Treatment and prevention of malaria in pregnancy and newborn

Global prevalence of congenital malaria: A systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis is to pool the prevalence of congenital malaria.

STUDY DESIGN

The guideline of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was strictly followed. The published studies were searched in international and national databases. Quality assessment for studied was performed using the modified Newcastle - Ottawa scale. Pooled Meta logistic regression was computed using OpenMeta Analyst software. The heterogeneity was explored by the subgroup and meta-regression method.

RESULTS

Twenty-four studies enrolling 8148 newborns were conducted. All the studies were high-quality studies. The prevalence of congenital malaria ranged from 0.0 % in Colombia to 46.7 % in Nigeria. The overall prevalence of congenital malaria was 6.9 % (95 % CI: 4.8-7.9 %) (562/8148). There was large heterogeneity in prevalence of congenital malaria estimates among the different settings (I² = 96.1 %). Hence the random effect model was used. In subgroup analyses, with respect to the type of malaria transmission, the prevalence of congenital malaria was significantly higher in areas characterized by unstable malaria transmission vs. the rate in areas with stable malaria transmission [16.8 % (95 % CI: 8.0-25.6 %) vs. 3.5 % (95 % CI: 2.3-4.6 %), Coefficient = 0.111; P = 0.035]. The results of additional sub- group (meta-regression) analyses showed a non-significant difference in prevalence of congenital malaria in study-sample sizes (Coefficient = -0.001, 95 % CI: -0.001 to 0.001), P-value = 0.534) and year of publication (C = -0.005; 95 % CI: -0.016 to 0.006), P-value = 0.369).

CONCLUSION

This meta-analysis showed a varied prevalence of congenital malaria across endemic areas and it was higher in areas with unstable malaria transmissions.

Case Report: Delayed Diagnosis of Congenital Malaria by Plasmodium vivax in a Newborn of an Eritrean Woman with Varicella Infection

Congenital malaria (CM) is uncommon in both malaria-endemic and non-endemic countries. It may be caused by any Plasmodium spp., although Plasmodium falciparum and Plasmodium vivax are the more frequent etiologic agents. We report a case of delayed diagnosis of CM by P. vivax in a newborn of an Eritrean primigravida. The mother developed pregnancy-related immunodepression and varicella-zoster viral infection 9 days before natural delivery; therefore, the child was admitted in the neonatal intensive care unit (NICU) to administer specific varicella-zoster immunoglobulin prophylaxis and for clinical monitoring. During the NICU stay, the newborn presented a febrile syndrome with vomiting, anemia, and thrombocytopenia. A P. vivax severe malaria diagnosis was made by detecting trophozoites in the thick and thin blood smears. The infant was successfully treated with intravenous artesunate and clindamycin. Our experience suggests that malaria diagnostic tests need to be included in routine blood analyses in newborns with febrile syndrome from mothers with an epidemiologic link to malaria-endemic areas.

Antimalarial treatment patterns among pregnant women attending antenatal care clinics in south east Nigeria and the future implications

BACKGROUND

Prompt and effective treatment of malaria in pregnancy in accordance with recommended guidelines is essential to help prevent adverse events among pregnant mothers and the foetus.

AIM

The aim of this study was to assess current prescribing of antimalarial medicines in pregnancy against policy guidelines in south east Nigeria to provide future guidance.

METHODS

A review of prescription records of pregnant women treated for malaria over a 6-month period between August 2013 and January 2014 was carried out to assess the prescribing patterns for both the prevention and treatment of malaria in each trimester and analyzed for conformity to recommended guidelines.

RESULTS

Among 859 antenatal records reviewed, the majority (83.2%) were in the second and third trimesters. Artemisinin-based combination therapies (40.9%) and sulfadoxine-pyrimethamine (37.5%) were the most prescribed antimalarial medicines for both treatment and prophylaxis (prevention), respectively, in all trimesters. Overall, 68.5% of the prescriptions conformed to guideline recommendations, with the prescriptions for non-recommended drugs occurring most often in the first trimester. In the second and three trimesters, up to 79.9% of pregnant women received appropriate medicines for both treatment and prevention of malaria, with artemether-lumefantrine the most prescribed regimen.

CONCLUSION

Current practice indicates greater conformity with guidelines particularly in the second and three trimesters vs previous studies. However, there are still concerns with prescribing practices in the first trimester, especially in private health facilities. This needs addressing.

