Abstract
Plasmodium falciparum in pregnancy is a major cause of adverse pregnancy outcomes. We combine performance estimates of standard rapid diagnostic tests (RDT) from trials of intermittent screening and treatment in pregnancy (ISTp) with modelling to assess whether screening at antenatal visits improves upon current intermittent preventative therapy with sulphadoxine-pyrimethamine (IPTp-SP). We estimate that RDTs in primigravidae at first antenatal visit are substantially more sensitive than in non-pregnant adults (OR = 17.2, 95% Cr.I. 13.8-21.6), and that sensitivity declines in subsequent visits and with gravidity, likely driven by declining susceptibility to placental infection. Monthly ISTp with standard RDTs, even with highly effective drugs, is not superior to monthly IPTp-SP. However, a hybrid strategy, recently adopted in Tanzania, combining testing and treatment at first visit with IPTp-SP may offer benefit, especially in areas with high-grade SP resistance. Screening and treatment in the first trimester, when IPTp-SP is contraindicated, could substantially improve pregnancy outcomes.
Highlights
Plasmodium falciparum in pregnancy is a major cause of adverse pregnancy outcomes
There have been four large-scale trials comparing ISTp with intermittent preventative therapy with sulphadoxine-pyrimethamine (IPTp-SP), three of them had matched rapid diagnostic tests (RDT) (First Response Malaria pLDH/HRP2 Combo Test, Premier Medical Corporation, India) and PCR samples collected from 1559 women based in six countries (Burkina Faso, The Gambia, Ghana, and Mali in West Africa and Kenya and Malawi in East Africa)[8,9,10]
Infection by conventional RDT and PCR was measured throughout pregnancy: Ghana, Kenya and Malawi
Summary
Impact of pregnancy upon detectability of infection by RDT. There have been four large-scale trials comparing ISTp with IPTp-SP, three of them had matched RDT (First Response Malaria pLDH/HRP2 Combo Test, Premier Medical Corporation, India) and PCR samples collected from 1559 women based in six countries (Burkina Faso, The Gambia, Ghana, and Mali in West Africa and Kenya and Malawi in East Africa)[8,9,10]. A large proportion of infections are likely to have been sub-patent at the beginning of pregnancy, by the time primigravidae receive the first dose of IPTp-SP, the density of infection has increased to the extent that very few remain below the limit of detection of standard RDTs (Fig. 7a)[18]. Clearing these infections during any first trimester ANC visit irrespective of the immediate density of the infection, is likely to have a large impact on the overall exposure to placental infection (Fig. 7c). It is difficult to assess the extent to which future IPTp-SP will modify the impact of these early infections upon birth outcome
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