"There is iron and iron…" Burkinabè women's perceptions of iron supplementation: a qualitative study

Most pregnant women in Burkina Faso are iron deficient and many are anemic. This study assessed women's understanding of anemia and the role of iron in preventing and treating this condition. A qualitative study was conducted within a randomized controlled trial of weekly iron supplementation in a rural malaria endemic area. Focus groups with women of similar age, parity, and marital status took place in 12 of 24 study villages. Two additional focus groups were conducted with female field workers. Tape-recorded transcripts were translated into French and analyzed using Framework analysis. Anemia, for which no Mooré term or traditional treatment for anemia was evident, was described in terms of blood volume. Moderate blood loss (diminished blood) could be easily replaced by eating well and was not considered serious. Massive blood loss (finished blood) was a rare, life-threatening illness. Iron tablets could increase blood volume and help women withstand massive blood loss at delivery, but for the latter, transfusion was indicated. Women had no knowledge of iron's role and did not readily concede that iron supplements contained elemental iron. Neither adolescents nor field workers were convinced of the benefits of supplementing non-pregnant adolescents, who were incorrectly considered to be at low risk of anemia. Young women's knowledge of anemia did not provide an adequate explanatory framework to motivate anemia prevention. Improving information on the role of iron is especially important for adolescent girls who may be incorrectly considered at low risk of anemia as they have not yet experienced pregnancy.

New cut-off values for ferritin and soluble transferrin receptor for the assessment of iron deficiency in children in a high infection pressure area

Background:

Due to the potential risk of iron supplementation in iron replete children, it is important to properly identify children who may require iron supplementation. However, assessment of the iron status has proven to be difficult, especially in children living in areas with high infection pressure (including malaria).

Aims and Methods:

Biochemical iron markers were compared to bone marrow iron findings in 381 Malawian children with severe anaemia.

Results:

Soluble transferrin receptor/log ferritin (TfR-F index), using a cut-off of 5.6, best predicted bone marrow iron stores deficiency (sensitivity 74%, specificity 73%, accuracy 73%). In order to improve the diagnostic accuracy of ferritin or sTfR as a stand-alone marker, the normal cut-off value needed to be increased by 810% and 83% respectively. Mean cell haemoglobin concentration (MCHC), using a cut-off of 32.1 g/dl, had a sensitivity of 67% and specificity of 64% for detecting iron stores deficiency.

Conclusion:

TfR-F index incorporated the high sensitivity of sTfR, a proxy for cellular iron need, and the high specificity of ferritin, a proxy for iron stores. In areas with a high infection pressure, the TfR-F index best predicted iron deficiency. However, in settings where diagnostic tests are limited, MCHC may be an acceptable alternative screening test.

Improved method for assessing iron stores in the bone marrow

BACKGROUND

Bone marrow iron microscopy has been the "gold standard" method of assessing iron deficiency. However, the commonly used method of grading marrow iron remains highly subjective.

AIM

To improve the bone marrow grading method by developing a detailed protocol that assesses iron in fragments, in macrophages around fragments and in erythroblasts.

METHODS

A descriptive study of marrow aspirates of 303 children (aged 6-60 months) with severe anaemia and 22 controls (children undergoing elective surgery) was conducted at hospitals in southern Malawi (2002-04).

RESULTS

Using an intensive marrow iron grading method, 22% and 39% of cases and controls had deficient iron stores, and 40% and 46% had functional iron deficiency, respectively. Further evaluation of the iron status classification by the intensive method showed that functional iron deficiency was associated with significantly increased C-reactive protein concentrations (126.7 (85.6) mg/l), and iron stores deficiency with significantly increased soluble transferrin receptor concentrations (21.7 (12.5) mug/ml).

CONCLUSIONS

Iron assessment can be greatly improved by a more intense marrow examination. This provides a useful iron status classification which is of particular importance in areas where there is a high rate of inflammatory conditions.