Prevalence and diagnostics of congenital malaria in rural Burundi, a cross-sectional study

BACKGROUND

Congenital malaria, defined as the presence of asexual forms of malaria parasites in the peripheral blood during the first 7 days of life, remains a neglected area of research. Knowledge gaps exist about prevalence and management of malaria in this age group. The objective of this study was to evaluate the prevalence of congenital malaria and the validity of a rapid diagnostic test (RDT) for its diagnosis in rural Burundi.

METHODS

A cross-sectional study was conducted in a meso-endemic malaria context in Burundi among 290 mothers, and their newborns (n = 303), who delivered at the maternity departments of Kirundo and Mukenke Hospitals during March and April 2014. Peripheral blood samples were collected from all mothers/newborns pairs in order to examine the presence of malaria parasites with two RDT (SD-Bioline HRP2 and Carestart pan-pLDH) and a blood slide. In addition, quantitative real-time polymerase chain reaction (PCR) was performed from the newborn peripheral sample. Frequencies and proportions were calculated for categorical variables. Sensitivity and specificity were calculated with a 95 % confidence interval (CI).

RESULTS

None of the newborns were found positive by PCR (0/303; 95 % CI 0.0-1.3). The prevalence in newborns born from microscopy-positive mothers was 0 % (0/44; 95 % CI 0.0-8.0). Two newborns were positive with SD-Bioline HRP2 (0.7 %, 95 % CI 0.2-2.4) but none with Carestart pan-pLDH or microscopy. Sensitivity of the diagnostic tests could not be evaluated as no congenital malaria was detected. Specificity of SD-Bioline HRP2, Carestart pan-pLDH and microscopy to detect congenital malaria was 99.3 % (95 % CI 97.6-99.8), 100.0 % (95 % CI 98.3-100.0) and 100.0 % (95 % CI 98.8-100.0), respectively.

CONCLUSION

In Burundi or the Central African region, no recent prevalence studies for congenital malaria have been carried out. This study found that the prevalence of congenital malaria in two hospitals in Kirundo province is zero. RDT showed to have an excellent specificity and, therefore, can be used to rule out congenital malaria: the risk of overtreatment is low. However, as no cases of congenital malaria were detected, the study was not able to draw conclusions about the sensitivity of the RDT, nor about risk factors for congenital malaria. Further studies evaluating the sensitivity of RDT for diagnosis of congenital malaria are needed.

Assessment of the usage and effectiveness of intermittent preventive treatment and insecticide-treated nets on the indicators of malaria among pregnant women attending antenatal care in the Buea Health District, Cameroon

BACKGROUND

Malaria in pregnancy is an immense public health problem with at least 50 million pregnant women living in malaria endemic areas. To prevent malaria and its complications in pregnancy the World Health Organization recommends the use of intermittent preventive treatment sulfadoxine-pyrimethamine (IPTp-SP), the use of insecticide-treated nets (ITNs), and effective case management. In most malaria endemic countries in Africa, 40% of pregnant women sleep under ITNs. In Cameroon, about 90% of pregnant women receive the first dose of SP, while 64% take the complete dose. Following the 2011 mass-campaign of free distribution of ITNs coupled with routine ANC distribution of ITN and adoption of IPTp in Cameroon, little has been done to assess the effectiveness of both interventions outside of Yaoundé, the capital city. This study sought to assess the usage and effectiveness of IPTp-SP and ITNs on malaria in pregnancy.

METHODS

The research was a cross-sectional hospital-based study that included 410 pregnant women attending antenatal clinics in the Buea Health District. Capillary blood samples were collected to check malaria parasite by microscopy and haemoglobin levels by microhaematocrit technique.

RESULTS

A prevalence of 13.4 and 41.7% was detected for malaria and anaemia, respectively. The Overall coverage of ITN was 32.4% while that of ITPp was 63.2%. Malaria prevalence was least (7.2%) amongst women using both IPTp-SP and ITN while those with no intervention had the highest malaria prevalence of 18.6% (χ2 = 6.188; P = 0.103). Of the women with malaria, 12.73% were using ITN and had taken at least one dose of SP, 38.18% had taken at least one dose IPTp only, 10.91% were using only ITN and 38.18% were not using any preventive measure. There was a difference in anaemia status within the different intervention groups (χ2 = 8.673; P = 0.034). Pregnant women using both interventions were less associated to malaria (OR = 0.341, 95% CI = 0.138-0.841) compared to those using only one control method.

