Preventive Treatment Of Malaria Research Articles

Uptake of intermittent preventive treatment for malaria in Nigeria

Background: In 2000, the World Health Organization recommended the use of at least 2 doses of intermittent preventive treatment with sulphadoxine-pyrimethamine (IPTp-SP) to reduce the burden of malaria in pregnancy. Aims: This research described the pattern of IPTp-SP uptake among pregnant women. Methods: This study involved re-analyses of the Nigeria Demographic and Health Survey datasets for 2003 and 2008. Frequencies and chi-square (c2) (2x2) tests were used to describe the pattern of IPTp-SP uptake. Findings: The percentage of pregnant women who used any dosage of sulphadoxine-pyrimethamine and at least 2 doses of IPTp-SP increased significantly at P<0.05. There was significant increase whe classified by residence, region, socioeconomic status, education, literacy, partner's education, religion and employment status. Conclusions: Uptake of IPTp-SP is still low and calls for intensified improvement of awareness.

Socio-demographic and regional disparities in utilization of intermittent preventive treatment for malaria in pregnancy - Nigeria demographic health survey 2013.

Introductionmalaria in pregnancy can lead to medical emergencies. Utilization of intermittent preventive treatment for prevention of malaria in pregnancy with Sulphadoxine- Pyrimethamine (IPTp-SP) has remained low in developing countries in sub-Saharan Africa. This study aimed to identify the factors determining uptake of IPTp-SP in Nigeria using the 2013 Nigeria Demographic Health Survey.Methodswe conducted a secondary analysis of data extracted from the National Demographic Health Survey 2013 which used a three stage stratified sampling method to select respondents. Independent variables considered were age, marital status, the level of education of respondents and their spouses, region, location of residence, wealth-index and birth order. The dependent variable was the use of two or more doses of SP for IPTp in the two years before the survey. Descriptive statistics for socio-demographic and selected characteristics was done. Chi-square test was used to test associations between sociodemographic characteristics and IPTp-SP uptake. Multiple logistic regressions at 95% confidence interval were used to determine predictors of IPTp utilization using STATA version14 software.Resultsof the 38,948 women interviewed 12,473 (32%) had given birth two years preceding the survey and 15% used at least two doses of SP for IPTp. Women aged 30 years and above [aOR 1.4, C.I:1.1-1.7], in the middle class or higher wealth index [aOR 1.5, CI: 1.1-2.0], with two or more ANC visits [aOR 4.2, CI: 1.4 - 12.5], were more likely to use IPTp.Conclusionlate initiation of IPTp after the second trimester was a contributory factor for poor SP utilization. Interventions targeted at ensuring pregnant women attend ANC and use of IPTp-SP after quickening should be promoted.

Consequences of Climate Variation on Malaria Incidence in Uganda

Introduction: Temperature and rainfall are assumed to play an important role in the transmission of malaria. According to Zhou simultaneous analysis of the long-term time series of meteorological and parasitological data are critically needed to understand the effects of climate on malaria incidence. However, it would be more plausible to assess the effect of climate variation on the malaria incidence since increase or decrease in the number of malaria cases does not quantify the disease frequency. Objective: This study therefore, seeks to examine the consequences of variation in climatic factors such as temperature and rainfall on the malaria incidence among the Ugandan population. Methods: To account for variation and dynamics in monthly malaria incidence among the Ugandan population, data on environmental factors like minimum and maximum temperature, and rainfall were obtained from Uganda National Meteorological Authority (UNMA) while monthly malaria counts for the period (2006-2016) were obtained from Ministry of Health (MoH). Dynamically complete models were used to simultaneously investigate the impact of environmental factors on monthly malaria incidence in the population. Findings: Findings revealed that the long-run impact of three months successive one percent increase in maximum temperature would result into an 8.1% reduction in monthly malaria incidence. Similarly, three months successive one percent increase in minimum temperature would increase monthly malaria incidence by about 16.7% in the long-run. The impact of rainfall was also significant in that successive one percent three months increase in rainfall would reduce malaria incidence by about 14% in the long-run. Conclusion: Increasing maximum temperature is associated with a reduction in malaria incidence while increasing minimum temperature is associated with an increase in monthly malaria incidence. Lastly, increasing amount of rainfall is associated with a reduction in monthly malaria incidence. Recommendations: In order to lower the incidence of malaria among the population, it’s imperative that malaria control and preventive interventions consider environmental modifications that lower minimum temperature and increase the amount of rainfall. These interventions include land use methods such as conversion of land from forests to settlements and agricultural activities, wetlands for settlements and other economic activities.

