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Salam RA, Das JK, Bhutta ZA. Effect of mass deworming with antihelminthics for soil-transmitted helminths during pregnancy. Cochrane Database Syst Rev 2021; 5:CD005547. [PMID: 33998661 PMCID: PMC8127571 DOI: 10.1002/14651858.cd005547.pub4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Helminthiasis is an infestation of the human body with parasitic worms. It is estimated to affect 44 million pregnancies, globally, each year. Intestinal helminthiasis (hookworm infestation) is associated with blood loss and decreased supply of nutrients for erythropoiesis, resulting in iron-deficiency anaemia. Over 50% of the pregnant women in low- and middle-income countries (LMIC) suffer from iron-deficiency anaemia. Though iron-deficiency anaemia is multifactorial, hookworm infestation is a major contributory cause in women of reproductive age in endemic areas. Antihelminthics are highly efficacious, but evidence of their beneficial effect and safety when given during pregnancy has not been established. This is an update of a Cochrane Review last published in 2015. OBJECTIVES To determine the effects of mass deworming with antihelminthics for soil-transmitted helminths (STH) during the second or third trimester of pregnancy on maternal and pregnancy outcomes. SEARCH METHODS For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) (8 March 2021) and reference lists of retrieved studies. SELECTION CRITERIA We included all prospective randomised controlled trials evaluating the effect of administration of antihelminthics versus placebo or no treatment during the second or third trimester of pregnancy; both individual-randomised and cluster-randomised trials were eligible. We excluded quasi-randomised trials and studies that were only available as abstracts with insufficient information. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data, checked accuracy and assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included a total of six trials (24 reports) that randomised 7873 pregnant women. All of the included trials were conducted in antenatal clinics within hospitals in LMICs (Uganda, Nigeria, Peru, India, Sierra Leone and Tanzania). Among primary outcomes, five trials reported maternal anaemia, one trial reported preterm birth and three trials reported perinatal mortality. Among secondary outcomes, included trials reported maternal worm prevalence, low birthweight (LBW) and birthweight. None of the included studies reported maternal anthropometric measures or infant survival at six months. Overall, we judged the included trials to be generally at low risk of bias for most domains, while the certainty of evidence ranged from low to moderate. Analysis suggests that administration of a single dose of antihelminthics in the second trimester of pregnancy may reduce maternal anaemia by 15% (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.72 to 1.00; I²= 86%; 5 trials, 5745 participants; low-certainty evidence). We are uncertain of the effect of antihelminthics during pregnancy on preterm birth (RR 0.84, 95% CI 0.38 to 1.86; 1 trial, 1042 participants; low-certainty evidence) or perinatal mortality (RR 1.01, 95% CI 0.67 to 1.52; 3 trials, 3356 participants; low-certainty evidence). We are uncertain of the effect of antihelminthics during pregnancy on hookworm (average RR 0.31, 95% CI 0.05 to 1.93; Tau² = 1.76, I² = 99%; 2 trials, 2488 participants; low-certainty evidence). Among other secondary outcomes, findings suggest that administration of antihelminthics during pregnancy may reduce the prevalence of trichuris (average RR 0.68, 95% CI 0.48 to 0.98; I²=75%; 2 trials, 2488 participants; low-certainty evidence) and ascaris (RR 0.24, 95% CI 0.19 to 0.29; I²= 0%; 2 trials, 2488 participants; moderate-certainty evidence). Antihelminthics during pregnancy probably make little or no difference to LBW (RR 0.89, 95% CI 0.69 to 1.16; 3 trials, 2960 participants; moderate-certainty evidence) and birthweight (mean difference 0.00 kg, 95% CI -0.03 kg to 0.04 kg; 3 trials, 2960 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS The evidence suggests that administration of a single dose of antihelminthics in the second trimester of pregnancy may reduce maternal anaemia and worm prevalence when used in settings with high prevalence of maternal helminthiasis. Further data is needed to establish the benefit of antihelminthic treatment on other maternal and pregnancy outcomes. Future research should focus on evaluating the effect of these antihelminthics among various subgroups in order to assess whether the effect varies. Future studies could also assess the effectiveness of co-interventions and health education along with antihelminthics for maternal and pregnancy outcomes.
