The objectives of this study were to determine the proportion of malaria, bacteraemia, scrub typhus, leptospirosis, chikungunya and dengue among hospitalized patients with acute undifferentiated fever in India, and to describe the performance of standard diagnostic methods. Methods During April 2011–November 2012, 1564 patients aged ≥5 years with febrile illness for 2–14 days were consecutively included in an observational study at seven community hospitals in six states in India. Malaria microscopy, blood culture, Dengue rapid NS1 antigen and IgM Combo test, Leptospira IgM ELISA, Scrub typhus IgM ELISA and Chikungunya IgM ELISA were routinely performed at the hospitals. Second line testing, Dengue IgM capture ELISA (MAC-ELISA), Scrub typhus immunofluorescence (IFA), Leptospira Microscopic Agglutination Test (MAT), malaria PCR and malaria immunochromatographic rapid diagnostic test (RDT) Parahit Total™ were performed at the coordinating centre. Convalescence samples were not available. Case definitions were as follows: Leptospirosis: Positive ELISA and positive MAT. Scrub typhus: Positive ELISA and positive IFA. Dengue: Positive RDT and/or positive MAC-ELISA. Chikungunya: Positive ELISA. Bacteraemia: Growth in blood culture excluding those defined as contaminants. Malaria: Positive genus-specific PCR. Results Malaria was diagnosed in 17% (268/1564) and among these 54% had P. falciparum. Dengue was diagnosed in 16% (244/1564). Bacteraemia was found in 8% (124/1564), and among these Salmonella typhi or S. paratyphi constituted 35%. Scrub typhus was diagnosed in 10%, leptospirosis in 7% and chikungunya in 6%. Fulfilling more than one case definition was common, most frequent in chikungunya where 26% (25/98) also had positive dengue test. Conclusions Malaria and dengue were the most common causes of fever in this study. A high overlap between case definitions probably reflects high prevalence of prior infections, cross reactivity and subclinical infections, rather than high prevalence of coinfections. Low accuracy of routine diagnostic tests should be taken into consideration when approaching the patient with acute undifferentiated fever in India.
Collapse
Affiliation(s)
- Kristine Mørch
- National Centre for Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway. .,Department of Clinical Science, University of Bergen, Bergen, Norway.
| | - Anand Manoharan
- Infectious Diseases Training and Research Centre, Department of Medicine, Christian Medical College, Vellore, India
| | - Sara Chandy
- Infectious Diseases Training and Research Centre, Department of Medicine, Christian Medical College, Vellore, India
| | | | | | - Suvarna Patil
- B.K.L. Walawalkar Hospital, Ratnagiri, Maharashtra, India
| | - Anil Henry
- Christian Hospital, Mungeli, Chhattisgarh, India
| | | | - Cijoy Kuriakose
- Christian Fellowship Hospital, Oddanchatram, Tamil Nadu, India
| | - Ashita Singh
- Baptist Christian Hospital, Tezpur, Assam, India
| | - Siby Kurian
- Infectious Diseases Training and Research Centre, Department of Medicine, Christian Medical College, Vellore, India
| | - Christel Gill Haanshuus
- National Centre for Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Nina Langeland
- National Centre for Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Bjørn Blomberg
- National Centre for Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - George Vasanthan Antony
- Infectious Diseases Training and Research Centre, Department of Medicine, Christian Medical College, Vellore, India
| | - Dilip Mathai
- Infectious Diseases Training and Research Centre, Department of Medicine, Christian Medical College, Vellore, India
| |
Collapse
|
13
|
Corrêa G, Das M, Kovelamudi R, Jaladi N, Pignon C, Vysyaraju K, Yedla U, Laxmi V, Vemula P, Gowthami V, Sharma H, Remartinez D, Kalon S, de Polnay K, De Smet M, Isaakidis P. High burden of malaria and anemia among tribal pregnant women in a chronic conflict corridor in India. Confl Health 2017. [PMID: 28649273 PMCID: PMC5477337 DOI: 10.1186/s13031-017-0113-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background With more than 200 million cases a year, malaria is an important global health concern, especially among pregnant women. The forested tribal areas of Andhra Pradesh, Telangana and Chhattisgarh in India are affected by malaria and by an on-going chronic conflict which seriously limits access to health care. The burden of malaria and anemia among pregnant women in these areas is unknown; moreover there are no specific recommendations for pregnant women in the Indian national malaria policy. The aim of this study is to measure the burden of malaria and anemia among pregnant women presenting in mobile clinics for antenatal care in a conflict-affected corridor in India. Methods This is a descriptive study of routine programme data of women presenting at first visit for antenatal care in Médecins sans Frontières mobile clinics during 1 year (2015). Burden of malaria and anemia were estimated using rapid diagnostic tests (SD BIOLINE® and HemoCue® respectively). Results Among 575 pregnant women (median age: 26 years, interquartile range: 25-30) 29% and 22% were in their first and second pregnancies respectively. Mid-Upper Arm Circumference (MUAC) was below 230 mm in 74% of them. The prevalence of anemia was 92.4% (95% Confidence Intervals (CI): 89.9–94.3), while severe anemia was identified in 6.9% of the patients. The prevalence of malaria was 29.3% (95%CI: 25.7–33.2) with 64% caused by isolated P. falciparum, 35% by either P. falciparum or mixed malaria and 1% by either P. vivax, or P.malariae or P. ovale. Malaria test was positive in 20.8% of asymptomatic cases. Malaria was associated with severe anemia (prevalence ratio: 2.56, 95%CI: 1.40–4.66, p < 0.01). Conclusions Systematic screening for malaria and anemia should be integrated into maternal and child health services for conflict affected populations in highly endemic tribal areas. Interventions should include the use of rapid diagnostic test for all pregnant women at every visit, regardless of symptoms. Further studies should evaluate the impact of this intervention alone or in combination with intermittent malaria preventive treatment.