CONCLUSION

Repeated doses of SP in combination with ITN use are effective in reducing malaria parasitaemia and improving haemoglobin level of pregnant women.

[Imported infectious diseases in tertiary hospital]

INTRODUCTION

An Imported Diseases Clinic was created in the hospital in 2009. The aim of this study was to asses its contribution in terms of capacity, quality of care and teaching offered.

PATIENTS AND METHODS

A retrospective study was conducted from 2009 to 2011, analyzing: A) development of knowledge by means of protocols and publications created, and subject taught; B) capacity and quality of care offered by the analysis of patients seen, the adequacy of the protocols and accessibility. The patients were classified into 3 groups. Group 1: immigrant patient screening, group 2: patient consultation after tropical or sub-tropical travel, group 3: screening of vertical transmission of imported disease.

RESULTS

Six protocols have been developed and disseminated on the unit website, as well as 5 scientific publications. A total of 316 patients were evaluated: 191 included in group 1 (29 Adopted and 162 Immigrants), 57 in group 2 (94.7% Visiting Friends and Relatives and 81.5% without a pre-travel consultation). They consulted due to, gastrointestinal symptoms (52.6%) and fever (43.8%), with 68 included in group 3 at risk of imported disease by vertical transmission (62 Trypanosoma cruzi, 1 Human T Lymphotropic Virus and 5 Plasmodium spp.). The overall adherence to the protocols was about 77.1%.

DISCUSSION

Infectious Diseases Units must adapt to the reality of the population and be flexible in its structure. Periodic assessment of the quality of care offered is essential, as well as an evaluation on the need for additional studies.

Prevalence of congenital malaria in high-risk Ghanaian newborns: a cross-sectional study

Background

Congenital malaria is defined as malaria parasitaemia in the first week of life. The reported prevalence of congenital malaria in sub-Saharan Africa is variable (0 - 46%). Even though the clinical significance of congenital malaria parasitaemia is uncertain, anti-malarial drugs are empirically prescribed for sick newborns by frontline health care workers. Data on prevalence of congenital malaria in high-risk newborns will inform appropriate drug use and timely referral of sick newborns.

Methods

Blood samples of untreated newborns less than 1 week of age at the time of referral to Korle Bu Teaching hospital in Accra, Ghana during the peak malaria seasons (April to July) of 2008 and 2010 were examined for malaria parasites by, i) Giemsa-stained thick and thin blood smears for parasite count and species identification, ii) histidine-rich protein- and lactic dehydrogenase-based rapid diagnosis tests, or iii) polymerase chain reaction amplification of the merozoite surface protein 2 gene, for identification of sub-microscopic parasitaemia. Other investigations were also done as clinically indicated.

Results

In 2008, nine cases of Plasmodium falciparum parasitaemia were diagnosed by microscopy in 405 (2.2%) newborns. All the nine newborns had low parasite densities (≤50 per microlitre). In 2010, there was no case of parasitaemia by either microscopy or rapid diagnosis tests in 522 newborns; however, 56/467 (12%) cases of P. falciparum were detected by polymerase chain reaction.

Conclusion

Congenital malaria is an uncommon cause of clinical illness in high-risk untreated newborns referred to a tertiary hospital in the first week of life. Empirical anti-malarial drug treatment for sick newborns without laboratory confirmation of parasitaemia is imprudent. Early referral of sick newborns to hospitals with resources and skills for appropriate care is recommended.

Congenital parasitic infections: a review

This review defines the concepts of maternal-fetal (congenital) and vertical transmissions (mother-to-child) of pathogens and specifies the human parasites susceptible to be congenitally transferred. It highlights the epidemiological features of this transmission mode for the three main congenital parasitic infections due to Toxoplasma gondii, Trypanosoma cruzi and Plasmodium sp. Information on the possible maternal-fetal routes of transmission, the placental responses to infection and timing of parasite transmission are synthesized and compared. The factors susceptible to be involved in parasite transmission and development of congenital parasitic diseases, such as the parasite genotypes, the maternal co-infections and parasitic load, the immunological features of pregnant women and the capacity of some fetuses/neonates to overcome their immunological immaturity to mount an immune response against the transmitted parasites are also discussed and compared. Analysis of clinical data indicates that parasitic congenital infections are often asymptomatic, whereas symptomatic newborns generally display non-specific symptoms. The long-term consequences of congenital infections are also mentioned, such as the imprinting of neonatal immune system and the possible trans-generational transmission. The detection of infection in pregnant women is mainly based on standard serological or parasitological investigations. Amniocentesis and cordocentesis can be used for the detection of some fetal infections. The neonatal infection can be assessed using parasitological, molecular or immunological methods; the place of PCR in such neonatal diagnosis is discussed. When such laboratory diagnosis is not possible at birth or in the first weeks of life, standard serological investigations can also be performed 8-10 months after birth, to avoid detection of maternal transmitted antibodies. The specific aspects of treatment of T. gondii, T. cruzi and Plasmodium congenital infections are mentioned. The possibilities of primary and secondary prophylaxes, as well as the available WHO corresponding recommendations are also presented.

