The effect of malaria and intestinal helminth coinfection on birth outcomes in Kumasi, Ghana

Association between multimorbidity of pregnancy and adverse birth outcomes: A systemic review and meta-analysis

Multimorbidity (≥2 co-existing conditions) in pregnancy is a significant public health issue with a rising prevalence worldwide. However, the association between pregnancy multimorbidity and adverse birth outcomes is unclear. So, this review assessed the association between pregnancy-multimorbidity and adverse birth outcomes (preterm birth, abnormal birth weight, neonatal mortality, and stillbirth). Relevant peer-reviewed papers in PubMed, Web of Science, Elsevier/ScienceDirect, and Google Scholar were systematically search from January 1990 to March 2023. We used the random-effects model to calculate the multimorbidity pooled odds ratio, quantified heterogeneity using I2 statistics, and performed subgroup and sensitivity analyses in Stata version 17. The review protocol is registered with PROSPERO (CRD42023421336). The meta-analysis included 21 observational studies involving 6,523,741 pregnant women. The overall pooled odds of pregnancy multimorbidity associated with adverse birth outcomes were 3.11(2.14-4.09), 3.76(2.56-4.96) in Europe, 3.38(1.18-5.58) in North America, and 2.94(0.78-5.09) in Asia. Pregnant women with psychological and physical multimorbidity had increased odds of 5.65(1.71-9.59) and 2.75(1.71-9.58), respectively, for adverse birth outcomes. Pregnancy multimorbidity was associated with preterm birth 4.28(2.23-6.34), large gestational age (>90 percentile) 3.33(1.50-5.17), macrosomia (≥4000 g) 2.16(0.34-3.98), and small gestational age (<10th percentile) 3.52(1.54-5.51). There is substantial variance in the odds of pregnancy multimorbidity by type of comorbidity and type of adverse birth outcome, attributed to differences in the healthcare system by geographical location. Therefore, prioritizing pregnant women with multimorbidity is crucial for effective and integrative interventions.

Disparities in health and nutrition between semi-urban and rural mothers and birth outcomes of their newborns in Bukavu, DR Congo: a baseline assessment

AIM

This research aimed to evaluate health and nutritional practices of mothers during pregnancy and birth outcomes of their newborns in Bukavu, Democratic Republic of the Congo (DRC), comparing semi-urban and rural areas.

BACKGROUND

Health and nutrition during pregnancy are crucial for adequate development of the fetus. Health care plays an important role but is often poor in rural areas of developing countries.

METHODS

A baseline survey of a nutritional follow-up study was conducted in two semi-urban and one rural hospital in the vicinity of Bukavu, DRC. In total, 471 mother-child pairs were recruited after delivery. Data collection included socio-demographic parameters, nutrition and health measures during pregnancy, and anthropometric parameters. Semi-urban and rural study locations were compared and predictors of birth weight evaluated.

FINDINGS

Semi-urban and rural mothers differed significantly in nutrition and health practices during pregnancy, as well as birth outcomes. In the rural area, there was a higher rate of newborns with low birth weight (10.7%) and lower rates of antimalarial medication (80.8%), deworming (24.6%), consumption of nutritional supplements (81.5%), and being informed about nutrition by medical staff (32.8%) during pregnancy as well as practicing family planning (3.1%) than in the semi-urban areas (2.7%, 88.6%, 88.3%; 89.3%, 46.5%, and 17.1%, respectively). Birth weight was positively predicted by increasing maternal MUAC, age, and gestational age and negatively by rural location, being primipara, being a farmer, and female newborn sex.

CONCLUSION

The findings highlight the importance of strengthening antenatal care activities especially in rural areas in order to ameliorate both maternal and infantile health and ensure appropriate development.

Intestinal Helminth Infections in Ghanaian Children from the Ashanti Region between 2007 and 2008—A Retrospective Cross-Sectional Real-Time PCR-Based Assessment

In spite of ongoing eradication programs, helminth infections are still a medical issue in Ghana. For follow-up assessments on the decline of regional helminth infections, historic baseline prevalence values obtained with standardized diagnostic procedures can be helpful. In this retrospective cross-sectional study, real-time PCR targeting the nematodes Ancylostoma spp. (ITS2), Ascaris lumbricoides (ITS1), Enterobius vermicularis (ITS1), Necator americanus (ITS2), Strongyloides stercoralis (18S rRNA) and Trichuris trichiura (18S rRNA), the trematodes Schistosoma spp. (ITS2) as well as the cestodes Hymenolepis nana (ITS1), Taenia saginata (ITS1) and Taenia solium (ITS1) was applied with 2046 DNA eluates from stool samples of Ghanaian children from the Ashanti region collected between 2007 and 2008 in order to retrospectively define prevalence values. The overall prevalence was low with 3.8% (n = 77) and only 0.1% (n = 2) double infections with helminths were recorded. The three most frequently detected enteric helminth species comprised 2% S. stercoralis (n = 41), 0.8% H. nana (n = 16), and 0.7% N. americanus (n = 14), while only sporadic infection events were recorded for other helminth species comprising 0.1% E. vermicularis (n = 2), 0.1% Schistosoma spp. (n = 2), 0.1% T. saginata (n = 1) and 0.1% T. trichiura (n = 1). A. lumbricoides, Ancylostoma spp. and T. solium were not detected at all. In conclusion, the retrospective assessment suggests a low prevalence of enteric helminth infections in Ghanaian children from the Ashanti Region within the assessment period between 2007 and 2008.

Malaria in pregnancy control and pregnancy outcomes: a decade's overview using Ghana's DHIMS II data

Background

Malaria in pregnancy control interventions have been implemented through antenatal care services for more than 2 decades in Ghana. The uptake of these interventions has seen steady improvement over the years. This has occurred within the context of decreasing global trends of malaria infection confirmed by decreasing malaria in pregnancy prevalence in Ghana. However, not much is known about how these improvements in interventions uptake and reduction in malaria infection prevalence have impacted pregnancy outcomes in the country. This study aimed at describing trends of maternal anaemia and low birth weight prevalence and uptake of malaria in pregnancy control interventions over the last decade using data from Ghana’s District Health Information Management System (DHIMS II).