Micronutrient concentrations in respiratory syncytial virus and human metapneumovirus in Yemeni children

BACKGROUND

Acute respiratory infections (ARI) cause significant childhood mortality. Nutritional homeostasis, particularly micronutrient levels, is important in modulating response to infection. More information is required regarding micronutrient levels in ARI viral infections, especially newly identified viruses such as human metapneumovirus (HMPV).

AIM

To describe zinc, copper, selenium and vitamins A and E concentrations in children with respiratory syncytial virus (RSV) and/or HMPV in relation to levels of C-reactive protein (CRP).

METHODS

The presence of RSV/HMPV in nasopharyngeal aspirates (NPA) was identified in 246 children using RTPCR. Zinc, copper, selenium and vitamins A and E concentrations were measured using inductive coupled plasma mass spectrometry and high performance liquid chromatography.

RESULTS

183 children had RSV, 39 had HMPV and 24 were co-infected. Zinc concentrations were lower in children with HMPV than in children with RSV or RSV/HMPV co-infection. Copper concentrations were lower in children with RSV than in children with RSV/HMPV or HMPV and zinc/copper ratios were lower in children with HMPV/RSV or RSV than in children with HMPV alone. Retinol and a alpha-tocopherol were lower in children with RSV than in children with HMPV. Most children had low selenium concentrations. Children with RSV and raised CRP (>5 mg/L) had higher copper and lower zinc/copper ratios than those with low CRP (< or =5 mg/L). Children with HMPV and raised CRP had higher copper and lower zinc concentrations than children with low CRP. Children with RSV/HMPV and raised CRP had higher copper concentrations. Children with RSV/HMPV and raised CRP had higher a alpha-tocopherol concentrations.

CONCLUSION

The profiles of micronutrients differ in children with RSV and HMPV and are confounded by CRP. These results may guide strategies for micronutrient supplementation in ARI.

The effects of smoking on birthweight-for-gestational-age curves in teenage and adult primigravidae

OBJECTIVE

To compare the effect of smoking on the birthweight-for-gestational-age curves of teenage and adult primigravidae.

METHODS

A retrospective analysis of the perinatal database at the Liverpool Women's Hospital for the years 1997-1999 for teenage and adult primigravidae.

RESULTS

Records on 1157 primigravidae were available. There were no significant differences between the mean birthweight (3220 g +/- 666 vs 3244 g +/- 680, P = 0.43) and the proportion with low birthweight (LBW) babies (8.9% vs 10.6%, P = 0.39) between teenage and adult primigravidae, respectively. The percentage of women who smoked increased from the middle class (Townsend score -6- - 3) to the working class group (Townsend score +4- + 12) for both teenagers (33.3-51.3%) and adults (6.9-29.6%). The mean birthweight of babies of smoking mothers was significantly lower than for non-smoking mothers (3112 g +/- 639 vs 3327 g +/- 663, P = 0.00002). The birthweight-for-gestational-age pattern was lower at all gestational ages for smoking mothers in both the teenage and adult groups. Risk of LBW was significantly increased in teenagers who smoked (10.8% vs 3.9%, P < 0.01), but not in adult smokers.

CONCLUSION

Lower birthweights at all gestational ages were observed in babies of teenage and adult mothers who smoked.

Breast-feeding knowledge and attitudes of teenage mothers in Liverpool

OBJECTIVES

To determine the knowledge and attitudes of teenage mothers towards breast-feeding.

DESIGN

A questionnaire of teenage (< 20 years) and non-teenage (> or = 20 years) primigravidae attending the antenatal care services at the Liverpool Women's Hospital, during the period April-May 2000.

RESULTS

Forty teenage primigravidae and 40 non-teenage primigravidae registered for the survey. Teenagers had poorer knowledge about breast-feeding than the non-teenagers, and fewer teenagers considered breast milk the best food for their baby. More teenagers than non-teenagers planned to bottle feed [23 (57.5%) vs. 9 (22.5%), P=0.002]. Only one teenager had knowledge about colostrum. Teenagers were more often single, had a lower level of education, higher unemployment, higher smoking frequency and less contact with a person who had previously breast-fed.

