Women In Blantyre Research Articles

Durations of asymptomatic, symptomatic, and care-seeking phases of tuberculosis disease with a Bayesian analysis of prevalence survey and notification data

BackgroundRatios of bacteriologically positive tuberculosis (TB) prevalence to notification rates are used to characterise typical durations of TB disease. However, this ignores the clinical spectrum of tuberculosis disease and potentially long infectious periods with minimal or no symptoms prior to care-seeking.MethodsWe developed novel statistical models to estimate progression from initial bacteriological positivity including smear conversion, symptom onset and initial care-seeking. Case-detection ratios, TB incidence, durations, and other parameters were estimated by fitting the model to tuberculosis prevalence survey and notification data (one subnational and 11 national datasets) within a Bayesian framework using Markov chain Monte Carlo methods.ResultsAnalysis across 11 national datasets found asymptomatic tuberculosis durations in the range 4–8 months for African countries; three countries in Asia (Cambodia, Lao PDR, and Philippines) showed longer durations of > 1 year. For the six countries with relevant data, care-seeking typically began half-way between symptom onset and notification. For Kenya and Blantyre, Malawi, individual-level data were available. The sex-specific durations of asymptomatic bacteriologically-positive tuberculosis were 9.0 months (95% credible interval [CrI]: 7.2–11.2) for men and 8.1 months (95% CrI: 6.2–10.3) for women in Kenya, and 4.9 months (95% CrI: 2.6–7.9) for men and 3.5 months (95% CrI: 1.3–6.2) for women in Blantyre. Age-stratified analysis of data for Kenya showed no strong age-dependence in durations. For Blantyre, HIV-stratified analysis estimated an asymptomatic duration of 1.3 months (95% CrI: 0.3–3.0) for HIV-positive people, shorter than the 8.5 months (95% CrI: 5.0–12.7) for HIV-negative people. Additionally, case-detection ratios were higher for people living with HIV than HIV-negative people (93% vs 71%).ConclusionAsymptomatic TB disease typically lasts around 6 months. We found no evidence of age-dependence, but much shorter durations among people living with HIV, and longer durations in some Asian settings. To eradicate TB transmission, greater gains may be achieved by proactively screening people without symptoms through active case finding interventions

Blood flows: mapping journeys of menstrual waste in Blantyre, Malawi

ABSTRACT The interplay between menstrual waste and urban sanitation infrastructure is largely hidden from view. Qualitative research has highlighted socio-cultural aspects of menstruation, but few quantitative studies have mapped the physical situation at scale. This study surveyed 258 women in Blantyre, Malawi about their menstrual absorbent choices, disposal practices, and socio-demographic characteristics. A Sankey diagram visualised flows of menstrual waste in the urban environment and identified ultimate disposal points. Most participants used either disposable pads and/or old cloth and disposed of them by either burning and/or throwing in pit latrines. Pad and cloth use were associated with age, education, employment, marital status, and household wealth. Younger women’s preference for disposable pads suggests that demographic shifts may cause volumes of menstrual waste to increase. However, differences in waste volume produced by disposable and reusable absorbents was less than previously assumed. The volume of menstrual waste discarded in pit latrines, and cultural barriers to disposing it elsewhere, highlights challenges for the pit emptying industry and faecal sludge value recovery sector, with the problem anticipated to be most acute in high-density settlements. Widening access to sustainable disposal strategies, affordable reusable menstrual products, and tackling stigma, are key to addressing this social and environmental challenge.

Knowledge of Cervical Cancer and Prevalence of the Screening Services among HIV-Infected Women in Blantyre, Malawi