Methods

Data from Ghana’s DHIMS II on variables of interest covering the period 2012 to 2021 was analysed descriptively using Microsoft Excel 365. Results were computed as averages and percentages and presented in tables and graphs.

Results

The prevalence of maternal anaemia at booking and at term and low birth weight increased marginally from 31.0%, 25.5% and 8.5% in 2012 to 36.6%, 31.9% and 9.5% in 2021 respectively. Severe anaemia prevalence at booking and at term remained under 2% over the study period. Women making at least 4 ANC visits, receiving at least 3 doses of intermittent preventive treatment of malaria and an insecticide-treated net increased from 77.0%, 41.4% and 4.1% in 2012 to 82%, 55.0% and 93.3% in 2021, respectively. Malaria test positivity rate reduced from 54.0% to 34.3% between 2014 and 2021 while women receiving iron and folate supplementation for 3 and 6 months rose from 43.0% and 25.5% to 89.7% and 61.8%, respectively between 2017 and 2021.

Conclusion

Maternal anaemia and low birth weight prevalence showed marginal upward trends over the last decade despite reduced malaria infection rate and improved uptake of malaria in pregnancy control interventions. There is room for improvement in current intervention implementation levels but the complex and multi-factorial aetiologies of maternal anaemia and low birth weight need urgent investigation and quantification to inform policy and practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04331-2.

Trends of malaria infection in pregnancy in Ghana over the past two decades: a review

Background

There has been a global decline in malaria transmission over the past decade. However, not much is known of the impact of this observation on the burden of malaria infection in pregnancy in endemic regions including Ghana. A narrative review was undertaken to help describe trends in malaria infection in pregnancy in Ghana. Among others, such information is important in showing any progress made in malaria in pregnancy control.

Methods

To describe trends in pregnancy-associated malaria infection in Ghana, a search and review of literature reporting data on the prevalence of asymptomatic Plasmodium falciparum infection in pregnancy was conducted.

Results

Thirty-six (36) studies, conducted over 1994–2019, were included in the review. In the northern savannah zone with largely seasonal malaria transmission, prevalence appeared to reduce from about 50–60% in 1994–2010 to 13–26% by 2019. In the middle transitional/forest zone, where transmission is perennial with peaks in the rainy season, prevalence apparently reduced from 60% in the late 1990 s to about 5–20% by 2018. In the coastal savannah area, there was apparent reduction from 28 to 35% in 2003–2010 to 5–11% by 2018–2019. The burden of malaria infection in pregnancy continues to be highest among teenagers and younger-aged pregnant women and paucigravidae.

Conclusions

There appears to be a decline in asymptomatic parasite prevalence in pregnancy in Ghana though this has not been uniform across the different transmission zones. The greatest declines were noticeably in urban settings. Submicroscopic parasitaemia remains a challenge for control efforts. Further studies are needed to evaluate the impact of the reduced parasite prevalence on maternal anaemia and low birthweight and to assess the local burden of submicroscopic parasitaemia in relation to pregnancy outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-04031-3.

A Review on Strongyloidiasis in Pregnant Women

Strongyloidiasis is a parasitic infection distributed worldwide, with an estimated 614 million people infected. Strongyloidiasis usually presents asymptomatically or with aspecific and mild clinical symptoms, mainly cutaneous, respiratory, or gastrointestinal. Disseminated disease and hyperinfection syndrome are the most serious complications, have a high mortality rate, usually occur in immunosuppressed patients, and are particularly associated with the use of corticosteroids. Strongyloidiasis is the most neglected of the neglected diseases, and its occurrence in pregnancy has been neglected and understudied. In this review, we focus on the effects of strongyloidiasis during pregnancy and highlight the knowledge shortage and the need for more research on the subject. There are few studies addressing strongyloidiasis prevalence during pregnancy and hyperinfection incidence during pregnancy is practically unknown, with only isolated case reports published. Although data are scarce, the infection has been associated with developmental disabilities and anemia during pregnancy, while hyperinfection may cause both maternal and neonatal death. Data on the best screening and diagnostic strategies during pregnancy are lacking. There is insufficient evidence on ivermectin safety in pregnancy, complicating treatment recommendations.

Association of low birth weight and polyparasitic infection during pregnancy in Lambaréné, Gabon

OBJECTIVE

To report the prevalence of polyparasitism during pregnancy in the Lambaréné region of Gabon and its association with newborn birth weight.

METHOD

Pregnant women in their third trimester were recruited in a prospective study between November 2011 and March 2015. Parasite infection status was assessed microscopically in stool, urine and blood samples. Maternal demographic and obstetrical characteristics and newborns anthropometric data were collected. Multivariable logistic regression was used to assess the association between low birth weight and polyparasitism.

RESULTS

678 of 927 pregnant women were included for analysis with mean age (SD) of 25 (6.8) years. The analysis showed that 69% (468/678) were infected with at least one parasite (Plasmodium spp., Schistosoma spp., soil-transmitted helminths, filarial infections). This comprised of 38% with monoparasitism and 31% polyparasitism. The proportion of newborn babies with a weight below 2500 g (LBW) in our study was 21% (142/678). Compared to pregnant women without infection, women with monoparasitic infection had adjusted Odds Ratio confidence interval 95% CI (aOR [95%CI]) of 1.6 [0.95-2.73], those with two parasites had aOR 95%CI of 2.63 [1.51-4.62], and those with more than two parasites had aOR of 5.08 [2.5-10.38] for delivering a newborn with low birth weight.

CONCLUSION

In Lambaréné, an endemic area for multiple parasite infections, there is a high prevalence of polyparasitism in pregnant women. Polyparasitism is associated with low birth weight. Therefore, there is an urgent need for active screening and treatment of parasite infections in pregnant women to assess the potential public health benefit of such interventions.