CONCLUSION

Teenage primigravidae have poor knowledge regarding breast-feeding compared with non-teenage primigravidae. A greater proportion of teenagers opted not to breast-feed compared with non-teenagers. Health education classes stressing the importance of breast-feeding should be emphasized in antenatal teenage clinics. More research is needed to understand how to improve the knowledge and motivation of adolescent girls to breast feed.

Tetanus antibody levels among adolescent girls in developing countries

Neonatal and maternal tetanus infections remain an important cause of death in many countries. Few studies have reported tetanus toxoid antibody levels of adolescent girls. As part of the Expanded Programme on Immunization most girls receive up to 3 injections in early childhood, and many subsequently do not receive booster vaccinations until pregnant. We determined (by ELISA) tetanus antibody seropositivity in adolescent girls from Malawi (in 1996), Nigeria (in 1993) and Pakistan (in 1996), and response to tetanus vaccination in adolescent girls from Pakistan. Geometric mean titres (GMT, IU/mL) were 0.94 in 117 Malawian, 0.32 in 154 Nigerian and 1.08 in 162 Pakistani girls. In Nigeria, 54.7% of adolescents were seronegative, of whom 26.8% had a history of unsafe abortion. In Malawi and Pakistan all girls were seropositive and in Pakistan, following a booster vaccination, titres increased 3-fold, with a lower response in older girls. The results indicated that adequate childhood immunization is likely to provide protective levels through adolescence. Booster vaccination in late childhood/early adolescence should protect the majority of women throughout their reproductive lives. This practice would reduce the risks of girls exposed to infection through unsafe abortions, and may be the best option for countries seeking to improve their vaccination schedule, especially where tetanus vaccine coverage in pregnant women is unacceptably low.

Lack of protection against vertical transmission of HIV-1 by interferons produced during pregnancy in a cohort from East African republic of Malawi

Interferons (IFNs) associated with pregnancy were studied for their possible role in inhibition of vertical transmission of the human immunodeficiency virus type 1 (HIV-1). A study group was composed of 43 HIV-1-positive mothers, of whom 15 transmitted the virus to the offspring and 28 did not. The control group included 48 HIV-1-negative mother-infant pairs. The IFN-alpha was detected only sporadically in the maternal sera from the groups of transmitters (27%), nontransmitters (21%), and controls (19%). The average levels of IFN-alpha were low, 16.3 +/- 2.5 pg/ml, 21.4 +/- 9.9 pg/ml, and 21.3 +/- 9.4 pg/ml among the transmitters, nontransmitters, and control subjects, respectively. In the cord blood, IFN-alpha was detected only on two occasions among transmitters, and on a single occasion in the control group. IFN-beta was absent from both maternal and cord blood in the study group, and found to be present in one case in the control group simultaneously in the maternal and fetal sera. In the placentas, on the other hand, both type I and II IFNs were expressed universally in the villous trophoblast, and IFN-alpha and -beta in the stromal macrophages as well. In one case among transmitters, no IFNs were detected; nevertheless, no significant difference with respect to nontransmitters could be confirmed. Our data suggest that although the placental IFNs have an antiviral potential, they are not sufficient to suppress transmission of HIV from mother to infant.

Are orphans at increased risk of malnutrition in Malawi?