Determinants of intermittent preventive treatment of malaria among women attending antenatal clinics in primary health care centers in Ogbomoso, Oyo State, Nigeria.

IntroductionDespite the effectiveness of intermittent preventive treatment in pregnancy using sulphadoxine-pyrimethamine (IPTp-SP), the uptake and coverage in southwest Nigeria are low. We assessed the factors influencing utilisation of IPTp-SP.MethodsA multistage sampling technique was used to select 400 pregnant women from six primary healthcare centers in Oyo State. Data on socio-demographic characteristics, knowledge, attitude towards IPTp-SP and its utilisation were obtained using a semi-structured questionnaire. Data were analyzed using SPSS software. Focus group discussions (FGD) and key informant interviews (KII) were held for pregnant women and healthcare workers and analysed thematically.ResultsMean age of respondents was 27.2 (SD ± 5.5) years. Mean gestational age was 29.5 weeks (SD ± 5.4). Overall, 320 (80.0%) took SP, of which 152 (47.5%) took 2 doses and 112 (35.0%) took under directly observed therapy (DOT). We found that early booking for ANC, more than two visits to ANC (adjusted odds ratio (aOR) = 5.6; 95% CI: 1.2 - 26.6), good knowledge on IPTp (aOR = 9.3; 95% CI: 5.4 - 16.0), positive attitude towards IPTp (aOR = 2.1; 95% CI: 1.5 - 2.9) and being employed (aOR = 1.4; 95% CI: 1.1 - 1.7) were factors associated with IPTp-SP utilisation. The FGD and KII revealed that IPTp-SP drugs were mostly taken at home due to stock out.ConclusionLate ANC booking with stock out of IPTp-SP drugs was responsible for its low utilisation. There is need to encourage pregnant women to book early for ANC. Adherence to the practice of DOT scheme is recommended to improve IPTp-SP utilisation.

Impact of Adherence to a Full Course of Intermittent Preventive Treatment of Malaria in Pregnancy on Pregnancy Outcome in Muyuka Health District: A Cross-Sectional Study

Impact of Adherence to a Full Course of Intermittent Preventive Treatment of Malaria in Pregnancy on Pregnancy Outcome in Muyuka Health District: A Cross-Sectional Study

Regular Antenatal Attendance and Education Influence the Uptake of Intermittent Preventive Treatment of Malaria in Pregnancy: A Cross-Sectional Study at the University Hospital, Kumasi, Ghana.

Background The World Health Organization (WHO) recommends the use of Insecticide Treated Bed-Nets and Intermittent Preventive Treatment (IPT) with Sulphadoxine-Pyrimethamine (SP) as interventions in curbing malaria during pregnancy. However, increasing evidence shows a gap in coverage where not all pregnant women receive the recommended SP dose. This study evaluated the factors influencing uptake of IPTp-SP among pregnant women in Kumasi, Ghana. Methodology This cross-sectional study was conducted among 280 pregnant women attending the Kwame Nkrumah University of Science and Technology Hospital in Kumasi, Ghana. Validated structured questionnaires were administered to obtain sociodemographic, medical/reproductive information, and IPTp-SP uptake among participants. Statistical analyses were performed using IBM SPSS 25.0 statistics. Results The mean age of respondents was 29.7±4.9 years. Of the 280 women interviewed, 74.6% attended the antenatal care (ANC) clinic at least four times with only 31.8% completing the recommended doses. Tertiary education [aOR=3.15, 95% CI (0.94 -10.97), and p=0.042] and ≥ 4 ANC visits [aOR=24.6, 95% CI (5.87-103.07), p<0.0001] had statistically significant higher odds of completing the recommended IPTp-SP dose. However, participants employed by the formal sector [aOR=0.28, 95% CI (0.09 - 0.79), p=0.016] and participants with more than four children [aOR=0.14, 95% CI (0.03 - 0.63), and p=0.011] had statistically significant lower odds of completing the recommended IPT dose. Conclusion ANC attendance is critical in IPTp uptake. The results emphasize the need for the Health Policy Makers in Kumasi to encourage pregnant women, especially women working in the formal sector and women having more than four children to patronize ANC attendance to ensure high coverage of the recommended IPTp dose.