Effect of Lymphatic Filariasis and Hookworm Infection on Pregnancy Course and Outcome in Women Living in the Democratic Republic of the Congo

Little is known about the effect of helminth infections on the natural gynecological and pregnancy course. Our goal was to assess the relationship between Wuchereria bancrofti and hookworm (HW) infections with pregnancy course and outcome in a group of 82 women living in a rural area of the Democratic Republic of the Congo. Demographics and information on gynecological and obstetrical histories were collected retrospectively with standardized questionnaires. Wuchereria bancrofti and HW infections were diagnosed using a filarial antigen-detection test and the Kato-Katz method, respectively. Analyses consisted of multivariable logistic regressions adjusting for age, number of deliveries, and history of anthelmintic treatment (HAHT). The median age of study participants was 35 (interquartile range [IQR]: 30-44) years, and the median number of deliveries was five (IQR: 3-7). Wuchereria bancrofti and HW infection rates were 44.5% and 43.3%, respectively. Filarial antigenemia and HW infection were not significantly associated with the number of deliveries. The proportions of women with a history of pregnancy resulting in neonatal death, miscarriage, premature birth, and postpartum hemorrhage were 56%, 44%, 23%, and 36%, respectively. History of pregnancy associated with neonatal death was less frequent in women with HAHT, tended to be more frequent in women with filarial antigenemia, and was not associated with HW infection. None of the three other pregnancy events studied (miscarriage, premature birth, and postpartum hemorrhage) were associated with filarial antigenemia or HW infection. The positive association found between HAHT and lower risk of neonatal death warrants investigation in larger groups of women.

Comorbidity of Geo-Helminthes among Malaria Outpatients of the Health Facilities in Ethiopia: Systematic Review and Meta-Analysis

Background: Coinfection of malaria and intestinal helminths affects one third of the global population, largely among communities with severe poverty. The spread of these parasitic infections overlays in several epidemiological locations and the host shows different outcomes. This systematic review and meta-analysis determine the pooled prevalence of malaria and intestinal helminthiases coinfections among malaria suspected patients in Ethiopia. Methods: Primary studies published in English language were retrieved using appropriate search terms on Google Scholar, PubMed/MEDLINE, CINHAL, Scopus, and Embase. The Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used for critical appraisal of studies. A pooled statistical meta-analysis was conducted using STATA Version 14.0 software. The heterogeneity and publication bias were assessed using the I2 statistics and Egger’s test, respectively. Duval and Tweedie’s nonparametric trim and fill analysis using the random-effect analysis. The Random effects model was used to estimate the summary prevalence of comorbidity of malaria and soil transmitted helminthiases and the corresponding 95% confidence intervals (CI). The review protocol has registered in PROSPERO number CRD42019144803. Results: We identified ten studies (n = 6633 participants) in this study. The overall pooled result showed 13% of the ambulatory patients infected by malaria and intestinal helminths concurrently in Ethiopia. The pooled prevalence of Plasmodium falciparum and Plasmodium vivax, and mixed infections were 12, 30, and 6%, respectively. The most common intestinal helminth parasites detected were Hookworm, Ascaris lumbricoides, and Tirchuris trichiura. Conclusions: The comorbidity of malaria and intestinal helminths causes lower hemoglobin level leading to maternal anemia, preterm delivery, and still birth in pregnant women and lactating mother. School-aged children and neonates coinfected by plasmodium species and soil transmitted helminths develop cognitive impairment, protein energy malnutrition, low birth weight, small for gestational age, and gross motor delay. The Ministry of Health of Ethiopia and its international partners working on malaria elimination programs should give more emphasis to the effect of the interface of malaria and soil transmitted helminths, which calls for an integrated disease control and prevention.

Maternal Hookworm Infection and Its Effects on Maternal Health: A Systematic Review and Meta-Analysis

Hookworm is an intestinal parasite that infects nearly 230 million people, with another 5.1 billion at risk, especially in poverty-stricken tropical and subtropical regions. Pregnancy is an especially vulnerable time for hookworm infection because of its effect on both maternal and subsequently fetal health. A systematic review and meta-analysis was conducted. The meta-analysis was performed on the association between maternal hookworm and maternal anemia, as well as maternal hookworm coinfection with malaria. The prevalence of hookworm ranged from 1% to 78% in pregnant women, whereas malaria prevalence ranged from 11% to 81%. Pregnant women with hookworm infection were more likely to have anemia (combined odds ratio [cOR] 2.55 [2.20, 2.96], P < 0.001). In addition, pregnant woman with hookworm were more likely to have malaria coinfection (cOR 1.60 [1.38, 1.86], P < 0.001). Other effects on maternal and child health were investigated and summarized without systematic review or meta-analysis because of the limited study numbers. Despite current deworming recommendations in pregnant women, heavy hookworm burden, coinfection with malaria, and subsequent anemia persist. Although this is likely due, in part, to a lack of implementation of preventive chemotherapy, additional interventions such as health education, proper waste management, or linking malaria and soil-transmitted helminth treatment and prevention programs may also be needed. Further investigations on maternal-child outcomes as a result of hookworm infection during pregnancy will highlight public health interventional targets to reduce morbidity in pregnant women and children globally.

Malaria and Geohelminthiasis Coinfections in Expectant Women: Effect on Maternal Health and Birth Outcomes in a Malaria Endemic Region in Kenya

Geohelminthiasis and malaria coinfections in pregnancy are common in sub-Saharan Africa. The consequences of the disease combination on maternal health and birth outcomes are poorly understood. For a better understanding of this coinfection in expectant mothers, a cross-sectional study was carried out to evaluate the effect of the coinfection on maternal health and birth outcomes in expectant mothers in Bungoma County, Kenya. To collect data on malaria and maternal haematological parameters, blood samples were obtained from 750 participants aged 18-49 years and analyzed. Haemoglobin and eosinophils levels were determined by coulter counter while malaria parasitemia levels and red blood cell morphology were assessed by preparing and observing blood smears under the microscope. Fresh stool samples were collected and processed for identification and quantification of geohelminths species using Kato-Katz. Harada Mori technique was used to increase chances of detecting hookworms and Strongyloides infections. Neonate's health was evaluated based on the appearance, pulse, grimace, activity, and respiration (APGAR) scale. Parasites identified were Plasmodium falciparum, P. malariae, P. ovale, Ascaris lumbricoides, Necator americanus, Enterobius vermicularis, and Schistosoma mansoni. The prevalence of geohelminths, malaria parasites, and coinfection was 24.7%, 21.6%, and 6.8%, respectively. Those coinfected with geohelminths and malaria parasites were four times likely to have anaemia (OR 4.137; 95% CI 2.088-8.195; P=0.001) compared with those infected with geohelminths or malaria parasites alone (OR 0.505; 95% CI 0.360-0.709; P=0.001 and OR 0.274; 95%CI 0.187-0.402 P=0.001, respectively). The odds of having preterm deliveries (OR 6.896; 95% CI 1.755-27.101; P=0.006) and still births (OR 3.701; 95% CI 1.008-13.579 P< 0.048) were greater in those coinfected than in those infected with either geohelminths or malaria parasites. Geohelminths and malaria coinfections were prevalent among study participants; consequently the risk of maternal anaemia, preterm deliveries, and still births were high. Routine screening and prompt treatment during antenatal visits should be encouraged to mitigate the adverse consequences associated with the coinfections.