The objective of this study was to compare the nutritional status and health problems of village orphans, non-orphans and orphanage children, and to identify factors associated with undernutrition. A cross-sectional study was conducted in three orphanages and two villages near Blantyre, Malawi. Seventy-six orphanage children, 137 village orphans and 80 village non-orphans were recruited. Anthropometric measurement was done and guardians were interviewed. In the group of children aged < 5 years, the prevalence of undernutrition in orphanage children was 54.8% compared with 33.3% and 30% of village orphans and non-orphans, respectively. Sixty-four per cent of young orphanage children were stunted compared with 50% of village orphans and 46.4% of non-orphans. The mean (SD) Z-score of height/age was significantly lower in the orphanage group, -2.75 (1.29) compared with -2.20 (1.51) and -1.61 (1.57) in the village orphan and non-orphan groups (p < 0.05). Conversely, older orphanage children (> or = 5 years) were less stunted and wasted than orphans and non-orphans in villages. Illness of children in the last month was reported to be higher in the non-orphan group, especially diarrhoeal disease, which occurred in 30% compared with 10.8% of village orphans and 6.6% of orphanage children. More than three children in a family being cared for by guardians was significantly associated with undernutrition. Orphanage girls were more likely to be malnourished than orphanage boys. Children who had been admitted to an orphanage for more than a year were less malnourished. In village orphans, there was no association between undernutrition and duration of stay in extended families. Age and education of guardians were not associated with the nutritional status of children. We conclude that young orphanage children are more likely to be undernourished and more stunted than village children. Older orphanage children seem to have better nutrition than village orphans. There was no significant difference in nutritional status between village orphans and non-orphans.

A community based study of vitamin A and vitamin E status of adolescent girls living in the Shire Valley, Southern Malawi

OBJECTIVE

To assess vitamin A and E status and anaemia in non-pregnant Malawian adolescent girls.

DESIGN

A cross-sectional study in rural village communities in the Shire Valley, Southern Malawi.

SUBJECTS

Adolescent girls, n = 118, aged between 10 and 19 y, 112 of whom were unmarried.

METHODS

Socio-demographic information was collected by questionnaire, heights and weights were measured. Vitamin A was assessed by the Modified Relative Dose Response (MRDR) test, in addition to serum retinol values. Blood samples were collected 4-5 h after administration of 3,4-didehydroretinyl acetate. Retinol and alpha-tocopherol levels were measured by HPLC. Serum retinol results for non-pregnant girls were compared with values for 43 adolescent pregnant girls which were available from a previous study.

RESULTS

26.6% of non-pregnant girls had serum retinol values < 0.70 micromol/L; 40.2% had an MRDR ratio > 0.060. In 59.3%, serum tocopherol levels were < 11.5 micromol/L and the tocopherol/cholesterol ratio was < 2.2 in 23.9%. 11.3% had a haemoglobin > or = 12 g/dl. Vitamin A levels were significantly related to age, and younger girls were more likely to be deficient. Significant correlations were found between serum retinol, MRDR values and serum tocopherol. Girls with a low body mass index for age had tocopherol cholesterol ratios < 2.2. Low serum retinol values occurred significantly more often in stunted girls (P=0.01). Serum retinol values of adolescent pregnant girls were significantly lower than those of non-pregnant adolescents (P=0.002).

CONCLUSIONS

Vitamin A and E deficiency and anaemia were common in adolescent non-pregnant girls, and thought to partly result from increased growth requirements. Girls who become pregnant at an early age are at risk of depletion of their nutritional reserves. Measures to reduce nutritional deficiencies before the first pregnancy are needed.

Malaria-related maternal mortality in urban Mozambique

All pregnancy-related maternal deaths that occurred at the central hospital of Maputo during the 5 years between 1989 and 1993 were reviewed. The 239 maternal deaths recorded represented a maternal mortality ratio of 320/100,000 live births. Overall, 15.5% of the deaths were directly attributable to malaria, and 19.7% of the women who died were found to be parasitaemic (with Plasmodium falciparum) prior to death. Autopsies on 161 of the women who died showed histological evidence of malarial infection in the spleens of 44 (27.3%). Many (37.8%) of the malaria-related deaths occurred in adolescent primigravidae, and most were associated with severe anaemia. Pregnancy outcome was generally poor. Unbooked deliveries, and poor antenatal care were identified as risk factors for maternal death from malaria. The current policy of prescribing antimalarials in pregnancy based on symptomatic malaria alone should be reviewed. Improved primary prevention is required in order to reduce the high risk of malaria-related mortality in all pregnant women in the urban study area, especially among adolescents.