HIV-infected women are at high risk of developing cervical cancer and are encouraged to undergo cervical cancer screening regularly. However, very little has been documented about the knowledge of cervical cancer and the utilization of the screening services by these women. This study aimed to investigate the knowledge of cervical cancer, prevalence of cervical cancer screening uptake and predictive factors that affect utilization of cervical cancer screening services among HIV-infected women. The study employed quantitative methods for data collection and analysis. It was conducted at Queen Elizabeth Central Hospital (QECH) from December 2017 to February 2018 where HIV-positive patients accessing QECH Antiretroviral Therapy (ART) clinic were recruited. Systematic random sampling was employed to select HIV-positive women for the survey. Data were collected using semi-structured questionnaires. STATA version 12 was used to analyze the data. Out of the 196 recruited women, the majority (98%; n = 192) indicated having heard of cervical cancer and of the 192 women, only 57% (n = 109) were able to know at least a single sign/symptom of cervical cancer, furthermore, only 47% (n = 91) indicated ever been screened, finally, getting information from health facilities and knowing at least a single sign/symptom of cervical cancer influenced HIV-infected women to go for cervical cancer screening services. The study revealed that knowledge of cervical cancer and the utilization of its screening services among HIV-infected women is low. Therefore, there is need to increase knowledge and strengthen cervical cancer screening services among HIV-infected women in the country.

Low back pain during pregnancy: Prevalence, risk factors and association with daily activities among pregnant women in urban Blantyre, Malawi.

Low back pain (LBP) is a significant musculoskeletal problem during pregnancy with potential to negatively affect the woman's quality of life. Data on LBP among pregnant women in Malawi is almost non-existent. We investigated the prevalence and risk factors of LBP and its association with functional activities in pregnant women in Malawi. We conducted a cross-sectional study in Blantyre, Malawi, from December 2017 to January 2018. Participants were drawn from low-risk antenatal clinics in selected local health facilities. Written informed consent was sourced from study participants, permission was granted at each study site and the study received ethics approval from the College of Medicine Research Ethics Committee (COMREC). Descriptive statistics were used to summarize the data. Categorical variables were summarized as frequencies and percentages. The association between occurrence of LBP and selected factors was assessed using the Chi-Square test (X2) (α=5%) followed by a multiple logistic regression. Odds ratios (OR) and their 95% confidence intervals were calculated. We interviewed 404 pregnant women; the mean age of respondents was 25.83 years old (SD: ±5.91). Prevalence of LBP in pregnancy was 62% (n=249); 172 (69%) of these reported LBP for the first time during the current pregnancy. Gestational age was significantly associated with presence of LBP (P= 0.03). LBP was associated with the women's sleep patterns, mobility, lifting techniques and sexual activities. However, a reasonable high proportion of those with LBP (34%) did not seek care for their low back pain. LBP is highly prevalent and an important clinical condition among pregnant women in Blantyre, Malawi. Given the significant effect of LBP on quality of life, health workers need to be proactive in identifying LBP and provide the appropriate management.

Incidence and Seasonality of Influenza-Like Illnesses Among Pregnant Women in Blantyre, Malawi

Pregnant women with influenza infection are at increased risk of developing complications compared with other adults. Information about burden of influenza in pregnant women in Africa is limited. To determine incidence and seasonality of influenza-like illness (ILI) in pregnant women in Blantyre, Malawi, we recruited a cohort of 450 pregnant women and conducted surveillance for ILI and malaria infection. We recorded gestational age and birthweight. We accrued 157 person-years of observation (PYO) and detected 37 episodes of ILI (24/100 PYO) and 83 episodes of malaria infection (including all new episodes of parasitemia) (53/100 PYO). ILI was the most common cause of fever, but was not associated with adverse pregnancy outcomes. ILI incidence peaked during the hot dry season. These results indicate that ILI is a significant burden among Malawian pregnant women and it is somewhat seasonal. Studies with molecular diagnostics are needed to establish influenza-specific burden and the potential role of vaccination.

Moving targets: The challenges of studying infectious diseases among pregnant women in resource limited settings

Conducting clinical trials to prevent and treat infectious diseases in pregnancy is essential to saving maternal and newborn lives, though it is fraught with challenges. We have been conducting research in malaria treatment and prevention in children and pregnant women in Blantyre, Malawi for over a decade. Here, we review some of the unique challenges that we have faced in leading research studies that with rigor and integrity and maintaining the highest ethical standard. We conclude with concrete strategies to overcome some of the apparent obstacles that frequently focus on building trust through bidirectional communication with local health workers and communities. We also highlight the key role of local and international investigators to advocate for the health of the communities in which they work.

Timing of malaria infection during pregnancy has characteristic maternal, infant and placental outcomes.