Prevalence of chloroquine and antifolate drug resistance alleles in Plasmodium falciparum clinical isolates from three areas in Ghana.

Background: The emergence and spread of resistance in Plasmodium falciparum to chloroquine (CQ) necessitated the change from CQ to artemisinin-based combination therapies (ACTs) as first-line drug for the management of uncomplicated malaria in Ghana in 2005. Sulphadoxine-pyrimethamine (SP) which was the second line antimalarial drug in Ghana, was now adopted for intermittent preventive treatment of malaria in pregnancy (IPTp). Methods: To examine the prevalence of molecular markers associated with CQ and antifolate drug resistance in Ghana, we employed restriction fragment length polymorphism polymerase chain reaction to genotype and compare single nucleotide polymorphisms (SNPs) in the P. falciparum chloroquine resistance transporter ( pfcrt, PF3D7_0709000), multidrug resistance ( pfmdr1, PF3D7_0523000), bifunctional dihydrofolate reductase-thymidylate synthase ( pfdhfr, PF3D7_0417200) and dihydropteroate synthase ( pfdhps, PF3D7_0810800) genes. Parasites were collected from children with malaria reporting to hospitals in three different epidemiological areas of Ghana (Accra, Kintampo and Navrongo) in 2012-2013 and 2016-2017. Results: The overall prevalence of the CQ resistance-associated pfcrt 76T allele was 8%, whereas pfmdr1 86Y and 184F alleles were present in 10.2% and 65.1% of infections, respectively. The majority of the isolates harboured the antifolate resistance-associated pfdhfr alleles 51I (83.4%), 59R (85.9 %) and 108N (90.5%). Pfdhps 437G and 540E were detected in 90.6% and 0.7% of infections, respectively. We observed no significant difference across the three study sites for all the polymorphisms except for pfdhps 437G , which was more common in Accra compared to Kintampo for the 2016-2017 isolates. Across both pfdhfr and pfdhps genes, a large proportion (61%) of the isolates harboured the quadruple mutant combination ( I 51 R 59 N 108/ G 437). CQ resistance alleles decreased during the 12 years after CQ withdrawal, but an mediate SP resistance alleles increased. Conclusion: Surveillance of the prevalence of resistance alleles is necessary in monitoring the efficacy of antimalarial drugs.

Drivers of intermittent preventive treatment of malaria during pregnancy in Ghana: a generalized linear model with negative binomial approach

BackgroundThis study identified the main drivers of intermittent preventive therapy (IPTp) of malaria in pregnancy with the malaria drugs’ sulfadoxine–pyrimethamine (SP) uptake from a longitudinal data set in Ghana.MethodThe data set was obtained from a municipal hospital and spanned a period of 9 years (December 2008–January 2017) and was captured on a monthly basis. We employed the generalized linear modeling approach with negative binomial method to analyze the 9 year data set. A log-linear time-series model was introduced which was then used to validate the results obtained from the logistic model.ResultsIt is evident from the results that antenatal registration of pregnant women, male partner involvement in antenatal clinic attendance, and frequency of visits to antenatal clinics are the key drivers of IPTp-SP uptake.ConclusionsWe recommend that the Family Planning and the Community Health Nursing units of the Ministry of Health, Ghana, should carry effective health campaigns geared towards raising awareness, promoting the early antenatal registration by pregnant women, encourage male partner involvement in antenatal clinics, and increase the frequency of visits (at least 4) to antenatal clinics by the pregnant women to improve upon the low uptake of IPTp-SP in Ghana.

Group antenatal care is associated with increased uptake of intermittent preventive treatment of malaria in pregnancy among women in nigeria, compared to routine antenatal care: secondary analysis of a cluster randomized controlled trial

Group antenatal care is associated with increased uptake of intermittent preventive treatment of malaria in pregnancy among women in nigeria, compared to routine antenatal care: secondary analysis of a cluster randomized controlled trial

Mefloquine for preventing malaria in pregnant women.

Mefloquine for preventing malaria in pregnant women.