Collapse
Affiliation(s)
- Gustavo Corrêa
- Médecins sans Frontières, Bhadrachalam, Khammam District, Telangana, 507111 India.,Médecins Sans Frontières, Brussels, 46, Rue de l'Arbre Bénit, 1050 Brussels, Belgium
| | - Mrinalini Das
- Médecins sans Frontières, Bhadrachalam, Khammam District, Telangana, 507111 India
| | - Rama Kovelamudi
- Médecins sans Frontières, Bhadrachalam, Khammam District, Telangana, 507111 India
| | - Nagendra Jaladi
- Government Hospital, Bhadrachalam, Khammam District, Telangana, 507111 India
| | - Charlotte Pignon
- Médecins sans Frontières, Bhadrachalam, Khammam District, Telangana, 507111 India
| | - Kalyan Vysyaraju
- Médecins sans Frontières, Bhadrachalam, Khammam District, Telangana, 507111 India
| | - Usha Yedla
- Médecins sans Frontières, Bhadrachalam, Khammam District, Telangana, 507111 India
| | - Vijya Laxmi
- Médecins sans Frontières, Bhadrachalam, Khammam District, Telangana, 507111 India
| | - Pavani Vemula
- Médecins sans Frontières, Bhadrachalam, Khammam District, Telangana, 507111 India
| | - Vijaya Gowthami
- Médecins sans Frontières, Bhadrachalam, Khammam District, Telangana, 507111 India
| | - Hemant Sharma
- Médecins sans Frontières, Bhadrachalam, Khammam District, Telangana, 507111 India
| | - Daniel Remartinez
- Médecins sans Frontières, Bhadrachalam, Khammam District, Telangana, 507111 India.,Médecins Sans Frontières, Brussels, 46, Rue de l'Arbre Bénit, 1050 Brussels, Belgium
| | - Stobdan Kalon
- Médecins sans Frontières, Bhadrachalam, Khammam District, Telangana, 507111 India.,Médecins Sans Frontières, Brussels, 46, Rue de l'Arbre Bénit, 1050 Brussels, Belgium
| | - Kirrily de Polnay
- Médecins Sans Frontières, Brussels, 46, Rue de l'Arbre Bénit, 1050 Brussels, Belgium
| | - Martin De Smet
- Médecins Sans Frontières, Brussels, 46, Rue de l'Arbre Bénit, 1050 Brussels, Belgium
| | - Petros Isaakidis
- Médecins sans Frontières, Bhadrachalam, Khammam District, Telangana, 507111 India.,Operational Research Unit, Médecins Sans Frontières, Luxembourg, 68, rue de Gasperich, L-1617 Luxembourg, Belgium
| |
Collapse
|
14
|
Bardají A, Martínez-Espinosa FE, Arévalo-Herrera M, Padilla N, Kochar S, Ome-Kaius M, Bôtto-Menezes C, Castellanos ME, Kochar DK, Kochar SK, Betuela I, Mueller I, Rogerson S, Chitnis C, Hans D, Menegon M, Severini C, del Portillo H, Dobaño C, Mayor A, Ordi J, Piqueras M, Sanz S, Wahlgren M, Slutsker L, Desai M, Menéndez C. Burden and impact of Plasmodium vivax in pregnancy: A multi-centre prospective observational study. PLoS Negl Trop Dis 2017; 11:e0005606. [PMID: 28604825 PMCID: PMC5481034 DOI: 10.1371/journal.pntd.0005606] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 06/22/2017] [Accepted: 04/27/2017] [Indexed: 11/22/2022] Open
Abstract
Background Despite that over 90 million pregnancies are at risk of Plasmodium vivax infection annually, little is known about the epidemiology and impact of the infection in pregnancy. Methodology and principal findings We undertook a health facility-based prospective observational study in pregnant women from Guatemala (GT), Colombia (CO), Brazil (BR), India (IN) and Papua New Guinea PNG). Malaria and anemia were determined during pregnancy and fetal outcomes assessed at delivery. A total of 9388 women were enrolled at antennal care (ANC), of whom 53% (4957) were followed until delivery. Prevalence of P. vivax monoinfection in maternal blood at delivery was 0.4% (20/4461) by microscopy [GT 0.1%, CO 0.5%, BR 0.1%, IN 0.2%, PNG 1.2%] and 7% (104/1488) by PCR. P. falciparum monoinfection was found in 0.5% (22/4463) of women by microscopy [GT 0%, CO 0.5%, BR 0%, IN 0%, PNG 2%]. P. vivax infection was observed in 0.4% (14/3725) of placentas examined by microscopy and in 3.7% (19/508) by PCR. P. vivax in newborn blood was detected in 0.02% (1/4302) of samples examined by microscopy [in cord blood; 0.05% (2/4040) by microscopy, and 2.6% (13/497) by PCR]. Clinical P. vivax infection was associated with increased risk of maternal anemia (Odds Ratio-OR, 5.48, [95% CI 1.83–16.41]; p = 0.009), while submicroscopic vivax infection was not associated with increased risk of moderate-severe anemia (Hb<8g/dL) (OR, 1.16, [95% CI 0.52–2.59]; p = 0.717), or low birth weight (<2500g) (OR, 0.52, [95% CI, 0.23–1.16]; p = 0.110). Conclusions In this multicenter study, the prevalence of P. vivax infection in pregnancy by microscopy was overall low across all endemic study sites; however, molecular methods revealed a significant number of submicroscopic infections. Clinical vivax infection in pregnancy was associated with maternal anemia, which may be deleterious for infant’s health. These results may help to guide maternal health programs in settings where vivax malaria is endemic; they also highlight the need of addressing a vulnerable population such as pregnant women