Prevalence and associated factors of Plasmodium falciparum and soil transmitted helminth infections among pregnant women in Osun state, Nigeria

BACKGROUND

Plasmodium falciparum and soil transmitted helminth (STHs) infection are widespread in sub-Sahara Africa, where co-infection is also common. This study assessed the prevalence of these infections and their risk factors among pregnant women in Osogbo, Nigeria.

METHODS

A total of 200 pregnant women attending the antenatal clinic were recruited. Plasmodium falciparum was detected using thick and thin film methods, while formol ether concentration method was used for STHs detection. A questionnaire was used to investigate the possible risk factors associated with acquisition of malaria and helminth infections.

RESULTS

The prevalence of P. falciparum, STHs and their co-infection was 29.5%, 12% and 5% respectively. P. falciparum, STHs and P. falciparum + STHs co-infection was significantly higher in primigravidae (52.5% vs 58.3% vs 80%) than in secongravidae (18.6% vs 25.0% vs 20%) and multigravidae (28.8% vs 16.7% vs 0%) (p=0.02). Prevalence associated factors identified for P. falciparum was age (p=0.0001) while gravidity (p=0.02) was identified for P. falciparum + STHs co-infection.

CONCLUSION

High prevalence of P. falciparum and helminth infections was observed among the pregnant women with primigravidae being the most susceptible to co-infection. There is an urgent need to implement an effective malaria and STHs preventive method for this high risk population.

The Health Effects of Strongyloidiasis on Pregnant Women and Children: A Systematic Literature Review

Strongyloidiasis is a helminth infection that remains under-researched despite its ability to cause significant illness. Women and children may be at particular risk of health consequences from this parasite. This systematic literature review aims to examine research on the long-term health effects that strongyloidiasis has in pregnant women and children. We conducted a structured search using multiple databases to collect all primary studies discussing health effects of strongyloidiasis in the aforementioned groups. The review included 20 results: 16 primary studies and four case reports. The methodological quality of studies was substandard, and there was substantial heterogeneity to the statistical analysis and outcomes assessed in the literature. Statistically significant associations were found between strongyloidiasis and low birth weight, as well as wasting. No links were found between strongyloidiasis and anaemia. Due to testing methods used in the studies, the prevalence of Strongyloides stercoralis in these studies was probably under-estimated. Current research is suggestive that strongyloidiasis has long-term adverse health effects on the offspring of infected mothers and in chronically-infected children. Data analysis was hindered by both methodological and statistical flaws, and as such, reliable conclusions regarding the health impacts could not be formed.

Cytokine profiles among patients co-infected with Plasmodium falciparum malaria and soil borne helminths attending Kampala International University Teaching Hospital, in Uganda

BACKGROUND

Malaria and helminths share the same geographical distribution in tropical Africa. Studies of the interaction of helminth and malaria co-infection in humans have been few and are mainly epidemiological, with little information on cellular immune responses. This study aimed to determine Cytokine profiles among patients co-infected with Plasmodium falciparum malaria and soil borne helminth attending Kampala International University Teaching Hospital (KIU).

METHODS

A case control study of 240 patients were recruited at KIU teaching hospital. Patients with Plasmodium falciparum malaria were 55 (22.9%) and those with soil-borne helminths were 63 (26.3%). The controls were 89 (37.1%), while those co-infected with Plasmodium falciparum malaria and soil-borne helminths were 33 (13.8%). Cases were defined as having a positive blood smear for P. falciparum malaria, those with helminths or co-infections of the two. Negative controls were those with a negative blood smear for P. falciparum malaria and those with no stool parasitic infections. Patients presenting with signs and symptoms of malaria or those suspected of having helminths were recruited for the study. A panel of five cytokines (IFN-γ, TNF-α, IL-6, TGF-β and IL-10) were assayed from plasma samples in patients with and without Plasmodium falciparum malaria, patients with and without helminth, and then those co-infected with the two diseases diagnosis was done using thick blood smears stained with 10% Giemsa and stool examination was done following the Kato Katz technique following standard procedures.

RESULTS

The prevalence of Plasmodium falciparum malaria by sex was 28 (11.7%) and 27 (11.3%) in male and female respectively. The overall prevalence of soil borne helminth was 26.3%, and among those harbouring helminths, 13.8% were co-infected with Plasmodium falciparum. Cytokine levels significantly differed across Plasmodium falciparum malaria, soil borne helminth infected patients and health controls for IFN-γ (P = 0.023), IL-10 (P = 0.008) and TGF-β (P = 0.0001). Cytokine levels significantly differed across Plasmodium falciparum malaria, soil borne helminth infected patients and patients co-infected with Plasmodium falciparum malaria and soil borne helminth for IL-10 (P = 0.004), IL-6 (P = 0.011) and TGF-β (P = 0.003).

CONCLUSION

An up-regulation of IFN-γ during Plasmodium falciparum malaria and an up-regulation of IL-10 and TGF-β in soil borne helminth infections was demonstrated. We demonstrate that co-infections of Plasmodium falciparum and soil borne helminth lead to an up-regulation of IL-10 and IL-6 and a down-regulation of TGF-β.Trial registration No17/10-16.