The effect of malaria prevention and control interventions on malaria morbidity among children under 5 years and pregnant women in Kintampo North Municipality, Ghana

Background: Malaria prevention and control interventions have been scaled-up in the last decade in Ghana. We analysed the malaria surveillance data to assess the trends and the association between some malaria prevention interventions and malaria incidence in Kintampo North Municipality (KNM).Methods: We extracted data on malaria indicators and interventions from the District Health Information Management System 2 database for 2012–2016. Proportions and cumulative incidence of malaria episodes were computed using STATA 14 software. We performed correlation analysis between malaria interventions and malaria morbidity. We used linear regression models to determine the association between Long-Lasting Insecticide-treated Nets (LLINS) distribution, Intermittent Preventive Treatment in Pregnancy (IPTp) and episodes of malaria in children <5 years old and pregnant women. Results: A total of 280,890 episodes of malaria were recorded in the KNM from 2012–2016. Of the total malaria episodes, 64,953 (23.1%) were children <5 years and 57.5% (161,486/280,890) were females. The incidence of malaria in KNM declined from 650/1,000 population in 2012 to 444/1,000 population in 2016. The proportion of confirmed malaria increased from 35.2% in 2012 to 80.7% in 2015, and subsequently declined to 77.5% in 2016. The malaria Case Fatality Rate decreased by 65% in 2012 to 0.04% (16/37646) in 2016. Long Lasting Nets distribution to children showed a weak negative linear relationship with malaria morbidity in children <5 years (R= – 0.20). IPTp1, IPTp2 showed a weak negative linear relationship with malaria morbidity in pregnancy, IPTp3 showed a weak positive linear relationship while IPTp4 and IPTp5 showed a negative moderate linear relationship with malaria morbidity in pregnancy. A unit increase in LLINs distribution to pregnant women was significantly associated with a reduction in malaria in pregnancy episodes by 0.21 (R2 = 0.19, 95% CI: - 0.3 ─ -0.7). The IPTp first dose (IPTp1) coverage declined from 75.5% in 2012 to 69.0% in 2014, but rose to 80.9% in 2016. IPTp5 (fifth dose) increased from 0.7% in 2014 to 4.8% in 2016. A percentage increase in the coverage of only IPTp4 was associated with a reduction of malaria in pregnancy by two episodes (R2 = 0.34, 95% CI = ─ 1.68 – (─0.78. Conclusion: Malaria morbidity trend declined in the municipality. Increase coverage in LLINs and IPTp were associated with declines in malaria episodes in children <5years old and pregnancy women. Coverage of IPTp4 and IPTp5 were relatively low. Health staff should intensify promotion of the use of malaria prevention interventions among pregnant women and children < 5 years old. Midwives should promote uptake of optimal IPTp doses through health education and community antenatal outreach services.

Intermittent Preventive Treatment with Dihydroartemisinin-Piperaquine in Young Ugandan Children and Risk of Malaria Following Cessation: A Randomised Controlled Trial

Background. Intermittent preventive treatment of malaria (IPT) with dihydroartemisinin-piperaquine (DP) is a promising strategy for malaria prevention in young African children. However, the optimal dosing strategy is unclear and there are conflicting results regarding the risk of malaria following cessation of chemoprevention. Methods. We conducted a double-blind, randomised controlled trial of IPT with DP every 4 weeks versus every 12 weeks in a historically high transmission district of Uganda. Children received study drugs from 8 weeks to 24 months of age and followed to 36 months of age. The primary outcome was the incidence of malaria; secondary outcomes included parasite prevalence. All analyses were modified intention to treat and adjusted for potential confounders (maternal gravidity, maternal parasitemia status at enrollment, and placental malaria). Findings. Between October 2014 and May 2015, 191 children were born, and 183 children reached 8 weeks of age and assigned to receive DP every 4 (n=96) or 12 weeks (n=87) and included in the primary analysis. During the intervention, children receiving DP every 4 weeks had a significantly lower incidence of malaria (adjusted incident rate ratio (aIRR) 0*03, 95% CI 0*01-0*13, p<0*001) and parasite prevalence (0*6% vs 4*9%, p<0*001) compared to children receiving DP every 12 weeks. After stopping IPT, children who previously received DP every 4 weeks had a lower incidence of malaria (aIRR 0*61, 95% CI 0*40-0*93, p=0*02) and parasite prevalence (9*6% vs 14*9%, p=0*004) compared to children who previously received DP every 12 weeks. Both treatment arms were safe and well tolerated. Interpretation. IPT with DP given every 4 weeks was superior to DP given every 12 weeks for the prevention of malaria during childhood, and this protection was extended for up to one year after stopping IPT. This suggests that prevention of malaria with DP in children may enhance immunity against infection. Clinical Trial Number: This trial is registered at ClinicalTrials.gov (NCT02163447). Funding Statement: This study was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (P01 HD059454). Declaration of Interests: All authors declare no competing interests. Ethics Approval Statement: The study was approved by the ethics committees of Makerere University School of Biomedical Sciences, the Uganda National Council for Science and Technology, and the University of California San Francisco. Written informed consent was provided by all study participants.