while embracing malaria elimination in endemic countries. More than 90 million pregnancies are exposed to P. vivax infection every year. While it is well known that pregnant women have an increased risk of P. falciparum infection and disease, much less is known on the epidemiology and the impact of P. vivax in pregnancy. A health-facility based observational study was conducted in pregnant women living in five vivax endemic countries aimed to determine the burden of the infection in pregnancy and its impact on the mother and the newborn health. We found that the prevalence of P. vivax malaria in pregnant women attending the routine antenatal clinic visits was overall low across all sites, however submicroscopic infections were unexpectedly high in some areas. Pregnant women with clinical malaria experienced an increased risk of anemia, which may have a deleterious impact on infant health. These findings may be useful for guiding maternal health programs in vivax endemic settings, as well as for malaria elimination activities.
Collapse
Affiliation(s)
- Azucena Bardají
- Barcelona Center for International Health Research, CRESIB, ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- * E-mail:
| | - Flor Ernestina Martínez-Espinosa
- Gerência de Malária, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
- Instituto Leônidas e Maria Deane, FIOCRUZ Amazônia, Manaus, Brazil
| | | | - Norma Padilla
- Centro de Estudios en Salud, Universidad del Valle de Guatemala, Guatemala, Guatemala
| | - Swati Kochar
- Department of Medicine, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | - Maria Ome-Kaius
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Camila Bôtto-Menezes
- Gerência de Malária, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | | | | | - Sanjay Kumar Kochar
- Department of Medicine, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | - Inoni Betuela
- Papua New Guinea Institute of Medical Research, Madang, Madang Province, Papua New Guinea
| | - Ivo Mueller
- Barcelona Center for International Health Research, CRESIB, ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- The Walter and Eliza Hall Institute, Parkville, Victoria, Australia
| | - Stephen Rogerson
- Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Parkville, Victoria, Australia
| | - Chetan Chitnis
- International Center for Genetic Engineering and Biotechnology, New Delhi, India
| | - Dhiraj Hans
- International Center for Genetic Engineering and Biotechnology, New Delhi, India
| | - Michela Menegon
- Department of Infectious, Parasitic and Immunomediated Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Carlo Severini
- Department of Infectious, Parasitic and Immunomediated Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Hernando del Portillo
- Barcelona Center for International Health Research, CRESIB, ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain
| | - Carlota Dobaño
- Barcelona Center for International Health Research, CRESIB, ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Alfredo Mayor
- Barcelona Center for International Health Research, CRESIB, ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Jaume Ordi
- Barcelona Center for International Health Research, CRESIB, ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Mireia Piqueras
- Barcelona Center for International Health Research, CRESIB, ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Sergi Sanz
- Barcelona Center for International Health Research, CRESIB, ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | | | - Laurence Slutsker
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Meghna Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Clara Menéndez
- Barcelona Center for International Health Research, CRESIB, ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | | |
Collapse
|
15
|
Haanshuus CG, Chandy S, Manoharan A, Vivek R, Mathai D, Xena D, Singh A, Langeland N, Blomberg B, Vasanthan G, Sitaram U, Appasamy J, Nesaraj J, Henry A, Patil S, Alvarez-Uria G, Armstrong L, Mørch K. A High Malaria Prevalence Identified by PCR among Patients with Acute Undifferentiated Fever in India. PLoS One 2016; 11:e0158816. [PMID: 27389396 PMCID: PMC4936667 DOI: 10.1371/journal.pone.0158816] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 06/22/2016] [Indexed: 11/29/2022] Open
Abstract