Patterns of anti-malarial drug treatment among pregnant women in Uganda

Background

Prompt use of an effective anti-malarial drug is essential for controlling malaria and its adverse effects in pregnancy. The World Health Organization recommends an artemisinin-based combination therapy as the first-line treatment of uncomplicated malaria in the second and third trimesters of pregnancy. The study objective was to determine the degree to which presumed episodes of uncomplicated symptomatic malaria in pregnancy were treated with a recommended anti-malarial regimen in a region of Uganda.

Methods

Utilizing a population-based random sample, we interviewed women living in Jinja, Uganda who had been pregnant in the past year.

Results

Self-reported malaria during the index pregnancy was reported among 67% (n = 334) of the 500 participants. Among the 637 self-reported episodes of malaria, an anti-malarial drug was used for treatment in 85% of the episodes. Use of a currently recommended treatment in the first trimester was uncommon (5.6%). A contraindicated anti-malarial drug (sulphadoxine-pyrimethamine and/or artemether-lumefantrine) was involved in 70% of first trimester episodes. Recommended anti-malarials were used according to the guidelines in only 30.1% of all second and third trimester episodes.

Conclusions

Self-reported malaria was extremely common in this population and adherence to treatment guidelines for the management of malaria in pregnancy was poor. Use of artemether-lumefantrine combined with non-recommended anti-malarials was common practice. Overuse of anti-malarial drugs, especially ones that are no longer recommended, undermines malaria control efforts by fueling the spread of drug resistance and delaying appropriate treatment of non-malarial febrile illnesses. Improved diagnostic capacity is essential to ultimately improving the management of malaria-like symptoms during pregnancy and appropriate use of currently available anti-malarials.

Infection-related stillbirths

Infection is an important cause of stillbirths worldwide: in low-income and middle-income countries, 50% of stillbirths or more are probably caused by infection. By contrast, in high-income countries only 10-25% of stillbirths are caused by infection. Syphilis, where prevalent, causes most infectious stillbirths, and is the infection most amenable to screening and treatment. Ascending bacterial infection is a common cause of stillbirths, but prevention has proven elusive. Many viral infections cause stillbirths but aside from vaccination for common childhood diseases, we do not have a clear prevention strategy. Malaria, because of its high prevalence and extensive placental damage, accounts for large numbers of stillbirths. Intermittent malarial prophylaxis and insecticide-treated bednets should decrease stillbirths. Many infections borne by animals and vectors cause stillbirths, and these types of infections occur frequently in low-income countries. Research that better defines the relation between these infections and stillbirths, and develops strategies to reduce associated adverse outcomes, should play an important part in reduction of stillbirths in low-income countries.

Current world literature

This bibliography is compiled by clinicians from the journals listed at the end of this publication. It is based on literature entered into our database between 1 February 2008 and 31 January 2009 (articles are generally added to the database about two and a half months after publication). In addition, the bibliography contains every paper annotated by reviewers; these references were obtained from a variety of bibliographic databases and published between the beginning of the review period and the time of going to press. The bibliography has been grouped into topics that relate to the reviews in this issue.

Malaria in pregnancy: a literature review

Pregnant women are more likely than nonpregnant women to become infected with malaria and to have severe infection. The effects of malaria during pregnancy include spontaneous abortion, preterm delivery, low birth weight, stillbirth, congenital infection, and maternal death. Malaria is caused by the four species of the protozoa of the genus Plasmodium, which is transmitted by the bite of the female Anopheline mosquito, congenitally, or through exposure to infected blood products. This article reviews the epidemiology, pathology, clinical symptoms, diagnosis, and treatment of malaria in pregnant women. Interventions to prevent malaria include intermittent preventive treatment, insecticide-treated nets, and case management of malaria infection and anemia.