Vivax malaria in pregnancy and lactation: a long way to health equity

Tobias Brummaier,Germana Bancone,Kesinee Chotivanich,Rose Mcgready,Cindy S Chu,Mupawjay Pimanpanarak,Gornpan Gornsawun,Mary Ellen Gilder,François Nosten

doi:10.1186/s12936-020-3123-1

Abstract

BackgroundThe Sustainable Development Goals (SDG) call for increased gender equity and reduction in malaria-related mortality and morbidity. Plasmodium vivax infections in pregnancy are associated with maternal anaemia and increased adverse perinatal outcomes. Providing radical cure for women with 8-aminoquinolines (e.g., primaquine) is hindered by gender-specific complexities.Case presentationA symptomatic episode of vivax malaria at 18 weeks of gestation in a primigravid woman was associated with maternal anaemia, a recurrent asymptomatic P. vivax episode, severe intra-uterine growth restriction with no other identifiable cause and induction to reduce the risk of stillbirth. At 5 months postpartum a qualitative glucose-6-phosphate dehydrogenase (G6PD) point-of-care test was normal and radical cure with primaquine was prescribed to the mother. A 33% fractional decrease in haematocrit on day 7 of primaquine led to further testing which showed intermediate phenotypic G6PD activity; the G6PD genotype could not be identified. Her infant daughter was well throughout maternal treatment and found to be heterozygous for Mahidol variant.ConclusionAdverse effects of vivax malaria in pregnancy, ineligibility of radical cure for pregnant and postpartum women, and difficulties in diagnosing intermediate levels of G6PD activity multiplied morbidity in this woman. Steps towards meeting the SDG include prevention of malaria in pregnancy, reducing unnecessary exclusion of women from radical cure, and accessible quantitative G6PD screening in P. vivax-endemic settings.

Highlights

The Sustainable Development Goals (SDG) call for increased gender equity and reduction in malariarelated mortality and morbidity
As the historical legacy of gender-based inequality is deeply embedded in medical research and the health sector, action to prevent undue gender-specific disparities in health outcomes is an ethical imperative and mandated in the SDG [32]
The reproductive impact of malaria is limited to females, and they suffer a double burden of more severe personal illness and poor outcomes for their offspring

Summary

Conclusion

Recognizing gender-specific aspects of disease acquisition, detection, treatment options, and response to treatment can help ensure that health policies are effective and equitable. Due to the loss of G6PD-deficient cells to haemolysis during illness, heterozygote females with even less than 30–40% activity could be misdiagnosed as normal if the test is done during an acute P. vivax episode Such a misdiagnosis could result in fatal haemolysis if 8-aminoquinolines are inappropriately prescribed to females with intermediate G6PD activity, which is an important consideration as the new single radical curative dose TQ has a long terminal half-life. Field-validated point-of-care quantitative G6PD tests are an urgent priority to meet the ambitious WHO target of reducing malaria by 90% by the year 2030 [37] This is especially true in areas with high prevalence of G6PD deficiency in order to avoid iatrogenic morbidity and mortality for females.

Background

Findings