Background Approximately one million malaria cases were reported in India in 2015, based on microscopy. This study aims to assess the malaria prevalence among hospitalised fever patients in India identified by PCR, and to evaluate the performance of routine diagnostic methods. Methods During June 2011-December 2012, patients admitted with acute undifferentiated fever to seven secondary level community hospitals in Assam (Tezpur), Bihar (Raxaul), Chhattisgarh (Mungeli), Maharashtra (Ratnagiri), Andhra Pradesh (Anantapur) and Tamil Nadu (Oddanchatram and Ambur) were included. The malaria prevalence was assessed by polymerase chain reaction (PCR), routine microscopy, and a rapid diagnostic test (RDT) with PCR as a reference method. Results The malaria prevalence by PCR was 19% (268/1412) ranging from 6% (Oddanchatram, South India) to 35% (Ratnagiri, West India). Among malaria positive patients P. falciparum single infection was detected in 46%, while 38% had P. vivax, 11% mixed infections with P. falciparum and P. vivax, and 5% P. malariae. Compared to PCR, microscopy had sensitivity of 29% and specificity of 98%, while the RDT had sensitivity of 24% and specificity of 99%. Conclusions High malaria prevalence was identified by PCR in this cohort. Routine diagnostic methods had low sensitivity compared to PCR. The results suggest that malaria is underdiagnosed in rural India. However, low parasitaemia controlled by immunity may constitute a proportion of PCR positive cases, which calls for awareness of the fact that other pathogens could be responsible for the febrile disease in submicroscopic malaria.
Collapse
Affiliation(s)
- Christel Gill Haanshuus
- National Centre for Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Sara Chandy
- Infectious Diseases Training and Research Center, Department of Medicine Unit-1 and Infectious Diseases, Christian Medical College, Vellore, India
| | - Anand Manoharan
- Infectious Diseases Training and Research Center, Department of Medicine Unit-1 and Infectious Diseases, Christian Medical College, Vellore, India
- * E-mail:
| | - Rosario Vivek
- Infectious Diseases Training and Research Center, Department of Medicine Unit-1 and Infectious Diseases, Christian Medical College, Vellore, India
| | - Dilip Mathai
- Infectious Diseases Training and Research Center, Department of Medicine Unit-1 and Infectious Diseases, Christian Medical College, Vellore, India
| | - Deepika Xena
- Infectious Diseases Training and Research Center, Department of Medicine Unit-1 and Infectious Diseases, Christian Medical College, Vellore, India
| | - Ashita Singh
- Baptist Christian Hospital, Tezpur, Assam, India
| | - Nina Langeland
- National Centre for Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Bjørn Blomberg
- National Centre for Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - George Vasanthan
- Infectious Diseases Training and Research Center, Department of Medicine Unit-1 and Infectious Diseases, Christian Medical College, Vellore, India
| | - Usha Sitaram
- Infectious Diseases Training and Research Center, Department of Medicine Unit-1 and Infectious Diseases, Christian Medical College, Vellore, India
| | | | | | - Anil Henry
- Christian Hospital, Mungeli, Chhattisgarh, India
| | - Suvarna Patil
- B.K.L. Walawalkar Hospital, Ratnagiri, Maharashtra, India
| | | | | | - Kristine Mørch
- National Centre for Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
16
|
Sharma RK, Thakor HG, Saha KB, Sonal GS, Dhariwal AC, Singh N. Malaria situation in India with special reference to tribal areas. Indian J Med Res 2016; 141:537-45. [PMID: 26139770 PMCID: PMC4510751 DOI: 10.4103/0971-5916.159510] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background & objectives: In India, malaria is a major public health problem in States having predominantly tribal population. The objective of this analysis was to find out the incidence of malaria in various States/districts having varied proportions of tribal population using National Vector Borne Disease Control Programme (NVBDCP) data. Methods: States and districts were classified into three categories based on proportions of Scheduled Tribes (ST) population as <10, 10-29.9 and 30 per cent + ST population. Five year average (2008-2012) of all important malaria indicators collected by NVBDCP was taken to normalize the effect of annual fluctuations in malaria incidence. Results: State level analysis revealed that ten States/UTs with 30 per cent or more tribal population comprising only three per cent of total population, contributed 14 per cent of total malaria, 21 per cent Plasmodium falciparum and 29 per cent of deaths due to malaria. Similarly, district level analysis showed that districts with 30 per cent or more tribal population comprising about eight per cent country's population contributed to 46 per cent of total malaria cases, 70 per cent P. falciparum and 47 per cent malarial deaths in the country. Interpretation & conclusions: Our analysis showed that the neglect of the ethnic communities in tribal areas would be detrimental to the overall reduction of morbidity and mortality due to malaria. The fight against the increasing burden of malaria in tribal belt requires adoption of multiple approaches and socio-economic development of the tribal communities.