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MESH Headings
- Female
- Humans
- Pregnancy
- Albendazole/administration & dosage
- Anemia, Iron-Deficiency/parasitology
- Anemia, Iron-Deficiency/prevention & control
- Anthelmintics/administration & dosage
- Bias
- Helminthiasis/drug therapy
- Helminthiasis/transmission
- Intestinal Diseases, Parasitic/drug therapy
- Iron Compounds/administration & dosage
- Perinatal Mortality
- Pregnancy Complications, Hematologic/parasitology
- Pregnancy Complications, Hematologic/prevention & control
- Pregnancy Complications, Parasitic/drug therapy
- Pregnancy Complications, Parasitic/etiology
- Pregnancy Outcome
- Pregnancy Trimester, Second
- Pregnancy Trimester, Third
- Randomized Controlled Trials as Topic
- Soil/parasitology
- Infant, Newborn
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Affiliation(s)
- Rehana A Salam
- Division of Women and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Jai K Das
- Division of Women and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
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Shepherd V. An under-represented and underserved population in trials: methodological, structural, and systemic barriers to the inclusion of adults lacking capacity to consent. Trials 2020; 21:445. [PMID: 32471488 PMCID: PMC7257506 DOI: 10.1186/s13063-020-04406-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/11/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND There is increasing international recognition that populations included in trials should adequately represent the population treated in clinical practice; however, adults who lack the capacity to provide informed consent are frequently excluded from trials. Addressing the under-representation of groups such as those with impaired capacity to consent is essential to develop effective interventions and provide these groups with the opportunity to benefit from evidence-based care. While the spotlight has been on ensuring only appropriate and justifiable exclusion criteria are used in trials, barriers to the inclusion of adults lacking capacity are multifactorial and complex, and addressing their under-representation will require more than merely widening eligibility criteria. This commentary draws on the literature exploring the inclusion of adults lacking the capacity to consent in research and a number of recent studies to describe the methodological, structural, and systemic factors that have been identified. MAIN TEXT A number of potentially modifiable factors contributing to the under-representation of adults lacking the capacity to consent in trials have been identified. In addition to restrictive eligibility criteria, methodological issues include developing appropriate interventions and outcome measures for populations with impaired capacity. Structurally determined factors include the resource-intensive nature of these trials, the requirement for more appropriate research infrastructure, and a lack of interventions to inform and support proxy decision-makers. Systemic factors include the complexities of the legal frameworks, the challenges of ethical review processes, and paternalistic attitudes towards protecting adults with incapacity from the perceived harms of research. CONCLUSIONS Measures needed to address under-representation include greater scrutiny of exclusion criteria by those reviewing study proposals, providing education and training for personnel who design, conduct, and review research, ensuring greater consistency in the reviews undertaken by research ethics committees, and extending processes for advance planning to include prospectively appointing a proxy for research and documenting preferences about research participation. Negative societal and professional attitudes towards the inclusion of adults with impaired capacity in research should also be addressed, and the development of trials that are more person-centred should be encouraged. Further work to conceptualise under-representation in trials for such populations may also be helpful.
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He Z, Tang X, Yang X, Guo Y, George TJ, Charness N, Quan Hem KB, Hogan W, Bian J. Clinical Trial Generalizability Assessment in the Big Data Era: A Review. Clin Transl Sci 2020; 13:675-684. [PMID: 32058639 PMCID: PMC7359942 DOI: 10.1111/cts.12764] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 01/25/2020] [Indexed: 01/04/2023] Open
Abstract
Clinical studies, especially randomized, controlled trials, are essential for generating evidence for clinical practice. However, generalizability is a long‐standing concern when applying trial results to real‐world patients. Generalizability assessment is thus important, nevertheless, not consistently practiced. We performed a systematic review to understand the practice of generalizability assessment. We identified 187 relevant articles and systematically organized these studies in a taxonomy with three dimensions: (i) data availability (i.e., before or after trial (a priori vs. a posteriori generalizability)); (ii) result outputs (i.e., score vs. nonscore); and (iii) populations of interest. We further reported disease areas, underrepresented subgroups, and types of data used to profile target populations. We observed an increasing trend of generalizability assessments, but < 30% of studies reported positive generalizability results. As a priori generalizability can be assessed using only study design information (primarily eligibility criteria), it gives investigators a golden opportunity to adjust the study design before the trial starts. Nevertheless, < 40% of the studies in our review assessed a priori generalizability. With the wide adoption of electronic health records systems, rich real‐world patient databases are increasingly available for generalizability assessment; however, informatics tools are lacking to support the adoption of generalizability assessment practice.