We conducted a clinical study of pregnant women in Blantyre, Malawi to determine the effect of the timing of malaria infection during pregnancy on maternal, infant and placental outcomes. Women were enrolled in their first or second trimester of their first or second pregnancy and followed every four weeks until delivery. Three doses of sulfadoxine-pyrimethamine were given for intermittent preventive treatment for malaria, and all episodes of parasitemia were treated according to the national guidelines. Placentas were collected at delivery and examined for malaria parasites and pigment by histology. Pregnant women had 0.6 episodes of malaria per person year of follow up. Almost all episodes of malaria were detected at enrollment and malaria infection during the follow up period was rare. Malaria and anemia at the first antenatal visit were independently associated with an increased risk of placental malaria detected at delivery. When all episodes of malaria were treated with effective antimalarial medication, only peripheral malaria infection at the time of delivery was associated with adverse maternal and infant outcomes. One quarter of the analyzed placentas had evidence of malaria infection. Placental histology was 78% sensitive and 89% specific for peripheral malaria infection during pregnancy. This study suggests that in this setting of high antifolate drug resistance, three doses of sulfadoxine-pyrimethamine maintain some efficacy in suppressing microscopically detectable parasitemia, although placental infection remains frequent. Even in this urban setting, a large proportion of women have malaria infection at the time of their first antenatal care visit. Interventions to control malaria early and aggressive case detection are required to limit the detrimental effects of pregnancy-associated malaria.

Fertility Intentions of HIV-1 Infected and Uninfected Women in Malawi: A Longitudinal Study

This study aimed to determine changes in fertility intentions of HIV-1 infected and uninfected reproductive age women in Blantyre, Malawi. Participants were asked about their fertility intentions at baseline and at 3-month visits for 1 year. Time-to-event statistical models were used to determine factors associated with changes in fertility intentions. Overall, 842 HIV uninfected and 844 HIV infected women were enrolled. The hazard of changing from wanting no more children at baseline to wanting more children at follow-up was 61% lower among HIV infected women compared to HIV uninfected women (P < 0.01) after adjusting for other factors, while HIV infected women were approximately 3 times more likely to change to wanting no more children. The overall pregnancy rate after 12 months was 14.9 per 100 person-years and did not differ among 102 HIV uninfected and 100 infected women who became pregnant. HIV infection is a significant predictor of fertility intentions over time.

Socio-demographic characteristics associated with HIV and syphilis seroreactivity among pregnant women in Blantyre, Malawi, 2000-2004

We aimed to evaluate socio-demographic factors associated with HIV and syphilis seroreactivity in pregnant Malawians presenting for antenatal care in late third trimester of pregnancy. Between December 2000 and March 2004 at Queen Elizabeth Central Hospital Blantyre, Malawi, we collected cross-sectional clinical and socioeconomic data from consenting women. HIV-1 status was determined using rapid HIV antibody tests and syphilis seroreactivity was determined using Rapid Plasma Reagin (RPR) and confirmed with Treponema pallidum hemagglutination assay (TPHA). Of 3,824 women screened for HIV, 1156 (30%) were HIV seropositive and 198 (5%) were RPR and TPHA seroreactive. In the multivariate analysis, HIV infection was positively associated with elevated socio-economic status, being formerly married, and age, but not with education level. HIV prevalence was lower in women of Yao ethnicity than in other women (OR: 0.78, 95%CI: 0.64-0.95). Increased maternal education was negatively associated with syphilis seroreactivity. The seroprevalence of HIV and syphilis among women attending the antenatal ward in Blantyre remains unacceptably high. Demographic correlates of HIV and syphilis infections were different. Our results demonstrate the need for better strategies to prevent HIV and syphilis in women and calls for optimizing antenatal syphilis screening and treatment in Malawi.

Socio-demographic characteristics associated with HIV and syphilis seroreactivity among pregnant women in Blantyre, Malawi, 2000-2004

Socio-demographic characteristics associated with HIV and syphilis seroreactivity among pregnant women in Blantyre, Malawi, 2000-2004

A Randomized Controlled Pilot Trial of Azithromycin or Artesunate Added to Sulfadoxine-Pyrimethamine as Treatment for Malaria in Pregnant Women