Collapse
Affiliation(s)
| | | | | | | | | | - Neeru Singh
- National Institute for Research in Tribal Health (ICMR), Jabalpur, Madhya Pradesh, India
| |
Collapse
|
17
|
Microsatellite Genotyping of Plasmodium vivax Isolates from Pregnant Women in Four Malaria Endemic Countries. PLoS One 2016; 11:e0152447. [PMID: 27011010 PMCID: PMC4807005 DOI: 10.1371/journal.pone.0152447] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 03/14/2016] [Indexed: 11/19/2022] Open
Abstract
Plasmodium vivax is the most widely distributed human parasite and the main cause of human malaria outside the African continent. However, the knowledge about the genetic variability of P. vivax is limited when compared to the information available for P. falciparum. We present the results of a study aimed at characterizing the genetic structure of P. vivax populations obtained from pregnant women from different malaria endemic settings. Between June 2008 and October 2011 nearly 2000 pregnant women were recruited during routine antenatal care at each site and followed up until delivery. A capillary blood sample from the study participants was collected for genotyping at different time points. Seven P. vivax microsatellite markers were used for genotypic characterization on a total of 229 P. vivax isolates obtained from Brazil, Colombia, India and Papua New Guinea. In each population, the number of alleles per locus, the expected heterozygosity and the levels of multilocus linkage disequilibrium were assessed. The extent of genetic differentiation among populations was also estimated. Six microsatellite loci on 137 P. falciparum isolates from three countries were screened for comparison. The mean value of expected heterozygosity per country ranged from 0.839 to 0.874 for P. vivax and from 0.578 to 0.758 for P. falciparum. P. vivax populations were more diverse than those of P. falciparum. In some of the studied countries, the diversity of P. vivax population was very high compared to the respective level of endemicity. The level of inter-population differentiation was moderate to high in all P. vivax and P. falciparum populations studied.
Collapse
|
18
|
Sharma D, Shastri S, Farahbakhsh N, Sharma P. Intrauterine growth restriction - part 1. J Matern Fetal Neonatal Med 2016; 29:3977-87. [PMID: 26856409 DOI: 10.3109/14767058.2016.1152249] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Intrauterine growth restriction (IUGR) is a major and silent cause of various morbidity and mortality for the fetal and neonatal population. It is defined as a rate of fetal growth that is less than normal for the growth potential of that specific infant. The terms IUGR and small for gestational age (SGA) are often used interchangeably, although there exists subtle differences between the two. IUGR/SGA is an end result of various etiologies that includes maternal, placental and fetal factors and recently added genetic factors too, also contribute to IUGR. In this review article we will cover the antenatal aspect of IUGR and management with proven preventive intervention.
Collapse
Affiliation(s)
- Deepak Sharma
- a Department of Pediatrics , Pt. B.D. Sharma PGIMS , Rohtak , India
| | - Sweta Shastri
- b Department of Pathology , N.K.P Salve Medical College , Nagpur , India
| | - Nazanin Farahbakhsh
- c Department of Pediatrics , Shiraz University of Medicine , Shiraz , Iran , and
| | | |
Collapse
|
19
|
Pradhan A, Anasuya A, Pradhan MM, AK K, Kar P, Sahoo KC, Panigrahi P, Dutta A. Trends in Malaria in Odisha, India-An Analysis of the 2003-2013 Time-Series Data from the National Vector Borne Disease Control Program. PLoS One 2016; 11:e0149126. [PMID: 26866696 PMCID: PMC4750863 DOI: 10.1371/journal.pone.0149126] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 01/27/2016] [Indexed: 11/26/2022] Open
Abstract
Background Although Odisha is the largest contributor to the malaria burden in India, no systematic study has examined its malaria trends. Hence, the spatio-temporal trends in malaria in Odisha were assessed against the backdrop of the various anti-malaria strategies implemented in the state. Methods Using the district-wise malaria incidence and blood examination data (2003–2013) from the National Vector Borne Disease Control Program, blood examination-adjusted time-trends in malaria incidence were estimated and predicted for 2003–2013 and 2014–2016, respectively. An interrupted time series analysis using segmented regression was conducted to compare the disease trends between the pre (2003–2007) and post-intensification (2009–2013) periods. Key-informant interviews of state stakeholders were used to collect the information on the various anti-malaria strategies adopted in the state. Results The state annual malaria incidence declined from 10.82/1000 to 5.28/1000 during 2003–2013 (adjusted annual decline: -0.54/1000, 95% CI: -0.78 to -0.30). However, the annual blood examination rate remained almost unchanged from 11.25% to 11.77%. The keyinformants revealed that intensification of anti-malaria activities in 2008 led to a more rapid decline in malaria incidence during 2009–2013 as compared to that in 2003–2007 [adjusted decline: -0.83 (-1.30 to -0.37) and -0.27 (-0.41 to -0.13), respectively]. There was a significant difference in the two temporal slopes, i.e., -0.054 (-0.10 to -0.002, p = 0.04) per 1000 population per month, between these two periods, indicating almost a 200% greater decline in the post-intensification period. Although, the seven southern high-burden districts registered the highest decline, they continued to remain in that zone, thereby, making the achievement of malaria elimination (incidence <1/1000) unlikely by 2017. Conclusion The anti-malaria strategies in Odisha, especially their intensification since 2008, have helped improve its malaria situation in recent years. These successful measures need to be sustained and perhaps intensified further for eliminating malaria from Odisha.