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Affiliation(s)
- Zhe He
- School of Information, Florida State University, Tallahassee, Florida, USA
| | - Xiang Tang
- Department of Statistics, Florida State University, Tallahassee, Florida, USA
| | - Xi Yang
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Yi Guo
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Thomas J George
- Hematology & Oncology, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Neil Charness
- Department of Psychology, Florida State University, Tallahassee, Florida, USA
| | - Kelsa Bartley Quan Hem
- Calder Memorial Library, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - William Hogan
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
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Lule SA, Namara B, Akurut H, Muhangi L, Lubyayi L, Nampijja M, Akello F, Tumusiime J, Aujo JC, Oduru G, Smeeth L, Elliott AM, Webb EL. Are birthweight and postnatal weight gain in childhood associated with blood pressure in early adolescence? Results from a Ugandan birth cohort. Int J Epidemiol 2020; 48:148-156. [PMID: 29982658 PMCID: PMC6380421 DOI: 10.1093/ije/dyy118] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 05/25/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In Africa, where low birthweight (LBW), malnutrition and high blood pressure (BP) are prevalent, the relationships between birthweight (BW), weight gain and BP later in life remain uncertain. We examined the effects of early life growth on BP among Ugandan adolescents. METHODS Data were collected prenatally from women and their offspring were followed from birth, with BP measured following standard protocols in early adolescence. Weight-for-age Z-scores (WAZ) were computed using World Health Organization references. Linear regression was used to relate BW, and changes in WAZ between birth and 5 years, to adolescents' BP, adjusting for confounders. RESULTS Among 2345 live offspring, BP was measured in 1119 (47.7%) adolescents, with mean systolic BP 105.9 mmHg and mean diastolic BP 65.2 mmHg. There was little evidence of association between BW and systolic [regression coefficient β = 0.14, 95% confidence interval (CI) (-1.00, 1.27)] or diastolic [β = 0.43, 95% CI (-0.57, 1.43)] BP. Accelerated weight gain between birth and 5 years was associated with increased BP: systolic β = 1.17, 95% CI (0.69, 1.66) and diastolic β = 1.03, 95% CI (0.59, 1.47). Between birth and 6 months of age, effects of accelerated weight gain on adolescent BP were strongest among the LBW (both premature and small-for-gestational-age) children [BW < 2.5 kg: β = 2.64, 95% CI (0.91, 4.37), BW≥2.5 kg: β = 0.58, 95% CI (0.01, 1.14), interaction P-value = 0.024]. CONCLUSIONS Findings from this large tropical birth cohort in Uganda suggest that postnatal weight gain rather than BW is important in the developmental programming of BP, with fast-growing LBW children at particular risk. Efforts to control BP should adopt a life course approach.
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Affiliation(s)
- Swaib A Lule
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.,Endemic, Neglected, Emerging and Re-emerging Infections Programme, MRC/UVRI Uganda Research Unit, Entebbe, Uganda
| | - Benigna Namara
- Endemic, Neglected, Emerging and Re-emerging Infections Programme, MRC/UVRI Uganda Research Unit, Entebbe, Uganda
| | - Helen Akurut
- Endemic, Neglected, Emerging and Re-emerging Infections Programme, MRC/UVRI Uganda Research Unit, Entebbe, Uganda
| | - Lawrence Muhangi
- Endemic, Neglected, Emerging and Re-emerging Infections Programme, MRC/UVRI Uganda Research Unit, Entebbe, Uganda
| | - Lawrence Lubyayi
- Endemic, Neglected, Emerging and Re-emerging Infections Programme, MRC/UVRI Uganda Research Unit, Entebbe, Uganda
| | - Margaret Nampijja
- Endemic, Neglected, Emerging and Re-emerging Infections Programme, MRC/UVRI Uganda Research Unit, Entebbe, Uganda
| | - Florence Akello
- Endemic, Neglected, Emerging and Re-emerging Infections Programme, MRC/UVRI Uganda Research Unit, Entebbe, Uganda
| | | | - Judith C Aujo
- Department of Paediatrics, Mulago Hospital, Kampala, Uganda
| | - Gloria Oduru
- Endemic, Neglected, Emerging and Re-emerging Infections Programme, MRC/UVRI Uganda Research Unit, Entebbe, Uganda
| | - Liam Smeeth
- Department of Non-communicable Disease Epidemiology
| | - Alison M Elliott
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Emily L Webb
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Salam RA, Cousens S, Welch V, Gaffey M, Middleton P, Makrides M, Arora P, Bhutta ZA. Mass deworming for soil-transmitted helminths and schistosomiasis among pregnant women: A systematic review and individual participant data meta-analysis. CAMPBELL SYSTEMATIC REVIEWS 2019; 15:e1052. [PMID: 37131518 PMCID: PMC8356523 DOI: 10.1002/cl2.1052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The objective of the review is to use individual participant data (IPD) meta-analysis to explore the effect of mass deworming during pregnancy. We developed a search strategy and searched the databases till March 2018. We included individually randomised controlled trials; cluster randomised controlled trials and quasi randomised studies providing preventive or therapeutic deworming drugs for soil transmitted helminthiases and schistosomiasis during pregnancy. All IPD were assessed for completeness, compared to published reports and entered into a common data spreadsheet. Out of the seven trials elgible for IPD, we received data from three trials; out of 8,515 potential IPD participants; data were captured for 5,957 participants. Findings from this IPD suggest that mass deworming during pregnancy reduces maternal anaemia by 23% (Risk ratio [RR]: 0.77, 95% confidence intreval [CI]: 0.73-0.81; three trials; 5,216 participants; moderate quality evidence). We did not find any evidence of an effect of mass deworming during pregnancy on any of the other outcomes. There was no evidence of effect modification; however these findings should be interpreted with caution due to small sample sizes. The quality of evidence was rated as moderate for our findings. Our analyses suggest that mass deworming during pregnancy is associated with reducing anaemia with no evidence of impact on any other maternal or pregnancy outcomes. Our analyses were limited by the availability of data for the impact by subgroups and effect modification. There is also a need to support and promote open data for future IPDs.