Anaemia- and malaria-attributable low birthweight in two populations in Papua New Guinea

We studied 7300 singleton births in the highlands and 4881 in coastal Papua New Guinea in order to examine the separate contribution of anaemia or malaria to low birthweight. The highland sample was selected from a non-malarious area (Goroka) and the coastal sample from an area with perennial malaria transmission (Madang). There was an approximately three-fold increased risk of low birthweight (< 2500 g) in live-births in Madang compared to Goroka. The prevalence of anaemia in the two areas was strikingly different, with 29.2% of Goroka and 89.0% of Madang women anaemic. There was a trend towards increased low birthweight with decreasing haemoglobin levels in both areas, but this was significant only for Madang. It was assumed that for a given haemoglobin level the increased low birth weight percentage in Madang compared to Goroka was due to malaria exposure, and on this basis relative risk values were estimated for the effect of malaria exposure on low birthweight. Using this approach separate estimates for anaemia and malaria population-attributable risk for low birth weight in Madang were calculated. These indicated that up to 40% of low birthweight babies born in malarious areas may be attributable to malaria and less than 10% attributable to severe anaemia (Hb < 7.0 g dl-1). The magnitude of the malaria effect estimated in this analysis places a high priority on malaria control in pregnancy as a strategy for improving birthweight and child survival.

Randomised placebo-controlled trial of iron supplementation and malaria chemoprophylaxis for prevention of severe anaemia and malaria in Tanzanian infants

BACKGROUND

Malaria and anaemia, especially that due to iron deficiency, are two leading causes of morbidity worldwide. Little is known about the relative contribution of Plasmodium falciparum infection and iron deficiency to the aetiology of anaemia in malaria-endemic areas. We undertook a randomised comparison of different strategies for control of anaemia and malaria in infants, including an assessment of the effect of iron supplementation on malaria susceptibility.

METHODS

832 infants born at one hospital in a malaria-hyperendemic area of Tanzania between January and October, 1995, were randomly assigned to group DI, receiving daily oral iron (2 mg/kg daily) plus weekly Deltaprim (3.125 mg pyrimethamine plus 25 mg dapsone); group IP, receiving iron plus weekly placebo; group DP, receiving daily placebo plus weekly Deltaprim; or group PP. supplementation was given from 8 to 24 weeks of age, and the weekly chemoprophylaxis from 8 to 48 weeks. The frequency of severe anaemia (packed-cell volume < 25%) and malaria episodes was assessed through a combination of passive case detection and cross-sectional surveys.

FINDINGS

The groups that received iron supplementation had a lower frequency of severe anaemia than those that did not receive iron (0.62 vs 0.87 cases per person-year; protective efficacy 28.8% [95% CI 6.3-45.8). Iron supplementation had no effect on the frequency of malaria (0.87 vs 1.00 cases per person-year; protective efficacy 12.8% [-12.8 to 32.5]). The groups that received malaria prophylaxis had lower frequencies of both severe anaemia (0.45 vs 1.04 episodes per person-year; protective efficacy 57.3% [43.0-67.9]) and malaria (0.53 vs 1.34 episodes per person-year; protective efficacy 60.5% [48.2-69.9]) than the groups that did not receive prophylaxis. After the end of the intervention period, children who had received malaria chemoprophylaxis had higher rates of severe anaemia and malaria than non-chemoprophylaxis groups (relative risks 2.2 [1.3-3.7] and 1.8 [1.3-2.6]).

INTERPRETATION

Malaria chemoprophylaxis during the first year of life was effective in prevention of malaria and anaemia but apparently impaired the development of natural immunity. Iron supplementation was effective in preventing severe anaemia without increasing susceptibility to malaria. Our findings support iron supplementation of infants to prevent iron-deficiency anaemia, even in malaria-endemic areas.