When Epidemiology Is the Clue to a Positive Outcome: A Case of Malaria During Pregnancy

BACKGROUND Malaria infection during pregnancy is associated with increased perinatal and maternal morbidity and mortality. CASE REPORT A 29-year-old primigravida at 37 weeks of gestation, with no significant medical history, presented complaining of fever, chills, and generalized body aches. She had been living in Malawi for 1 year and was on atovaquone/proguanil prophylaxis until she was found to be pregnant. Prophylaxis was changed to mefloquine and discontinued upon her return to the US. Six weeks prior to presentation, she traveled to Malawi for 1 month when she was off prophylaxis. On admission, vital signs and physical exam results were normal. Given epidemiologic findings, a malaria smear was performed and showed 4% parasitemia. She was treated with mefloquine and discharged. Two days after discharge, she again presented with fever, chills, and body aches. A malaria smear showed <0.01% parasitemia, with 2 ring forms. Serologies for dengue, chikungunya, leptospira, and blood cultures were negative. These symptoms were deemed secondary to early recrudescence. The species was later identified as P. falciparum. The patient was treated with quinine sulfate and clindamycin. She delivered at full term without complication. CONCLUSIONS Pregnant women are more susceptible to severe forms of malaria, such as P. falciparum. A high index of suspicion and early identification of malaria are vital to prevent deleterious outcomes.

Helminth infection during pregnancy: insights from evolutionary ecology

Helminths are parasitic nematodes and trematodes, grouped together because of morphological similarities and commonalities in the effects infections have on hosts. These include complications such as anemia and biasing of immune responses, which can alter susceptibility for other diseases. For pregnant women, these complications might have implications for pregnancy outcomes or neonatal health. Here, I review studies of helminth infections during pregnancy, and ask the following questions: Do helminths affect maternal health or pregnancy outcomes? Are there consequences of maternal infection for infants? What are the effects of antihelminth treatment during pregnancy? The evidence suggests that the answers to these questions depend on the particular helminth species in question, maternal nutritional status, and the presence or absence of comorbid infection with other species, such as malaria. Moreover, there may also be unexpected consequences of treatment, as maternal infections can affect the priming of infant immune systems, with potential effects on infants later in life. These complex interactions suggest that a consideration of the evolutionary history of human–helminth interactions, as well as the ecological context of infections, can help to clarify an understanding of these host–parasite interactions and provide direction for future investigations.

Association between malaria immunity and pregnancy outcomes among Malawian pregnant women receiving nutrient supplementation

Background

Malaria antibody responses measured at delivery have been associated with protection from maternal anaemia and low birth weight deliveries. Whether malarial antibodies present in the first half of pregnancy may protect from these or other poor birth outcomes is unclear. To determine whether malaria antibodies in the first half of pregnancy predict pregnancy outcomes, antibodies were measured to a range of merozoite antigens and to antigens expressed on the surface of parasitized red blood cells (pRBCs) in plasma samples collected at 14–20 weeks of gestation from Malawian women. The latter antibodies were measured as total IgG to pRBCs, and antibodies promoting opsonic phagocytosis of pRBCs. Associations between antibodies and maternal haemoglobin in late pregnancy or newborn size were investigated, after adjusting for potential covariates.

Results

Antibodies to pRBC surface antigens were associated with higher haemoglobin concentration at 36 weeks. Total IgG to pRBCs was associated with 0.4 g/l [(95% confidence interval (0.04, 0.8)] increase in haemoglobin, and opsonizing antibody with 0.5 (0.05, 0.9) increase in haemoglobin for each 10% increase in antibody. These antibodies were not associated with birthweight, placental malaria, or newborn anthropometrics. Antibodies to merozoite antigens and non-placental-binding IEs were not associated with decreased risk of any of these outcomes. In some instances, they were negatively associated with outcomes of interest.

Conclusion

Antibodies to placental-binding infected erythrocytes may be associated with higher haemoglobin levels in pregnancy, whereas antibodies to other malaria antigens may instead be markers of malaria exposure.

Trial registration clinicaltrials.gov NCT01239693. Registered Nov 10, 2010.

Iron Supplementation Alters Heme and Heme Oxygenase 1 (HO-1) Levels In Pregnant Women in Ghana

BACKGROUND

Iron supplementation is recommended for pregnant women to meet their iron requirement for a healthy pregnancy. The benefits and risks of universal iron supplementation during pregnancy in malaria endemic countries are currently being debated. As part of a broader study that focused on the effect of heme/HO-1 on pregnancy outcomes in malaria in pregnancy, we determined the association between iron supplementation and free heme levels in blood of pregnant women with and without malaria in Ghana. We hypothesized that pregnant women with malaria who took iron supplements will have higher levels of Heme/HO-1 than those who did not take iron supplements.

METHODS

A total of 337 women were recruited for this study. Blood samples were collected for malaria diagnosis and heme/HO-1 measurement. Quantification of heme was done using a heme colorimetric assay kit and HO-1 levels were performed using Enzyme-Linked Immunosorbent Assay (ELISA) on plasma samples.

RESULTS

Malaria positive iron supplemented women, in their third trimester, had significantly higher median levels of heme 59.3(43.1 - 60.4) than non-malaria iron supplemented women 35.7(33.0 - 62.2), p = 0.026. Also, malaria positive iron supplemented women had significant higher median levels of HO-16.2(IQR 4.9 - 8.1) than pregnant women who did not take iron supplements 2.9 (IQR 2.1 - 3.8), p = <0.001.

CONCLUSION

Although iron supplementation may be highly beneficial and improve pregnancy outcomes for iron deficient or anemic mothers, it is also likely that iron supplementation for pregnant women who are not iron deficient may put this group of women at risk for adverse pregnancy outcomes. Findings from this study sheds light on the effect of iron supplementation on malaria derived heme in pregnancy, which may inform how iron supplementation is recommended for pregnant women who are not iron deficient.

Antenatal care attendance, a surrogate for pregnancy outcome? The case of Kumasi, Ghana

Antenatal care (ANC) has been shown to influence infant and maternal outcomes. WHO recommends 4 ANC visits for uncomplicated pregnancies. However, pregnant women in Ghana are required to attend 8-13 antenatal visits. We investigated the association of ANC attendance with adverse pregnancy outcomes (defined as low infant birth weight, stillbirth, preterm delivery or small for gestational age). A quantitative cross-sectional study was conducted on 629 women, age 19-48 years who presented for delivery at two selected public hospitals and 16 traditional birth attendants from July to November 2011. Socio-demographic and antenatal information were collected using a structured questionnaire. ANC attendance, medical and obstetric/gynecological history were abstracted from maternal antenatal records. Data were analyzed using Chi square and logistic regression. Twenty-two percent of the women experienced an adverse outcome. Eleven percent of the women attended <4 ANC visits. In an unadjusted model, these women had an increased likelihood of experiencing an adverse outcome (OR 2.27; 95% CI 1.30-3.94; p = 0.0038). High parity (>5 children) was also associated with adverse birth outcomes. Women screened for syphilis or use of insecticide-treated bed nets had a 40 and 36% (p = 0.0447 and p = 0.0293) reduced likelihood of experiencing an adverse pregnancy outcome respectively. After adjusting for confounders, attending <4 antenatal visits was associated with adverse pregnancy outcome compared with ≥4 ANC visits (Adjusted OR 2.55; 95% CI 1.16-5.63; p = 0.0202). Attending <4 antenatal visits and high parity were associated with adverse pregnancy outcomes for uncomplicated pregnancies.