Collapse
Affiliation(s)
- Ashirbad Pradhan
- Centre for Disease Epidemiology and Surveillance, Asian Institute of Public Health, Bhubaneswar, Odisha, India
| | - Anita Anasuya
- Department for International Development, United Kingdom supported Technical and Management Support Team, Bhubaneswar, Odisha, India
| | - Madan Mohan Pradhan
- National Vector Borne Disease Control Programme, Department of Health and Family Welfare, Government of Odisha, Bhubaneswar, Odisha, India
| | - Kavitha AK
- Centre for Disease Epidemiology and Surveillance, Asian Institute of Public Health, Bhubaneswar, Odisha, India
| | - Priyanka Kar
- National Vector Borne Disease Control Programme, Department of Health and Family Welfare, Government of Odisha, Bhubaneswar, Odisha, India
| | - Krushna Chandra Sahoo
- Centre for Disease Epidemiology and Surveillance, Asian Institute of Public Health, Bhubaneswar, Odisha, India
| | - Pinaki Panigrahi
- Center for Global Health and Development, College of Public Health, University of Nebraska Medical Center, Omaha, United States of America
| | - Ambarish Dutta
- Centre for Disease Epidemiology and Surveillance, Asian Institute of Public Health, Bhubaneswar, Odisha, India
- Indian Institute of Public Health, Public Health Foundation of India, Bhubaneswar, Odisha, India
- * E-mail:
| |
Collapse
|
20
|
Wylie BJ, Singh MP, Coull BA, Quinn A, Yeboah-Antwi K, Sabin L, Hamer DH, Singh N, MacLeod WB. Association between wood cooking fuel and maternal hypertension at delivery in central East India. Hypertens Pregnancy 2015; 34:355-68. [PMID: 26153626 DOI: 10.3109/10641955.2015.1046604] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Smoke from burning of biomass fuels has been linked with adverse pregnancy outcomes and hypertension among nonpregnant subjects; association with hypertension during pregnancy has not been well studied. We evaluated whether the use of wood cooking fuel increases the risk of maternal hypertension at delivery compared to gas which burns with less smoke. METHODS Information on fuel use and blood pressure was available for analysis from a cross-sectional survey of 1369 pregnant women recruited at delivery in India. RESULTS Compared to gas users, women using wood as fuel had on average lower mean arterial pressure (adjusted effect size - 2.0 mmHg; 95% CI: -3.77, -0.31) and diastolic blood pressure (adjusted effect size -1.96 mmHg; 95% CI: -3.60, -0.30) at delivery. Risk of hypertension (systolic >139 mmHg or diastolic >89 mmHg) was 14.6% for wood users compared to 19.6% for gas users although this did not reach significance after adjustment, using propensity score techniques, for factors that make wood and gas users distinct (adjusted prevalence ratio 0.76; 95% CI: 0.49, 1.17). CONCLUSIONS Combustion products from the burning of biomass fuels are similar to those released with tobacco smoking, which has been linked with a reduced risk for preeclampsia. The direction of our findings suggests the possibility of a similar effect for biomass cook smoke. Whether clean cooking interventions being promoted by international advocacy organizations will impact hypertension in pregnancy warrants further analysis as hypertension remains a leading cause of maternal death worldwide and cooking with biomass fuels is widespread.
