Epidemiology and burden of malaria in pregnancy

Malaria Branch, Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA.
The Lancet Infectious Diseases (Impact Factor: 22.43). 03/2007; 7(2):93-104. DOI: 10.1016/S1473-3099(07)70021-X
Source: PubMed


We reviewed evidence of the clinical implications and burden of malaria in pregnancy. Most studies come from sub-Saharan Africa, where approximately 25 million pregnant women are at risk of Plasmodium falciparum infection every year, and one in four women have evidence of placental infection at the time of delivery. P falciparum infections during pregnancy in Africa rarely result in fever and therefore remain undetected and untreated. Meta-analyses of intervention trials suggest that successful prevention of these infections reduces the risk of severe maternal anaemia by 38%, low birthweight by 43%, and perinatal mortality by 27% among paucigravidae. Low birthweight associated with malaria in pregnancy is estimated to result in 100,000 infant deaths in Africa each year. Although paucigravidae are most affected by malaria, the consequences for infants born to multigravid women in Africa may be greater than previously appreciated. This is because HIV increases the risk of malaria and its adverse effects, particularly in multigravidae, and recent observational studies show that placental infection almost doubles the risk of malaria infection and morbidity in infants born to multigravidae. Outside Africa, malaria infection rates in pregnant women are much lower but are more likely to cause severe disease, preterm births, and fetal loss. Plasmodium vivax is common in Asia and the Americas and, unlike P falciparum, does not cytoadhere in the placenta, yet, is associated with maternal anaemia and low birthweight. The effect of infection in the first trimester, and the longer term effects of malaria beyond infancy, are largely unknown and may be substantial. Better estimates are also needed of the effects of malaria in pregnancy outside Africa, and on maternal morbidity and mortality in Africa. Global risk maps will allow better estimation of potential impact of successful control of malaria in pregnancy.

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    • "Approximately 125 million pregnancies occur in areas at risk of Plasmodium falciparum and P. vivax infections every year; an estimated 1.3 million of these occur in Kenya[1]. Malaria in pregnancy (MiP) can have devastating consequences for the woman and her unborn baby, including maternal anemia, fetal loss, intrauterine growth retardation, premature delivery and low birth weight (LBW) with increased risk for neonatal death[2]. In line with World Health Organization (WHO) recommendations, the Kenya Ministry of Health (MoH) recommends that pregnant women use long-lasting insecticidal nets (LLINs), intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP), and receive prompt and effective diagnosis and treatment of malaria with a safe drug in order to prevent adverse consequences. "
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    ABSTRACT: Background: Although prompt, effective treatment is a cornerstone of malaria control, information on provider adherence to malaria in pregnancy (MIP) treatment guidelines is limited. Incorrect or sub-optimal treatment can adversely affect the mother and fetus. This study assessed provider knowledge of and adherence to national case management guidelines for uncomplicated MIP. Methods: We conducted a cross-sectional study from September to November 2013, in 51 health facilities (HF) and a randomly-selected sample of 39 drug outlets (DO) in the KEMRI/CDC Health and Demographic Surveillance System area in western Kenya. Provider knowledge of national treatment guidelines was assessed with standardized questionnaires. Correct practice required adequate diagnosis, pregnancy assessment, and treatment with correct drug and dosage. In HF, we conducted exit interviews in all women of childbearing age assessed for fever. In DO, simulated clients posing as first trimester pregnant women or as relatives of third trimester pregnant women collected standardized information. Results: Correct MIP case management knowledge and practice were observed in 45% and 31% of HF and 0% and 3% of DO encounters, respectively. The correct drug and dosage for pregnancy trimester was prescribed in 62% of HF and 42% of DO encounters; correct prescription occurred less often in first than in second/ third trimesters (HF: 24% vs. 65%, p<0.01; DO: 0% vs. 40%, p<0.01). Sulfadoxine-pyrimethamine, which is not recommended for malaria treatment, was prescribed in 3% of HF and 18% of DO encounters. Exposure to artemether-lumefantrine in first trimester, which is contraindicated, occurred in 29% and 49% of HF and DO encounters, respectively. Conclusion: This study highlights knowledge inadequacies and incorrect prescribing practices in the treatment of MIP. Particularly concerning is the prescription of contraindicated medications in the first trimester. These issues should be addressed through comprehensive trainings and increased supportive supervision. Additional innovative means to improve care should be explored.
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    • "The highest rate of malaria infection appears to be in the second trimester. The highest risk for infection and morbidity is in primigravidas, adolescents, and those infected with HIV (Desai et al. 2007). It is assumed that the majority of malaria infections during pregnancy results from two main factors: the immunocompromised state of pregnancy and placental sequestration of infected erythrocytes. "

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    • "particularly interesting that experimental bacterial (LPS), viral (Poly I:C) and PGE 2 fevers in several species are reduced late in pregnancy (for review Mouihate et al., 2008; Spencer et al., 2008). It is not known if there is a similar suppression of the febrile response in late gestation in pregnant women, but it is reported that malarial infections during pregnancy are often asymptomatic, i.e. presenting without fever (Desai et al., 2007). Thus one might conclude that there is normally a natural means, through fever suppression, to prevent the complications associated with fever at parturition that are reported in the clinical literature. "
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    ABSTRACT: Fever has been recognized as an important symptom of disease since ancient times. For many years, fever was treated as a putative life-threatening phenomenon. More recently, it has been recognized as an important part of the body's defense mechanisms; indeed at times it has even been used as a therapeutic agent. The knowledge of the functional role of the central nervous system in the genesis of fever has greatly improved over the last decade. It is clear that the febrile process, which develops in the sick individual, is just one of many brain-controlled sickness symptoms. Not only will the sick individual appear "feverish" but they may also display a range of behavioral changes, such as anorexia, fatigue, loss of interest in usual activities, social withdrawal, listlessness or malaise, hyperalgesia, sleep disturbances and cognitive dysfunction, collectively termed "sickness behavior". In this review we consider the issue of whether fever and sickness behaviors are friend or foe during: a critical illness, the common cold or influenza, in pregnancy and in the newborn. Deciding whether these sickness responses are beneficial or harmful will very much shape our approach to the use of antipyretics during illness. Copyright © 2015. Published by Elsevier Inc.
    Full-text · Article · Jul 2015 · Brain Behavior and Immunity
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