Pregnancy and helminth infections

It has been proposed that helminth infection may be particularly detrimental during pregnancy, through adverse effects on maternal anaemia and on birth outcomes, and that anthelminthic treatment during pregnancy will therefore be particularly beneficial. However, the few treatment trials that have been conducted have given, but little support to this notion and further trials in settings of nutritional stress are needed. It has also been proposed that prenatal exposure to helminth infection has an important effect on the development of the foetal immune response. There is evidence that this may impact, long-term, upon responses to helminth and nonhelminth antigens, and to allergens. Exposure to helminths in utero may also have nonspecific effects that may modify the offspring's susceptibility to diseases mediated by inflammation, including metabolic disorders. The mechanisms of such effects are not known, but they deserve to be explored as current epidemiological findings suggest the possibility of primary prevention for inflammatory conditions such as allergy, through intervention during pregnancy.

Rationale for the coadministration of albendazole and ivermectin to humans for malaria parasite transmission control

Recently there have been calls for the eradication of malaria and the elimination of soil-transmitted helminths (STHs). Malaria and STHs overlap in distribution, and STH infections are associated with increased risk for malaria. Indeed, there is evidence that suggests that STH infection may facilitate malaria transmission. Malaria and STH coinfection may exacerbate anemia, especially in pregnant women, leading to worsened child development and more adverse pregnancy outcomes than these diseases would cause on their own. Ivermectin mass drug administration (MDA) to humans for malaria parasite transmission suppression is being investigated as a potential malaria elimination tool. Adding albendazole to ivermectin MDAs would maximize effects against STHs. A proactive, integrated control platform that targets malaria and STHs would be extremely cost-effective and simultaneously reduce human suffering caused by multiple diseases. This paper outlines the benefits of adding albendazole to ivermectin MDAs for malaria parasite transmission suppression.

Helminth parasites alter protection against Plasmodium infection

More than one-third of the world's population is infected with one or more helminthic parasites. Helminth infections are prevalent throughout tropical and subtropical regions where malaria pathogens are transmitted. Malaria is the most widespread and deadliest parasitic disease. The severity of the disease is strongly related to parasite density and the host's immune responses. Furthermore, coinfections between both parasites occur frequently. However, little is known regarding how concomitant infection with helminths and Plasmodium affects the host's immune response. Helminthic infections are frequently massive, chronic, and strong inductors of a Th2-type response. This implies that infection by such parasites could alter the host's susceptibility to subsequent infections by Plasmodium. There are a number of reports on the interactions between helminths and Plasmodium; in some, the burden of Plasmodium parasites increased, but others reported a reduction in the parasite. This review focuses on explaining many of these discrepancies regarding helminth-Plasmodium coinfections in terms of the effects that helminths have on the immune system. In particular, it focuses on helminth-induced immunosuppression and the effects of cytokines controlling polarization toward the Th1 or Th2 arms of the immune response.

The association of parasitic infections in pregnancy and maternal and fetal anemia: a cohort study in coastal Kenya

Background

Relative contribution of these infections on anemia in pregnancy is not certain. While measures to protect pregnant women against malaria have been scaling up, interventions against helminthes have received much less attention. In this study, we determine the relative impact of helminthes and malaria on maternal anemia.

Methods

A prospective observational study was conducted in coastal Kenya among a cohort of pregnant women who were recruited at their first antenatal care (ANC) visit and tested for malaria, hookworm, and other parasitic infections and anemia at enrollment. All women enrolled in the study received presumptive treatment with sulfadoxine-pyrimethamine, iron and multi-vitamins and women diagnosed with helminthic infections were treated with albendazole. Women delivering a live, term birth, were also tested for maternal anemia, fetal anemia and presence of infection at delivery.

Principal Findings

Of the 706 women studied, at the first ANC visit, 27% had moderate/severe anemia and 71% of women were anemic overall. The infections with highest prevalence were hookworm (24%), urogenital schistosomiasis (17%), trichuria (10%), and malaria (9%). In adjusted and unadjusted analyses, moderate/severe anemia at first ANC visit was associated with the higher intensities of hookworm and P. falciparum microscopy-malaria infections. At delivery, 34% of women had moderate/severe anemia and 18% of infants' cord hemoglobin was consistent with fetal anemia. While none of the maternal infections were significantly associated with fetal anemia, moderate/severe maternal anemia was associated with fetal anemia.

Conclusions

More than one quarter of women receiving standard ANC with IPTp for malaria had moderate/severe anemia in pregnancy and high rates of parasitic infection. Thus, addressing the role of co-infections, such as hookworm, as well as under-nutrition, and their contribution to anemia is needed.

International guidelines recommend routine prevention and treatments which are safe and effective during pregnancy to reduce hookworm, malaria and other infections among pregnant women living in geographic areas where these infections are prevalent. Despite their effectiveness, programs to address common infections such as hookworm, schistosomiasis and malaria during pregnancy have not been widely adopted. Hookworm, malaria and other infections have been associated with anemia in children, but the studies on the impact of these infections on anemia in pregnancy have not been as clear. This study was undertaken to evaluate the prevalence of parasitic infections among women attending antenatal care which provided the nationally recommended malaria preventive treatment program in coastal Kenya. At the first ANC visit, more than 70% of women were anemic, nearly one-fourth had hookworm and about 10% had malaria. Women with high levels of hookworm or malaria infections were at risk of anemia.

Effect of Malaria and Geohelminth Infection on Birth Outcomes in Kumasi, Ghana

Aim

In 2005, the Ghana Health Service mandated malaria and helminths chemoprophylaxis during antenatal care visits. The aim of this study was to investigate the prevalence of malaria and helminth infections and their relationship with adverse birth outcomes (low birth weight, stillbirth, and preterm) following the implementation of these treatments.