Collapse
Affiliation(s)
- Blair J Wylie
- Division of Maternal-Fetal Medicine, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School , Boston, MA , USA
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Singh N, Bharti PK, Singh MP, Singh R, Yeboah-Antwi K, Desai M, Udhayakumar V, Muniyandi M, Hamer DH, Wylie BJ. What is the burden of submicroscopic malaria in pregnancy in central India? Pathog Glob Health 2015; 109:30-8. [PMID: 25627878 DOI: 10.1179/2047773215y.0000000002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Conventional microscopy underestimates the burden of malarial infection when compared with molecular diagnosis using polymerase chain reaction (PCR)-based methods. Lower density parasitemias serve as a reservoir for infection. We evaluated the prevalence of submicroscopic infections in an area of unstable malarial transmission in India and determined whether these infections negatively impacted maternal or fetal outcomes. METHODS This cross-sectional study (2007-2008) was undertaken in two districts of Chhattisgarh, recruiting women from both antenatal clinics (ANCs) and delivery units (DUs). For ANC/DU subjects, peripheral/placental blood, respectively, was obtained for conventional microscopy and collected onto filter paper for PCR analysis. RESULTS There were 3425 pregnant women, including 2477 ANC subjects and 948 DU subjects who had both microscopic and PCR samples available. Polymerase chain reaction detected significantly more Plasmodium infections than traditional light microscopy both from peripheral (3·4 vs 1·2%; OR 2·9, 95% confidence intervals (CIs) 1·9-4·5) and placental (4·2 vs 1·7%; OR 2·5, 95% CIs 1·4-4·8) blood samples. Submicroscopic infections were not associated with anemia or severe maternal anemia among ANC or DU participants and were not associated with low birth weight (LBW) among DU participants. In contrast, microscopically detected infections were associated with severe anemia and LBW. CONCLUSIONS In this area of unstable malarial transmission from India, submicroscopic infections did not identify a set of pregnant women at increased risk for anemia or LBW. Until PCR techniques become much less expensive and available as a point of care test for the field setting, its use will be limited for malarial detection.
Collapse
|
22
|
Cisse M, Sangare I, Lougue G, Bamba S, Bayane D, Guiguemde RT. Prevalence and risk factors for Plasmodium falciparum malaria in pregnant women attending antenatal clinic in Bobo-Dioulasso (Burkina Faso). BMC Infect Dis 2014; 14:631. [PMID: 25408152 PMCID: PMC4240871 DOI: 10.1186/s12879-014-0631-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 11/11/2014] [Indexed: 11/10/2022] Open
Abstract
Background Malaria during pregnancy remains a serious public health problem. The aim of this study was to determine the prevalence and possible risk factors for malaria in pregnant women attending antenatal clinic at two primary health facilities in Bobo-Dioulasso. Methods We conducted a cross sectional study from September to December 2010 in two primary health facilities located in the periurban area of Bobo-Dioulasso. Pregnant women attending antenatal clinic (ANC) were included in the study after signing informed consent. For each participant, the social-demographic profile, malaria and obstetric histories were investigated through a questionnaire. Peripheral blood was collected and thick and thin blood smears were prepared to check Plasmodium falciparum parasitaemia. Hemoglobin concentration was measured. The associations between age, parity, gestational age, schooling, number of ANC visits, use of IPTp-SP, use of insecticide-treated nets (ITN) and anemia with the occurrence of P. falciparum malaria infection during pregnancy were analyzed through logistic regression. Results During the period of study, 105 (18.1%) out of 579 pregnant women were infected by P. falciparum. The hemoglobin concentration mean was 10.5 ± 1.7/dL and was significantly lower in pregnant women with malaria infection (9.8 g/dL ±1.6) than in those who had no malaria infection (10.6 g/dL ±1.7) (P < 0.001). Multivariate analysis indicated that, education (AOR 1.9, 95% CI = [1.2-3.2]), parity [primigravidae (AOR 5.0, 95% CI = [2.5-9.8]) and secundigravidae (AOR 2.1, 95% CI = [1.2-3.8])], and anaemia (AOR 2.1, 95% CI = [1.3-3.5]) were significantly associated with P. falciparum malaria infection. The use of IPTp-SP was not associated with P. falciparum malaria infection. Conclusions P. falciparum malaria infection is common in pregnant women attending antenatal clinic and anaemia is an important complication. The results show that the use of IPTp-SP does not reduce the risk of malaria incidence during pregnancy. Electronic supplementary material The online version of this article (doi:10.1186/s12879-014-0631-z) contains supplementary material, which is available to authorized users.