A decade since sulfonamide-based anti-malarial medicines were limited for intermittent preventive treatment of malaria among pregnant women in Tanzania

BackgroundDespite the development of resistance to Plasmodium falciparum malaria, sulfadoxine–pyrimethamine is still effective for intermittent preventive treatment of malaria in pregnancy (IPTp). In Tanzania, more than 10 years have passed since sulfadoxine–pyrimethamine and sulfamethopyrazine–pyrimethamine (SPs) were reserved for IPTp only. However, the retail pharmaceutical outlet dispensers’ knowledge and their compliance with the policies have not been recently explored. Therefore, this study was designed to investigate dispensers’ knowledge about these medications together with their actual dispensing practices, a decade since they were limited for IPTp use only.MethodsThis descriptive cross-sectional study was conducted between February and July 2017 in all municipalities of Dar-es-Salaam city. Data were collected by direct interviews using a structured questionnaire to assess knowledge and a simulated client approach was used to assess the actual practice of medicine dispensers. Data analysis was done by using SPSS version 20 and Chi square test was used to test significant differences in proportions between different categorical variables. A p-value of less than 0.05 was considered to be statistically significant.ResultsA random sample of 422 medicine dispensers participated in this study whereby 185 (43.8%) were from community pharmacies and 237 (56.2%) from accredited drug dispensing outlets. The study revealed that SPs were available in 76% of the community pharmaceutical outlets in Dar es Salaam. In general majority of the dispensers (64%) had moderate to high knowledge about SPs and their indication. About 80% of the dispensers were aware that SP is reserved for IPTp. However, irrespective of the level of knowledge, almost all dispensers (92%) were willing to dispense the medicines for the purpose of treating malaria, contrary to the current Tanzania malaria treatment guideline.ConclusionMajority of the medicine dispensers in the community pharmaceutical outlets were knowledgeable about SPs and their indications. Disappointingly, almost all dispensers irrespective of their levels of knowledge were willing to dispense SPs for treatment of malaria contrary to the available treatment guidelines.

Modulation of innate immune responses at birth by prenatal malaria exposure and association with malaria risk during the first year of life

BackgroundFactors driving inter-individual differences in immune responses upon different types of prenatal malaria exposure (PME) and subsequent risk of malaria in infancy remain poorly understood. In this study, we examined the impact of four types of PME (i.e., maternal peripheral infection and placental acute, chronic, and past infections) on both spontaneous and toll-like receptors (TLRs)-mediated cytokine production in cord blood and how these innate immune responses modulate the risk of malaria during the first year of life.MethodsWe conducted a birth cohort study of 313 mother-child pairs nested within the COSMIC clinical trial (NCT01941264), which was assessing malaria preventive interventions during pregnancy in Burkina Faso. Malaria infections during pregnancy and infants’ clinical malaria episodes detected during the first year of life were recorded. Supernatant concentrations of 30 cytokines, chemokines, and growth factors induced by stimulation of cord blood with agonists of TLRs 3, 7/8, and 9 were measured by quantitative suspension array technology. Crude concentrations and ratios of TLR-mediated cytokine responses relative to background control were analyzed.ResultsSpontaneous production of innate immune biomarkers was significantly reduced in cord blood of infants exposed to malaria, with variation among PME groups, as compared to those from the non-exposed control group. However, following TLR7/8 stimulation, which showed higher induction of cytokines/chemokines/growth factors than TLRs 3 and 9, cord blood cells of infants with evidence of past placental malaria were hyper-responsive in comparison to those of infants not-exposed. In addition, certain biomarkers, which levels were significantly modified depending on the PME category, were independent predictors of either malaria risk (GM-CSF TLR7/8 crude) or protection (IL-12 TLR7/8 ratio and IP-10 TLR3 crude, IL-1RA TLR7/8 ratio) during the first year of life.ConclusionsThese findings indicate that past placental malaria has a profound effect on fetal immune system and that the differential alterations of innate immune responses by PME categories might drive heterogeneity between individuals to clinical malaria susceptibility during the first year of life.