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Affiliation(s)
- R. A. Salam
- Healthy Mother, Babies and Children ThemeSouth Australian Health and MedicalResearch InstituteAdelaideAustralia
- Paediatrics and Reproductive HealthUniversity of AdelaideAdelaideAustralia
| | - S. Cousens
- Maternal Adolescent Reproductive & Child Health (MARCH) CentreLondon School of Hygiene and Tropical MedicineLondonUK
| | - V. Welch
- School of Epidemiology, Public Health and Preventive MedicineUniversity of OttawaOttawaCanada
| | - M. Gaffey
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
| | - P. Middleton
- Healthy Mother, Babies and Children ThemeSouth Australian Health and MedicalResearch InstituteAdelaideAustralia
- Robinson Research InstituteUniversity of AdelaideAdelaideAustralia
| | - M. Makrides
- Healthy Mother, Babies and Children ThemeSouth Australian Health and MedicalResearch InstituteAdelaideAustralia
| | - P. Arora
- Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
| | - Z. A. Bhutta
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
- Centre of Excellence in Women and Child HealthThe Aga Khan UniversityKarachiPakistan
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Salam RA, Haider BA, Humayun Q, Bhutta ZA. Effect of administration of antihelminthics for soil-transmitted helminths during pregnancy. Cochrane Database Syst Rev 2015:CD005547. [PMID: 26087057 DOI: 10.1002/14651858.cd005547.pub3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Helminthiasis is infestation of the human body with parasitic worms and it is estimated to affect 44 million pregnancies, globally, each year. Intestinal helminthiasis (hook worm) is associated with blood loss and decreased supply of nutrients for erythropoiesis, resulting in iron-deficiency anaemia. Over 50% of the pregnant women in low- and middle-income countries suffer from iron-deficiency anaemia. Though iron-deficiency anaemia is multifactorial, hook worm infestation is a major contributory cause in women of reproductive age in endemic areas. Antihelminthics are highly efficacious in treating hook worm but evidence of their beneficial effect and safety, when given during pregnancy, has not been established. OBJECTIVES To determine the effects of administration of antihelminthics for soil-transmitted helminths during the second or third trimester of pregnancy on maternal anaemia and pregnancy outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015) and reference lists of retrieved studies. SELECTION CRITERIA All prospective randomised controlled trials evaluating the effect of administration of antihelminthics during the second or third trimester of pregnancy. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS A total of four trials including 4265 participants were included in this review. Two of the included trials were of high quality, while two were of relatively low quality with limitations and biases in design and conduct.Analysis showed that administration of a single dose of antihelminthic in the second trimester of pregnancy is not associated with any impact on maternal anaemia in the third trimester (risk ratio (RR) 0.94; 95% confidence interval (CI) 0.81 to 1.10; 3266 participants; four trials; low quality evidence). Subgroup analysis on the basis of co-interventions other than antihelminthic, which included iron supplementation given to both groups was also not associated with any impact on maternal anaemia (RR 0.76; 95% CI 0.47 to 1.23; 1290 participants; three trials; moderate quality evidence). No impact was found for the outcomes of low birthweight (RR 1.00; 95% CI 0.79 to 1.27; 3255 participants; three trials; moderate quality evidence), preterm birth (RR 0.88; 95% CI 0.43 to 1.78; 1318 participants; two trials, moderate quality evidence) and perinatal mortality (RR 1.09; 95% CI 0.71 to 1.67; 3385 participants; two trials; moderate quality evidence). None of the included studies reported impact on infant survival at six months of age. AUTHORS' CONCLUSIONS The evidence to date is insufficient to recommend use of antihelminthic for pregnant women after the first trimester of pregnancy. More well-designed, large scale randomised controlled trials are needed to establish the benefit of antihelminthic treatment during pregnancy.
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Affiliation(s)
- Rehana A Salam
- Division of Women and Child Health, Aga Khan University Hospital, Stadium Road, PO Box 3500, Karachi, Sind, Pakistan, 74800
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Chatterjee S, Nutman TB. Helminth-induced immune regulation: implications for immune responses to tuberculosis. PLoS Pathog 2015; 11:e1004582. [PMID: 25632943 PMCID: PMC4310592 DOI: 10.1371/journal.ppat.1004582] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Soumya Chatterjee
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Thomas B Nutman
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
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