Pneumocystis carinii pneumonia in Malawian children

Sixty children aged between 1 and 23 months admitted to Queen Elizabeth Central Hospital in Blantyre, Malawi for diagnosis of acute lower respiratory tract infections (ALRI) were investigated for laboratory diagnosis of Pneumocystis carinii pneumonia (PCP) by indirect immunofluorescence assay on nasopharyngeal secretions. P. carinii was found in five of the 60 children. Three PCP cases had AIDS. The clinical presentation of children with PCP was of little diagnostic value and all the children were infants. Arterial oxygen saturation was significantly lower in PCP cases. Of the five PCP cases, four died, indicating that the marked hypoxaemia was associated with poor prognosis. These results indicate that an immunofluorescence assay on nasopharyngeal secretions could be used for first-line diagnosis of PCP in Africa.

Respiratory morbidity in Merseyside schoolchildren exposed to coal dust and air pollution

A cross sectional study was carried out to determine whether schoolchildren in a specific locality exposed to pollution from steam coal dust have an excess of respiratory symptoms compared with children in control areas. A total of 1872 primary schoolchildren (aged 5-11 years) from five primary schools in the Bootle dock area of Liverpool (exposed area), five primary schools in South Sefton (control area), and five primary schools in Wallasey (control area) were studied. A questionnaire was distributed through the schools and was completed by the parents of the children. The questionnaire inquired about respiratory symptoms (cough, wheezing, and shortness of breath), allergy, atopy, smoking, and socioeconomic factors. Height, weight, and peak expiratory flow were measured. Compliance was good (92%) and similar in the three study areas. The children in the three areas were of similar mean age (7.5 years), height (1.24 m), sex ratio, and had a similar prevalence of paternal (6.2%) and maternal (7%) asthma. The exposed zone contained more unemployed parents (41, 29, and 29% respectively), more rented housing (64, 45, 34%), and more smoking parents (71, 60, 59%) than the control areas. Respiratory symptoms were significantly more common in the exposed area, including wheeze (25.0, 20.6, and 17.5%), excess cough (40.0, 23.4, and 25.1%), and school absences for respiratory symptoms (47.5, 35.9, and 34.9%). These differences remained significant even if the groups were subdivided according to whether or not parents smoked or were employed. Multiple logistic regression analysis confirmed the exposed zone as a significant risk factor for absenteeism from school due to respiratory symptoms (odds ratio 1.55, 95% confidence interval 1.17 to 2.06) after adjusting for confounding factors. Standard dust deposit gauges on three schools confirmed a significantly higher dust burden in the exposed zone. An increased prevalence of respiratory symptoms in primary schoolchildren exposed to coal dust is confirmed. Although the association with known coal dust pollution is suggestive a cross sectional study cannot confirm a casual relation and further studies are needed.

The consequences of malaria infection in pregnant women and their infants

Preliminary results are presented from this study which indicate that 84.8% of pregnant women present at first antenatal visit with anemia (Hb 11g/dl) an 8.7% of their infants (n = 230) have a hemoglobin at birth below 14g/dl. There is an association between pregnancy anemia and malaria. A case control study in pregnant women and an infant cohort study to 18 months of age, are employed to study the cause and effects of anemia and malaria on women and their infants health.

A review of randomized controlled trials of routine antimalarial drug prophylaxis during pregnancy in endemic malarious areas

Current global recommendations for routine malaria chemoprophylaxis in pregnant women living in endemic malarious areas are not clear. To assist in policy formulation, the evidence from randomized controlled trials was reviewed. The literature was extensively searched, and studies identified were systematically analysed in relation to outcomes in the mother and the baby. Routine chemoprophylaxis appears to have an effect on antenatal morbid episodes and packed cell volume. There is a trend towards higher birth-weight values in chemoprophylaxis groups, which reached statistical significance in some studies. Evidence of an effect on gestation was only examined in one study. The effects on perinatal and neonatal mortality have only been examined in a few studies, with small sample sizes. The analysis questions whether routine malaria chemoprophylaxis is the best use of scarce resources in developing countries, and suggests that chemoprophylaxis might be targeted at anaemic women and primigravidae. Large controlled trials, with treatment available to placebo groups, are required to test whether routine chemoprophylaxis has advantages over early, effective treatment of clinical malaria.