PO444 Improving Recognition and Referral of Acute Rheumatic Fever Through Community Education

Intermittent preventive treatment (IPT) of malaria with dihydroartemisinin–piperaquine is a promising strategy for malaria prevention in young African children. However, the optimal dosing strategy is unclear and conflicting evidence exists regarding the risk of malaria after cessation of chemoprevention. We aimed to compare two dosing strategies of IPT with dihydroartemisinin–piperaquine in young Ugandan children, and to evaluate the risk of malaria after cessation of IPT.In this double-blind, randomised controlled phase 2 trial, women and their unborn children were recruited at Tororo District Hospital (Tororo, Uganda). Eligible participants were HIV-negative women aged 16 years or older with a viable pregnancy (gestational age 12–20 weeks). Women and their unborn children were randomly assigned (1:1:1:1) to one of four treatment groups, all receiving dihydroartemisinin–piperaquine, on the basis of the IPT intervention received by the woman during pregnancy: women every 8 weeks, children every 4 weeks; women every 4 weeks, children every 4 weeks; women every 8 weeks, children every 12 weeks; and women every 4 weeks, children every 12 weeks. Block randomisation was done by an independent investigator using a computer-generated randomisation list (permuted block sizes of six and 12). We analysed children on the basis of their random assignment to receive dihydroartemisinin–piperaquine (20 mg/160 mg tablets) once daily for 3 consecutive days every 4 weeks or 12 weeks. Children received study drugs from age 8 weeks to 24 months and were followed-up to age 36 months. Participants and investigators were masked to treatment allocation. The primary outcome was the incidence of symptomatic malaria during the intervention and following cessation of the intervention, adjusted for potential confounders. The primary outcome and safety were assessed in the modified intention-to-treat population, which included all children who reached 8 weeks of age and received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, number NCT02163447.Between Oct 21, 2014, and May 18, 2015, 191 children were born, of whom 183 reached 8 weeks of age and received at least one dose of study drug and thus were included in the primary analysis (96 children in the 4-week group and 87 in the 12-week group). During the intervention, the incidence of symptomatic malaria was significantly lower among children treated every 4 weeks than children treated every 12 weeks; three episodes occurred among children treated every 4 weeks (incidence 0·018 episodes per person-year) compared with 61 episodes among children treated every 12 weeks (incidence 0·39 episodes per person-year; adjusted incidence rate ratio [aIRR] 0·041, 95% CI 0·012–0·150, p<0·0001). After cessation of IPT, children who had previously received dihydroartemisinin–piperaquine every 4 weeks had a lower incidence of symptomatic malaria than children who were treated every 12 weeks; 62 episodes occurred among children previously treated every 4 weeks (incidence 0·73 episodes per person-year) compared with 83 episodes among children treated every 12 weeks (incidence 1·1 episodes per person-year; aIRR 0·62, 0·40–0·95, p=0·028). In the 4-week group, 94 (98%) of 96 children had adverse events versus 87 (100%) of 87 children in the 12-week group. The most commonly reported adverse event was cough in both treatment groups (94 [98%] in the 4-week group vs 87 [100%] in the 12-week group). 16 children had severe adverse events (seven [7%] children in the 4-week group vs nine [10%] children in the 12-week group). No severe adverse events were thought to be related to study drug administration. One death occurred during the intervention (age 8 weeks to 24 months), which was due to respiratory failure unrelated to malaria.IPT with dihydroartemisinin–piperaquine given every 4 weeks was superior to treatment every 12 weeks for the prevention of malaria during childhood, and this protection was extended for up to 1 year after cessation of IPT.Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Improving health worker performance through text messaging: A mixed-methods evaluation of a pilot intervention designed to increase coverage of intermittent preventive treatment of malaria in pregnancy in West Nile, Uganda.

Poor health worker performance is a well-documented obstacle to quality service provision. Due to the increasingly widespread availability of mobile devices, mobile health (mHealth) has received growing attention as a service improvement tool. This pilot study explored feasibility, acceptability and outcomes of an mHealth intervention designed to increase coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) in two districts of West Nile, Uganda. In both districts, selected health workers (N = 48) received classroom training on malaria in pregnancy. All health workers in one district (N = 49) subsequently received 24 text messages reinforcing the training content. The intervention was evaluated using a mixed-methods approach, including four focus group discussions with health workers and three in-depth interviews with district health officials, health worker knowledge assessments one month (N = 90) and six months (N = 89) after the classroom training, and calculation of IPTp coverage from participating health facilities’ (N = 16) antenatal care registers covering six months pre- and post-intervention. Complementing classroom training with text messaging was found to be a feasible, acceptable and inexpensive approach to improving health worker performance. The messages served as reminders to those who had attended the classroom training and helped spread information to those who had not. Health workers in the district where text messages were sent had significantly better knowledge of IPTp, achieving an increased composite knowledge score of 6.00 points (maximum score: 40) compared with those in the district where only classroom training was provided. Average facility coverage of three doses of IPTp was also significantly higher where text messages were sent (85.8%) compared with the district where only classroom training was provided (54.1%). This intervention shows promise for the improvement of health worker performance for delivery of IPTp, and could have significant broader application.