ObjectiveNew anti-malarial regimens are urgently needed in sub-Saharan Africa because of the increase in drug resistance. We investigated the safety and efficacy of azithromycin or artesunate combined with sulfadoxine-pyrimethamine used for treatment of malaria in pregnant women in Blantyre, Malawi.Methods/FindingsThis was a randomized open-label clinical trial, conducted at two rural health centers in Blantyre district, Malawi. A total of 141 pregnant women with uncomplicated Plasmodium falciparum malaria were recruited and randomly allocated to 3 treatment groups: sulfadoxine-pyrimethamine (SP; 3 tablets, 500 mg sulfadoxine and 25 mg pyrimethamine per tablet); SP plus azithromycin (1 g/day×2 days); or SP plus artesunate (200 mg/day×3 days). Women received two doses administered at least 4 weeks apart. Heteroduplex tracking assays were performed to distinguish recrudescence from new infections. Main outcome measures were incidence of adverse outcomes, parasite and fever clearance times and recrudescence rates. All treatment regimens were well tolerated. Two women vomited soon after ingesting azithromycin. The parasite clearance time was significantly faster in the SP-artesunate group. Recrudescent episodes of malaria were less frequent with SP-azithromycin [Hazard Ratio 0.19 (95% confidence interval 0.06 to 0.63)] and SP-artesunate [Hazard Ratio 0.25 (95% confidence interval 0.10 to 0.65)] compared with SP monotherapy. With one exception (an abortion in the SP-azithromycin group), all adverse pregnancy outcomes could be attributed to known infectious or obstetrical causes. Because of the small sample size, the effect on birth outcomes, maternal malaria or maternal anemia could not be evaluated.ConclusionsBoth SP-artesunate and SP-azithromycin appeared to be safe, well tolerated and efficacious for the treatment of malaria during pregnancy. A larger study is needed to determine their safety and efficacy in preventing poor birth outcomes.Trial RegistrationClinialTrials.gov NCT00287300

Malaria during pregnancy and foetal haematological status in Blantyre, Malawi

BackgroundAlthough maternal anaemia often stems from malaria infection during pregnancy, its effects on foetal haemoglobin levels are not straightforward. Lower-than-expected cord haemoglobin values in malarious versus non-malarious regions were noted by one review, which hypothesized they resulted from foetal immune activation to maternal malaria. This study addressed this idea by examining cord haemoglobin levels in relation to maternal malaria, anaemia, and markers of foetal immune activation.MethodsCord haemoglobin levels were examined in 32 malaria-infected and 58 uninfected women in Blantyre, Malawi, in relation to maternal haemoglobin levels, malaria status, and markers of foetal haematological status, hypoxia, and inflammation, including TNF-α, TGF-β, and ferritin. All women were HIV-negative.ResultsAlthough malaria was associated with a reduction in maternal haemoglobin (10.8 g/dL vs. 12.1 g/dL, p < 0.001), no reduction in cord haemoglobin and no significant relationship between maternal and cord haemoglobin levels were found. Cord blood markers of haematological and hypoxic statuses did not differ between malaria-infected and uninfected women. Maternal malaria was associated with decreased TGF-β and increased cord ferritin, the latter of which was positively correlated with parasitaemia (r = 0.474, p = 0.009). Increased cord ferritin was associated with significantly decreased birth weight and gestational length, although maternal and cord haemoglobin levels and malaria status had no effect on birth outcome.ConclusionIn this population, cord haemoglobin levels were protected from the effect of maternal malaria. However, decreased TGF-β and elevated ferritin levels in cord blood suggest foetal immune activation to maternal malaria, which may help explain poor birth outcomes.

Likely stakeholders in the prevention of mother to child transmission of HIV/AIDS in Blantyre, Malawi.

To determine potential partners for pregnant women in the prevention of mother to child transmission of HIV and to determine pregnant women's perceptions towards selected potential HIV prevention efforts. Cross sectional, questionnaire-administered study. Ante-natal clinics of eleven public health centers and the major referral and university teaching hospital of Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi. A total of 321 pregnant women attending ante-natal clinics. Antenatal women in Blantyre, Malawi obtain health information on HIV/AIDS from the radio (96.3%), health workers (82.2%), religious gatherings (66.7%), friends (54.8%) and newspapers (39.3%). The majority intend to be accompanied by own mother and sister for delivery (52.4% and 15.4% respectively). Almost all (99%) planned to breast feed with 91.8% reporting an intended breastfeeding period of at least 6 months. About 97% of married women reported desire to tell spouse in case of HIV sero-positive results while only 65.1% had ever discussed about HIV with spouse, and only 5.2% had ever attended antenatal clinic with spouse. Whether woman had ever discussed about HIV/AIDS with spouse or not did not influence desire to disclose HIV status to spouse. Close relatives, spouse and the media are important stakeholders in the health of pregnant women. Programs aimed at prevention of mother to child transmission of HIV should give serious consideration to these partners.