Collapse
|
23
|
Qureshi IA, Arlappa N, Qureshi MA. Prevalence of malaria and anemia among pregnant women residing in malaria-endemic forest villages in India. Int J Gynaecol Obstet 2014; 127:93. [PMID: 25092357 DOI: 10.1016/j.ijgo.2014.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 06/20/2014] [Accepted: 07/14/2014] [Indexed: 11/26/2022]
|
24
|
Ahmed R, Singh N, ter Kuile FO, Bharti PK, Singh PP, Desai M, Udhayakumar V, Terlouw DJ. Placental infections with histologically confirmed Plasmodium falciparum are associated with adverse birth outcomes in India: a cross-sectional study. Malar J 2014; 13:232. [PMID: 24927762 PMCID: PMC4065549 DOI: 10.1186/1475-2875-13-232] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 06/08/2014] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Few studies have assessed placental malaria infections from low transmission areas by histopathology to define their impact and underlying mechanisms. METHODS Peripheral smears and rapid diagnostic tests (RDTs), placental smears and histological samples, birth weight and gestational age were collected from 2,282 deliveries in three hospitals during a one-year (2006-2007) continuous cross-sectional survey in Madhya Pradesh. Placental histopathology included all 50 cases positive by microscopy or RDT plus 456 randomly selected samples of women negative for malaria by microscopy or RDT. Histological examination included parasites, inflammatory cells, pigment in fibrin, and morphological changes. RESULTS There were 52 histology-positive cases; 38 (73.1%) active (acute and chronic) and 14 past infections. Intervillous parasitaemia was low (60% had < 1% parasitaemia) and monocytosis mostly mild (63%). Compared with uninfected placentas, acute Plasmodium falciparum infections were associated with stillbirth (RR 3.8, 95% CI 1.2-12.1), lower maternal haemoglobin (mean difference: 1.5 g/dL, 95% CI 0.5-2.5), lower birth weight (mean difference 451 g, 95% CI 169-609) and shorter gestation (mean difference 0.8 weeks, 95% CI 0.2-1.4). Chronic or past infections were not associated with these outcomes. Among the 11 peripheral Plasmodium vivax cases, placental parasites were absent, but they were associated with increased placental polymorphonuclear cells. CONCLUSIONS Malaria associated stillbirth and low birth weight in women with low protective immunity may result, at least in part, from a shortened gestation triggered by acute infection, stressing the importance of early malaria detection.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Dianne J Terlouw
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
| |
Collapse
|
25
|
Wylie BJ, Coull BA, Hamer DH, Singh MP, Jack D, Yeboah-Antwi K, Sabin L, Singh N, MacLeod WB. Impact of biomass fuels on pregnancy outcomes in central East India. Environ Health 2014; 13:1. [PMID: 24405644 PMCID: PMC3922846 DOI: 10.1186/1476-069x-13-1] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 01/02/2014] [Indexed: 05/20/2023]
Abstract
BACKGROUND Smoke from biomass burning has been linked to reduced birth weight; association with other birth outcomes is poorly understood. Our objective was to evaluate effects of exposure to biomass smoke on birth weight, preterm birth and stillbirth. METHODS Information on household cooking fuel was available for secondary analysis from two cohorts of pregnant women enrolled at delivery in India (n = 1744). Birth weight was measured and the modified Ballard performed to assess gestational age. Linear and logistic regression models were used to explore associations between fuel and birth outcomes. Effect sizes were adjusted in multivariate models for socio-demographic characteristics using propensity score techniques and for medical/obstetric covariates. RESULTS Compared to women who use gas (n = 265), women cooking with wood (n = 1306) delivered infants that were on average 112 grams lighter (95% CI -170.1, -54.6) and more likely to be preterm (OR 3.11, 95% CI 2.12, 4.59). Stillbirths were also more common in the wood group (4% versus 0%, p < 0.001). In adjusted models, the association between wood use and birth weight was no longer significant (14 g reduction; 95% CI -93, 66); however, the increased odds for preterm birth persisted (aOR 2.29; 95% CI 1.24, 4.21). Wood fuel use did not increase the risk of delivering either a low birth weight or small for gestational age infant. CONCLUSIONS The association between wood fuel use and reduced birth weight was insignificant in multivariate models using propensity score techniques to account for socio-demographic differences. In contrast, we demonstrated a persistent adverse impact of wood fuel use on preterm delivery. If prematurity is confirmed as a consequence of antenatal exposure to household air pollution, perinatal morbidity and mortality from household air pollution may be higher than previously appreciated.
Collapse
Affiliation(s)
- Blair J Wylie
- Division of Maternal-Fetal Medicine, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, USA
- Center for Global Health and Development, Boston University, Boston, MA, USA
- Department of International Health, Boston University of School of Public Health, Boston, MA, USA
- Department of Environmental Health, Harvard School of Public Health, Boston, MA, USA
| | - Brent A Coull
- Department of Environmental Health, Harvard School of Public Health, Boston, MA, USA
- Departments of Biostatistics, Harvard School of Public Health, Boston, MA, USA
| | - Davidson H Hamer
- Center for Global Health and Development, Boston University, Boston, MA, USA
- Department of International Health, Boston University of School of Public Health, Boston, MA, USA
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA
- Zambia Centre for Applied Health Research and Development (ZCAHRD), Lusaka, Zambia
| | - Mrigendra P Singh
- National Institute for Malaria Research Field Station, Jabalpur, Madhya Pradesh, India
| | - Darby Jack
- Department of Environmental Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Kojo Yeboah-Antwi
- Center for Global Health and Development, Boston University, Boston, MA, USA
| | - Lora Sabin
- Center for Global Health and Development, Boston University, Boston, MA, USA
| | - Neeru Singh
- Regional Medical Research Centre for Tribals (Indian Council for Medical Research), Jabalpur, Madhya Pradesh, India
| | - William B MacLeod
- Center for Global Health and Development, Boston University, Boston, MA, USA
- Department of International Health, Boston University of School of Public Health, Boston, MA, USA
| |
Collapse
|