Chloroquine as weekly chemoprophylaxis or intermittent treatment to prevent malaria in pregnancy in Malawi: a randomised controlled trial

Sulfadoxine-pyrimethamine resistance threatens efficacy of intermittent preventive treatment of malaria during pregnancy, and alternative regimens need to be identified. With the return of chloroquine efficacy in southern Africa, we postulated that chloroquine either as an intermittent therapy or as weekly chemoprophylaxis would be more efficacious than intermittent sulfadoxine-pyrimethamine for prevention of malaria in pregnancy and associated maternal and newborn adverse outcomes. We did an open-label, single-centre, randomised controlled trial at Ndirande Health Centre, Blantyre, in southern Malawi. We enrolled pregnant women (first or second pregnancy) at 20-28 weeks' gestation who were HIV negative. Participants were randomly assigned in a 1:1:1 ratio using a computer-generated list to either intermittent sulfadoxine-pyrimethamine (two doses of 1500 mg sulfadoxine and 75 mg pyrimethamine, 4 weeks apart), intermittent chloroquine (two doses of 600 mg on day 1, 600 mg on day 2, and 300 mg on day 3), or chloroquine prophylaxis (600 mg on day 1 then 300 mg every week). The primary endpoint was placental malaria in the modified intent-to-treat population, which consisted of participants who contributed placental histopathology data at birth. Secondary outcomes included clinical malaria, maternal anaemia, low birthweight, and safety. This trial is registered with ClinicalTrials.gov, number NCT01443130. Between February, 2012, and May, 2014, we enrolled and randomly allocated 900 women, of whom 765 contributed histopathological data and were included in the primary analysis. 108 (14%) women had placental malaria, which was lower than the anticipated prevalence of placental malaria infection. Protection from placental malaria was not improved by chloroquine as either prophylaxis (30 [12%] of 259 had positive histopathology; relative risk [RR] 0·75, 95% CI 0·48-1·17) or intermittent therapy (39 [15%] of 253; RR 1·00, 0·67-1·50) compared with intermittent sulfadoxine-pyrimethamine (39 [15%] of 253). In protocol-specified analyses adjusted for maternal age, gestational age at enrolment, bednet use the night before enrolment, anaemia at enrolment, and malaria infection at enrolment, women taking chloroquine as prophylaxis had 34% lower placental infections than did those allocated intermittent sulfadoxine-pyrimethamine (RR 0·66, 95% CI 0·46-0·95). Clinical malaria was reported in nine women assigned intermittent sulfadoxine-pyrimethamine, four allocated intermittent chloroquine (p=0·26), and two allocated chloroquine prophylaxis (p=0·063). Maternal anaemia was noted in five women assigned intermittent sulfadoxine-pyrimethamine, 15 allocated intermittent chloroquine (p=0·038), and six assigned chloroquine prophylaxis (p>0·99). Low birthweight was recorded for 31 babies born to women allocated intermittent sulfadoxine-pyrimethamine, 29 assigned intermittent chloroquine (p=0·78), and 41 allocated chloroquine prophylaxis (p=0·28). Four women assigned intermittent sulfadoxine-pyrimethamine had adverse events possibly related to study product compared with 94 women allocated intermittent chloroquine (p<0·0001) and 26 allocated chloroquine prophylaxis (p<0·0001). Three women had severe or life-threatening adverse events related to study product, of whom all were assigned intermittent chloroquine (p=0·25). Chloroquine administered as intermittent therapy did not provide better protection from malaria and related adverse effects compared with intermittent sulfadoxine-pyrimethamine in a setting of high resistance to sulfadoxine-pyrimethamine. Chloroquine chemoprophylaxis might provide benefit in protecting against malaria during pregnancy, but studies with larger sample sizes are needed to confirm these results. US National Institutes of Health.