Risk factors and mechanisms of preterm delivery in Malawi.

We examined risk factors and mechanisms of preterm delivery (PTD) in malaria-exposed pregnant women in Blantyre, Malawi. The human immunodeficiency virus (HIV), malaria, syphilis, and anemia were assessed in a cross-sectional study of 572 pregnant women. In a nested case-control study, chorioamnionitis (CAM) was examined; tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-8, macrophage inflammatory protein (MIP)-1alpha, monocyte chemotactic protein (MCP)-1, transforming growth factor (TGF)-beta, cortisol, and corticotropin-releasing hormone were measured in placental, maternal and/or cord blood. HIV, infrequent antenatal clinic attendance, low-maternal weight, no intermittent preventive malaria therapy (IPT), and CAM were associated with PTD, while malaria was not. Of the 18 compartmental cytokine measurements, elevations in placental and/or cord IL-6 and IL-8 were associated with both CAM and PTD. In contrast, there was no overlap between the cytokines affected by malaria and those associated with PTD. The HIV and CAM were the major infections associated with PTD in this study. CAM, but not malaria, causes PTD via its effect on proinflammatory cytokines.

Etiology of anemia in pregnancy in south Malawi

Anemia in pregnancy is a major public health problem in developing countries. In sub-Saharan Africa, such anemia is generally accepted as resulting from nutritional deficiencies, particularly iron deficiency. We comprehensively assessed the full spectrum of nutritional and nonnutritional factors associated with pregnancy anemia. Iron, folate, vitamin B-12, and vitamin A were measured in serum in a cross-sectional study of 150 pregnant women in Blantyre, Malawi. Bone marrow aspirates were evaluated, peripheral blood films were examined for malaria parasites, stool and urine samples were examined for helminthic infection, and tests were done for genetic disorders and for HIV infection. C-reactive protein (CRP) concentrations and erythrocyte sedimentation rates were measured as markers of inflammation. Of the 150 anemic women, 23% were iron deficient with no evidence of folate, vitamin B-12, or vitamin A deficiencies; 32% were deficient in iron and one or more of the other micronutrients; 26% were not iron deficient but had evidence of one of the other micronutrient deficiencies, most often vitamin A; and 19% were not deficient in any of the micronutrients studied. CRP concentrations were notably high in 54% of the anemic women with no nutritional deficiencies and in 73.5% of the anemic women who were iron replete by bone marrow assessment. The role of chronic inflammation as a possible contributing factor to anemia in pregnancy has important implications for the clinical evaluation and treatment of women.

Mastitis and immunological factors in breast milk of lactating women in Malawi.

Although an elevated sodium concentration in human milk is suggested to be an indicator of mastitis, it is unclear whether elevated sodium concentrations are associated with immunological and inflammatory mediators in human milk. We conducted a cross-sectional study to evaluate the relationships between elevated breast milk sodium concentrations and levels of lactoferrin, lysozyme, secretory leukocyte protease inhibitor (SLPI), interleukin-8 (IL-8), and RANTES (regulated on activation normal T cell expressed and secreted) in human milk at 6 weeks postpartum in 96 lactating women in Blantyre, Malawi. Mastitis, as indicated by an elevated breast milk sodium concentration, was present in 15.6% of the women. Women with and without mastitis had respective median levels of other factors as follows: lactoferrin, 1,230 versus 565 mg/liter (P < 0. 0007); lysozyme, 266 versus 274 mg/liter (P = 0.55); SLPI, 76 versus 15 microg/liter, (P < 0.0002); IL-8, 339 versus 25 ng/liter (P < 0. 0001); and RANTES, 82 versus 3 ng/liter (P < 0.0001). Elevated sodium concentrations in breast milk are associated with an increase in levels of some immunological and inflammatory factors in breast milk.