A study of the consequences of malarial infection in pregnant women and their infants

An outline is given of a field research study to be undertaken in Malawi to investigate the pattern and consequences of malaria in pregnancy and infants. The central question to be investigated is whether babies born to anaemic mothers in malarious areas are at increased risk of developing anaemia or altered risk for morbidity from malaria or develop anaemia in the first year of life. The framework for the case control and cohort study to be undertaken is outlined.

Fetal anaemia in malarious areas: its causes and significance

This analysis reviews published studies of cord haemoglobin values in developing countries and compares findings for populations that are either exposed or not exposed to malaria. The review indicates: first, that fetal anaemia is common in women with chronic moderate-to-severe iron deficiency anaemia; second, that a severe degree of fetal anaemia is reported in several areas where malaria in pregnancy is common. Different levels of fetal anaemia or polycythaemia arise in relation to the duration and severity of maternal anaemia during pregnancy, but in malarious areas the fetal anaemia appears to be out of proportion to the level of maternal anaemia. Haemoglobinopathies are likely to play a contributory role in causing fetal anaemia. The concept is advanced that malaria may contribute to fetal anaemia as a result of immune haemolysis of sensitized red cells. Sensitization could be from malaria antibodies and antigens which cross the placenta. Further evidence is required to prove this hypothesis. The importance of fetal anaemia is that it is likely to relate to the pattern and risk of developing anaemia in infancy.

An assessment of low birthweight risk in primiparae as an indicator of malaria control in pregnancy

Malaria is an important environmental factor which reduces fetal growth in primiparae more than multiparae living under holoendemic conditions for malaria. This relates to greater susceptibility to malaria infection in first pregnancies. The relative risk for low birthweight (less than 2500 g) associated with primiparity is increased in malaria-endemic areas and significantly correlates with the malaria parasite rate at delivery in primiparae. Because of this association, the relative risk is proposed as an indicator to assess malaria control in pregnant women as well as in the community. The sensitivity and specificity of the relative risk for low birthweight in primiparae are calculated for 13 malarious and 15 non-malarious populations. The highest sensitivity and specificity is achieved at a relative risk of 1.7. Social and environmental variables which could alter the sensitivity of the estimate are discussed. Estimates of the population-attributable risk per cent of low birthweight due to malaria in primiparae are calculated and vary between 10% and 40% in endemic areas. The method is applied to observations from malaria-intervention studies in pregnancy in the Solomon Islands and Papua New Guinea and appears sensitive in these prospective studies to changes in malaria prevalence. Calculation of these estimates is straightforward and their use to assess malaria control measures in areas of high transmission has not been suggested previously, it could have wide epidemiological application and requires further field evaluation.

Cortisol and Plasmodium falciparum infection in pregnant women in Kenya

Women living under holoendemic conditions of malaria in Kenya exhibited an increased prevalence of clinical malaria during pregnancy. In addition parasite rate and density were higher in primigravidae compared to multigravidae. Higher serum cortisol concentrations were found in women with patent malaria during pregnancy and the levels were higher before, during and after the malaria episode. A causal relation between serum cortisol levels and suppression of malaria immunity during pregnancy is discussed.

The effect of iron therapy on malarial infection in Papua New Guinean schoolchildren

The effect of iron therapy on malarial infection was investigated in Papua New Guinea, where malaria is endemic. Prepubescent schoolchildren with hemoglobin levels of 8-12 g/dl were randomly assigned to receive either 200 mg ferrous sulfate or a placebo twice daily for 16 weeks. Iron status and malarial infection were assessed at baseline, after 6 and 16 weeks of therapy, and 8 weeks after therapy was discontinued. Iron status was significantly improved by the treatment. The treatment did not significantly affect parasite rate, parasite density, or levels of anti-malarial IgG. No changes in spleen size were observed in either group. Furthermore, there was no significant difference between the groups in reported episodes of suspected malaria during the therapy. These results suggest that, in malaria endemic areas, oral treatment for iron deficiency can be carried out in semi-immune or immune schoolchildren without adverse consequences.