Study Design

A quantitative cross-sectional study.

Method

The study was conducted on 630 women presenting for delivery in the Komfo Anokye Teaching Hospital and the Manhyia District Hospital from July to November 2011. Socio-demographic information and medical and obstetric history were collected. Laboratory analyses for the presence of malaria and helminths were performed. Association of malaria and helminths with birth outcomes was assessed using logistic regression to obtain odds ratios (ORs) and 95% confidence intervals.

Results

The prevalence of malaria, helminths and adverse birth outcomes was 9.0%, 5.0% and 22.2%, respectively. Compared with women who received malaria prophylaxis, women without malaria prophylaxis were two times more likely to have malaria infection (aOR = 2.1; 95% CI = 1.06-4.17). Women who were not screened for helminths were twice as likely to be infected with helminths (aOR = 2.4; 95% CI = 1.15-5.12) than women who were screened for helminths. For women infected with hookworm or Schistosoma mansoni, the odds of having an adverse birth outcome (aOR = 3.9; 95% CI = 1.09-14.20) and stillbirth (aOR = 7.7; 95% CI = 1.21-36.38) were greater than for women who were not infected.

Conclusion

The prevalence of malaria, helminths and adverse birth outcomes was lower than previously reported 9.0% vs. 36.3, 5.0% vs. 25.7 and 22.2% vs. 44.6, respectively. Helminth but not malaria infection was found to be significantly associated with adverse birth outcomes.

Development, coinfection, and the syndemics of pregnancy in Sub-Saharan Africa

Notable among gaps in the achievement of the global health Millennium Development Goals (MDG) are shortcomings in addressing maternal health, an issue addressed in the fifth MDG. This shortfall is particularly acute in Sub-Saharan Africa (SSA), where over half of all maternal deaths occur each year. While there is not as yet a comprehensive understanding of the biological and social causes of maternal death in SSA, it is evident that poverty, gendered economic marginalization, social disruptions, hindered access to care, unevenness in the quality of care, illegal and clandestine abortions, and infections are all critical factors. Beyond these factors, this paper presents a review of the existing literature on maternal health in SSA to argue that syndemics constitute a significant additional source of maternal morbidity and mortality in the region. Increasing focus on the nature, prevention, and treatment of syndemics, as a result, should be part and parcel of improving maternal health in SSA.

Birthweight in offspring of mothers with high prevalence of helminth and malaria infection in coastal Kenya

Results of studies on the associations of maternal helminth infection and malaria-helminth co-infection on birth outcomes have been mixed. A group of 696 pregnant women from the Kwale district in Kenya were recruited and tested for malaria and helminth infection at delivery. Birthweight was documented for 664 infants. A total of 42.7% of the mothers were infected with Plasmodium falciparum, 30.6% with Schistosoma haematobium, 36.2% with filariasis, 31.5% with hookworm, and 5.9% with Trichuris trichiura; co-infection was present in 46.7%. Low birthweight (LBW) (weight < 2,500 grams) was present in 15.4% of the offspring, and 8.3% had a weight z-score ≤ 2 SD below the World Health Organization mean. Only gravida, age, and locale had a significant association with LBW. The high prevalence of maternal infection coupled with a higher than expected percentage of LBW highlight a need for further investigation of the association of maternal co-infection with LBW.

Antihelminthics in pregnancy and maternal, newborn and child health

Soil-transmitted helminths (STHs), primarily Ascaris, Trichuris and hookworm, inflict a substantial morbidity burden on poor populations living in tropical and subtropical regions. Chronic STH infections can cause intestinal blood loss and nutrient loss and/or malabsorption, which can result in or exacerbate iron deficiency, anaemia and other nutritional deficiencies. More than 1 billion people are infected with at least one STH, and at least 44 million pregnant women are infected with hookworm alone. Pregnant women are especially vulnerable to the harmful consequences of these parasitic infections due to increased nutritional demands during pregnancy. We aimed to determine the effect of antihelminthics in pregnancy on maternal, newborn and child health (MNCH) outcomes. A systematic review was conducted using online databases, and relevant articles were hand searched. We included four observational studies in the general review and four randomised controlled trials (RCTs) in the meta-analysis (total n = 3777 for the meta-analysis). Antihelminthics in pregnancy had no overall benefit on maternal anaemia [risk ratio (RR) = 0.93 [95% confidence interval (CI) 0.79, 1.10]], low birthweight (RR = 0.96 [95% CI 0.72, 1.29]) or perinatal mortality (RR = 0.98 [95% CI 0.58, 1.68]). The risk of very low birthweight was lower in the antihelminthics group (RR = 0.21 [95% CI 0.05, 0.83]); however, this estimate included data from only two trials (total n = 1936). In all four trials, antihelminthics in pregnancy significantly decreased the prevalence of STH infection. Three observational studies showed that antihelminthics in pregnancy improved maternal iron status, two studies reported beneficial effects on birthweight, and two studies found a beneficial effect on infant survival. Although few RCTs to date have failed to collectively demonstrate a clear beneficial impact of antihelminthics in pregnancy on maternal, newborn and child health outcomes, findings from observational studies suggest a potential benefit on maternal anaemia, birthweight and infant mortality. This meta-analysis was limited by a dearth of evidence from RCTs, and further trials examining the effect of antihelminthics starting in the second trimester of pregnancy in poor, STH-endemic regions with high rates of anaemia are needed.

Moderate to severe, but not mild, maternal anemia is associated with increased risk of small-for-gestational-age outcomes

Anemia is highly prevalent globally, estimated at 40-50% in women of reproductive age. Prior studies have produced inconclusive evidence as to the association between maternal anemia and intrauterine growth restriction (IUGR). We conducted a systematic review of the literature containing associations between maternal anemia and small for gestational age (SGA) outcomes (as a proxy for IUGR). A meta-analysis was performed to pool associations, categorized by the hemoglobin cutoffs presented by the authors. We identified 12 studies reporting associations between maternal anemia and SGA. For the meta-analysis, there were 7 associations with a hemoglobin cutoff <110 g/L, 7 with a cutoff <100 g/L, and 5 with a cutoff <90 or <80 g/L. Although the <110- and <100-g/L categories showed no significant relationship with SGA, the <90- or <80-g/L category was associated with a 53% increase in risk of the newborn being SGA [pooled OR = 1.53 (95% CI: 1.24-1.87); P < 0.001]. Moderate to severe, but not mild, maternal anemia appears to have an association with SGA outcomes, but the findings must be viewed with caution due to the great heterogeneity of the studies. Further examination should be conducted using datasets with better standardized definitions and measurements of exposure and outcome.