Pregnancy Outcomes for Women Receiving and not Receiving Intermittent Preventive Treatment for Malaria in Pregnancy using SulphadoxinePyrimethamine in Gokwe North, Midlands Province, 2011

Pregnancy Outcomes for Women Receiving and not Receiving Intermittent Preventive Treatment for Malaria in Pregnancy using SulphadoxinePyrimethamine in Gokwe North, Midlands Province, 2011

Downscaling incidence risk mapping for a Colombian malaria endemic region

To map at a fine spatial scale, the risk of malaria incidence for the important endemic region is Urabá-Bajo Cauca and Alto Sinú, NW Colombia, using a new modelling framework based on GIS and remotely sensed environmental data. The association between environmental and topographic variables obtained from remote sensors and the annual parasite incidence (API) for the years 2013-2015 was calculated using multiple regression analysis; subsequently, a model was constructed to estimate the API and to project it to the entire endemic region in order to design the risk map. The model was validated by relating the obtained API values with the presence of the three main Colombian malaria vectors, Anopheles darlingi, Anopheles albimanus and Anopheles nuneztovari. Temperature and Normalized Difference Water Index (NDWI) showed a significant correlation with the observed API. The risk map of malaria incidence showed that the zones at higher risk in the Urabá-Bajo Cauca and Alto Sinú region were located south-east of the region, while the northern area presented the lowest malaria risk. A method was generated to estimate the API for small urban centres, instead of the used reports at the municipality level. These results provide evidence of the utility of risk maps to identify environmentally vulnerable areas at a fine spatial resolution in the Urabá-Bajo Cauca and Alto Sinú region. This information contributes to the implementation of vector control interventions at the microgeographic scale at areas of high malaria risk.

Intermittent screening and treatment with artemether\u2013lumefantrine versus intermittent preventive treatment with sulfadoxine\u2013pyrimethamine for malaria in pregnancy: a facility-based, open-label, non-inferiority trial in Nigeria

BackgroundThe spread of SP resistance may compromise the effectiveness of intermittent preventive treatment of malaria in pregnancy (MiP) with sulfadoxine–pyrimethamine (IPTp-SP) across Africa. However, there is no recommended alternative medicine for IPTp or alternative strategy for prevention of MiP. This poses problems for the prevention of MiP. This study investigated, whether screening with a rapid diagnostic test for malaria at routine antenatal clinic attendances and treatment of only those who are positive (intermittent screening and treatment) with artemether–lumefantrine is as effective and safe as IPTp-SP in pregnant women.MethodsDuring antenatal clinic sessions at the General Hospital Calabar, Nigeria, held between October 2013 and November 2014, 459 pregnant women were randomized into either the current standard IPTp-SP or intermittent screening and treatment with artemether–lumefantrine (ISTp-AL). All women received a long-lasting insecticide-treated net at enrolment. Study women had a maximum of four scheduled visits following enrolment. Haemoglobin concentration and peripheral parasitaemia were assessed in the third trimester (36–40 weeks of gestation). Birth weight was documented at delivery or within a week for babies delivered at home.ResultsIn the third trimester, the overall prevalence of severe anaemia (Hb < 8 g/dl) and moderate (8–10.9 g/dl) anaemia was 0.8 and 27.7%, respectively, and was similar in both treatment groups (p = 0.204). The risk of third-trimester severe anaemia did not differ significantly between both treatment arms (risk difference − 1.75% [95% CI − 4.16 to 0.66]) although the sample was underpowered for this outcome due to several participants being unavailable to give a blood sample. The risk of third-trimester maternal parasitaemia was significantly lower in the ISTp-AL arm (RD − 3.96% [95% CI − 7.76 to − 0.16]). The risk of low birthweight was significantly lower in the ISTp-AL arm after controlling for maternal age, gravidity and baseline parasitaemia (risk difference − 1.53% [95% CI − 1.54 to − 1.15]). Women in the ISTp-AL arm complained of fever more frequently compared to women in the IPTp-SP arm (p = 0.022).ConclusionsThe trial results suggest that in an area of high malaria transmission with moderate sulfadoxine–pyrimethamine resistance, ISTp with artemether–lumefantrine may be an effective strategy for controlling malaria in pregnancy.Trial registration PACTR, PACTR201308000543272. Registered 29 April 2013, http://www.pactr.org/ATMWeb/appmanager/atm/atmregistry?dar=true&tNo=PACTR201308000543272