Endectocides for malaria control

Systemic endectocidal drugs, used to control nematodes in humans and other vertebrates, can be toxic to Anopheles spp. mosquitoes when they take a blood meal from a host that has recently received one of these drugs. Recent laboratory and field studies have highlighted the potential of ivermectin to control malaria parasite transmission if this drug is distributed strategically and more often. There are important theoretical benefits to this strategy, as well as caveats. A better understanding of drug effects against vectors and malaria ecologies are needed. In the near future, ivermectin and other endectocides could serve as potent and novel malaria transmission control tools that are directly linked to the control of neglected tropical diseases in the same communities.

Epidemiology of hookworm infection in Kintampo North Municipality, Ghana: patterns of malaria coinfection, anemia, and albendazole treatment failure

A cross-sectional pilot study of hookworm infection was carried out among 292 subjects from 62 households in Kintampo North, Ghana. The overall prevalence of hookworm infection was 45%, peaking in those 11-20 years old (58.5%). In children, risk factors for hookworm infection included coinfection with malaria and increased serum immunoglobulin G reactivity to hookworm secretory antigens. Risk factors for infection in adults included poor nutritional status, not using a latrine, not wearing shoes, and occupation (farming). Although albendazole therapy was associated with an overall egg reduction rate of 82%, 37 subjects (39%) remained infected. Among those who failed therapy, treatment was not associated with a significant reduction in egg excretion, and nearly one-third had higher counts on repeat examination. These data confirm a high prevalence of low-intensity hookworm infection in central Ghana and its association with poor nutritional status. The high rate of albendazole failure raises concern about emerging resistance.

Mass drug administration of ivermectin in south-eastern Senegal reduces the survivorship of wild-caught, blood fed malaria vectors

Background

In south-eastern Senegal, malaria and onchocerciasis are co-endemic. Onchocerciasis in this region has been controlled by once or twice yearly mass drug administration (MDA) with ivermectin (IVM) for over fifteen years. Since laboratory-raised Anopheles gambiae s.s. are susceptible to ivermectin at concentrations found in human blood post-ingestion of IVM, it is plausible that a similar effect could be quantified in the field, and that IVM might have benefits as a malaria control tool.

Methods

In 2008 and 2009, wild-caught blood fed An. gambiae s.l. mosquitoes were collected from huts of three pairs of Senegalese villages before and after IVM MDAs. Mosquitoes were held in an insectary to assess their survival rate, subsequently identified to species, and their blood meals were identified. Differences in mosquito survival were statistically analysed using a Glimmix model. Lastly, changes in the daily probability of mosquito survivorship surrounding IVM MDAs were calculated, and these data were inserted into a previously developed, mosquito age-structured model of malaria transmission.

Results

Anopheles gambiae s.s. (P < 0.0001) and Anopheles arabiensis (P = 0.0191) from the treated villages had significantly reduced survival compared to those from control villages. Furthermore, An gambiae s.s. caught 1-6 days after MDA in treated villages had significantly reduced survival compared to control village collections (P = 0.0003), as well as those caught pre-MDA (P < 0.0001) and >7 days post-MDA (P < 0.0001). The daily probability of mosquito survival dropped >10% for the six days following MDA. The mosquito age-structured model of malaria transmission demonstrated that a single IVM MDA would reduce malaria transmission (R_o) below baseline for at least eleven days, and that repeated IVM MDAs would result in a sustained reduction in malaria R_o.

Conclusions

Ivermectin MDA significantly reduced the survivorship of An. gambiae s.s. for six days past the date of the MDA, which is sufficient to temporarily reduce malaria transmission. Repeated IVM MDAs could be a novel and integrative malaria control tool in areas with seasonal transmission, and which would have simultaneous impacts on neglected tropical diseases in the same villages.

Complex Interactions between soil-transmitted helminths and malaria in pregnant women on the Thai-Burmese border

BACKGROUND

Deworming is recommended by the WHO in girls and pregnant and lactating women to reduce anaemia in areas where hookworm and anaemia are common. There is conflicting evidence on the harm and the benefits of intestinal geohelminth infections on the incidence and severity of malaria, and consequently on the risks and benefits of deworming in malaria affected populations. We examined the association between geohelminths and malaria in pregnancy on the Thai-Burmese border.

METHODOLOGY

Routine antenatal care (ANC) included active detection of malaria (weekly blood smear) and anaemia (second weekly haematocrit) and systematic reporting of birth outcomes. In 1996 stool samples were collected in cross sectional surveys from women attending the ANCs. This was repeated in 2007 when malaria incidence had reduced considerably. The relationship between geohelminth infection and the progress and outcome of pregnancy was assessed.

PRINCIPAL FINDINGS

Stool sample examination (339 in 1996, 490 in 2007) detected a high prevalence of geohelminths 70% (578/829), including hookworm (42.8% (355)), A. lumbricoides (34.4% (285)) and T.trichuria (31.4% (250)) alone or in combination. A lower proportion of women (829) had mild (21.8% (181)) or severe (0.2% (2)) anaemia, or malaria 22.4% (186) (P.vivax monoinfection 53.3% (101/186)). A. lumbricoides infection was associated with a significantly decreased risk of malaria (any species) (AOR: 0.43, 95% CI: 0.23-0.84) and P.vivax malaria (AOR: 0.29, 95% CI: 0.11-0.79) whereas hookworm infection was associated with an increased risk of malaria (any species) (AOR: 1.66, 95% CI: 1.06-2.60) and anaemia (AOR: 2.41, 95% CI: 1.18-4.93). Hookworm was also associated with low birth weight (AOR: 1.81, 95% CI: 1.02-3.23).

CONCLUSION/SIGNIFICANCE

A. lumbricoides and hookworm appear to have contrary associations with malaria in pregnancy.